Family physicians can play a key role in recognizing risk factors for overdose or misuse in persons with chronic pain taking opioids, and to properly use prescription drug monitoring programs, drug screening, treatment agreements, or other methods to counter risk factors.
Pharmacy Benefit Manager (PBM) Reform
Public Act 104-0027 (effective Jan. 1, 2026) significantly reforms the practices of pharmacy benefit managers (PBMs), with provisions designed to enhance transparency, curb excessive pricing, and preserve patient choice. Key provisions include:
Prohibition of spread pricing: PBMs cannot charge insurers more than they reimburse pharmacies.
Ban on patient steering: PBMs cannot force patients to use PBM-owned pharmacies.
Transparency reporting: PBMs must disclose pricing and rebate practices.
Ban on gag clauses: pharmacists may tell patients about lower-cost alternatives.
Stronger oversight: Illinois Department of Insurance gains greater authority to enforce compliance.
Implications for Patient Care: For family physicians, PBM reforms mean fewer hidden barriers when prescribing affordable medications. Patients should have greater pharmacy choice and may experience more transparency in drug pricing. Physicians may also benefit from fewer patient issues related to unexplained pharmacy restrictions or unexpected price shifts.
Public Act 104-369 (effective Jan. 1, 2026) authorizes the Illinois Department of Public Health (IDPH) to publish and promote non-opioid alternatives for pain management.
Implications for Patient Care: Family physicians are often the first point of contact for pain complaints. Having state-supported, vetted guidance on non-opioid treatments helps reinforce conversations about safe pain management. This law provides a framework to broaden patient understanding, reduce reliance on opioids, and strengthen trust when physicians recommend pain management alternatives.
Substance Use & Mental Health Parity Reforms
Public Act 104-446 (effective Jan. 1, 2026) introduces significant enhancements to insurance parity requirements for mental health and substance use disorder (MH/SUD) treatment. The law establishes a reimbursement rate floor for in-network MH/SUD services, with enforcement and oversight responsibilities split between the Illinois Department of Insurance and the Department of Human Services. Rate-setting will be informed by Illinois-specific data and evaluated over multiple years, with rulemaking due by May 1, 2026.
Physicians should provide patient-centered care, including coordinating with other disciplines, to patients with chronic pain or dependence on opioids.
Practices should encourage their physicians to use medication-assisted treatment options for patients with opioid dependence.
Physicians are encouraged to use their state prescription drug monitoring programs for tracking purposes, to identify abuse or diversion, and recognize persons who might be at risk.
Methadone, buprenorphine, and naltrexone are used as opioid substitutes in medication-assisted treatment.
Ongoing education and guideline updates are necessary and available from the Illinois Academy of Family Physicians and American Academy of Family Physicians.