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Provider Notice Issued 08/24/2022

Date:   August 24, 2022

To:       Enrolled Pharmacies

Re:      HFS 1409X – Illinois Medicaid Pharmacy Prior Authorization Request Form


This notice announces a new standardized Pharmacy Prior Authorization Request Form prompted by Public Act 102-0409. This form may be used in the Medicaid fee-for-service (FFS) pharmacy program.

The HFS 1409X on the HFS Pharmacy page of the website is the PDF-fillable version that may be used in the FFS program only. The patient's name and 9-digit health number (Recipient Identification Number) will auto-populate if the space bar or "Enter" is hit after the initial entries of those fields. The completed form should be faxed to the HFS Pharmacy Unit at

Each HealthChoice Illinois (HCI) managed care organization (MCO) plan will have its own version of the form available. Please contact the individual plan for details on its use.   

Please note, use of the form is not mandatory for the ordering provider. It is another alternative for providers to streamline the pharmacy approval process. All other prior authorization options may still be utilized.

Questions regarding this notice may be directed to the Pharmacy Unit in the Bureau of Professional and Ancillary Services at 877-782-5565 (FFS) or the applicable HCI MCO plan.

Kelly Cunningham, Administrator
Division of Medical Programs


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