305 ILCS 5/5-5.12b — Illinois Code / Chapter 305 / Act 5 / Section 5-5.12b
Section 5-5.12b
Status: in_force

(305 ILCS 5/5-5.12b) (Text of Section before amendment by P.A. 104-27) Sec. 5-5.12b. Critical access care pharmacy program. (a) As used in this Section: "Critical access care pharmacy" means an Illinois-based brick and mortar pharmacy that is located in a county with fewer than 50,000 residents and that owns fewer than 10 pharmacies. "Critical access care pharmacy program payment" means the number of individual prescriptions a critical access care pharmacy fills during that quarter multiplied by the lesser of the individual payment amount or the dispensing reimbursement rate made by the Department under the medical assistance program as of April 1, 2018. "Individual payment amount" means the dividend of 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter. (b) Subject to appropriations, the Department shall establish a critical access care pharmacy program to ensure the sustainability of critical access pharmacies throughout the State of Illinois. (c) The critical access care pharmacy program shall not exceed $10,000,000 annually and individual payment amounts per prescription shall not exceed the dispensing rate that the Department would have reimbursed under the Medical Assistance Program as of April 1, 2018. (d) Quarterly, the Department shall determine the number of prescriptions filled by critical access care pharmacies reimbursed by Medicaid managed care organizations utilizing encounter data available to the Department. The Department shall determine the individual payment amount per prescription by dividing 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter. If the individual payment amount per prescription as calculated using quarterly prescription amounts exceeds the reimbursement rate under the medical assistance program as of April 1, 2018, then the individual payment amount per prescription shall be the dispensing reimbursement rate under the medical assistance program as of April 1, 2018. (e) Quarterly, the Department shall distribute to critical access care pharmacies a critical access care pharmacy program payment. The first payment shall be calculated utilizing the encounter data from the last quarter of State fiscal year 2018. (f) The Department may adopt rules permitting an Illinois-based brick and mortar pharmacy that owns fewer than 10 pharmacies to receive critical access care pharmacy program payments in the same manner as a critical access care pharmacy, regardless of whether the pharmacy is located in a county with a population of less than 50,000. (Source: P.A. 100-587, eff. 6-4-18.) (Text of Section after amendment by P.A. 104-27) Sec. 5-5.12b. Critical access care pharmacy program. (a) As used in this Section: "Critical access care pharmacy" means an Illinois-based brick and mortar retail pharmacy located in Illinois that is owned by a person or entity with an ownership or control interest in fewer than 10 pharmacies, is either located in a county with fewer than 50,000 residents or in a county with 50,000 or more residents and in an area within Illinois that is designated as a Medically Underserved Area by the Health Resources and Services Administration, an agency of the U.S. Department of Health and Human Services and has attested and been approved by the Department for participation in the critical access care pharmacy program. "Critical access care pharmacy program payment" means the number of individual prescriptions a critical access care pharmacy fills during that quarter multiplied by the lesser of the individual payment amount or the dispensing reimbursement rate made by the Department under the medical assistance program as of April 1, 2018. "Individual payment amount" means the dividend of 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter. "Ownership or control interest" has the meaning given to "person with an ownership or control interest" in 42 CFR 455.101. (b) Subject to appropriations and federal approval, the Department shall establish a critical access care pharmacy program to ensure the sustainability of critical access pharmacies throughout the State of Illinois. (c) The critical access care pharmacy program disbursed by the managed care plans shall not exceed $45,000,000 annually and individual payment amounts per prescription shall not exceed the brand name dispensing rate that the Department would have reimbursed to a critical access care pharmacy under the Medical Assistance Program as of July 1, 2024. (c-5) 340B pharmacies that are participants in the critical access care pharmacy program shall only be reimbursed for the actual acquisition costs of the 340B covered drugs dispensed to participants in the State's medical assistance program as defined in the Illinois Public Aid Code. (d) Annually, beginning January 1, 2026, the Department shall determine the number of prescriptions filled by critical access care pharmacies reimbursed by Medicaid managed care organizations utilizing encounter data available to the Department. The Department shall determine the individual payment amount per prescription by dividing 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter. If the individual payment amount per prescription as calculated using quarterly prescription amounts exceeds the reimbursement rate under the medical assistance program as of April 1, 2018, then the individual payment amount per prescription shall be the dispensing reimbursement rate under the medical assistance program as of April 1, 2018. (e) Quarterly, the Department shall distribute to critical access care pharmacies a critical access care pharmacy program payment. The first payment shall be calculated utilizing the encounter data from the last quarter of State fiscal year 2018. This payment shall sunset on December 31, 2025. (f) Effective January 1, 2026, the Department shall issue a quarterly directed critical access care pharmacy program payment to critical access care pharmacies for any prescription drug dispensed to a managed care client. (g) The Department may adopt rules necessary to implement this Section. The rules may include, but are not limited to, permitting an Illinois-based brick and mortar pharmacy that owns fewer than 10 pharmacies to receive critical access care pharmacy program payments in the same manner as a critical access care pharmacy, regardless of whether the pharmacy meets the other requirements of a critical access care pharmacy in subsection (a). (Source: P.A. 104-27, eff. 1-1-26.)