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HB1697 Enrolled LRB104 03541 RTM 13564 b
1 AN ACT concerning State government.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. This Act may be referred to as the Prescription
5 Drug Affordability Act.
6 Section 5. The State Employees Group Insurance Act of 1971
7 is amended by changing Section 6.11 as follows:
8 (5 ILCS 375/6.11)
9 Sec. 6.11. Required health benefits; Illinois Insurance
10 Code requirements. The program of health benefits shall
11 provide the post-mastectomy care benefits required to be
12 covered by a policy of accident and health insurance under
13 Section 356t of the Illinois Insurance Code. The program of
14 health benefits shall provide the coverage required under
15 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10,
16 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
17 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
18 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
19 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
20 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59,
21 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and
22 356z.70, and 356z.71, 356z.74, 356z.76, and 356z.77 of the
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1 Illinois Insurance Code. The program of health benefits must
2 comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and
3 370c.1 and Article XXXIIB of the Illinois Insurance Code. The
4 program of health benefits shall provide the coverage required
5 under Section 356m of the Illinois Insurance Code and, for the
6 employees of the State Employee Group Insurance Program only,
7 the coverage as also provided in Section 6.11B of this Act. The
8 Department of Insurance shall enforce the requirements of this
9 Section with respect to Sections 370c and 370c.1 and Article
10 XXXIIB of the Illinois Insurance Code; all other requirements
11 of this Section shall be enforced by the Department of Central
12 Management Services.
13 Rulemaking authority to implement Public Act 95-1045, if
14 any, is conditioned on the rules being adopted in accordance
15 with all provisions of the Illinois Administrative Procedure
16 Act and all rules and procedures of the Joint Committee on
17 Administrative Rules; any purported rule not so adopted, for
18 whatever reason, is unauthorized.
19 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
20 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
21 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768,
22 eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
23 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
24 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84,
25 eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24;
26 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff.
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1 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751,
2 eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25;
3 103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff.
4 1-1-25; revised 11-26-24.)
5 Section 10. The Department of Commerce and Economic
6 Opportunity Law of the Civil Administrative Code of Illinois
7 is amended by changing Section 605-60 as follows:
8 (20 ILCS 605/605-60)
9 Sec. 605-60. DCEO Projects Fund.
10 (a) The DCEO Projects Fund is created as a trust fund in
11 the State treasury. The Department is authorized to accept and
12 deposit into the Fund moneys received from any gifts, grants,
13 transfers, or other sources, public or private, unless deposit
14 into a different fund is otherwise mandated.
15 (b) Subject to appropriation, the Department shall use
16 moneys in the Fund to make grants or loans to and enter into
17 contracts with units of local government, local and regional
18 economic development corporations, retail associations, and
19 not-for-profit organizations for municipal development
20 projects, for the specific purposes established by the terms
21 and conditions of the gift, grant, or award, and for related
22 administrative expenses. As used in this Section, the term
23 "municipal development projects" includes, but is not limited
24 to, grants for reducing food insecurity in urban and rural
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1 areas.
2 (c) In this subsection, "rural tract" and "urban tract"
3 have the meanings given to those terms in Section 5 of the
4 Grocery Initiative Act.
5 Subject to appropriation, the Department shall use moneys
6 deposited into the Fund pursuant to Section 513b2 of the
7 Illinois Insurance Code to make a grant to a statewide retail
8 association representing pharmacies to promote access to
9 pharmacies and pharmacist services. Grant funds under this
10 subsection shall be made available to the following
11 beneficiaries:
12 (1) critical access care pharmacies as defined in
13 Section 5-5.12b of the Illinois Public Aid Code;
14 (2) retail pharmacies with a physical location in
15 Illinois owned by a person or entity with an ownership or
16 control interest in fewer than 10 pharmacies;
17 (3) retail pharmacies with a physical location in a
18 county in Illinois with fewer than 50,000 residents;
19 (4) retail pharmacies with a physical location in a
20 county in Illinois with 50,000 or more residents and in an
21 area within Illinois that is designated by the United
22 States Department of Health and Human Services as either:
23 (A) a Medically Underserved Area, including Governor's
24 Exceptions; or (B) a Medically Underserved Population,
25 including Governor's Exceptions;
26 (5) pharmacies whose claims constitute 65% or greater
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1 for Medicaid services and at least 80% of their total
2 claims are for pharmacy services administered in Illinois;
3 (6) a pharmacy located in an Illinois census tract
4 that meets both of the following poverty and population
5 density and pharmacy accessibility standards:
6 (A) the census tract has either: (i) 20% or more of
7 its population living below the poverty guidelines
8 updated periodically in the Federal Register by the
9 U.S. Department of Health and Human Services under the
10 authority of 42 U.S.C. 9902(2); or (ii) a median
11 household income of less than 80% of the median income
12 of the nearest metropolitan area; and
13 (B) the census tract has at least 33% of its
14 population living one mile or more from the pharmacy
15 for urban tracts or more than 10 miles from the
16 pharmacy for rural tracts.
17 At least annually, the Department shall file with the
18 Governor and the General Assembly a report that includes:
19 (1) the number of beneficiaries who applied for
20 funding;
21 (2) the number of beneficiaries who received funding;
22 and
23 (3) the pharmacies that were awarded funding,
24 including the location, the amount of funding, and the
25 subsection category or categories under which the pharmacy
26 qualified.
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1 (Source: P.A. 103-588, eff. 6-5-24.)
2 Section 12. The State Finance Act is amended by adding
3 Section 5.1030 as follows:
4 (30 ILCS 105/5.1030 new)
5 Sec. 5.1030. The Prescription Drug Affordability Fund.
6 Section 15. The School Code is amended by changing Section
7 10-22.3f as follows:
8 (105 ILCS 5/10-22.3f)
9 Sec. 10-22.3f. Required health benefits. Insurance
10 protection and benefits for employees shall provide the
11 post-mastectomy care benefits required to be covered by a
12 policy of accident and health insurance under Section 356t and
13 the coverage required under Sections 356g, 356g.5, 356g.5-1,
14 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a,
15 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14,
16 356z.15, 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.56, 356z.57, 356z.59, 356z.60,
19 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and
20 356z.71, 356z.74, and 356z.77 of the Illinois Insurance Code.
21 Insurance policies shall comply with Section 356z.19 of the
22 Illinois Insurance Code. The coverage shall comply with
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1 Sections 155.22a, 355b, and 370c and Article XXXIIB of the
2 Illinois Insurance Code. The Department of Insurance shall
3 enforce the requirements of this Section.
4 Rulemaking authority to implement Public Act 95-1045, if
5 any, is conditioned on the rules being adopted in accordance
6 with all provisions of the Illinois Administrative Procedure
7 Act and all rules and procedures of the Joint Committee on
8 Administrative Rules; any purported rule not so adopted, for
9 whatever reason, is unauthorized.
10 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
11 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
12 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804,
13 eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
14 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff.
15 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420,
16 eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23;
17 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff.
18 7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918,
19 eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)
20 Section 20. The Illinois Insurance Code is amended by
21 changing Sections 513b1, 513b2, and 513b3 and by adding
22 Section 513b1.1 as follows:
23 (215 ILCS 5/513b1)
24 Sec. 513b1. Pharmacy benefit manager contracts.
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1 (a) As used in this Section:
2 "340B drug discount program" means the program established
3 under Section 340B of the federal Public Health Service Act,
4 42 U.S.C. 256b.
5 "340B entity" means a covered entity as defined in 42
6 U.S.C. 256b(a)(4) authorized to participate in the 340B drug
7 discount program.
8 "340B pharmacy" means any pharmacy used to dispense 340B
9 drugs for a covered entity, whether entity-owned or external.
10 "Affiliate" means a person or entity that directly or
11 indirectly through one or more intermediaries controls or is
12 controlled by, or is under common control with, the person or
13 entity specified. The location of a person or entity's
14 domicile, whether in Illinois or a foreign or alien
15 jurisdiction, does not affect the person or entity's status as
16 an affiliate.
17 "Biological product" has the meaning ascribed to that term
18 in Section 19.5 of the Pharmacy Practice Act.
19 "Brand name drug" means a drug that has been approved
20 under 42 U.S.C. 262 or 21 U.S.C. 355(c), as applicable, and is
21 marketed, sold, or distributed under a proprietary,
22 trademark-protected name.
23 "Complex or chronic medical condition" means a physical,
24 behavioral, or developmental condition that has no known cure,
25 is progressive, or can be debilitating or fatal if unmanaged
26 or untreated.
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1 "Covered individual" means a member, participant,
2 enrollee, contract holder, policyholder, or beneficiary of a
3 health benefit plan who is provided a drug benefit by the
4 health benefit plan.
5 "Critical access pharmacy" means a critical access care
6 pharmacy as defined in Section 5-5.12b of the Illinois Public
7 Aid Code.
8 "Drugs" has the meaning ascribed to that term in Section 3
9 of the Pharmacy Practice Act and includes biological products.
10 "Generic drug" means a drug that has been approved under
11 42 U.S.C. 262 or 21 U.S.C. 355(c), as applicable, and is
12 marketed, sold, or distributed directly or indirectly to the
13 retail class of trade with labeling, packaging (other than
14 repackaging as the listed drug in blister packs, unit doses,
15 or similar packaging for use in institutions), product code,
16 labeler code, trade name, or trademark that differs from that
17 of the brand name drug.
