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What is a preferred drug list? Here are further guidelines. |
| 2014 |
| Category | Preferred | Non-Preferred |
| Alzheimer’s Agents |
Aricept 23mg donepezil |
Exelon Patch galantamine rivastigmine Namenda |
| Angiotensin Blockers |
losartan losartan HCT |
Atacand Atacand HCT Azor Benicar Benicar HCT Diovan Diovan HCT Edarbi Edarbyclor Exforge Exforge HCT irbesartan irbesartan-HCT Micardis Micardis HCT Teveten Teveten HCT Tribenzor Twynsta Valturna |
| Antibiotics - Cephalosporins & Related Antibiotics |
amox tr-k clv cefaclor cefadroxil cefdinir suspension (for children through age 10) cefprozil suspension (for children through age 10) ceftriaxone cefuroxime cephalexin |
Cedax cefaclor tablets cefdinir capsules cefditoren cefpodoxime cefprozil tablets cefuroxime suspension cephalexin tablets Keflex 750mg Capsule Suprax Suspension Suprax Tablet * |
| Antibiotics -Macrolides/Ketolides | azithromycin clarithromycin clarithromycin XL erythromycin | Dificid Ketek Z-Max |
| Antibiotics - Quinolones | ciprofloxacin levofloxacin | Avelox ciprofloxacin XR Factive Noroxin ofloxacin |
| Anticholinergics, Inhaled | Atrovent HFA Combivent Spiriva | Combivent Respimat Tudorza Pressair |
| Anticoagulants | fondaparinux enoxaparin Fragmin heparin warfarin Xarelto (Prior Approval required; restricted to knee/hip replacement and atrial fibrillation) | Pradaxa |
| Anticonvulsants | carbamazepine carbamazepine XR divalproex divalproex ER ethosuximide gabapentin lamotrigine levetiracetam levetiracetam XR* mephobarbital oxcarbazepine phenobarbital phenytoin primidone topiramate valproic acid zonisamide | Banzel carbamazepine ER capsule Celontin felbamate Gabitril Lamictal ODT Lamictal XR Lamictal Starter Pack Lyrica Onfi Peganone Potiga Sabril Stavzor Vimpat Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 3 of 16 Category Preferred Non-Preferred |
| Antidepressants - Selective Serotonin Reuptake | Inhibitors (SSRIs) citalopram escitalopram* fluoxetine fluvoxamine paroxetine sertraline | fluoxetine 20 mg tablets fluoxetine 40 mg Caps fluoxetine weekly Luvox CR paroxetine CR Pexeva Sarafem |
| Antidepressants - Other | bupropion mirtazapine mirtazapine soltab trazodone venlafaxine immediate release tablets venlafaxine ER capsules | Aplenzin Cymbalta Emsam Forfivo XL nefazodone Oleptro Pristiq trazodone 300mg venlafaxine ER Viibryd |
| Antiemetic/Antivertigo Agents | Emend Bi-Fold Pack Emend Tripack meclizine metoclopramide ondansetron ondansetron ODT prochlorperazine promethazine Transderm Scop | Aloxi Antivert 50mg Anzemet Cesamet dronabinol granisetron Metozolv ODT Sancuso Zuplenz Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 4 of 16 Category Preferred Non-Preferred |
| Antifungals - Topical | clotrimazole econazole ketoconazole nystatin | ciclopirox 8% solution ciclopirox cream, gel, shampoo, solution ciclopirox 8% kit Ertaczo Exelderm nystatin/triamcinolone ketoconazole 2% foam Mentax Naftin Oxistat Pedipirox-4 Nail Kit Vusion Xolegel |
| Antiparkinson Agents | amantadine benztropine bromocriptine 2.5mg carbidopa/levodopa Comtan pramipexole ropinirole selegiline trihexyphenidyl | Azilect bromocriptine 5mg carbidopa/levodopa/entacapone carbidopa/levodopa ODT Mirapex ER Neupro ropinirole XL Tasmar Zelapar |
| Antivirals | Tamiflu, Relenza and rimantadine are preferred drugs during flu season only. Please refer to IDPH website for Flu Activity Reports acyclovir amantadine ganciclovir Relenza rimantadine Tamiflu Valcyte valacyclovir | famciclovir Valcyte Solution Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 5 of 16 Category Preferred Non-Preferred |
