Preferred Drug List Illinois Medicaid€¦ · · 2018-02-20atrovent hfa incruse ellipta ... albuterol syp 2mg/5ml arcapta neohaler proair hfa brovana proventil hfa levalbuterol

Category Preferred Preferred, Requires PA Non-PreferredAminoglycosides BETHKIS KITABIS PAK

TOBRAMYCIN TOBI

TOBRAMYCIN INHALATION SOLUTION PAK TOBI PODHALER

Antiretrovirals - CCR5 Antagonists (Entry Inhibitor) SELZENTRY

Antiretrovirals - Fusion Inhibitors FUZEON

Antiretrovirals - Integrase Inhibitors ISENTRESS VITEKTA

ISENTRESS HD

TIVICAY

Antiretrovirals - Protease Inhibitors APTIVUS

ATAZANAVIR

ATAZANAVIR SULFATE

CRIXIVAN

FOSAMPRENAVIR CALCIUM

INVIRASE

LEXIVA

NORVIR

PREZISTA

REYATAZ

VIRACEPT

Antiretrovirals - RTI-Nucleoside Analogues-Purines ABACAVIR VIDEX EC

DIDANOSINE ZIAGEN TAB 300MG

VIDEXPEDIATRIC

ZIAGEN SOL 20MG/ML

Antiretrovirals - RTI-Nucleoside Analogues-Pyrimidines EMTRIVA EPIVIR

LAMIVUDINE

Antiretrovirals - RTI-Nucleoside Analogues-Thymidines STAVUDINE RETROVIR

ZIDOVUDINE ZERIT

Antiretrovirals - RTI-Nucleotide Analogues TENOFOVIR DISOPROXIL FUMARATE

VIREAD

Preferred Drug ListIllinois Medicaid

1/1/2018 (Updated 2/16/18)

Page 1 of 22

Category Preferred Preferred, Requires PA Non-Preferred


1/1/2018 (Updated 2/16/18)

Antiretrovirals - RTI-Non-Nucleoside Analogues EDURANT VIRAMUNE

EFAVIRENZ VIRAMUNE XR

INTELENCE

NEVIRAPINE

NEVIRAPINE ER

RESCRIPTOR

SUSTIVA

Antiretrovirals Adjuvants TYBOST

Antiretroviral Combinations ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE COMBIVIR

ABACAVIR/LAMIVUDINE COMPLERA

ATRIPLA EPZICOM

DESCOVY EVOTAZ

GENVOYA JULUCA

KALETRA TAB 100-25MG KALETRA SOL

KALETRA TAB 200-50MG ODEFSEY

LAMIVUDINE/ZIDOVUDINE PREZCOBIX

LOPINAVIR/RITONAVIR STRIBILD

TRUVADA TRIUMEQ

TRIZIVIR

Hepatitis C Agents MODERIBA TAB 200MG PEGINTRON COPEGUS

RIBASPHERE CAP 200MG SOVALDI DAKLINZA

RIBASPHERE TAB 200MG MODERIBA TAB 1000/DAY

RIBAVIRIN MODERIBA TAB 600/DAY

MODERIBA 1200 DOSE PACK

MODERIBA 800 DOSE PACK

OLYSIO

PEGASYS

PEGASYS PROCLICK

REBETOL

RIBASPHERE TAB 400MG

RIBASPHERE TAB 600MG

RIBASPHERE RIBAPAK

Page 2 of 22



1/1/2018 (Updated 2/16/18)