18 "Health benefit plan" means a policy, contract,
19 certificate, or agreement entered into, offered, or issued by
20 an insurer to provide, deliver, arrange for, pay for, or
21 reimburse any of the costs of physical, mental, or behavioral
22 health care services. Notwithstanding Sections 122-1 through
23 122-4 of this Code, "health benefit plan" includes self-funded
24 employee welfare benefit plans. Notwithstanding Sections 122-1
25 through 122-4 of this Code, "health benefit plan" includes
26 self-funded employee welfare benefit plans except for
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1 self-funded multiemployer plans that are not nonfederal
2 government plans.
3 "Maximum allowable cost" means the maximum amount that a
4 pharmacy benefit manager will reimburse a pharmacy for the
5 cost of a drug.
6 "Maximum allowable cost list" means a list of drugs for
7 which a maximum allowable cost has been established by a
8 pharmacy benefit manager.
9 "Pharmacy benefit manager" means a person, business, or
10 entity, including a wholly or partially owned or controlled
11 subsidiary of a pharmacy benefit manager, that provides claims
12 processing services or other prescription drug or device
13 services, or both, for health benefit plans.
14 "Pharmacy" has the meaning given to that term in Section 3
15 of the Pharmacy Practice Act.
16 "Pharmacy services" means the provision of any services
17 listed within the definition of "practice of pharmacy" under
18 subsection (d) of Section 3 of the Pharmacy Practice Act.
19 "Rare medical condition" means a physical, behavioral, or
20 developmental condition that affects fewer than 200,000
21 individuals in the United States or approximately 1 in 1,500
22 individuals worldwide.
23 "Rebate" means a discount or pricing concession based on
24 drug utilization or administration that is paid by the
25 manufacturer to a pharmacy benefit manager or its client.
26 "Rebate aggregator" means a person or entity, including
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1 group purchasing organizations, that negotiate rebates or
2 other fees with drug manufacturers on behalf or for the
3 benefit of a pharmacy benefit manager or its client and may
4 also be involved in contracts that entitle the rebate
5 aggregator or its client to receive rebates or other fees from
6 drug manufacturers based on drug utilization or
7 administration.
8 "Retail price" means the price an individual without
9 prescription drug coverage would pay at a retail pharmacy, not
10 including a pharmacist dispensing fee.
11 "Specialty drug" means a drug that:
12 (1) is prescribed for a person with a complex or
13 chronic medical condition or a rare medical condition;
14 (2) has limited or exclusive distribution; and
15 (3) requires both:
16 (A) specialized product handling by the dispensing
17 pharmacy or administration by the dispensing pharmacy;
18 and
19 (B) specialized clinical care, including frequent
20 dosing adjustments, intensive clinical monitoring, or
21 expanded services for patients, including intensive
22 patient counseling, education, or ongoing clinical
23 support beyond traditional dispensing activities, such
24 as individualized disease and therapy management to
25 support improved health outcomes.
26 "Spread pricing" means the model of drug pricing in which
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1 the pharmacy benefit manager charges a health benefit plan a
2 contracted price for drugs, and the contracted price for the
3 drugs differs from the amount the pharmacy benefit manager
4 directly or indirectly pays the pharmacist or pharmacy for the
5 drugs, pharmacist services, or drug and dispensing fees.
6 "Steer" includes, but is not limited to:
7 (1) requiring a covered individual to only use a
8 pharmacy, including a mail-order or specialty pharmacy, in
9 which the pharmacy benefit manager or its affiliate
10 maintains an ownership interest or control;
11 (2) offering or implementing a plan design that
12 encourages a covered individual to only use a pharmacy in
13 which the pharmacy benefit manager or an affiliate
14 maintains an ownership interest or control, if the plan
15 design increases costs for the covered individual. This
16 includes a plan design that requires a covered individual
17 to pay higher costs or an increased share of costs for a
18 drug or drug-related service if the covered individual
19 uses a pharmacy that is not owned or controlled by the
20 pharmacy benefit manager or its affiliate.
21 (3) reimbursing a pharmacy or pharmacist for a drug
22 and pharmacist service in an amount less than the amount
23 that the pharmacy benefit manager reimburses itself or an
24 affiliate, including affiliated manufacturers or joint
25 ventures for providing the same drug or service.
26 "Third-party payer" means any entity that pays for
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1 prescription drugs on behalf of a patient other than a health
2 care provider or sponsor of a plan subject to regulation under
3 Medicare Part D, 42 U.S.C. 1395w-101 et seq.
4 (a-5) In this Article, references to an "insurer" or
5 "health insurer" shall include commercial private health
6 insurance issuers, managed care organizations, managed care
7 community networks, and any other third-party payer that
8 contracts with pharmacy benefit managers or with the
9 Department of Healthcare and Family Services to provide
10 benefits or services under the Medicaid program or to
11 otherwise engage in the administration or payment of pharmacy
12 benefits. However, the terms do not refer to the plan sponsor
13 of a self-funded, single-employer employee welfare benefit
14 plan or self-funded multiemployer plan subject to 29 U.S.C.
15 1144.
16 (b) A contract between a health insurer and a pharmacy
17 benefit manager must require that the pharmacy benefit
18 manager:
19 (1) Update maximum allowable cost pricing information
20 at least every 7 calendar days.
21 (2) Maintain a process that will, in a timely manner,
22 eliminate drugs from maximum allowable cost lists or
23 modify drug prices to remain consistent with changes in
24 pricing data used in formulating maximum allowable cost
25 prices and product availability.
26 (3) Provide access to its maximum allowable cost list
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1 to each pharmacy or pharmacy services administrative
2 organization subject to the maximum allowable cost list.
3 Access may include a real-time pharmacy website portal to
4 be able to view the maximum allowable cost list. As used in
5 this Section, "pharmacy services administrative
6 organization" means an entity operating within the State
7 that contracts with independent pharmacies to conduct
8 business on their behalf with third-party payers. A
9 pharmacy services administrative organization may provide
10 administrative services to pharmacies and negotiate and
11 enter into contracts with third-party payers or pharmacy
12 benefit managers on behalf of pharmacies.
13 (4) Provide a process by which a contracted pharmacy
14 can appeal the provider's reimbursement for a drug subject
15 to maximum allowable cost pricing. The appeals process
16 must, at a minimum, include the following:
17 (A) A requirement that a contracted pharmacy has
18 14 calendar days after the applicable fill date to
19 appeal a maximum allowable cost if the reimbursement
20 for the drug is less than the net amount that the
21 network provider paid to the supplier of the drug.
22 (B) A requirement that a pharmacy benefit manager
23 must respond to a challenge within 14 calendar days of
24 the contracted pharmacy making the claim for which the
25 appeal has been submitted.
26 (C) A telephone number and e-mail address or
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1 website to network providers, at which the provider
2 can contact the pharmacy benefit manager to process
3 and submit an appeal.
4 (D) A requirement that, if an appeal is denied,
5 the pharmacy benefit manager must provide the reason
6 for the denial and the name and the national drug code
7 number from national or regional wholesalers.
8 (E) A requirement that, if an appeal is sustained,
9 the pharmacy benefit manager must make an adjustment
10 in the drug price effective the date the challenge is
11 resolved and make the adjustment applicable to all
12 similarly situated network pharmacy providers, as
13 determined by the managed care organization or
14 pharmacy benefit manager.
15 (5) Allow a plan sponsor or insurer whose coverage is
16 administered by the contracting with a pharmacy benefit
17 manager an annual right to audit compliance with the terms
18 of the contract by the pharmacy benefit manager,
19 including, but not limited to, full disclosure of any and
20 all rebate amounts secured, whether product specific or
21 generalized rebates, that were provided to the pharmacy
22 benefit manager by a pharmaceutical manufacturer. The cost
23 of the audit shall be borne exclusively by the pharmacy
24 benefit manager.
25 (6) Allow a plan sponsor or insurer whose coverage is
26 administered by the contracting with a pharmacy benefit
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1 manager to request that the pharmacy benefit manager
2 disclose the actual amounts paid by the pharmacy benefit
3 manager to the pharmacy.
4 (7) Provide notice to the plan sponsor or the insurer
5 party contracting with the pharmacy benefit manager of any
6 consideration that the pharmacy benefit manager receives
7 from the manufacturer for dispense as written
8 prescriptions once a generic or biologically similar
9 product becomes available.
10 (c) In order to place a particular prescription drug on a
11 maximum allowable cost list, the pharmacy benefit manager
12 must, at a minimum, ensure that:
13 (1) if the drug is a generically equivalent drug, it
14 is listed as therapeutically equivalent and
15 pharmaceutically equivalent "A" or "B" rated in the United
16 States Food and Drug Administration's most recent version
17 of the "Orange Book" or have an NR or NA rating by
18 Medi-Span, Gold Standard, or a similar rating by a
19 nationally recognized reference;
20 (2) the drug is available for purchase by each
21 pharmacy in the State from national or regional
22 wholesalers operating in Illinois; and
23 (3) the drug is not obsolete.
24 (d) A pharmacy benefit manager is prohibited from limiting
25 a pharmacist's ability to disclose whether the cost-sharing
26 obligation exceeds the retail price for a covered prescription
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1 drug, and the availability of a more affordable alternative
2 drug, if one is available in accordance with Section 42 of the
3 Pharmacy Practice Act.
4 (e) A health insurer or pharmacy benefit manager shall not
5 require a covered individual an insured to make a payment for a
6 prescription drug at the point of sale in an amount that
7 exceeds the lesser of:
8 (1) the applicable cost-sharing amount; or
9 (2) the retail price of the drug in the absence of
10 prescription drug coverage;
11 (3) the discounted price presented by the covered
12 individual through a no-cost drug program or drug
13 manufacturer voucher provided by or for the covered
14 individual at the point of sale; or
15 (4) the discounted price presented by the covered
16 individual through a discounted health care services plan
17 provided by or for the covered individual at the point of
18 sale.
