Illinois General Assembly - Full Text of HB0465
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Full Text of HB0465  101st General Assembly


Rep. Gregory Harris

Filed: 3/11/2019





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2    AMENDMENT NO. ______. Amend House Bill 465 by replacing
3everything after the enacting clause with the following:
4    "Section 1. The Freedom of Information Act is amended by
5changing Section 7.5 as follows:
6    (5 ILCS 140/7.5)
7    Sec. 7.5. Statutory exemptions. To the extent provided for
8by the statutes referenced below, the following shall be exempt
9from inspection and copying:
10        (a) All information determined to be confidential
11    under Section 4002 of the Technology Advancement and
12    Development Act.
13        (b) Library circulation and order records identifying
14    library users with specific materials under the Library
15    Records Confidentiality Act.
16        (c) Applications, related documents, and medical



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1    records received by the Experimental Organ Transplantation
2    Procedures Board and any and all documents or other records
3    prepared by the Experimental Organ Transplantation
4    Procedures Board or its staff relating to applications it
5    has received.
6        (d) Information and records held by the Department of
7    Public Health and its authorized representatives relating
8    to known or suspected cases of sexually transmissible
9    disease or any information the disclosure of which is
10    restricted under the Illinois Sexually Transmissible
11    Disease Control Act.
12        (e) Information the disclosure of which is exempted
13    under Section 30 of the Radon Industry Licensing Act.
14        (f) Firm performance evaluations under Section 55 of
15    the Architectural, Engineering, and Land Surveying
16    Qualifications Based Selection Act.
17        (g) Information the disclosure of which is restricted
18    and exempted under Section 50 of the Illinois Prepaid
19    Tuition Act.
20        (h) Information the disclosure of which is exempted
21    under the State Officials and Employees Ethics Act, and
22    records of any lawfully created State or local inspector
23    general's office that would be exempt if created or
24    obtained by an Executive Inspector General's office under
25    that Act.
26        (i) Information contained in a local emergency energy



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1    plan submitted to a municipality in accordance with a local
2    emergency energy plan ordinance that is adopted under
3    Section 11-21.5-5 of the Illinois Municipal Code.
4        (j) Information and data concerning the distribution
5    of surcharge moneys collected and remitted by carriers
6    under the Emergency Telephone System Act.
7        (k) Law enforcement officer identification information
8    or driver identification information compiled by a law
9    enforcement agency or the Department of Transportation
10    under Section 11-212 of the Illinois Vehicle Code.
11        (l) Records and information provided to a residential
12    health care facility resident sexual assault and death
13    review team or the Executive Council under the Abuse
14    Prevention Review Team Act.
15        (m) Information provided to the predatory lending
16    database created pursuant to Article 3 of the Residential
17    Real Property Disclosure Act, except to the extent
18    authorized under that Article.
19        (n) Defense budgets and petitions for certification of
20    compensation and expenses for court appointed trial
21    counsel as provided under Sections 10 and 15 of the Capital
22    Crimes Litigation Act. This subsection (n) shall apply
23    until the conclusion of the trial of the case, even if the
24    prosecution chooses not to pursue the death penalty prior
25    to trial or sentencing.
26        (o) Information that is prohibited from being



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1    disclosed under Section 4 of the Illinois Health and
2    Hazardous Substances Registry Act.
3        (p) Security portions of system safety program plans,
4    investigation reports, surveys, schedules, lists, data, or
5    information compiled, collected, or prepared by or for the
6    Regional Transportation Authority under Section 2.11 of
7    the Regional Transportation Authority Act or the St. Clair
8    County Transit District under the Bi-State Transit Safety
9    Act.
10        (q) Information prohibited from being disclosed by the
11    Personnel Record Records Review Act.
12        (r) Information prohibited from being disclosed by the
13    Illinois School Student Records Act.
14        (s) Information the disclosure of which is restricted
15    under Section 5-108 of the Public Utilities Act.
16        (t) All identified or deidentified health information
17    in the form of health data or medical records contained in,
18    stored in, submitted to, transferred by, or released from
19    the Illinois Health Information Exchange, and identified
20    or deidentified health information in the form of health
21    data and medical records of the Illinois Health Information
22    Exchange in the possession of the Illinois Health
23    Information Exchange Authority due to its administration
24    of the Illinois Health Information Exchange. The terms
25    "identified" and "deidentified" shall be given the same
26    meaning as in the Health Insurance Portability and