Hepatitis C Agent - Combinations EPCLUSA (Preferred for genotypes 2 & 3) HARVONI

ZEPATIER MAVYRET

TECHNIVIE

VIEKIRA PAK

VIEKIRA XR

VOSEVI

Progestins MAKENA

Human Insulin HUMALOG ADMELOG

HUMALOG JUNIOR KWIKPEN ADMELOG SOLOSTAR

HUMALOG KWIKPEN AFREZZA

HUMALOG MIX 50/50 APIDRA

HUMALOG MIX 50/50 KWIKPEN APIDRA SOLOSTAR

HUMALOG MIX 75/25 BASAGLAR KWIKPEN

HUMALOG MIX 75/25 KWIKPEN FIASP

HUMULIN 70/30 FIASP FLEXTOUCH

HUMULIN 70/30 KWIKPEN NOVOLIN 70/30

HUMULIN N NOVOLIN 70/30 RELION

HUMULIN N KWIKPEN NOVOLIN N

HUMULIN R NOVOLIN N RELION

HUMULIN R U-500 (CONCENTRATED) NOVOLIN R

HUMULIN R U-500 KWIKPEN NOVOLIN R RELION

LANTUS NOVOLOG

LANTUS SOLOSTAR NOVOLOG FLEXPEN

LEVEMIR NOVOLOG MIX 70/30

LEVEMIR FLEXTOUCH NOVOLOG MIX 70/30 PREFILLED FLEXPEN

NOVOLOG PENFILL

TOUJEO SOLOSTAR

TRESIBA FLEXTOUCH

Antidiabetic - Amylin Analogs SYMLINPEN 120

SYMLINPEN 60

Page 3 of 22



1/1/2018 (Updated 2/16/18)

Antidiabetics - Incretin Mimetic Agents (GLP-1 Receptor Agonists) BYETTA ADLYXIN

VICTOZA ADLYXIN STARTER PACK

BYDUREON

BYDUREON BCISE

BYDUREON PEN

OZEMPIC

TANZEUM

TRULICITY

Antidiabetics - Sulfonylureas CHLORPROPAMIDE AMARYL

GLIMEPIRIDE GLUCOTROL

GLIPIZIDE GLUCOTROL XL

GLIPIZIDE ER GLYNASE

GLIPIZIDE XL

GLYBURIDE

GLYBURIDE MICRONIZED

TOLAZAMIDE

TOLBUTAMIDE

Antidiabetics - Biguanides METFORMIN TAB 500MG ER FORTAMET

METFORMIN TAB 750MG ER GLUCOPHAGE

METFORMIN HCL GLUCOPHAGE XR

METFORMIN HYDROCHLORIDE GLUMETZA

METFORMIN TAB 1000 ER

METFORMIN TAB 500MG ER

METFORMIN ER TAB 1000MG

METFORMIN HYDROCHLORIDE ER

RIOMET

Antidiabetics - Meglitinide Analogues NATEGLINIDE PRANDIN

REPAGLINIDE

STARLIX

Antidiabetics - Alpha-Glucosidase Inhibitors ACARBOSE GLYSET

MIGLITOL PRECOSE

Antidiabetics - Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA ALOGLIPTIN

TRADJENTA NESINA

ONGLYZA

Antidiabetics - Dopamine Receptor Agonists - Ergot Derivatives CYCLOSET

Page 4 of 22



1/1/2018 (Updated 2/16/18)

Antidiabetics - Thiazolidinediones AVANDIA ACTOS

PIOGLITAZONE HCL

Antidiabetics - Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors INVOKANA FARXIGA

JARDIANCE STEGLATRO

Antidiabetics - Insulin-Incretin Mimetic Combinations SOLIQUA 100/33

XULTOPHY 100/3.6

Antidiabetics - Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations ALOGLIPTIN/METFORMIN HCL

JANUMET

JANUMET XR

JENTADUETO

JENTADUETO XR

KAZANO

KOMBIGLYZE XR

Antidiabetics - DPP-4 Inhibitor-Thiazolidinedione Combinations ALOGLIPTIN/PIOGLITAZONE

OSENI

Antidiabetics - Meglitinide-Biguanide Combinations REPAGLINIDE/METFORMIN HYDROCHLORIDE

Antidiabetics - Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide

Comb

INVOKAMET

INVOKAMET XR

SYNJARDY

SYNJARDY XR

XIGDUO XR

Antidiabetics - SGLT2 Inhibitor - DPP-4 Inhibitor Combinations GLYXAMBI

QTERN

Antidiabetics - Sulfonylurea-Biguanide Combinations GLYBURIDE/METFORMIN HCL GLIPIZIDE/METFORMIN HCL

GLUCOVANCE

Antidiabetics - Sulfonylurea-Thiazolidinedione Combinations DUETACT

PIOGLITAZONE HCL-GLIMEPIRIDE

Page 5 of 22



1/1/2018 (Updated 2/16/18)

