Illinois Healthcare and Family Services Illinois Healthcare and Family Services  
www.hfs.illinois.gov/
Bruce Rauner, Govenor
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Pharmacy Information
Prior Approval Process Information
Four Prescription Policy Override Request and Status Inquiry
Medical Home
HFS Home
Four Prescription Limit Form
General Form
MEDI System
Special Forms
Refill Too Soon Form
Fax:217-524-7264
Preferred Drug List
Approval Criteria
Illinois Healthy Women Formulary
Vaccines for Children
Drug Utilization Review
ACE Inhibitor Combinations
ACE Inhibitors
Calcium Channel Blockers
Diabetes Test Strips
Eye Drops & Ointments
H2 Blockers
Intermittent Claudication Agents
Narcotics
NSAIDS
Oral Antifungals
Oral Contraceptives
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Sedative Hypnotics
Skeletal Muscle Relaxants
Stimulants
Thyroid Hormones
Topical Corticosteroids
Triptans

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Label Name Generic Name BrandGeneric 
DILTIAZEM 12HR ER 120 MG CAP DILTIAZEM HCL PA RequiredNo PA Required
DILTIAZEM 12HR ER 60 MG CAP DILTIAZEM HCL PA RequiredNo PA Required
DILTIAZEM 12HR ER 90 MG CAP DILTIAZEM HCL PA RequiredNo PA Required
CARDIZEM 120 MG TABLET DILTIAZEM HCL PA RequiredNo PA Required
DILTIAZEM 120 MG TABLET DILTIAZEM HCL PA RequiredNo PA Required
CARDIZEM 30 MG TABLET DILTIAZEM HCL PA RequiredNo PA Required
DILTIAZEM 30 MG TABLET DILTIAZEM HCL PA RequiredNo PA Required
CARDIZEM 60 MG TABLET DILTIAZEM HCL PA RequiredNo PA Required
DILTIAZEM 60 MG TABLET DILTIAZEM HCL PA RequiredNo PA Required
DILTIAZEM 90 MG TABLET DILTIAZEM HCL PA RequiredNo PA Required
DILTIAZEM 125 MG/25 ML VIAL DILTIAZEM HCL PA RequiredPA Required
DILTIAZEM 25 MG/5 ML VIAL DILTIAZEM HCL PA RequiredPA Required
DILTIAZEM 50 MG/10 ML VIAL DILTIAZEM HCL PA RequiredPA Required
CARDIZEM CD 180 MG CAPSULE DILTIAZEM HCL PA RequiredNo PA Required
CARTIA XT 180 MG CAPSULE DILTIAZEM HCL PA RequiredNo PA Required
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*This site is designed to provide information regarding Medicaid covered drugs. The search function contains prescription drugs covered by Medicaid, including those that require prior authorization. This information is current as of Thursday, January 12, 2017. For additional information please call 1-800-252-8942.

It is important to note that individual client eligibility may limit coverage for some drug categories.

Please Note: This site should be used for reference only; it is not to be used to verify payment of a particular product by Illinois Department of Healthcare and Family Services. It is intended as an education and information resource.
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