Illinois 2023-2024 Regular Session

Illinois Senate Bill SB2790 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2790 Introduced 1/17/2024, by Sen. Laura M. Murphy SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-36a new Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services shall not enter into a contract with a managed care organization that relies on a pharmacy benefit manager that does not do the following: (i) utilize a pharmacy reimbursement methodology of the lesser of national average drug acquisition cost plus a professional dispensing fee as determined by the Department, the wholesale acquisition cost plus a professional dispensing fee as determined by the Department, or the usual and customary charge by the pharmacy; (ii) reimburse for a legally valid claim at a rate not less than the rate in effect at the time the original claim adjudication was submitted at the point of sale; (iii) agree to move to a transparent pass-through pricing model, in which the pharmacy benefit manager discloses the administrative fee as a percentage of the professional dispensing costs to the Department; (iv) agree to not create new pharmacy administration fees and to not increase current fees more than the rate of inflation; and (v) agree to not terminate an existing contract with a pharmacy licensed under the Pharmacy Practice Act for the sole reason of the additional professional dispensing fee authorized under item (i). Requires each pharmacy benefit manager that receives reimbursement for medical services, either directly or through a Medicaid managed care health plan, to submit by January 15, 2026, and each January 15 thereafter, certain data and information to the Department for the previous fiscal year, including: (1) the total number of prescriptions that were dispensed; (2) the aggregate wholesale acquisition cost for each drug on its formulary; (3) the aggregate amount of rebates, discounts, and price concessions that the pharmacy benefit manager received for each drug on its formulary; (4) the aggregate amount of administrative fees that the pharmacy benefit manager received from all pharmaceutical manufacturers; and (5) any other information considered necessary by the Department. Requires the Department to submit such data and information to the General Assembly and to the Governor's Office of Management and Budget. Provides that such information is confidential and not subject to disclosure under the Freedom of Information Act. LRB103 36211 KTG 66304 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2790 Introduced 1/17/2024, by Sen. Laura M. Murphy SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-36a new 305 ILCS 5/5-36a new Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services shall not enter into a contract with a managed care organization that relies on a pharmacy benefit manager that does not do the following: (i) utilize a pharmacy reimbursement methodology of the lesser of national average drug acquisition cost plus a professional dispensing fee as determined by the Department, the wholesale acquisition cost plus a professional dispensing fee as determined by the Department, or the usual and customary charge by the pharmacy; (ii) reimburse for a legally valid claim at a rate not less than the rate in effect at the time the original claim adjudication was submitted at the point of sale; (iii) agree to move to a transparent pass-through pricing model, in which the pharmacy benefit manager discloses the administrative fee as a percentage of the professional dispensing costs to the Department; (iv) agree to not create new pharmacy administration fees and to not increase current fees more than the rate of inflation; and (v) agree to not terminate an existing contract with a pharmacy licensed under the Pharmacy Practice Act for the sole reason of the additional professional dispensing fee authorized under item (i). Requires each pharmacy benefit manager that receives reimbursement for medical services, either directly or through a Medicaid managed care health plan, to submit by January 15, 2026, and each January 15 thereafter, certain data and information to the Department for the previous fiscal year, including: (1) the total number of prescriptions that were dispensed; (2) the aggregate wholesale acquisition cost for each drug on its formulary; (3) the aggregate amount of rebates, discounts, and price concessions that the pharmacy benefit manager received for each drug on its formulary; (4) the aggregate amount of administrative fees that the pharmacy benefit manager received from all pharmaceutical manufacturers; and (5) any other information considered necessary by the Department. Requires the Department to submit such data and information to the General Assembly and to the Governor's Office of Management and Budget. Provides that such information is confidential and not subject to disclosure under the Freedom of Information Act. LRB103 36211 KTG 66304 b LRB103 36211 KTG 66304 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2790 Introduced 1/17/2024, by Sen. Laura M. Murphy SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-36a new 305 ILCS 5/5-36a new
4	4	305 ILCS 5/5-36a new
