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Illinois Medicaid Preferred Drug ListEffective July 1, 2021 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 andolder 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 adiagnosis of epilepsy or seizure disorder in Department records Antipsychotics: Prior authorization required for participants under 8 years of age and long-term care residents Proton Pump Inhibitors, oral: Prior authorization required for participants age 21 and over. Adults with noncomplicated GERD have to pay out of pocket for a PPI or use a prescribed H2 blocker. PA is needed for coverage ofindications requiring longer term use. Lansoprazole ODT: Prior authorization NOT required for participants age 10 years and under. For drugs not found on this list, go to the drug search engine at: www.ilpriorauth.com5/21/2021 8:21:47 PMPage 1 of 120

Drug ClassADHD / ANTI-NARCOLEPSY AGENTS :AMPHETAMINESDrug Name5/21/2021 8:21:47 PMPDL StatusSUERNON PREFERREDAMPHETAMINE ERSUERNON PREFERREDDYANAVEL XRSUERNON PREFERREDADZENYS XR-ODTTBEDNON PREFERREDAMPHETAMINE SULFATETABSNON PREFERREDEVEKEOTABSNON PREFERREDEVEKEO ODTTBDPNON PREFERREDDEXEDRINECP24NON PREFERREDDEXTROAMPHETAMINE SULFATE ERCP24NON PREFERREDDEXTROAMPHETAMINE SULFATESOLNNON PREFERREDPROCENTRASOLNNON PREFERREDDEXEDRINETABSNON PREFERREDDEXTROAMPHETAMINE SULFATETABSNON PREFERREDZENZEDITABSNON ESOXYNTABSNON PREFERREDMETHAMPHETAMINE HCLTABSNON PREFERREDADDERALL XRCP24NON P24NON PREFERREDADDERALLTABSNON DTB12PREFERREDCLONIDINE HYDROCHLORIDETB12PREFERREDCLONIDINE HYDROCHLORIDE ERTB12PREFERREDGUANFACINE ERTB24PREFERREDGUANFACINE HYDROCHLORIDETB24PREFERREDINTUNIVTB24NON PREFERREDATOMOXETINECAPSNON PREFERREDATOMOXETINE HYDROCHLORIDECAPSNON PREFERREDSTRATTERACAPSNON PREFERREDQELBREECP24NON PREFERREDSUNOSITABSNON PREFERREDWAKIXTABSNON PREFERREDARMODAFINILTABSNON PREFERREDNUVIGILTABSNON PREFERREDDEXMETHYLPHENIDATE HCL ERCP24NON PREFERREDADHD / ANTI-NARCOLEPSY AGENTS : MISC CLONIDINE HCL ERADHD / ANTI-NARCOLEPSY AGENTS :STIMULANTSDosage FormADZENYS ERPREFERREDPage 2 of 120

STIMULANTSDrug ClassDrug NameDosage FormPDL StatusDEXMETHYLPHENIDATE HYDROCHLORIDECP24NON PREFERREDDEXMETHYLPHENIDATE HYDROCHLORIDE ERCP24NON PREFERREDFOCALIN XRCP24PREFERREDDEXMETHYLPHENIDATE HCLTABSPREFERREDDEXMETHYLPHENIDATE HYDROCHLORIDETABSPREFERREDFOCALINTABSNON PREFERREDDAYTRANAPTCHNON PREFERREDCOTEMPLA XR-ODTTBEDNON PREFERREDQUILLICHEW ERCHERNON PREFERREDMETHYLPHENIDATE HYDROCHLORIDECHEWNON PREFERREDADHANSIA XRCP24NON PREFERREDAPTENSIO XRCP24NON PREFERREDJORNAY PMCP24NON PREFERREDMETHYLPHENIDATE HYDROCHLORIDE ERCP24NON PREFERREDMETHYLPHENIDATE HYDROCHLORIDE ER (LA)CP24NON PREFERREDRITALIN LACP24NON PREFERREDMETHYLPHENIDATE HYDROCHLORIDE CDCPCRNON PREFERREDMETHYLPHENIDATE HYDROCHLORIDE ERCPCRNON PREFERREDMETHYLINSOLNNON PREFERREDMETHYLPHENIDATE HYDROCHLORIDESOLNNON PREFERREDQUILLIVANT XRSRERNON PREFERREDMETHYLPHENIDATE HYDROCHLORIDETABSRITALINTABSNON PREFERREDMETHYLPHENIDATE HYDROCHLORIDE ERTB24NON PREFERREDMETHYLPHENIDATE TAB 10MG ERTBCRPREFERREDMETHYLPHENIDATE TAB 20MG E TAB 18MG ERTBCRNON PREFERREDMETHYLPHENIDATE TAB 27MG ERTBCRNON PREFERREDMETHYLPHENIDATE TAB 36MG ERTBCRNON PREFERREDMETHYLPHENIDATE TAB 54MG ERTBCRNON PREFERREDMETHYLPHENIDATE TAB 72MG ERTBCRNON PREFERREDMETHYLPHENIDATE HYDROCHLORIDE ERTBCRNON PREFERREDRELEXXIITBCRNON PREFERREDMODAFINILTABSNON PREFERREDPROVIGILTABSNON PREFERREDANALGESICS - ANTI-INFLAMMATORY : MISC RIDAURACAPSNON PREFERREDSOAJNON PREFERREDOTREXUP5/21/2021 8:21:47 PMPREFERREDPage 3 of 120

