Illinois Medicaid Preferred Drug List Effective January 1, 2020 (Updated January 27, 2020) ▪ The Preferred Drug List (PDL) has products listed in groups by drug class, drug name, dosage form, and PDL status ▪ Multi-source drugs are listed by both brand and generic names when applicable ▪ ADHD Agents: Prior authorization required for participants under 6 years of age and participants 19 years of age and older ▪ Spiriva AER 1.25mcg: Prior authorization NOT required for participants ages 6-17 years ▪ Budesonide: Prior authorization NOT required for participants age 7 years and under ▪ Anticonvulsants: Prior authorization NOT required for non-preferred epilepsy agents for those participants with a diagnosis of epilepsy or seizure disorder in Department records ▪ Antipsychotics: Prior authorization required for participants under 8 years of age and long-term care residents ▪ For drugs not found on this list, go to the drug search engine at: www.ilpriorauth.com Page 1 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ADHD / ANTI-NARCOLEPSY AGENTS : AMPHETAMINES ADZENYS ER SUER NON_PREFERRED AMPHETAMINE ER SUER NON_PREFERRED DYANAVEL XR SUER NON_PREFERRED ADZENYS XR-ODT TBED NON_PREFERRED AMPHETAMINE SULFATE TABS NON_PREFERRED EVEKEO TABS NON_PREFERRED EVEKEO ODT TBDP NON_PREFERRED DEXEDRINE CP24 NON_PREFERRED DEXTROAMPHETAMINE SULFATE ER CP24 NON_PREFERRED DEXTROAMPHETAMINE SULFATE SOLN NON_PREFERRED PROCENTRA SOLN NON_PREFERRED DEXTROAMPHETAMINE SULFATE TABS NON_PREFERRED ZENZEDI TABS NON_PREFERRED VYVANSE CAPS PREFERRED VYVANSE CHEW PREFERRED DESOXYN TABS NON_PREFERRED METHAMPHETAMINE HCL TABS NON_PREFERRED ADDERALL XR CP24 NON_PREFERRED AMPHETAMINE/DEXTROAMPHETAMINE CP24 PREFERRED MYDAYIS CP24 NON_PREFERRED ADDERALL TABS NON_PREFERRED AMPHETAMINE/DEXTROAMPHETAMINE TABS PREFERRED ADHD / ANTI-NARCOLEPSY AGENTS : MISC CLONIDINE HCL ER TB12 PREFERRED CLONIDINE HYDROCHLORIDE TB12 PREFERRED CLONIDINE HYDROCHLORIDE ER TB12 PREFERRED GUANFACINE ER TB24 PREFERRED GUANFACINE HYDROCHLORIDE TB24 PREFERRED INTUNIV TB24 NON_PREFERRED ATOMOXETINE CAPS NON_PREFERRED ATOMOXETINE HYDROCHLORIDE CAPS NON_PREFERRED STRATTERA CAPS NON_PREFERRED SUNOSI TABS NON_PREFERRED ADHD / ANTI-NARCOLEPSY AGENTS : STIMULANTS ARMODAFINIL TABS NON_PREFERRED NUVIGIL TABS NON_PREFERRED DEXMETHYLPHENIDATE HCL ER CP24 NON_PREFERRED DEXMETHYLPHENIDATE HYDROCHLORIDE CP24 NON_PREFERRED DEXMETHYLPHENIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED FOCALIN XR CP24 PREFERRED DEXMETHYLPHENIDATE HCL TABS PREFERRED DEXMETHYLPHENIDATE HYDROCHLORIDE TABS PREFERRED FOCALIN TABS NON_PREFERRED DAYTRANA PTCH NON_PREFERRED COTEMPLA XR-ODT TBED NON_PREFERRED QUILLICHEW ER CHER NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE CHEW NON_PREFERRED ADHANSIA XR CP24 NON_PREFERRED APTENSIO XR CP24 NON_PREFERRED Page 2 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM JORNAY PM CP24 NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE ER CP24 NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE ER (LA) CP24 NON_PREFERRED RITALIN LA CP24 NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE CD CPCR NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE ER CPCR NON_PREFERRED METHYLIN SOLN NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE