103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1348 Introduced , by Rep. Lakesia Collins SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.60 new215 ILCS 5/513b7 new Amends the Illinois Insurance Code. Provides that no later than July 1, 2024, each health plan and pharmacy benefit manager operating in this State shall, upon request of a covered individual, his or her health care provider, or an authorized third party on his or her behalf, furnish specified cost, benefit, and coverage data to the covered individual, his or her health care provider, or the third party of his or her choosing and shall ensure that the data is: (1) current no later than one business day after any change is made; (2) provided in real time; and (3) in a format that is easily accessible to the covered individual or, in the case of his or her health care provider, through an electronic health records system. Provides that the format of the request shall use specified industry content and transport standards. Provides that a facsimile is not an acceptable electronic format. Provides that upon request, specified data shall be provided for any drug covered under the covered individual's health plan. Makes other changes. Defines terms. LRB103 05999 BMS 51023 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1348 Introduced , by Rep. Lakesia Collins SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.60 new215 ILCS 5/513b7 new 215 ILCS 5/356z.60 new 215 ILCS 5/513b7 new Amends the Illinois Insurance Code. Provides that no later than July 1, 2024, each health plan and pharmacy benefit manager operating in this State shall, upon request of a covered individual, his or her health care provider, or an authorized third party on his or her behalf, furnish specified cost, benefit, and coverage data to the covered individual, his or her health care provider, or the third party of his or her choosing and shall ensure that the data is: (1) current no later than one business day after any change is made; (2) provided in real time; and (3) in a format that is easily accessible to the covered individual or, in the case of his or her health care provider, through an electronic health records system. Provides that the format of the request shall use specified industry content and transport standards. Provides that a facsimile is not an acceptable electronic format. Provides that upon request, specified data shall be provided for any drug covered under the covered individual's health plan. Makes other changes. Defines terms. LRB103 05999 BMS 51023 b LRB103 05999 BMS 51023 b A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1348 Introduced , by Rep. Lakesia Collins SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.60 new215 ILCS 5/513b7 new 215 ILCS 5/356z.60 new 215 ILCS 5/513b7 new
215 ILCS 5/356z.60 new
215 ILCS 5/513b7 new
Amends the Illinois Insurance Code. Provides that no later than July 1, 2024, each health plan and pharmacy benefit manager operating in this State shall, upon request of a covered individual, his or her health care provider, or an authorized third party on his or her behalf, furnish specified cost, benefit, and coverage data to the covered individual, his or her health care provider, or the third party of his or her choosing and shall ensure that the data is: (1) current no later than one business day after any change is made; (2) provided in real time; and (3) in a format that is easily accessible to the covered individual or, in the case of his or her health care provider, through an electronic health records system. Provides that the format of the request shall use specified industry content and transport standards. Provides that a facsimile is not an acceptable electronic format. Provides that upon request, specified data shall be provided for any drug covered under the covered individual's health plan. Makes other changes. Defines terms.
LRB103 05999 BMS 51023 b LRB103 05999 BMS 51023 b
LRB103 05999 BMS 51023 b
A BILL FOR
HB1348LRB103 05999 BMS 51023 b HB1348 LRB103 05999 BMS 51023 b
HB1348 LRB103 05999 BMS 51023 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5 adding Sections 356z.60 and 513b7 as follows:
6 (215 ILCS 5/356z.60 new)
7 Sec. 356z.60. Patient prescription pricing transparency.
8 (a) As used in this Section:
9 "Authorized third party" includes a third party legally
10 authorized under State or federal law subject to a Health
11 Insurance Portability and Accountability Act of 1996 business
12 associate agreement.
13 "Cost-sharing information" means the amount a covered
14 individual is required to pay to receive a drug that is covered
15 under the covered individual's health plan.
16 "Coverage" means those health care services to which a
17 covered individual is entitled under the terms of the health
18 plan.
19 "Electronic health record" means a digital version of a
20 patient's paper chart and medical history that makes
21 information available instantly and securely to authorized
22 users.
23 "Electronic prescribing system" means a system that
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB1348 Introduced , by Rep. Lakesia Collins SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.60 new215 ILCS 5/513b7 new 215 ILCS 5/356z.60 new 215 ILCS 5/513b7 new
215 ILCS 5/356z.60 new
215 ILCS 5/513b7 new
Amends the Illinois Insurance Code. Provides that no later than July 1, 2024, each health plan and pharmacy benefit manager operating in this State shall, upon request of a covered individual, his or her health care provider, or an authorized third party on his or her behalf, furnish specified cost, benefit, and coverage data to the covered individual, his or her health care provider, or the third party of his or her choosing and shall ensure that the data is: (1) current no later than one business day after any change is made; (2) provided in real time; and (3) in a format that is easily accessible to the covered individual or, in the case of his or her health care provider, through an electronic health records system. Provides that the format of the request shall use specified industry content and transport standards. Provides that a facsimile is not an acceptable electronic format. Provides that upon request, specified data shall be provided for any drug covered under the covered individual's health plan. Makes other changes. Defines terms.
