The Department of Healthcare and Family Services is currently offering several new behavioral health courses through its Provider Assistance and Training Hub (PATH). All courses are open for registration in the Medicaid Technical Assistance Center (MTAC) Learning Center. Create or sign into your MTAC account at https://go.uillinois.edu/MTAC to access all available training courses. For training questions, please contact PATH-BH@illinois.edu. For questions about the MTAC Learning Management system, please reach out to omi.training@uillinois.edu. 

Also in Illinois, the Illinois Legislative Black Caucus Foundation (ILBCF) is looking to host a statewide Veteran’s Day Event November 10-12. Its goal is to give away 1,500-2,000 bags of groceries to Black Veterans throughout the state. To date, they have secured a donation of 500 bags of groceries and are trying to secure 1,000-1,500 additional. They say gift cards would be helpful as well. The groceries would be distributed throughout the state but particularly East St. Louis, Peoria, Champaign, Chicago (south and west sides) and the south suburbs of Chicago/Will County. If you are interested in supporting this event, please contact Tiffany Hightower, the Executive Director of the ILBCF at executivedirector@ilbcf.org or 773-896-6805.  

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

Effective October 1, 2023, due to the increased prevalence of Respiratory Syncytial Virus (RSV), providers may submit prior approval requests for Synagis (palivizumab). This applies to customers covered under Medicaid fee-for-service or a managed care plan. Providers should contact the appropriate managed care plan for approval guidance. For fee-for-service customers, providers must complete the Drug Authorization Request Form for Synagis and fax it to the Pharmacy Unit at 217-524-7264. Approval for the early dosing will be provided for those customers who meet the Department’s Synagis Prior Approval Criteria.  

For both fee-for-service and managed care customers, the approval period for the dose will be effective through February 29, 2024. The Department will continue to monitor for necessary changes. This is a temporary deviation from the usual Synagis guidelines, and the Department will continue to monitor RSV prevalence and respond accordingly. 

Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565, or to the appropriate managed care plan.  

Also in Illinois, the Department of Healthcare and Family Services (HFS) is notifying all pharmacies of billing instructions for the new commercial COVID-19 vaccines now in circulation. These instructions apply to the fee-for-service program only.  

As HFS is still finalizing programming for the administration fee for the COVID vaccine, pharmacies cannot use “MA” in the Professional Service Code Field, nor add the administration fee until the new programming is complete. Pharmacies can still provide COVID-19 vaccinations and submit claims to HFS for reimbursement for the cost of the vaccination plus a dispensing fee as they would for other vaccinations that do not pay an administration fee.  

Once the programming is complete, pharmacies can then void and rebill for services rendered to receive the full payment including the applicable administration fee.  

A provider notice will be sent to pharmacies once programming is complete and pharmacies can bill for the administration fee. The void and rebill process to receive full payment for claims that were submitted without receiving the administration fee can commence at that time.  

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.

HB 3203, legislation that authorizes pharmacists or retailers to sell fentanyl test strips over the counter and authorizes county health departments to distribute fentanyl test strings at their facilities for no fee was signed by Gov. JB Pritzker (D) on August 4th and goes into effect January 1, 2024.  

Also signed by Gov. Pritzker (D) on August 4th was HB 3631, legislation that prohibits a pharmacy benefit manager (PBM) from retaliating against a pharmacist or pharmacy for disclosing information in a court, administrative hearing, before a legislative commission or committee, or any proceeding, if the pharmacist or pharmacy has reasonable cause to believe that the disclosed information is evidence of a violation of state or federal law, rule or regulation. The bill also prohibits a PBM from retaliating against a pharmacist or pharmacy for disclosing information to a government or law enforcement agency, if the pharmacist or pharmacy has reasonable cause to believe that the disclosed information is evidence of a violation of state or federal law, rule, or regulation. A pharmacist or pharmacy must make reasonable efforts to limit the disclosure of confidential and proprietary information. This measure went into effect July 1, 2023.  

Also in Illinois, the Illinois Department of Healthcare and Family Services (HFS) has issued notice that implements Public Act 102-1051 which allows pharmacists to be reimbursed for human immunodeficiency virus (HIV) pre- and post-exposure prophylaxis assessment and consultation. This new policy is effective with dates of service on and after January 1, 2023, and applies to the Medicaid fee-for-service (FFS) program and the HealthChoice Illinois (HCI) managed care organizations (MCOs). 

