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Preferred Drug ListIllinois Medicaid

October 1, 2011Changes 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/

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Category Preferred Non-Preferred

Alzheimers AgentsAricept 23mgdonepezil

Exelon*Exelon Patch*galantamine*Namenda* (current patients will be grandfathered)

Angiotensin Blockers AvalideAvaproBenicarBenicar HCTDiovanDiovan HCTlosartanlosartan HCTMicardisMicardis HCT

AtacandAtacand HCTAzorEdarbiExforgeExforge HCTTevetenTeveten HCTTribenzorTwynstaValturna

Antibiotics -Cephalosporins &Related Antibiotics

amox tr-k clvcefaclorcefadroxilcefdinir suspension (for children through age 10)cefprozil suspension (for children through age 10)ceftriaxonecefuroximecephalexinSuprax Tablet (Quantity limit of 1 tablet. Preferred for thetreatment of STDs only)

Augmentin XRCedaxcefaclor tabletscefdinir capsulescefditorencefpodoximecefprozil tabletscefuroxime suspensioncephalexin tabletsKeflex 750mg CapsuleSuprax Suspension

Antibiotics -Macrolides/Ketolides

azithromycinclarithromycinerythromycin

clarithromycin XLDificidKetekZ-Max

Antibiotics - Quinolones Aveloxciprofloxacinlevofloxacin

ciprofloxacin XRFactiveNoroxinofloxacinProquin XR
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Anticholinergics, InhaledAtrovent HFACombiventSpiriva

Anticoagulants ArixtraFragminHeparinLovenoxwarfarinXarelto* (Prior Approval Required will only be approvedfor knee/hip replacement)

BrilintaPradaxa

Anticonvulsants carbamazepinecarbamazepine XRdivalproexdivalproex ERethosuximidegabapentinlamotriginelevetiracetammephobarbitaloxcarbazepinephenobarbitalphenytoinprimidonetopiramatevalproic acidzonisamide

BanzelCarbatrolCelontinFelbatolGabitrilKeppra XRLamictal ODTLamictal XRLamictal Starter PackLyricaPeganoneSabrilStavzorVimpat

Antidepressants -Selective SerotoninReuptake Inhibitors(SSRIs)

citalopramfluoxetinefluvoxamineparoxetinesertraline

fluoxetine 20 mg tabletsfluoxetine 40 mg Capsfluoxetine weeklyLexaproLuvox CRparoxetine CRPexevaSarafem

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Category Preferred Non-PreferredAntidepressants - Other bupropion

mirtazapinemirtazapine soltabtrazodonevenlafaxine immediate release tabletsvenlafaxine ER capsules

AplenzinCymbaltaEffexor XREmsamnefazodoneOleptroPristiqtrazodone 300mgvenlafaxine ER tabletsViibryd

Antiemetic/AntivertigoAgents

Emend Bi-Fold PackEmend Tripackmeclizinemetoclopramideondansetronondansetron ODTprochlorperazinepromethazineScopaceTransderm Scop

AloxiAntivert 50mgAnzemetCesametdronabinol*granisetronMetozolv ODTSancuso*Zuplenz

Antifungals - Topical clotrimazoleeconazoleErtaczoketoconazolenystatinnystatin/triamcinolone

ciclopirox 8% solutionciclopirox cream, gel, shampoo, solutionclotrimazole/betamethasoneCNL 8 Nail KitExeldermExtinaMentaxNaftinOxistatVersiclearVusionXolegel

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Category Preferred Non-PreferredAntiparkinson Agents amantadine

benztropinebromocriptine 2.5mgcarbidopa/levodopaComtanpramipexoleropiniroleselegilinetrihexyphenidyl

Azilectbromocriptine 5mgcarbidopa/levodopa ODTMirapex ERNeuproRequip XLStalevoTasmarZelapar

