Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Alzheimer’s Agents donepezil donepezil 23mg galantamine memantine rivastigmine Namenda XR Namzaric Angiotensin Blockers irbesartan amlodipine-olmesartan irbesartan HCT amlodipine-valsartan losartan amlodipine-valsartan-HCT losartan HCT candesartan valsartan HCT candesartan HCT Edarbi Edarbyclor olmesartan olmesartan HCT telmisartan telmisartan HCT telmisartan-amlodipine Tribenzor valsartan
Antibiotics - amox tr-k clv amox tr-k clv XR Cephalosporins & cefaclor cefaclor tablets Related Antibiotics cefadroxil cefdinir capsules cefdinir suspension (for children through age 10) cefditoren cefprozil suspension (for children through age 10) cefixime suspension
ceftriaxone cefpodoxime cefuroxime cefprozil tablets cephalexin ceftibuten Suprax Capsule and Tablet (Quantity limit of 1 tablet or cefuroxime suspension capsule. Preferred for the treatment of STDs only) cephalexin 750mg capsule
Antibiotics - azithromycin Dificid Macrolides/Ketolides clarithromycin Ketek clarithromycin XL Z-Max erythromycin
Page 1 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Antibiotics - Quinolones ciprofloxacin ciprofloxacin XR levofloxacin moxifloxacin ofloxacin Anticholinergics, Inhaled Atrovent HFA Anoro Ellipta Combivent Respimat Bevespi Spiriva Incruse Ellipta Spiriva Respimat Stiolto Respimat Tudorza Pressair Utibron Neohaler Anticoagulants, enoxaparin Injectable fondaparinux Fragmin heparin
Anticoagulants, Oral warfarin
Anticoagulants, NOAC Eliquis (Prior Approval required; restricted to knee/hip Pradaxa replacement, atrial fibrillation, deep vein thrombosis, Savaysa and pulmonary embolism)
Xarelto (Prior Approval required; restricted to knee/hip replacement, atrial fibrillation, deep vein thrombosis, and pulmonary embolism)
Page 2 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Anticonvulsants carbamazepine Aptiom carbamazepine XR Banzel divalproex Briviact divalproex ER carbamazepine ER capsule Prior authorization is not ethosuximide Celontin required for non-preferred gabapentin Duopa epilepsy agents for those lamotrigine felbamate levetiracetam Fycompa participants with a levetiracetam XR lamotrigine ODT diagnosis of epilepsy or seizure disorder in oxcarbazepine lamotrigine Starter Pack Department records phenobarbital lamotrigine XR phenytoin Lyrica
primidone Onfi topiramate Oxtellar XR valproic acid Peganone zonisamide Potiga Qudexy XR Sabril Spritam tiagabine Trokendi XR Vimpat Antidepressants - citalopram fluoxetine 10mg tablets Selective Serotonin escitalopram fluoxetine 20 mg tablets Reuptake Inhibitors fluoxetine fluoxetine 40 mg Caps (SSRIs) fluvoxamine fluoxetine weekly paroxetine fluvoxamine CR sertraline paroxetine CR Pexeva
Page 3 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Antidepressants - Other bupropion Aplenzin mirtazapine duloxetine mirtazapine soltab Emsam trazodone Fetzima venlafaxine immediate release tablets Forfivo XL venlafaxine ER capsules Irenka nefazodone Oleptro Pristiq trazodone 300mg Trintellix (formerly Brintellix) venlafaxine ER Viibryd Antiemetic/Antivertigo Emend Bi-Fold Pack Akynzeo Agents Emend Tripack Aloxi meclizine Anzemet metoclopramide Cesamet ondansetron Diclegis ondansetron ODT dronabinol prochlorperazine granisetron promethazine metoclopramide ODT Transderm Scop Sancuso Varubi Zuplenz
Page 4 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Antifungals - Topical clotrimazole ciclopirox 8% solution econazole ciclopirox cream, gel, shampoo, solution ketoconazole ciclopirox 8% kit nystatin Ertaczo Exelderm Luzu nystatin/triamcinolone Jublia ketoconazole 2% foam Mentax Naftin Oxistat Vusion
Antiparkinson Agents amantadine bromocriptine 5mg benztropine carbidopa/levodopa/entacapone bromocriptine 2.5mg carbidopa/levodopa ODT carbidopa/levodopa Neupro entacapone pramipexole ER pramipexole rasagiline ropinirole ropinirole XL selegiline Rytary trihexyphenidyl tolcapone Zelapar
