PHARMACY BENEFIT REIMBURSE

Illinois General Assembly - Full Text of HB4761

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104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB4761

Introduced , by Rep. Natalie A. Manley

SYNOPSIS AS INTRODUCED:

215 ILCS 5/513b1

Amends the Illinois Insurance Code. In provisions concerning pharmacy
benefit manager contracts, provides that a pharmacy benefit manager must
not reimburse a pharmacy or pharmacist for a prescription drug or pharmacy
service in an amount less than the national average drug acquisition cost
for the prescription drug or pharmacy service at the time the drug is
administered or dispensed, plus a professional dispensing fee of $10.49.
Provides that, if the national average drug acquisition cost is not
available at the time a drug is administered or dispensed, a pharmacy
benefit manager may not reimburse in an amount that is less than the
wholesale acquisition cost of the drug, plus a professional dispensing fee
of $10.49.
LRB104 19429 BAB 32877 b

A BILL FOR

HB4761
LRB104 19429 BAB 32877 b
1

AN ACT concerning regulation.

2

Be it enacted by the People of the State of Illinois,
3
represented in the General Assembly:

4

Section 5.
The Illinois Insurance Code is amended by
5
changing Section 513b1 as follows:

6

(215 ILCS 5/513b1)
7

Sec. 513b1.
Pharmacy benefit manager contracts.
8

(a) As used in this Article:
9

"340B drug discount program" means the program established
10
under Section 340B of the federal Public Health Service Act,
11
42 U.S.C. 256b.
12

"340B entity" means a covered entity as defined in 42
13
U.S.C. 256b(a)(4) authorized to participate in the 340B drug
14
discount program.
15

"340B pharmacy" means any pharmacy used to dispense 340B
16
drugs for a covered entity, whether entity-owned or external.
17

"Affiliate" means a person or entity that directly or
18
indirectly through one or more intermediaries controls or is
19
controlled by, or is under common control with, the person or
20
entity specified. The location of a person or entity's
21
domicile, whether in Illinois or a foreign or alien
22
jurisdiction, does not affect the person or entity's status as
23
an affiliate.

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LRB104 19429 BAB 32877 b
1

"Biological product" has the meaning ascribed to that term
2
in Section 19.5 of the Pharmacy Practice Act.
3

"Brand name drug" means a drug that has been approved
4
under 42 U.S.C. 262 or 21 U.S.C. 355(c), as applicable, and is
5
marketed, sold, or distributed under a proprietary,
6
trademark-protected name.
7

"Complex or chronic medical condition" means a physical,
8
behavioral, or developmental condition that has no known cure,
9
is progressive, or can be debilitating or fatal if unmanaged
10
or untreated.
11

"Covered individual" means a member, participant,
12
enrollee, contract holder, policyholder, or beneficiary of a
13
health benefit plan who is provided a drug benefit by the
14
health benefit plan.
15

"Critical access pharmacy" means a critical access care
16
pharmacy as defined in Section 5-5.12b of the Illinois Public
17
Aid Code.
18

"Drugs" has the meaning ascribed to that term in Section 3
19
of the Pharmacy Practice Act and includes biological products.
20

"Employee welfare benefit plan" has the meaning given to
21
that term in 29 U.S.C. 1002(1), without regard for whether the
22
employee welfare benefit plan is covered under 29 U.S.C. 1003.
23

"Federal governmental plan" has the meaning given to that
24
term in 42 U.S.C. 300gg-91(d)(8)(B).
25

"Generic drug" means a drug that has been approved under
26
42 U.S.C. 262 or 21 U.S.C. 355(c), as applicable, and is

HB4761
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LRB104 19429 BAB 32877 b
1
marketed, sold, or distributed directly or indirectly to the
2
retail class of trade with labeling, packaging (other than
3
repackaging as the listed drug in blister packs, unit doses,
4
or similar packaging for use in institutions), product code,
5
labeler code, trade name, or trademark that differs from that
6
of the brand name drug.
7

"Health benefit plan" means a policy, contract,
8
certificate, or agreement entered into, offered, or issued by
9
an insurer to provide, deliver, arrange for, pay for, or
10
reimburse any of the costs of physical, mental, or behavioral
11
health care services. Notwithstanding Sections 122-1 through
12
122-4 of this Code, "health benefit plan" includes self-funded
13
employee welfare benefit plans except for self-funded
14
multiemployer plans that are not nonfederal government plans.
15
"Health benefit plan" does not include:
16

