Illinois Healthcare and Family Services Illinois Healthcare and Family Services  
www.hfs.illinois.gov/
Bruce Rauner, Govenor
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Pharmacy Information
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Four Prescription Policy Override Request and Status Inquiry
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Four Prescription Limit Form
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Fax:217-524-7264
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Label Name Generic Name BrandGeneric 
OXYCODONE-ACETAMINOPHEN 5-500 OXYCODONE HCL/ACETAMINOPHEN PA RequiredPA Required
OXYCODONE HCL 5 MG/5 ML SOLN OXYCODONE HCL PA RequiredNo PA Required
OXYCODONE HCL 5 MG TABLET OXYCODONE HCL PA RequiredNo PA Required
ROXICODONE 5 MG TABLET OXYCODONE HCL PA RequiredNo PA Required
OXYCODONE HCL 10 MG TABLET OXYCODONE HCL PA RequiredNo PA Required
OXYCODONE HCL 100 MG/5 ML SOLN OXYCODONE HCL PA RequiredNo PA Required
OXYCODONE HCL 5 MG CAPSULE OXYCODONE HCL PA RequiredNo PA Required
OXYCODONE HCL 20 MG TABLET OXYCODONE HCL PA RequiredNo PA Required
OXYCODONE HCL 15 MG TABLET OXYCODONE HCL PA RequiredNo PA Required
ROXICODONE 15 MG TABLET OXYCODONE HCL PA RequiredNo PA Required
OXYCODONE HCL 30 MG TABLET OXYCODONE HCL PA RequiredNo PA Required
ROXICODONE 30 MG TABLET OXYCODONE HCL PA RequiredNo PA Required
PRIMLEV 10-300 MG TABLET OXYCODONE HCL/ACETAMINOPHEN PA RequiredNot Available
OXYCODONE HCL ER 10 MG TABLET OXYCODONE HCL PA RequiredPA Required
OXYCONTIN 10 MG TABLET OXYCODONE HCL PA RequiredPA 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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