The Department of Healthcare and Family Services (HFS) will post its updated Preferred Drug List (PDL) on March 13. This update will include all changes that have been made during the past 12 months. While the Pharmacy Benefit Management System (PBMS) prior authorization system is pending restoration, HFS strongly encourages prescribers to prescribe and pharmacies to fill using drugs from the PDL, as clinically appropriate. This will prevent customers from having to change medications in the future when the prior authorization system is restored. As a reminder, HFS' PDL can be accessed online. For questions, please contact a pharmacy billing advisor at 877-782-5565, option 7. 

Also in Illinois, this notice informs providers of the Department of Healthcare and Family Services' (HFS) compliance with Public Act 103-0593, which removes prior authorization requirements for Serious Mental Illness (SMI) pharmaceuticals that treat certain diagnoses for patients experiencing a change in behavioral health provider, a change in insurance provider or a change in dosage. The Act clearly defines which diagnoses constitute serious mental illness and the circumstances under which prior authorization is prohibited. The policy applies to both the fee-for-service (FFS) program and the HealthChoice Illinois (HCI) managed care organizations (MCOs) and was effective January 1, 2025.  

HFS will waive the prior authorization requirement when the patient is stable on an SMI medication and one or more of the following conditions are met: 

• The patient has changed providers, including having changed from an inpatient to an outpatient, or 

• The patient has changed insurance providers or 

• When a prior authorization has been previously approved for a patient, and the new prescription modifies dosage, dosage frequency or both. 

A one-time prior authorization may be required in instances where HFS does not have the patient's prescription history and stability on the existing regimen must be confirmed.  

Select safety edits will remain in place, ie, clinically appropriate drug utilization review (DUR) edits, including, but not limited to, drug-drug, drug-age, drug-dose requirements. HFS may require generic use where one is available and meets the needs of the patient. Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims or the applicable HCI MCO. 

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.