19 (f) Unless required by law, a contract between a pharmacy
20 benefit manager or third-party payer and a 340B entity or 340B
21 pharmacy shall not contain any provision that:
22 (1) distinguishes between drugs purchased through the
23 340B drug discount program and other drugs when
24 determining reimbursement or reimbursement methodologies,
25 or contains otherwise less favorable payment terms or
26 reimbursement methodologies for 340B entities or 340B
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1 pharmacies when compared to similarly situated non-340B
2 entities;
3 (2) imposes any fee, chargeback, or rate adjustment
4 that is not similarly imposed on similarly situated
5 pharmacies that are not 340B entities or 340B pharmacies;
6 (3) imposes any fee, chargeback, or rate adjustment
7 that exceeds the fee, chargeback, or rate adjustment that
8 is not similarly imposed on similarly situated pharmacies
9 that are not 340B entities or 340B pharmacies;
10 (4) prevents or interferes with an individual's choice
11 to receive a covered prescription drug from a 340B entity
12 or 340B pharmacy through any legally permissible means,
13 except that nothing in this paragraph shall prohibit the
14 establishment of differing copayments or other
15 cost-sharing amounts within the health benefit plan for
16 covered individuals persons who acquire covered
17 prescription drugs from a nonpreferred or nonparticipating
18 provider;
19 (5) excludes a 340B entity or 340B pharmacy from a
20 pharmacy network on any basis that includes consideration
21 of whether the 340B entity or 340B pharmacy participates
22 in the 340B drug discount program;
23 (6) prevents a 340B entity or 340B pharmacy from using
24 a drug purchased under the 340B drug discount program; or
25 (7) any other provision that discriminates against a
26 340B entity or 340B pharmacy by treating the 340B entity
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1 or 340B pharmacy differently than non-340B entities or
2 non-340B pharmacies for any reason relating to the
3 entity's participation in the 340B drug discount program.
4 As used in this subsection, "pharmacy benefit manager" and
5 "third-party payer" do not include pharmacy benefit managers
6 and third-party payers acting on behalf of a Medicaid program.
7 (f-5) A pharmacy benefit manager or an affiliate acting on
8 its behalf shall not conduct spread pricing.
9 (f-10) A pharmacy benefit manager or an affiliate acting
10 on its behalf shall not steer a covered individual. Existing
11 agreements entered into before the effective date of this
12 amendatory Act of the 104th General Assembly shall supersede
13 this subsection until the termination of the current term of
14 such agreement.
15 (f-15) A pharmacy benefit manager or affiliated rebate
16 aggregator must remit no less than 100% of any amounts paid by
17 a pharmaceutical manufacturer, wholesaler, or other
18 distributor of a drug, including, but not limited to, rebates,
19 group purchasing fees, and other fees, to the health benefit
20 plan sponsor, covered individual, or employer. Records of
21 rebates and fees remitted from the pharmacy benefit manager or
22 rebate aggregator must be disclosed to the Department annually
23 in a format to be specified by the Department. The records
24 received by the Department shall be considered confidential
25 and privileged for all purposes, including for purposes of the
26 Freedom of Information Act, shall not be subject to subpoena
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1 from any private party, and shall not be admissible as
2 evidence in a civil action.
3 (f-20) A pharmacy benefit manager or an affiliate acting
4 on its behalf is prohibited from limiting a covered
5 individual's access to drugs from a pharmacy or pharmacist
6 enrolled with the health benefit plan under the terms offered
7 to all pharmacies in the plan coverage area by designating the
8 covered drug as a specialty drug contrary to the definition in
9 this Section.
10 (f-25) The contract between the pharmacy benefit manager
11 and the insurer or health benefit plan sponsor must allow and
12 provide for the pharmacy benefit manager's compliance with an
13 audit at least once per calendar year of the rebate and fee
14 records remitted from a pharmacy benefit manager or its
15 affiliated party to a health benefit plan. This audit may be
16 incorporated into the audit under paragraph (5) of subsection
17 (b) of this Section. Contracts with rebate aggregators,
18 pharmacy services administrative organizations, pharmacies, or
19 drug manufacturers must be available for audit by health
20 benefit plan sponsors, insurers, or their designees at least
21 once per plan year. Audits shall be performed by an auditor
22 selected by the health benefit plan sponsor, insurer, or its
23 designee. Health benefit plan sponsors and insurers shall give
24 the pharmacy benefit manager a complete copy of the audit and
25 the pharmacy benefit manager shall provide a complete copy of
26 those findings to the Department within 60 days of initial
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1 receipt. Rebate contracts with rebate aggregators, pharmacy
2 services administrative organizations, pharmacies, or drug
3 manufacturers shall be available for audit by health benefit
4 plan sponsor, insurer, or designee. Nothing in this Section
5 shall limit the Department's ability to access the books and
6 records and any and all copies thereof of pharmacy benefit
7 managers, their affiliates, or affiliated rebate aggregators.
8 The records received by the Department shall be considered
9 confidential and privileged for all purposes, including for
10 purposes of the Freedom of Information Act, shall not be
11 subject to subpoena from any private party, and shall not be
12 admissible as evidence in a civil action.
13 (g) A violation of this Section by a pharmacy benefit
14 manager constitutes an unfair or deceptive act or practice in
15 the business of insurance under Section 424.
16 (h) A provision that violates subsection (f) in a contract
17 between a pharmacy benefit manager or a third-party payer and
18 a 340B entity that is entered into, amended, or renewed after
19 July 1, 2022 shall be void and unenforceable. This subsection
20 and subsection (f) do not apply to a contract directly between
21 a 340B entity and the plan sponsor of a self-funded,
22 single-employer or multiemployer employee welfare benefit plan
23 subject to 29 U.S.C. 1144.
24 (i)(1) A pharmacy benefit manager may not retaliate
25 against a pharmacist or pharmacy for disclosing information in
26 a court, in an administrative hearing, before a legislative
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1 commission or committee, or in any other proceeding, if the
2 pharmacist or pharmacy has reasonable cause to believe that
3 the disclosed information is evidence of a violation of a
4 State or federal law, rule, or regulation.
5 (2) A pharmacy benefit manager may not retaliate against a
6 pharmacist or pharmacy for disclosing information to a
7 government or law enforcement agency, if the pharmacist or
8 pharmacy has reasonable cause to believe that the disclosed
9 information is evidence of a violation of a State or federal
10 law, rule, or regulation.
11 (3) A pharmacist or pharmacy shall make commercially
12 reasonable efforts to limit the disclosure of confidential and
13 proprietary information.
14 (4) Retaliatory actions against a pharmacy or pharmacist
15 include cancellation of, restriction of, or refusal to renew
16 or offer a contract to a pharmacy solely because the pharmacy
17 or pharmacist has:
18 (A) made disclosures of information that the
19 pharmacist or pharmacy has reasonable cause to believe is
20 evidence of a violation of a State or federal law, rule, or
21 regulation;
22 (B) filed complaints with the plan or pharmacy benefit
23 manager; or
24 (C) filed complaints against the plan or pharmacy
25 benefit manager with the Department.
26 (j) This Section applies to contracts entered into or
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1 renewed on or after July 1, 2022 and, unless provided
2 otherwise in this Section or in the Illinois Public Aid Code,
3 applies to pharmacy benefit managers that are contracted with
4 a Medicaid managed care entity on or after January 1, 2026.
5 (k) This Section applies to any health benefit group or
6 individual policy of accident and health insurance or managed
7 care plan that provides coverage for prescription drugs and
8 that is amended, delivered, issued, or renewed on or after
9 July 1, 2020. The changes made to this Section by this
10 amendatory Act of the 104th General Assembly shall apply with
11 respect to any health benefit plan that provides coverage for
12 drugs that is amended, delivered, issued, or renewed on or
13 after January 1, 2026.
14 (l) A pharmacy benefit manager is responsible for
15 compliance with all State requirements applicable to pharmacy
16 benefit managers even if an action or responsibility of a
17 pharmacy benefit manager is delegated to or completed by an
18 affiliate.
19 (Source: P.A. 102-778, eff. 7-1-22; 103-154, eff. 6-30-23;
20 103-453, eff. 8-4-23.)
21 (215 ILCS 5/513b1.1 new)
22 Sec. 513b1.1. Pharmacy benefit manager reporting
23 requirements.
