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:
§ 90-89. Schedule I controlled substances. This schedule includes the controlled substances listed or to be listed by whatever official name, common or usual name, chemical name, or trade name designated. In determining that a substance comes within this schedule, the Commission shall find: a high potential for abuse, no currently accepted medical use in the United States, or a lack of accep
¿Ha sido víctima de discriminación en servicios de vivienda? De acuerdo con la ley federal y estatal contra la discriminación, es ilegal discriminar en la venta o renta de viviendas o en los préstamos o seguros de viviendas por razones de: Condición familiar (familias con hijos menores de 18 años) Condición como veterano o miembro de las Fuerzas Armadas de Estados Unidos Co