104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2152 Introduced 2/7/2025, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.11215 ILCS 200/10215 ILCS 200/50215 ILCS 200/65 Amends the Prior Authorization Reform Act. Provides that the Act applies to policies issued or delivered to persons who are enrolled in the State Employee Group Health Insurance Program to the extent required under a provision of the State Employees Group Insurance Act of 1971 concerning required health benefits. Provides that a health insurance issuer shall not require prior authorization where a covered medication, with the exception of benzodiazepines or Schedule II narcotic drugs: (1) is prescribed for the management and treatment of multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, diabetes type 1, diabetes type 2, or pre-diabetes; and (2) is for a patient currently managed with an established treatment regimen for at least 12 months. Provides that nothing in the provision prevents a health care plan from denying an enrollee coverage or imposing a prior authorization requirement if the United States Food and Drug Administration has issued a statement about the drug that calls into question the clinical safety of the drug, the drug manufacturer has notified the United States Food and Drug Administration of a manufacturing discontinuance or potential discontinuance of the drug, or the drug manufacturer has removed the drug from the market. In a provision concerning the length of prior authorization approval for treatment of chronic or long-term condition, excludes a provision of the State Employees Group Insurance Act of 1971 concerning coverage for injectable medicines to improve glucose or weight loss. Effective January 1, 2027. LRB104 11051 BAB 21133 b A BILL FOR 104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2152 Introduced 2/7/2025, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.11215 ILCS 200/10215 ILCS 200/50215 ILCS 200/65 5 ILCS 375/6.11 215 ILCS 200/10 215 ILCS 200/50 215 ILCS 200/65 Amends the Prior Authorization Reform Act. Provides that the Act applies to policies issued or delivered to persons who are enrolled in the State Employee Group Health Insurance Program to the extent required under a provision of the State Employees Group Insurance Act of 1971 concerning required health benefits. Provides that a health insurance issuer shall not require prior authorization where a covered medication, with the exception of benzodiazepines or Schedule II narcotic drugs: (1) is prescribed for the management and treatment of multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, diabetes type 1, diabetes type 2, or pre-diabetes; and (2) is for a patient currently managed with an established treatment regimen for at least 12 months. Provides that nothing in the provision prevents a health care plan from denying an enrollee coverage or imposing a prior authorization requirement if the United States Food and Drug Administration has issued a statement about the drug that calls into question the clinical safety of the drug, the drug manufacturer has notified the United States Food and Drug Administration of a manufacturing discontinuance or potential discontinuance of the drug, or the drug manufacturer has removed the drug from the market. In a provision concerning the length of prior authorization approval for treatment of chronic or long-term condition, excludes a provision of the State Employees Group Insurance Act of 1971 concerning coverage for injectable medicines to improve glucose or weight loss. Effective January 1, 2027. LRB104 11051 BAB 21133 b LRB104 11051 BAB 21133 b A BILL FOR
104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2152 Introduced 2/7/2025, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED:
5 ILCS 375/6.11215 ILCS 200/10215 ILCS 200/50215 ILCS 200/65 5 ILCS 375/6.11 215 ILCS 200/10 215 ILCS 200/50 215 ILCS 200/65
5 ILCS 375/6.11
215 ILCS 200/10
215 ILCS 200/50
215 ILCS 200/65
Amends the Prior Authorization Reform Act. Provides that the Act applies to policies issued or delivered to persons who are enrolled in the State Employee Group Health Insurance Program to the extent required under a provision of the State Employees Group Insurance Act of 1971 concerning required health benefits. Provides that a health insurance issuer shall not require prior authorization where a covered medication, with the exception of benzodiazepines or Schedule II narcotic drugs: (1) is prescribed for the management and treatment of multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, diabetes type 1, diabetes type 2, or pre-diabetes; and (2) is for a patient currently managed with an established treatment regimen for at least 12 months. Provides that nothing in the provision prevents a health care plan from denying an enrollee coverage or imposing a prior authorization requirement if the United States Food and Drug Administration has issued a statement about the drug that calls into question the clinical safety of the drug, the drug manufacturer has notified the United States Food and Drug Administration of a manufacturing discontinuance or potential discontinuance of the drug, or the drug manufacturer has removed the drug from the market. In a provision concerning the length of prior authorization approval for treatment of chronic or long-term condition, excludes a provision of the State Employees Group Insurance Act of 1971 concerning coverage for injectable medicines to improve glucose or weight loss. Effective January 1, 2027.
