State of Illinois
92nd General Assembly
Legislation

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92_SB1822

 
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 1        AN ACT in relation to public aid.

 2        Be  it  enacted  by  the People of the State of Illinois,
 3    represented in the General Assembly:

 4        Section 5. The Illinois Public Aid  Code  is  amended  by
 5    adding Sections 5-23 through 5-23.50 as follows:

 6        (305 ILCS 5/5-23 new)
 7        Sec. 5-23. Prescribed-drug spending-control program.
 8        (a)  Subject  to appropriations, the Department of Public
 9    Aid    shall    establish    a    Medicaid    prescribed-drug
10    spending-control  program  that   includes   the   components
11    described in Sections 5-23.5 through 5-23.50.
12        (b)  The Department of Public Aid may contract all or any
13    part of the implementation of  the  Medicaid  prescribed-drug
14    spending-control    program    to    private   organizations.
15    Notwithstanding any other provision of law,  the  Department,
16    at  its  discretion,  may  renew  a contract or contracts for
17    fiscal intermediary services one or more  times  for  periods
18    determined  by the Department. All such renewals combined may
19    not exceed a  total  period  longer  than  the  term  of  the
20    original contract, however.

21        (305 ILCS 5/5-23.5 new)
22        Sec. 5-23.5. Brand-name-drug restriction.
23        (a)  Except  as otherwise provided in this Section and in
24    Section  5-23.10,  Medicaid  prescribed-drug   coverage   for
25    brand-name  drugs for adult Medicaid recipients is limited to
26    the dispensing of 4 brand-name drugs per month per recipient.
27    Children are exempt  from  this  restriction.  Antiretroviral
28    agents are excluded from this restriction. No requirement for
29    prior authorization or other restrictions on medications used
30    to  treat  mental  illnesses  such  as  schizophrenia, severe
 
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 1    depression, or bipolar disorder may be  imposed  on  Medicaid
 2    recipients.   Medications  that  must  be  available  without
 3    restriction  for  persons  with  mental   illnesses   include
 4    atypical      antipsychotic     medications,     conventional
 5    antipsychotic  medications,  selective   serotonin   reuptake
 6    inhibitors,  and  other medications used for the treatment of
 7    serious mental illnesses. Although a drug may be included  on
 8    the  preferred  drug  formulary,  it  is  not exempt from the
 9    4-brand-name-drug limit.
10        (b) The Department of Public Aid shall limit  the  amount
11    of  a  prescribed  drug  dispensed  to  no more than a 34-day
12    supply.
13        (c) The Department of Public Aid must continue to provide
14    unlimited generic drugs, contraceptive drugs and  items,  and
15    diabetic supplies.
16        (d) After the Department of Public Aid adopts a preferred
17    drug  formulary  under  Section  5-23.30, if a product in the
18    formulary is one of the first 4 brand-name drugs  used  by  a
19    recipient  in  a  month,  reimbursement  for  the drug is not
20    subject to prior authorization under Section 5-23.20.

21        (305 ILCS 5/5-23.10 new)
22        Sec. 5-23.10.  Exception  based  on  patient's  treatment
23    needs.   The  Department  of  Public  Aid  may  authorize  an
24    exception to the brand-name-drug  restriction  under  Section
25    5-23.5  based  on a patient's treatment needs. The Department
26    may authorize such an exception only if it is based on  prior
27    consultation  provided  by  the  Department  or  a Department
28    contractor.  The  Department  must  establish  procedures  to
29    ensure the following:
30             (1) There must be a response to a request for  prior
31        consultation  by  telephone  or  other  telecommunication
32        device within 24 hours after receipt of the request.
33             (2)  A 72-hour supply of the drug prescribed must be
 
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 1        provided in an emergency or when the Department of Public
 2        Aid does not  provide  a  response  within  24  hours  as
 3        required by paragraph (1).
 4             (3)  Except  for  the  exception  for  nursing  home
 5        residents   and   other  institutionalized  adults  under
 6        Section 5-23.20 and except for drugs  on  the  restricted
 7        formulary  for which prior authorization may be sought by
 8        an   institutional   or   community    pharmacy,    prior
 9        authorization  for  an  exception  to the brand-name-drug
10        restriction may be sought only by the prescriber and  not
11        by   the   pharmacy.  When  prior  authorization  for  an
12        exception to the brand-name-drug restriction  is  granted
13        for  a  patient in an institutional setting, the approval
14        is  authorized  for   12   months   and   monthly   prior
15        authorization is not required for that patient.

16        (305 ILCS 5/5-23.15 new)
17        Sec.  5-23.15.  Reimbursement  rate for prescribed drugs.
18    Medicaid reimbursements to pharmacies  for  prescribed  drugs
19    must be set at the average wholesale price less 13.25%.