SOLN NON_PREFERRED QUILLIVANT XR SUSR NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE TABS PREFERRED RITALIN TABS NON_PREFERRED METHYLPHENIDATE HYDROCHLORIDE ER TB24 NON_PREFERRED METHYLPHENID TAB 10MG ER TBCR PREFERRED METHYLPHENID TAB 20MG ER TBCR PREFERRED CONCERTA TBCR PREFERRED METHYLPHENID TAB 18MG ER TBCR NON_PREFERRED METHYLPHENID TAB 27MG ER TBCR NON_PREFERRED METHYLPHENID TAB 36MG ER TBCR NON_PREFERRED METHYLPHENID TAB 54MG ER TBCR NON_PREFERRED METHYLPHENID TAB 72MG ER TBCR NON_PREFERRED METHYLPHENIDATE HYDROCHLO TBCR NON_PREFERRED RELEXXII TBCR NON_PREFERRED MODAFINIL TABS NON_PREFERRED PROVIGIL TABS NON_PREFERRED ANALGESICS - ANTI-INFLAMMATORY : MISC RIDAURA CAPS NON_PREFERRED OTREXUP SOAJ NON_PREFERRED RASUVO SOAJ NON_PREFERRED ARAVA TABS NON_PREFERRED LEFLUNOMIDE TABS PREFERRED ANALGESICS - ANTI-INFLAMMATORY : NONSTEROIDAL ANTI- INFLAMMATORY AGENTS (NSAIDs) ZORVOLEX CAPS NON_PREFERRED ZIPSOR CAPS NON_PREFERRED DICLOFENAC POTASSIUM TABS PREFERRED DICLOFENAC SODIUM ER TB24 PREFERRED DICLOFENAC SODIUM DR TBEC PREFERRED ETODOLAC CAPS PREFERRED ETODOLAC TABS PREFERRED ETODOLAC ER TB24 PREFERRED FENOPROFEN CALCIUM CAPS NON_PREFERRED NALFON CAPS NON_PREFERRED FENOPROFEN CALCIUM TABS NON_PREFERRED NALFON TABS NON_PREFERRED FLURBIPROFEN TABS PREFERRED IBUPROFEN SUSP NON_PREFERRED IBU TABS PREFERRED IBUPROFEN TABS PREFERRED INDOMETHACIN CAPS PREFERRED Page 3 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM TIVORBEX CAPS NON_PREFERRED INDOMETHACIN ER CPCR PREFERRED INDOCIN SUPP NON_PREFERRED INDOCIN SUSP NON_PREFERRED KETOPROFEN ER CP24 NON_PREFERRED SPRIX SOLN NON_PREFERRED KETOROLAC TROMETHAMINE TABS PREFERRED MECLOFENAMATE SODIUM CAPS NON_PREFERRED MEFENAMIC ACID CAPS NON_PREFERRED VIVLODEX CAPS NON_PREFERRED MELOXICAM TABS PREFERRED MOBIC TABS NON_PREFERRED QMIIZ ODT TBDP NON_PREFERRED NABUMETONE TABS PREFERRED RELAFEN DS TABS NON_PREFERRED NAPROXEN SUSP PREFERRED NAPROXEN TABS PREFERRED EC-NAPROXEN TBEC NON_PREFERRED NAPROXEN DR TBEC PREFERRED NAPROXEN SODIUM TABS PREFERRED NAPRELAN TB24 NON_PREFERRED NAPROXEN SODIUM TB24 NON_PREFERRED NAPROXEN SODIUM CR TB24 NON_PREFERRED NAPROXEN SODIUM ER TB24 NON_PREFERRED DAYPRO TABS NON_PREFERRED OXAPROZIN TABS NON_PREFERRED FELDENE CAPS NON_PREFERRED PIROXICAM CAPS NON_PREFERRED SULINDAC TABS PREFERRED TOLMETIN SODIUM CAPS NON_PREFERRED TOLMETIN SODIUM TABS NON_PREFERRED CELEBREX CAPS NON_PREFERRED CELECOXIB CAPS PREFERRED INFLAMMACIN THPK NON_PREFERRED ARTHROTEC 50 TBEC NON_PREFERRED ARTHROTEC 75 TBEC NON_PREFERRED DICLOFENAC SODIUM/MISOPROSTOL TBEC NON_PREFERRED DUEXIS TABS NON_PREFERRED VIMOVO TBEC NON_PREFERRED ANALGESICS - NONNARCOTIC DIFLUNISAL TABS PREFERRED SALSALATE TABS PREFERRED BUTALBITAL/ACETAMINOPHEN CAPS NON_PREFERRED ALLZITAL TABS NON_PREFERRED BUPAP TABS NON_PREFERRED BUTALBITAL/ACETAMINOPHEN TABS PREFERRED BUTALBITAL/ACETAMINOPHEN/ CAPS PREFERRED BUTALBITAL/ACETAMINOPHEN/CAFFEINE CAPS PREFERRED Page 4 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM ESGIC CAPS PREFERRED FIORICET CAPS NON_PREFERRED ZEBUTAL CAPS PREFERRED VANATOL LQ SOLN NON_PREFERRED VANATOL S SOLN NON_PREFERRED BUTALBITAL/ACETAMINOPHEN/CAFFEINE TABS PREFERRED ESGIC TABS NON_PREFERRED BUTALBITAL/ASPIRIN/CAFFEINE CAPS PREFERRED