(1) workers compensation insurance, a federal
17

governmental plan, Medicare Advantage, Medicare Part D, a
18

Medicare demonstration program, or Tricare; or
19

(2) any program for dually eligible Medicare-Medicaid
20

beneficiaries enrolled in a program under which Medicare
21

pays for most or all of the covered drugs.
22

"Health benefit plan sponsor" or "plan sponsor" means:
23

(1) a plan sponsor, as defined in 29 U.S.C.
24

1002(16)(B), without regard for whether the employee
25

welfare benefit plan is covered under 29 U.S.C. 1003.
26

Except as provided by subsection (m), "plan sponsor"

HB4761
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LRB104 19429 BAB 32877 b
1

includes the plan sponsor of a nonfederal governmental
2

plan, including a joint insurance pool described in
3

Section 6 of the Intergovernmental Cooperation Act; and
4

(2) any other governmental unit or public agency to
5

which any State law grants the rights of a plan sponsor
6

when incorporating this Article by reference.
7

"Maximum allowable cost" means the maximum amount that a
8
pharmacy benefit manager will reimburse a pharmacy for the
9
cost of a drug.
10

"Maximum allowable cost list" means a list of drugs for
11
which a maximum allowable cost has been established by a
12
pharmacy benefit manager.
13

"Multiemployer plan" has the meaning given to that term in
14
29 U.S.C. 1002(37).
15

"Nonfederal governmental plan" has the meaning given to
16
that term in 42 U.S.C. 300gg-91(d)(8)(C).
17

"Pharmacy benefit manager" means a person, business, or
18
entity, including a wholly or partially owned or controlled
19
subsidiary of a pharmacy benefit manager, that provides claims
20
processing services or other drug or device services, or both,
21
for health benefit plans.
22

"Pharmacy" has the meaning given to that term in Section 3
23
of the Pharmacy Practice Act.
24

"Pharmacy services" means the provision of any services
25
listed within the definition of "practice of pharmacy" under
26
subsection (d) of Section 3 of the Pharmacy Practice Act.

HB4761
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LRB104 19429 BAB 32877 b
1

"Rare medical condition" means a physical, behavioral, or
2
developmental condition that affects fewer than 200,000
3
individuals in the United States or approximately 1 in 1,500
4
individuals worldwide.
5

"Rebate" means a discount or pricing concession based on
6
drug utilization or administration that is paid by the
7
manufacturer to a pharmacy benefit manager or its client.
8

"Rebate aggregator" means a person or entity, including
9
group purchasing organizations, that negotiate rebates or
10
other fees with drug manufacturers on behalf or for the
11
benefit of a pharmacy benefit manager or its client and may
12
also be involved in contracts that entitle the rebate
13
aggregator or its client to receive rebates or other fees from
14
drug manufacturers based on drug utilization or
15
administration.
16

"Retail price" means the price an individual without drug
17
coverage would pay at a retail pharmacy, not including a
18
pharmacist dispensing fee.
19

"Specialty drug" means a drug that:
20

(1) is prescribed for a person with a complex or
21

chronic medical condition or a rare medical condition;
22

(2) has limited or exclusive distribution; and
23

(3) requires both:
24

(A) specialized product handling by the dispensing
25

pharmacy or administration by the dispensing pharmacy;
26

and

HB4761
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LRB104 19429 BAB 32877 b
1

(B) specialized clinical care, including frequent
2

dosing adjustments, intensive clinical monitoring, or
3

expanded services for patients, including intensive
4

patient counseling, education, or ongoing clinical
5

support beyond traditional dispensing activities, such
6

as individualized disease and therapy management to
7

support improved health outcomes.
8

"Spread pricing" means the model of drug pricing in which
9
the pharmacy benefit manager charges a health benefit plan a
10
contracted price for drugs, and the contracted price for the
11
drugs differs from the amount the pharmacy benefit manager
12
directly or indirectly pays the pharmacist or pharmacy for the
13
drugs, pharmacist services, or drug and dispensing fees.
14

