Sent a notice to inform providers that, due to the continued prevalence of Respiratory Syncytial Virus (RSV), the Department of Healthcare and Family Services (HFS) is extending its coverage for Synagis (palivizumab) through March 31, 2024. This applies to customers covered under Medicaid fee-for-service (FFS) or a managed care plan. Providers should contact the appropriate managed care plan for approval guidance.
Due to the security breach and subsequent system outage at Change Healthcare, HFS’ Pharmacy Benefits Management System (PBMS) for the FFS program, providers are unable to obtain prior approval. Providers billing on the 837 Professional claim format may submit their claims for Synagis without prior approval. Pharmacies are encouraged, in good faith, to continue to provide this medication as needed. Once the system is operational, HFS will make pharmacies whole and assist with claim submissions and provide any necessary overrides.
Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565, or the appropriate managed care plan.
Also in Illinois, HFS would like to thank our pharmacy partners who have been working tirelessly to ensure Medicaid customers receive their necessary medications. During this system outage, medications, including medications that normally require prior authorization, will not be subject to a post approval process. HFS will pay all clean claims submitted once the PBMS system is operational. Prescriptions filled in good faith will be paid in full as soon as the issue is resolved. HFS cannot provide an estimate on when the system issue will be resolved.
We want to reiterate that pharmacies should continue to check eligibility, which they can do by checking one of the following resources:
- MEDI – www.myhfs.illinois.gov
- AVRS – 800-846-1461
- Recipient Eligibility Verification (REV) System
- During business hours, calling 800-252-8942 or 877-782-5565 Option 7
Additionally, pharmacists should take particular care to consult with their patients regarding their current medications, and health and medication history to reduce the risk of adverse events.
Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.