Connecticut Medicaid Preferred Drug List (PDL) Changes ***Effective 7/1/2021*** Therapeutic Classes Additions (preferred) Removals (non-preferred)

ACNE AGENTS, TOPICAL EPIDUO FORTE GEL W/PUMP (TOPICAL) AZELEX (TOPICAL)

ANALGESICS, CODEINE (ORAL) NARCOTICS SHORT HYDROCODONE / IBUPROFEN (ORAL) OXYCODONE / APAP TABLET (PROLATE) (ORAL) TRAMADOL 100 MG (ORAL) ANDROGENIC AGENTS ANDROGEL GEL PUMP (TRANSDERM) TESTOSTERONE GEL (AG) (VOGELXO) (TRANSDERM) TESTOSTERONE GEL (VOGELXO) (TRANSDERM) TESTOSTERONE GEL PACKET (AG) (VOGELXO) (TRANSDERM) TESTOSTERONE GEL PUMP (AG) (ANDROGEL) (TRANSDERM) TESTOSTERONE GEL PUMP (AG) (VOGELXO) (TRANSDERM) TESTOSTERONE GEL PUMP (ANDROGEL) (TRANSDERM) ANGIOTENSIN AMLODIPINE / VALSARTAN / HCTZ (ORAL) MODULATOR COMBINATIONS ANGIOTENSIN BENAZEPRIL (ORAL) MODULATORS OLMESARTAN (AG) (ORAL) OLMESARTAN (ORAL) OLMESARTAN HCTZ (AG) (ORAL) OLMESARTAN HCTZ (ORAL) ANTIBIOTICS, GI TINIDAZOLE (ORAL) VANCOMYCIN CAPSULE (AG) (ORAL) VANCOMYCIN CAPSULE (ORAL) ANTIBIOTICS, VAGINAL METRONIDAZOLE (VAGINAL) VANDAZOLE (VAGINAL)

ANTIEMETIC/ANTIVERTI EMEND CAPSULE (ORAL) GO AGENTS

ANTIFUNGALS, ORAL NOXAFIL TABLET (ORAL)

ANTIFUNGALS, TOPICAL NYSTATIN-TRIAMCINOLONE CREAM (TOPICAL) NYSTATIN-TRIAMCINOLONE OINT (TOPICAL) ANTIMIGRAINE AGENTS, UBRELVY (ORAL) DIHYDROERGOTAMINE MESYLATE (NASAL) OTHER NURTEC ODT (ORAL)

ANTIMIGRAINE AGENTS, IMITREX (NASAL) SUMATRIPTAN (AG) (NASAL) TRIPTANS SUMATRIPTAN (NASAL)

PDL Changes Effective: 7/1/2021 Connecticut Medicaid Preferred Drug List (PDL) Changes ***Effective 7/1/2021***

Therapeutic Classes Additions (preferred) Removals (non-preferred)

BONE RESORPTION TERIPARATIDE (BRAND) (SUBCUTANEOUS) FORTEO (SUBCUTANE.) SUPPRESSION AND RELATED AGENTS CEPHALOSPORINS AND AMOXICILLIN/CLAV SUSPENSION (AG) RELATED ANTIBIOTICS (ORAL)

CONTRACEPTIVES, ORAL CHARLOTTE 24 FE (ORAL) LEVONORGESTREL OTC (ORAL) MELODETTA 24 FE (ORAL) MINASTRIN 24 FE (ORAL) MY CHOICE OTC (ORAL) OPTION 2 OTC (ORAL) GROWTH FACTORS EGRIFTA (SUB-Q)

GROWTH HORMONE GENOTROPIN CARTRIDGE (INJECTION) NUTROPIN AQ PEN (INJECTION) GENOTROPIN DISP SYRIN (INJECTION)

H. PYLORI TREATMENT HELIDAC (ORAL)

HEPATITIS C AGENTS SOFOSBUVIR/VELPATASVIR (AG) (ORAL) EPCLUSA (ORAL)

HYPOGLYCEMICS, OZEMPIC (SUBCUTANE.) INCRETIN MIMETICS/ENHANCERS HYPOGLYCEMICS, INSULIN ASPART CARTRIDGE (AG) HUMULIN PEN OTC (SUBCUTANE.) INSULIN AND RELATED (SUBCUTANEOUS) AGENTS INSULIN ASPART PEN (AG) (SUBCUTANEOUS) INSULIN ASPART VIAL (AG) (SUBCUTANEOUS) INSULIN ASPART/INSULIN ASPART PROTAMINE INSULIN PEN (AG) (SUBCUTANEOUS) INSULIN ASPART/INSULIN ASPART PROTAMINE VIAL (AG) (SUBCUTANEOUS) INSULIN LISPRO JUNIOR KWIKPEN (AG) (SUBCUTANEOUS) INSULIN LISPRO PEN (AG) (SUBCUTANEOUS) INSULIN LISPRO PROTAMINE MIX KWIKPEN (AG) (SUBCUTANEOUS) INSULIN LISPRO VIAL (AG) (SUBCUTANEOUS) IMMUNOSUPPRESSIVES, EVEROLIMUS TABLET (ZORTRESS) (ORAL) ORAL

LIPOTROPICS, OTHER FENOFIBRATE CAPSULE (LOFIBRA) (ORAL) EVKEEZA (INTRAVEN) FENOFIBRATE TABLET (LOFIBRA) (ORAL) GEMFIBROZIL (AG) (ORAL)

PDL Changes Effective: 7/1/2021 Connecticut Medicaid Preferred Drug List (PDL) Changes ***Effective 7/1/2021***

Therapeutic Classes Additions (preferred) Removals (non-preferred)

MULTIPLE SCLEROSIS AUBAGIO (ORAL) AGENTS GILENYA (ORAL)

OPIATE DEPENDENCE BUPRENORPHINE/NALOXONE TAB TREATMENTS (SUBLINGUAL)

PAH AGENTS, ORAL AND LETAIRIS (ORAL) AMBRISENTAN (ORAL) INHALED REVATIO SUSPENSION (ORAL)

PHOSPHATE BINDERS RENVELA TABLET (ORAL) SEVELAMER CARBONATE TABLET (AG) (ORAL) SEVELAMER CARBONATE TABLET (ORAL)

PITUITARY SUPPRESSIVE FENSOLVI (SUBCUTANEOUS) AGENTS, LHRH

PLATELET ASPIRIN/DIPYRIDAMOLE (AG) (ORAL) AGGREGATION INHIBITORS PRENATAL VITAMINS PNV COMBO#47/IRON/FA #1/DHA (ORAL) PNV 11-IRON FUM-FOLIC ACID-OM3 (ORAL) PRENATAL VIT/FE FUMARATE/FA OTC PNV#16/IRON FUM & PS/FA/OM-3 (ORAL) (ORAL) PNV53/IRON B-G HCL-P/FA/OMEGA3 (ORAL) VITAFOL FE+ (ORAL) PROTON PUMP ESOMEPRAZOLE CAPSULES OTC (ORAL) INHIBITORS

SKELETAL MUSCLE CHLORZOXAZONE (ORAL) RELAXANTS

UTERINE DISORDER ORIAHNN (ORAL) TREATMENTS

VASODILATORS, ISOSORBIDE DINITRATE (AG) (ORAL) CORONARY

* New Therapeutic Class added to PDL effective 7/1/2021.

Please Note: The additions and removals listed refer to all strengths and dosage forms unless otherwise stated.

PDL Changes Effective: 7/1/2021