HB4079 Summary

• Requires pharmacy benefits managers (PBMs) operating in Illinois to register with the Department of Insurance and maintain a certificate of registration, with annual renewal and fees established by the Director.

• Establishes pricing regulations for PBMs including requirements for maximum allowable cost (MAC) pricing based on multiple data sources, bi-weekly price updates, appeals processes for pharmacy providers, and prohibits transaction fees for electronic claims.

• Prohibits PBMs from mandating use of specific pharmacies, requiring network participation as a condition for other networks, or excluding qualified pharmacists/pharmacies; requires adequate pharmacy network coverage (90% of beneficiaries within 2-5 miles in urban/suburban areas, 70% within 15 miles in rural areas).

• Sets strict standards for on-site pharmacy audits including 30-day advance notice, 4-hour maximum duration, one audit per year per pharmacy, appeals process, and prohibition on extrapolation methods; requires audits be conducted by or consulted with a pharmacist.

• Requires health plans to permit 90-day supplies at community pharmacies, permits medication synchronization with prorated cost-sharing, and prohibits using days' supply to calculate dispensing fees; authorizes Department oversight of PBM claims processing, network management, rebate administration, and data handling practices.