Antidiabetics - Thiazolidinedione-Biguanide Combinations ACTOPLUS MET

ACTOPLUS MET XR

PIOGLITAZONE HCL/METFORMIN HCL

Growth Hormones OMNITROPE GENOTROPIN

GENOTROPIN MINIQUICK

HUMATROPE

HUMATROPE COMBO PACK

NORDITROPIN FLEXPRO

NUTROPIN AQ NUSPIN 10



SAIZEN

SAIZEN CLICK.EASY

SAIZENPREP RECONSTITUTIONKIT

SEROSTIM

ZOMACTON

ZORBTIVE

Pulmonary Hypertension - Prostacyclin Receptor Agonist UPTRAVI

Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (sGC) ADEMPAS

Pulmonary Hypertension - Phosphodiesterase Inhibitors ADCIRCA

REVATIO

SILDENAFIL

Pulmonary Hypertension - Endothelin Receptor Antagonists LETAIRIS OPSUMIT

TRACLEER

Prostaglandin Vasodilators EPOPROSTENOL SODIUM ORENITRAM

FLOLAN REMODULIN

TYVASO

TYVASO REFILL

TYVASO STARTER

VELETRI

VENTAVIS

Page 6 of 22



1/1/2018 (Updated 2/16/18)

Nitrate & Vasodilator Combinations BIDIL

Antiasthmatic And Bronchodilator Agents - Bronchodilators -

Anticholinergics*

ATROVENT HFA INCRUSE ELLIPTA

IPRATROPIUM BROMIDE SEEBRI NEOHALER

SPIRIVA AER 1.25MCG SPIRIVA SPR 2.5MCG

SPIRIVA HANDIHALER TUDORZA PRESSAIR

Antiasthmatic And Bronchodilator Agents - Beta Adrenergics ALBUTEROL NEB 0.083% ALBUTEROL

ALBUTEROL NEB 0.5% ALBUTEROL TAB 2MG

ALBUTEROL NEB 0.63MG/3 ALBUTEROL TAB 4MG

ALBUTEROL NEB 1.25MG/3 ALBUTEROL SULFATE ER

ALBUTEROL SYP 2MG/5ML ARCAPTA NEOHALER

PROAIR HFA BROVANA

PROVENTIL HFA LEVALBUTEROL

SEREVENT DISKUS LEVALBUTEROL HCL

TERBUTALINE SULFATE LEVALBUTEROL HYDROCHLORIDE

LEVALBUTEROL TARTRATE HFA

METAPROTERENOL SULFATE

PERFOROMIST

PROAIR RESPICLICK

STRIVERDI RESPIMAT

VENTOLIN HFA

VOSPIRE ER

XOPENEX

XOPENEX CONCENTRATE

XOPENEX HFA

Antiasthmatic And Bronchodilator Agents - Adrenergic Combinations ADVAIR DISKUS ADVAIR HFA

BEVESPI AEROSPHERE AIRDUO RESPICLICK 113/14

DULERA AIRDUO RESPICLICK 232/14

IPRATROPIUM BROMIDE/ALBUTEROL SULFATE AIRDUO RESPICLICK 55/14

SYMBICORT ANORO ELLIPTA

BREO ELLIPTA

COMBIVENT RESPIMAT

FLUTICASONE PROPIONATE/SALMETEROL

STIOLTO RESPIMAT

TRELEGY ELLIPTA

UTIBRON NEOHALER

Page 7 of 22



1/1/2018 (Updated 2/16/18)

Antiasthmatic And Bronchodilator Agents - Steroid Inhalants* ASMANEX TWISTHALER 120 METERED DOSES AEROSPAN

ASMANEX TWISTHALER 14 METERED DOSES ALVESCO

ASMANEX TWISTHALER 30 METERED DOSES ARMONAIR RESPICLICK 113



BUDESONIDE ARNUITY ELLIPTA

FLOVENT DISKUS ASMANEX HFA

FLOVENT HFA PULMICORT

QVAR PULMICORT FLEXHALER

QVAR REDIHALER

Antiasthmatic And Bronchodilator Agents - Leukotriene Modulators ZILEUTON ER

ZYFLO

ZYFLO CR

Antiasthmatic And Bronchodilator Agents - Leukotriene Receptor

Antagonists

MONTELUKAST SODIUM ACCOLATE

ZAFIRLUKAST SINGULAIR

Antiemetics - 5-HT3 Receptor Antagonists ONDANSETRON HCL ANZEMET

ONDANSETRON ODT GRANISETRON HCL

SANCUSO

ZOFRAN

ZOFRAN ODT

ZUPLENZ

Antiemetics - Substance P/Neurokinin 1 (NK1) Receptor Antagonists EMEND CAP 125MG APREPITANT

EMEND CAP 40MG CINVANTI

EMEND CAP 80MG EMEND SOL 150MG

EMEND TRIPACK EMEND SUS 125MG

VARUBI

Antiemetics - Miscellaneous CESAMET

DRONABINOL

MARINOL

SYNDROS

Antiemetic Combinations AKYNZEO

DICLEGIS

Digestive Enzymes CREON PANCREAZE

PANCRELIPASE PERTZYE

ZENPEP VIOKACE

Page 8 of 22



1/1/2018 (Updated 2/16/18)