LRB104 11051 BAB 21133 b LRB104 11051 BAB 21133 b
LRB104 11051 BAB 21133 b
A BILL FOR
SB2152LRB104 11051 BAB 21133 b SB2152 LRB104 11051 BAB 21133 b
SB2152 LRB104 11051 BAB 21133 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 State Employees Group Insurance Act of 1971
5 is amended by changing Section 6.11 as follows:
6 (5 ILCS 375/6.11)
7 Sec. 6.11. Required health benefits; Illinois Insurance
8 Code requirements. The program of health benefits shall
9 provide the post-mastectomy care benefits required to be
10 covered by a policy of accident and health insurance under
11 Section 356t of the Illinois Insurance Code. The program of
12 health benefits shall provide the coverage required under
13 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10,
14 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
15 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
16 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
17 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
18 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59,
19 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and
20 356z.70, and 356z.71, 356z.74, 356z.76, and 356z.77 of the
21 Illinois Insurance Code. The program of health benefits must
22 comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and
23 370c.1 and Article XXXIIB of the Illinois Insurance Code, and
104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB2152 Introduced 2/7/2025, by Sen. Cristina Castro SYNOPSIS AS INTRODUCED:
5 ILCS 375/6.11215 ILCS 200/10215 ILCS 200/50215 ILCS 200/65 5 ILCS 375/6.11 215 ILCS 200/10 215 ILCS 200/50 215 ILCS 200/65
5 ILCS 375/6.11
215 ILCS 200/10
215 ILCS 200/50
215 ILCS 200/65
Amends the Prior Authorization Reform Act. Provides that the Act applies to policies issued or delivered to persons who are enrolled in the State Employee Group Health Insurance Program to the extent required under a provision of the State Employees Group Insurance Act of 1971 concerning required health benefits. Provides that a health insurance issuer shall not require prior authorization where a covered medication, with the exception of benzodiazepines or Schedule II narcotic drugs: (1) is prescribed for the management and treatment of multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, diabetes type 1, diabetes type 2, or pre-diabetes; and (2) is for a patient currently managed with an established treatment regimen for at least 12 months. Provides that nothing in the provision prevents a health care plan from denying an enrollee coverage or imposing a prior authorization requirement if the United States Food and Drug Administration has issued a statement about the drug that calls into question the clinical safety of the drug, the drug manufacturer has notified the United States Food and Drug Administration of a manufacturing discontinuance or potential discontinuance of the drug, or the drug manufacturer has removed the drug from the market. In a provision concerning the length of prior authorization approval for treatment of chronic or long-term condition, excludes a provision of the State Employees Group Insurance Act of 1971 concerning coverage for injectable medicines to improve glucose or weight loss. Effective January 1, 2027.
LRB104 11051 BAB 21133 b LRB104 11051 BAB 21133 b
LRB104 11051 BAB 21133 b
A BILL FOR
5 ILCS 375/6.11
215 ILCS 200/10
215 ILCS 200/50
215 ILCS 200/65
LRB104 11051 BAB 21133 b
SB2152 LRB104 11051 BAB 21133 b
SB2152- 2 -LRB104 11051 BAB 21133 b SB2152 - 2 - LRB104 11051 BAB 21133 b
SB2152 - 2 - LRB104 11051 BAB 21133 b
1 the Prior Authorization Reform Act. The program of health
2 benefits shall provide the coverage required under Section
3 356m of the Illinois Insurance Code and, for the employees of
4 the State Employee Group Insurance Program only, the coverage
5 as also provided in Section 6.11B of this Act. The Department
6 of Insurance shall enforce the requirements of this Section
7 with respect to Sections 370c and 370c.1 of the Illinois
8 Insurance Code and the Prior Authorization Reform Act; all
9 other requirements of this Section shall be enforced by the
10 Department of Central Management Services.
11 Rulemaking authority to implement Public Act 95-1045, if
12 any, is conditioned on the rules being adopted in accordance
13 with all provisions of the Illinois Administrative Procedure
14 Act and all rules and procedures of the Joint Committee on
15 Administrative Rules; any purported rule not so adopted, for
16 whatever reason, is unauthorized.
17 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
18 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
19 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768,
20 eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
21 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
22 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84,
23 eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24;
24 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff.
25 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751,
26 eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25;
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1 103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff.
2 1-1-25; revised 11-26-24.)