Antivirals

Tamiflu, Relenza and

rimantadine are preferreddrugs during flu seasononly. Please refer toIDPHWeb site for Flu ActivityReports

acycloviramantadineganciclovirRelenzarimantadineTamifluValcytevalacyclovir

famciclovirValcyte Solution

Atypical Antipsychotics

All medications requireprior approval forchildren under 8 yearsAND long-term care

residents.Specialized formulationsalso require priorapproval for all ages.Prior Approval Forms

clozapineGeodonInvega Sustenna (Prior Approval Required)

risperidone +Zyprexa

+ risperidone is the 1st line agent indicated for childrenages 5-7 years

Abilifyclozapine 50mgclozapine 200mgFanaptFazacloInvega ERLatuda

Risperdal ConstaSaphrisSeroquelSeroquel XRZyprexa Relprevv
http://ilpriorauth.com/http://www.idph.state.il.us/flu/surveillance.htmhttp://www.idph.state.il.us/flu/surveillance.htmhttp://www.idph.state.il.us/flu/surveillance.htmhttp://www.idph.state.il.us/flu/surveillance.htmhttp://www.idph.state.il.us/flu/surveillance.htmhttp://www.hfs.illinois.gov/pharmacy/guidelines.htmlhttp://www.hfs.illinois.gov/pharmacy/guidelines.htmlhttp://www.idph.state.il.us/flu/surveillance.htmhttp://www.idph.state.il.us/flu/surveillance.htmhttp://www.idph.state.il.us/flu/surveillance.htmhttp://ilpriorauth.com/

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Category Preferred Non-PreferredBeta-Adrenergic Agents albuterol inhalation solution

ProAir HFAProventil HFAterbutaline

albuterol ERalbuterol tabletsArcaptaBrovanaForadilipratropium/albuterol sulfate solutionMaxair Autohalermetaproterenol syrup and tabletsPerforomistSerevent DiskusVentolin HFAXopenex Inhalation SolutionXopenex HFA

Beta-AdrenergicReceptor BlockingAgents

acebutololatenololbetaxololbisoprololcarvedilolCoreg CRlabetalolmetoprololmetoprolol XLnadololpindololpropranolol

sotaloltimolol

BystolicInnopran XLLevatolpropranolol LAsotalol AF

Biologic ResponseModifiersPrior approval requiredfor all Biologic ResponseModifiers.

CimziaEnbrelHumira

ActemraKineretOrenciaRemicadeSimponiStelara

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Category Preferred Non-PreferredBlood Glucose Monitorsand Test Strips

NDCs for Institutional orDME use are not billablethrough pharmacy POSsystem. Refer to the listofPreferred 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)Prodigy AutoCode (Diagnostic Device )Smartest Meters (Progressive HEA)Smartest Talking Meter (Progressive HEA)

Bone ResorptionSuppression & RelatedAgents

alendronateFosamax Plus DMiacalcin

ActonelActonel with CalciumAtelviaBonivaetidronateEvistaForteoForticalProliaReclastSkelidXgeva

BPH Agents Avodartdoxazosintamsulosinterazosin

alfuzosin

finasterideJalynRapaflo
http://ilpriorauth.com/http://www.hfs.illinois.gov/pharmacy/teststrips.htmlhttp://www.hfs.illinois.gov/pharmacy/teststrips.htmlhttp://www.hfs.illinois.gov/pharmacy/teststrips.htmlhttp://ilpriorauth.com/

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Category Preferred Non-PreferredDiabetes acarbose

ActosAvandiachlorpropamideglimepirideglipizideglipizide XLglyburideglyburide/metforminGlysetmetformin (IR and ER)nateglinidetolazamide

tolbutamide

ActoPlus MetActoPlus Met XRAvandametAvandarylDuetactFortamet ERglipizide/metforminGlumetza ERPrandimetPrandinRiomet

DPP-4 Inhibitors* Januvia JanumetKombliglyze XROnglyzaTradjenta

Erythropoietins AranespProcrit

Epogen

Growth Hormones

Prior Approval requiredfor all Growth Hormones.

