Public Act 096-0766
 		





HB0152 Enrolled
LRB096 02980 RPM 12994 b






    AN ACT concerning insurance.

 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:




 
    Section 1. Short title.  This Act may be cited as the Organ 
Transplant Medication Notification Act.
 
    Section 5. Applicability. This Act shall apply solely to 
cases of immunosuppressive therapy when (i) an 
immunosuppressant drug has been prescribed to a patient to 
prevent the rejection of transplanted organs and
tissues and 
(ii) as set forth in Section 15 of this Act, a prescribing 
physician has indicated on a prescription "may not substitute". 
This Act does not apply to medication orders issued for 
immunosuppressant drugs for any in-patient care in a licensed 
hospital.
 
    Section 10. Definitions. For the purpose of this Act:
    "Health insurance policy or health care service plan" means 
any policy of health or accident insurance subject to the 
provisions of the Illinois Insurance Code, Health Maintenance 
Organization Act, Voluntary Health Services Plan Act, Counties 
Code, Municipal Code, School Code, and State Employees Group 
Insurance Act.
    "Immunosuppressant drugs" mean drugs that are used in 
immunosuppressive therapy to inhibit or prevent the activity of 
the immune system. "Immunosuppressant drugs" are used 
clinically to prevent the rejection of transplanted organs and 
tissues. "Immunosuppressant drugs" do not include drugs for the 
treatment of autoimmune diseases or diseases that are most 
likely of autoimmune origin.
 
    Section 15. Quality assurance in patient care. In 
accordance with the Pharmacy Practice Act, when a prescribing 
physician has indicated on a prescription "may not substitute", 
a health insurance policy or health care service plan that 
covers immunosuppressant drugs may not require or cause a 
pharmacist to interchange another immunosuppressant drug or 
formulation issued on behalf of a person to inhibit or prevent 
the activity of the immune system of a patient to prevent the 
rejection of transplanted organs and tissues without 
notification and the documented consent of the prescribing 
physician and the patient, or the parent or guardian if the 
patient is a child, or the spouse of a patient who is 
authorized to consent to the treatment of the person.
    Except as provided by subsections (a), (b), and (c) of 
Section 20 of this Act, patient co-payments, deductibles, or 
other
charges for the prescribed drug for which another 
immunosuppressant drug or formulation is not interchanged 
shall remain the same for the enrollment period established by 
the health insurance policy or plan.

 
    Section 20. Provision of notice; formulary changes.  
    (a) At least 60 days prior to making any formulary change 
that alters the terms of coverage for a patient receiving 
immunosuppressant drugs or discontinues coverage for a 
prescribed immunosuppressant drug that a patient is receiving, 
a policy or plan sponsor must, to the extent possible, notify 
the prescribing physician and the patient, or the parent or 
guardian if the patient is a child, or the spouse of a patient 
who is authorized to consent to the treatment of the patient. 
The notification shall be in writing and shall disclose the 
formulary change, indicate that the prescribing physician may 
initiate an appeal, and include information regarding the 
procedure for the prescribing physician to initiate the policy 
or plan sponsor's appeal process.
    (b) As an alternative to providing written notice, a policy 
or plan sponsor may provide the notice electronically if, and 
only if, the patient affirmatively elects to receive such 
notice electronically. The notification shall disclose the 
formulary change, indicate that the prescribing physician may 
initiate an appeal, and include information regarding the 
procedure for the prescribing physician to initiate the policy 
or plan sponsor's appeal process.
    (c) At the time a patient requests a refill of the 
immunosuppressant drug, a policy or plan sponsor may provide 
the patient with the written notification required under 
subsection (a) of this Section along with a 60-day supply of 
the immunosuppressant drug under the same terms as previously 
allowed.
    (d) Nothing in this Section shall prohibit insurers or 
pharmacy benefit managers from using managed pharmacy care 
tools, including, but not limited to, formulary tiers, generic 
substitution, therapeutic interchange, prior authorization, or 
step therapy, so long as an exception process is in place 
allowing the prescriber to petition for coverage of a 
non-preferred drug if sufficient clinical reasons justify an 
exception to the normal protocol.