5	5	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services shall not enter into a contract with a managed care organization that relies on a pharmacy benefit manager that does not do the following: (i) utilize a pharmacy reimbursement methodology of the lesser of national average drug acquisition cost plus a professional dispensing fee as determined by the Department, the wholesale acquisition cost plus a professional dispensing fee as determined by the Department, or the usual and customary charge by the pharmacy; (ii) reimburse for a legally valid claim at a rate not less than the rate in effect at the time the original claim adjudication was submitted at the point of sale; (iii) agree to move to a transparent pass-through pricing model, in which the pharmacy benefit manager discloses the administrative fee as a percentage of the professional dispensing costs to the Department; (iv) agree to not create new pharmacy administration fees and to not increase current fees more than the rate of inflation; and (v) agree to not terminate an existing contract with a pharmacy licensed under the Pharmacy Practice Act for the sole reason of the additional professional dispensing fee authorized under item (i). Requires each pharmacy benefit manager that receives reimbursement for medical services, either directly or through a Medicaid managed care health plan, to submit by January 15, 2026, and each January 15 thereafter, certain data and information to the Department for the previous fiscal year, including: (1) the total number of prescriptions that were dispensed; (2) the aggregate wholesale acquisition cost for each drug on its formulary; (3) the aggregate amount of rebates, discounts, and price concessions that the pharmacy benefit manager received for each drug on its formulary; (4) the aggregate amount of administrative fees that the pharmacy benefit manager received from all pharmaceutical manufacturers; and (5) any other information considered necessary by the Department. Requires the Department to submit such data and information to the General Assembly and to the Governor's Office of Management and Budget. Provides that such information is confidential and not subject to disclosure under the Freedom of Information Act.
6	6	LRB103 36211 KTG 66304 b LRB103 36211 KTG 66304 b
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8	8	A BILL FOR
9	9	SB2790LRB103 36211 KTG 66304 b SB2790 LRB103 36211 KTG 66304 b
10	10	SB2790 LRB103 36211 KTG 66304 b
11	11	1 AN ACT concerning public aid.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Public Aid Code is amended by
15	15	5 adding Section 5-36a as follows:
16	16	6 (305 ILCS 5/5-36a new)
17	17	7 Sec. 5-36a. Managed care organizations; pharmacy benefit
18	18	8 managers; contract requirements.
19	19	9 (a) Notwithstanding any law or rule to the contrary, the
20	20	10 Department shall not enter into a contract with a managed care
21	21	11 organization that relies on a pharmacy benefit manager that
22	22	12 does not do all of the following:
23	23	13 (1) For pharmacies licensed under the Pharmacy
24	24	14 Practice Act, including offsite institutional pharmacies
25	25	15 as defined in Section 39.5 of the Pharmacy Practice Act,
26	26	16 utilize a pharmacy reimbursement methodology of the lesser
27	27	17 of national average drug acquisition cost plus a
28	28	18 professional dispensing fee as determined by the
29	29	19 Department, the wholesale acquisition cost plus a
30	30	20 professional dispensing fee as determined by the
31	31	21 Department, or the usual and customary charge by the
32	32	22 pharmacy. The pharmacy benefit manager or the involved
33	33	23 pharmacy services administrative organization, as defined
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2790 Introduced 1/17/2024, by Sen. Laura M. Murphy SYNOPSIS AS INTRODUCED:
38	38	305 ILCS 5/5-36a new 305 ILCS 5/5-36a new
39	39	305 ILCS 5/5-36a new
40	40	Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services shall not enter into a contract with a managed care organization that relies on a pharmacy benefit manager that does not do the following: (i) utilize a pharmacy reimbursement methodology of the lesser of national average drug acquisition cost plus a professional dispensing fee as determined by the Department, the wholesale acquisition cost plus a professional dispensing fee as determined by the Department, or the usual and customary charge by the pharmacy; (ii) reimburse for a legally valid claim at a rate not less than the rate in effect at the time the original claim adjudication was submitted at the point of sale; (iii) agree to move to a transparent pass-through pricing model, in which the pharmacy benefit manager discloses the administrative fee as a percentage of the professional dispensing costs to the Department; (iv) agree to not create new pharmacy administration fees and to not increase current fees more than the rate of inflation; and (v) agree to not terminate an existing contract with a pharmacy licensed under the Pharmacy Practice Act for the sole reason of the additional professional dispensing fee authorized under item (i). Requires each pharmacy benefit manager that receives reimbursement for medical services, either directly or through a Medicaid managed care health plan, to submit by January 15, 2026, and each January 15 thereafter, certain data and information to the Department for the previous fiscal year, including: (1) the total number of prescriptions that were dispensed; (2) the aggregate wholesale acquisition cost for each drug on its formulary; (3) the aggregate amount of rebates, discounts, and price concessions that the pharmacy benefit manager received for each drug on its formulary; (4) the aggregate amount of administrative fees that the pharmacy benefit manager received from all pharmaceutical manufacturers; and (5) any other information considered necessary by the Department. Requires the Department to submit such data and information to the General Assembly and to the Governor's Office of Management and Budget. Provides that such information is confidential and not subject to disclosure under the Freedom of Information Act.