Page 5 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Antiretrovirals abacavir Complera abacavir-lamivudine-zidovudine Evotaz Aptivus Fuzeon Atripla Odefsey Crixivan Prezcobix
Descovy Selzentry didanosine Stribild Edurant Triumeq Emtriva Tybost Epzicom Vitekta Genvoya Intelence Invirase Isentress Kaletra lamivudine lamivudine-zidovudine Lexiva nevirapine Norvir Prezista Rescriptor Reyataz stavudine Sustiva Tivicay Truvada Viracept Viread zidovudine
Page 6 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Antivirals acyclovir famciclovir amantadine rimantadine Tamiflu, Relenza and ganciclovir Rapivab rimantadine are preferred Relenza Sitavig Tamiflu Valcyte Solution drugs during flu season valacyclovir only. Please refer to IDPH valganciclovir website for Flu Activity Reports Atypical Antipsychotics Abilify Maintena ER (Prior Approval Required) aripiprazole Aristada (Prior Approval Required) clozapine 200mg All medications require clozapine Fanapt prior approval for Invega Sustenna (Prior Approval Required) Fazaclo Latuda Invega Trinza children under 8 years olanzapine paliperidone ER AND long-term care quetiapine IR Rexulti residents. risperidone + Risperdal Consta Specialized formulations ziprasidone Saphris also require prior Seroquel XR approval for all ages. Vraylar Prior Approval Forms + risperidone is the 1st line agent indicated for children Zyprexa Relprevv ages 5-7 years
Beta-Adrenergic Agents albuterol inhalation solution albuterol ER ipratropium/albuterol sulfate solution albuterol tablets Foradil Arcapta ProAir HFA Brovana Proventil HFA levalbuterol inhalation solution Serevent Diskus metaproterenol syrup and tablets terbutaline Perforomist ProAir Respiclick Striverdi Ventolin HFA Xopenex HFA
Page 7 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Beta-Adrenergic acebutolol Bystolic Receptor Blocking atenolol Coreg CR Agents betaxolol Innopran XL bisoprolol Levatol carvedilol propranolol LA labetalol sotalol AF metoprolol Sotylize metoprolol XL nadolol pindolol propranolol sotalol timolol Biologic Response Cimzia Actemra Modifiers Enbrel Entyvio Prior approval required Humira Inflectra for all Biologic Response Kineret Orencia Modifiers. Otezla Remicade Simponi Stelara Xeljanz Blood Glucose Monitors One Touch Ultra (Lifescan) Freestyle Lite (Abbott) and Test Strips Glucocard Shine (Arkray) Breeze 2 (Bayer) NDCs for Institutional or Contour Next (Bayer) Fora V10 (Fora Care) DME use are not billable Approval of non-preferred test strips for use with insulin pumps One Touch Verio (Lifescan) through pharmacy POS is limited to clients who are less than 14 years of age or who Prodigy Autocode (Prodigy Diabetes) system. Click here for a have a condition that makes them unable to enter blood Accu-Chek Aviva (Roche) list of preferred NDCs. glucose levels into the pump Accu-Chek Nano Smartview (Roche) True Metrix (Trividia, formerly Nipro Diagnostics)
Page 8 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Bone Resorption alendronate Binosto Suppression & Related calcitonin etidronate Agents Forteo Fortical Fosamax Plus D ibandronate Prolia raloxifine risedronate Xgeva zoledronic acid solution BPH Agents alfuzosin dutasteride doxazosin dutasteride/tamsulosin finasteride Rapaflo tamsulosin terazosin Diabetes acarbose Fortamet ER Avandia glipizide/metformin chlorpropamide Glumetza ER glimepiride pioglitazone/glimepiride glipizide pioglitazone/metformin glipizide XL repaglinide glyburide repaglinide/metformin glyburide/metformin Riomet metformin (IR and ER) miglitol nateglinide pioglitazone tolazamide tolbutamide
Page 9 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred DPP-4 Inhibitors Januvia alogliptin Tradjenta alogliptin/metformin alogliptin/pioglitazone Janumet Janumet XR Jentadueto Kombiglyze XR Onglyza
Erythropoietins Aranesp Epogen Procrit Prior Approval required for all Erythropoietins
Growth Hormones Omnitrope Genotropin Humatrope Prior Approval required Norditropin for all Growth Hormones. Nutropin AQ Saizen
