Illinois Compiled Statutes 215 ILCS 5/513b1 – Pharmacy benefit manager contracts
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(a) As used in this Section:
“340B drug discount program” means the program established under Section 340B of the federal Public Health Service Act, 42 U.S.C. § 256b.
“340B entity” means a covered entity as defined in 42 U.S.C. § 256b(a)(4) authorized to participate in the 340B drug discount program.
“340B pharmacy” means any pharmacy used to dispense 340B drugs for a covered entity, whether entity-owned or external.
“Biological product” has the meaning ascribed to that term in Section 19.5 of the Pharmacy Practice Act.
“Maximum allowable cost” means the maximum amount that a pharmacy benefit manager will reimburse a pharmacy for the cost of a drug.
“Maximum allowable cost list” means a list of drugs for which a maximum allowable cost has been established by a pharmacy benefit manager.
“Pharmacy benefit manager” means a person, business, or entity, including a wholly or partially owned or controlled subsidiary of a pharmacy benefit manager, that provides claims processing services or other prescription drug or device services, or both, for health benefit plans.
“Retail price” means the price an individual without prescription drug coverage would pay at a retail pharmacy, not including a pharmacist dispensing fee.
“Third-party payer” means any entity that pays for prescription drugs on behalf of a patient other than a health care provider or sponsor of a plan subject to regulation under Medicare Part D, 42 U.S.C. §§ 1395w-101 et seq.
(b) A contract between a health insurer and a pharmacy benefit manager must require that the pharmacy benefit manager:
(1) Update maximum allowable cost pricing information
“340B drug discount program” means the program established under Section 340B of the federal Public Health Service Act, 42 U.S.C. § 256b.
Terms Used In Illinois Compiled Statutes 215 ILCS 5/513b1
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- individual: shall include every infant member of the species homo sapiens who is born alive at any stage of development. See Illinois Compiled Statutes 5 ILCS 70/1.36
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- State: when applied to different parts of the United States, may be construed to include the District of Columbia and the several territories, and the words "United States" may be construed to include the said district and territories. See Illinois Compiled Statutes 5 ILCS 70/1.14
- United States: may be construed to include the said district and territories. See Illinois Compiled Statutes 5 ILCS 70/1.14
“340B entity” means a covered entity as defined in 42 U.S.C. § 256b(a)(4) authorized to participate in the 340B drug discount program.
“340B pharmacy” means any pharmacy used to dispense 340B drugs for a covered entity, whether entity-owned or external.
“Biological product” has the meaning ascribed to that term in Section 19.5 of the Pharmacy Practice Act.
“Maximum allowable cost” means the maximum amount that a pharmacy benefit manager will reimburse a pharmacy for the cost of a drug.
“Maximum allowable cost list” means a list of drugs for which a maximum allowable cost has been established by a pharmacy benefit manager.
“Pharmacy benefit manager” means a person, business, or entity, including a wholly or partially owned or controlled subsidiary of a pharmacy benefit manager, that provides claims processing services or other prescription drug or device services, or both, for health benefit plans.
“Retail price” means the price an individual without prescription drug coverage would pay at a retail pharmacy, not including a pharmacist dispensing fee.
“Third-party payer” means any entity that pays for prescription drugs on behalf of a patient other than a health care provider or sponsor of a plan subject to regulation under Medicare Part D, 42 U.S.C. §§ 1395w-101 et seq.
(b) A contract between a health insurer and a pharmacy benefit manager must require that the pharmacy benefit manager:
(1) Update maximum allowable cost pricing information
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at least every 7 calendar days.
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(2) Maintain a process that will, in a timely manner,
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eliminate drugs from maximum allowable cost lists or modify drug prices to remain consistent with changes in pricing data used in formulating maximum allowable cost prices and product availability.
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(3) Provide access to its maximum allowable cost list
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to each pharmacy or pharmacy services administrative organization subject to the maximum allowable cost list. Access may include a real-time pharmacy website portal to be able to view the maximum allowable cost list. As used in this Section, “pharmacy services administrative organization” means an entity operating within the State that contracts with independent pharmacies to conduct business on their behalf with third-party payers. A pharmacy services administrative organization may provide administrative services to pharmacies and negotiate and enter into contracts with third-party payers or pharmacy benefit managers on behalf of pharmacies.
