Illinois § 20

§ 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. (Source: P.A. 96-766, eff. 1-1-10.)