Provider Notice Issued 09/29/2025

In accordance with Public Act 104-0027, the Department of Healthcare and Family Services (HFS) is implementing a major update to the Critical Access Pharmacy (CAP) program. Effective January 1, 2026, the revised CAP program will consolidate the two existing initiatives into a single, streamlined model.

Eligibility Criteria

Under the updated program, independent pharmacies must meet all of the following criteria to qualify:

• Pharmacy owner(s) have ownership or control interest in fewer than 10 pharmacies

• Pharmacy is located within the boundaries of Illinois and is brick and mortar, meaning the pharmacy location is open to the public and recipients present at the pharmacy to fill prescriptions, and which is not owned/operated by a hospital or located within a hospital

• Pharmacy’s mail-order business represents no more than 50% of prescriptions filled by the pharmacy

   

  and

• Pharmacy address is physically located in a county with a population under 50,000, or

• Situated within a Medically Underserved Area (MUA) as designated by the Health Resources and Services Administration (HRSA)

Final 2025 MCO Payment

The Department will issue the final CAP Managed Care Organization (MCO) payment for calendar year 2025 during the regularly scheduled payment cycle in December 2025.

Dispensing Fee Update

Effective January 1, 2026, the dispensing fee for CAP pharmacies will be increased as follows:

Fee-For-Service (FFS): Updated to $21.05, pending approval of the State Plan Amendment (SPA) by the Centers for Medicare & Medicaid Services (CMS)

Managed Care Organizations (MCOs): Also set at $21.05, issued as a quarterly directed payment to pharmacies that have successfully attested for the program.

Attestation Procedures and Annual Enrollment

To participate in the updated CAP program, pharmacies must complete a new, consolidated attestation form annually. Please note the following:

Form Location: The attestation form is available on the HFS Pharmacy Webpage.

Deadline: To be eligible for the program in Calendar Year 2026, all participants must submit their final documentation no later than October 31, 2025. No submissions will be accepted after October 31, 2025.  New Pharmacies will be handled on a case-by-case basis.

Annual Notification: The Department will announce the attestation process for future years via subsequent provider notices.

Important: Please ensure the attestation form is completed in its entirety to avoid delays or disqualification. Forms previously located in MEDI will no longer be accepted for the 2026 and future attestations. 

Contact Information

To minimize confusion during the transition, the Department has established a dedicated email address for all CAP-related inquiries.

Please direct questions to:  HFS.CriticalAccessPharmacy@illinois.gov

Laura Phelan, Administrator

Division of Medical Programs