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1    Accountability Act of 1996, Public Law 104-191, or any
2    subsequent amendments thereto, and any regulations
3    promulgated thereunder.
4        (u) Records and information provided to an independent
5    team of experts under the Developmental Disability and
6    Mental Health Safety Act (also known as Brian's Law).
7        (v) Names and information of people who have applied
8    for or received Firearm Owner's Identification Cards under
9    the Firearm Owners Identification Card Act or applied for
10    or received a concealed carry license under the Firearm
11    Concealed Carry Act, unless otherwise authorized by the
12    Firearm Concealed Carry Act; and databases under the
13    Firearm Concealed Carry Act, records of the Concealed Carry
14    Licensing Review Board under the Firearm Concealed Carry
15    Act, and law enforcement agency objections under the
16    Firearm Concealed Carry Act.
17        (w) Personally identifiable information which is
18    exempted from disclosure under subsection (g) of Section
19    19.1 of the Toll Highway Act.
20        (x) Information which is exempted from disclosure
21    under Section 5-1014.3 of the Counties Code or Section
22    8-11-21 of the Illinois Municipal Code.
23        (y) Confidential information under the Adult
24    Protective Services Act and its predecessor enabling
25    statute, the Elder Abuse and Neglect Act, including
26    information about the identity and administrative finding



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1    against any caregiver of a verified and substantiated
2    decision of abuse, neglect, or financial exploitation of an
3    eligible adult maintained in the Registry established
4    under Section 7.5 of the Adult Protective Services Act.
5        (z) Records and information provided to a fatality
6    review team or the Illinois Fatality Review Team Advisory
7    Council under Section 15 of the Adult Protective Services
8    Act.
9        (aa) Information which is exempted from disclosure
10    under Section 2.37 of the Wildlife Code.
11        (bb) Information which is or was prohibited from
12    disclosure by the Juvenile Court Act of 1987.
13        (cc) Recordings made under the Law Enforcement
14    Officer-Worn Body Camera Act, except to the extent
15    authorized under that Act.
16        (dd) Information that is prohibited from being
17    disclosed under Section 45 of the Condominium and Common
18    Interest Community Ombudsperson Act.
19        (ee) Information that is exempted from disclosure
20    under Section 30.1 of the Pharmacy Practice Act.
21        (ff) Information that is exempted from disclosure
22    under the Revised Uniform Unclaimed Property Act.
23        (gg) Information that is prohibited from being
24    disclosed under Section 7-603.5 of the Illinois Vehicle
25    Code.
26        (hh) Records that are exempt from disclosure under



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1    Section 1A-16.7 of the Election Code.
2        (ii) Information which is exempted from disclosure
3    under Section 2505-800 of the Department of Revenue Law of
4    the Civil Administrative Code of Illinois.
5        (jj) Information and reports that are required to be
6    submitted to the Department of Labor by registering day and
7    temporary labor service agencies but are exempt from
8    disclosure under subsection (a-1) of Section 45 of the Day
9    and Temporary Labor Services Act.
10        (kk) Information prohibited from disclosure under the
11    Seizure and Forfeiture Reporting Act.
12        (ll) Information the disclosure of which is restricted
13    and exempted under Section 5-30.8 of the Illinois Public
14    Aid Code.
15        (mm) (ll) Records that are exempt from disclosure under
16    Section 4.2 of the Crime Victims Compensation Act.
17        (nn) (ll) Information that is exempt from disclosure
18    under Section 70 of the Higher Education Student Assistance
19    Act.
20        (oo) Information that is exempt from disclosure under
21    subsection (j) of Section 5-36 of the Illinois Public Aid
22    Code.
23(Source: P.A. 99-78, eff. 7-20-15; 99-298, eff. 8-6-15; 99-352,
24eff. 1-1-16; 99-642, eff. 7-28-16; 99-776, eff. 8-12-16;
2599-863, eff. 8-19-16; 100-20, eff. 7-1-17; 100-22, eff. 1-1-18;
26100-201, eff. 8-18-17; 100-373, eff. 1-1-18; 100-464, eff.



