Illinois 2025-2026 Regular Session

Illinois House Bill HB1018 Compare Versions

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

Old	New	Differences
1	1	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1018 Introduced , by Rep. John M. Cabello SYNOPSIS AS INTRODUCED: 215 ILCS 5/513b1 Amends the Illinois Insurance Code. Provides that a pharmacy benefit manager or an affiliate acting on the pharmacy benefit manager's behalf is prohibited from steering a covered individual. Defines "steer". Effective July 1, 2025. LRB104 03422 BAB 13444 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1018 Introduced , by Rep. John M. Cabello SYNOPSIS AS INTRODUCED: 215 ILCS 5/513b1 215 ILCS 5/513b1 Amends the Illinois Insurance Code. Provides that a pharmacy benefit manager or an affiliate acting on the pharmacy benefit manager's behalf is prohibited from steering a covered individual. Defines "steer". Effective July 1, 2025. LRB104 03422 BAB 13444 b LRB104 03422 BAB 13444 b A BILL FOR
2	2	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1018 Introduced , by Rep. John M. Cabello SYNOPSIS AS INTRODUCED:
3	3	215 ILCS 5/513b1 215 ILCS 5/513b1
4	4	215 ILCS 5/513b1
5	5	Amends the Illinois Insurance Code. Provides that a pharmacy benefit manager or an affiliate acting on the pharmacy benefit manager's behalf is prohibited from steering a covered individual. Defines "steer". Effective July 1, 2025.
6	6	LRB104 03422 BAB 13444 b LRB104 03422 BAB 13444 b
7	7	LRB104 03422 BAB 13444 b
8	8	A BILL FOR
9	9	HB1018LRB104 03422 BAB 13444 b HB1018 LRB104 03422 BAB 13444 b
10	10	HB1018 LRB104 03422 BAB 13444 b
11	11	1 AN ACT concerning regulation.
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 Insurance Code is amended by
15	15	5 changing Section 513b1 as follows:
16	16	6 (215 ILCS 5/513b1)
17	17	7 Sec. 513b1. Pharmacy benefit manager contracts.
18	18	8 (a) As used in this Section:
19	19	9 "340B drug discount program" means the program established
20	20	10 under Section 340B of the federal Public Health Service Act,
21	21	11 42 U.S.C. 256b.
22	22	12 "340B entity" means a covered entity as defined in 42
23	23	13 U.S.C. 256b(a)(4) authorized to participate in the 340B drug
24	24	14 discount program.
25	25	15 "340B pharmacy" means any pharmacy used to dispense 340B
26	26	16 drugs for a covered entity, whether entity-owned or external.
27	27	17 "Biological product" has the meaning ascribed to that term
28	28	18 in Section 19.5 of the Pharmacy Practice Act.
29	29	19 "Maximum allowable cost" means the maximum amount that a
30	30	20 pharmacy benefit manager will reimburse a pharmacy for the
31	31	21 cost of a drug.
32	32	22 "Maximum allowable cost list" means a list of drugs for
33	33	23 which a maximum allowable cost has been established by a
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37	37	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1018 Introduced , by Rep. John M. Cabello SYNOPSIS AS INTRODUCED:
38	38	215 ILCS 5/513b1 215 ILCS 5/513b1
39	39	215 ILCS 5/513b1
40	40	Amends the Illinois Insurance Code. Provides that a pharmacy benefit manager or an affiliate acting on the pharmacy benefit manager's behalf is prohibited from steering a covered individual. Defines "steer". Effective July 1, 2025.
41	41	LRB104 03422 BAB 13444 b LRB104 03422 BAB 13444 b
42	42	LRB104 03422 BAB 13444 b
43	43	A BILL FOR
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49	49	215 ILCS 5/513b1
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53	53	LRB104 03422 BAB 13444 b
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68	68	1 pharmacy benefit manager.
69	69	2 "Pharmacy benefit manager" means a person, business, or
70	70	3 entity, including a wholly or partially owned or controlled
71	71	4 subsidiary of a pharmacy benefit manager, that provides claims
72	72	5 processing services or other prescription drug or device
73	73	6 services, or both, for health benefit plans.