ANALGESICS - ANTI-INFLAMMATORY : MISCDrug ClassANALGESICS - ANTI-INFLAMMATORY :NONSTEROIDAL ANTI-INFLAMMATORYAGENTS (NSAIDs)Drug NamePDL StatusSOAJNON PREFERREDREDITREXSOSYNON PREFERREDARAVATABSNON PREFERREDLEFLUNOMIDETABSZORVOLEXCAPSNON PREFERREDZIPSORCAPSNON PREFERREDDICLOFENAC POTASSIUMTABSPREFERREDDICLOFENAC SODIUM ERTB24PREFERREDDICLOFENAC SODIUM EFERREDETODOLAC ERTB24PREFERREDFENOPROFEN CALCIUMCAPSNON PREFERREDNALFONCAPSNON PREFERREDFENOPROFEN CALCIUMTABSNON PREFERREDNALFONTABSNON PREFERREDFLURBIPROFENTABSIBUPAK5/21/2021 8:21:47 PMDosage FormRASUVOPREFERREDPREFERREDKITNON PREFERREDIBUPROFENSUSPNON OMETHACINCAPSPREFERREDTIVORBEXCAPSINDOMETHACIN ERCPCRINDOCINSUPPINDOCINSUSPKETOPROFENCAPSNON PREFERREDPREFERREDNON PREFERREDNON PREFERREDPREFERREDKETOPROFEN ERCP24NON PREFERREDKETOROLAC TROMETHAMINESOLNNON PREFERREDSPRIXSOLNNON PREFERREDKETOROLAC TROMETHAMINETABSMECLOFENAMATE SODIUMCAPSPREFERREDNON PREFERREDMEFENAMIC ACIDCAPSNON PREFERREDMELOXICAMCAPSNON PREFERREDVIVLODEXCAPSNON PREFERREDMELOXICAMTABSPREFERREDMOBICTABSNON PREFERREDQMIIZ ODTTBDPNON PREFERREDPage 4 of 120

Drug ClassANALGESICS - NONNARCOTIC5/21/2021 8:21:47 PMDrug NameDosage FormPDL StatusNABUMETONETABSPREFERREDRELAFEN DSTABSNON PREFERREDNAPROSYNSUSPNON OXEN SODIUMTABSPREFERREDNAPRELANTB24NON PREFERREDNAPROXEN SODIUMTB24NON PREFERREDNAPROXEN SODIUM CRTB24NON PREFERREDNAPROXEN SODIUM ERTB24NON PREFERREDDAYPROTABSNON PREFERREDOXAPROZINTABSNON PREFERREDFELDENECAPSNON PREFERREDPIROXICAMCAPSNON PREFERREDSULINDACTABSTOLMETIN SODIUMCAPSNON PREFERREDTOLMETIN SODIUMTABSNON PREFERREDCELEBREXCAPSCELECOXIBCAPSARTHROTEC 50TBECNON PREFERREDARTHROTEC 75TBECNON PREFERREDDICLOFENAC SODIUM/MISOPROSTOLTBECNON PREFERREDDUEXISTABSNON PREFERREDNAPROXEN/ESOMEPRAZOLE MAGNESIUMTBECNON PREFERREDVIMOVOTBECNON BUTALCAPSPREFERREDNON PREFERREDPREFERREDNON PREFERREDNON PREFERREDNON PREFERREDPREFERREDPage 5 of 120