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18-28-17; 100-465, eff. 8-31-17; 100-512, eff. 7-1-18; 100-517,
2eff. 6-1-18; 100-646, eff. 7-27-18; 100-690, eff. 1-1-19;
3100-863, eff. 8-14-18; 100-887, eff. 8-14-18; revised
5    Section 5. The State Employees Group Insurance Act of 1971
6is amended by changing Section 6.11 as follows:
7    (5 ILCS 375/6.11)
8    Sec. 6.11. Required health benefits; Illinois Insurance
9Code requirements. The program of health benefits shall provide
10the post-mastectomy care benefits required to be covered by a
11policy of accident and health insurance under Section 356t of
12the Illinois Insurance Code. The program of health benefits
13shall provide the coverage required under Sections 356g,
14356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
15356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
16356z.14, 356z.15, 356z.17, 356z.22, 356z.25, and 356z.26, and
17356z.29, and 356z.32 of the Illinois Insurance Code. The
18program of health benefits must comply with Sections 155.22a,
19155.37, 355b, 356z.19, 370c, and 370c.1, and Article XXXIIB of
20the Illinois Insurance Code. The Department of Insurance shall
21enforce the requirements of this Section.
22    Rulemaking authority to implement Public Act 95-1045, if
23any, is conditioned on the rules being adopted in accordance
24with all provisions of the Illinois Administrative Procedure



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1Act and all rules and procedures of the Joint Committee on
2Administrative Rules; any purported rule not so adopted, for
3whatever reason, is unauthorized.
4(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
5100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
61-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
8    Section 10. The Illinois Insurance Code is amended by
9adding Article XXXIIB as follows:
10    (215 ILCS 5/Art. XXXIIB heading new)

12    (215 ILCS 5/513b1 new)
13    Sec. 513b1. Pharmacy benefit manager contracts.
14    (a) As used in this Section:
15    "Maximum allowable cost" means the per-unit amount that a
16pharmacy benefit manager reimburses a pharmacist for a
17prescription drug, excluding dispensing fees, prior to the
18application of copayments, coinsurance, and other cost-sharing
19charges, if any.
20    "Pharmacy benefit manager" means a person, business, or
21entity, including a wholly or partially owned or controlled
22subsidiary of a pharmacy benefit manager, that provides claims
23processing services or other prescription drug or device



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1services, or both, for health benefit plans.
2    (b) A contract between a health insurer and a pharmacy
3benefit manager must require that the pharmacy benefit manager:
4        (1) Update maximum allowable cost pricing information
5    at least every 7 calendar days.
6        (2) Maintain a process that will, in a timely manner,
7    eliminate drugs from maximum allowable cost lists or modify
8    drug prices to remain consistent with changes in pricing
9    data used in formulating maximum allowable cost prices and
10    product availability.
11    (c) In order to place a particular prescription drug on a
12maximum allowable cost list, the pharmacy benefit manager must,
13at a minimum, ensure that:
14        (1) The drug must have at least 3 or more nationally
15    available, therapeutically equivalent, multiple source
16    generic drugs with a significant cost difference.
17        (2) The products must be listed as therapeutically and
18    pharmaceutically equivalent or "A" or "AB" rated in the
19    Food and Drug Administration's most recent version of the
20    "Orange Book."
21        (3) The product must be available for purchase without
22    limitations by all pharmacies in the State from national or
23    regional wholesalers and not obsolete or temporarily
24    unavailable.
25    (d) A contract between a health insurer and a pharmacy
26benefit manager must prohibit the pharmacy benefit manager from



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1limiting a pharmacist's ability to disclose whether the
2cost-sharing obligation exceeds the retail price for a covered
3prescription drug, and the availability of a more affordable
4alternative drug, in accordance with Section 42 of the Pharmacy
5Practice Act.
6    (e) A contract between a health insurer and a pharmacy
7benefit manager must prohibit the pharmacy benefit manager from
8requiring an insured to make a payment for a prescription drug
9at the point of sale in an amount that exceeds the lesser of:
10        (1) the applicable cost-sharing amount; or
11        (2) the retail price of the drug in the absence of
12    prescription drug coverage.
13    (f) This Section applies to contracts entered into or
14renewed on or after July 1, 2020.
15    (g) This Section applies to any group or individual policy
16of accident and health insurance or managed care plan that
17provides coverage for prescription drugs and that is amended,
18delivered, issued, or renewed on or after July 1, 2020.
19    (215 ILCS 5/513b2 new)
20    Sec. 513b2. Licensure requirements.
21    (a) Beginning on July 1, 2020, to conduct business in this
22State, a pharmacy benefit manager must register with the
23Director. To initially register or renew a registration, a
24pharmacy benefit manager shall submit:
25        (1) A nonrefundable fee not to exceed $500.



