Drug Benefit Equity Law – Illinois

Date: 1 May 2008 | posted in: Retail | 0 Facebooktwitterredditmail

Illinois enacted an HMO reform bill in 1999 that includes a provision barring health insurers from favoring certain types of pharmacies (e.g., mail order) over others (e.g., independent retail pharmacies). The law requires that co-payments, deductibles, and limits on the quantity of drugs that can be dispensed at one time be applied uniformly regardless of the type of pharmacy the consumer chooses.

Below is the text of the relevant section of the statute. (The full law is entitled the Managed Care Reform and Patient Rights Act.)

(215 ILCS 134/72)

Sec. 72. Pharmacy providers.

(a) Before entering into an agreement with pharmacy providers, a health care plan must establish terms and conditions that must be met by pharmacy providers desiring to contract with the health care plan. The terms and conditions shall not discriminate against a pharmacy provider. A health care plan may not refuse to contract with a pharmacy provider that meets the terms and conditions established by the health care plan. If a pharmacy provider rejects the terms and conditions established, the health care plan may offer other terms and conditions necessary to comply with network adequacy requirements.

(b) A health care plan shall apply the same co-insurance, copayment, and deductible factors to all drug prescriptions filled by a pharmacy provider that participates in the health care plan’s network. Nothing in this subsection, however, prohibits a health care plan from applying different co-insurance, copayment, and deductible factors between brand name drugs and generic drugs when a generic equivalent exists for the brand name drug.

(c)A health care plan may not set a limit on the quantity of drugs that an enrollee may obtain at one time with a prescription unless the limit is applied uniformly to all pharmacy providers in the health care plan’s network.

(Source: P.A. 91-617, eff. 1-1-00.)

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Stacy Mitchell

Stacy Mitchell is co-director of the Institute for Local Self-Reliance and directs its Independent Business Initiative, which produces research and designs policy to counter concentrated corporate power and strengthen local economies.

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