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Are you on Medicaid? Do you have patients, friends or clients who are on Medicaid? If the answer is “yes,” keep reading the important information below!

On Jan. 1, 2020, prescription drug coverage is changing for Illinois Medicaid. Previously, Medicaid managed care plans covered whatever drugs they wanted. Starting in January, every plan in the state will have to cover the same drugs. This is called a “uniform preferred drug list (PDL).” The goal is to save the state money and simplify coverage.

You can see the new drug list here: https://www.illinois.gov/hfs/SiteCollectionDocuments/UPDLFinal11202019.pdf

However, the transition to a uniform preferred drug list means some medications might not be covered anymore. It’s critical for people living with HIV and hepatitis C to have uninterrupted access to their medications to maintain an undetectable viral load, cure hep C and to get to zero (https://gtzillinois.hiv/).  Here’s what you should know:

  1. The new drug list covers nearly all of the most common single-tablet HIV medications and some hep C treatments. AFC thanks Illinois Medicaid for adding several HIV drugs to the formulary in the past year; we’re glad that Medicaid and drug manufacturers made sure coverage is more comprehensive, although there is still more work to do.
  2. If you’re taking an HIV or hep C medication now that is not covered on the new formulary, you can keep taking it for one year. Coverage may be renewed after that year. This is called “grandfathering.” Check the new drug list https://www.illinois.gov/hfs/SiteCollectionDocuments/UPDLFinal11202019.pdf now to see which of your meds are covered. Medications for a number of different health conditions will be grandfathered.
  3. If you’re new to Medicaid, had a gap in coverage (maybe you missed your redetermination notice), or switch to a different managed care plan, you’ll have to take one of the HIV or hep C medications on the uniform preferred drug list. However, your health care provider may be able to get an exception if you have a special medical need.
  4. Managed care plans are allowed to have their own rules or procedures about how people can access medications, called utilization management policies. For example, plans might have different limits on the number of pills you can get each month. Plans might require that a provider get permission (also known as prior authorization) before the provider prescribes a specific prescription drug.  If the health plan’s policy is less restrictive than the Illinois Medicaid fee-for-service policy, this is allowable.

Some tips important tips to make sure you don’t miss your meds:

  • Get your medications refilled before the end of 2019. Pharmacies and plans are swamped in the beginning of January with changes.
  • If you can’t get your meds at the pharmacy, don’t give up. Call your health care provider or AFC (312-690-8860) for help.
  • ADAP is here for you. The AIDS Drug Assistance Program https://hivcareconnect.com/adap/ (ADAP) can cover HIV medications that Medicaid doesn’t cover. AFC can help you sign up if you call 312-690-8860 between 9 a.m. – 5 p.m. on weekdays.

Here are some important resources to help you navigate this change:

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