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1        (2) A copy of the registrant's corporate charter,
2    articles of incorporation, or other charter document.
3        (3) A completed registration form adopted by the
4    Director containing:
5            (A) The name and address of the registrant.
6            (B) The name, address, and official position of
7        each officer and director of the registrant.
8    (b) The registrant shall report any change in information
9required under this Section to the Director in writing within
1060 days after the change occurs.
11    (c) Upon receipt of a completed registration form, the
12required documents, and the registration fee, the Director
13shall issue a registration certificate. The certificate may be
14in paper or electronic form, and shall clearly indicate the
15expiration date of the registration. Registration certificates
16are nontransferable.
17    (d) A registration certificate is valid for 2 years after
18its date of issue. The Director shall adopt by rule an initial
19registration fee not to exceed $500 and a registration renewal
20fee not to exceed $500, both of which shall be nonrefundable.
21Total fees may not exceed the cost of administering this
23    (e) The Department shall adopt any rules necessary to
24implement this Section.
25    (215 ILCS 5/513b3 new)



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1    Sec. 513b3. Examination.
2    (a) The Director, or his or her designee, may examine a
3registered pharmacy benefit manager.
4    (b) Any pharmacy benefit manager being examined shall
5provide to the Director, or his or her designee, convenient and
6free access to all books, records, documents, and other papers
7relating to such pharmacy benefit manager's business affairs at
8all reasonable hours at its offices.
9    (c) The Director, or his or her designee, may administer
10oaths and thereafter examine any individual about the business
11of the pharmacy benefit manager.
12    (d) The examiners designated by the Director under this
13Section may make reports to the Director. Any report alleging
14substantive violations of this Article, any applicable
15provisions of this Code, or any applicable Part of Title 50 of
16the Illinois Administrative Code shall be in writing and be
17based upon facts obtained by the examiners. The report shall be
18verified by the examiners.
19    (e) If a report is made, the Director shall either deliver
20a duplicate report to the pharmacy benefit manager being
21examined or send such duplicate by certified or registered mail
22to the pharmacy benefit manager's address specified in the
23records of the Department. The Director shall afford the
24pharmacy benefit manager an opportunity to request a hearing to
25object to the report. The pharmacy benefit manager may request
26a hearing within 30 days after receipt of the duplicate report



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1by giving the Director written notice of such request together
2with written objections to the report. Any hearing shall be
3conducted in accordance with Sections 402 and 403 of this Code.
4The right to a hearing is waived if the delivery of the report
5is refused or the report is otherwise undeliverable or the
6pharmacy benefit manager does not timely request a hearing.
7After the hearing or upon expiration of the time period during
8which a pharmacy benefit manager may request a hearing, if the
9examination reveals that the pharmacy benefit manager is
10operating in violation of any applicable provision of this
11Code, any applicable Part of Title 50 of the Illinois
12Administrative Code, a provision of this Article, or prior
13order, the Director, in the written order, may require the
14pharmacy benefit manager to take any action the Director
15considers necessary or appropriate in accordance with the
16report or examination hearing. If the Director issues an order,
17it shall be issued within 90 days after the report is filed, or
18if there is a hearing, within 90 days after the conclusion of
19the hearing. The order is subject to review under the
20Administrative Review Law.
21    (215 ILCS 5/513b4 new)
22    Sec. 513b4. Administrative fine.
23    (a) If the Director finds that one or more grounds exist
24for the revocation or suspension of a registration issued under
25this Article, the Director may, in lieu of or in addition to



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1such suspension or revocation, impose a fine upon the pharmacy
2benefit manager as provided under subsection (b).
3    (b) With respect to any knowing and willful violation of a
4lawful order of the Director, any applicable portion of this
5Code, Part of Title 50 of the Illinois Administrative Code, or
6provision of this Article, the Director may impose a fine upon
7the pharmacy benefit manager in an amount not to exceed $50,000
8for each violation.
9    (215 ILCS 5/513b5 new)
10    Sec. 513b5. Failure to register. Any pharmacy benefit
11manager that operates without a registration or fails to
12register with the Director and pay the fee prescribed by this
13Article is an unauthorized insurer as defined in Article VII of
14this Code and shall be subject to all penalties provided for
16    (215 ILCS 5/513b6 new)
17    Sec. 513b6. Insurance Producer Administration Fund. All
18fees and fines paid to and collected by the Director under this
19Article shall be paid promptly after receipt thereof, together
20with a detailed statement of such fees, into the Insurance
21Producer Administration Fund. The moneys deposited into the
22Insurance Producer Administration Fund may be transferred to
23the Professions Indirect Cost Fund, as authorized under Section
242105-300 of the Department of Professional Regulation Law of



