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(305 ILCS 5/5-5.12f) Sec. 5-5.12f. Prescription drugs for mental illness; no utilization or prior approval mandates. (a) Notwithstanding any other provision of this Code to the contrary, except as otherwise provided in subsection (b), for the purpose of removing barriers to the timely treatment of serious mental illnesses, prior authorization mandates and utilization management controls shall not be imposed under the fee-for-service and managed care medical assistance programs on any FDA-approved prescription drug that is recognized by a generally accepted standard medical reference as effective in the treatment of conditions specified in the most recent Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association if a preferred or non-preferred drug is prescribed to an adult patient to treat serious mental illness and one of the following applies: (1) the patient has changed providers, including, but |
| not limited to, a change from an inpatient to an outpatient provider, and is stable on the drug that has been previously prescribed, and received prior authorization, if required;
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(2) the patient has changed insurance coverage and is
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| stable on the drug that has been previously prescribed and received prior authorization under the previous source of coverage; or
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(3) subject to federal law on maximum dosage limits
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| and safety edits adopted by the Department's Drug and Therapeutics Board, including those safety edits and limits needed to comply with federal requirements contained in 42 CFR 456.703, the patient has previously been prescribed and obtained prior authorization for the drug and the prescription modifies the dosage, dosage frequency, or both, of the drug as part of the same treatment for which the drug was previously prescribed.
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(b) The following safety edits shall be permitted for prescription drugs covered under this Section:
(1) clinically appropriate drug utilization review
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| (DUR) edits, including, but not limited to, drug-to-drug, drug-age, and drug-dose;
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(2) generic drug substitution if a generic drug is
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| available for the prescribed medication in the same dosage and formulation; and
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(3) any utilization management control that is
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| necessary for the Department to comply with any current consent decrees or federal waivers.
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(c) As used in this Section, "serious mental illness" means any one or more of the following diagnoses and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes listed by the Department of Human Services' Division of Mental Health, as amended, on its official website:
(1) Delusional Disorder (F22)
(2) Brief Psychotic Disorder (F23)
(3) Schizophreniform Disorder (F20.81)
(4) Schizophrenia (F20.9)
(5) Schizoaffective Disorder (F25.x)
(6) Catatonia Associated with Another Mental Disorder
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| (Catatonia Specifier) (F06.1)
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(7) Other Specified Schizophrenia Spectrum and Other
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(8) Unspecified Schizophrenia Spectrum and Other
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(9) Bipolar I Disorder (F31.xx)
(10) Bipolar II Disorder (F31.81)
(11) Cyclothymic Disorder (F34.0)
(12) Unspecified Bipolar and Related Disorder (F31.9)
(13) Disruptive Mood Dysregulation Disorder (F34.8)
(14) Major Depressive Disorder Single episode (F32.xx)
(15) Major Depressive Disorder, Recurrent episode
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(16) Obsessive-Compulsive Disorder (F42)
(17) Posttraumatic Stress Disorder (F43.10)
(18) Anorexia Nervosa (F50.0x)
(19) Bulimia Nervosa (F50.2)
(20) Postpartum Depression (F53.0)
(21) Puerperal Psychosis (F53.1)
(22) Factitious Disorder Imposed on Another (F68.A)
(d) Notwithstanding any other provision of law, nothing in this Section shall not be construed to conflict with Section 1927(a)(1) and (b)(1)(A) of the federal Social Security Act and any implementing regulations and agreements.
(Source: P.A. 103-593, eff. 6-7-24.)
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