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.

The Department of Healthcare and Family Services (HFS) wishes to inform providers that due to the widespread availability of generic Tamiflu (oseltamivir), the Department will end the temporary procedures outlined in the December 9, 2022 provider notice effective March 1. This affects the Medicaid fee-for-service (FFS) program and the managed care organizations (MCOs).  

Effective March 1, the Department will no longer reimburse providers for dispensing brand name Tamiflu or for compounding suspensions with brand name Tamiflu. While there is no current shortage of oral suspension, compounding with the generic oseltamivir will be allowed only in emergency situations, as there still may be localized areas of shortage where demand is high.  

The drugs will be removed as preferred products on the Preferred Drug List, and prior authorization will again be required for brand Tamiflu under the FFS program and the MCOs. 

Please direct questions regarding this notice to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or the appropriate MCO.

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

Supplemental Nutrition Assistance Program (SNAP) Emergency Allotments (EAs), which have been issued since the beginning of the COVID-19 Pandemic to address food insecurity challenges, will end in Illinois after February, when the federal increases expire. This change will impact over one million households and two million people in Illinois.  

The benefit amount participants will receive starting in March will be noted in a client letter sent to all SNAP recipient households.  

The Illinois Department of Human Services seeks to prepare SNAP Participants for U.S. Department of Agriculture’s return of SNAP benefits to the pre- pandemic levels. Grocery and pharmacy retailers can assist in the effort by posting SNAP Reduction Customer Notice posters in their stores.  

Also in Illinois, the Department of Healthcare and Family Services will review the following classes at the Drugs &Therapeutics Advisory Board meeting on April 6: CGRP migraine agents, Oral Antipsychotic (class clean-up). All clinical and financial submissions are due to the Department by 3:00 p.m. CST on March 16. Submissions should be sent to: HFS.SupplementalRebaleProgram@illinois.gov. For more information, please visit here.  

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

The Illinois Department of Labor (“IDOL”) recently issued the new 2023 “Your Rights Under Illinois Employment Laws” poster that ALL ILLINOIS EMPLOYERS are required to post in a conspicuous place in the workplace, where notices are customarily posted. See the links here. The poster includes information related to the Wage Payment and Collection Act, Child Labor Law, Minimum Wage Law, Equal Pay Act, Victims’ Economic Security and Safety Act and the One Day Rest in Seven Act (“ODRISA”).  

Importantly, the ODRISA amendments that went into effect on January 1, 2023, require not only posting in the workplace, but also, for employees who do not regularly report to a physical workplace, and instead work remotely or travel for work, the poster must be provided to them via email or uploaded onto the employer’s website. The ODRISA amendments also now include civil penalties for failure to comply with the ODRISA, including the posting requirements. Employers who fail to comply with the posting requirements will be subject to a civil penalty not to exceed $250, payable to the IDOL.  

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

This notice implements the section of Public Act 102-0103 that allows pharmacists to bill and be reimbursed for patient care services for hormonal contraceptives. This new policy is effective with dates of service on and after August 1, 2022, and applies to the Medicaid fee-for-service (FFS) program and the HealthChoice Illinois (HCI) managed care organization (MCO) plans.  

Also in Illinois, this notice provides an update on coverage of the new COVID-19 bivalent boosters. The update applies to claims for customers covered under traditional Medicaid fee-for-service (FFS) and the HealthChoice Illinois (HCI) managed care organization (MCO) plans.  

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

The Department of Healthcare and Family Services has posted a new Provider Notice regarding Post Kidney Transplant Preferred Drugs under the Emergency Medical Program.

Also, the Department of Healthcare and Family Services has posted a new Provider Notice regarding Prior Approval Requests for Synagis Dosing.

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

The Illinois D&T Advisory Board will be reviewing the Biologic Modifiers at its October 20, 2022 meeting. All clinical and financial submissions are due to the Department by 3:00pm CST September 29, 2022. Please submit to: HFS.SupplementalRebaleProgram@illinois.gov. 

Also in Illinois, the Department of Healthcare and Family Services has posted a new Provider Notice regarding Sexual Assault Treatment Program Private Insurance Opt-Out Alternative Per Public Act 102-1097. 

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