74	74	7 "Retail price" means the price an individual without
75	75	8 prescription drug coverage would pay at a retail pharmacy, not
76	76	9 including a pharmacist dispensing fee.
77	77	10 "Steer" includes, but is not limited to:
78	78	11 (1) requiring a covered individual to use only a
79	79	12 pharmacy, including a mail-order pharmacy, in which the
80	80	13 pharmacy benefit manager maintains an ownership interest
81	81	14 or control;
82	82	15 (2) offering or implementing a plan design that
83	83	16 encourages a covered individual to use a pharmacy in which
84	84	17 the pharmacy benefit manager maintains an ownership
85	85	18 interest or control, if such plan design increases costs
86	86	19 for the covered individual, including requiring a covered
87	87	20 individual to pay full costs for a prescription if the
88	88	21 covered individual chooses not to use a pharmacy owned or
89	89	22 controlled by the pharmacy benefit manager;
90	90	23 (3) reimbursing a pharmacy or pharmacist for a
91	91	24 pharmaceutical product or pharmacist service in an amount
92	92	25 less than the amount that the pharmacy benefit manager
93	93	26 reimburses itself or an affiliate for providing the same
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104	104	1 product or services, unless the pharmacy or pharmacist
105	105	2 contractually agrees to a lower reimbursement amount; or
106	106	3 (4) any other actions determined by the Department by
107	107	4 rule.
108	108	5 "Third-party payer" means any entity that pays for
109	109	6 prescription drugs on behalf of a patient other than a health
110	110	7 care provider or sponsor of a plan subject to regulation under
111	111	8 Medicare Part D, 42 U.S.C. 1395w-101 et seq.
112	112	9 (b) A contract between a health insurer and a pharmacy
113	113	10 benefit manager must require that the pharmacy benefit
114	114	11 manager:
115	115	12 (1) Update maximum allowable cost pricing information
116	116	13 at least every 7 calendar days.
117	117	14 (2) Maintain a process that will, in a timely manner,
118	118	15 eliminate drugs from maximum allowable cost lists or
119	119	16 modify drug prices to remain consistent with changes in
120	120	17 pricing data used in formulating maximum allowable cost
121	121	18 prices and product availability.
122	122	19 (3) Provide access to its maximum allowable cost list
123	123	20 to each pharmacy or pharmacy services administrative
124	124	21 organization subject to the maximum allowable cost list.
125	125	22 Access may include a real-time pharmacy website portal to
126	126	23 be able to view the maximum allowable cost list. As used in
127	127	24 this Section, "pharmacy services administrative
128	128	25 organization" means an entity operating within the State
129	129	26 that contracts with independent pharmacies to conduct
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140	140	1 business on their behalf with third-party payers. A
141	141	2 pharmacy services administrative organization may provide
142	142	3 administrative services to pharmacies and negotiate and
143	143	4 enter into contracts with third-party payers or pharmacy
144	144	5 benefit managers on behalf of pharmacies.
145	145	6 (4) Provide a process by which a contracted pharmacy
146	146	7 can appeal the provider's reimbursement for a drug subject
147	147	8 to maximum allowable cost pricing. The appeals process
148	148	9 must, at a minimum, include the following:
149	149	10 (A) A requirement that a contracted pharmacy has
150	150	11 14 calendar days after the applicable fill date to
151	151	12 appeal a maximum allowable cost if the reimbursement
152	152	13 for the drug is less than the net amount that the
153	153	14 network provider paid to the supplier of the drug.
154	154	15 (B) A requirement that a pharmacy benefit manager
155	155	16 must respond to a challenge within 14 calendar days of
156	156	17 the contracted pharmacy making the claim for which the
157	157	18 appeal has been submitted.
158	158	19 (C) A telephone number and e-mail address or
159	159	20 website to network providers, at which the provider
160	160	21 can contact the pharmacy benefit manager to process
161	161	22 and submit an appeal.
162	162	23 (D) A requirement that, if an appeal is denied,
163	163	24 the pharmacy benefit manager must provide the reason
164	164	25 for the denial and the name and the national drug code
165	165	26 number from national or regional wholesalers.
