MedicaidPrior AuthMedium impact
Changes to Prior Approval for Serious Mental Illness (SMI) Drugs per Public Act 103-0593 Effective January 1, 2025
Illinois Medicaid - HFS·IL · Psychiatry, Family Medicine, Internal Medicine +1 more·Provider Notice
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
Effective January 1, 2025, Illinois Medicaid (HFS) and HealthChoice Illinois managed care plans will waive prior authorization requirements for serious mental illness (SMI) medications when patients change providers, change insurance, or modify dosage on previously stable regimens. Safety drug utilization review edits and generic substitution requirements remain in place.
Action Required
Immediately: Billing team should verify that Illinois Medicaid/HFS claims for SMI medications no longer require prior authorization when patients have changed providers, insurance, or dosage modifications. Update prior authorization workflows to reflect these exceptions. Contact HFS pharmacy consultant at 877-782-5565 for FFS claims or applicable HCI MCO for questions about specific cases.