Healthcare (Prescription Drugs)

This bill establishes a minimum reimbursement standard for pharmacies that are not classified as critical access care facilities, requiring Medicaid managed care organizations to pay at least the same rates as the traditional fee-for-service program. The law mandates that these payments cover both the professional dispensing fee and the acquisition cost of the medication, regardless of whether the managed care organization pays the pharmacy directly or uses a third-party pharmacy benefit manager. Additionally, the bill directs the state Department of Healthcare Finance to implement various cost-control measures, such as limiting the number of prescriptions for certain drugs within a 30-day period and requiring prior approval for specific high-cost medications.

Urges the Illinois Department of Healthcare and Family Services (HFS) to ensure that pharmacies participating in Medicaid managed care networks are reimbursed for covered outpatient prescription drugs at a rate no less than the reimbursement that would be paid under the Illinois Medicaid fee-for-service pharmacy program. Urges HFS to implement such reimbursement parity through Medicaid managed care organization contracts and pharmacy benefit manager agreements. Urges HFS to monitor and report to the General Assembly on the impact of reimbursement parity on pharmacy network participation, patient access to medications, and pharmacy closures within the State. Encourages HFS to evaluate the effect of reimbursement parity on pharmacy deserts, rural health access, and Medicaid beneficiary access to pharmacist-provided patient care services.

Amends the Pharmacy Practice Act. Provides that a pharmacist who is exercising his or her professional judgment may add missing non-pharmaceutical devices or durable medical equipment that aid in the appropriate clinical usage of a medication or in achieving a positive therapeutic outcome to a prescription. Provides that a pharmacist may complete missing information on a prescription if there is evidence to support the change. Requires any adaptations to a prescription to be documented in the patient's record. In provisions concerning the distribution of a prescription drug for less than its fair market value, provides that it shall be unlawful to require a pharmacist or pharmacy to dispense a prescription drug for less than its fair market value, including the cost of dispensing. Provides that a payor that reimburses a pharmacy for less than fair market value, including the cost of dispensing, shall not be able to include the pharmacy toward any network adequacy requirements and shall not be deemed in compliance with any willing provider provisions.

Creates the 340B Drug Pricing Program Reporting Act. On or before April 1, 2027 and each April 1 thereafter, requires a 340B covered entity to report the specified information and transactions to the Department of Public Health concerning the 340B covered entity's participation in or participation on behalf of the 340B covered entity in the federal 340B Program for the previous calendar year. On or before November 15, 2027 and each November 15 thereafter, requires the Department to prepare a report that aggregates the data submitted; submit the report to the General Assembly in an electronic format; and post the report on the Department's website. Provides that pharmaceutical manufacturers may request a 340B covered entity to provide specified information concerning the dispensation of 340B drugs. Sets forth provisions concerning penalties, exemptions for pharmaceutical manufacturers, and rulemaking. Provides that the Act is repealed on January 1, 2031. Effective immediately.

Amends the Pharmacy Practice Act. Provides that "practice of pharmacy" includes the monitoring of medication recalls, including notifying patients of applicable medication recalls at the point of sale.

Creates the 340B Integrity Act. Defines terms. Provides that, beginning January 1, 2027, 340B covered entities shall not bill any medical assistance fee-for-service or medical assistance managed care programs under the Illinois Public Aid Code for 340B drugs. Provides that, beginning July 1, 2026 a 340B covered entity shall use 80% of 340B profits from the prior year to decrease at the point of sale, including at the 340B contract pharmacy, the out-of-pocket costs paid for 340B drugs that are dispensed or administered to low-income patients of the 340B covered entity. Provides that, on or before September 1, 2026, and on or before September 1 of each year thereafter, each 340B covered entity shall annually report to the Department of Insurance, with respect to the 340B covered entity and separately for each offsite outpatient facility associated with the 340B covered entity, the specified information about the prior year. Provides that, on or before December 31, 2026, the Department of Central Management Services shall submit a report to the General Assembly on any impact to the State employee health plan arising from 340B covered entity purchases, 340B contract pharmacy arrangements, and general practices related to 340B drugs, regardless of whether the 340B drugs were self-administered or provider-administered. Provides that the report shall include, but not be limited to, an analysis of foregone rebates, the impact on premiums, and the impact to State employee out-of-pocket costs. Provides that, on or before December 31, 2026, the Department of Healthcare and Family Services shall report to the General Assembly on certain items for total aggregated covered outpatient drug units dispensed or administered in the State for the prior calendar year in connection with the medical assistance program under the Illinois Public Aid Code, broken out by fee-for-service and by each managed care plan. Makes other changes. Effective immediately.

Amends the Illinois Insurance Code. Sets forth provisions requiring an individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2028 to provide coverage for up to a 12-month supply of prescription hormone therapy, and the necessary supplies for self-administration, that is prescribed by a network provider within the provider's scope of practice and dispensed at one time for an enrollee by a provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies. Amends the Pharmacy Practice Act. Provides that, notwithstanding any other provision of law, a dispensing provider or pharmacist shall dispense, at a patient's request, up to a 12-month supply of a prescription hormone therapy and the necessary supplies for self-administration pursuant to a valid prescription that specifies an initial quantity followed by periodic refills, except as specified. Amends the State Employees Group Insurance Act of 1971 and the Illinois Public Aid Code to require coverage under the provisions of those Acts.

Amends the Illinois Controlled Substances Act. Provides that, if a pharmacy is unable to fill an initial prescription received electronically because the prescribed drug is not in stock, the dispenser must immediately contact the patient to notify the patient of the situation and ask if the patient would like the prescription transferred electronically to a pharmacy of the patient's choosing, consistent with federal regulations concerning the prescribing of controlled substances. Provides that the prescriber shall not be required to issue prescriptions electronically if the prescriptions need to be filled outside of typical retail pharmacy operating hours or may be difficult to obtain because of drug shortages or pharmacy inventory limitations. Amends the Pharmacy Practice Act to make conforming changes. Effective immediately.

Amends the Pharmacy Practice Act. Provides that every licensed pharmacy directly serving patients at a physical location shall conspicuously post a sign provided by the Department of Human Services that contains the following: (i) a statement that the Department of Human Services runs a Suicide and Crisis Lifeline; (ii) the Lifeline number; and (iii) any other information the Department of Human Services deems appropriate. Provides that the sign shall be printed in color ink or displayed electronically in color, measure at least 8.5 x 11 inches in size, and be posted at either a cashier counter or a waiting area that is clearly visible to patients. Requires licensed pharmacies that do not maintain a physical location that directly serves patients to include a copy of the sign with any dispensed prescriptions. Provides that the sign shall also be available to download on the Department of Human Services's website.

Amends the Illinois Insurance Code. Provides that, on and after the effective date of the amendatory Act, coverage for all abortifacients, hormonal therapy medication, human immunodeficiency virus pre-exposure prophylaxis, and post-exposure prophylaxis drugs approved by the United States Food and Drug Administration, and follow-up services related to that coverage, shall include screenings for pre-PrEP HIV and sexually transmitted infections. Provides that the coverage shall also include kidney function analysis, routine laboratory testing, and routine provider visits associated with those screenings. Amends the Prior Authorization Reform Act. Prohibits a health insurance issuer from requiring prior authorization for the following prescription drug types and their therapeutic equivalents approved by the United States Food and Drug Administration: human immunodeficiency virus pre-exposure prophylaxis and post-exposure prophylaxis medication or human immunodeficiency virus treatment medication. Effective January 1, 2028.