Inflammatory Bowel Agents BALSALAZIDE DISODIUM APRISO

CANASA ASACOL HD

MESALAMINE ENE 4GM AZULFIDINE

PENTASA AZULFIDINE EN-TABS

SFROWASA COLAZAL

SULFASALAZINE DELZICOL

DIPENTUM

GIAZO

LIALDA

MESALAMINE KIT 4GM

MESALAMINE DR

ROWASA

Inflammatory Bowel Agents - Integrin Receptor Antagonists ENTYVIO

Inflammatory Bowel Agents - Interleukin Antagonists STELARA

Inflammatory Bowel Agents - Tumor Necrosis Factor Alpha Blockers CIMZIA INFLECTRA

CIMZIA STARTER KIT REMICADE

RENFLEXIS

Phosphate Binder Agents CALCIUM ACETATE AURYXIA

FOSRENOL ELIPHOS

LANTHANUM CARBONATE PHOSLYRA

RENAGEL RENVELA

SEVELAMER CARBONATE

VELPHORO

Antidepressants - Alpha-2 Receptor Antagonists (Tetracyclics) MIRTAZAPINE REMERON

MIRTAZAPINE ODT REMERON SOLTAB

Antidepressants - Serotonin Modulators TRAZODONE TAB 100MG BRINTELLIX

TRAZODONE TAB 150MG NEFAZODONE HCL

TRAZODONE TAB 50MG OLEPTRO

TRAZODONE TAB 300MG

TRINTELLIX

VIIBRYD

VIIBRYD STARTER PACK

Page 9 of 22



1/1/2018 (Updated 2/16/18)

Antidepressants - Selective Serotonin Reuptake Inhibitors (SSRIs) CITALOPRAM HYDROBROMIDE CELEXA

ESCITALOPRAM OXALATE FLUOXETINE

FLUOXETINE CAP 10MG FLUOXETINE TAB 10MG



FLUOXETINE SOL 20MG/5ML FLUOXETINE DR

FLUVOXAMINE MALEATE FLUOXETINE HYDROCHLORIDE

PAROXETINE HCL FLUVOXAMINE MALEATE ER

SERTRALINE HCL LEXAPRO

PAROXETINE HCL ER

PAXIL

PAXIL CR

PEXEVA

PROZAC

ZOLOFT

Antidepressants - Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) DULOXETINE CAP 20MG CYMBALTA

DULOXETINE CAP 30MG DESVENLAFAXINE ER

DULOXETINE CAP 60MG DULOXETINE CAP 40MG

VENLAFAXINE CAP 150MG ER EFFEXOR XR

VENLAFAXINE CAP 37.5 ER FETZIMA

VENLAFAXINE CAP 75MG ER FETZIMA TITRATION PACK

VENLAFAXINE HCL KHEDEZLA

PRISTIQ

VENLAFAXINE TAB 150MG ER


VENLAFAXINE TAB 37.5 ER


Antidepressants - Misc. BUPROPION HCL APLENZIN

BUPROPION HCL ER FORFIVO XL

BUPROPION HCL SR WELLBUTRIN SR

BUPROPION HCL XL WELLBUTRIN XL

BUPROPION HYDROCHLORIDE

MAPROTILINE HCL

Page 10 of 22



1/1/2018 (Updated 2/16/18)

Antipsychotics/Antimanic Agents - Benzisoxazoles* RISPERIDONE INVEGA SUSTENNA FANAPT

INVEGA TRINZA FANAPT TITRATION PACK

INVEGA

PALIPERIDONE ER

RISPERDAL

RISPERDAL CONSTA

RISPERDAL M-TAB

RISPERIDONE M-TAB

RISPERIDONE ODT

Antipsychotics/Antimanic Agents - Dibenzodiazepines* CLOZAPINE TAB 100MG CLOZAPINE TAB 200MG

CLOZAPINE TAB 25MG CLOZAPINE ODT

CLOZAPINE TAB 50MG CLOZARIL

FAZACLO

VERSACLOZ

Antipsychotics/Antimanic Agents - Dibenzothiazepines* QUETIAPINE FUMARATE QUETIAPINE FUMARATE ER

