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Provider Notice issued 12/12/2025
2026 Critical Access Pharmacy (CAP) Program Payments
| Date: | December 12, 2025 |
| To: | Pharmacies |
| Re: | 2026 Critical Access Pharmacy (CAP) Program Payments |
This notice serves as supplement to the previous notice (Provider Notice Issued 09/29/2025) regarding the update to the Critical Access Pharmacy (CAP) program. Effective January 1, 2026, the Department of Healthcare and Family Services (HFS) is changing the administration of the Critical Access Pharmacy Program in accordance with Public Act 104-0027 . The eligible pharmacy list can be found on the Pharmacy webpage.
HealthChoice Illinois Managed Care Organization (MCO) Claims
As of January 1, 2026, Critical Access Pharmacies will receive a point-of-sale dispensing fee of $21.05 applied to each HCI/MCO claim paid during the incurred timeframe for eligible pharmacies.
Final quarterly payments under previous program are expected to be released for 2025 2nd Quarter December, 3rd Quarter January 2026, and 2025 4th Quarter April 2026. Payments will be based on the attestation completed during the October 1-October 31, 2025 period. These will be the last set of payments under the prior program, sunset under P.A. 104-007.
Fee-For-Service (FFS) Claims
Upon State Plan Amendment (SPA) approval by the Centers for Medicare & Medicaid Services (CMS) and effective January 1st, 2026, CAP professional dispensing fees for FFS claims will increase from $15.55 to $21.05 at the point-of-sale.
Pharmacies are to continue to bill at $15.55. Additional information about this process will be issued after receiving SPA approval.
This notice applies to all approved pharmacies who attested to be included in the 2026 Critical Access Pharmacy Program in October 2025, using the updated form included in the September 29th notice (linked above).
Questions regarding this notice may be directed to HFS.CriticalAccessPharmacy@illinois.gov , or the applicable MCO.
Laura Phelan, Administrator
Division of Medical Programs