24 (a) A pharmacy benefit manager that provides services for
25 a health benefit plan must submit an annual report no later
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1 than September 1, to the Department, each health benefit plan
2 sponsor, and each insurer that includes the following:
3 (1) data on the health benefit plan including:
4 (A) a list of drugs including corresponding
5 information on therapeutic class, brand name, generic
6 name, or specialty drug name;
7 (B) number of covered individuals;
8 (C) number of drug-related claims;
9 (D) dosage units;
10 (E) dispensing channel used;
11 (F) average wholesale acquisition cost per drug;
12 and
13 (G) total out-of-pocket spending by deidentified
14 covered individual per drug, per transaction;
15 (2) amount received by the health benefit plan in
16 rebates, fees, or discounts related to drug utilization or
17 spending;
18 (3) total gross spending on drugs by the health
19 benefit plan;
20 (4) total net spending, gross spending less
21 administrative portion of the medical loss ratio, on drugs
22 by the health benefit plan;
23 (5) the amount paid by the health benefit plan to the
24 pharmacy benefit manager for reimbursement cost of a drug
25 and service per transaction;
26 (6) the amount a pharmacy benefit manager paid for
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1 pharmacists' services and drugs rendered related to the
2 health benefit plan per transaction, including, but not
3 limited to, any dispensing fee;
4 (7) the specific rebate amount received by the
5 pharmacy benefit manager per transaction, the amount of
6 the rebates passed through to the health benefit plan per
7 transaction, and the amount of the rebates passed on to
8 covered individuals at the point of sale that reduced the
9 covered individuals' applicable deductible, copayment,
10 coinsurance, or other cost-sharing amount per transaction;
11 (8) any information collected from drug manufacturers
12 pertaining to copayment assistance to the extent such
13 information is collected;
14 (9) any compensation paid to brokers, consultants,
15 advisors, or any other individual or firm for referrals,
16 consideration, or retention by the health benefit plan;
17 (10) explanation of benefit design parameters
18 encouraging or requiring covered individuals to use
19 affiliated pharmacies, percentage of drugs charged by
20 these pharmacies, and a list of drugs dispensed by
21 affiliated pharmacies with their associated costs; and
22 (11) a complete copy of each unredacted contract the
23 pharmacy benefit manager has with the health benefit plan
24 sponsor or insurer.
25 (b) Annual reports pursuant to subsection (a):
26 (1) must be written in plain language to ensure ease
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1 of reading and accessibility;
2 (2) must only contain summary health information to
3 ensure plan, coverage, or covered individual information
4 remains private and confidential;
5 (3) upon request by a covered individual, must be
6 available in summary format and provide aggregated
7 information to help covered individuals understand their
8 health benefit plan's drug coverage; and
9 (4) must be filed with the Department no later than
10 September 1 of each year via the Systems for Electronic
11 Rates & Forms Filing (SERFF). The filing shall include the
12 summary version of the report described in paragraph (3)
13 of this subsection, which shall be marked for public
14 access.
15 The Department may share all reports with an established
16 institution of higher education in this State for the creation
17 of a pharmacist dispensing cost report to be produced
18 annually. This annual pharmacist dispensing cost report shall
19 provide a survey of the average cost of dispensing a
20 prescription for pharmacists in Illinois. The institution of
21 higher education shall have the ability to request additional
22 information from pharmacists for its analysis. The institution
23 of higher education shall issue the report to the General
24 Assembly no later than December 31, 2026 and annually
25 thereafter.
26 (c) A pharmacy benefit manager may petition the Department
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1 for a filing submission extension. The Director may grant or
2 deny the extension within 5 business days.
3 (d) Failure by a pharmacy benefit manager to submit all
4 required elements in an annual report to the Department may
5 result in a fine levied by the Director not to exceed $10,000
6 per day, per offense. Funds derived from fines levied shall be
7 deposited into the Insurance Producer Administration Fund.
8 Fine information shall be posted on the Department's website.
9 (e) A pharmacy benefit manager found in violation of
10 subsection (a) or paragraph (4) of subsection (b) may request
11 a hearing from the Director within 10 days of receipt of the
12 Director's order, or, if the violation is found in a market
13 conduct examination, as provided in Section 132 of this Code.
14 (f) Except for the summary version, the annual reports
15 submitted by pharmacy benefit managers shall be considered
16 confidential and privileged for all purposes, including for
17 purposes of the Freedom of Information Act, shall not be
18 subject to subpoena from any private party, and shall not be
19 admissible as evidence in a civil action.
20 (g) A copy of an adverse decision against a pharmacy
21 benefit manager for failing to submit an annual report to the
22 Department must be posted to the Department's website.
23 (h) Nothing in this Section shall be construed as
24 permitting a pharmacy benefit manager to avoid or otherwise
25 fail to comply with the reporting requirements set forth in
26 Section 5-36 of the Illinois Public Aid Code.
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1 (215 ILCS 5/513b2)
2 Sec. 513b2. Licensure requirements.
3 (a) Beginning on July 1, 2020, to conduct business in this
4 State, a pharmacy benefit manager must register with the
5 Director. To initially register or renew a registration, a
6 pharmacy benefit manager shall submit:
7 (1) A nonrefundable fee not to exceed $500.
8 (2) A copy of the registrant's corporate charter,
9 articles of incorporation, or other charter document.
10 (3) A completed registration form adopted by the
11 Director containing:
12 (A) The name and address of the registrant.
13 (B) The name, address, and official position of
14 each officer and director of the registrant.
15 (b) The registrant shall report any change in information
16 required under this Section to the Director in writing within
17 60 days after the change occurs.
18 (c) Upon receipt of a completed registration form, the
19 required documents, and the registration fee, the Director
20 shall issue a registration certificate. The certificate may be
21 in paper or electronic form, and shall clearly indicate the
22 expiration date of the registration. Registration certificates
23 are nontransferable.
24 (d) A registration certificate is valid for 2 years after
25 its date of issue. The Director shall adopt by rule an initial
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1 registration fee not to exceed $500 and a registration renewal
2 fee not to exceed $500, both of which shall be nonrefundable.
3 Total fees may not exceed the cost of administering this
4 Section.
5 (e) The Department shall adopt any rules necessary to
6 implement this Section.
7 (f) On or before August 1, 2025, the pharmacy benefit
8 manager shall submit a report to the Department that lists the
9 name of each health benefit plan it administers, provides the
10 number of covered individuals for each health benefit plan as
11 of the date of submission, and provides the total number of
12 covered individuals across all health benefit plans the
13 pharmacy benefit manager administers. On or before September
14 1, 2025, a registered pharmacy benefit manager, as a condition
15 of its authority to transact business in this State, must
16 submit to the Department an amount equal to $15 or an alternate
17 amount as determined by the Director by rule per covered
18 individual enrolled by the pharmacy benefit manager in this
19 State, as detailed in the report submitted to the Department
20 under this subsection, during the preceding calendar year. On
21 or before September 1, 2026 and each September 1 thereafter,
22 payments submitted under this subsection shall be based on the
23 number of covered individuals reported to the Department in
24 Section 513b1.1.
25 (g) All amounts collected under this Section shall be
26 deposited into the Prescription Drug Affordability Fund, which
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1 is hereby created as a special fund in the State treasury. Of
2 the amounts collected under this Section each fiscal year, the
3 Department shall transfer the first $25,000,000 into the DCEO
4 Projects Fund for grants to pharmacies under Section 605-60 of
5 the Department of Commerce and Economic Opportunity Law.
6 (Source: P.A. 101-452, eff. 1-1-20.)
7 (215 ILCS 5/513b3)
8 Sec. 513b3. Examination.
9 (a) The Director, or his or her designee, may examine a
10 registered pharmacy benefit manager related to all of its
11 lines of business, including government programs, under the
12 Director's jurisdiction in accordance with Sections 132-132.7.
13 If the Director or the examiners find that the pharmacy
14 benefit manager has violated this Article or any other
15 insurance-related or health benefits-related laws, rules, or
16 regulations under the Director's jurisdiction because of the
17 manner in which the pharmacy benefit manager has conducted
18 business on behalf of a health insurer or plan sponsor, then,
19 unless the health insurer or plan sponsor is included in the
20 examination and has been afforded the same opportunity to
21 request or participate in a hearing on the examination report,
22 the examination report shall not allege a violation by the
23 health insurer or plan sponsor and the Director's order based
24 on the report shall not impose any requirements, prohibitions,
25 or penalties on the health insurer or plan sponsor. Nothing in
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1 this Section shall prevent the Director from using any
2 information obtained during the examination of an
3 administrator to examine, investigate, or take other
4 appropriate regulatory or legal action with respect to a
5 health insurer or plan sponsor.
6 (b) The examination requirement for the pharmacy benefit
7 manager to provide convenient and free access to all books and
8 records under Sections 132 and 132.4 of this Code includes, at
9 the Director's discretion, unredacted copies furnished
10 electronically to the Director's market conduct surveillance
11 personnel or examiners. Access must include information
12 related to third-party entities affiliated or contracted with
13 the pharmacy benefit manager, including, but not limited to,
14 rebate aggregators and pharmacy services administrative
15 organizations.
16 (c) The Department may examine any pharmacy benefit
17 manager as often as the Department deems appropriate, but
18 shall, at a minimum, conduct an examination of the 3 largest
19 pharmacy benefit managers with the most covered individuals
20 not less frequently than once every 5 years beginning in 2026,
21 or following the conclusion of any market conduct exams
22 already in progress for the 3 largest pharmacy benefit
23 managers. In determining pharmacy benefit plan market share,
24 the Department may consider, but is not limited to, the
25 following:
26 (1) the number of covered individuals;
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1 (2) the Illinois Market share;
2 (3) the number of drug-related claims;
3 (4) the total gross spending on drugs;
4 (5) the aggregate amounts of rebates, fees, and
5 discounts remitted by the pharmacy benefit manager or
6 rebate aggregator;
7 (6) the dispensing channel used;
8 (7) the previous violations; and
9 (8) the complaints received.
10 (Source: P.A. 103-897, eff. 1-1-25.)