"Steer" includes, but is not limited to:
15

(1) requiring a covered individual to only use a
16

pharmacy, including a mail-order or specialty pharmacy, in
17

which the pharmacy benefit manager or its affiliate, or an
18

insurer or its affiliate, maintains an ownership interest
19

or control;
20

(2) offering or implementing a plan design that
21

encourages a covered individual to only use a pharmacy in
22

which the pharmacy benefit manager or an affiliate, or an
23

insurer or its affiliate, maintains an ownership interest
24

or control, if the plan design increases costs for the
25

covered individual. This includes a plan design that
26

requires a covered individual to pay higher costs or an

HB4761
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LRB104 19429 BAB 32877 b
1

increased share of costs for a drug or drug-related
2

service if the covered individual uses a pharmacy that is
3

not owned or controlled by the pharmacy benefit manager or
4

its affiliate or an insurer or its affiliate; and
5

(3) reimbursing a pharmacy or pharmacist for a drug
6

and pharmacist service in an amount less than the amount
7

that the pharmacy benefit manager or an insurer reimburses
8

itself or an affiliate, including affiliated manufacturers
9

or joint ventures for providing the same drug or service.
10

"Third-party payer" means any entity that pays for drugs
11
on behalf of a patient other than a health care provider or
12
sponsor of a plan subject to regulation under Medicare Part D,
13
42 U.S.C. 1395w-101 et seq.
14

The changes made to this subsection by this amendatory Act
15
of the 104th General Assembly shall be deemed to be operative
16
on and after July 1, 2025.
17

(a-5) In this Article, references to an "insurer" or
18
"health insurer" shall include commercial private health
19
insurance issuers, managed care organizations, managed care
20
community networks, and any other third-party payer that
21
contracts with pharmacy benefit managers or with the
22
Department of Healthcare and Family Services to provide
23
benefits or services under the Medicaid program or to
24
otherwise engage in the administration or payment of pharmacy
25
benefits. However, the terms do not refer to the plan sponsor
26
of a self-funded, single-employer employee welfare benefit

HB4761
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LRB104 19429 BAB 32877 b
1
plan or self-funded multiemployer plan if either plan is
2
covered by 29 U.S.C. 1003. This subsection shall be deemed to
3
be operative on and after July 1, 2025.
4

(b) A contract between a health insurer or plan sponsor
5
and a pharmacy benefit manager must require that the pharmacy
6
benefit manager:
7

(1) Update maximum allowable cost pricing information
8

at least every 7 calendar days.
9

(2) Maintain a process that will, in a timely manner,
10

eliminate drugs from maximum allowable cost lists or
11

modify drug prices to remain consistent with changes in
12

pricing data used in formulating maximum allowable cost
13

prices and product availability.
14

(3) Provide access to its maximum allowable cost list
15

to each pharmacy or pharmacy services administrative
16

organization subject to the maximum allowable cost list.
17

Access may include a real-time pharmacy website portal to
18

be able to view the maximum allowable cost list. As used in
19

this Section, "pharmacy services administrative
20

organization" means an entity operating within the State
21

that contracts with independent pharmacies to conduct
22

business on their behalf with third-party payers. A
23

pharmacy services administrative organization may provide
24

administrative services to pharmacies and negotiate and
25

enter into contracts with third-party payers or pharmacy
26

benefit managers on behalf of pharmacies.

HB4761
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LRB104 19429 BAB 32877 b
1

(4) Provide a process by which a contracted pharmacy
2

can appeal the provider's reimbursement for a drug subject
3

to maximum allowable cost pricing. The appeals process
4

must, at a minimum, include the following:
5

(A) A requirement that a contracted pharmacy has
6

14 calendar days after the applicable fill date to
7

appeal a maximum allowable cost if the reimbursement
8

for the drug is less than the net amount that the
9

network provider paid to the supplier of the drug.
10

(B) A requirement that a pharmacy benefit manager
11

must respond to a challenge within 14 calendar days of
12

the contracted pharmacy making the claim for which the
13

appeal has been submitted.
14

(C) A telephone number and e-mail address or
15

website to network providers, at which the provider
16

can contact the pharmacy benefit manager to process
17

and submit an appeal.
18

(D) A requirement that, if an appeal is denied,
19

the pharmacy benefit manager must provide the reason
20

for the denial and the name and the national drug code
21

number from national or regional wholesalers.
22

(E) A requirement that, if an appeal is sustained,
23

the pharmacy benefit manager must make an adjustment
24

in the drug price effective the date the challenge is
25

resolved and make the adjustment applicable to all
26

similarly situated network pharmacy providers, as

HB4761
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LRB104 19429 BAB 32877 b
1