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176	176	1 (E) A requirement that, if an appeal is sustained,
177	177	2 the pharmacy benefit manager must make an adjustment
178	178	3 in the drug price effective the date the challenge is
179	179	4 resolved and make the adjustment applicable to all
180	180	5 similarly situated network pharmacy providers, as
181	181	6 determined by the managed care organization or
182	182	7 pharmacy benefit manager.
183	183	8 (5) Allow a plan sponsor contracting with a pharmacy
184	184	9 benefit manager an annual right to audit compliance with
185	185	10 the terms of the contract by the pharmacy benefit manager,
186	186	11 including, but not limited to, full disclosure of any and
187	187	12 all rebate amounts secured, whether product specific or
188	188	13 generalized rebates, that were provided to the pharmacy
189	189	14 benefit manager by a pharmaceutical manufacturer.
190	190	15 (6) Allow a plan sponsor contracting with a pharmacy
191	191	16 benefit manager to request that the pharmacy benefit
192	192	17 manager disclose the actual amounts paid by the pharmacy
193	193	18 benefit manager to the pharmacy.
194	194	19 (7) Provide notice to the party contracting with the
195	195	20 pharmacy benefit manager of any consideration that the
196	196	21 pharmacy benefit manager receives from the manufacturer
197	197	22 for dispense as written prescriptions once a generic or
198	198	23 biologically similar product becomes available.
199	199	24 (c) In order to place a particular prescription drug on a
200	200	25 maximum allowable cost list, the pharmacy benefit manager
201	201	26 must, at a minimum, ensure that:
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212	212	1 (1) if the drug is a generically equivalent drug, it
213	213	2 is listed as therapeutically equivalent and
214	214	3 pharmaceutically equivalent "A" or "B" rated in the United
215	215	4 States Food and Drug Administration's most recent version
216	216	5 of the "Orange Book" or have an NR or NA rating by
217	217	6 Medi-Span, Gold Standard, or a similar rating by a
218	218	7 nationally recognized reference;
219	219	8 (2) the drug is available for purchase by each
220	220	9 pharmacy in the State from national or regional
221	221	10 wholesalers operating in Illinois; and
222	222	11 (3) the drug is not obsolete.
223	223	12 (d) A pharmacy benefit manager is prohibited from limiting
224	224	13 a pharmacist's ability to disclose whether the cost-sharing
225	225	14 obligation exceeds the retail price for a covered prescription
226	226	15 drug, and the availability of a more affordable alternative
227	227	16 drug, if one is available in accordance with Section 42 of the
228	228	17 Pharmacy Practice Act.
229	229	18 (e) A health insurer or pharmacy benefit manager shall not
230	230	19 require an insured to make a payment for a prescription drug at
231	231	20 the point of sale in an amount that exceeds the lesser of:
232	232	21 (1) the applicable cost-sharing amount; or
233	233	22 (2) the retail price of the drug in the absence of
234	234	23 prescription drug coverage.
235	235	24 (f) Unless required by law, a contract between a pharmacy
236	236	25 benefit manager or third-party payer and a 340B entity or 340B
237	237	26 pharmacy shall not contain any provision that:
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248	248	1 (1) distinguishes between drugs purchased through the
249	249	2 340B drug discount program and other drugs when
250	250	3 determining reimbursement or reimbursement methodologies,
251	251	4 or contains otherwise less favorable payment terms or
252	252	5 reimbursement methodologies for 340B entities or 340B
253	253	6 pharmacies when compared to similarly situated non-340B
254	254	7 entities;
255	255	8 (2) imposes any fee, chargeback, or rate adjustment
256	256	9 that is not similarly imposed on similarly situated
257	257	10 pharmacies that are not 340B entities or 340B pharmacies;
258	258	11 (3) imposes any fee, chargeback, or rate adjustment
259	259	12 that exceeds the fee, chargeback, or rate adjustment that
260	260	13 is not similarly imposed on similarly situated pharmacies
261	261	14 that are not 340B entities or 340B pharmacies;
262	262	15 (4) prevents or interferes with an individual's choice
263	263	16 to receive a covered prescription drug from a 340B entity
264	264	17 or 340B pharmacy through any legally permissible means,
265	265	18 except that nothing in this paragraph shall prohibit the
266	266	19 establishment of differing copayments or other
267	267	20 cost-sharing amounts within the benefit plan for covered
268	268	21 persons who acquire covered prescription drugs from a
269	269	22 nonpreferred or nonparticipating provider;
270	270	23 (5) excludes a 340B entity or 340B pharmacy from a
271	271	24 pharmacy network on any basis that includes consideration
272	272	25 of whether the 340B entity or 340B pharmacy participates
273	273	26 in the 340B drug discount program;
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284	284	1 (6) prevents a 340B entity or 340B pharmacy from using
285	285	2 a drug purchased under the 340B drug discount program; or
286	286	3 (7) any other provision that discriminates against a
287	287	4 340B entity or 340B pharmacy by treating the 340B entity
288	288	5 or 340B pharmacy differently than non-340B entities or
289	289	6 non-340B pharmacies for any reason relating to the
290	290	7 entity's participation in the 340B drug discount program.