Serostim Zomacton
Page 10 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Hepatitis B entecavir adefovir dipivoxil Epivir HBV Tyzeka Vemlidy
Hepatitis C ribavirin 200mg Daklinza Epclusa (preferred for genotypes 2 and 3) Harvoni Prior Approval required Sovaldi Infergen for all Hepatitis C Agents Zepatier Olysio Pegasys Technivie Viekira Pak Viekira XR Hormone Replacement Activella Angeliq Therapy Combipatch Climara Pro estradiol Divigel estradiol transdermal patches Elestrin estropipate Enjuvia Menest Evamist Premarin Femhrt Premphase Menostar Prempro Prefest
Page 11 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Inhaled Steroids Asmanex Advair Dulera Advair HFA Flovent Aerospan Qvar Alvesco Symbicort Arnuity Ellipta Breo Ellipta budesonide respules (Prior approval NOT required for participants age 7 and under.) Pulmicort Insulins Most Humalog Products Afrezza All Humulin Products All Novolin Products Lantus (vial only) All Novolog Products Apidra Basaglar Humalog 200U Kwikpen Levemir Relion Soliqua Toujeo Tresiba Xultophy Leukotriene Antagonists montelukast Zyflo zafirlukast Zyflo CR
Lice Treatments permethrin 1% OTC lindane pyrethrin 0.33% OTC malathion Participants age 21 and Sklice Ulesfia over must purchase OTC spinosad products out-of-pocket
Page 12 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Lipotropics – Statins & atorvastatin Altoprev Combinations lovastatin fluvastatin pravastatin fluvastatin XL simvastatin Livalo rosuvastatin simvastatin 80mg Vytorin
Lipotropics – Other cholestyramine Antara fenofibrate colestipol gemfibrozil fenofibrate, nanocrystallized Zetia fenofibric acid Fenoglide Lipofen Niacin ER omega-3 ethyl esters Triglide Vascepa Welchol LMWH’s and Related*
*See Anticoagulants Multiple Sclerosis Agents Avonex Ampyra ER Copaxone 20mg Aubagio Rebif Betaseron Copaxone 40mg Extavia Gilenya Glatopa Lemtrada Plegridy Tecfidera Tysabri Zinbryta
Page 13 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Narcotics codeine/acetaminophen Abstral codeine sulfate Belbuca Embeda ER butalbital-caff-apap-codeine hydrocodone/acetaminophen butorphanol nasal spray hydrocodone/ibuprofen 7.5-200 Butrans hydromorphone fentanyl citrate lozenge meperidine fentanyl patches Click here for more information morphine sulfate IR Fentora morphine sulfate ER tablets hydrocodone/ibuprofen oxycodone IR hydromorphone ER oxycodone/acetaminophen Hysingla ER tramadol Lazanda Levorphanol methadone morphine sulfate ER capsules ***Narcotics with greater than 325mg APAP are non-preferred. Nucynta The FDA no longer permits manufacturers to produce Nucynta ER combinations of narcotics with > 325mg APAP per dose due Opana ER to safety risks with APAP oxycodone ER oxycodone/acetaminophen 2.5-325 oxycodone/ibuprofen oxymorphone IR pentazocine/naloxone Primlev Subsys tramadol ER tramadol/acetaminophen Xartemis XR Xtampza ER Zohydro ER
Page 14 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Nasal Steroids flunisolide Beconase AQ fluticasone Rx budesonide Flonase OTC mometasone Omnaris Qnasal triamcinolone AQ Veramyst Zetonna Nasal Preparations - First-Line azelastine 0.15% Other azelastine (For children through age 18) Dymista olopatadine (For children through age 18) ipratropium spray Non Sedating Antihistamines Second-Line azelastine (For participants over age 18) olopatadine (For participants over age 18) Ophthalmics – Antihistamines and azelastine Bepreve Allergic Conjunctivitis Antihistamine/ Mast Cell Stabilizer Pazeo Emadine epinastine Lastacaft olopatadine Pataday
Anti-Inflammatory Agents ketorolac Lotemax Ophthalmic Gel and Ointment Alrex Lotemax Mast Cell Stabilizers cromolyn sodium Alocril Alomide Ophthalmics – bacitracin Azasite Antibiotics ciprofloxacin Besivance erythromycin gatifloxacin gentamicin Moxeza levofloxacin Vigamox ofloxacin tobramycin