SEROQUEL

SEROQUEL XR

Antipsychotics/Antimanic Agents - Dibenzoxazepines* LOXAPINE ADASUVE

LOXAPINE SUCCINATE

Antipsychotics/Antimanic Agents - Dibenzo-oxepino Pyrroles* SAPHRIS

Antipsychotics/Antimanic Agents - Thienbenzodiazepines* OLANZAPINE TAB 10MG OLANZAPINE INJ 10MG

OLANZAPINE TAB 15MG OLANZAPINE ODT

OLANZAPINE TAB 2.5MG ZYPREXA

OLANZAPINE TAB 20MG ZYPREXA RELPREVV

OLANZAPINE TAB 5MG ZYPREXA ZYDIS

OLANZAPINE TAB 7.5MG

Antipsychotics/Antimanic Agents - Quinolinone Derivatives* ARIPIPRAZOLE TAB 10MG ABILIFY MAINTENA ABILIFY

ARIPIPRAZOLE TAB 15MG ARISTADA ARIPIPRAZOLE ODT

ARIPIPRAZOLE TAB 20MG ARIPIPRAZOLE SOL 1MG/ML

ARIPIPRAZOLE TAB 2MG REXULTI

ARIPIPRAZOLE TAB 30MG

ARIPIPRAZOLE TAB 5MG

Page 11 of 22



1/1/2018 (Updated 2/16/18)

Antipsychotics - Misc.* LATUDA EQUETRO

ZIPRASIDONE HCL GEODON

NUPLAZID

VRAYLAR

Amphetamines* VYVANSE ADZENYS XR-ODT

DESOXYN

DEXEDRINE

DEXTROAMPHETAMINE SULFATE

DEXTROAMPHETAMINE SULFATE ER

DYANAVEL XR

EVEKEO

METHAMPHETAMINE HCL

PROCENTRA

ZENZEDI

Amphetamine Mixtures* ADDERALL XR ADDERALL

AMPHET/DEXTR TAB 10MG AMPHET/DEXTR CAP 10MG ER

AMPHET/DEXTR TAB 12.5MG AMPHET/DEXTR CAP 15MG ER





AMPHET/DEXTR TAB 7.5MG MYDAYIS

ADHD Agent - Selective Alpha Adrenergic Agonists* CLONIDINE HCL ER

CLONIDINE HYDROCHLORIDE ER

CLONIDINE HYDROCLORIDE

GUANFACINE ER

INTUNIV

KAPVAY

ADHD Agent - Selective Norepinephrine Reuptake Inhibitor* ATOMOXETINE

STRATTERA

Page 12 of 22



1/1/2018 (Updated 2/16/18)

Stimulants - Misc.* CONCERTA APTENSIO XR

DEXMETHYLPHENIDATE HCL ARMODAFINIL

DEXMETHYLPHENIDATE HYDROCHLORIDE COTEMPLA XR-ODT

FOCALIN XR DAYTRANA

METADATE CD DEXMETHYLPHENIDATE HCL ER

METADATE ER FOCALIN

METHYLPHENID TAB 10MG METHLPHENIDA CHW 2.5MG

METHYLPHENID TAB 10MG ER METHYLIN

METHYLPHENID TAB 20MG METHYLPHENID CAP 10MG

METHYLPHENID TAB 20MG ER METHYLPHENID CAP 20MG

METHYLPHENID TAB 5MG METHYLPHENID CAP 20MG ER

METHYLPHENID CAP 30MG

METHYLPHENID CAP 30MG ER


METHYLPHENID CAP 40MG ER



METHYLPHENID CHW 10MG

METHYLPHENID CHW 5MG

METHYLPHENID TAB 18MG ER





METHYLPHENIDATE HCL CD

METHYLPHENIDATE HCL ER (LA)

METHYLPHENIDATE HYDROCHLORIDE

MODAFINIL

NUVIGIL

PROVIGIL

QUILLICHEW ER

QUILLIVANT XR

RITALIN

RITALIN LA

Page 13 of 22



1/1/2018 (Updated 2/16/18)

