Please see the updated Continuous Glucose Monitor (CGM) Prior Authorization Criteria from the Department of Healthcare and Family Services.

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

The Department of Revenue (IDOR) released an Informational Bulletin to all retailers and servicepersons. For sales and use tax and other related returns due on or after January 1, 2025, the retailers’ discount amount is limited to $1,000 per month. The retailers’ discount is an amount that retailers and servicepersons may claim only if the return is filed on or before the due date and only for a percentage of the taxes paid on or before the due date. The discount is allowed as a reimbursement for the expenses incurred in keeping records, preparing and filing returns, remitting the tax and supplying data to the IDOR on request.

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

The Department of Healthcare and Family Services (HFS) recently released 2023 Q4 and 2024 Q1 payments for the Critical Access Pharmacy (CAP) Program. Due to the Change Healthcare System outage earlier in the year, the Q4 data was not complete, and the Q1 data was estimated, and both will be reconciled as part of the 2024 Q2 payments once all the data from the Medicaid managed care plans has been submitted.

HFS made the estimated payments to ensure CAPs received these important funds. Please note that new pharmacies who have never received CAP funds had no estimated payment available for Q1, and therefore did not receive an initial CAP payment. HFS will also reconcile these pharmacy payments when the Q2 payments are processed.

If you have any questions, please contact a pharmacy billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.

Also in Illinois, the Department informed pharmacies that the 2024-2025 influenza vaccine National Drug Codes (NDCs) have been loaded to the Pharmacy Billing Management System (PBMS) and can now be billed.

To receive the vaccine administration fee, pharmacies billing the Medicaid fee-for-service (FFS) program should enter the administration fee amount in the Incentive Amount Submitted field (438-E3). If the value in this field exceeds $6.40, the maximum allowed by the Department of Healthcare and Family Services (HFS), the claim will only pay an administration fee of $6.40. If the value of the field is less than or equal to the HFS allowed amount, the system will pay the lesser of the two. The value ‘MA’ must be entered in the Professional Service Code field (440-E5) unless no administration fee is billed. The claim will reject if it is submitted with an incorrect value in one of these fields. If a claim is submitted with an NDC for an influenza vaccine, but neither of these fields is populated, no administration fee will be paid.

For managed care organization (MCO) claims, please contact the applicable MCO for billing instructions.

Questions should be directed to a billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.

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

The Department of Healthcare and Family Services’ (HFS) Pharmacy Benefit Management System (PBMS) for the fee-for-service program, Change Healthcare, experienced a nationwide system outage as noted in the provider notice dated February 22, 2024. During the system outage, HFS was unable to add new National Drug Codes (NDCs) to the formulary. Providers were asked to hold fee-for-service (FFS) claims until the issue was resolved.

The new NDCs are now available and have been added to the formulary; therefore, providers may release all FFS claims that have been held pending the update.

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.

Gov. JB Pritzker (D) has signed SB 3268 Medicaid Omnibus legislation which includes a large expansion in the practice of pharmacy which will allow pharmacists to test and treat for influenza, SARS-COV 2, RSV, Group A Strep and adult-stage head louse. The bill also includes PBM transparency provisions.

Also in Illinois, please see the updated Department of Healthcare and Family Services Pharmacist Fee Schedule (updated July 11, 2024).

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

The April 4, 2024, provider notice includes an update to pharmacies on billing for the COVID-19 vaccine administration fee. This update applies only to the Medicaid fee-for-service program for dates of service beginning September 11, 2023, through December 31, 2023. 

A September 28, 2023, provider notice stated the Department of Healthcare and Family Services (HFS) was still finalizing programming for the administration fee for the COVID-19 vaccine, and providers could not include administration fee charges on their claims at that time. Pharmacies could still provide COVID-19 vaccinations and submit claims to HFS for reimbursement for the cost of the vaccine and a professional dispensing fee, without an administration fee.  

HFS has completed part of the programming for pharmacies to receive the applicable administration fee for COVID-19 vaccines. Pharmacies can now void and rebill claims that were initially submitted without the administration fee for dates of service beginning September 11, 2023, through December 31, 2023. Pharmacies must use “MA” in the Professional Service Code Field, in addition to identifying the administration fee. 

Claims with dates of service beginning January 1, 2024, must continue to be billed without an administration fee until further notice. 

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.

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.

This notice serves to inform providers that Medicaid coverage for the respiratory syncytial virus (RSV) vaccine, Abrysvo, for pregnant customers, 32-36 weeks, will end January 31, 2024, in accordance with the latest Centers for Disease Control (CDC) and Advisory Committee on Immunization Practices (ACIP) guidelines.  

To prevent and protect high risk children from RSV at the tail-end of the season, coverage for monoclonal antibodies, Beyfortus (Nirsevimab) and Synagis (Palivizumab), will be continued at least until the end of February this year with plans to reevaluate RSV incidence and hospitalizations before coverage is ended. 

Abrysvo or Arexvy will remain available for Medicaid customers aged 60 years and over through the pharmacy point-of-sale and medical billing without a prior authorization.  

Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565 for fee-for-service (FFS) claims or the appropriate managed care organization (MCO). 

Also in Illinois, the Department of Health and Family Services will review the following classes for the April 11 Drug and Therapeutics (D and T) Advisory Board meeting: 

• Antiasthmatics-Adrenergic Combination Inhalers 
• Antiasthmatics-Anticholinergic Inhalers 
• Antiasthmatics-Beta Adrenergic Inhalers 
• Antiasthmatics-Steroid Inhalers 

D and T Call-In Information 

All clinical and financial submissions are due to the Department by 3:00 pm CST on March 21. Submissions should be sent to: HFS.SupplementalRebaleProgram@illinois.gov. 

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

The Department of Healthcare and Family Services (HFS) submitted a State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS) to change the methodology by which HFS will reimburse providers for costs associated with the administration of the COVID-19 vaccine. 

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