LRB103 05999 BMS 51023 b LRB103 05999 BMS 51023 b
LRB103 05999 BMS 51023 b
A BILL FOR
215 ILCS 5/356z.60 new
215 ILCS 5/513b7 new
LRB103 05999 BMS 51023 b
HB1348 LRB103 05999 BMS 51023 b
HB1348- 2 -LRB103 05999 BMS 51023 b HB1348 - 2 - LRB103 05999 BMS 51023 b
HB1348 - 2 - LRB103 05999 BMS 51023 b
1 enables prescribers to enter prescription information into a
2 computer prescription device and securely transmit the
3 prescription to pharmacies using a special software program
4 and connectivity to a transmission network.
5 "Prescriber" means a health care provider licensed to
6 prescribe medication or medical devices in this State.
7 "Real-time benefit tool" means an electronic prescription
8 decision support tool that (i) is capable of integrating with
9 prescribers' electronic prescribing and, if feasible,
10 electronic health record systems; and (ii) complies with the
11 technical standards adopted by an American National Standards
12 Institute accredited standards development organization.
13 (b) No later than July 1, 2024, each health plan operating
14 in this State shall, upon request of a covered individual, his
15 or her health care provider, or an authorized third party on
16 his or her behalf, furnish the cost, benefit, and coverage
17 data required under this Section to the covered individual,
18 his or her health care provider, or the third party of his or
19 her choosing and shall ensure that the data is:
20 (1) current no later than one business day after any
21 change is made;
22 (2) provided in real time; and
23 (3) in a format that is easily accessible to the
24 covered individual or, in the case of his or her health
25 care provider, through an electronic health records
26 system.
HB1348 - 2 - LRB103 05999 BMS 51023 b
HB1348- 3 -LRB103 05999 BMS 51023 b HB1348 - 3 - LRB103 05999 BMS 51023 b
HB1348 - 3 - LRB103 05999 BMS 51023 b
1 (c) The format of the request shall use established
2 industry content and transport standards published by:
3 (1) a standards developing organization accredited by
4 the American National Standards Institute, including the
5 National Council for Prescription Drug Programs,
6 Accredited Standards Committee X12, and Health Level 7;
7 (2) a relevant federal or state governing body,
8 including the Centers for Medicare & Medicaid Services or
9 the Office of the National Coordinator for Health
10 Information Technology; or
11 (3) another format deemed acceptable to the Department
12 that provides the data described in subsection (a) and
13 with the same timeliness as required by this Section.
14 (d) A facsimile is not an acceptable electronic format
15 under this Section.
16 (e) Upon request, the following data shall be provided for
17 any drug covered under the covered individual's health plan:
18 (1) patient-specific eligibility information;
19 (2) patient-specific prescription cost and benefit
20 data, such as applicable formulary, benefit, coverage and
21 cost-sharing data for the prescribed drug, and clinically
22 appropriate alternatives, when appropriate;
23 (3) patient-specific cost-sharing information that
24 describes variance in cost sharing based on the pharmacy
25 dispensing the prescribed drug or its alternatives, and in
26 relation to the patient's benefit, such as spending
HB1348 - 3 - LRB103 05999 BMS 51023 b
HB1348- 4 -LRB103 05999 BMS 51023 b HB1348 - 4 - LRB103 05999 BMS 51023 b
HB1348 - 4 - LRB103 05999 BMS 51023 b
1 related to the out-of-pocket maximum;
2 (4) information regarding lower cost clinically
3 appropriate treatment alternatives; and
4 (5) applicable utilization management requirements.
5 (f) Any health plan shall furnish the data as required
6 whether the request is made using the drug's unique billing
7 code, such as a National Drug Code or Healthcare Common
8 Procedure Coding System code, or descriptive term. A health
9 plan shall not deny or unreasonably delay a request as a method
10 of blocking the required data from being shared based on how
11 the drug was requested.
12 (g) A health plan shall not restrict, prohibit, or
13 otherwise hinder the prescriber from communicating or sharing
14 benefit and coverage information that reflects other choices,
15 such as cash price, lower cost clinically appropriate
16 alternatives, whether or not they are covered under the
17 covered individual's plan and support programs, and the cost
18 available at the patient's pharmacy of choice.
19 (h) A health plan shall not, except as may be required by
20 law, interfere with, prevent, or materially discourage access,
21 exchange, or use of the data as required, which may include
22 charging fees or not responding to a request for such data in a
23 reasonable time frame; nor penalize a health care provider or
24 professional for disclosing such information to a covered
25 individual or legally prescribing, administering, or ordering
26 a clinically appropriate or lower cost alternative.
HB1348 - 4 - LRB103 05999 BMS 51023 b
HB1348- 5 -LRB103 05999 BMS 51023 b HB1348 - 5 - LRB103 05999 BMS 51023 b
HB1348 - 5 - LRB103 05999 BMS 51023 b
1 (i) Nothing in this Section shall be construed to limit
2 access to the most up-to-date patient-specific eligibility or
3 patient-specific prescription cost and benefit data by the
4 health plan.