11 Section 25. The Illinois Public Aid Code is amended by
12 changing Sections 5-5.12b and 5-36 as follows:
13 (305 ILCS 5/5-5.12b)
14 Sec. 5-5.12b. Critical access care pharmacy program.
15 (a) As used in this Section:
16 "Critical access care pharmacy" means an Illinois-based
17 brick and mortar retail pharmacy that is located in Illinois
18 that is owned by a person or entity with an ownership or
19 control interest in a county with fewer than 50,000 residents
20 and that owns fewer than 10 pharmacies, is either located in a
21 county with fewer than 50,000 residents or in a county with
22 50,000 or more residents and in an area within Illinois that is
23 designated as a Medically Underserved Area by the Health
24 Resources and Services Administration, an agency of the U.S.
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1 Department of Health and Human Services and has attested and
2 been approved by the Department for participation in the
3 critical access care pharmacy program.
4 "Critical access care pharmacy program payment" means the
5 number of individual prescriptions a critical access care
6 pharmacy fills during that quarter multiplied by the lesser of
7 the individual payment amount or the dispensing reimbursement
8 rate made by the Department under the medical assistance
9 program as of April 1, 2018.
10 "Individual payment amount" means the dividend of 1/4 of
11 the annual amount appropriated for the critical access care
12 pharmacy program by the number of prescriptions filled by all
13 critical access care pharmacies reimbursed by Medicaid managed
14 care organizations that quarter.
15 "Ownership or control interest" has the meaning given to
16 "person with an ownership or control interest" in 42 CFR
17 455.101.
18 (b) Subject to appropriations and federal approval, the
19 Department shall establish a critical access care pharmacy
20 program to ensure the sustainability of critical access
21 pharmacies throughout the State of Illinois.
22 (c) The critical access care pharmacy program disbursed by
23 the managed care plans shall not exceed $45,000,000
24 $10,000,000 annually and individual payment amounts per
25 prescription shall not exceed the brand name dispensing rate
26 that the Department would have reimbursed to a critical access
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1 care pharmacy under the Medical Assistance Program as of July
2 1, 2024 April 1, 2018.
3 (c-5) 340B pharmacies that are participants in the
4 critical access care pharmacy program shall only be reimbursed
5 for the actual acquisition costs of the 340B covered drugs
6 dispensed to participants in the State's medical assistance
7 program as defined in the Illinois Public Aid Code.
8 (d) Annually, beginning January 1, 2026 Quarterly, the
9 Department shall determine the number of prescriptions filled
10 by critical access care pharmacies reimbursed by Medicaid
11 managed care organizations utilizing encounter data available
12 to the Department. The Department shall determine the
13 individual payment amount per prescription by dividing 1/4 of
14 the annual amount appropriated for the critical access care
15 pharmacy program by the number of prescriptions filled by all
16 critical access care pharmacies reimbursed by Medicaid managed
17 care organizations that quarter. If the individual payment
18 amount per prescription as calculated using quarterly
19 prescription amounts exceeds the reimbursement rate under the
20 medical assistance program as of April 1, 2018, then the
21 individual payment amount per prescription shall be the
22 dispensing reimbursement rate under the medical assistance
23 program as of April 1, 2018.
24 (e) Quarterly, the Department shall distribute to critical
25 access care pharmacies a critical access care pharmacy program
26 payment. The first payment shall be calculated utilizing the
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1 encounter data from the last quarter of State fiscal year
2 2018. This payment shall sunset on December 31, 2025.
3 (f) Effective January 1, 2026, the Department shall issue
4 a quarterly directed critical access care pharmacy program
5 payment to critical access care pharmacies for any
6 prescription drug dispensed to a managed care client.
7 (g) (f) The Department may adopt rules necessary to
8 implement this Section. The rules may include, but are not
9 limited to, permitting an Illinois-based brick and mortar
10 pharmacy that owns fewer than 10 pharmacies to receive
11 critical access care pharmacy program payments in the same
12 manner as a critical access care pharmacy, regardless of
13 whether the pharmacy meets the other requirements of a
14 critical access care pharmacy in subsection (a) is located in
15 a county with a population of less than 50,000.
16 (Source: P.A. 100-587, eff. 6-4-18.)
17 (305 ILCS 5/5-36)
18 Sec. 5-36. Pharmacy benefits.
19 (a)(1) The Department may enter into a contract with a
20 third party on a fee-for-service reimbursement model for the
21 purpose of administering pharmacy benefits as provided in this
22 Section for members not enrolled in a Medicaid managed care
23 organization; however, these services shall be approved by the
24 Department. The Department shall ensure coordination of care
25 between the third-party administrator and managed care
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1 organizations as a consideration in any contracts established
2 in accordance with this Section. Any managed care techniques,
3 principles, or administration of benefits utilized in
4 accordance with this subsection shall comply with State law.
5 (2) The following shall apply to contracts between
6 entities contracting relating to the Department's third-party
7 administrators and pharmacies:
8 (A) the Department shall approve any contract between
9 a third-party administrator and a pharmacy;
10 (B) the Department's third-party administrator shall
11 not change the terms of a contract between a third-party
12 administrator and a pharmacy without written approval by
13 the Department; and
14 (C) the Department's third-party administrator shall
15 not create, modify, implement, or indirectly establish any
16 fee on a pharmacy, pharmacist, or a recipient of medical
17 assistance without written approval by the Department.
18 (b) The provisions of this Section shall not apply to
19 outpatient pharmacy services provided by a health care
20 facility registered as a covered entity pursuant to 42 U.S.C.
21 256b or any pharmacy owned by or contracted with the covered
22 entity. A Medicaid managed care organization shall, either
23 directly or through a pharmacy benefit manager, administer and
24 reimburse outpatient pharmacy claims submitted by a health
25 care facility registered as a covered entity pursuant to 42
26 U.S.C. 256b, its owned pharmacies, and contracted pharmacies
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1 in accordance with the contractual agreements the Medicaid
2 managed care organization or its pharmacy benefit manager has
3 with such facilities and pharmacies and in accordance with
4 subsection (h-5).
5 (b-5) Any pharmacy benefit manager that contracts with a
6 Medicaid managed care organization to administer and reimburse
7 pharmacy claims as provided in this Section must be registered
8 with the Director of Insurance in accordance with Section
9 513b2 of the Illinois Insurance Code. A pharmacy benefit
10 manager must comply with all provisions of Article XXXIIB of
11 the Illinois Insurance Code to the extent that the provisions
12 do not prevent the application of any provision of this
13 Article or applicable federal law. Nothing in this Section
14 shall be construed to limit the authority of the Illinois
15 Department or the Inspector General to administer or enforce
16 any provisions of this Section or any other Section in the
17 Illinois Public Aid Code related to pharmacy benefit managers
18 or Medicaid managed care entity.
19 (c) On at least an annual basis, the Director of the
20 Department of Healthcare and Family Services shall submit a
21 report beginning no later than one year after January 1, 2020
22 (the effective date of Public Act 101-452) that provides an
23 update on any contract, contract issues, formulary, dispensing
24 fees, and maximum allowable cost concerns regarding a
25 third-party administrator and managed care. The requirement
26 for reporting to the General Assembly shall be satisfied by
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1 filing copies of the report with the Speaker, the Minority
2 Leader, and the Clerk of the House of Representatives and with
3 the President, the Minority Leader, and the Secretary of the
4 Senate. The Department shall take care that no proprietary
5 information is included in the report required under this
6 Section.
7 (d) (Blank). A pharmacy benefit manager shall notify the
8 Department in writing of any activity, policy, or practice of
9 the pharmacy benefit manager that directly or indirectly
10 presents a conflict of interest that interferes with the
11 discharge of the pharmacy benefit manager's duty to a managed
12 care organization to exercise its contractual duties.
13 "Conflict of interest" shall be defined by rule by the
14 Department.
15 (e) A pharmacy benefit manager shall, upon request,
16 disclose to the Department the following information:
17 (1) whether the pharmacy benefit manager has a
18 contract, agreement, or other arrangement with a
19 pharmaceutical manufacturer to exclusively dispense or
20 provide a drug to a managed care organization's enrollees,
21 and the aggregate amounts of consideration of economic
22 benefits collected or received pursuant to that
23 arrangement;
24 (2) the percentage of claims payments made by the
25 pharmacy benefit manager to pharmacies owned, managed, or
26 controlled by the pharmacy benefit manager or any of the
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1 pharmacy benefit manager's management companies, parent
2 companies, subsidiary companies, or jointly held
3 companies;
4 (3) the aggregate amount of the fees or assessments
5 imposed on, or collected from, pharmacy providers;
6 (4) the average annualized percentage of revenue
7 collected by the pharmacy benefit manager as a result of
8 each contract it has executed with a managed care
9 organization contracted by the Department to provide
10 medical assistance benefits which is not paid by the
11 pharmacy benefit manager to pharmacy providers and
12 pharmaceutical manufacturers or labelers or in order to
13 perform administrative functions pursuant to its contracts
14 with managed care organizations;
15 (5) the total number of prescriptions dispensed under
16 each contract the pharmacy benefit manager has with a
17 managed care organization (MCO) contracted by the
18 Department to provide medical assistance benefits;
19 (6) the aggregate wholesale acquisition cost for drugs
20 that were dispensed to enrollees in each MCO with which
21 the pharmacy benefit manager has a contract by any
22 pharmacy owned, managed, or controlled by the pharmacy
23 benefit manager or any of the pharmacy benefit manager's
24 management companies, parent companies, subsidiary
25 companies, or jointly-held companies;
26 (7) the aggregate amount of administrative fees that
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1 the pharmacy benefit manager received from all
2 pharmaceutical manufacturers for prescriptions dispensed
3 to MCO enrollees;
4 (8) for each MCO with which the pharmacy benefit
5 manager has a contract, the aggregate amount of payments
6 received by the pharmacy benefit manager from the MCO;
7 (9) for each MCO with which the pharmacy benefit
8 manager has a contract, the aggregate amount of
9 reimbursements the pharmacy benefit manager paid to
10 contracting pharmacies; and
11 (10) any other information considered necessary by the
12 Department.
13 (f) The information disclosed under subsection (e) shall
14 include all retail, mail order, specialty, and compounded
15 prescription products. All information made available to the
16 Department under subsection (e) is confidential and not
17 subject to disclosure under the Freedom of Information Act.