Smoking Deterrents BUPROPION HCL SR

CHANTIX

CHANTIX CONTINUING MONTHPAK

CHANTIX STARTING MONTH PAK

GNP NICOTINE MINI LOZENGE

GNP NICOTINE POLACRILEX

GNP NICOTINE POLACRILEX MINI

GNP NICOTINE TRANSDERMALSYSTEM

GOODSENSE NICOTINE

GOODSENSE NICOTINE GUM

GOODSENSE NICOTINE POLACRILEX

HM NICOTINE POLACRILEX

HM NICOTINE TRANSDERMAL SYSTEM

HM NICOTINE TRANSDERMAL SYSTEM STEP 3

HM NICOTINE TRANSDERMALSYSTEM

NICODERM CQ

NICORELIEF

NICORETTE

NICORETTE MINI

NICORETTE STARTER KIT

NICOTINE POLACRILEX

NICOTINE TRANSDERMAL SYSTEM

NICOTINE TRANSDERMAL SYSTEM STEP 1



NICOTROL INHALER

NICOTROL NS

SM NICOTINE

SM NICOTINE POLACRILEX

SM NICOTINE TRANSDERMAL SYSTEM

ZYBAN

Multiple Sclerosis Agents COPAXONE INJ 20MG/ML COPAXONE INJ 40MG/ML

GLATIRAMER ACETATE

GLATOPA

Page 14 of 22



1/1/2018 (Updated 2/16/18)

Multiple Sclerosis Agents - Interferons AVONEX BETASERON

AVONEX PEN EXTAVIA

REBIF PLEGRIDY

REBIF REBIDOSE PLEGRIDY STARTER PACK

REBIF REBIDOSE TITRATIONPACK

REBIF TITRATION PACK

MS Agents - Pyrimidine Synthesis Inhibitors AUBAGIO

Multiple Sclerosis Agents - Monoclonal Antibodies LEMTRADA

OCREVUS

TYSABRI

ZINBRYTA

Multiple Sclerosis Agents - Nrf2 Pathway Activators TECFIDERA

TECFIDERA STARTER PACK

Multiple Sclerosis Agents - Potassium Channel Blockers AMPYRA

Multiple Sclerosis Agents - Sphingosine 1-Phosphate (S1P) Receptor

Modulators

GILENYA

Alcohol Deterrents ACAMPROSATE CALCIUM DR

ANTABUSE

DISULFIRAM

Page 15 of 22



1/1/2018 (Updated 2/16/18)

Opioid Agonists CODEINE SULFATE ABSTRAL

EMBEDA ACTIQ

HYDROMORPHONE HCL ARYMO ER

MEPERIDINE HCL CONZIP

MORPHINE SUL TAB 100MG ER DEMEROL

MORPHINE SUL TAB 15MG ER DILAUDID

MORPHINE SUL TAB 200MG ER DOLOPHINE

MORPHINE SUL TAB 30MG ER DURAGESIC

MORPHINE SUL TAB 60MG ER EXALGO

MORPHINE SULFATE FENTANYL

OXYCODONE HCL FENTANYL CITRATE ORAL TRANSMUCOSAL

OXYCODONE HYDROCHLORIDE FENTORA

TRAMADOL HCL HYDROMORPHONE HCL ER

HYDROMORPHONE HYDROCHLORIDE

HYDROMORPHONE HYDROCHLORIDE ER

HYSINGLA ER

IONSYS

KADIAN

LAZANDA

LEVORPHANOL TARTRATE

METHADONE HCL

METHADONE HCL INTENSOL

METHADOSE

METHADOSE SUGAR-FREE

MORPHABOND ER

MORPHINE SUL CAP 100MG ER











MS CONTIN

NUCYNTA

NUCYNTA ER

OPANA

Page 16 of 22



1/1/2018 (Updated 2/16/18)

OPANA ER (CRUSH RESISTANT)

OXAYDO

OXYCODONE HCL ER

OXYCONTIN

OXYMORPHONE HYDROCHLORIDE

OXYMORPHONE HYDROCHLORIDE ER

ROXICODONE

SUBSYS

TRAMADOL HCL ER

ULTRAM

XTAMPZA ER

ZOHYDRO ER

Opioid Partial Agonists BUNAVAIL BELBUCA

BUPRENORPHINE HCL BUPRENORPHINE

BUPRENORPHINE HCL/NALOXONE HCL BUTORPHANOL TARTRATE

PROBUPHINE IMPLANT KIT BUTRANS

SUBLOCADE PENTAZOCINE/NALOXONE HCL

SUBOXONE

ZUBSOLV

Opioid Combinations ENDOCET OXYCODONE/ASPIRIN

OXYCODONE/ACETAMINOPHEN OXYCODONE/IBUPROFEN

PERCOCET

PRIMLEV

XARTEMIS XR

Codeine Combinations ACETAMINOPHEN/CODEINE BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE

