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Elizabeth M. Whitehorn, Director

Provider Notice issued 02/14/2025

 

To: Enrolled Physicians; Advanced Practice Registered Nurses; Physician Assistants; and Pharmacies
​Date February 14, 2025
​Re:
 Changes to Prior Approval for Serious Mental Illness (SMI) Drugs per Public Act 103-0593 Effective January 1, 2025

This notice informs providers of the Department of Healthcare and Family Services’ (HFS) compliance with Public Act 103-0593, which removes prior authorization requirements for Serious Mental Illness (SMI) pharmaceuticals that treat certain diagnoses for patients experiencing a change in behavioral health provider, a change in insurance provider, or a change in dosage. The Act clearly defines which diagnoses constitute serious mental illness and the circumstances under which prior authorization is prohibited. The policy applies to both the fee-for-service (FFS) program and the HealthChoice Illinois (HCI) managed care organizations (MCOs), effective January 1, 2025. 

HFS will waive the prior authorization requirement when the patient is stable on an SMI medication and one or more of the following conditions are met:

-       The patient has changed providers, including having changed from an inpatient to an outpatient, or

-       The patient has changed insurance providers, or

-       When a prior authorization has been previously approved for a patient, and the new prescription modifies dosage, dosage frequency, or both.

A one-time prior authorization may be required in instances where HFS does not have the patient’s prescription history and stability on the existing regimen must be confirmed.

Select safety edits will remain in place, i.e., clinically appropriate drug utilization review (DUR) edits, including, but not limited to, drug-drug, drug-age, drug-dose requirements. HFS may require generic use where one is available and meets the needs of the patient.

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 applicable HCI MCO.

 

 

Kelly Cunningham, Administrator

Division of Medical Programs