Nutropin AQ GenotropinHumatropeNorditropinNutropinOmnitropeSaizenSerostimTev-tropin

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Category Preferred Non-PreferredHepatitis B and HepatitisC Agents

BaracludePegasysPeg-Intronribavirin 200mgVictrelis*

Epivir HBVHepseraIncivekInfergenIntron ATyzeka

Hormone ReplacementTherapy

ActivellaCenestinCombipatchestradiolestradiol Transdermal PatchesestropipateMenest

PremarinPremphasePrempro

AngeliqClimara ProDivigelElestrinEnjuviaEstrasorbEvamist

FemhrtFemtraceMenostarPrefest

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Category Preferred Non-PreferredImmunosuppressive/Corticosteroid Agents Topical

Patients must try and failone first-line productbefore second-lineproducts will beapproved.

First-Linemost topical corticosteroids

Click herefor a list of topical corticosteroids, categorizedby potency.

Second-LineElidelProtopic

Inhaled Steroids AdvairAdvair HFAAsmanex

DuleraFloventQvarSymbicort

AlvescoPulmicort Respules (Prior approval NOT required forpatients age 7 and under.)

Pulmicort

Insulins All Humalog ProductsAll Humulin ProductsLantus (vial only)

All Novolin ProductsAll Novolog ProductsApidraLevemirRelion

Leukotriene Antagonists Singulairzafirlukast

ZyfloZyflo CR

Lice Treatments

Patients age 21 and overmust purchase OTCproducts out-of-pocket

Ovidepermethrin 1% OTCpyrethrin 0.33% OTC

LindaneNatrobaUlesfia
http://ilpriorauth.com/http://www.hfs.illinois.gov/pharmacy/topical.htmlhttp://www.hfs.illinois.gov/pharmacy/topical.htmlhttp://www.hfs.illinois.gov/pharmacy/topical.htmlhttp://ilpriorauth.com/

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Category Preferred Non-PreferredLipotropics Statins &Combinations

Crestorlovastatinpravastatinsimvastatin

AdvicorAltoprevLescolLescol XLLipitorLivaloSimcorVytorin

Lipotropics Other Antaracholestyraminefenofibrategemfibrozil

NiaspanTrilipixZetia

ColestidFenoglideFibricorLipofen

LovazaTricorTriglideWelchol

LMWHs and Related*

*See AnticoagulantsMultiple Sclerosis Agents Avonex

BetaseronCopaxoneExtavia

Rebif

Ampyra ERGilenyaTysabri

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Narcotics Most Genericsfentanyl patches (limit of 15 per month) generic onlyKadianRoxicet

AbstralAvinzabuprenorphinebutalbital-caff-apap-codeinebutorphanol Nasal SprayButransEmbedaExalgo ERfentanyl citrate lozengeFentoraNucyntaNucynta ER

OnsolisOpana ERoxycodone ERoxycodone/ibuprofenOxycontinoxymorphonepentazocine/apappentazocine/naloxoneSuboxone (Indicated for opioid dependence)tramadol/apaptramadol ER

Nasal Steroids flunisolidefluticasone Beconase AQNasacort AQ*Nasonex*OmnarisRhinocort AquaVeramyst

Nasal Preparations -Other

First-LineAstepro (For children through age 18)Patanase* (For children through age 18)

Astelinipratropium spray

Second-LinePatanase (For patients over age 18)Astepro (For patients over age 18)

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Category Preferred Non-PreferredOphthalmics Allergic Conjunctivitis