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1the Civil Administrative Code of Illinois.
2    Section 15. The Health Maintenance Organization Act is
3amended by changing Section 5-3 as follows:
4    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
5    Sec. 5-3. Insurance Code provisions.
6    (a) Health Maintenance Organizations shall be subject to
7the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
8141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
9154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
10355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
11356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
12356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
13356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 364,
14364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e,
15370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
16444, and 444.1, paragraph (c) of subsection (2) of Section 367,
17and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV,
18and XXVI, and XXXIIB of the Illinois Insurance Code.
19    (b) For purposes of the Illinois Insurance Code, except for
20Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
21Maintenance Organizations in the following categories are
22deemed to be "domestic companies":
23        (1) a corporation authorized under the Dental Service
24    Plan Act or the Voluntary Health Services Plans Act;



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1        (2) a corporation organized under the laws of this
2    State; or
3        (3) a corporation organized under the laws of another
4    state, 30% or more of the enrollees of which are residents
5    of this State, except a corporation subject to
6    substantially the same requirements in its state of
7    organization as is a "domestic company" under Article VIII
8    1/2 of the Illinois Insurance Code.
9    (c) In considering the merger, consolidation, or other
10acquisition of control of a Health Maintenance Organization
11pursuant to Article VIII 1/2 of the Illinois Insurance Code,
12        (1) the Director shall give primary consideration to
13    the continuation of benefits to enrollees and the financial
14    conditions of the acquired Health Maintenance Organization
15    after the merger, consolidation, or other acquisition of
16    control takes effect;
17        (2)(i) the criteria specified in subsection (1)(b) of
18    Section 131.8 of the Illinois Insurance Code shall not
19    apply and (ii) the Director, in making his determination
20    with respect to the merger, consolidation, or other
21    acquisition of control, need not take into account the
22    effect on competition of the merger, consolidation, or
23    other acquisition of control;
24        (3) the Director shall have the power to require the
25    following information:
26            (A) certification by an independent actuary of the



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1        adequacy of the reserves of the Health Maintenance
2        Organization sought to be acquired;
3            (B) pro forma financial statements reflecting the
4        combined balance sheets of the acquiring company and
5        the Health Maintenance Organization sought to be
6        acquired as of the end of the preceding year and as of
7        a date 90 days prior to the acquisition, as well as pro
8        forma financial statements reflecting projected
9        combined operation for a period of 2 years;
10            (C) a pro forma business plan detailing an
11        acquiring party's plans with respect to the operation
12        of the Health Maintenance Organization sought to be
13        acquired for a period of not less than 3 years; and
14            (D) such other information as the Director shall
15        require.
16    (d) The provisions of Article VIII 1/2 of the Illinois
17Insurance Code and this Section 5-3 shall apply to the sale by
18any health maintenance organization of greater than 10% of its
19enrollee population (including without limitation the health
20maintenance organization's right, title, and interest in and to
21its health care certificates).
22    (e) In considering any management contract or service
23agreement subject to Section 141.1 of the Illinois Insurance
24Code, the Director (i) shall, in addition to the criteria
25specified in Section 141.2 of the Illinois Insurance Code, take
26into account the effect of the management contract or service



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1agreement on the continuation of benefits to enrollees and the
2financial condition of the health maintenance organization to
3be managed or serviced, and (ii) need not take into account the
4effect of the management contract or service agreement on
6    (f) Except for small employer groups as defined in the
7Small Employer Rating, Renewability and Portability Health
8Insurance Act and except for medicare supplement policies as
9defined in Section 363 of the Illinois Insurance Code, a Health
10Maintenance Organization may by contract agree with a group or
11other enrollment unit to effect refunds or charge additional
12premiums under the following terms and conditions:
13        (i) the amount of, and other terms and conditions with
14    respect to, the refund or additional premium are set forth
15    in the group or enrollment unit contract agreed in advance
16    of the period for which a refund is to be paid or
17    additional premium is to be charged (which period shall not
18    be less than one year); and
19        (ii) the amount of the refund or additional premium
20    shall not exceed 20% of the Health Maintenance
21    Organization's profitable or unprofitable experience with
22    respect to the group or other enrollment unit for the
23    period (and, for purposes of a refund or additional
24    premium, the profitable or unprofitable experience shall
25    be calculated taking into account a pro rata share of the
26    Health Maintenance Organization's administrative and



