Illinois 2025-2026 Regular Session

Illinois House Bill HB4034 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB4034 Introduced , by Rep. Maurice A. West, II SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5.12f Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions prohibiting prior authorization mandates and utilization management controls under the fee-for-service and managed care medical assistance programs on specified FDA-approved prescription drugs for mental illness, provides that the prohibition shall apply if a preferred or non-preferred drug is prescribed to an adult patient to treat a serious mental illness and (i) during the preceding 60 days, the patient who experienced an inadequate response was prescribed and unsuccessfully treated with a 14-day treatment trial of a drug for the same clinical condition that is included on the preferred drug list and (ii) one of the statutory conditions apply. LRB104 12955 KTG 24520 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB4034 Introduced , by Rep. Maurice A. West, II SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5.12f 305 ILCS 5/5-5.12f Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions prohibiting prior authorization mandates and utilization management controls under the fee-for-service and managed care medical assistance programs on specified FDA-approved prescription drugs for mental illness, provides that the prohibition shall apply if a preferred or non-preferred drug is prescribed to an adult patient to treat a serious mental illness and (i) during the preceding 60 days, the patient who experienced an inadequate response was prescribed and unsuccessfully treated with a 14-day treatment trial of a drug for the same clinical condition that is included on the preferred drug list and (ii) one of the statutory conditions apply. LRB104 12955 KTG 24520 b LRB104 12955 KTG 24520 b A BILL FOR
2	2	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB4034 Introduced , by Rep. Maurice A. West, II SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-5.12f 305 ILCS 5/5-5.12f
4	4	305 ILCS 5/5-5.12f
5	5	Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions prohibiting prior authorization mandates and utilization management controls under the fee-for-service and managed care medical assistance programs on specified FDA-approved prescription drugs for mental illness, provides that the prohibition shall apply if a preferred or non-preferred drug is prescribed to an adult patient to treat a serious mental illness and (i) during the preceding 60 days, the patient who experienced an inadequate response was prescribed and unsuccessfully treated with a 14-day treatment trial of a drug for the same clinical condition that is included on the preferred drug list and (ii) one of the statutory conditions apply.
6	6	LRB104 12955 KTG 24520 b LRB104 12955 KTG 24520 b
7	7	LRB104 12955 KTG 24520 b
8	8	A BILL FOR
9	9	HB4034LRB104 12955 KTG 24520 b HB4034 LRB104 12955 KTG 24520 b
10	10	HB4034 LRB104 12955 KTG 24520 b
11	11	1 AN ACT concerning public aid.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Public Aid Code is amended by
15	15	5 changing Section 5-5.12f as follows:
16	16	6 (305 ILCS 5/5-5.12f)
17	17	7 Sec. 5-5.12f. Prescription drugs for mental illness; no
18	18	8 utilization or prior approval mandates.
19	19	9 (a) Notwithstanding any other provision of this Code to
20	20	10 the contrary, except as otherwise provided in subsection (b),
21	21	11 for the purpose of removing barriers to the timely treatment
22	22	12 of serious mental illnesses, prior authorization mandates and
23	23	13 utilization management controls shall not be imposed under the
24	24	14 fee-for-service and managed care medical assistance programs
25	25	15 on any FDA-approved prescription drug that is recognized by a
26	26	16 generally accepted standard medical reference as effective in
27	27	17 the treatment of conditions specified in the most recent
28	28	18 Diagnostic and Statistical Manual of Mental Disorders
29	29	19 published by the American Psychiatric Association if a
30	30	20 preferred or non-preferred drug is prescribed to an adult
31	31	21 patient to treat serious mental illness and (i) during the
32	32	22 preceding 60 days, the patient who experienced an inadequate
33	33	23 response was prescribed and unsuccessfully treated with a
34	34
35	35
36	36
37	37	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB4034 Introduced , by Rep. Maurice A. West, II SYNOPSIS AS INTRODUCED:
38	38	305 ILCS 5/5-5.12f 305 ILCS 5/5-5.12f
39	39	305 ILCS 5/5-5.12f
40	40	Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions prohibiting prior authorization mandates and utilization management controls under the fee-for-service and managed care medical assistance programs on specified FDA-approved prescription drugs for mental illness, provides that the prohibition shall apply if a preferred or non-preferred drug is prescribed to an adult patient to treat a serious mental illness and (i) during the preceding 60 days, the patient who experienced an inadequate response was prescribed and unsuccessfully treated with a 14-day treatment trial of a drug for the same clinical condition that is included on the preferred drug list and (ii) one of the statutory conditions apply.
