§ 513b3 — Examination

Illinois § 513b3

• Jurisdiction: Illinois
• Topic: REGULATION
• Ch. 215: INSURANCE
• Act 215 ILCS 5/: Illinois Insurance Code.
• Art.: Article XXXIIB - Pharmacy Benefit Managers

Text

(a) The Director, or his or her designee, may examine a registered pharmacy benefit manager related to all of its lines of business, including government programs, under the Director's jurisdiction in accordance with Sections 132-132.7. If the Director or the examiners find that the pharmacy benefit manager has violated this Article or any other insurance-related or health benefits-related laws, rules, or regulations under the Director's jurisdiction because of the manner in which the pharmacy benefit manager has conducted business on behalf of a health insurer or plan sponsor, then, unless the health insurer or plan sponsor is included in the examination and has been afforded the same opportunity to request or participate in a hearing on the examination report, the examination report shall not allege a violation by the health insurer or plan sponsor and the Director's order based on the report shall not impose any requirements, prohibitions, or penalties on the health insurer or plan sponsor. Nothing in this Section shall prevent the Director from using any information obtained during the examination of an administrator to examine, investigate, or take other appropriate regulatory or legal action with respect to a health insurer or plan sponsor. (b) The examination requirement for the pharmacy benefit manager to provide convenient and free access to all books and records under Sections 132 and 132.4 of this Code includes, at the Director's discretion, unredacted copies furnished electronically to the Director's market conduct surveillance personnel or examiners. Access must include information related to third-party entities affiliated or contracted with the pharmacy benefit manager, including, but not limited to, rebate aggregators and pharmacy services administrative organizations. (c) The Department may examine any pharmacy benefit manager as often as the Department deems appropriate, but shall, at a minimum, conduct an examination of the 3 largest pharmacy benefit managers with the most covered individuals not less frequently than once every 5 years beginning in 2026, or following the conclusion of any market conduct exams already in progress for the 3 largest pharmacy benefit managers. In determining pharmacy benefit plan market share, the Department may consider, but is not limited to, the following: (1) the number of covered individuals; (2) the Illinois Market share; (3) the number of drug-related claims; (4) the total gross spending on drugs; (5) the aggregate amounts of rebates, fees, and discounts remitted by the pharmacy benefit manager or rebate aggregator; (6) the dispensing channel used; (7) the previous violations; and (8) the complaints received.

Legislative History

(Source: P.A. 103-897, eff. 1-1-25; 104-27, eff. 7-1-25.)