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1    marketing expenses, but shall not include any refund to be
2    made or additional premium to be paid pursuant to this
3    subsection (f)). The Health Maintenance Organization and
4    the group or enrollment unit may agree that the profitable
5    or unprofitable experience may be calculated taking into
6    account the refund period and the immediately preceding 2
7    plan years.
8    The Health Maintenance Organization shall include a
9statement in the evidence of coverage issued to each enrollee
10describing the possibility of a refund or additional premium,
11and upon request of any group or enrollment unit, provide to
12the group or enrollment unit a description of the method used
13to calculate (1) the Health Maintenance Organization's
14profitable experience with respect to the group or enrollment
15unit and the resulting refund to the group or enrollment unit
16or (2) the Health Maintenance Organization's unprofitable
17experience with respect to the group or enrollment unit and the
18resulting additional premium to be paid by the group or
19enrollment unit.
20    In no event shall the Illinois Health Maintenance
21Organization Guaranty Association be liable to pay any
22contractual obligation of an insolvent organization to pay any
23refund authorized under this Section.
24    (g) Rulemaking authority to implement Public Act 95-1045,
25if any, is conditioned on the rules being adopted in accordance
26with all provisions of the Illinois Administrative Procedure



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1Act and all rules and procedures of the Joint Committee on
2Administrative Rules; any purported rule not so adopted, for
3whatever reason, is unauthorized.
4(Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17;
5100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff.
68-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
8    Section 20. The Managed Care Reform and Patient Rights Act
9is amended by changing Sections 30 and 65 as follows:
10    (215 ILCS 134/30)
11    Sec. 30. Prohibitions.
12    (a) No health care plan or its subcontractors may prohibit
13or discourage health care providers by contract or policy from
14discussing any health care services and health care providers,
15utilization review and quality assurance policies, terms and
16conditions of plans and plan policy with enrollees, prospective
17enrollees, providers, or the public.
18    (b) No health care plan by contract, written policy, or
19procedure may permit or allow an individual or entity to
20dispense a different drug in place of the drug or brand of drug
21ordered or prescribed without the express permission of the
22person ordering or prescribing the drug, except as provided
23under Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
24    (c) No health care plan or its subcontractors may by



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1contract, written policy, procedure, or otherwise mandate or
2require an enrollee to substitute his or her participating
3primary care physician under the plan during inpatient
4hospitalization, such as with a hospitalist physician licensed
5to practice medicine in all its branches, without the agreement
6of that enrollee's participating primary care physician.
7"Participating primary care physician" for health care plans
8and subcontractors that do not require coordination of care by
9a primary care physician means the participating physician
10treating the patient. All health care plans shall inform
11enrollees of any policies, recommendations, or guidelines
12concerning the substitution of the enrollee's primary care
13physician when hospitalization is necessary in the manner set
14forth in subsections (d) and (e) of Section 15.
15    (d) A health care plan shall apply any third-party
16payments, financial assistance, discount, product vouchers, or
17any other reduction in out-of-pocket expenses made by or on
18behalf of such insured for prescription drugs toward a covered
19individual's deductible, copay, or cost-sharing
20responsibility, or out-of-pocket maximum associated with the
21individual's health insurance.
22    (e) (d) Any violation of this Section shall be subject to
23the penalties under this Act.
24(Source: P.A. 94-866, eff. 6-16-06.)
25    (215 ILCS 134/65)



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1    Sec. 65. Emergency services prior to stabilization.
2    (a) A health care plan that provides or that is required by
3law to provide coverage for emergency services shall provide
4coverage such that payment under this coverage is not dependent
5upon whether the services are performed by a plan or non-plan
6health care provider and without regard to prior authorization.
7This coverage shall be at the same benefit level as if the
8services or treatment had been rendered by the health care plan
9physician licensed to practice medicine in all its branches or
10health care provider.
11    (b) Prior authorization or approval by the plan shall not
12be required for emergency services.
13    (c) Coverage and payment shall only be retrospectively
14denied under the following circumstances:
15        (1) upon reasonable determination that the emergency
16    services claimed were never performed;
17        (2) upon timely determination that the emergency
18    evaluation and treatment were rendered to an enrollee who
19    sought emergency services and whose circumstance did not
20    meet the definition of emergency medical condition; any
21    denial under this paragraph (2) shall be based on the
22    prudent layperson standard at the time the enrollee first
23    sought emergency evaluation and treatment for his or her
24    symptoms; insurers are prohibited from denying claims
25    under this paragraph (2) based on the use of diagnosis or
26    procedure codes;