Antihistamines andAntihistamine/ Mast Cell Stabilizer

Bepreve

OptivarPataday

Emadine

epinastineLastacaftPatanol

Anti-Inflammatory Agents Alrex ketorolac

Mast Cell Stabilizers cromolyn sodium AlamastAlocrilAlomide

Ophthalmics Antibiotics

bacitracinciprofloxacinerythromycingentamicinIquixofloxacinQuixintobramycinZymar

AzasiteBesivanceMoxezaVigamoxZymaxid

Ophthalmics Anti-Inflammatories

GenericsAcular LSFML ForteFML S.O.P.LotemaxMaxidexPred Mild

AcuvailBromdayDurezolNevanacVexolXibrom

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Category Preferred Non-PreferredOphthalmics Glaucoma Agents

Prostaglandins latanoprost*LumiganTravatan Z

Carbonic AnhydraseInhibitors

Azoptdorzolamide-timolol

dorzolamide

Alpha-2 AdrenoreceptorAgonists

Alphagan P (5 ml and 10 ml)brimonidineCombigan

Alphagan P (15 ml)

Direct-Acting Miotics pilocarpine Isopto Carbachol

Beta-AdrenergicBlockers

GenericsBetimol

Betoptic SIstalol

Ophthalmics Steroid/AntibioticCombinations

genericsTobradex

Poly-PredPred-GTobradex STZylet

Otic Anti-Infectives genericsCetraxalCiprodex

acetic acid/hydrocortisoneCipro HCColy-Mycin SCortisporin-TC

Pancreatic Enzymes Creon DRPancrelipaseZenpep DR

Pancreaze DR

Phosphate Binders calcium acetateFosrenolRenagel

MagnebindRenvela

Platelet AggregationInhibitors

AggrenoxdipyridamolePlavix

Effientticlopidine

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Category Preferred Non-PreferredProton Pump Inhibitors

OTC Products are notcovered for adults age 21and over.

First Line

omeprazole OTCpantoprazole (for children through age 20)Prilosec OTC

Aciphex

Dexilant (formerly Kapidex)lansoprazolelansoprazole Solutabs (PA not required for children throughage 10)Nexiumomeprazole RXZegerid

Second Linepantoprazole (for patients over age 20)

Pulmonary ArterialHypertension Agents

Adcirca (Prior Authorization Required)epoprostenolLetairisTracleerRevatio (Prior Authorization Required)

RemodulinTyvasoVentavis

Retinoids - Topical First Linegeneric tretinoin products (PA not required for ages 10 to20yrs)

AtralinDifferin 0.3%TazoracVeltinZianaSecond Line

adapalene 0.1%Retin-A Micro

Stimulants/ADHD Agents

All medications requireprior approval for

children under 6 yrs.Prior Approval Forms

amphetamine salts +dexmethylphenidate

methylphenidate +methylphenidate SR

Metadate ERMethylin ERRitalin SR

+short acting stimulants are 1st

line agents for childrenages 3-5 years old

All Stimulants/ADHD Agents require prior approval for patients19 years of age and older.

Adderall XRConcertaDaytranaDesoxyndextroamphetaminedextroamp-amphet ER CapFocalin XRIntunivKapvayMetadate CDMethylin Chewable and SolutionNuvigilProvigilRitalin LAStratteraVyvanse
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Category Preferred Non-PreferredUlcerative Colitis Agents Canasa

mesalaminePentasasulfasalazine

Apriso

AsacolAsacol HDbalsalazideDipentumLialda

Urinary Anti-IncontinenceAgents

oxybutyninoxybutynin XLOxytrol PatchVesicare

DetrolDetrol LAEnablexflavoxateGelniqueSanctura XRToviaz

trospium

***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 thePrior Authorization Search Engineat:http://www.ilpriorauth.com/

1. Ace Inhibitors

2. Antifungals Oral

3. Calcium Channel Blockers

4. Histamine 2 Antagonists

5. Intermittent Claudication Agents

6. Non-Sedating Antihistamines

7. NSAIDs

8. Prenatal Vitamins

9. Sedative/Hypnotics

10.Skeletal Muscle Relaxants

11.Triptans
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