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Illinois medicaid program

Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Alzheimer’s Agents
Exelon Patch galantamine rivastigmine Namenda Namenda XR Angiotensin Blockers
valsartan HCT*
Diovan Edarbi Edarbyclor Exforge Exforge HCT Micardis Micardis HCT Teveten Teveten HCT Tribenzor Twynsta Valturna Antibiotics -
Cephalosporins &
Related Antibiotics
cefdinir suspension (for children through age 10) cefprozil suspension (for children through age 10) cephalexin tablets Keflex 750mg Capsule Suprax Suspension Suprax Tablet Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Antibiotics -
Macrolides/Ketolides
Antibiotics - Quinolones
ciprofloxacin XR Factive Noroxin ofloxacin Anticholinergics, Inhaled
Anticoagulants
Fragmin heparin warfarin Xarelto (Prior Approval required; restricted to knee/hip replacement, atrial fibrillation, deep vein thrombosis, and pulmonary embolism) Anticonvulsants
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Antidepressants -
Selective Serotonin
Reuptake Inhibitors
Antidepressants - Other
Forfivo XL nefazodone Oleptro Pristiq trazodone 300mg venlafaxine ER Viibryd Antiemetic/Antivertigo
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Antifungals - Topical
ciclopirox cream, gel, shampoo, solution Exelderm nystatin/triamcinolone ketoconazole 2% foam Mentax Naftin Oxistat Pedipirox-4 Nail Kit Vusion Xolegel Antiparkinson Agents
Antivirals
Tamiflu, Relenza and
rimantadine are preferred Relenza
drugs during flu season
only. Please refer to IDPH Valcyte
website for Flu Activity
Reports at

Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Atypical Antipsychotics
Invega Sustenna (Prior Approval Required) All medications require
prior approval for
children under 8 years
AND long-term care
residents.
Specialized formulations
also require prior
+ risperidone is the 1st line agent indicated for children approval for all ages.
Beta-Adrenergic Agents
levalbuterol inhalation solution Maxair Autohaler metaproterenol syrup and tablets Perforomist Serevent Diskus Ventolin HFA Xopenex HFA Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Beta-Adrenergic
Receptor Blocking
metoprolol metoprolol XL nadolol pindolol propranolol sotalol timolol Biologic Response
Modifiers
Prior approval required
for all Biologic Response
Modifiers.
Blood Glucose Monitors
and Test Strips
NDCs for Institutional or
DME use are not billable
Approval of non-preferred test strips for use with insulin pumps through pharmacy POS
is limited to clients who are less than 14 years of age or who system. Refer to the list
have a condition that makes them unable to enter blood Gdrive Blood Glucose System (Genesis)
Glucolab (Infopia)
Precision (Abbott)
Prodigy AutoCode (Diagnostic Device )
Smartest Meters (Progressive HEA)
Smartest Talking Meter (Progressive HEA)
True2Go (Nipro Diagnostics)
TrueResult (Nipro Diagnostics)
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Bone Resorption
Suppression & Related
Evista Forteo Fortical Fosamax Plus D ibandronate Prolia Reclast Skelid Xgeva BPH Agents
Diabetes
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
DPP-4 Inhibitors
Janumet Janumet XR Jentadueto Kazano Kombiglyze XR Nesina Onglyza Oseni Tradjenta Erythropoietins
Prior Approval required
for all Erythropoietins

Growth Hormones
Prior Approval required
for all Growth Hormones.
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Hepatitis B and Hepatitis
ribavirin 200mg (Prior Approval Required) Prior Approval required
for all Hepatitis C Agents
Hormone Replacement
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Immunosuppressive/
First-Line
Corticosteroid Agents –
Refer to the categorized by
potency.
Second-Line
Elidel
Protopic
Inhaled Steroids
Breo Ellipta budesonide respules (Prior approval NOT required for patients age 7 and under.) Pulmicort Insulins
Leukotriene Antagonists
Lice Treatments
Patients age 21 and over
must purchase OTC
products out-of-pocket
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Lipotropics – Statins &
Combinations
fluvastatin Lescol XL Liptruzet Livalo Simcor simvastatin 80mg Vytorin Lipotropics – Other
Lipofen Lovaza Niaspan Tricor Triglide Trilipix Vascepa Welchol LMWH’s and Related*

*See Anticoagulants
Multiple Sclerosis Agents
Avonex
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Narcotics
buprenorphine (narcotic withdrawal agent) buprenorphine/naloxone (narcotic withdrawal agent) Kadian Nucynta Nucynta ER Onsolis Opana ER oxycodone ER oxycodone/ibuprofen Oxycontin oxymorphone pentazocine/apap pentazocine/naloxone Suboxone (narcotic withdrawal agent) Subsys tramadol/apap tramadol ER Zubsolv (narcotic withdrawal agent) Nasal Steroids
Omnaris Qnasal Rhinocort Aqua triamcinolone AQ Veramyst Zetonna Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Nasal Preparations -
First-Line
azelastine (For children through age 18) Second-Line
azelastine (For patients over age 18)
Patanase (For patients over age 18)
Ophthalmics –
Antihistamines and
Allergic Conjunctivitis
Antihistamine/ Mast Cell Stabilizer Pataday
Anti-Inflammatory Agents
Mast Cell Stabilizers
Ophthalmics –
Antibiotics
Ophthalmics –
Anti-Inflammatories
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Ophthalmics –
Prostaglandins
Glaucoma Agents
Carbonic Anhydrase
Inhibitors
Alpha-2 Adrenoreceptor Alphagan P (5 ml and 10 ml)
Agonists
Direct-Acting Miotics

Beta-Adrenergic

Blockers
Ophthalmics –
Steroid/Antibiotic
Combinations
Otic Anti-Infectives
Pancreatic Enzymes
Phosphate Binders
Platelet Aggregation
Brilinta (will be approved in patients with Acute Coronary Inhibitors
Effient (will be approved in patients with Acute Coronary Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Progesterone/
Crinone Gel – Requires Prior Approval (will not be approved for Hydroxyprogesterone
hydroxyprogesterone caproate powder Makena – Requires Prior Approval progesterone capsules progesterone oil Proton Pump Inhibitors
omeprazole RX (for children through age 20) pantoprazole (for children through age 20) Patients age 21 and over
must purchase OTC
lansoprazole lansoprazole Solutabs (PA not required for children through products out-of-pocket
Nexium omeprazole OTC omeprazole 10mg omeprazole-bicarbonate rabeprazole Pulmonary Arterial
Hypertension Agents
sildenafil (Prior Authorization Required) Retinoids - Topical
First Line
generic tretinoin products (PA not required for ages 10 to Second Line
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Stimulants/ADHD Agents
Short Acting:
All medications require
prior approval for
children under 6 yrs.Long Acting:
Metadate CD Brand - Temporary due to shortage *short acting stimulants are 1st line treatment for children ages All Stimulants/ADHD Agents require prior approval for patients 19 years of age and older. Ulcerative Colitis Agents
Preferred Drug List
Illinois Medicaid
Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at:
Category
Preferred
Non-Preferred
Urinary Anti-Incontinence oxybutynin
flavoxate Gelnique Myrbetriq Oxytrol Patch Sanctura XR tolterodine Toviaz trospium Vesicare
***The following classes have been removed from the PDL as they are all or almost all generic.
We cover most generics in these classes. In order to check the prior approval status of a drug not on the PDL,
please go to the Prior Authorization Search Engine at:

Source: http://www.qureshiuniversity.com/pdl.pdf

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