3 Section 10. The Prior Authorization Reform Act is amended
4 by changing Sections 10, 50, and 65 as follows:
5 (215 ILCS 200/10)
6 Sec. 10. Applicability; scope. This Act applies to health
7 insurance coverage as defined in the Illinois Health Insurance
8 Portability and Accountability Act, policies issued or
9 delivered to persons who are enrolled in the State Employees
10 Group Health Insurance Program to the extent required under
11 Section 6.11 of the State Employees Group Insurance Act of
12 1971, and policies issued or delivered in this State to the
13 Department of Healthcare and Family Services and providing
14 coverage to persons who are enrolled under Article V of the
15 Illinois Public Aid Code or under the Children's Health
16 Insurance Program Act, amended, delivered, issued, or renewed
17 on or after the effective date of this Act, with the exception
18 of employee or employer self-insured health benefit plans
19 under the federal Employee Retirement Income Security Act of
20 1974, health care provided pursuant to the Workers'
21 Compensation Act or the Workers' Occupational Diseases Act,
22 county, municipal, and State, employee, unit of local
23 government, or school district health plans. This Act does not
24 diminish a health care plan's duties and responsibilities
SB2152 - 3 - LRB104 11051 BAB 21133 b
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SB2152 - 4 - LRB104 11051 BAB 21133 b
1 under other federal or State law or rules promulgated
2 thereunder. This Act is not intended to alter or impede the
3 provisions of any consent decree or judicial order to which
4 the State or any of its agencies is a party.
5 (Source: P.A. 102-409, eff. 1-1-22.)
6 (215 ILCS 200/50)
7 Sec. 50. Limitations on Review of prior authorization
8 requirements.
9 (a) A health insurance issuer shall not require
10 periodically review its prior authorization requirements and
11 consider removal of prior authorization where a covered
12 medication, with the exception of benzodiazepines or Schedule
13 II narcotic drugs requirements:
14 (1) is where a medication or procedure prescribed for
15 the management and treatment of multiple sclerosis,
16 rheumatoid arthritis, systemic lupus erythematosus,
17 diabetes type 1, diabetes type 2, or pre-diabetes is
18 customary and properly indicated or is a treatment for the
19 clinical indication as supported by peer-reviewed medical
20 publications; and or
21 (2) is for a patient patients currently managed with
22 an established treatment regimen for at least 12 months.
23 (b) Nothing in this Section prevents a health care plan
24 from denying an enrollee coverage or imposing a prior
25 authorization requirement if the United States Food and Drug
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1 Administration has issued a statement about the drug that
2 calls into question the clinical safety of the drug, the drug
3 manufacturer has notified the United States Food and Drug
4 Administration of a manufacturing discontinuance or potential
5 discontinuance of the drug as required by Section 506C of the
6 Federal Food, Drug, and Cosmetic Act, as codified in 21 U.S.C.
7 356c, or the drug manufacturer has removed the drug from the
8 market.
9 (c) Except to the extent required by medical exceptions
10 processes for prescription drugs set forth in Section 45.1 of
11 the Managed Care and Patient Rights Act, nothing in this
12 Section shall require a policy to cover any care, treatment,
13 or services for any health condition that the terms of
14 coverage otherwise completely exclude from the policy's
15 covered benefits without regard for whether the care,
16 treatment, or services are medically necessary.
17 (Source: P.A. 102-409, eff. 1-1-22.)
18 (215 ILCS 200/65)
19 Sec. 65. Length of prior authorization approval for
20 treatment for chronic or long-term conditions. If a health
21 insurance issuer requires a prior authorization for a
22 recurring health care service or maintenance medication for
23 the treatment of a chronic or long-term condition other than
24 those specified in Section 50, the approval shall remain valid
25 for the lesser of 12 months from the date the health care
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1 professional or health care provider receives the prior
2 authorization approval or the length of the treatment as
3 determined by the patient's health care professional. This
4 Section shall not apply to the prescription of benzodiazepines
5 or Schedule II narcotic drugs, such as opioids. This Section
6 does not apply to Section 6.11C of the State Employees Group
7 Insurance Act of 1971. Except to the extent required by
8 medical exceptions processes for prescription drugs set forth
9 in Section 45.1 of the Managed Care Reform and Patient Rights
10 Act, nothing in this Section shall require a policy to cover
11 any care, treatment, or services for any health condition that
12 the terms of coverage otherwise completely exclude from the
13 policy's covered benefits without regard for whether the care,
14 treatment, or services are medically necessary.
15 (Source: P.A. 102-409, eff. 1-1-22.)
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