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Elizabeth M. Whitehorn, Director

Provider Notice issued 05/14/15

Introducing Illinois Medicaid’s Pharmacy Benefits Management System

To:​ Participating Pharmacies ​
Date:​ ​May 14, 2015
​Re: Introducing Illinois Medicaid’s Pharmacy Benefits Management System​

Healthcare and Family Services (HFS) is pleased to announce that later this year, we will implement a new Pharmacy Benefits Management System (PBMS) for pharmacy claims billed fee-for-service to the department.  This notice does not impact pharmacy claims billed to managed care plans for participants enrolled in those plans.

This is one of the first systems being upgraded under the larger Medicaid Management Information Systems (MMIS) upgrade project.  The new PBMS is a state-of-the-art, real time point of sale claims adjudication system.  It will enhance the HFS’ Pharmacy Program by providing improved functionality that is not available in the current claims processing system.  The new system will result in:

  • Expanded provider portal that contains improved prior authorization request functionality, including the ability to search for prior authorization status as well as claim submission functionality;

  • Enhanced prior approval review process that uses diagnosis and other information collected from pharmacy and medical claims data to systematically approve certain drugs in certain circumstances;

  • Enhanced third party liability claims processing functionality, reducing the need for pharmacies to request third party liability overrides in certain circumstances;

  • Enhanced override capabilities eliminating the need for most paper claims;

  • Enhanced functionality and provider messaging;

  • Improved Payer Sheet format;

  • Enhanced claims and service billing reversals; and

  • E-Prescribing capabilities

HFS encourages providers to look for additional informational notices to assist in the transition to the new system.  Providers are encouraged to link to the Provider notices and bulletins website.

Felicia F. Norwood

Director