41	41	LRB103 36211 KTG 66304 b LRB103 36211 KTG 66304 b
42	42	LRB103 36211 KTG 66304 b
43	43	A BILL FOR
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49	49	305 ILCS 5/5-36a new
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53	53	LRB103 36211 KTG 66304 b
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68	68	1 in Section 5-36 of this Code, shall not receive any
69	69	2 portion of the professional dispensing fee. The Department
70	70	3 shall identify the pharmacies this subsection applies to
71	71	4 and provide the list of applicable pharmacies to managed
72	72	5 care organizations contracted with the Department.
73	73	6 (2) Reimburse for a legally valid claim at a rate not
74	74	7 less than the rate in effect at the time the original claim
75	75	8 adjudication was submitted at the point of sale.
76	76	9 (3) Agree to move to a transparent pass-through
77	77	10 pricing model, in which the pharmacy benefit manager
78	78	11 discloses the administrative fee as a percentage of the
79	79	12 professional dispensing costs to the Department.
80	80	13 (4) Agree to not create new pharmacy administration
81	81	14 fees and to not increase current fees more than the rate of
82	82	15 inflation. This paragraph does not apply to any federal
83	83	16 rule or action that creates a new fee.
84	84	17 (5) Agree to not terminate an existing contract with a
85	85	18 pharmacy licensed under the Pharmacy Practice Act for the
86	86	19 sole reason of the additional professional dispensing fee
87	87	20 authorized under this Section.
88	88	21 (b) Nothing in this Section shall be construed to prohibit
89	89	22 a managed care organization from implementing the provisions
90	90	23 of subsection (a) before the effective date of this amendatory
91	91	24 Act of the 103rd General Assembly.
92	92	25 (c) By January 15, 2026, and each January 15 thereafter,
93	93	26 each pharmacy benefit manager that receives reimbursement,
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104	104	1 either directly or through a Medicaid managed care health
105	105	2 plan, for medical services must submit all of the following
106	106	3 information to the Department for the previous fiscal year:
107	107	4 (1) The total number of prescriptions that were
108	108	5 dispensed.
109	109	6 (2) The aggregate wholesale acquisition cost for each
110	110	7 drug on its formulary.
111	111	8 (3) The aggregate amount of rebates, discounts, and
112	112	9 price concessions that the pharmacy benefit manager
113	113	10 received for each drug on its formulary. The amount of
114	114	11 rebates shall include any utilization discounts the
115	115	12 pharmacy benefit manager receives from a manufacturer.
116	116	13 (4) The aggregate amount of administrative fees that
117	117	14 the pharmacy benefit manager received from all
118	118	15 pharmaceutical manufacturers.
119	119	16 (5) The aggregate amount identified in paragraphs (2)
120	120	17 and (3) that was retained by the pharmacy benefit manager
121	121	18 and did not pass through to the Department or to the
122	122	19 Medicaid managed care health plan.
123	123	20 (6) The aggregate amount of reimbursements the
124	124	21 pharmacy benefit manager pays to contracting pharmacies.
125	125	22 (7) Any other information considered necessary by the
126	126	23 Department.
127	127	24 (d) By March 1, 2026 and each March 1 thereafter, the
128	128	25 Department shall submit the information provided under
129	129	26 subsection (c) to the General Assembly and the Governor's
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