Preferred Drug List Illinois Medicaid SOL 20MG/ML Antiretrovirals - RTI-Nucleoside...
Transcript of Preferred Drug List Illinois Medicaid SOL 20MG/ML Antiretrovirals - RTI-Nucleoside...
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
Hepatitis C Agent - Combinations EPCLUSA 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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
NUTROPIN AQ NUSPIN 20
NUTROPIN AQ NUSPIN 5
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
ASMANEX TWISTHALER 60 METERED DOSES ARMONAIR RESPICLICK 232
ASMANEX TWISTHALER 7 METERED DOSES ARMONAIR RESPICLICK 55
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
Antidepressants - Selective Serotonin Reuptake Inhibitors (SSRIs) CITALOPRAM HYDROBROMIDE CELEXA
ESCITALOPRAM OXALATE FLUOXETINE
FLUOXETINE CAP 10MG FLUOXETINE TAB 10MG
FLUOXETINE CAP 20MG FLUOXETINE TAB 20MG
FLUOXETINE CAP 40MG FLUOXETINE TAB 60MG
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 225MG ER
VENLAFAXINE TAB 37.5 ER
VENLAFAXINE TAB 75MG 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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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 15MG AMPHET/DEXTR CAP 20MG ER
AMPHET/DEXTR TAB 20MG AMPHET/DEXTR CAP 25MG ER
AMPHET/DEXTR TAB 30MG AMPHET/DEXTR CAP 30MG ER
AMPHET/DEXTR TAB 5MG AMPHET/DEXTR CAP 5MG 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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
METHYLPHENID CAP 40MG ER
METHYLPHENID CAP 50MG
METHYLPHENID CAP 60MG
METHYLPHENID CHW 10MG
METHYLPHENID CHW 5MG
METHYLPHENID TAB 18MG ER
METHYLPHENID TAB 27MG ER
METHYLPHENID TAB 36MG ER
METHYLPHENID TAB 54MG ER
METHYLPHENID TAB 72MG ER
METHYLPHENIDATE HCL CD
METHYLPHENIDATE HCL ER (LA)
METHYLPHENIDATE HYDROCHLORIDE
MODAFINIL
NUVIGIL
PROVIGIL
QUILLICHEW ER
QUILLIVANT XR
RITALIN
RITALIN LA
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
NICOTINE TRANSDERMAL SYSTEM STEP 2
NICOTINE TRANSDERMAL SYSTEM STEP 3
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
MORPHINE SUL CAP 10MG ER
MORPHINE SUL CAP 120MG ER
MORPHINE SUL CAP 20MG ER
MORPHINE SUL CAP 30MG ER
MORPHINE SUL CAP 45MG ER
MORPHINE SUL CAP 50MG ER
MORPHINE SUL CAP 60MG ER
MORPHINE SUL CAP 75MG ER
MORPHINE SUL CAP 80MG ER
MORPHINE SUL CAP 90MG ER
MS CONTIN
NUCYNTA
NUCYNTA ER
OPANA
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
Anticonvulsants - Misc. 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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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
Category Preferred Preferred, Requires PA Non-Preferred
Preferred Drug ListIllinois Medicaid
1/1/2018
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