20        (305 ILCS 5/5-23.20 new)
21        Sec. 5-23.20. Prior authorization.
22        (a)    Except    for    mental    health-related   drugs,
23    anti-retroviral drugs, and drugs for nursing  home  residents
24    and  other  institutional  residents, reimbursement for drugs
25    not included  in  the  formulary  established  under  Section
26    5-23.30 is subject to prior authorization.
27        (b)  The  Department  of  Public  Aid may establish prior
28    authorization  requirements  for   certain   populations   of
29    Medicaid  beneficiaries,  certain drug classes, or particular
30    drugs  to  prevent  fraud,  abuse,  overuse,   and   possible
31    dangerous drug interactions.
32        (c)   The   Medicaid   Pharmaceutical   and  Therapeutics
 
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 1    Committee  created   under   Section   5-23.35   shall   make
 2    recommendations  to  the  Department  of Public Aid regarding
 3    drugs  for  which  prior  authorization  is   required.   The
 4    Department  shall  inform  the  committee of the Department's
 5    decisions regarding drugs subject to prior authorization.

 6        (305 ILCS 5/5-23.25 new)
 7        Sec. 5-23.25. Manufacturer rebates for generic drugs. The
 8    Department of Public Aid may enter  into  arrangements  under
 9    which  manufacturers  of generic drugs prescribed to Medicaid
10    recipients must provide rebates of  at  least  15.1%  of  the
11    average  manufacturer  price  for  the manufacturer's generic
12    products.  These  arrangements  must  require   that   if   a
13    generic-drug    manufacturer   pays   federal   rebates   for
14    Medicaid-reimbursed  drugs  at  a  level  below  15.1%,   the
15    manufacturer  must provide a supplemental rebate to the State
16    in an amount necessary to achieve a 15.1% rebate level.

17        (305 ILCS 5/5-23.30 new)
18        Sec.  5-23.30.  Preferred  drug  formulary;  supplemental
19    rebates.
20        (a)  The  Department  of  Public  Aid  may  establish   a
21    preferred   drug  formulary  in  accordance  with  42  U.S.C.
22    1396r-8. In establishing the formulary,  the  Department  may
23    negotiate supplemental rebates from manufacturers that are in
24    addition  to  those  required  by  Title  XIX  of  the Social
25    Security  Act  and  at  no  less  than  10%  of  the  average
26    manufacturer price as defined in 42  U.S.C.  1396r-8  on  the
27    last  day  of  a  quarter  unless the federal or supplemental
28    rebate, or both, equals or exceeds 25%.  There  is  no  upper
29    limit   on   the  supplemental  rebates  the  Department  may
30    negotiate.  The  Department  may  determine   that   specific
31    products,  brand-name  or  generic,  are competitive at lower
32    rebate percentages.  The  Department  may  contract  with  an
 
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 1    outside  agency  or  contractor  to  conduct negotiations for
 2    supplemental rebates.
 3        (b) Agreement to  pay  the  minimum  supplemental  rebate
 4    percentage  shall  guarantee a manufacturer that the Medicaid
 5    Pharmaceutical  and  Therapeutics  Committee  created   under
 6    Section  5-23.35 will consider a product for inclusion in the
 7    preferred drug formulary. A  pharmaceutical  manufacturer  is
 8    not guaranteed placement of a drug in the formulary simply by
 9    paying  the  minimum supplemental rebate, however. Department
10    of Public  Aid  decisions  must  be  based  on  the  clinical
11    efficacy  of  a  drug  and  recommendations  of  the Medicaid
12    Pharmaceutical and Therapeutics Committee,  as  well  as  the
13    price of competing products minus federal and State rebates.
14        (c)  In this Section, "supplemental rebates" may include,
15    at the Department of Public Aid's  discretion,  cash  rebates
16    and   other   program   benefits   that   offset  a  Medicaid
17    expenditure. Those other program benefits  may  include,  but
18    need  not  be  limited  to, disease management programs, drug
19    product donation programs, drug utilization control programs,
20    prescriber and beneficiary counseling  and  education,  fraud
21    and  abuse  initiatives, and other services or administrative
22    investments with guaranteed savings to the  Medicaid  program
23    in the same year that the rebate reduction is included in the
24    appropriation to the Department for operation of the Medicaid
25    program.
26        (d)  The  Department of Public Aid shall seek any waivers
27    of federal law or regulations  necessary  to  implement  this
28    Section.
29        (e)  A  Medicaid  recipient  may appeal a decision of the
30    Department  of  Public  Aid  concerning  the  preferred  drug
31    formulary in the same manner as the appeal of other decisions
32    of the Department under this Article.
33        (f) The  Department  of  Public  Aid  shall  publish  and
34    disseminate  the  preferred  drug  formulary  to all Medicaid
 
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 1    vendors in the State.