determined by the managed care organization or
2

pharmacy benefit manager.
3

(5) Allow a plan sponsor or insurer whose coverage is
4

administered by the pharmacy benefit manager an annual
5

right to audit compliance with the terms of the contract
6

by the pharmacy benefit manager, including, but not
7

limited to, full disclosure of any and all rebate amounts
8

secured, whether product specific or generalized rebates,
9

that were provided to the pharmacy benefit manager by a
10

pharmaceutical manufacturer. The cost of the audit shall
11

be borne exclusively by the pharmacy benefit manager.
12

(6) Allow a plan sponsor or insurer whose coverage is
13

administered by the pharmacy benefit manager to request
14

that the pharmacy benefit manager disclose the actual
15

amounts paid by the pharmacy benefit manager to the
16

pharmacy.
17

(7) Provide notice to the plan sponsor or the insurer
18

party contracting with the pharmacy benefit manager of any
19

consideration that the pharmacy benefit manager receives
20

from the manufacturer for dispense as written once a
21

generic or biologically similar product becomes available.
22

(c) In order to place a particular drug on a maximum
23
allowable cost list, the pharmacy benefit manager described in
24
subsection (b) must, at a minimum, ensure that:
25

(1) if the drug is a generically equivalent drug, it
26

is listed as therapeutically equivalent and

HB4761
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LRB104 19429 BAB 32877 b
1

pharmaceutically equivalent "A" or "B" rated in the United
2

States Food and Drug Administration's most recent version
3

of the "Orange Book" or have an NR or NA rating by
4

Medi-Span, Gold Standard, or a similar rating by a
5

nationally recognized reference;
6

(2) the drug is available for purchase by each
7

pharmacy in the State from national or regional
8

wholesalers operating in Illinois; and
9

(3) the drug is not obsolete.
10

(d) A pharmacy benefit manager or an insurer is prohibited
11
from limiting a pharmacist's ability to disclose whether the
12
cost-sharing obligation exceeds the retail price for a covered
13
drug, and the availability of a more affordable alternative
14
drug, if one is available in accordance with Section 42 of the
15
Pharmacy Practice Act.
16

(e) A health insurer or pharmacy benefit manager shall not
17
require a covered individual to make a payment for a drug at
18
the point of sale in an amount that exceeds the lesser of:
19

(1) the applicable cost-sharing amount;
20

(2) the retail price of the drug in the absence of drug
21

coverage;
22

(3) the discounted price presented by the covered
23

individual through a no-cost drug program or drug
24

manufacturer voucher provided by or for the covered
25

individual at the point of sale; or
26

(4) the discounted price presented by the covered

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LRB104 19429 BAB 32877 b
1

individual through a discounted health care services plan
2

provided by or for the covered individual at the point of
3

sale.
4

This subsection applies to any covered individual of a
5
health benefit plan from an insurer, a nonfederal governmental
6
plan sponsor, or any other governmental unit or public agency
7
to which any State law grants the rights of a plan sponsor when
8
incorporating this Article by reference.
9

(f) Unless required by law, a contract between a pharmacy
10
benefit manager or third-party payer and a 340B entity or 340B
11
pharmacy shall not contain any provision that:
12

(1) distinguishes between drugs purchased through the
13

340B drug discount program and other drugs when
14

determining reimbursement or reimbursement methodologies,
15

or contains otherwise less favorable payment terms or
16

reimbursement methodologies for 340B entities or 340B
17

pharmacies when compared to similarly situated non-340B
18

entities;
19

(2) imposes any fee, chargeback, or rate adjustment
20

that is not similarly imposed on similarly situated
21

pharmacies that are not 340B entities or 340B pharmacies;
22

(3) imposes any fee, chargeback, or rate adjustment
23

that exceeds the fee, chargeback, or rate adjustment that
24

is not similarly imposed on similarly situated pharmacies
25

that are not 340B entities or 340B pharmacies;
26

(4) prevents or interferes with an individual's choice

HB4761
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LRB104 19429 BAB 32877 b
1

to receive a covered drug from a 340B entity or 340B
2

pharmacy through any legally permissible means, except
3

that nothing in this paragraph shall prohibit the
4

establishment of differing copayments or other
5

cost-sharing amounts within the health benefit plan for
6

covered individuals who acquire covered drugs from a
7

nonpreferred or nonparticipating provider;
8

(5) excludes a 340B entity or 340B pharmacy from a
9

pharmacy network on any basis that includes consideration
10

of whether the 340B entity or 340B pharmacy participates
11

in the 340B drug discount program;
12

(6) prevents a 340B entity or 340B pharmacy from using
13

a drug purchased under the 340B drug discount program; or
14

(7) any other provision that discriminates against a
15

340B entity or 340B pharmacy by treating the 340B entity
16

or 340B pharmacy differently than non-340B entities or
17

non-340B pharmacies for any reason relating to the
18

entity's participation in the 340B drug discount program.
19

As used in this subsection, "pharmacy benefit manager" and
20
"third-party payer" do not include pharmacy benefit managers
21
and third-party payers acting on behalf of a Medicaid program.
22

(f-5) A pharmacy benefit manager or an affiliate acting on
23
its behalf shall not conduct spread pricing.
24

(f-10) A pharmacy benefit manager or an affiliate acting
25
on its behalf shall not steer a covered individual. This
26
prohibition also applies to an insurer and its affiliates.