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(4) Provide a process by which a contracted pharmacy
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can appeal the provider’s reimbursement for a drug subject to maximum allowable cost pricing. The appeals process must, at a minimum, include the following:
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(A) A requirement that a contracted pharmacy has
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14 calendar days after the applicable fill date to appeal a maximum allowable cost if the reimbursement for the drug is less than the net amount that the network provider paid to the supplier of the drug.
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(B) A requirement that a pharmacy benefit manager
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must respond to a challenge within 14 calendar days of the contracted pharmacy making the claim for which the appeal has been submitted.
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(C) A telephone number and e-mail address or
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website to network providers, at which the provider can contact the pharmacy benefit manager to process and submit an appeal.
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(D) A requirement that, if an appeal is denied,
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the pharmacy benefit manager must provide the reason for the denial and the name and the national drug code number from national or regional wholesalers.
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(E) A requirement that, if an appeal is
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sustained, the pharmacy benefit manager must make an adjustment in the drug price effective the date the challenge is resolved and make the adjustment applicable to all similarly situated network pharmacy providers, as determined by the managed care organization or pharmacy benefit manager.
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(5) Allow a plan sponsor contracting with a pharmacy
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benefit manager an annual right to audit compliance with the terms of the contract by the pharmacy benefit manager, including, but not limited to, full disclosure of any and all rebate amounts secured, whether product specific or generalized rebates, that were provided to the pharmacy benefit manager by a pharmaceutical manufacturer.
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(6) Allow a plan sponsor contracting with a pharmacy
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benefit manager to request that the pharmacy benefit manager disclose the actual amounts paid by the pharmacy benefit manager to the pharmacy.
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(7) Provide notice to the party contracting with the
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pharmacy benefit manager of any consideration that the pharmacy benefit manager receives from the manufacturer for dispense as written prescriptions once a generic or biologically similar product becomes available.
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(c) In order to place a particular prescription drug on a maximum allowable cost list, the pharmacy benefit manager must, at a minimum, ensure that:
(1) if the drug is a generically equivalent drug, it
(1) if the drug is a generically equivalent drug, it
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is listed as therapeutically equivalent and pharmaceutically equivalent “A” or “B” rated in the United States Food and Drug Administration’s most recent version of the “Orange Book” or have an NR or NA rating by Medi-Span, Gold Standard, or a similar rating by a nationally recognized reference;
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(2) the drug is available for purchase by each
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pharmacy in the State from national or regional wholesalers operating in Illinois; and
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(3) the drug is not obsolete.
(d) A pharmacy benefit manager is prohibited from limiting a pharmacist’s ability to disclose whether the cost-sharing obligation exceeds the retail price for a covered prescription drug, and the availability of a more affordable alternative drug, if one is available in accordance with Section 42 of the Pharmacy Practice Act.
(e) A health insurer or pharmacy benefit manager shall not require an insured to make a payment for a prescription drug at the point of sale in an amount that exceeds the lesser of:
(1) the applicable cost-sharing amount; or
(2) the retail price of the drug in the absence of
(d) A pharmacy benefit manager is prohibited from limiting a pharmacist’s ability to disclose whether the cost-sharing obligation exceeds the retail price for a covered prescription drug, and the availability of a more affordable alternative drug, if one is available in accordance with Section 42 of the Pharmacy Practice Act.
(e) A health insurer or pharmacy benefit manager shall not require an insured to make a payment for a prescription drug at the point of sale in an amount that exceeds the lesser of:
(1) the applicable cost-sharing amount; or
(2) the retail price of the drug in the absence of
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prescription drug coverage.
