MedicaidAdministrativeLow impact
HFS 1409X – Illinois Medicaid Pharmacy Prior Authorization Request Form
Illinois Medicaid - HFS·IL · Pharmacy·Provider Notice
Effective date
Aug 24, 2022
We identified it
Jun 20, 2026
Summary
Illinois Medicaid has introduced a new standardized Pharmacy Prior Authorization Request Form (HFS 1409X) that can be used as an alternative method for streamlining pharmacy prior authorization approvals. The form is optional and does not replace existing prior authorization processes.
Action Required
Optional: Billing team may download the HFS 1409X form from the Illinois HFS Pharmacy website if they wish to use this alternative method for Medicaid pharmacy prior authorizations. The completed form can be faxed to 217-524-7264. No immediate action required as existing prior authorization methods remain valid.