Skip to main content
  • Notice of Privacy Incident
  • Medicaid Provider Termination Alert: Revalidation deadlines are approaching. Failure by providers to revalidate will lead to termination and payment suspension. Check your account now at https://impact.illinois.gov/ to learn if your required revalidation is due this month. More revalidation information here.
Elizabeth M. Whitehorn, Director

Provider Notice issued 06/30/12

Prior Approval for Certain Drugs

To:​ Participating Advanced Practice Nurses, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Encounter Rate Clinics (ERCs), Hospitals, Local Health Departments, Pharmacies and Physicians​
​Date: ​June 30, 2012
​Re: Prior Approval for Certain Drugs​

As a result of Public Act 097-0689(pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, the department must develop utilization controls, including prior approval, for specialty drugs, oncolytic drugs, drugs for the treatment of HIV or AIDS, immunosuppressant drugs, and biological products in order to maximize savings on these drugs. This notice provides information about changes to the prior approval status of drugs effective July 1, 2012, when billed through the pharmacy system. Changes to prior approval status of drugs billed by other provider types will be announced at a later date.

Immunosuppressive Agents

The following brand name immunosuppressive agents will require prior approval. Their generic equivalents will remain available without prior approval.

  • Cellcept (mycophenolate mofetil)

  • Imuran (azathioprine)

  • Neoral (cyclosporine, modified)

  • Prograf (tacrolimus)

  • Sandimmune (cyclosporine)

Hepatitis C Products

The following Hepatitis C agents will require prior approval in order to ensure appropriate utilization. The department maintains a Preferred Drug List (PDL) for Hepatitis C products. Items that are preferred are marked with an asterisk below, and should be used unless there is a clinical reason that a patient must use the non-preferred product. The PDL can be accessed on the department’s Web site. Prior approval criteria will be posted on the department’s Web site.

With the exception of Pegasys, patients currently on the below-listed drugs will be grandfathered for a 60-day period. Patients currently on Pegasys will be grandfathered on Peg-Intron and will be expected to switch to Peg-Intron unless there is a clinical reason they must remain on Pegasys.

  • Ribavirin 200mg*

  • Incivek (telaprevir)

  • Peg-Intron* (peginterferon alfa-2b)

  • Pegasys (peginterferon alfa-2a)

  • Victrelis* (boceprevir)

Erythropoietin Products

All erythropoietin products will require prior approval. Those products are listed below. The Department maintains a Preferred Drug List (PDL) for erythropoietin products. Items that are preferred are marked with an asterisk below, and should be used unless there is a clinical reason that a patient must use the non-preferred product. The PDL can be accessed on the department’s Web site. Prior approval criteria will be posted on the department’s Web site.

  • Aranesp* (darbepoetin alfa injection)

  • Procrit* (epoetin alfa injection)

  • Epogen (epoetin alfa injection)

  • Omontys (peginesatide)

HIV/AIDS Products

The following drugs for the treatment of HIV/AIDS will require prior approval. Prior approval criteria will be posted on the department’s Web site.

Patients currently on the below-listed drugs will be grandfathered long-term.

  • Fuzeon (enfuvirtide powder for injection)

  • Selzentry (maraviroc tablets)

Oncolytic Products

The following oncolytic drugs will require prior approval. Prior approval criteria will be posted on the department’s Web site.

Patients currently on the below-listed drugs who have a diagnosis of cancer will be grandfathered long-term.

  • Afinitor (everolimus)

  • Etopophos (etoposide)

  • Gleevec (imatinib)

  • Revlimid (lenalidomide)

  • Rituxan (Rituximab)

  • Sprycel (dasatinib) Tasigna (nilotinib)

  • Tykerb (lapatinib)

  • Xalkori (crizotinib)

  • Xeloda (capecitabine)

  • Zelboraf (vemurafenib)

  • Zolinza (vorinostat)

In addition, effective July 1, 2012, the department has revised its prior approval criteria for Immune Globulin, Gamma –Intravenous & Subcutaneous (IVIG/SCIG) products. The criteria are posted on the department’s Web site.

The department continues to review drugs in the affected categories. Providers will be notified when the prior approval status of additional products changes.

Any questions regarding this notice should be directed to the Bureau of Pharmacy Services at 1-877-782-5565, option 7.

Theresa A. Eagleson, Administrator

Division of Medical Programs