41	41	LRB104 12955 KTG 24520 b LRB104 12955 KTG 24520 b
42	42	LRB104 12955 KTG 24520 b
43	43	A BILL FOR
44	44
45	45
46	46
47	47
48	48
49	49	305 ILCS 5/5-5.12f
50	50
51	51
52	52
53	53	LRB104 12955 KTG 24520 b
54	54
55	55
56	56
57	57
58	58
59	59
60	60
61	61
62	62
63	63	HB4034 LRB104 12955 KTG 24520 b
64	64
65	65
66	66	HB4034- 2 -LRB104 12955 KTG 24520 b HB4034 - 2 - LRB104 12955 KTG 24520 b
67	67	HB4034 - 2 - LRB104 12955 KTG 24520 b
68	68	1 14-day treatment trial of a drug for the same clinical
69	69	2 condition that is included on the preferred drug list and (ii)
70	70	3 one of the following applies:
71	71	4 (1) the patient has changed providers, including, but
72	72	5 not limited to, a change from an inpatient to an
73	73	6 outpatient provider, and is stable on the drug that has
74	74	7 been previously prescribed, and received prior
75	75	8 authorization, if required;
76	76	9 (2) the patient has changed insurance coverage and is
77	77	10 stable on the drug that has been previously prescribed and
78	78	11 received prior authorization under the previous source of
79	79	12 coverage; or
80	80	13 (3) subject to federal law on maximum dosage limits
81	81	14 and safety edits adopted by the Department's Drug and
82	82	15 Therapeutics Board, including those safety edits and
83	83	16 limits needed to comply with federal requirements
84	84	17 contained in 42 CFR 456.703, the patient has previously
85	85	18 been prescribed and obtained prior authorization for the
86	86	19 drug and the prescription modifies the dosage, dosage
87	87	20 frequency, or both, of the drug as part of the same
88	88	21 treatment for which the drug was previously prescribed.
89	89	22 (b) The following safety edits shall be permitted for
90	90	23 prescription drugs covered under this Section:
91	91	24 (1) clinically appropriate drug utilization review
92	92	25 (DUR) edits, including, but not limited to, drug-to-drug,
93	93	26 drug-age, and drug-dose;
94	94
95	95
96	96
97	97
98	98
99	99	HB4034 - 2 - LRB104 12955 KTG 24520 b
100	100
101	101
102	102	HB4034- 3 -LRB104 12955 KTG 24520 b HB4034 - 3 - LRB104 12955 KTG 24520 b
103	103	HB4034 - 3 - LRB104 12955 KTG 24520 b
104	104	1 (2) generic drug substitution if a generic drug is
105	105	2 available for the prescribed medication in the same dosage
106	106	3 and formulation; and
107	107	4 (3) any utilization management control that is
108	108	5 necessary for the Department to comply with any current
109	109	6 consent decrees or federal waivers.
110	110	7 (c) As used in this Section, "serious mental illness"
111	111	8 means any one or more of the following diagnoses and
112	112	9 International Classification of Diseases, Tenth Revision,
113	113	10 Clinical Modification (ICD-10-CM) codes listed by the
114	114	11 Department of Human Services' Division of Mental Health, as
115	115	12 amended, on its official website:
116	116	13 (1) Delusional Disorder (F22)
117	117	14 (2) Brief Psychotic Disorder (F23)
118	118	15 (3) Schizophreniform Disorder (F20.81)
119	119	16 (4) Schizophrenia (F20.9)
120	120	17 (5) Schizoaffective Disorder (F25.x)
121	121	18 (6) Catatonia Associated with Another Mental Disorder
122	122	19 (Catatonia Specifier) (F06.1)
123	123	20 (7) Other Specified Schizophrenia Spectrum and Other
124	124	21 Psychotic Disorder (F28)
125	125	22 (8) Unspecified Schizophrenia Spectrum and Other
126	126	23 Psychotic Disorder (F29)
127	127	24 (9) Bipolar I Disorder (F31.xx)
128	128	25 (10) Bipolar II Disorder (F31.81)
129	129	26 (11) Cyclothymic Disorder (F34.0)
130	130
131	131
132	132
133	133
134	134
135	135	HB4034 - 3 - LRB104 12955 KTG 24520 b
136	136
137	137
138	138	HB4034- 4 -LRB104 12955 KTG 24520 b HB4034 - 4 - LRB104 12955 KTG 24520 b
139	139	HB4034 - 4 - LRB104 12955 KTG 24520 b
140	140	1 (12) Unspecified Bipolar and Related Disorder (F31.9)
141	141	2 (13) Disruptive Mood Dysregulation Disorder (F34.8)
142	142	3 (14) Major Depressive Disorder Single episode (F32.xx)
143	143	4 (15) Major Depressive Disorder, Recurrent episode
144	144	5 (F33.xx)
145	145	6 (16) Obsessive-Compulsive Disorder (F42)
146	146	7 (17) Posttraumatic Stress Disorder (F43.10)
147	147	8 (18) Anorexia Nervosa (F50.0x)
148	148	9 (19) Bulimia Nervosa (F50.2)
149	149	10 (20) Postpartum Depression (F53.0)
150	150	11 (21) Puerperal Psychosis (F53.1)
151	151	12 (22) Factitious Disorder Imposed on Another (F68.A)
152	152	13 (d) Notwithstanding any other provision of law, nothing in
153	153	14 this Section shall not be construed to conflict with Section
154	154	15 1927(a)(1) and (b)(1)(A) of the federal Social Security Act
155	155	16 and any implementing regulations and agreements.
156	156	17 (Source: P.A. 103-593, eff. 6-7-24.)
157	157
158	158
159	159
160	160
161	161
162	162	HB4034 - 4 - LRB104 12955 KTG 24520 b