305 ILCS 5/5-5.12f

(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;

(2) the patient has changed Medical assistance program or managed care plan coverage and is stable on the drug that has been previously prescribed and received prior authorization under the previous source of coverage; or

(3) subject to federal law on maximum dosage limits 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.

(b) The following safety edits shall be permitted for prescription drugs covered under this Section:

(1) clinically appropriate drug utilization review (DUR) edits, including, but not limited to, drug-to-drug, drug-age, and drug-dose;

(2) generic drug substitution if a generic drug is available for the prescribed medication in the same dosage and formulation; and

(3) any utilization management control that is necessary for the Department to comply with any current consent decrees or federal waivers.

(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 (Catatonia Specifier) (F06.1)

(7) Other Specified Schizophrenia Spectrum and Other Psychotic Disorder (F28)

(8) Unspecified Schizophrenia Spectrum and Other Psychotic Disorder (F29)

(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 (F33.xx)

(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.

(e) The Department shall publish a report semi-annually on its website on compliance with the conditions of this Section by the fee-for-service program and managed care organizations beginning with dates of service on and after July 1, 2025. These reports shall be due 12 months after the end of the period to be reported. These reports shall include:

(1) The number of clinically denied prescriptions summarized by each of the allowed categories specified in subsection (b). This paragraph shall include the number of prior authorization denials.

(2) The number of clinically denied prescriptions as summarized by each of the nonallowed categories specified in subsection (a), categorized by denial reason.

(3) The number of prior authorizations of prescriptions contrary to the prohibition described in subsection (a).

(4) The number of complaints filed concerning denials for prescriptions, which meet the conditions specified in subsection (a).

(5) The number of approved and paid prescriptions described in subsection (a) and the potential net cost to the State.

(6) The number of persons enrolled in the medical assistance program using emergency room services based on categories specified in subsection (c) as the primary diagnosis for the emergency room visit.

(7) The number of persons admitted into a hospital and the number of hospital readmissions, based on categories specified in subsection (c) as the primary diagnosis for the hospital admission or readmission.

As used in this Section, "net cost" means the difference in total ingredient cost due to changes in product mix plus total loss in aggregate rebate revenue based on product mix realized in Fiscal Year 2025. Nothing in this Section shall require the Department to disclose information that is exempt from disclosure under paragraph (g) of subsection (1) of Section 7 of the Freedom of Information Act.

For purposes of this Section, a hospital readmission occurs when a patient is discharged from a hospital and then admitted into the same or another hospital within 30 days of discharge for the same primary diagnosis.

(Source: P.A. 103-593, eff. 6-7-24; 104-9, eff. 6-16-25.)