ACETAMINOPHEN/CODEINE PHOSPHATE CAPITAL/CODEINE

ASCOMP/CODEINE FIORICET/CODEINE

BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE FIORINAL/CODEINE #3

TYLENOL/CODEINE #3

TYLENOL/CODEINE #4

Dihydrocodeine Combinations ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATE

ASPIRIN-CAFFEINE-DIHYDROCODEINE

SYNALGOS-DC

Page 17 of 22



1/1/2018 (Updated 2/16/18)

Hydrocodone Combinations HYDROCO/APAP SOL 7.5-325 HYDROCO/APAP SOL 7.5-500

HYDROCO/APAP TAB 10-325MG HYDROCO/APAP TAB 10-300MG

HYDROCO/APAP TAB 5-325MG HYDROCO/APAP TAB 2.5-325

HYDROCO/APAP TAB 7.5-325 HYDROCO/APAP TAB 5-300MG

HYDROCOD/IBU TAB 7.5-200 HYDROCO/APAP TAB 7.5-300

HYDROCODONE SOL 10-325MG HYDROCOD/IBU TAB 10-200MG

LORCET HYDROCOD/IBU TAB 5-200MG

LORCET HD IBUDONE

LORCET PLUS LORTAB

NORCO

REPREXAIN

VERDROCET

VICODIN

VICODIN ES

VICODIN HP

XODOL

XYLON

ZAMICET

Tramadol Combinations TRAMADOL HYDROCHLORIDE/ACETAMINOPHEN

ULTRACET

Analgesics - Anti-Inflammatory - Interleukin-1 Receptor Antagonist (IL-

1Ra)

KINERET

Analgesics - Anti-Inflammatory - Anti-TNF-alpha - Monoclonal Antibodies HUMIRA SIMPONI

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK SIMPONI ARIA

HUMIRA PEN

HUMIRA PEN-CROHNS DISEASESTARTER

HUMIRA PEN-PSORIASIS STARTER

Analgesics - Anti-Inflammatory - Soluble Tumor Necrosis Factor Receptor

Agents

ENBREL

ENBREL MINI

ENBREL SURECLICK

Analgesics - Anti-Inflammatory - Selective Costimulation Modulators ORENCIA

ORENCIA CLICKJECT

Analgesics - Anti-Inflammatory - Interleukin-6 Receptor Inhibitors ACTEMRA

KEVZARA

Page 18 of 22



1/1/2018 (Updated 2/16/18)

Analgesics - Anti-Inflammatory - Antirheumatic - Janus Kinase (JAK)

Inhibitors

XELJANZ

XELJANZ XR

Analgesics - Anti-Inflammatory - Phosphodiesterase 4 (PDE4) Inhibitors OTEZLA

Anticonvulsants - Benzodiazepines* CLONAZEPAM CLONAZEPAM ODT

DIASTAT ACUDIAL KLONOPIN

DIASTAT PEDIATRIC ONFI

DIAZEPAM

DIAZEPAM RECTAL GEL

Anticonvulsants - Carbamates* FELBAMATE

FELBATOL

Anticonvulsants - GABA Modulators* GABITRIL

SABRIL

TIAGABINE HYDROCHLORIDE

VIGABATRIN

Anticonvulsants - Hydantoins* DILANTIN CAP 30MG DILANTIN CAP 100MG

PHENYTOIN DILANTIN INFATABS

PHENYTOIN INFATABS DILANTIN-125

PHENYTOIN SODIUM EXTENDED PEGANONE

PHENYTEK

Anticonvulsants - Succinimides* ETHOSUXIMIDE CELONTIN

ZARONTIN

Anticonvulsants - Valproic Acid* DIVALPROEX SODIUM DEPAKENE

DIVALPROEX SODIUM DR DEPAKOTE

DIVALPROEX SODIUM ER DEPAKOTE ER

VALPROIC ACID DEPAKOTE SPRINKLES

Anticonvulsants - AMPA Glutamate Receptor Antagonists* FYCOMPA

Page 19 of 22



1/1/2018 (Updated 2/16/18)