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(f) Unless required by law, a contract between a pharmacy benefit manager or third-party payer and a 340B entity or 340B pharmacy shall not contain any provision that:
(1) distinguishes between drugs purchased through the
(1) distinguishes between drugs purchased through the
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340B drug discount program and other drugs when determining reimbursement or reimbursement methodologies, or contains otherwise less favorable payment terms or reimbursement methodologies for 340B entities or 340B pharmacies when compared to similarly situated non-340B entities;
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(2) imposes any fee, chargeback, or rate adjustment
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that is not similarly imposed on similarly situated pharmacies that are not 340B entities or 340B pharmacies;
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(3) imposes any fee, chargeback, or rate adjustment
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that exceeds the fee, chargeback, or rate adjustment that is not similarly imposed on similarly situated pharmacies that are not 340B entities or 340B pharmacies;
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(4) prevents or interferes with an individual’s
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choice to receive a covered prescription drug from a 340B entity or 340B pharmacy through any legally permissible means, except that nothing in this paragraph shall prohibit the establishment of differing copayments or other cost-sharing amounts within the benefit plan for covered persons who acquire covered prescription drugs from a nonpreferred or nonparticipating provider;
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(5) excludes a 340B entity or 340B pharmacy from a
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pharmacy network on any basis that includes consideration of whether the 340B entity or 340B pharmacy participates in the 340B drug discount program;
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(6) prevents a 340B entity or 340B pharmacy from
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using a drug purchased under the 340B drug discount program; or
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(7) any other provision that discriminates against a
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340B entity or 340B pharmacy by treating the 340B entity or 340B pharmacy differently than non-340B entities or non-340B pharmacies for any reason relating to the entity’s participation in the 340B drug discount program.
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As used in this subsection, “pharmacy benefit manager” and “third-party payer” do not include pharmacy benefit managers and third-party payers acting on behalf of a Medicaid program.
(g) A violation of this Section by a pharmacy benefit manager constitutes an unfair or deceptive act or practice in the business of insurance under Section 424.
(h) A provision that violates subsection (f) in a contract between a pharmacy benefit manager or a third-party payer and a 340B entity that is entered into, amended, or renewed after July 1, 2022 shall be void and unenforceable.
(i)(1) A pharmacy benefit manager may not retaliate against a pharmacist or pharmacy for disclosing information in a court, in an administrative hearing, before a legislative commission or committee, or in any other proceeding, if the pharmacist or pharmacy has reasonable cause to believe that the disclosed information is evidence of a violation of a State or federal law, rule, or regulation.
(2) A pharmacy benefit manager may not retaliate against a pharmacist or pharmacy for disclosing information to a government or law enforcement agency, if the pharmacist or pharmacy has reasonable cause to believe that the disclosed information is evidence of a violation of a State or federal law, rule, or regulation.
(3) A pharmacist or pharmacy shall make commercially reasonable efforts to limit the disclosure of confidential and proprietary information.
(4) Retaliatory actions against a pharmacy or pharmacist include cancellation of, restriction of, or refusal to renew or offer a contract to a pharmacy solely because the pharmacy or pharmacist has:
(A) made disclosures of information that the
(g) A violation of this Section by a pharmacy benefit manager constitutes an unfair or deceptive act or practice in the business of insurance under Section 424.
(h) A provision that violates subsection (f) in a contract between a pharmacy benefit manager or a third-party payer and a 340B entity that is entered into, amended, or renewed after July 1, 2022 shall be void and unenforceable.
(i)(1) A pharmacy benefit manager may not retaliate against a pharmacist or pharmacy for disclosing information in a court, in an administrative hearing, before a legislative commission or committee, or in any other proceeding, if the pharmacist or pharmacy has reasonable cause to believe that the disclosed information is evidence of a violation of a State or federal law, rule, or regulation.
(2) A pharmacy benefit manager may not retaliate against a pharmacist or pharmacy for disclosing information to a government or law enforcement agency, if the pharmacist or pharmacy has reasonable cause to believe that the disclosed information is evidence of a violation of a State or federal law, rule, or regulation.
(3) A pharmacist or pharmacy shall make commercially reasonable efforts to limit the disclosure of confidential and proprietary information.
(4) Retaliatory actions against a pharmacy or pharmacist include cancellation of, restriction of, or refusal to renew or offer a contract to a pharmacy solely because the pharmacy or pharmacist has:
(A) made disclosures of information that the
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pharmacist or pharmacy has reasonable cause to believe is evidence of a violation of a State or federal law, rule, or regulation;
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(B) filed complaints with the plan or pharmacy
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benefit manager; or
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(C) filed complaints against the plan or pharmacy
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benefit manager with the Department.
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(j) This Section applies to contracts entered into or renewed on or after July 1, 2022.
(k) This Section applies to any group or individual policy of accident and health insurance or managed care plan that provides coverage for prescription drugs and that is amended, delivered, issued, or renewed on or after July 1, 2020.
(k) This Section applies to any group or individual policy of accident and health insurance or managed care plan that provides coverage for prescription drugs and that is amended, delivered, issued, or renewed on or after July 1, 2020.