In accordance with the Act, the Department of Healthcare and Family Services (HFS) will cover patient care services provided by a pharmacist for HIV pre- and post-exposure prophylaxis assessment and consultation at 85% of the physician rate. Pharmacists must have a standing order with an associated physician, be licensed to practice medicine in all its branches and be enrolled in the Illinois Medical Assistance Program to perform the assessment and consultation services.  

HFS has also issued notice informing pharmacies that HFS has opened additional procedure codes that may be billed for pharmacists providing hormonal contraceptive assessment and consultation services. This applies to the Medicaid fee-for-service (FFS) program and the HealthChoice Illinois (HCI) managed care organization (MCO) plans. 

By provider notice dated October 31, 2022, the Department of Healthcare and Family Services (HFS) notified providers that patient care services provided by a pharmacist for hormonal contraceptive assessment and consultation would be covered at 85% of the physician rate. HFS identified CPT procedure code 99401 – Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes, for billing. Modifier FP must be billed in conjunction with procedure code 99401.  

Effective retroactive to August 1, 2022, pharmacies may bill on behalf of pharmacists for one of the following Evaluation and Management procedure codes with the FP modifier, in addition to 99401, for the assessment component of the family planning service. 

HFS has been notified of an extreme shortage of Cisplatin, which has been determined to constitute a medical emergency for those patients in need. In accordance with the actions by the Food and Drug Administration (FDA), a non-FDA approved Cisplatin, manufactured by Qilu Pharmaceutical Company in conjunction with Apotex Corporation, can be distributed into and within the State of Illinois and will be reimbursable for Illinois Medicaid enrolled providers. Additional information can be found here. 

Finally in Illinois, Snap EBT (Electronic Benefit Transfer) data theft has been on the rise in stores across the Country. The Department of Human Services (IDHS) has confirmed a recent surge in compromised cards in Illinois. Retailers are urged to immediately contact their POS (Point of Sale) vendor, local police, FNS and IDHS if skimming devices are discovered, or your pin pads have been compromised in any way. With prompt notification, IDHS can move to protect cardholders before their benefits are stolen. Tracking skimming after the theft is exceedingly difficult to do. Contact IDHS at: dhs.ebtretailer.reportfraud@illinois.gov  

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

In 2022, the General Assembly passed Public Act (P.A.) 102-0700, which suspended the state’s 1 percent (1%) low rate of sales and use tax on retail sales of groceries from July 1, 2022, through June 30, 2023. The 1% grocery sales tax suspension ended on Friday, June 30. Retailers are now required to collect and remit the 1% sales tax on groceries. 

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

Gov. JB Pritzker (D) has signed SB 303. https://www.ilga.gov/legislation/billstatus.asp?DocNum=303&GAID=17&GA=103&DocTypeID=SB&LegID=144008&SessionID=112 Effective January 1, 2024, it will be the joint responsibility of a pharmacy and its pharmacist–in–charge to ensure that all new pharmacy technicians are educated and trained using a standard nationally accredited education and training program, such as those accredited by the Accreditation Council for Pharmacy Education (ACPE)/the American Society of Health-System Pharmacists (ASHP), or equivalent work experience of 500 hours as a pharmacy technician covering the practice areas as required by the Illinois Pharmacy Practice Act.

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

Due to the access to care issue for bronchodilation medications for customers with asthma and other respiratory issues, the Department of Healthcare and Family Services (HFS) will temporarily remove the prior authorization requirements for generic albuterol sulfate inhalers, effective immediately. Pharmacy providers with questions may contact the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or the applicable MCO.

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

After the release of the Illinois State Auditor’s report on PBMs, language from Senate Bill 757, PBM Audit Reform, which was stalled in the House, was included in Senate Bill 1298, the Medicaid Omnibus bill which has now passed both Chambers and is on the way to Gov. J.B. Pritzker’s (D) desk for signature. 

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

Gov. J.B. Pritzker (D) has signed HB 559 (Public Act 103-001), which codifies the COVID Executive Order that was in effect throughout the pandemic and governed the provision of healthcare services.  