18 All information made available to the Department under
19 subsection (e) shall not be reported or distributed in any way
20 that compromises its competitive, proprietary, or financial
21 value. The information shall only be used by the Department to
22 assess the contract, agreement, or other arrangements made
23 between a pharmacy benefit manager and a pharmacy provider,
24 pharmaceutical manufacturer or labeler, managed care
25 organization, or other entity, as applicable.
26 (g) A pharmacy benefit manager shall disclose directly in
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1 writing to a pharmacy provider or pharmacy services
2 administrative organization contracting with the pharmacy
3 benefit manager of any material change to a contract provision
4 that affects the terms of the reimbursement, the process for
5 verifying benefits and eligibility, dispute resolution,
6 procedures for verifying drugs included on the formulary, and
7 contract termination at least 30 days prior to the date of the
8 change to the provision. The terms of this subsection shall be
9 deemed met if the pharmacy benefit manager posts the
10 information on a website, viewable by the public. A pharmacy
11 service administration organization shall notify all contract
12 pharmacies of any material change, as described in this
13 subsection, within 2 days of notification. As used in this
14 Section, "pharmacy services administrative organization" means
15 an entity operating within the State that contracts with
16 independent pharmacies to conduct business on their behalf
17 with third-party payers. A pharmacy services administrative
18 organization may provide administrative services to pharmacies
19 and negotiate and enter into contracts with third-party payers
20 or pharmacy benefit managers on behalf of pharmacies.
21 (h) A pharmacy benefit manager shall not include the
22 following in a contract with a pharmacy provider:
23 (1) a provision prohibiting the provider from
24 informing a patient of a less costly alternative to a
25 prescribed medication; or
26 (2) a provision that prohibits the provider from
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1 dispensing a particular amount of a prescribed medication,
2 if the pharmacy benefit manager allows that amount to be
3 dispensed through a pharmacy owned or controlled by the
4 pharmacy benefit manager, unless the prescription drug is
5 subject to restricted distribution by the United States
6 Food and Drug Administration or requires special handling,
7 provider coordination, or patient education that cannot be
8 provided by a retail pharmacy.
9 (h-5) Unless required by law, a Medicaid managed care
10 organization or pharmacy benefit manager administering or
11 managing benefits on behalf of a Medicaid managed care
12 organization shall not refuse to contract with a 340B entity
13 or 340B pharmacy for refusing to accept less favorable payment
14 terms or reimbursement methodologies when compared to
15 similarly situated non-340B entities and shall not include in
16 a contract with a 340B entity or 340B pharmacy a provision
17 that:
18 (1) imposes any fee, chargeback, or rate adjustment
19 that is not similarly imposed on similarly situated
20 pharmacies that are not 340B entities or 340B pharmacies;
21 (2) imposes any fee, chargeback, or rate adjustment
22 that exceeds the fee, chargeback, or rate adjustment that
23 is not similarly imposed on similarly situated pharmacies
24 that are not 340B entities or 340B pharmacies;
25 (3) prevents or interferes with an individual's choice
26 to receive a prescription drug from a 340B entity or 340B
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1 pharmacy through any legally permissible means;
2 (4) excludes a 340B entity or 340B pharmacy from a
3 pharmacy network on the basis of whether the 340B entity
4 or 340B pharmacy participates in the 340B drug discount
5 program;
6 (5) prevents a 340B entity or 340B pharmacy from using
7 a drug purchased under the 340B drug discount program so
8 long as the drug recipient is a patient of the 340B entity;
9 nothing in this Section exempts a 340B pharmacy from
10 following the Department's preferred drug list or from any
11 prior approval requirements of the Department or the
12 Medicaid managed care organization that are imposed on the
13 drug for all pharmacies; or
14 (6) any other provision that discriminates against a
15 340B entity or 340B pharmacy by treating a 340B entity or
16 340B pharmacy differently than non-340B entities or
17 non-340B pharmacies for any reason relating to the
18 entity's participation in the 340B drug discount program.
19 A provision that violates this subsection in any contract
20 between a Medicaid managed care organization or its pharmacy
21 benefit manager and a 340B entity entered into, amended, or
22 renewed after July 1, 2022 shall be void and unenforceable.
23 In this subsection (h-5):
24 "340B entity" means a covered entity as defined in 42
25 U.S.C. 256b(a)(4) authorized to participate in the 340B drug
26 discount program.
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1 "340B pharmacy" means any pharmacy used to dispense 340B
2 drugs for a covered entity, whether entity-owned or external.
3 (i) Nothing in this Section shall be construed to prohibit
4 a pharmacy benefit manager from requiring the same
5 reimbursement and terms and conditions for a pharmacy provider
6 as for a pharmacy owned, controlled, or otherwise associated
7 with the pharmacy benefit manager.
8 (j) A pharmacy benefit manager shall establish and
9 implement a process for the resolution of disputes arising out
10 of this Section, which shall be approved by the Department.
11 (k) The Department shall adopt rules establishing
12 reasonable dispensing fees for fee-for-service payments in
13 accordance with guidance or guidelines from the federal
14 Centers for Medicare and Medicaid Services.
15 (Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22;
16 103-593, eff. 6-7-24.)
17 Section 30. The Juvenile Court Act of 1987 is amended by
18 changing Section 5-515 as follows:
19 (705 ILCS 405/5-515)
20 Sec. 5-515. Medical, and dental, and pharmaceutical
21 treatment and care.
22 (a) At all times during temporary custody, detention or
23 shelter care, the court may authorize a physician, a hospital
24 or any other appropriate health care provider to provide
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1 medical, dental or surgical procedures or pharmaceuticals if
2 those procedures or pharmaceuticals are necessary to safeguard
3 the minor's life or health. If the minor is covered under an
4 existing medical or dental plan, the county shall be
5 reimbursed for the expenses incurred for such services as if
6 the minor were not held in temporary custody, detention, or
7 shelter care.
8 (b) If a provider of temporary custody, detention, or
9 shelter care has a contract with a pharmacy benefit manager or
10 a contract with an insurance company, health maintenance
11 organization, limited health service organization,
12 administrative services organization, or any other managed
13 care organization or health insurance issuer where a pharmacy
14 benefit manager administers the provider's coverage of,
15 payment for, or formulary design for drugs necessary to
16 safeguard the minor's life or health, the contract with the
17 pharmacy benefit manager and the pharmacy benefit manager's
18 activities shall be subject to Article XXXIIB of the Illinois
19 Insurance Code and the authority of the Director of Insurance
20 to enforce those provisions. The provider shall have all the
21 rights of a plan sponsor under those provisions.
22 (Source: P.A. 90-590, eff. 1-1-99.)
23 Section 35. The Unified Code of Corrections is amended by
24 changing Section 3-2-2 as follows:
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1 (730 ILCS 5/3-2-2) (from Ch. 38, par. 1003-2-2)
2 Sec. 3-2-2. Powers and duties of the Department.
3 (1) In addition to the powers, duties, and
4 responsibilities which are otherwise provided by law, the
5 Department shall have the following powers:
6 (a) To accept persons committed to it by the courts of
7 this State for care, custody, treatment, and
8 rehabilitation, and to accept federal prisoners and
9 noncitizens over whom the Office of the Federal Detention
10 Trustee is authorized to exercise the federal detention
11 function for limited purposes and periods of time.
12 (b) To develop and maintain reception and evaluation
13 units for purposes of analyzing the custody and
14 rehabilitation needs of persons committed to it and to
15 assign such persons to institutions and programs under its
16 control or transfer them to other appropriate agencies. In
17 consultation with the Department of Alcoholism and
18 Substance Abuse (now the Department of Human Services),
19 the Department of Corrections shall develop a master plan
20 for the screening and evaluation of persons committed to
21 its custody who have alcohol or drug abuse problems, and
22 for making appropriate treatment available to such
23 persons; the Department shall report to the General
24 Assembly on such plan not later than April 1, 1987. The
25 maintenance and implementation of such plan shall be
26 contingent upon the availability of funds.
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1 (b-1) To create and implement, on January 1, 2002, a
2 pilot program to establish the effectiveness of
3 pupillometer technology (the measurement of the pupil's
4 reaction to light) as an alternative to a urine test for
5 purposes of screening and evaluating persons committed to
6 its custody who have alcohol or drug problems. The pilot
7 program shall require the pupillometer technology to be
8 used in at least one Department of Corrections facility.
9 The Director may expand the pilot program to include an
10 additional facility or facilities as he or she deems
11 appropriate. A minimum of 4,000 tests shall be included in
12 the pilot program. The Department must report to the
13 General Assembly on the effectiveness of the program by
14 January 1, 2003.
15 (b-5) To develop, in consultation with the Illinois
16 State Police, a program for tracking and evaluating each
17 inmate from commitment through release for recording his
18 or her gang affiliations, activities, or ranks.
