Provider Notice Issued 09/30/2022

Date:   September 30, 2022

To:       Enrolled Pharmacies; Physicians; Advanced Practice Registered Nurses; Physician Assistants; and Hospitals        

Re:      Post Kidney Transplant Preferred Drugs under the Emergency Medical Program

_________________________________________________________________________________________________________

This notice identifies to pharmacies the drugs covered for persons who have received a kidney transplant under the Emergency Medical Program. This program provides coverage for persons aged 19 and older who do not meet immigration status and is administered through the Medicaid fee-for-service (FFS) program.  

The Public Aid Code at 305 ILCS 5/5-5 allows persons who have been receiving Emergency Medical coverage for end stage renal dialysis treatment to be considered for a kidney transplant. For those persons who have received a kidney transplant at least 12 months prior at an Illinois Medicaid Certified transplant center located in Illinois, and are otherwise qualified based on Illinois residency and other requirements specified in 89 Ill. Admin. Code 118.790, the Department of Healthcare and Family Services (HFS) will cover the following drugs for post kidney transplant patients without prior authorization:  

 
Select non-preferred drugs may be available with prior authorization.
 
Until the Pharmacy Benefit Manager (PBM) programming for post kidney transplant patients is complete, HFS will require that pharmacies contact HFS to have a billing consultant manually add the patient's drug coverage segment prior to each group of claims for the same date of service being billed through the point-of-sale system. To have an eligibility segment added for drug coverage, or for additional questions regarding this notice, please contact the Bureau of Professional and Ancillary Services at 877-782-5565.

 
Kelly Cunningham, Administrator
Division of Medical Programs