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
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
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
LRB104 12955 KTG 24520 b
A BILL FOR
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HB4034 LRB104 12955 KTG 24520 b
1 AN ACT concerning public aid.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5 changing Section 5-5.12f as follows:
6 (305 ILCS 5/5-5.12f)
7 Sec. 5-5.12f. Prescription drugs for mental illness; no
8 utilization or prior approval mandates.
9 (a) Notwithstanding any other provision of this Code to
10 the contrary, except as otherwise provided in subsection (b),
11 for the purpose of removing barriers to the timely treatment
12 of serious mental illnesses, prior authorization mandates and
13 utilization management controls shall not be imposed under the
14 fee-for-service and managed care medical assistance programs
15 on any FDA-approved prescription drug that is recognized by a
16 generally accepted standard medical reference as effective in
17 the treatment of conditions specified in the most recent
18 Diagnostic and Statistical Manual of Mental Disorders
19 published by the American Psychiatric Association if a
20 preferred or non-preferred drug is prescribed to an adult
21 patient to treat serious mental illness and (i) during the
22 preceding 60 days, the patient who experienced an inadequate
23 response was prescribed and unsuccessfully treated with a
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
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
LRB104 12955 KTG 24520 b
A BILL FOR
305 ILCS 5/5-5.12f
LRB104 12955 KTG 24520 b
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1 14-day treatment trial of a drug for the same clinical
2 condition that is included on the preferred drug list and (ii)
3 one of the following applies:
4 (1) the patient has changed providers, including, but
5 not limited to, a change from an inpatient to an
6 outpatient provider, and is stable on the drug that has
7 been previously prescribed, and received prior
8 authorization, if required;
9 (2) the patient has changed insurance coverage and is
10 stable on the drug that has been previously prescribed and
11 received prior authorization under the previous source of
12 coverage; or
13 (3) subject to federal law on maximum dosage limits
14 and safety edits adopted by the Department's Drug and
15 Therapeutics Board, including those safety edits and
16 limits needed to comply with federal requirements
17 contained in 42 CFR 456.703, the patient has previously
18 been prescribed and obtained prior authorization for the
19 drug and the prescription modifies the dosage, dosage
20 frequency, or both, of the drug as part of the same
21 treatment for which the drug was previously prescribed.
22 (b) The following safety edits shall be permitted for
23 prescription drugs covered under this Section:
24 (1) clinically appropriate drug utilization review
25 (DUR) edits, including, but not limited to, drug-to-drug,
26 drug-age, and drug-dose;
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1 (2) generic drug substitution if a generic drug is
2 available for the prescribed medication in the same dosage
3 and formulation; and
4 (3) any utilization management control that is
5 necessary for the Department to comply with any current
6 consent decrees or federal waivers.
7 (c) As used in this Section, "serious mental illness"
8 means any one or more of the following diagnoses and
9 International Classification of Diseases, Tenth Revision,
10 Clinical Modification (ICD-10-CM) codes listed by the
11 Department of Human Services' Division of Mental Health, as
12 amended, on its official website:
13 (1) Delusional Disorder (F22)
14 (2) Brief Psychotic Disorder (F23)
15 (3) Schizophreniform Disorder (F20.81)
16 (4) Schizophrenia (F20.9)
17 (5) Schizoaffective Disorder (F25.x)
18 (6) Catatonia Associated with Another Mental Disorder
19 (Catatonia Specifier) (F06.1)
20 (7) Other Specified Schizophrenia Spectrum and Other
21 Psychotic Disorder (F28)
22 (8) Unspecified Schizophrenia Spectrum and Other
23 Psychotic Disorder (F29)
24 (9) Bipolar I Disorder (F31.xx)
25 (10) Bipolar II Disorder (F31.81)
26 (11) Cyclothymic Disorder (F34.0)
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1 (12) Unspecified Bipolar and Related Disorder (F31.9)
2 (13) Disruptive Mood Dysregulation Disorder (F34.8)
3 (14) Major Depressive Disorder Single episode (F32.xx)
4 (15) Major Depressive Disorder, Recurrent episode
5 (F33.xx)
6 (16) Obsessive-Compulsive Disorder (F42)
7 (17) Posttraumatic Stress Disorder (F43.10)
8 (18) Anorexia Nervosa (F50.0x)
9 (19) Bulimia Nervosa (F50.2)
10 (20) Postpartum Depression (F53.0)
11 (21) Puerperal Psychosis (F53.1)
12 (22) Factitious Disorder Imposed on Another (F68.A)
13 (d) Notwithstanding any other provision of law, nothing in
14 this Section shall not be construed to conflict with Section
15 1927(a)(1) and (b)(1)(A) of the federal Social Security Act
16 and any implementing regulations and agreements.
17 (Source: P.A. 103-593, eff. 6-7-24.)
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