291	291	8 As used in this subsection, "pharmacy benefit manager" and
292	292	9 "third-party payer" do not include pharmacy benefit managers
293	293	10 and third-party payers acting on behalf of a Medicaid program.
294	294	11 (f-5) A pharmacy benefit manager or an affiliate acting on
295	295	12 the pharmacy benefit manager's behalf shall not steer a
296	296	13 covered individual.
297	297	14 (g) A violation of this Section by a pharmacy benefit
298	298	15 manager constitutes an unfair or deceptive act or practice in
299	299	16 the business of insurance under Section 424.
300	300	17 (h) A provision that violates subsection (f) in a contract
301	301	18 between a pharmacy benefit manager or a third-party payer and
302	302	19 a 340B entity that is entered into, amended, or renewed after
303	303	20 July 1, 2022 shall be void and unenforceable.
304	304	21 (i)(1) A pharmacy benefit manager may not retaliate
305	305	22 against a pharmacist or pharmacy for disclosing information in
306	306	23 a court, in an administrative hearing, before a legislative
307	307	24 commission or committee, or in any other proceeding, if the
308	308	25 pharmacist or pharmacy has reasonable cause to believe that
309	309	26 the disclosed information is evidence of a violation of a
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320	320	1 State or federal law, rule, or regulation.
321	321	2 (2) A pharmacy benefit manager may not retaliate against a
322	322	3 pharmacist or pharmacy for disclosing information to a
323	323	4 government or law enforcement agency, if the pharmacist or
324	324	5 pharmacy has reasonable cause to believe that the disclosed
325	325	6 information is evidence of a violation of a State or federal
326	326	7 law, rule, or regulation.
327	327	8 (3) A pharmacist or pharmacy shall make commercially
328	328	9 reasonable efforts to limit the disclosure of confidential and
329	329	10 proprietary information.
330	330	11 (4) Retaliatory actions against a pharmacy or pharmacist
331	331	12 include cancellation of, restriction of, or refusal to renew
332	332	13 or offer a contract to a pharmacy solely because the pharmacy
333	333	14 or pharmacist has:
334	334	15 (A) made disclosures of information that the
335	335	16 pharmacist or pharmacy has reasonable cause to believe is
336	336	17 evidence of a violation of a State or federal law, rule, or
337	337	18 regulation;
338	338	19 (B) filed complaints with the plan or pharmacy benefit
339	339	20 manager; or
340	340	21 (C) filed complaints against the plan or pharmacy
341	341	22 benefit manager with the Department.
342	342	23 (j) This Section applies to contracts entered into or
343	343	24 renewed on or after July 1, 2022.
344	344	25 (k) This Section applies to any group or individual policy
345	345	26 of accident and health insurance or managed care plan that
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356	356	1 provides coverage for prescription drugs and that is amended,
357	357	2 delivered, issued, or renewed on or after July 1, 2020.
358	358	3 (Source: P.A. 102-778, eff. 7-1-22; 103-154, eff. 6-30-23;
359	359	4 103-453, eff. 8-4-23.)
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