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Department of Social Services Acceptance of the Recommendations of the P&T Committee Concerning the Connecticut Medicaid

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Department of Social Services Acceptance of the Recommendations of the P&T Committee Concerning the Connecticut Medicaid Department of Social Services Acceptance of the Recommendations of the P&T Committee Concerning the Connecticut Medicaid Preferred Drug List (PDL) For Drug Class Products Reviewed and Voted on by the P&T Committee Thursday, November 5, 2020 On November 5th, 2020, the P&T Committee reviewed materials presented to them and voted to make Preferred Drug List (PDL) recommendations for the Connecticut Medicaid PDL for medications within the following drug classes: ALZHEIMER'S AGENTS ON PDL: DONEPEZIL ODT (ORAL), DONEPEZIL TABLET (ORAL), EXELON (TRANSDERM.), MEMANTINE TABLET (AG) (ORAL), MEMANTINE TABLET (ORAL), MEMANTINE TABLET DOSE PACK (AG) (ORAL), RIVASTIGMINE CAPSULES (ORAL) ANTHELMINTICS ON PDL: ALBENDAZOLE (AG) (ORAL), ALBENDAZOLE (ORAL), BILTRICIDE (ORAL), IVERMECTIN (ORAL), PYRANTEL PAMOATE OTC (ORAL) ANTI-ALLERGENS, ORAL ON PDL: All agents require a prior authorization ANTICONVULSANTS ON PDL: CARBAMAZEPINE CHEWABLE TABLET (ORAL), CARBAMAZEPINE TABLET (ORAL), CARBATROL (ORAL), CLOBAZAM TABLET (ORAL), CLONAZEPAM (ORAL), DEPAKOTE SPRINKLE (ORAL), DIAZEPAM (AG) (RECTAL), DIAZEPAM DEVICE (AG) (RECTAL), DIVALPROEX ER (ORAL), DIVALPROEX TABLET (ORAL), EPIDIOLEX (ORAL), ETHOSUXIMIDE CAPSULE (AG) (ORAL), ETHOSUXIMIDE CAPSULE (ORAL), ETHOSUXIMIDE SYRUP (ORAL), GABITRIL (ORAL), LAMOTRIGINE DISPERSIBLE TABLET (ORAL), LAMOTRIGINE TABLET (ORAL), LEVETIRACETAM SOLUTION (ORAL), LEVETIRACETAM TABLETS (ORAL), OXCARBAZEPINE TABLETS (ORAL), PHENOBARBITAL ELIXIR (ORAL), PHENOBARBITAL TABLET (ORAL), PHENYTOIN CAPSULE (ORAL), PHENYTOIN CHEWABLE TABLET (ORAL), PHENYTOIN EXT CAPSULE (GENERIC PHENYTEK) (ORAL), PHENYTOIN SUSPENSION (AG) (ORAL), PHENYTOIN SUSPENSION (ORAL), PRIMIDONE (AG) (ORAL), PRIMIDONE (ORAL), SABRIL POWDER PACK (ORAL), SABRIL TABLET (ORAL),TEGRETOL SUSPENSION (ORAL), TEGRETOL XR (ORAL), TOPIRAMATE SPRINKLE (ORAL), TOPIRAMATE TABLETS (ORAL), TRILEPTAL SUSPENSION (ORAL), VALPROIC ACID CAPSULE (ORAL), VALPROIC ACID SOLUTION (ORAL), VIMPAT SOLUTION (ORAL), VIMPAT TABLET (ORAL), ZONISAMIDE (ORAL) ANTIDEPRESSANTS, OTHER ON PDL: BUPROPION (ORAL), BUPROPION SR (ORAL), BUPROPION XL (ORAL), DESVENLAFAXINE ER (PRISTIQ) (AG) (ORAL), DESVENLAFAXINE ER (PRISTIQ) (ORAL), MIRTAZAPINE ODT (ORAL), MIRTAZAPINE TABLET (ORAL), TRAZODONE (ORAL), TRINTELLIX (ORAL), VENLAFAXINE ER CAPSULES (ORAL), VIIBRYD (ORAL) ANTIDEPRESSANTS, SSRIs ON PDL: CITALOPRAM SOLUTION (ORAL), CITALOPRAM TABLET (ORAL), ESCITALOPRAM SOLUTION (ORAL), ESCITALOPRAM TABLET (ORAL), FLUOXETINE CAPSULE (ORAL), FLUOXETINE