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.

The State Veterinary Medical Association asked NACDS to remind members that veterinarians have an exemption from the state’s e-prescribing law for the next two years. Please see HB 1358/Public Act 103-0563 (Section 311.6 (b-5, 10). 

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

The Department of Healthcare and Family Services (HFS) is providing this update regarding buprenorphine dosing for pregnant individuals with a substance use disorder (SUD) diagnosis, who, due to growing fetus and maternal weight gain, are likely to require a higher dosage than the usual 24 mg maximum dose.  

HFS is working on programming to allow a total daily dose of up to 32 mg of all buprenorphine products (monotherapy as well as combination products with naloxone) for pregnant individuals with SUD without a prior authorization, when both diagnoses (pregnancy and SUD) are noted on the prescription.  

These services will be covered under both the fee-for-service (FFS) program and managed care organizations (MCOs) with a target implementation date of February 1, 2024.  

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 appropriate MCO plan.  

Also in Illinois, Public Act 103-1425, which became effective January 1, 2024, requires prescriptions to be issued electronically unless one or more of a variety of exemptions are met.  

Illinois Retail Merchants Association (IRMA) and the Illinois Pharmacists Association (IPhA) are being inundated with complaints from prescribers because paper prescriptions are being denied by pharmacists primarily issued by prescribers who are exempt from having to issue electronically. The complaints are primarily coming from prescribers who will not issue more than 150 prescriptions in the calendar year. In addition to that exemption, below is a summary of the exemptions under the law.  

Importantly, any pharmacist who dispenses in good faith based upon a valid prescription that is not prescribed electronically may be exempt from any disciplinary action. A pharmacist is not required to ensure or be responsible for ensuring the prescriber’s compliance, nor may any other entity or organization require a pharmacist to ensure the prescriber’s compliance with that subsection.  

IRMA and IPhA have prepared and issued detailed guidance. You are strongly encouraged to distribute or utilize this guidance to ensure pharmacy personnel are fully aware of the exemptions under this law.  

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

The Department of Healthcare and Family Services (HFS) has issued a Provider Notice regarding Respiratory Syncytial Virus (RSV) vaccines for Medicaid customers. Additional information on other Provider Notices regarding these vaccines are available online.  

Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565 for Medicaid Fee-for-Service claims, or the appropriate Medicaid Managed Care program. 

Also in Illinois, the Department of Healthcare and Family Services (HFS) continues to prepare for the release of the new over-the-counter (OTC) birth control pill, Opill, which is anticipated in early 2024. Opill will be covered by HFS under both the Medicaid Fee-for-Service (FFS) and Managed Care programs without a prescription for women aged 18 years and older. 

HFS requires pharmacies to submit all claims, including those for OTC medications, with a prescriber National Provider Identifier (NPI) in the Prescriber ID field (411-DB). For Opill, pharmacies may bill using the Department of Public Health standing order prescriber NPI for hormonal contraceptives.    

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 appropriate Medicaid Managed Care program. 

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