Illinois SB 1390: DHFS-MCO-PBM-CONTRACTS

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 Full Text of SB1390

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104TH GENERAL ASSEMBLY 
State of Illinois 
2025 and 2026
SB1390

Introduced 1/29/2025, by Sen. David Koehler 

SYNOPSIS AS INTRODUCED:

305 ILCS 5/5-36a new

 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services shall not enter into a contract with a managed care organization that relies on a pharmacy benefit manager that does not do the following: (i) utilize a pharmacy reimbursement methodology of the lesser of national average drug acquisition cost plus a professional dispensing fee as determined by the Department, the wholesale acquisition cost plus a professional dispensing fee as determined by the Department, or the usual and customary charge by the pharmacy; (ii) reimburse for a legally valid claim at a rate not less than the rate in effect at the time the original claim adjudication was submitted at the point of sale; (iii) agree to move to a transparent pass-through pricing model, in which the pharmacy benefit manager discloses the administrative fee as a percentage of the professional dispensing costs to the Department; (iv) agree to not create new pharmacy administration fees and to not increase current fees more than the rate of inflation; and (v) agree to not terminate an existing contract with a pharmacy licensed under the Pharmacy Practice Act for the sole reason of the additional professional dispensing fee authorized under item (i). Requires each pharmacy benefit manager that receives reimbursement for medical services, either directly or through a Medicaid managed care health plan, to submit by January 15, 2027, and each January 15 thereafter, certain data and information to the Departmen