Drug ClassANALGESICS : OPIOID5/21/2021 8:21:47 PMDrug NameDosage FormPDL StatusVANATOL LQSOLNNON PREFERREDVANATOL SSOLNNON PREFERREDVTOL LQSOLNNON AFFEINECAPSFIORINALCAPSCODEINE SULFATETABSDURAGESICPT72NON PREFERREDFENTANYLPT72NON PREFERREDACTIQLPOPNON PREFERREDFENTANYL CITRATE ORAL TRANSMUCOSALLPOPNON PREFERREDABSTRALSUBLNON PREFERREDFENTANYL CITRATETABSNON PREFERREDFENTORATABSNON PREFERREDHYDROCODONE BITARTRATE ERCP12NON PREFERREDZOHYDRO ERCP12NON PREFERREDHYDROCODONE BITARTRATE ERT24ANON PREFERREDHYSINGLA ERT24ANON PREFERREDDILAUDIDLIQDNON PREFERREDHYDROMORPHONE HCLLIQDPREFERREDHYDROMORPHONE HCLSUPPPREFERREDDILAUDIDTABSHYDROMORPHONE HCLTABSPREFERREDHYDROMORPHONE HYDROCHLORIDETABSPREFERREDHYDROMORPHONE HCL ERTB24NON PREFERREDHYDROMORPHONE HYDROCHLORIDE ERTB24NON PREFERREDLEVORPHANOL TARTRATETABSNON PREFERREDMEPERIDINE HCLSOLNNON PREFERREDMEPERIDINE HCLTABSNON PREFERREDMETHADONE HCLCONCNON PREFERREDMETHADONE HCL INTENSOLCONCNON PREFERREDMETHADONE HYDROCHLORIDECONCNON PREFERREDMETHADOSECONCNON PREFERREDMETHADOSE SUGAR-FREECONCNON PREFERREDMETHADONE HCLSOLNNON PREFERREDMETHADONE HYDROCHLORIDESOLNNON PREFERREDNON PREFERREDPREFERREDNON PREFERREDPREFERREDNON PREFERREDPage 6 of 120

Drug Class5/21/2021 8:21:47 PMDrug NameDosage FormPDL StatusMETHADONE HCLTABSNON PREFERREDMETHADONE HYDROCHLORIDETABSNON PREFERREDMETHADONE HCLTBSONON PREFERREDMETHADOSETBSONON PREFERREDKADIANCP24NON PREFERREDMORPHINE SULFATE ERCP24NON PREFERREDMORPHINE SULFATESOLNPREFERREDMORPHINE SULFATESUPPPREFERREDMORPHABOND ERT12ANON PREFERREDMORPHINE SULFATETABSMORPHINE SULFATE ERTBCRPREFERREDMS CONTINTBCRNON PREFERREDMORPHINE SULFATE ERCP24NON PREFERREDXTAMPZA ERC12ANON PREFERREDOXYCODONE HCLCAPSPREFERREDOXYCODONE HYDROCHLORIDECAPSPREFERREDOXYCODONE HYDROCHLORIDECONCPREFERREDOXYCODONE HYDROCHLORIDESOLNPREFERREDOXYCODONE HCL ERT12ANON PREFERREDOXYCODONE HYDROCHLORIDE ERT12ANON PREFERREDOXYCONTINT12ANON PREFERREDOXAYDOTABSNON PREFERREDOXYCODONE HYDROCHLORIDETABSROXICODONETABSNON PREFERREDOXYMORPHONE HYDROCHLORIDETABSNON PREFERREDOXYMORPHONE HYDROCHLORIDE ERTB12NON PREFERREDOXYMORPHONE HYDROCHLORIDEERTB12NON PREFERREDNUCYNTATABSNON PREFERREDNUCYNTA ERTB12NON PREFERREDCONZIPCP24NON PREFERREDTRAMADOL HCL ERCP24NON PREFERREDQDOLOSOLNNON PREFERREDTRAMADOL HCLTABSTRAMADOL HYDROCHLORIDETABSTRAMADOL HYDROCHLORIDETABSULTRAMTABSNON PREFERREDTRAMADOL HCL ERTB24NON PREFERREDBUPRENORPHINEPTWKNON PREFERREDPREFERRED WITH PAPREFERREDPREFERREDNON PREFERREDPREFERREDPage 7 of 120