| Atypical Antipsychotics | All medications require prior approval for children under 8 years AND long-term care residents. Specialized formulations also require prior approval for all ages. Prior Approval Forms clozapine Invega Sustenna (Prior Approval Required) olanzapine quetiapine IR risperidone + ziprasidone + risperidone is the 1st line agent indicated for children ages 5-7 years | Abilify clozapine 200mg Fanapt Fazaclo Invega ER Latuda Risperdal Consta Saphris Seroquel XR Zyprexa Relprevv |
| Beta-Adrenergic Agents | albuterol inhalation solution ProAir HFA Proventil HFA terbutaline | albuterol ER albuterol tablets Arcapta Brovana Foradil ipratropium/albuterol sulfate solution levalbuterol inhalation solution Maxair Autohaler metaproterenol syrup and tablets Perforomist Serevent Diskus Ventolin HFA Xopenex HFA Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 6 of 16 Category Preferred Non-Preferred |
| Beta-Adrenergic Receptor Blocking Agents | acebutolol atenolol betaxolol bisoprolol carvedilol labetalol metoprolol metoprolol XL nadolol pindolol propranolol sotalol timolol | Bystolic Coreg CR Innopran XL Levatol propranolol LA sotalol AF |
| Biologic Response Modifiers | Prior approval required for all Biologic Response Modifiers. Cimzia Enbrel Humira | Actemra Kineret Orencia Remicade Simponi Stelara |
| Blood Glucose Monitors and Test Strips NDCs for Institutional or DME use are not billable through pharmacy POS system. Refer to the list of Preferred NDCs. | Freestyle Lite (Abbott) Precision (Abbott) True2Go (Nipro Diagnostics – formerly Home Diagnostics) TrueResult (Nipro Diagnostics – formerly Home Diagnostics) | Accu-Chek (Roche) Accu-Chek Aviva (Roche) Ascensia (Bayer) Contour (Bayer) Evolution (Infopia) Fora (Fora Care) Gdrive Blood Glucose System (Genesis) Glucolab (Infopia) One Touch (Lifescan)* *Approval for use with insulin pumps is limited to clients who are less than 14 years old or who are mentally or physically unable to program the pump. Prodigy AutoCode (Diagnostic Device ) Smartest Meters (Progressive HEA) Smartest Talking Meter (Progressive HEA) Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 7 of 16 Category Preferred Non-Preferred |
| Bone Resorption Suppression & Related Agents | alendronate calcitonin | Actonel Atelvia etidronate Evista Forteo Fortical Fosamax Plus D ibandronate Prolia Reclast Skelid Xgeva |
| BPH Agents | alfuzosin* doxazosin finasteride tamsulosin terazosin | Avodart Jalyn Rapaflo |
| Diabetes | acarbose Avandia chlorpropamide glimepiride glipizide glipizide XL glyburide glyburide/metformin Glyset metformin (IR and ER) nateglinide pioglitazone tolazamide tolbutamide | ActoPlus Met XR Avandamet Avandaryl Duetact Fortamet ER glipizide/metformin Glumetza ER pioglitazone-metformin Prandimet Prandin Riomet |
| DPP-4 Inhibitors | Januvia | Janumet Janumet XR Jentadueto Kombiglyze XR Onglyza Tradjenta Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 8 of 16 Category Preferred Non-Preferred |
| Erythropoietins | Aranesp Procrit | Epogen Omontys |
| Growth Hormones | Prior Approval required for all Growth Hormones. | Omnitrope Genotropin Humatrope Norditropin Nutropin Nutropin AQ Saizen Serostim Tev-tropin |