HB4761
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LRB104 19429 BAB 32877 b
1
Existing agreements entered into before the effective date of
2
this amendatory Act of the 104th General Assembly shall
3
supersede this subsection until the termination of the current
4
term of such agreement.
5

(f-15) A pharmacy benefit manager or affiliated rebate
6
aggregator must remit no less than 100% of any amounts paid by
7
a pharmaceutical manufacturer, wholesaler, or other
8
distributor of a drug, including, but not limited to, rebates,
9
group purchasing fees, and other fees, to the health benefit
10
plan sponsor, covered individual, or employer. Records of
11
rebates and fees remitted from the pharmacy benefit manager or
12
rebate aggregator must be disclosed to the Department annually
13
in a format to be specified by the Department. The records
14
received by the Department shall be considered confidential
15
and privileged for all purposes, including for purposes of the
16
Freedom of Information Act, shall not be subject to subpoena
17
from any private party, and shall not be admissible as
18
evidence in a civil action.
19

(f-20) A pharmacy benefit manager or an affiliate acting
20
on its behalf is prohibited from limiting a covered
21
individual's access to drugs from a pharmacy or pharmacist
22
enrolled with the health benefit plan under the terms offered
23
to all pharmacies in the plan coverage area by designating the
24
covered drug as a specialty drug contrary to the definition in
25
this Section. This prohibition also applies to an insurer and
26
its affiliates.

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LRB104 19429 BAB 32877 b
1

(f-25) The contract between the pharmacy benefit manager
2
and the insurer or health benefit plan sponsor must allow and
3
provide for the pharmacy benefit manager's compliance with an
4
audit at least once per calendar year of the rebate and fee
5
records remitted from a pharmacy benefit manager or its
6
affiliated party to a health benefit plan. This audit may be
7
incorporated into the audit under paragraph (5) of subsection
8
(b) of this Section. Contracts with rebate aggregators,
9
pharmacy services administrative organizations, pharmacies, or
10
drug manufacturers must be available for audit by health
11
benefit plan sponsors, insurers, or their designees at least
12
once per plan year. Audits shall be performed by an auditor
13
selected by the health benefit plan sponsor, insurer, or its
14
designee. Health benefit plan sponsors and insurers shall give
15
the pharmacy benefit manager a complete copy of the audit and
16
the pharmacy benefit manager shall provide a complete copy of
17
those findings to the Department within 60 days of initial
18
receipt. Rebate contracts with rebate aggregators, pharmacy
19
services administrative organizations, pharmacies, or drug
20
manufacturers shall be available for audit by health benefit
21
plan sponsor, insurer, or designee. Nothing in this Section
22
shall limit the Department's ability to access the books and
23
records and any and all copies thereof of pharmacy benefit
24
managers, their affiliates, or affiliated rebate aggregators.
25
The records received by the Department shall be considered
26
confidential and privileged for all purposes, including for

HB4761
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LRB104 19429 BAB 32877 b
1
purposes of the Freedom of Information Act, shall not be
2
subject to subpoena from any private party, and shall not be
3
admissible as evidence in a civil action.
4

(f-30) A pharmacy benefit manager must not reimburse a
5
pharmacy or pharmacist for a prescription drug or pharmacy
6
service in an amount less than the national average drug
7
acquisition cost for the prescription drug or pharmacy service
8
at the time the drug is administered or dispensed, plus a
9
professional dispensing fee of $10.49.
10

If the national average drug acquisition cost is not
11
available at the time a drug is administered or dispensed, a
12
pharmacy benefit manager may not reimburse in an amount that
13
is less than the wholesale acquisition cost of the drug, as
14
defined in 42 U.S.C. 1395w-3a(c)(6)(B), plus a professional
15
dispensing fee of $10.49.

