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to thrive as they age

April 25, 2025

Avisery Alert:

HFS Resuming Fee-For-Service Medicaid's Use of 

Prior Authorization for Some Prescription Drugs 

Illinois Department of Health and Family Services (HFS) released a provider notice announcing that the prior authorizations system for some prescription drugs under Fee-For-Service (FFS) Medicaid will resume on Tuesday, April 29, 2025. Please note that this change does not apply to most drugs for dually eligible individuals (those with Medicare and Medicaid coverage) who receive their drug coverage through Medicare Part D. Because Medicaid does cover some drugs not approved under Medicare, however, dually eligible individuals in the FFS Medicaid program may be subject to these prior authorization requirements for those medications. 

Prior Authorization System Resuming 4/29/2025

Medicaid coverage for some prescriptions and over-the counter drugs require prior authorization. In February of 2024, Change Healthcare, the vendor that operates the Pharmacy Benefit Management System (PBMS) for the FFS program, experienced a cyberattack that shut down their system for an extended period.  As a result, HFS waived prior authorization restrictions until further notice.   

The April 22, 2025 provider notice indicates that prior authorization of certain medications will begin again for customers receiving coverage through Medicaid Fee-For-Service starting on April 29, 2025. (Customers enrolled in Health Choice Illinois have their medications managed per their plan's specific policies.) Prior authorization will be needed for the following:  

• Non- preferred medications 

• Preferred medications requiring prior authorization 

• Practitioner administered drugs designated with an N on the Practitioner Fee Schedule 

Extensions will be granted to prior authorizations that expired during the system outage. Click here for the provider notice and the extension dates.  

Medicaid beneficiaries may qualify for a 90-day transition period if they are taking medications that would have required prior authorization. Additionally, any prior authorization requests submitted between February 21, 2024 – April 28, 2025, will need to be resubmitted if the Medicaid beneficiary continues to take that medication.  

Medicaid beneficiaries can talk to their prescribing provider or their pharmacies if they have concerns about their medications.  

If you have any questions or need help counseling older adults and adults with disabilities on Medicare, Medicaid, or other health benefits programs, please reach out to Avisery at avisery@ageoptions.org or 708-628-3440.  

About Avisery

Avisery by AgeOptions provides tools and support to professionals serving older adults and people with disabilities, enabling them to help their clients access healthcare coverage that allows them to thrive as they age.