Bill Text: IL HB5804 | 2025-2026 | 104th General Assembly | Introduced

---

Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires a Medicaid managed care organization to reimburse a pharmacy provider that is not a critical access care pharmacy for dispensing fees and acquisition costs at no less than the amounts established under the fee-for-service program whether the Medicaid managed care organization directly reimburses those pharmacy providers or contracts with a pharmacy benefit manager to reimburse those pharmacy providers. Provides that the reimbursement requirement applies to all pharmacy services for persons receiving benefits under the Code including other specified pharmacy services.

Sponsorship: Partisan Bill (Democrat 1)

Status: (Introduced - Dead) 2026-07-22 - Filed with the Clerk by Rep. Dave Vella [HB5804 Detail]

Download: Illinois-2025-HB5804-Introduced.html

---

104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026HB5804 Introduced , by Rep. Dave Vella SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12
Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires a Medicaid managed care organization to reimburse a pharmacy provider that is not a critical access care pharmacy for dispensing fees and acquisition costs at no less than the amounts established under the fee-for-service program whether the Medicaid managed care organization directly reimburses those pharmacy providers or contracts with a pharmacy benefit manager to reimburse those pharmacy providers. Provides that the reimbursement requirement applies to all pharmacy services for persons receiving benefits under the Code including other specified pharmacy services.
LRB104 22340 KTG 38782 b
A BILL FOR
HB5804 LRB104 22340 KTG 38782 b
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 5-5.12 as follows:
(305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
Sec. 5-5.12. Pharmacy payments.
(a) Every request submitted by a pharmacy for
reimbursement under this Article for prescription drugs
provided to a recipient of aid under this Article shall
include the name of the prescriber or an acceptable
identification number as established by the Department.
(b) Pharmacies providing prescription drugs under this
Article shall be reimbursed at a rate which shall include a
professional dispensing fee as determined by the Illinois
Department, plus the current acquisition cost of the
prescription drug dispensed. The Illinois Department shall
update its information on the acquisition costs of all
prescription drugs no less frequently than every 30 days.
However, the Illinois Department may set the rate of
reimbursement for the acquisition cost, by rule, at a
percentage of the current average wholesale acquisition cost.
(b-5) As used in this subsection, "critical access care

HB5804 - 2 - LRB104 22340 KTG 38782 b
pharmacy" has the meaning given to that term in Section
5-5.12b.
A Medicaid managed care organization must reimburse a
pharmacy provider that is not a critical access care pharmacy
for dispensing fees and acquisition costs at no less than the
amounts established under the fee-for-service program whether
the Medicaid managed care organization directly reimburses
those pharmacy providers or contracts with a pharmacy benefit
manager to reimburse those pharmacy providers. The
reimbursement requirement specified in this subsection applies
to all pharmacy services for persons receiving benefits under
this Code, including services reimbursed under Section 5-36.
(c) (Blank).
(d) The Department shall review utilization of narcotic
medications in the medical assistance program and impose
utilization controls that protect against abuse.
(e) When making determinations as to which drugs shall be
on a prior approval list, the Department shall include as part
of the analysis for this determination, the degree to which a
drug may affect individuals in different ways based on factors
including the gender of the person taking the medication.
(f) The Department shall cooperate with the Department of
Public Health and the Department of Human Services Division of
Mental Health in identifying psychotropic medications that,
when given in a particular form, manner, duration, or
frequency (including "as needed") in a dosage, or in

HB5804 - 3 - LRB104 22340 KTG 38782 b
conjunction with other psychotropic medications to a nursing
home resident or to a resident of a facility licensed under the
ID/DD Community Care Act or the MC/DD Act, may constitute a
chemical restraint or an "unnecessary drug" as defined by the
Nursing Home Care Act or Titles XVIII and XIX of the Social
Security Act and the implementing rules and regulations. The
Department shall require prior approval for any such
medication prescribed for a nursing home resident or to a
resident of a facility licensed under the ID/DD Community Care
Act or the MC/DD Act, that appears to be a chemical restraint
or an unnecessary drug. The Department shall consult with the
Department of Human Services Division of Mental Health in
developing a protocol and criteria for deciding whether to
grant such prior approval.
(g) The Department may by rule provide for reimbursement
of the dispensing of a 90-day supply of a generic or brand
name, non-narcotic maintenance medication in circumstances
where it is cost effective.
(g-5) On and after July 1, 2012, the Department may
require the dispensing of drugs to nursing home residents be
in a 7-day supply or other amount less than a 31-day supply.
The Department shall pay only one dispensing fee per 31-day
supply.
(h) Effective July 1, 2011, the Department shall
discontinue coverage of select over-the-counter drugs,
including analgesics and cough and cold and allergy

HB5804 - 4 - LRB104 22340 KTG 38782 b
medications.
(h-5) On and after July 1, 2012, the Department shall
impose utilization controls, including, but not limited to,
prior approval on specialty drugs, oncolytic drugs, drugs for
the treatment of HIV or AIDS, immunosuppressant drugs, and
biological products in order to maximize savings on these
drugs. The Department may adjust payment methodologies for
non-pharmacy billed drugs in order to incentivize the
selection of lower-cost drugs. For drugs for the treatment of
AIDS, the Department shall take into consideration the
potential for non-adherence by certain populations, and shall
develop protocols with organizations or providers primarily
serving those with HIV/AIDS, as long as such measures intend
to maintain cost neutrality with other utilization management
controls such as prior approval. For hemophilia, the
Department shall develop a program of utilization review and
control which may include, in the discretion of the
Department, prior approvals. The Department may impose special
standards on providers that dispense blood factors which shall
include, in the discretion of the Department, staff training
and education; patient outreach and education; case
management; in-home patient assessments; assay management;
maintenance of stock; emergency dispensing timeframes; data
collection and reporting; dispensing of supplies related to
blood factor infusions; cold chain management and packaging
practices; care coordination; product recalls; and emergency

HB5804 - 5 - LRB104 22340 KTG 38782 b
clinical consultation. The Department may require patients to
receive a comprehensive examination annually at an appropriate
provider in order to be eligible to continue to receive blood
factor.
(i) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(j) On and after July 1, 2012, the Department shall impose
limitations on prescription drugs such that the Department
shall not provide reimbursement for more than 4 prescriptions,
including 3 brand name prescriptions, for distinct drugs in a
30-day period, unless prior approval is received for all
prescriptions in excess of the 4-prescription limit. Drugs in
the following therapeutic classes shall not be subject to
prior approval as a result of the 4-prescription limit:
immunosuppressant drugs, oncolytic drugs, anti-retroviral
drugs, and, on or after July 1, 2014, antipsychotic drugs. On
or after July 1, 2014, the Department may exempt children with
complex medical needs enrolled in a care coordination entity
contracted with the Department to solely coordinate care for
such children, if the Department determines that the entity
has a comprehensive drug reconciliation program.
(k) No medication therapy management program implemented
by the Department shall be contrary to the provisions of the

HB5804 - 6 - LRB104 22340 KTG 38782 b
Pharmacy Practice Act.
(l) Any provider enrolled with the Department that bills
the Department for outpatient drugs and is eligible to enroll
in the federal Drug Pricing Program under Section 340B of the
federal Public Health Service Act shall enroll in that
program. No entity participating in the federal Drug Pricing
Program under Section 340B of the federal Public Health
Service Act may exclude fee-for-service Medicaid from their
participation in that program, however, entities defined in
Section 1905(l)(2)(B) of the Social Security Act are excluded
from this requirement. This subsection does not apply to
outpatient drugs billed to Medicaid managed care
organizations.
(Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)