16

(g) A violation of this Section by a pharmacy benefit
17
manager constitutes an unfair or deceptive act or practice in
18
the business of insurance under Section 424.
19

(h) A provision that violates subsection (f) in a contract
20
between a pharmacy benefit manager or a third-party payer and
21
a 340B entity that is entered into, amended, or renewed after
22
July 1, 2022 shall be void and unenforceable. This subsection
23
and subsection (f) do not apply to a contract directly between
24
a 340B entity and the plan sponsor of a self-funded,
25
single-employer or multiemployer employee welfare benefit plan
26
subject to 29 U.S.C. 1003.

HB4761
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LRB104 19429 BAB 32877 b
1

(i)(1) A pharmacy benefit manager may not retaliate
2
against a pharmacist or pharmacy for disclosing information in
3
a court, in an administrative hearing, before a legislative
4
commission or committee, or in any other proceeding, if the
5
pharmacist or pharmacy has reasonable cause to believe that
6
the disclosed information is evidence of a violation of a
7
State or federal law, rule, or regulation.
8

(2) A pharmacy benefit manager may not retaliate against a
9
pharmacist or pharmacy for disclosing information to a
10
government or law enforcement agency, if the pharmacist or
11
pharmacy has reasonable cause to believe that the disclosed
12
information is evidence of a violation of a State or federal
13
law, rule, or regulation.
14

(3) A pharmacist or pharmacy shall make commercially
15
reasonable efforts to limit the disclosure of confidential and
16
proprietary information.
17

(4) Retaliatory actions against a pharmacy or pharmacist
18
include cancellation of, restriction of, or refusal to renew
19
or offer a contract to a pharmacy solely because the pharmacy
20
or pharmacist has:
21

(A) made disclosures of information that the
22

pharmacist or pharmacy has reasonable cause to believe is
23

evidence of a violation of a State or federal law, rule, or
24

regulation;
25

(B) filed complaints with the plan or pharmacy benefit
26

manager; or

HB4761
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LRB104 19429 BAB 32877 b
1

(C) filed complaints against the plan or pharmacy
2

benefit manager with the Department.
3

(j) This Section applies to contracts entered into or
4
renewed on or after July 1, 2022. Unless provided otherwise in
5
this Section or in the Illinois Public Aid Code, this Section
6
applies to pharmacy benefit managers that are contracted with
7
a Medicaid managed care entity on or after January 1, 2026. To
8
the extent not otherwise provided, this Section applies to
9
contracts entered into, renewed, or amended on or after
10
January 1, 2026.
11

(k) This Section applies to any health benefit plan that
12
provides coverage for drugs and that is amended, delivered,
13
issued, or renewed on or after July 1, 2020. The changes made
14
to this Section by Public Act 104-27 shall apply with respect
15
to any health benefit plan that provides coverage for drugs
16
that is amended, delivered, issued, or renewed on or after
17
January 1, 2026.
18

(l) A pharmacy benefit manager is responsible for
19
compliance with all State requirements applicable to pharmacy
20
benefit managers even if an action or responsibility of a
21
pharmacy benefit manager is delegated to or completed by an
22
affiliate.
23

(m) This Article applies in relation to plan sponsors of
24
self-funded nonfederal governmental plans only when a State
25
law organizing the governmental unit incorporates this Article
26
by reference. Nothing shall be construed to exclude a joint

HB4761
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LRB104 19429 BAB 32877 b
1
self-insurance pool created under Section 6 of the
2
Intergovernmental Cooperation Act from references to a plan
3
sponsor if any pool member's organizing State law incorporates
4
this Article by reference, but a pharmacy benefit manager is
5
not subject to the requirements of this Article in relation to
6
any pool member whose organizing State law does not
7
incorporate this Article. This subsection shall be deemed to
8
be operative on and after July 1, 2025.
9

(n) Regardless of whether a health benefit plan is
10
insurance, the applicability of this Article to a health
11
benefit plan shall be determined in the same manner as the
12
determination of whether a person is transacting insurance in
13
this State under Sections 121-2.03, 121-2.04, and 121-2.05 and
14
subsections (a), (c), and (e) of Section 121-3. For any health
15
benefit plan subject to this Article, unless specifically
16
provided otherwise, this Article applies to all covered
17
individuals under the health benefit plan, regardless of the
18
individual's residence. The exemption for group accident and
19
health insurance described in subsection (c) of Section 352,
20
as implemented by Department regulation, extends in the same
21
manner to all other health benefit plans with respect to the
22
requirements of this Article. This subsection shall be deemed
23
to be operative on and after July 1, 2025.
24
(Source: P.A. 103-154, eff. 6-30-23; 103-453, eff. 8-4-23;
25
104-27, eff. 1-1-26; 104-439, eff. 12-2-25.)

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