FIORINAL CAPS NON_PREFERRED BUTALBITAL/ASPIRIN/CAFFEINE TABS PREFERRED ANALGESICS : OPIOID CODEINE SULFATE TABS PREFERRED DURAGESIC PT72 NON_PREFERRED FENTANYL PT72 NON_PREFERRED ACTIQ LPOP NON_PREFERRED FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP NON_PREFERRED LAZANDA SOLN NON_PREFERRED ABSTRAL SUBL NON_PREFERRED FENTANYL CITRATE TABS NON_PREFERRED FENTORA TABS NON_PREFERRED HYDROCODONE BITARTRATE ER C12A NON_PREFERRED ZOHYDRO ER C12A NON_PREFERRED HYSINGLA ER T24A NON_PREFERRED DILAUDID LIQD NON_PREFERRED HYDROMORPHONE HCL LIQD PREFERRED HYDROMORPHONE HCL SUPP PREFERRED HYDROMORPHONE HCL ER T24A NON_PREFERRED HYDROMORPHONE HYDROCHLORIDE ER T24A NON_PREFERRED DILAUDID TABS NON_PREFERRED HYDROMORPHONE HCL TABS PREFERRED LEVORPHANOL TARTRATE TABS NON_PREFERRED MEPERIDINE HCL SOLN NON_PREFERRED MEPERIDINE HCL TABS NON_PREFERRED METHADONE HCL CONC NON_PREFERRED METHADONE HCL INTENSOL CONC NON_PREFERRED METHADOSE CONC NON_PREFERRED METHADOSE SUGAR-FREE CONC NON_PREFERRED METHADONE HCL SOLN NON_PREFERRED DOLOPHINE TABS NON_PREFERRED METHADONE HCL TABS NON_PREFERRED METHADONE HYDROCHLORIDE TABS NON_PREFERRED METHADONE HCL TBSO NON_PREFERRED METHADOSE TBSO NON_PREFERRED KADIAN CP24 NON_PREFERRED MORPHINE SULFATE ER CP24 NON_PREFERRED MORPHINE SULFATE SOLN PREFERRED MORPHINE SULFATE SUPP PREFERRED MORPHABOND ER T12A NON_PREFERRED Page 5 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM MORPHINE SULFATE TABS PREFERRED MORPHINE SULFATE ER TBCR PREFERRED_WITH_PA MS CONTIN TBCR NON_PREFERRED ARYMO ER TBEA NON_PREFERRED MORPHINE SULFATE ER CP24 NON_PREFERRED XTAMPZA ER C12A NON_PREFERRED OXYCODONE HCL CAPS PREFERRED OXYCODONE HYDROCHLORIDE CAPS PREFERRED OXYCODONE HCL CONC PREFERRED OXYCODONE HYDROCHLORIDE CONC PREFERRED OXYCODONE HYDROCHLORIDE SOLN PREFERRED OXYCODONE HCL ER T12A NON_PREFERRED OXYCODONE HYDROCHLORIDE ER T12A NON_PREFERRED OXYCONTIN T12A NON_PREFERRED OXAYDO TABA NON_PREFERRED OXYCODONE HCL TABS PREFERRED OXYCODONE HYDROCHLORIDE TABS PREFERRED ROXICODONE TABS NON_PREFERRED OPANA TABS NON_PREFERRED OXYMORPHONE HYDROCHLORIDE TABS NON_PREFERRED OXYMORPHONE HYDROCHLORIDE ER TB12 NON_PREFERRED OXYMORPHONE HYDROCHLORIDEER TB12 NON_PREFERRED NUCYNTA TABS NON_PREFERRED NUCYNTA ER TB12 NON_PREFERRED CONZIP CP24 NON_PREFERRED TRAMADOL HCL ER CP24 NON_PREFERRED TRAMADOL HCL TABS PREFERRED ULTRAM TABS NON_PREFERRED TRAMADOL HCL ER TB24 NON_PREFERRED BUPRENORPHINE PTWK NON_PREFERRED BUTRANS PTWK NON_PREFERRED BELBUCA FILM NON_PREFERRED BUTORPHANOL TARTRATE SOLN NON_PREFERRED PENTAZOCINE/NALOXONE HCL TABS NON_PREFERRED ANALGESICS : OPIOID COMBINATIONS APADAZ TABS NON_PREFERRED BENZHYDROCODONE/ACETAMINOPHEN TABS NON_PREFERRED ENDOCET TABS PREFERRED NALOCET TABS NON_PREFERRED OXYCODONE/ACETAMINOPHEN TABS PREFERRED PERCOCET TABS NON_PREFERRED PRIMLEV TABS NON_PREFERRED OXYCODONE/ASPIRIN TABS NON_PREFERRED OXYCODONE/IBUPROFEN TABS NON_PREFERRED ACETAMINOPHEN/CODEINE SOLN PREFERRED ACETAMINOPHEN/CODEINE TABS PREFERRED ACETAMINOPHEN/CODEINE PHOSPHATE TABS PREFERRED TYLENOL/CODEINE #3 TABS NON_PREFERRED Page 6 of 92 DOSAGE DRUG CLASS DRUG NAME PDL STATS FORM TYLENOL/CODEINE #4 TABS NON_PREFERRED BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE CAPS NON_PREFERRED ASCOMP/CODEINE CAPS PREFERRED