Page 15 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Ophthalmics – generics Acuvail Anti-Inflammatories FML Forte bromfenac FML S.O.P. Durezol ketorolac LS Ilevro Lotemax Lotemax Ophthalmic Gel and Ointment Maxidex Nevanac Pred Mild Prolensa Vexol
Ophthalmics – Prostaglandins latanoprost Lumigan Glaucoma Agents Travatan Z Zioptan Carbonic Anhydrase dorzolamide Azopt Inhibitors dorzolamide-timolol Cosopt PF
Alpha-2 Adrenoreceptor Alphagan P Combigan Agonists brimonidine Simbrinza
Direct-Acting Miotics pilocarpine
Beta-Adrenergic betaxolol Betimol Blockers carteolol Betoptic S timolol maleate Istalol
Ophthalmics – neomycin/polymyx B /dexamethasone Pred-G Steroid/Antibiotic neomycin/bacitracin Zn/polymyxin B/HC Tobradex Ointment Combinations neomycin/polymyxin B /HC Tobradex ST tobramycin/dexamethasone Zylet Otic Anti-Infectives acetic acid acetic acid/hydrocortisone Cetraxal Cipro HC Ciprodex Coly-Mycin S neomycin-polymyxin-HC Cortisporin-TC ofloxacin Otovel
Page 16 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Pancreatic Enzymes Creon DR Pancreaze DR Pancrelipase Pertzye Zenpep DR Phosphate Binders calcium acetate Auryxia Fosrenol Magnebind Renagel Renvela Ultresa Velphoro Platelet Aggregation Aggrenox Brilinta (will be approved in participants with Acute Inhibitors clopidogrel Coronary Syndrome) dipyridamole Effient (will be approved in participants with Acute Coronary Syndrome) ticlopidine Zontivity Progesterone/ Crinone Gel – Requires Prior Approval (will not be approved for Hydroxyprogesterone use to promote fertility) Agents hydroxyprogesterone caproate Makena – Requires Prior Approval (see criteria and forms) progesterone capsules progesterone oil
Page 17 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Proton Pump Inhibitors omeprazole RX (for children through age 20) Aciphex Sprinkle pantoprazole (for children through age 20) Dexilant Participants age 21 and esomeprazole strontium over must purchase OTC lansoprazole lansoprazole Solutabs (PA not required for children through products out-of-pocket age 10) Nexium omeprazole OTC omeprazole 10mg omeprazole-bicarbonate rabeprazole Pulmonary Arterial Adcirca Adempas Hypertension Agents epoprostenol Opsumit Letairis Orenitram ER Prior approval required sildenafil Remodulin Tracleer Tyvaso for all PAH Drugs Uptravi Veletri Ventavis Retinoids - Topical First Line adapalene 0.3% generic tretinoin products (PA not required for ages 10 to Tazorac 20yrs) Fabior tretinoin 0.05% gel Second Line Veltin adapalene 0.1% Ziana Retin-A Micro
Page 18 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Stimulants/ADHD Agents Short Acting: Adzenys XR-ODT amphetamine salts Aptensio XR All medications require methylphenidate armodafinil prior approval for dexmethylphenidate clonidine ER Concerta children under 6 yrs. Long Acting: Daytrana Prior Approval Forms dextroamphetamine Adderall XR Brand Only dextroamp-amphet ER Cap Focalin XR Brand Only Dyanavel XR methylphenidate ER – 10mg, 20mg Evekeo methylphenidate SR – 20mg Focalin XR generic Metadate CD Brand Only guanfacine ER Metadate ER – 20mg Metadate CD generic methamphetamine methylphenidate chewable and solution modafinil Quillivant XR Ritalin LA Strattera All Stimulants/ADHD Agents require prior approval for Vyvanse participants 19 years of age and older. Zenzedi Ulcerative Colitis Agents balsalazide Apriso Canasa Asacol HD mesalamine Delzicol Pentasa Dipentum sulfasalazine Giazo Lialda Uceris
Page 19 of 20 Preferred Drug List Illinois Medicaid April 1, 2017 Changes are highlighted in blue and marked with an asterisk (*) ***For drugs not found on this list, go to the drug search engine at: www.ilrxportal.illinois.gov The Illinois Provider Portal is available to registered prescribers and pharmacists
Category Preferred Non-Preferred Urinary Anti-Incontinence oxybutynin darifenacin ER Agents oxybutynin XL flavoxate Gelnique Myrbetriq Oxytrol Patch Sanctura XR tolterodine tolterodine ER Toviaz trospium Vesicare
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