| Hepatitis B and Hepatitis C Agents Prior Approval required for all Hepatitis C Agents | Baraclude Peg-Intron (Prior Approval Required) ribavirin 200mg (Prior Approval Required) Victrelis (Prior Approval Required) | Epivir HBV Hepsera Incivek Infergen Intron A Pegasys Tyzeka |
| Hormone Replacement Therapy | Activella Cenestin Combipatch estradiol estradiol Transdermal Patches estropipate Menest Premarin Premphase Prempro | Angeliq Climara Pro Divigel Elestrin Enjuvia Estrasorb Evamist Femhrt Femtrace Menostar Prefest Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 9 of 16 Category Preferred Non-Preferred |
| Immunosuppressive/ Corticosteroid Agents – Topical | First-Line most topical corticosteroids Refer to the list of topical corticosteroids, categorized by potency. Second-Line Elidel Protopic | |
| Inhaled Steroids | Advair Advair HFA Asmanex Dulera Flovent Qvar Symbicort | Alvesco budesonide respules (Prior approval NOT required for patients age 7 and under.) Pulmicort |
| Insulins | All Humalog Products All Humulin Products Lantus (vial only) | All Novolin Products All Novolog Products Apidra Levemir Relion |
| Leukotriene Antagonists | montelukast zafirlukast | Zyflo Zyflo CR |
| Lice Treatments | Patients age 21 and over must purchase OTC products out-of-pocket malathion permethrin 1% OTC pyrethrin 0.33% OTC | Lindane Natroba Sklice Spinosad Ulesfia Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 10 of 16 Category Preferred Non-Preferred |
| Lipotropics – Statins & Combinations | atorvastatin lovastatin pravastatin simvastatin | Advicor Altoprev Crestor fluvastatin Lescol XL Livalo Simcor Vytorin |
| Lipotropics – Other | cholestyramine fenofibrate gemfibrozil Niaspan Zetia | Antara Colestid fenofibric acid Lipofen Lovaza Tricor Triglide Trilipix Welchol |
| LMWH’s and Related* *See Anticoagulants | ||
| Multiple Sclerosis Agents | Avonex Betaseron Copaxone Extavia Rebif | Ampyra ER Gilenya Tysabri |
| Narcotics | codeine/acetaminophen fentanyl hydrocodone/acetaminophen hydrocodone/ibuprofen hydromorphone meperidine methadone morphine sulfate IR and ER oxycodone IR oxycodone/acetaminophen tramadol | Abstral Avinza buprenorphine butalbital-caff-apap-codeine butorphanol Nasal Spray Butrans Embeda Exalgo ER fentanyl citrate lozenge Fentora Kadian Nucynta Nucynta ER Onsolis Opana ER oxycodone ER oxycodone/ibuprofen Oxycontin oxymorphone pentazocine/apap pentazocine/naloxone Suboxone (Indicated for opioid dependence) Subsys tramadol/apap tramadol ER |
| Nasal Steroids | flunisolide fluticasone | Beconase AQ Nasonex Omnaris Qnasal Rhinocort Aqua triamcinolone AQ Veramyst Zetonna |
| Nasal Preparations - Other | First-Line azelastine (For children through age 18) Patanase (For children through age 18) | Astepro Dymista ipratropium spray Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 12 of 16 Category Preferred Non-Preferred Second-Line azelastine (For patients over age 18) Patanase (For patients over age 18) |
| Ophthalmics – Allergic Conjunctivitis | Antihistamines and Antihistamine/ Mast Cell Stabilizer azelastine Bepreve Pataday | Emadine epinastine Lastacaft Patanol Anti-Inflammatory Agents ketorolac* Alrex Mast Cell Stabilizers cromolyn sodium Alamast Alocril Alomide |
| Ophthalmics – Antibiotics | bacitracin ciprofloxacin erythromycin gentamicin Iquix levofloxacin ofloxacin tobramycin Zymar | Azasite Besivance Moxeza Vigamox Zymaxid |
| Ophthalmics – Anti-Inflammatories | generics Acular LS FML Forte FML S.O.P. Lotemax Maxidex Pred Mild | Acuvail bromfenac Durezol Nevanac Vexol Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 13 of 16 Category Preferred Non-Preferred |
