Bill Text: IL HB2438 | 2025-2026 | 104th General Assembly | Introduced

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Bill Title: 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 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. Removes provisions conditioning the receipt of prescription drugs without prior authorization on: (i) the patient changing providers while receiving a previously authorized prescription drug; (ii) the patient changing insurance coverage while receiving a previously authorized prescription drug; and (iii) the patient's prescription for a previously authorized drug modifies the dosage, dosage frequency, or both, of the drug as part of the same treatment for which the drug was previously prescribed.

Sponsorship: Partisan Bill (Democrat 1)

Status: (Introduced) 2025-02-04 - Referred to Rules Committee [HB2438 Detail]

Download: Illinois-2025-HB2438-Introduced.html

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104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2438 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 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. Removes provisions conditioning the receipt of prescription drugs without prior authorization on: (i) the patient changing providers while receiving a previously authorized prescription drug; (ii) the patient changing insurance coverage while receiving a previously authorized prescription drug; and (iii) the patient's prescription for a previously authorized drug modifies the dosage, dosage frequency, or both, of the drug as part of the same treatment for which the drug was previously prescribed.
LRB104 04068 KTG 14092 b
A BILL FOR
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AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Public Aid Code is amended by
changing Section 5-5.12f as follows:
(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 during the
preceding 60 days, the patient who experienced an inadequate
response was prescribed and unsuccessfully treated with a

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14-day treatment trial of a drug for the same clinical
condition that is included on the preferred drug list. 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 insurance 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;

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(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)

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(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.
(Source: P.A. 103-593, eff. 6-7-24.)