 For Illinois pharmacy, this means the following: 

• continuing to test and treat COVID and test for influenza and other health conditions identified by a statewide public health emergency. 
• pharmacists may administer flu and COVID vaccinations to patients seven years of age and older under the pharmacists’ own authority. 
• pharmacists may delegate to technicians the administrative and technical act of performing tests. Technicians must complete an ACPE (Accreditation Council for Pharmacy Education) vaccination training course, basic CPR certificate and complete two (2) hours of immunization related continuing education per licensing period. 
• Group or individual policy of accident and health insurance and managed care plans are required to provide coverage on or after January 1, 2025 for pharmacist-provided test and treatment services if the plan provides coverage for the same services provided by a licensed physician, and APRN, or a physician assistant, the pharmacist is included in the health benefit plan’s network of participating providers, and reimbursement has been successfully negotiated in good faith between the pharmacist and the health plan. 

Also in Illinois, this notice provides information regarding pharmacy billing policies that will resume at the end of the COVID-19 public health emergency (PHE). The PHE is scheduled to end on May 11, 2023. The requirements discussed in this notice apply to the Department of Healthcare and Family Services’ (HFS) fee-for-service (FFS) program. The Medicaid managed care organizations (MCOs) do not have prescription limits as in the FFS program. The MCOs follow the Preferred Drug List (PDL) but set their own coverage policies and may have later implementation dates for the requirements below. Pharmacies may contact the applicable MCO with questions.  

Effective with dates of service on and after May 12, 2023, the following pharmacy requirements that were in place prior to the PHE will resume:  

Refill Too Soon  

Pharmacies will no longer be able to override Refill Too Soon (RTS) claims by entering a Submission Clarification Code (420-DK) of 13, Payer, Recognized Emergency/Disaster Assistance Request. When a claim rejects for RTS, the pharmacy will need to request an override through pre-COVID processes. The RTS percentages will also be set back to the same tolerances in place prior to the PHE.  

Preferred Drug List (PDL)  

Changes made to the preferred drug list (PDL) due to potential drug shortages will be removed from the PDL. During the PHE, all albuterol HFA inhalers, levalbuterol inhalers and generic levalbuterol nebulizer solutions were changed to preferred status. These will revert to the pre-PHE classification.  

Updates/changes will be maintained on the Department’s website on the PDL webpage.  

Quantity for supplies  

Blood glucose/reagent test strips quantity will be decreased to a maximum of 200 per month. Lancet quantity will be decreased to a maximum of 200 per month. Providers are reminded to bill an accurate day supply even if it exceeds one month.  

Quantity limits will be reinstated for Tamiflu, insulin and suboxone. 

OTC (Over-the-Counter) Coverage  

The temporary coverage granted during the PHE for acetaminophen and cough suppressants containing guaifenesin, dextromethorphan or their combinations will revert to the same status in place prior to the PHE.  

3 Brand Limit 

Edits that were removed to allow a customer to receive three brand name drugs during a 30-day period will be put back in place.  

4 Prescription Policy 

Edits that were removed to allow a customer to receive more than four prescriptions during a 30-day period will be put back in place.  

Third Party Liability  

Drugs will again be subject to prior approval in situations where the primary insurance did not pay due to a rejection or customer deductible requirement. These edits will resume, and claims will require an override in accordance with pre-PHE billing policy.  

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565. 

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

This notice relays information released from the Drug Enforcement Administration (DEA) regarding removal of the DATA Waiver (X-Waiver) requirement for practitioners prescribing buprenorphine. This information applies to customers covered under the Medicaid fee-for-service (FFS) program and by the managed care organizations (MCOs). 

Previously, the federal government required practitioners with DEA licenses to also obtain a special waiver (known as an X-Waiver because the DEA Registration Number began with an X) to prescribe medications such as buprenorphine for the treatment of opioid use disorder (OUD) in office-based settings outside of federally registered opioid treatment programs. Health care providers were also restricted in the number of patients with OUD they could treat. 

Section 1262 of the Consolidated Appropriations Act, 2023 (also known as the Omnibus bill), removes the federal requirement for practitioners to submit a Notice of Intent (have a waiver) to prescribe buprenorphine for the treatment of OUD. All practitioners who have a current DEA registration that includes Schedule III authority may now prescribe buprenorphine for OUD. There are no longer any annual limits on the number of patients that a prescriber may treat for OUD with buprenorphine. The January 12, 2023, letter from the DEA to waiver registrants identified these changes. 

Pharmacies need to be aware of this change, as HFS [Department of Healthcare and Family Services] has received complaints that prescribers without a DEA X-Waiver are having trouble getting their prescriptions honored at local pharmacies. 

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for the FFS population or the applicable MCO.

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