| Ophthalmics – Glaucoma Agents Prostaglandins latanoprost Lumigan Travatan Z Zioptan Carbonic Anhydrase Inhibitors dorzolamide dorzolamide-timolol Azopt Cosopt PF Alpha-2 Adrenoreceptor Agonists Alphagan P (5 ml and 10 ml) brimonidine Alphagan P (15 ml) Combigan Direct-Acting Miotics pilocarpine Isopto Carbachol Beta-Adrenergic Blockers betaxolol carteolol metipranolol timolol maleate Betimol Betoptic S Istalol | ||
| Ophthalmics – Steroid/Antibiotic Combinations | neomycin/polymyx B /dexamethasone neomycin/bacitracin Zn/polymyxin B/HC neomycin/polymyxin B /HC tobramycin/dexamethasone | Pred-G Tobradex Ointment Tobradex ST Zylet |
| Otic Anti-Infectives | acetic acid Cetraxal Ciprodex neomycin-polymyxin-HC ofloxacin | acetic acid/hydrocortisone Cipro HC Coly-Mycin S Cortisporin-TC |
| Pancreatic Enzymes | Creon DR Pancrelipase Zenpep DR | Pancreaze DR |
| Phosphate Binders | calcium acetate Fosrenol Renagel | Magnebind Renvela |
| Platelet Aggregation Inhibitors | Aggrenox clopidogrel dipyridamole | Brilinta Effient ticlopidine Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 14 of 16 Category Preferred Non-Preferred |
| Proton Pump Inhibitors | Patients age 21 and over must purchase OTC products out-of-pocket omeprazole (for children through age 20) pantoprazole (for children through age 20) | Aciphex Dexilant (formerly Kapidex) lansoprazole lansoprazole Solutabs (PA not required for children through age 10) Nexium omeprazole 10mg omeprazole-bicarbonate |
| Pulmonary Arterial Hypertension Agents | Adcirca (Prior Authorization Required) epoprostenol Letairis Tracleer Revatio (Prior Authorization Required) | Remodulin Tyvaso Ventavis |
| Retinoids - Topical | First Line generic tretinoin products (PA not required for ages 10 to 20yrs) | Atralin Differin 0.3% Tazorac Veltin Ziana Second Line adapalene 0.1% Retin-A Micro Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ Page 15 of 16 Category Preferred Non-Preferred |
| Stimulants/ADHD Agents | All medications require prior approval for children under 6 yrs. Prior Approval Forms Short Acting: amphetamine salts* methylphenidate* dexmethylphenidate Long Acting: methylphenidate ER – 10mg, 20mg methylphenidate SR – 20mg Metadate ER – 20mg Methylin ER – 10mg, 20mg Ritalin SR – 20mg *short acting stimulants are 1st line treatment for children ages 3-5 years old All Stimulants/ADHD Agents require prior approval for patients 19 years of age and older. | Adderall XR Concerta Daytrana Desoxyn dextroamphetamine dextroamp-amphet ER Cap Focalin XR Intuniv Kapvay Metadate CD Methylin Chewable and Solution modafinil Nuvigil Ritalin LA Strattera Vyvanse |
| Ulcerative Colitis Agents | basalazide* Canasa mesalamine Pentasa sulfasalazine | Apriso Asacol Asacol HD Dipentum Lialda |
| Urinary Anti-Incontinence Agents | oxybutynin oxybutynin XL | Detrol LA Enablex flavoxate Gelnique Myrbetriq Oxytrol Patch Sanctura XR tolterodine Toviaz trospium Vesicare Preferred Drug List Illinois Medicaid October 1, 2012 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: http://ilpriorauth.com/ |
| ***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: http://www.ilpriorauth.com/ | ||
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1. Ace Inhibitors 2. Antifungals – Oral 3. Calcium Channel Blockers 4. Histamine 2 Antagonists 5. Intermittent Claudication Agents 6. Non-Sedating Antihistamines 7. NSAID’s 8. Prenatal Vitamins 9. Sedative/Hypnotics 10. Skeletal Muscle Relaxants 11. Triptans | ||