19 (c) To maintain and administer all State correctional
20 institutions and facilities under its control and to
21 establish new ones as needed. Pursuant to its power to
22 establish new institutions and facilities, the Department
23 may, with the written approval of the Governor, authorize
24 the Department of Central Management Services to enter
25 into an agreement of the type described in subsection (d)
26 of Section 405-300 of the Department of Central Management
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1 Services Law. The Department shall designate those
2 institutions which shall constitute the State Penitentiary
3 System. The Department of Juvenile Justice shall maintain
4 and administer all State youth centers pursuant to
5 subsection (d) of Section 3-2.5-20.
6 Pursuant to its power to establish new institutions
7 and facilities, the Department may authorize the
8 Department of Central Management Services to accept bids
9 from counties and municipalities for the construction,
10 remodeling, or conversion of a structure to be leased to
11 the Department of Corrections for the purposes of its
12 serving as a correctional institution or facility. Such
13 construction, remodeling, or conversion may be financed
14 with revenue bonds issued pursuant to the Industrial
15 Building Revenue Bond Act by the municipality or county.
16 The lease specified in a bid shall be for a term of not
17 less than the time needed to retire any revenue bonds used
18 to finance the project, but not to exceed 40 years. The
19 lease may grant to the State the option to purchase the
20 structure outright.
21 Upon receipt of the bids, the Department may certify
22 one or more of the bids and shall submit any such bids to
23 the General Assembly for approval. Upon approval of a bid
24 by a constitutional majority of both houses of the General
25 Assembly, pursuant to joint resolution, the Department of
26 Central Management Services may enter into an agreement
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1 with the county or municipality pursuant to such bid.
2 (c-5) To build and maintain regional juvenile
3 detention centers and to charge a per diem to the counties
4 as established by the Department to defray the costs of
5 housing each minor in a center. In this subsection (c-5),
6 "juvenile detention center" means a facility to house
7 minors during pendency of trial who have been transferred
8 from proceedings under the Juvenile Court Act of 1987 to
9 prosecutions under the criminal laws of this State in
10 accordance with Section 5-805 of the Juvenile Court Act of
11 1987, whether the transfer was by operation of law or
12 permissive under that Section. The Department shall
13 designate the counties to be served by each regional
14 juvenile detention center.
15 (d) To develop and maintain programs of control,
16 rehabilitation, and employment of committed persons within
17 its institutions.
18 (d-5) To provide a pre-release job preparation program
19 for inmates at Illinois adult correctional centers.
20 (d-10) To provide educational and visitation
21 opportunities to committed persons within its institutions
22 through temporary access to content-controlled tablets
23 that may be provided as a privilege to committed persons
24 to induce or reward compliance.
25 (e) To establish a system of supervision and guidance
26 of committed persons in the community.
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1 (f) To establish in cooperation with the Department of
2 Transportation to supply a sufficient number of prisoners
3 for use by the Department of Transportation to clean up
4 the trash and garbage along State, county, township, or
5 municipal highways as designated by the Department of
6 Transportation. The Department of Corrections, at the
7 request of the Department of Transportation, shall furnish
8 such prisoners at least annually for a period to be agreed
9 upon between the Director of Corrections and the Secretary
10 of Transportation. The prisoners used on this program
11 shall be selected by the Director of Corrections on
12 whatever basis he deems proper in consideration of their
13 term, behavior and earned eligibility to participate in
14 such program - where they will be outside of the prison
15 facility but still in the custody of the Department of
16 Corrections. Prisoners convicted of first degree murder,
17 or a Class X felony, or armed violence, or aggravated
18 kidnapping, or criminal sexual assault, aggravated
19 criminal sexual abuse or a subsequent conviction for
20 criminal sexual abuse, or forcible detention, or arson, or
21 a prisoner adjudged a Habitual Criminal shall not be
22 eligible for selection to participate in such program. The
23 prisoners shall remain as prisoners in the custody of the
24 Department of Corrections and such Department shall
25 furnish whatever security is necessary. The Department of
26 Transportation shall furnish trucks and equipment for the
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1 highway cleanup program and personnel to supervise and
2 direct the program. Neither the Department of Corrections
3 nor the Department of Transportation shall replace any
4 regular employee with a prisoner.
5 (g) To maintain records of persons committed to it and
6 to establish programs of research, statistics, and
7 planning.
8 (h) To investigate the grievances of any person
9 committed to the Department and to inquire into any
10 alleged misconduct by employees or committed persons; and
11 for these purposes it may issue subpoenas and compel the
12 attendance of witnesses and the production of writings and
13 papers, and may examine under oath any witnesses who may
14 appear before it; to also investigate alleged violations
15 of a parolee's or releasee's conditions of parole or
16 release; and for this purpose it may issue subpoenas and
17 compel the attendance of witnesses and the production of
18 documents only if there is reason to believe that such
19 procedures would provide evidence that such violations
20 have occurred.
21 If any person fails to obey a subpoena issued under
22 this subsection, the Director may apply to any circuit
23 court to secure compliance with the subpoena. The failure
24 to comply with the order of the court issued in response
25 thereto shall be punishable as contempt of court.
26 (i) To appoint and remove the chief administrative
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1 officers, and administer programs of training and
2 development of personnel of the Department. Personnel
3 assigned by the Department to be responsible for the
4 custody and control of committed persons or to investigate
5 the alleged misconduct of committed persons or employees
6 or alleged violations of a parolee's or releasee's
7 conditions of parole shall be conservators of the peace
8 for those purposes, and shall have the full power of peace
9 officers outside of the facilities of the Department in
10 the protection, arrest, retaking, and reconfining of
11 committed persons or where the exercise of such power is
12 necessary to the investigation of such misconduct or
13 violations. This subsection shall not apply to persons
14 committed to the Department of Juvenile Justice under the
15 Juvenile Court Act of 1987 on aftercare release.
16 (j) To cooperate with other departments and agencies
17 and with local communities for the development of
18 standards and programs for better correctional services in
19 this State.
20 (k) To administer all moneys and properties of the
21 Department.
22 (l) To report annually to the Governor on the
23 committed persons, institutions, and programs of the
24 Department.
25 (l-5) (Blank).
26 (m) To make all rules and regulations and exercise all
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1 powers and duties vested by law in the Department.
2 (n) To establish rules and regulations for
3 administering a system of sentence credits, established in
4 accordance with Section 3-6-3, subject to review by the
5 Prisoner Review Board.
6 (o) To administer the distribution of funds from the
7 State Treasury to reimburse counties where State penal
8 institutions are located for the payment of assistant
9 state's attorneys' salaries under Section 4-2001 of the
10 Counties Code.
11 (p) To exchange information with the Department of
12 Human Services and the Department of Healthcare and Family
13 Services for the purpose of verifying living arrangements
14 and for other purposes directly connected with the
15 administration of this Code and the Illinois Public Aid
16 Code.
17 (q) To establish a diversion program.
18 The program shall provide a structured environment for
19 selected technical parole or mandatory supervised release
20 violators and committed persons who have violated the
21 rules governing their conduct while in work release. This
22 program shall not apply to those persons who have
23 committed a new offense while serving on parole or
24 mandatory supervised release or while committed to work
25 release.
26 Elements of the program shall include, but shall not
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1 be limited to, the following:
2 (1) The staff of a diversion facility shall
3 provide supervision in accordance with required
4 objectives set by the facility.
5 (2) Participants shall be required to maintain
6 employment.
7 (3) Each participant shall pay for room and board
8 at the facility on a sliding-scale basis according to
9 the participant's income.
10 (4) Each participant shall:
11 (A) provide restitution to victims in
12 accordance with any court order;
13 (B) provide financial support to his
14 dependents; and
15 (C) make appropriate payments toward any other
16 court-ordered obligations.
17 (5) Each participant shall complete community
18 service in addition to employment.
19 (6) Participants shall take part in such
20 counseling, educational, and other programs as the
21 Department may deem appropriate.
22 (7) Participants shall submit to drug and alcohol
23 screening.
24 (8) The Department shall promulgate rules
25 governing the administration of the program.
26 (r) To enter into intergovernmental cooperation
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1 agreements under which persons in the custody of the
2 Department may participate in a county impact
3 incarceration program established under Section 3-6038 or
4 3-15003.5 of the Counties Code.
5 (r-5) (Blank).
6 (r-10) To systematically and routinely identify with
7 respect to each streetgang active within the correctional
8 system: (1) each active gang; (2) every existing
9 inter-gang affiliation or alliance; and (3) the current
10 leaders in each gang. The Department shall promptly
11 segregate leaders from inmates who belong to their gangs
12 and allied gangs. "Segregate" means no physical contact
13 and, to the extent possible under the conditions and space
14 available at the correctional facility, prohibition of
15 visual and sound communication. For the purposes of this
16 paragraph (r-10), "leaders" means persons who:
17 (i) are members of a criminal streetgang;
18 (ii) with respect to other individuals within the
19 streetgang, occupy a position of organizer,
20 supervisor, or other position of management or
21 leadership; and
22 (iii) are actively and personally engaged in
23 directing, ordering, authorizing, or requesting
24 commission of criminal acts by others, which are
25 punishable as a felony, in furtherance of streetgang
26 related activity both within and outside of the
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1 Department of Corrections.
2 "Streetgang", "gang", and "streetgang related" have the
3 meanings ascribed to them in Section 10 of the Illinois
4 Streetgang Terrorism Omnibus Prevention Act.
5 (s) To operate a super-maximum security institution,
6 in order to manage and supervise inmates who are
7 disruptive or dangerous and provide for the safety and
8 security of the staff and the other inmates.
