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SB 1238

Health insurance; cost sharing for breast examinations.

2025 Regular Session Introduced by Jennifer Carroll Foy and 12 co-sponsors

The act requires insurers and Medicaid to ensure broad access and parity for nonopioid pain treatments, prohibiting mandatory opioid trials before covering nonopioid options.

Incorporated by Commerce and Labor (SB1436-Perry) (15-Y 0-N)
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Bill Summary · SB 1238

SB 1238 — “Nonopioid Alternatives for Pain Act” (Public Act 104-0369) — Summary

Status: Enacted as Public Act 104-0369
Introduced: Feb 12, 2025 (Illinois) — Effective date (per text): January 1, 2027

Purpose
- Encourage and expand access to nonopioid treatments for acute and other types of pain by (1) informing patients and providers about nonopioid options and (2) requiring insurance coverage parity so nonopioid therapies are not disadvantaged relative to opioid treatments.

Key provisions
1. Department of Public Health — educational pamphlet (adds 20 ILCS 2310/2310‑735)
- Authorizes the Department to develop and publish on its website an educational pamphlet on nonopioid alternatives for:
- acute nonoperative pain, acute perioperative pain, subacute pain, and chronic pain.
- The pamphlet may follow the U.S. HHS Pain Management Best Practices Task Force recommendations and must include:
- information on available nonopioid options (FDA‑approved nonopioid medicinal drugs and nonpharmacologic therapies); and
- advantages and disadvantages of those alternatives.

  1. Insurance coverage parity (adds 215 ILCS 5/370c.3)

    • Beginning January 1, 2027, health insurance issuers must:
      • develop a plan to provide adequate coverage and access to a broad spectrum of pain‑management services (including nonopioid and nonmedication therapies) consistent with Department of Insurance guidelines;
      • file that plan with the Department of Insurance and post plan information on the insurer’s public website.
    • Draft and enrolled language also prohibits insurers from denying coverage of a prescribed nonopioid drug in favor of an opioid, or from requiring a patient to try an opioid first (step‑therapy) before covering an FDA‑approved nonopioid for acute pain.

  2. Medicaid preferred drug list parity (adds 305 ILCS 5/5‑58)

    • When maintaining the Illinois Medicaid Preferred Drug List, the Department must ensure nonopioid drugs approved for pain are not disadvantaged or discouraged relative to opioids.
    • The Department and Medicaid managed‑care organizations may not deny coverage of a nonopioid drug in favor of an opioid or require trying an opioid first.

Who is affected
- Patients prescribed medication or other therapies for acute/perioperative/subacute/chronic pain (including Medicaid enrollees).
- Prescribing clinicians (ability to obtain nonopioid coverage without mandatory opioid trials).
- Health insurance issuers (must prepare and file pain‑management access plans; adjust formulary, utilization, prior authorization and cost‑sharing practices).
- State agencies: Department of Public Health (education), Department of Insurance (plan oversight), and Department administering Medicaid (preferred drug list).

Implementation & impact notes
- Effective date: January 1, 2027 (per the Act’s effective‑date section). Insurers must have plans in place consistent with the Act by that date.
- The Act focuses on access and parity; it does not prescribe specific benefits or a federal funding mechanism. Enforcement and specifics of implementation (e.g., DOI guidance, how utilization controls are judged “disadvantaging”) will depend on subsequent agency rules, insurer filings, and Medicaid administrative actions.
- Anticipated effects include broader availability of nonopioid treatments, changes to formulary and utilization management policies, and administrative work for insurers and state agencies to comply and report.

Compiled from official sources — confirm details with the bill’s official record.

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