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1        (3) upon determination that the patient receiving such
2    services was not an enrollee of the health care plan; or
3        (4) upon material misrepresentation by the enrollee or
4    health care provider; "material" means a fact or situation
5    that is not merely technical in nature and results or could
6    result in a substantial change in the situation.
7    (d) When an enrollee presents to a hospital seeking
8emergency services, the determination as to whether the need
9for those services exists shall be made for purposes of
10treatment by a physician licensed to practice medicine in all
11its branches or, to the extent permitted by applicable law, by
12other appropriately licensed personnel under the supervision
13of or in collaboration with a physician licensed to practice
14medicine in all its branches. The physician or other
15appropriate personnel shall indicate in the patient's chart the
16results of the emergency medical screening examination.
17    (e) The appropriate use of the 911 emergency telephone
18system or its local equivalent shall not be discouraged or
19penalized by the health care plan when an emergency medical
20condition exists. This provision shall not imply that the use
21of 911 or its local equivalent is a factor in determining the
22existence of an emergency medical condition.
23    (f) The medical director's or his or her designee's
24determination of whether the enrollee meets the standard of an
25emergency medical condition shall be based solely upon the
26presenting symptoms documented in the medical record at the



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1time care was sought. Only a clinical peer may make an adverse
3    (g) Nothing in this Section shall prohibit the imposition
4of deductibles, copayments, and co-insurance. Nothing in this
5Section alters the prohibition on billing enrollees contained
6in the Health Maintenance Organization Act.
7(Source: P.A. 91-617, eff. 1-1-00.)
8    Section 25. The Pharmacy Practice Act is amended by adding
9Section 42 as follows:
10    (225 ILCS 85/42 new)
11    Sec. 42. Information disclosure. A pharmacist or her or his
12authorized employee must inform customers of a less expensive,
13generically equivalent drug product for her or his prescription
14and whether the cost-sharing obligation to the customer exceeds
15the retail price of the prescription in the absence of
16prescription drug coverage.
17    Section 30. The Illinois Public Aid Code is amended by
18adding Section 5-36 as follows:
19    (305 ILCS 5/5-36 new)
20    Sec. 5-36. Pharmacy benefits.
21    (a)(1) The Department may enter into a contract with any
22third party on a fee-for-service reimbursement model for the



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1purpose of administering pharmacy benefits as provided in this
2Section; however, these services shall be approved by the
3Department. The Department shall ensure coordination of care
4between the third-party administrator and managed care
5organizations as a consideration in any contracts established
6in accordance with this Section. Any managed care techniques,
7principles, or administration of benefits utilized in
8accordance with this subsection shall comply with State law.
9    (2) The following shall apply to contracts between entities
10contracting relating to third-party administrators and
12        (A) the Department shall approve any contract between a
13    third-party administrator and a pharmacy;
14        (B) a third-party administrator shall not change the
15    terms of a contract between a third-party administrator and
16    a pharmacy without written approval by the Department; and
17        (C) a third-party administrator shall not create,
18    modify, implement, or indirectly establish any fee on a
19    pharmacy, pharmacist, or a recipient of medical assistance
20    without written approval by the Department.
21    (b) The provisions of this Section shall not apply to
22outpatient pharmacy services provided by a health care facility
23registered as a covered entity pursuant to 42 U.S.C. 256b or
24any pharmacy owned by or contracted with the covered entity. A
25Medicaid managed care organization shall, either directly or
26through a pharmacy benefit manager, administer and reimburse



