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1 | AN ACT concerning public aid.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Public Aid Code is amended by | ||||||
5 | adding Section 5-5.12b as follows:
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6 | (305 ILCS 5/5-5.12b new) | ||||||
7 | Sec. 5-5.12b. Interferon-free therapy; prior approval. | ||||||
8 | (a)
Prior approval by the Department to administer to a | ||||||
9 | recipient of medical assistance any interferon-free therapy | ||||||
10 | for the treatment of the hepatitis C virus shall be limited to | ||||||
11 | the following criteria: | ||||||
12 | (1) The recipient must be 18 years of age. | ||||||
13 | (2) The recipient must have a diagnosis of chronic | ||||||
14 | hepatitis C infection, genotype 1, 2, 3, or 4, confirmed by | ||||||
15 | stage 2 fibrosis. | ||||||
16 | (3) The recipient may not have been previously denied a | ||||||
17 | prescription for any interferon-free therapy for the | ||||||
18 | treatment of the hepatitis C virus. | ||||||
19 | (4) The recipient may not have end-stage renal disease | ||||||
20 | requiring dialysis. | ||||||
21 | (5) The recipient must have sufficient kidney function | ||||||
22 | as defined by the Department by rule. | ||||||
23 | (6) The recipient may not have evidence of a known and |
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1 | incurable disease, with a life expectancy of less than 12 | ||||||
2 | months. | ||||||
3 | (7) The recipient may not be receiving hospice care. | ||||||
4 | (8) The recipient may not be taking another treatment | ||||||
5 | that is harmful to take in combination with any | ||||||
6 | interferon-free therapy for the treatment of the hepatitis | ||||||
7 | C virus. | ||||||
8 | (9) The recipient may not have abused a controlled | ||||||
9 | substance within the past 6 months. | ||||||
10 | (10) The recipient must take a drug test no more than | ||||||
11 | 15 days prior to submission of the prior approval request. | ||||||
12 | (b) The Department may not use the following criteria as a | ||||||
13 | basis for requiring prior approval to administer to a recipient | ||||||
14 | of medical assistance any interferon-free therapy for the | ||||||
15 | treatment of the hepatitis C virus: | ||||||
16 | (1) The fact that the recipient or any female partner | ||||||
17 | of the recipient is pregnant. | ||||||
18 | (2) The recipient's mental capacity or any | ||||||
19 | determination related to the recipient's ability to make | ||||||
20 | appropriate decisions about the interferon-free therapy | ||||||
21 | treatment or to comply with related instructions. | ||||||
22 | (3) Any evidence or known diagnosis of malignancy of | ||||||
23 | any body organ. | ||||||
24 | (4) The fact that the recipient is receiving or has | ||||||
25 | received chemotherapy or radiation therapy. | ||||||
26 | (5) The fact that the recipient was previously |
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1 | administered an interferon-free therapy for the treatment | ||||||
2 | of the hepatitis C virus. | ||||||
3 | (c) A prescriber of any interferon-free therapy for the | ||||||
4 | treatment of the hepatitis C virus to a recipient of medical | ||||||
5 | assistance shall be one of the following: | ||||||
6 | (1) A gastroenterologist or physician practicing in a | ||||||
7 | relevant sub-specialty. | ||||||
8 | (2) An infectious disease specialist. | ||||||
9 | (3) Any physician licensed to practice medicine in all | ||||||
10 | its branches with a current license who has received a | ||||||
11 | written consultation report from a board-certified | ||||||
12 | gastroenterologist or specialist in a relevant | ||||||
13 | sub-specialty or from an infectious disease specialist. A | ||||||
14 | formal request for prior approval to administer to a | ||||||
15 | medical assistance recipient any interferon-free therapy | ||||||
16 | for the treatment of the hepatitis C virus shall not be | ||||||
17 | submitted to the Department without a written consultation | ||||||
18 | report as provided in this paragraph. | ||||||
19 | (d) The prescriber must submit lab results to the | ||||||
20 | Department before the treatment begins, at the end of therapy, | ||||||
21 | and 12 weeks after the treatment. | ||||||
22 | (e) The Department shall establish an appeals process for | ||||||
23 | recipients who either fail to meet the criteria established in | ||||||
24 | subsection (a) but who demonstrate a reasonable consideration | ||||||
25 | for continuing treatment, or who received a positive drug test | ||||||
26 | within 15 days of the submission of the prior approval request. |
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1 | The Department shall review cases involving recipients who | ||||||
2 | received a positive drug test and who have documentation of a | ||||||
3 | drug interaction that would indicate a positive reading from a | ||||||
4 | urine test or other drug test. | ||||||
5 | (f) The Department shall pay managed care entities a | ||||||
6 | monthly non-capitated rate for any interferon-free therapy for | ||||||
7 | the treatment of the hepatitis C virus that is prescribed to a | ||||||
8 | recipient of medical assistance. The Department may consider | ||||||
9 | the fee-for-service cost of the prescription, the cost | ||||||
10 | differential of alternative treatments, and the utilization of | ||||||
11 | the drug being prescribed in the development of that rate.
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12 | Section 99. Effective date. This Act takes effect upon | ||||||
13 | becoming law.
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