CARBAMAZEPIN TAB 100MGER APTIOM

CARBAMAZEPIN TAB 200MG ER BANZEL

CARBAMAZEPIN TAB 400MG ER BRIVIACT

CARBAMAZEPINE CARBAMAZEPIN CAP 100MG ER

EPITOL CARBAMAZEPIN CAP 200MG ER

GABAPENTIN CARBAMAZEPIN CAP 300MG ER

LAMOTRIGINE CARBATROL

LEVETIRACETAM KEPPRA

LEVETIRACETAM ER KEPPRA XR

LYRICA LAMICTAL

OXCARBAZEPINE LAMICTAL CHEWABLE DISPERSIBLE

PRIMIDONE LAMICTAL ODT

ROWEEPRA LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE

TOPIRAMATE LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE

ZONISAMIDE LAMICTAL STARTER/TAKING VALPROATE

LAMICTAL XR

LAMOTRIGINE ER

LAMOTRIGINE ODT

LAMOTRIGINE STARTER KIT/BLUE

LAMOTRIGINE STARTER KIT/GREEN

LAMOTRIGINE STARTER KIT/ORANGE

LAMOTRIGINE TITRATION

MYSOLINE

NEURONTIN

OXTELLAR XR

POTIGA

QUDEXY XR

SPRITAM

TEGRETOL

TEGRETOL-XR

TOPAMAX

TOPAMAX SPRINKLE

TOPIRAMATE ER

TRILEPTAL

TROKENDI XR

VIMPAT

ZONEGRAN

Erythropoiesis-Stimulating Agents (ESAs) ARANESP ALBUMIN FREE EPOGEN

PROCRIT MIRCERA

Anticonvulsants - Misc.*

Prior authorization is not required for non-preferred epilepsy agents for

those participants with a diagnosis of epilepsy or seizure disorder in

Department records

Page 20 of 22



1/1/2018 (Updated 2/16/18)

Granulocyte Colony-Stimulating Factors (G-CSF) GRANIX NEULASTA

NEUPOGEN NEULASTA ONPRO KIT

ZARXIO

Anticoagulants - Low Molecular Weight Heparins ENOXAPARIN SODIUM LOVENOX

FRAGMIN

Anticoagulants - Synthetic Heparinoid-Like Agents FONDAPARINUX SODIUM ARIXTRA

Anticoagulants - Thrombin Inhibitors - Selective Direct & Reversible PRADAXA

Anticoagulants - Direct Factor Xa Inhibitors ELIQUIS SAVAYSA

XARELTO

XARELTO STARTER PACK

Ophthalmic Antiallergic AZELASTINE HCL ALOCRIL

CROMOLYN SODIUM ALOMIDE

PAZEO BEPREVE

ELESTAT

EMADINE

EPINASTINE HCL

LASTACAFT

OLOPATADINE HCL

OLOPATADINE HYDROCHLORIDE

PATADAY

PATANOL

Otic Steroid-Anti-infective Combinations CIPRODEX CIPRO HC

NEOMYCIN/POLYMYXIN/HC COLY-MYCIN S

NEOMYCIN/POLYMYXIN/HYDROCORTISONE OTOVEL

Scabicides & Pediculicides EURAX ELIMITE

GNP LICE TREATMENT LINDANE

HM LICE TREATMENT MALATHION

LICE TREATMENT OVIDE

NATROBA SPINOSAD

PERMETHRIN

SKLICE

Page 21 of 22



1/1/2018 (Updated 2/16/18)

Scabicide Combinations GNP LICE SOLUTION KIT

GNP LICE TREATMENT

HM LICE KILLING MAXIMUM STRENGTH

LICE KILLING MAXIMUM STRENGTH

LICE KILLING SHAMPOO

SM LICE KILLING MAXIMUM STRENGTH

Opioid Antagonists NALOXONE HCL

NALTREXONE HCL

NARCAN

VIVITROL

Diagnostic Tests ONETOUCH TES ULTRA BL All Other Products

Glucose Monitoring Test Supplies ONETOUCH KIT ULT MINI All Other Products

ONETOUCH KIT ULTRA 2

ONETOUCH ULTRA SYSTEM KIT

ONETOUCH ULTRASMART

*Exceptions as noted above*

All Antipsychotics: prior approval required for participants under 8 years of age and long-term care residents

All Amphetamines/ADHD Agents/Stimulants: prior approval required for participants under 6 years of age and participants 19 years of age and older

Budesonide: prior approval NOT required for participants age 7 and under

Spiriva Respimat 1.25mcg: Prior approval NOT required for participants ages 6-17

Anticonvulsants: Prior authorization is not required for non-preferred epilepsy agents for those participants with a diagnosis of epilepsy or seizure disorder in Department records

Page 22 of 22

Documents

Preferred Drug List Illinois Medicaid€¦ · · 2018-02-20atrovent hfa incruse ellipta ... albuterol syp 2mg/5ml arcapta neohaler proair hfa brovana proventil hfa levalbuterol