5 (j) Nothing in this Section shall interfere with patient
6 choice and a health care professional's ability to convey the
7 full range of prescription drug cost options to a patient.
8 Health plans shall not restrict a health care professional
9 from communicating prescription cost options to the patient.
10 (k) No real-time benefit tool shall require a patient to
11 use specific plan-preferred drugs or pharmacies.
12 (215 ILCS 5/513b7 new)
13 Sec. 513b7. Patient prescription pricing transparency.
14 (a) No later than July 1, 2024, each pharmacy benefit
15 manager operating in this State shall, upon request of a
16 covered individual, his or her health care provider, or an
17 authorized third party on his or her behalf, furnish the cost,
18 benefit, and coverage data required under this Section to the
19 covered individual, his or her health care provider, or the
20 third party of his or her choosing and shall ensure that the
21 data is:
22 (1) current no later than one business day after any
23 change is made;
24 (2) provided in real time; and
25 (3) in a format that is easily accessible to the
HB1348 - 5 - LRB103 05999 BMS 51023 b
HB1348- 6 -LRB103 05999 BMS 51023 b HB1348 - 6 - LRB103 05999 BMS 51023 b
HB1348 - 6 - LRB103 05999 BMS 51023 b
1 covered individual or, in the case of his or her health
2 care provider, through an electronic health records
3 system.
4 (b) The format of the request shall use established
5 industry content and transport standards published by:
6 (1) a standards developing organization accredited by
7 the American National Standards Institute, including the
8 National Council for Prescription Drug Programs,
9 Accredited Standards Committee X12, and Health Level 7;
10 (2) a relevant federal or state governing body,
11 including the Centers for Medicare & Medicaid Services or
12 the Office of the National Coordinator for Health
13 Information Technology; or
14 (3) another format deemed acceptable to the Department
15 that provides the data described in subsection (a) and
16 with the same timeliness as required by this Section.
17 (c) A facsimile is not an acceptable electronic format
18 under this Section.
19 (d) Upon request, the following data shall be provided for
20 any drug covered under the covered individual's health plan:
21 (1) patient-specific eligibility information;
22 (2) patient-specific prescription cost and benefit
23 data, such as applicable formulary, benefit, coverage and
24 cost-sharing data for the prescribed drug, and clinically
25 appropriate alternatives, when appropriate;
26 (3) patient-specific cost-sharing information that
HB1348 - 6 - LRB103 05999 BMS 51023 b
HB1348- 7 -LRB103 05999 BMS 51023 b HB1348 - 7 - LRB103 05999 BMS 51023 b
HB1348 - 7 - LRB103 05999 BMS 51023 b
1 describes variance in cost sharing based on the pharmacy
2 dispensing the prescribed drug or its alternatives, and in
3 relation to the patient's benefit, such as spending
4 related to the out-of-pocket maximum;
5 (4) information regarding lower cost clinically
6 appropriate treatment alternatives; and
7 (5) applicable utilization management requirements.
8 (e) A pharmacy benefit manager shall furnish the data as
9 required whether the request is made using the drug's unique
10 billing code, such as a National Drug Code or Healthcare
11 Common Procedure Coding System code, or descriptive term. A
12 pharmacy benefit manager shall not deny or unreasonably delay
13 a request as a method of blocking the required data from being
14 shared based on how the drug was requested.
15 (f) A pharmacy benefit manager shall not restrict,
16 prohibit, or otherwise hinder the prescriber from
17 communicating or sharing benefit and coverage information that
18 reflects other choices, such as cash price, lower cost
19 clinically appropriate alternatives, whether or not they are
20 covered under the covered individual's plan, patient
21 assistance programs, and support programs, and the cost
22 available at the patient's pharmacy of choice.
23 (g) A pharmacy benefit manager shall not, except as may be
24 required by law, interfere with, prevent, or materially
25 discourage access, exchange, or use of the data as required,
26 which may include charging fees or not responding to a request
HB1348 - 7 - LRB103 05999 BMS 51023 b
HB1348- 8 -LRB103 05999 BMS 51023 b HB1348 - 8 - LRB103 05999 BMS 51023 b
HB1348 - 8 - LRB103 05999 BMS 51023 b
1 for such data in a reasonable time frame; nor penalize a health
2 care provider or professional for disclosing such information
3 to a covered individual or legally prescribing, administering,
4 or ordering a clinically appropriate or lower cost
5 alternative.
6 (h) Nothing in this Section shall be construed to limit
7 access to the most up-to-date patient-specific eligibility or
8 patient-specific prescription cost and benefit data by the
9 pharmacy benefit manager.
10 (i) Nothing in this Section shall interfere with patient
11 choice and a health care professional's ability to convey the
12 full range of prescription drug cost options to a patient. A
13 pharmacy benefit manager shall not restrict a health care
14 professional from communicating prescription cost options to
15 the patient.
16 (j) No real-time benefit tool shall require a patient to
17 use specific plan-preferred drugs or pharmacies.
HB1348 - 8 - LRB103 05999 BMS 51023 b