Drug ClassANALGESICS : OPIOID COMBINATIONSANAPHYLAXIS THERAPY AGENTS5/21/2021 8:21:47 PMDrug NameDosage FormPDL StatusBUTRANSPTWKNON PREFERREDBELBUCAFILMNON PREFERREDBUTORPHANOL TARTRATESOLNNON PREFERREDPENTAZOCINE/NALOXONE HCLTABSNON PREFERREDAPADAZTABSNON PREFERREDBENZHYDROCODONE/ACETAMINOPHENTABSNON ENTABSPREFERREDPERCOCETTABSNON PREFERREDPRIMLEVTABSNON PREFERREDOXYCODONE/ASPIRINTABSNON NOPHEN/CODEINETABSPREFERREDACETAMINOPHEN/CODEINE FEINE/CODEINECAPSNON PREFERREDFIORICET/CODEINECAPSNON IRIN/CAFFEINE/CODEINECAPSPREFERREDFIORINAL/CODEINE #3CAPSNON NON PREFERREDACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATETABSNON PREFERREDPANLORTABSNON PREFERREDLORTABELIXHYDROCODONE BITARTRATE/ACETAMINOPHENSOLNPREFERREDNON PREFERREDHYDROCODONE CETAMINOPHENTABSPREFERREDLORCETTABSPREFERREDLORCET HDTABSPREFERREDLORCET YLONTABSPREFERREDTRAMADOL RINESOAJNON PREFERREDNON PREFERREDPREFERREDNON PREFERREDNON PREFERREDNON PREFERREDPREFERREDPage 8 of 120

ANAPHYLAXIS THERAPYAGENTSDrug ClassANORECTAL AGENTSDrug NamePDL StatusSOAJNON PREFERREDEPIPEN-JR 2-PAKSOAJNON PREFERREDSYMJEPISOSYNON ROCTO-MED HCCREAPREFERREDPROCTOSOL MCORTENEMAENEMHYDROCORTISONEENEMCORTIFOAMFOAMNON PREFERREDRECTIVOINTNON PREFERREDLIDOCAINE HCL/HYDROCORTISONE ACETATECREANON PREFERREDLIDOCORTNON PREFERREDNON PREFERREDNON PREFERREDPREFERREDCREANON PREFERREDLIDOCAINE HCL-HYDROCORTISONE ACETATE WITH ALOEGELNON PREFERREDANA-LEXKITNON PREFERREDKITNON PREFERREDFOAMNON PREFERREDLIDOCAINE HCL/HYDROCORTISONE ACETATEPROCTOFOAM HCANTIANXIETY AGENTS : BENZODIAZEPINES ALPRAZOLAM INTENSOL5/21/2021 8:21:47 PMDosage FormEPIPEN NON PREFERREDALPRAZOLAM ERTB24NON PREFERREDALPRAZOLAM XRTB24NON PREFERREDXANAX XRTB24NON PREFERREDALPRAZOLAM ODTTBDPCHLORDIAZEPOXIDE HCLCAPSPREFERREDNON PREFERREDCHLORDIAZEPOXIDE HYDROCHLORIDECAPSPREFERREDCLORAZEPATE DIPOTASSIUMTABSPREFERREDTRANXENE TTABSDIAZEPAMCONCPREFERREDDIAZEPAM TABSPREFERREDLORAZEPAMCONCPREFERREDLORAZEPAM INTENSOLCONCPREFERREDATIVANTABSLORAZEPAMTABSNON PREFERREDNON PREFERREDPREFERREDPage 9 of 120

