Illinois Code § 45.3

§ 45.3.

Prescription drug benefits; plan choice. (a) Notwithstanding any other provision of law, beginning January 1, 2023, every health insurance carrier that offers an individual health plan that provides coverage for prescription drugs shall ensure that at least 10% of individual health care plans offered in each applicable service area and at each level of coverage as defined in 42 U.S.C. 18022(d) apply a flat-dollar copayment structure to the entire drug benefit. Beginning January 1, 2024, every health insurance carrier that offers an individual health plan that provides coverage for prescription drugs shall ensure that at least 25% of individual health care plans offered in each applicable service area and at each level of coverage as defined in 42 U.S.C. 18022(d) apply a flat-dollar copayment structure to the entire drug benefit. If a health insurance carrier offers fewer than 4 plans in a service area, then the health insurance carrier shall ensure that one plan applies a flat-dollar copayment structure to the entire drug benefit. (b) Every health insurance carrier that offers a small group health plan that provides coverage for prescription drugs shall offer at least 2 small group health plans in each applicable service area and at each level of coverage as defined in 42 U.S.C. 18022(d) that apply a flat-dollar copayment structure to the entire drug benefit. (c) The flat-dollar copayment structure for prescription drugs under subsections (a) and (b) must be applied pre-deductible and be reasonably graduated and proportionately related in all tier levels such that the copayment structure as a whole does not discriminate against or discourage the enrollment of individuals with significant health care needs. Notwithstanding the other provisions of this subsection, beginning January 1, 2025, each level of coverage that a health insurance carrier offers of a standardized option in each applicable service area shall be deemed to satisfy the requirements for a flat-dollar copay structure in subsection (a). For purposes of this subsection, "standardized option" has the meaning given to that term in 45 CFR 155.20 or, when Illinois has a State-based exchange, a substantially similar definition to "standardized option" in 45 CFR 155.20 that substitutes the Illinois Health Benefits Exchange for the United States Department of Health and Human Services. (d) A health insurance carrier that offers individual or small group health care plans shall clearly and appropriately name the plans described in subsections (a) and (b) to aid in the individual or small group plan selection process. (e) A health insurance carrier shall market plans described in subsections (a) and (b) in the same manner as plans not described in subsections (a) and (b). (f) The Department shall adopt rules necessary to implement and enforce the provisions of this Section. (Source: P.A. 102-391, eff. 1-1-23; 103-777, eff. 8-2-24.)