 2        (305 ILCS 5/5-23.35 new)
 3        Sec. 5-23.35. Medicaid  Pharmaceutical  and  Therapeutics
 4    Committee.
 5        (a)   The   Medicaid   Pharmaceutical   and  Therapeutics
 6    Committee is created within the Department of Public Aid  for
 7    the purpose of developing a preferred drug formulary under 42
 8    U.S.C. 1396r-8. The committee shall be comprised as specified
 9    in  42  U.S.C.  1396r-8  and  shall  consist  of  11  members
10    appointed  by  the  Governor. Five members must be physicians
11    licensed to practice medicine in all of its branches, one  of
12    whom  must  possess  the  degree  of  doctor of osteopathy or
13    osteopathic medicine; 5 members must be pharmacists  licensed
14    under  the Pharmacy Practice Act of 1987; and one member must
15    be a consumer representative. The Governor shall ensure  that
16    at  least  some  of  the  members  of the committee represent
17    Medicaid participating physicians and pharmacies serving  all
18    segments  and  diversity of the Medicaid population, and have
19    experience  in  either  developing  or  practicing  under   a
20    preferred  drug  formulary.  At least one of the members must
21    represent the interests of pharmaceutical manufacturers.
22        The Governor shall appoint members to serve for terms  of
23    2  years from the date of their appointment. The Governor may
24    appoint members to more than one term.
25        (b) Committee members shall select a  chairperson  and  a
26    vice chairperson each year from the committee membership.
27        (c)  The committee shall meet at least once each calendar
28    quarter and may meet at other times at the discretion of  the
29    chairperson  and  members.  The  committee  shall comply with
30    rules adopted by the  Department  of  Public  Aid,  including
31    rules  for  providing  notice  of  any  committee meetings as
32    required under the Open Meetings Act.
33        (d) The Department of Public Aid shall provide staff  for
 
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 1    the  committee  and  shall  assist  the  committee  with  all
 2    ministerial duties.

 3        (305 ILCS 5/5-23.40 new)
 4        Sec. 5-23.40. Committee; preferred drug formulary.
 5        (a)   The   Medicaid   Pharmaceutical   and  Therapeutics
 6    Committee  shall  develop  its   preferred   drug   formulary
 7    recommendations by considering the clinical efficacy, safety,
 8    and  cost effectiveness of a product. To the extent feasible,
 9    the committee shall review all drug classes included  in  the
10    preferred  drug  formulary  at  least  every  12  months. The
11    committee may recommend additions to and deletions  from  the
12    formulary  so  that  the  formulary  provides  for  medically
13    appropriate   drug  therapies  for  Medicaid  patients  which
14    achieve cost  savings  contained  in  appropriations  to  the
15    Department  of  Public  Aid  for  operation  of  the Medicaid
16    program.
17        (b)  The   Medicaid   Pharmaceutical   and   Therapeutics
18    Committee  shall  ensure  that  pharmaceutical  manufacturers
19    agreeing  to  provide  a  supplemental  rebate as provided in
20    Section 5-23.30  have  an  opportunity  to  present  evidence
21    supporting  inclusion  of  a  product  in  the preferred drug
22    formulary. Upon timely notice, the Department of  Public  Aid
23    shall  ensure that any drug that has been approved or had any
24    of its particular uses approved by the United States Food and
25    Drug Administration under a priority review classification is
26    reviewed by the committee at the committee's  next  regularly
27    scheduled  meeting.  To the extent possible, upon notice by a
28    manufacturer, the Department shall also  schedule  a  product
29    review  for any new product at the committee's next regularly
30    scheduled meeting.

31        (305 ILCS 5/5-23.45 new)
32        Sec.  5-23.45.  Advisory   committee;   institutionalized
 
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 1    persons.  The  Department  of  Public  Aid shall establish an
 2    advisory committee  to  study  the  feasibility  of  using  a
 3    restricted  drug  formulary  for  nursing  home residents and
 4    other  institutionalized  adults.  The  committee  shall   be
 5    comprised  of  7  members appointed by the Director of Public
 6    Aid.   The  committee  members  must  include  2   physicians
 7    licensed  to  practice  medicine in all of its branches and 5
 8    pharmacists licensed under the Pharmacy Practice Act of 1987.
 9    Three of the pharmacists must be appointed  from  a  list  of
10    recommendations   provided   by   a   statewide  organization
11    representing pharmacists who provide pharmacy services  in  a
12    long-term care setting.

13        (305 ILCS 5/5-23.50 new)
14        Sec.  5-23.50.  Report. The Department of Public Aid must
15    submit a report to the Governor, the President of the Senate,
16    and the Speaker of the House of Representatives by January 15
17    of each year. The  report  must  include,  but  need  not  be
18    limited to, a discussion of the progress made in implementing
19    Medicaid   cost-containment  measures  and  their  effect  on
20    Medicaid prescribed-drug expenditures.

21        Section 99. Effective date. This Act  takes  effect  upon
22    becoming law.

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