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1outpatient pharmacy claims submitted by a health care facility
2registered as a covered entity pursuant to 42 U.S.C. 256b, its
3owned pharmacies, and contracted pharmacies in accordance with
4the contractual agreements the Medicaid managed care
5organization or its pharmacy benefit manager has with such
6facilities and pharmacies. A Medicaid managed care
7organization or its pharmacy benefit manager shall not exclude
8any health care facility registered as a covered entity
9pursuant to 42 U.S.C. 256b from its pharmacy network. Any
10pharmacy benefit manager that contracts with a Medicaid managed
11care organization to administer and reimburse outpatient
12pharmacy claims as provided in this Section must be registered
13with the Director of Insurance in accordance with Section 513b2
14of the Illinois Insurance Code.
15    (c) On at least an annual basis, the Director of the
16Department of Healthcare and Family Services shall submit a
17report beginning no later than one year after the effective
18date of this amendatory Act of the 101st General Assembly to
19the House and Senate Human Services Committees and the House
20and Senate Financial Institutions Committees that provides an
21update on any contract, contract issues, formulary, dispensing
22fees, and maximum allowable cost concerns regarding a
23third-party administrator and managed care.
24    (d) A pharmacy benefit manager shall notify the Department
25in writing of any activity, policy, or practice of the pharmacy
26benefit manager that directly or indirectly presents a conflict



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1of interest that interferes with the discharge of the pharmacy
2benefit manager's duty to a managed care organization to
3exercise its contractual duties.
4    (e) A pharmacy benefit manager shall, upon request,
5disclose to the Department the following information:
6        (1) whether the pharmacy benefit manager has a
7    contract, agreement, or other arrangement with a
8    pharmaceutical manufacturer to exclusively dispense or
9    provide a drug to a managed care organization's enrollees,
10    and the application of all consideration or economic
11    benefits collected or received pursuant to that
12    arrangement;
13        (2) the percentage of claims payments made by the
14    pharmacy benefit manager to pharmacies owned, managed, or
15    controlled by the pharmacy benefit manager or any of the
16    pharmacy benefit manager's management companies, parent
17    companies, subsidiary companies, jointly held companies,
18    or companies otherwise affiliated by a common owner,
19    manager, or holding company for the previous year;
20        (3) the aggregate amount of the fees or assessments
21    imposed on, or collected from, pharmacy providers; and
22        (4) the average annualized percentage of revenue
23    collected by the pharmacy benefit manager as a result of
24    each contract it has executed with a managed care
25    organization contracted by the Department to provide
26    medical assistance benefits which is not paid by the



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1    pharmacy benefit manager to pharmacy providers and
2    pharmaceutical manufacturers or labelers or in order to
3    perform administrative functions pursuant to its contracts
4    with managed care organizations.
5    (f) The information disclosed under subsection (e) shall
6include all retail, mail order, specialty, and compounded
7prescription products. All information made available to the
8Department under subsection (e) is confidential and not subject
9to disclosure under the Freedom of Information Act.
10    (g) A pharmacy benefit manager shall disclose directly in
11writing to a pharmacy provider contracting with the pharmacy
12benefit manager of any material change to a contract provision
13that affects the terms of the reimbursement, the process for
14verifying benefits and eligibility, dispute resolution,
15procedures for verifying drugs included on the formulary, and
16contract termination at least 30 days prior to the date of the
17change to the provision.
18    (h) A pharmacy benefit manager shall not include the
19following in a contract with a pharmacy provider:
20        (1) a provision prohibiting the provider from
21    informing a patient of a less costly alternative to a
22    prescribed medication; or
23        (2) a provision that prohibits the provider from
24    dispensing a particular amount of a prescribed medication,
25    if the pharmacy benefit manager allows that amount to be
26    dispensed through a pharmacy owned or controlled by the



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1    pharmacy benefit manager, unless the prescription drug is
2    subject to restricted distribution by the United States
3    Food and Drug Administration or requires special handling,
4    provider coordination, or patient education that cannot be
5    provided by a retail pharmacy.
6    (i) Nothing in this Section shall be construed to prohibit
7a pharmacy benefit manager from requiring the same
8reimbursement and terms and conditions for a pharmacy provider
9as for a pharmacy owned, controlled, or otherwise associated
10with the pharmacy benefit manager.
11    (j) A pharmacy benefit manager shall establish and
12implement a process for the resolution of disputes arising out
13of this Section, which shall be approved by the Department.
14    (k) The Department shall adopt rules establishing
15reasonable dispensing fees in accordance with guidance or
16guidelines from the federal Centers for Medicare and Medicaid
18    Section 97. Severability. If any provision of this Act or
19the application of this Act to any person or circumstance is
20held invalid, the invalidity shall not affect other provisions
21or applications of this Act which can be given effect without
22the invalid provision or application, and to this end, the
23provisions of this Act are declared severable.".