9 (t) To monitor any unprivileged conversation or any
10 unprivileged communication, whether in person or by mail,
11 telephone, or other means, between an inmate who, before
12 commitment to the Department, was a member of an organized
13 gang and any other person without the need to show cause or
14 satisfy any other requirement of law before beginning the
15 monitoring, except as constitutionally required. The
16 monitoring may be by video, voice, or other method of
17 recording or by any other means. As used in this
18 subdivision (1)(t), "organized gang" has the meaning
19 ascribed to it in Section 10 of the Illinois Streetgang
20 Terrorism Omnibus Prevention Act.
21 As used in this subdivision (1)(t), "unprivileged
22 conversation" or "unprivileged communication" means a
23 conversation or communication that is not protected by any
24 privilege recognized by law or by decision, rule, or order
25 of the Illinois Supreme Court.
26 (u) To establish a Women's and Children's Pre-release
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1 Community Supervision Program for the purpose of providing
2 housing and services to eligible female inmates, as
3 determined by the Department, and their newborn and young
4 children.
5 (u-5) To issue an order, whenever a person committed
6 to the Department absconds or absents himself or herself,
7 without authority to do so, from any facility or program
8 to which he or she is assigned. The order shall be
9 certified by the Director, the Supervisor of the
10 Apprehension Unit, or any person duly designated by the
11 Director, with the seal of the Department affixed. The
12 order shall be directed to all sheriffs, coroners, and
13 police officers, or to any particular person named in the
14 order. Any order issued pursuant to this subdivision
15 (1)(u-5) shall be sufficient warrant for the officer or
16 person named in the order to arrest and deliver the
17 committed person to the proper correctional officials and
18 shall be executed the same as criminal process.
19 (u-6) To appoint a point of contact person who shall
20 receive suggestions, complaints, or other requests to the
21 Department from visitors to Department institutions or
22 facilities and from other members of the public.
23 (v) To do all other acts necessary to carry out the
24 provisions of this Chapter.
25 (2) The Department of Corrections shall by January 1,
26 1998, consider building and operating a correctional facility
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1 within 100 miles of a county of over 2,000,000 inhabitants,
2 especially a facility designed to house juvenile participants
3 in the impact incarceration program.
4 (3) When the Department lets bids for contracts for
5 medical services to be provided to persons committed to
6 Department facilities by a health maintenance organization,
7 medical service corporation, or other health care provider,
8 the bid may only be let to a health care provider that has
9 obtained an irrevocable letter of credit or performance bond
10 issued by a company whose bonds have an investment grade or
11 higher rating by a bond rating organization.
12 (3.5) If the Department has a contract with a pharmacy
13 benefit manager or a contract with an insurance company,
14 health maintenance organization, limited health service
15 organization, administrative services organization, or any
16 other managed care entity or health insurance issuer where a
17 pharmacy benefit manager administers the provider's coverage
18 of, payment for, or formulary design for drugs necessary to
19 safeguard the minor's life or health, the contract with the
20 pharmacy benefit manager and the pharmacy benefit manager's
21 activities shall be subject to Article XXXIIB of the Illinois
22 Insurance Code and the authority of the Director of Insurance
23 to enforce those provisions. The provider shall have all the
24 rights of a plan sponsor under those provisions.
25 (4) When the Department lets bids for contracts for food
26 or commissary services to be provided to Department
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1 facilities, the bid may only be let to a food or commissary
2 services provider that has obtained an irrevocable letter of
3 credit or performance bond issued by a company whose bonds
4 have an investment grade or higher rating by a bond rating
5 organization.
6 (5) On and after the date 6 months after August 16, 2013
7 (the effective date of Public Act 98-488), as provided in the
8 Executive Order 1 (2012) Implementation Act, all of the
9 powers, duties, rights, and responsibilities related to State
10 healthcare purchasing under this Code that were transferred
11 from the Department of Corrections to the Department of
12 Healthcare and Family Services by Executive Order 3 (2005) are
13 transferred back to the Department of Corrections; however,
14 powers, duties, rights, and responsibilities related to State
15 healthcare purchasing under this Code that were exercised by
16 the Department of Corrections before the effective date of
17 Executive Order 3 (2005) but that pertain to individuals
18 resident in facilities operated by the Department of Juvenile
19 Justice are transferred to the Department of Juvenile Justice.
20 (6) The Department of Corrections shall provide lactation
21 or nursing mothers rooms for personnel of the Department. The
22 rooms shall be provided in each facility of the Department
23 that employs nursing mothers. Each individual lactation room
24 must:
25 (i) contain doors that lock;
26 (ii) have an "Occupied" sign for each door;
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1 (iii) contain electrical outlets for plugging in
2 breast pumps;
3 (iv) have sufficient lighting and ventilation;
4 (v) contain comfortable chairs;
5 (vi) contain a countertop or table for all necessary
6 supplies for lactation;
7 (vii) contain a wastebasket and chemical cleaners to
8 wash one's hands and to clean the surfaces of the
9 countertop or table;
10 (viii) have a functional sink;
11 (ix) have a minimum of one refrigerator for storage of
12 the breast milk; and
13 (x) receive routine daily maintenance.
14 (Source: P.A. 102-350, eff. 8-13-21; 102-535, eff. 1-1-22;
15 102-538, eff. 8-20-21; 102-813, eff. 5-13-22; 102-1030, eff.
16 5-27-22; 103-834, eff. 1-1-25.)
17 Section 40. The County Jail Act is amended by changing
18 Section 17 as follows:
19 (730 ILCS 125/17) (from Ch. 75, par. 117)
20 Sec. 17. Bedding, clothing, fuel, and medical aid;
21 reimbursement for medical expenses. The Warden of the jail
22 shall furnish necessary bedding, clothing, fuel, and medical
23 services for all committed persons under his charge, and keep
24 an accurate account of the same. When services that result in
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1 qualified medical expenses are required by any person held in
2 custody, the county, private hospital, physician or any public
3 agency which provides such services shall be entitled to
4 obtain reimbursement from the county for the cost of such
5 services. The county board of a county may adopt an ordinance
6 or resolution providing for reimbursement for the cost of
7 those services at the Department of Healthcare and Family
8 Services' rates for medical assistance. To the extent that
9 such person is reasonably able to pay for such care, including
10 reimbursement from any insurance program or from other medical
11 benefit programs available to such person, he or she shall
12 reimburse the county or arresting authority. If such person
13 has already been determined eligible for medical assistance
14 under the Illinois Public Aid Code at the time the person is
15 detained, the cost of such services, to the extent such cost
16 exceeds $500, shall be reimbursed by the Department of
17 Healthcare and Family Services under that Code. A
18 reimbursement under any public or private program authorized
19 by this Section shall be paid to the county or arresting
20 authority to the same extent as would have been obtained had
21 the services been rendered in a non-custodial environment.
22 The sheriff or his or her designee may cause an
23 application for medical assistance under the Illinois Public
24 Aid Code to be completed for an arrestee who is a hospital
25 inpatient. If such arrestee is determined eligible, he or she
26 shall receive medical assistance under the Code for hospital
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1 inpatient services only. An arresting authority shall be
2 responsible for any qualified medical expenses relating to the
3 arrestee until such time as the arrestee is placed in the
4 custody of the sheriff. However, the arresting authority shall
5 not be so responsible if the arrest was made pursuant to a
6 request by the sheriff. When medical expenses are required by
7 any person held in custody, the county shall be entitled to
8 obtain reimbursement from the County Jail Medical Costs Fund
9 to the extent moneys are available from the Fund. To the extent
10 that the person is reasonably able to pay for that care,
11 including reimbursement from any insurance program or from
12 other medical benefit programs available to the person, he or
13 she shall reimburse the county.
14 For the purposes of this Section, "arresting authority"
15 means a unit of local government, other than a county, which
16 employs peace officers and whose peace officers have made the
17 arrest of a person. For the purposes of this Section,
18 "qualified medical expenses" include medical and hospital
19 services but do not include (i) expenses incurred for medical
20 care or treatment provided to a person on account of a
21 self-inflicted injury incurred prior to or in the course of an
22 arrest, (ii) expenses incurred for medical care or treatment
23 provided to a person on account of a health condition of that
24 person which existed prior to the time of his or her arrest, or
25 (iii) expenses for hospital inpatient services for arrestees
26 enrolled for medical assistance under the Illinois Public Aid
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1 Code.
2 If a jail or a unit of local government operating the jail
3 has a contract with a pharmacy benefit manager or a contract
4 with an insurance company, health maintenance organization,
5 limited health service organization, administrative services
6 organization, or any other managed care organization or health
7 insurance issuer where a pharmacy benefit manager administers
8 coverage of, payment for, or formulary design for drugs
9 necessary to safeguard the life or health of any person in
10 custody, that contract and the pharmacy benefit manager's
11 activities shall be subject to Article XXXIIB of the Illinois
12 Insurance Code and the authority of the Director of Insurance
13 to enforce those provisions. The jail or unit of local
14 government shall have all the rights of a plan sponsor under
15 those provisions.
16 (Source: P.A. 103-745, eff. 1-1-25.)
17 Section 99. Effective date. This Act takes effect on
18 January 1, 2026, except that this Section, Section 10, and the
19 changes to Sections 513b2 and 513b3 of the Illinois Insurance
20 Code take effect upon becoming law.Every fact on this page links to its source, starting with the official bill record.