Illinois General Assembly - Full Text of HB4487
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Full Text of HB4487  98th General Assembly




State of Illinois
2013 and 2014


Introduced , by Rep. Marcus C. Evans, Jr.


305 ILCS 5/5-5.12  from Ch. 23, par. 5-5.12

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that notwithstanding any law to the contrary, all pharmacies providing prescription drugs under the medical assistance program shall receive the same rate of payment or reimbursement as set by the Department of Healthcare and Family Services. Effective immediately.

LRB098 14777 KTG 49699 b






HB4487LRB098 14777 KTG 49699 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5.12 as follows:
6    (305 ILCS 5/5-5.12)  (from Ch. 23, par. 5-5.12)
7    Sec. 5-5.12. Pharmacy payments.
8    (a) Every request submitted by a pharmacy for reimbursement
9under this Article for prescription drugs provided to a
10recipient of aid under this Article shall include the name of
11the prescriber or an acceptable identification number as
12established by the Department.
13    (b) Pharmacies providing prescription drugs under this
14Article shall be reimbursed at a rate which shall include a
15professional dispensing fee as determined by the Illinois
16Department, plus the current acquisition cost of the
17prescription drug dispensed. The Illinois Department shall
18update its information on the acquisition costs of all
19prescription drugs no less frequently than every 30 days.
20However, the Illinois Department may set the rate of
21reimbursement for the acquisition cost, by rule, at a
22percentage of the current average wholesale acquisition cost.
23    (b-5) Notwithstanding any law to the contrary, all



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1pharmacies providing prescription drugs under this Article
2shall receive the same rate of payment or reimbursement as set
3by the Department.
4    (c) (Blank).
5    (d) The Department shall review utilization of narcotic
6medications in the medical assistance program and impose
7utilization controls that protect against abuse.
8    (e) When making determinations as to which drugs shall be
9on a prior approval list, the Department shall include as part
10of the analysis for this determination, the degree to which a
11drug may affect individuals in different ways based on factors
12including the gender of the person taking the medication.
13    (f) The Department shall cooperate with the Department of
14Public Health and the Department of Human Services Division of
15Mental Health in identifying psychotropic medications that,
16when given in a particular form, manner, duration, or frequency
17(including "as needed") in a dosage, or in conjunction with
18other psychotropic medications to a nursing home resident or to
19a resident of a facility licensed under the ID/DD Community
20Care Act, may constitute a chemical restraint or an
21"unnecessary drug" as defined by the Nursing Home Care Act or
22Titles XVIII and XIX of the Social Security Act and the
23implementing rules and regulations. The Department shall
24require prior approval for any such medication prescribed for a
25nursing home resident or to a resident of a facility licensed
26under the ID/DD Community Care Act, that appears to be a



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1chemical restraint or an unnecessary drug. The Department shall
2consult with the Department of Human Services Division of
3Mental Health in developing a protocol and criteria for
4deciding whether to grant such prior approval.
5    (g) The Department may by rule provide for reimbursement of
6the dispensing of a 90-day supply of a generic or brand name,
7non-narcotic maintenance medication in circumstances where it
8is cost effective.
9    (g-5) On and after July 1, 2012, the Department may require
10the dispensing of drugs to nursing home residents be in a 7-day
11supply or other amount less than a 31-day supply. The
12Department shall pay only one dispensing fee per 31-day supply.
13    (h) Effective July 1, 2011, the Department shall
14discontinue coverage of select over-the-counter drugs,
15including analgesics and cough and cold and allergy
17    (h-5) On and after July 1, 2012, the Department shall
18impose utilization controls, including, but not limited to,
19prior approval on specialty drugs, oncolytic drugs, drugs for
20the treatment of HIV or AIDS, immunosuppressant drugs, and
21biological products in order to maximize savings on these
22drugs. The Department may adjust payment methodologies for
23non-pharmacy billed drugs in order to incentivize the selection
24of lower-cost drugs. For drugs for the treatment of AIDS, the
25Department shall take into consideration the potential for
26non-adherence by certain populations, and shall develop



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1protocols with organizations or providers primarily serving
2those with HIV/AIDS, as long as such measures intend to
3maintain cost neutrality with other utilization management
4controls such as prior approval. For hemophilia, the Department
5shall develop a program of utilization review and control which
6may include, in the discretion of the Department, prior
7approvals. The Department may impose special standards on
8providers that dispense blood factors which shall include, in
9the discretion of the Department, staff training and education;
10patient outreach and education; case management; in-home
11patient assessments; assay management; maintenance of stock;
12emergency dispensing timeframes; data collection and
13reporting; dispensing of supplies related to blood factor
14infusions; cold chain management and packaging practices; care
15coordination; product recalls; and emergency clinical
16consultation. The Department may require patients to receive a
17comprehensive examination annually at an appropriate provider
18in order to be eligible to continue to receive blood factor.
19    (i) On and after July 1, 2012, the Department shall reduce
20any rate of reimbursement for services or other payments or
21alter any methodologies authorized by this Code to reduce any
22rate of reimbursement for services or other payments in
23accordance with Section 5-5e.
24    (j) On and after July 1, 2012, the Department shall impose
25limitations on prescription drugs such that the Department
26shall not provide reimbursement for more than 4 prescriptions,



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1including 3 brand name prescriptions, for distinct drugs in a
230-day period, unless prior approval is received for all
3prescriptions in excess of the 4-prescription limit. Drugs in
4the following therapeutic classes shall not be subject to prior
5approval as a result of the 4-prescription limit:
6immunosuppressant drugs, oncolytic drugs, and anti-retroviral
8    (k) No medication therapy management program implemented
9by the Department shall be contrary to the provisions of the
10Pharmacy Practice Act.
11    (l) Any provider enrolled with the Department that bills
12the Department for outpatient drugs and is eligible to enroll
13in the federal Drug Pricing Program under Section 340B of the
14federal Public Health Services Act shall enroll in that
15program. No entity participating in the federal Drug Pricing
16Program under Section 340B of the federal Public Health
17Services Act may exclude Medicaid from their participation in
18that program, although the Department may exclude entities
19defined in Section 1905(l)(2)(B) of the Social Security Act
20from this requirement.
21(Source: P.A. 97-38, eff. 6-28-11; 97-74, eff. 6-30-11; 97-333,
22eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, eff. 6-14-12;
2397-813, eff. 7-13-12; 98-463, eff. 8-16-13.)
24    Section 99. Effective date. This Act takes effect upon
25becoming law.