Drug ClassANTIANXIETY AGENTS : MISCANTIASTHMATIC AND BRONCHODILATORAGENTS : ADRENERGIC COMBINATIONSANTIASTHMATIC AND BRONCHODILATORAGENTS : ANTICHOLINERGICS5/21/2021 8:21:47 PMDrug NameDosage FormPDL StatusOXAZEPAMCAPSPREFERREDBUSPIRONE HCLTABSPREFERREDBUSPIRONE HYDROCHLORIDETABSPREFERREDHYDROXYZINE HCLSYRPPREFERREDHYDROXYZINE HCLTABSPREFERREDHYDROXYZINE HYDROCHLORIDETABSPREFERREDHYDROXYZINE PAMOATECAPSPREFERREDVISTARILCAPSNON PREFERREDMEPROBAMATETABSNON PREFERREDCOMBIVENT RESPIMATAERSIPRATROPIUM BROMIDE/ALBUTEROL SULFATESOLNNON PREFERREDPREFERREDDUAKLIR PRESSAIRAEPBNON PREFERREDBUDESONIDE/FORMOTEROL FUMARATE DIHYDRATEAERONON PREFERREDSYMBICORTAEROPREFERREDBEVESPI AEROSPHEREAEROPREFERREDUTIBRON NEOHALERCAPSNON PREFERREDADVAIR DISKUSAEPBNON PREFERREDAIRDUO DIGIHALER 113/14AEPBNON PREFERREDAIRDUO DIGIHALER 232/14AEPBNON PREFERREDAIRDUO DIGIHALER 55/14AEPBNON PREFERREDAIRDUO RESPICLICK 113/14AEPBNON PREFERREDAIRDUO RESPICLICK 232/14AEPBNON PREFERREDAIRDUO RESPICLICK 55/14AEPBNON PREFERREDFLUTICASONE PROPIONATE/SALMETEROLAEPBNON PREFERREDFLUTICASONE PROPIONATE/SALMETEROLAEPBFLUTICASONE PROPIONATE/SALMETEROL DISKUSAEPBWIXELA INHUBAEPBADVAIR HFAAERONON PREFERREDBREO ELLIPTAAEPBNON PREFERREDDULERAAEROSTIOLTO RESPIMATAERSNON PREFERREDANORO ELLIPTAAEPBNON PREFERREDBREZTRI AEROSPHEREAERONON PREFERREDTRELEGY ELLIPTAAEPBNON PREFERREDTUDORZA PRESSAIRAEPBNON PREFERREDSEEBRI NEOHALERCAPSNON PREFERREDLONHALA MAGNAIR REFILL KITSOLNNON PREFERREDLONHALA MAGNAIR STARTER KITSOLNNON PREFERREDPREFERREDNON PREFERREDPREFERREDPREFERREDPage 10 of 120

Drug ClassANTIASTHMATIC AND BRONCHODILATORAGENTS : BETA ADRENERGICSANTIASTHMATIC AND BRONCHODILATORAGENTS : LEUKOTRIENE MODULATORS5/21/2021 8:21:47 PMDrug NameDosage FormPDL StatusIPRATROPIUM BROMIDESOLNPREFERREDATROVENT HFAAERSPREFERREDYUPELRISOLNSPIRIVA SPR 2.5MCGAERSSPIRIVA AER 1.25MCGAERSPREFERREDSPIRIVA HANDIHALERCAPSPREFERREDINCRUSE ELLIPTAAEPBCROMOLYN SODIUMNEBUPROAIR DIGIHALERAEPBNON PREFERREDNON PREFERREDNON PREFERREDPREFERREDNON PREFERREDPROAIR RESPICLICKAEPBALBUTEROL SULFATE HFAAERSPREFERREDNON PREFERREDPROAIR HFAAERSPREFERREDPROVENTIL HFAAERSPREFERREDVENTOLIN HFAAERSPREFERREDALBUTEROL SULFATENEBUPREFERREDALBUTEROL SULFATESYRPPREFERREDALBUTEROLTABSNON PREFERREDALBUTEROL S