SOLUTION (ORAL), FLUOXETINE TABLET (ORAL) 10mg, FLUVOXAMINE (ORAL), PAROXETINE TABLET (ORAL), SERTRALINE CONC (ORAL), SERTRALINE TABLET (ORAL) ANTIHISTAMINES, MINIMALLY SEDATING ON PDL: CETIRIZINE CAPSULE OTC (ORAL), CETIRIZINE SOLUTION (ORAL), CETIRIZINE-D OTC (ORAL), FEXOFENADINE SUSPENSION OTC (ORAL), FEXOFENADINE-D 12-HOUR OTC (ORAL), LEVOCETIRIZINE TABLETS (ORAL), LEVOCETIRIZINE TABLETS OTC (ORAL), LORATADINE SOLUTION OTC (ORAL), LORATADINE TABLETS OTC (ORAL) ANTIHYPERTENSIVES, SYMPATHOLYTICS ON PDL: CATAPRES-TTS (TRANSDERM), CLONIDINE (ORAL), GUANFACINE (ORAL), METHYLDOPA (ORAL) ANTIHYPERURICEMICS ON PDL: ALLOPURINOL (ORAL), MITIGARE (ORAL), PROBENECID (ORAL), PROBENECID / COLCHICINE (ORAL) ANTIPARKINSON'S AGENTS ON PDL: AMANTADINE CAPSULE (ORAL), AMANTADINE SYRUP (ORAL), AMANTADINE TABLET (ORAL), BENZTROPINE (ORAL), CARBIDOPA / LEVODOPA (ORAL), CARBIDOPA / LEVODOPA ER (ORAL), CARBIDOPA/LEVODOPA/ENTACAPONE (ORAL), PRAMIPEXOLE (ORAL), ROPINIROLE (ORAL), SELEGILINE CAPSULE (ORAL), SELEGILINE TABLET (ORAL), TRIHEXYPHENIDYL ELIXIR (ORAL), TRIHEXYPHENIDYL TABLET (ORAL) ANTIPSORIATICS, ORAL ON PDL: ACITRETIN (AG) (ORAL), ACITRETIN (ORAL) ANTIPSORIATICS, TOPICAL ON PDL: CALCIPOTRIENE OINTMENT (TOPICAL), CALCIPOTRIENE SOLUTION (TOPICAL), DOVONEX CREAM (TOPICAL), TACLONEX OINTMENT (TOPICAL), VECTICAL (TOPICAL) ANTIPSYCHOTICS ON PDL: ABILIFY MAINTENA (INTRAMUSC.), ADASUVE (INHALATION), AMITRIPTYLINE / PERPHENAZINE (ORAL), ARIPIPRAZOLE SOLUTION (ORAL), ARIPIPRAZOLE TABLET (ORAL), CHLORPROMAZINE (ORAL), CLOZAPINE (ORAL), FLUPHENAZINE DECANOATE (INJECTION), FLUPHENAZINE ELIXIR/SOLN (ORAL), FLUPHENAZINE TABLET (ORAL), HALOPERIDOL (ORAL), HALOPERIDOL DECANOATE (INJECTION), HALOPERIDOL LACTATE (INJECTION), HALOPERIDOL LACTATE CONC (ORAL), INVEGA SUSTENNA (INTRAMUSC), INVEGA TRINZA (INTRAMUSC), LATUDA (ORAL), LOXAPINE (ORAL), MOLINDONE (ORAL), OLANZAPINE ODT (ORAL), OLANZAPINE TABLET (ORAL), OLANZAPINE/FLUOXETINE (ORAL), PERPHENAZINE (ORAL), PIMOZIDE (ORAL), QUETIAPINE ER (AG) (ORAL), QUETIAPINE ER (ORAL), QUETIAPINE TABLETS (ORAL), REXULTI (ORAL), RISPERDAL CONSTA (INTRAMUSC), RISPERIDONE ODT (ORAL), RISPERIDONE SOLUTION (ORAL), RISPERIDONE TABLET (ORAL), THIORIDAZINE (ORAL), THIOTHIXENE (ORAL), TRIFLUOPERAZINE (ORAL), VRAYLAR (ORAL), ZIPRASIDONE CAPSULE (ORAL) ANXIOLYTICS ON PDL: ALPRAZOLAM TABLET (ORAL), BUSPIRONE (ORAL), CHLORDIAZEPOXIDE (ORAL), DIAZEPAM SOLUTION (ORAL), DIAZEPAM TABLET (ORAL), LORAZEPAM INTENSOL (ORAL), LORAZEPAM TABLET (ORAL) BILE SALTS ON PDL: URSODIOL 300 MG CAPSULE (ORAL), URSODIOL TABLET (ORAL) BOTULINUM TOXINS ON PDL: DYSPORT (INTRAMUSC) BRONCHODILATORS, BETA AGONIST ON PDL: ALBUTEROL NEB SOLN 0.63, 1.25 MG (INHALATION), ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION), ALBUTEROL NEB SOLN 2.5 MG/0.5 ML (INHALATION), ALBUTEROL NEB SOLN 2.5 MG/3 ML (INHALATION), ALBUTEROL SYRUP (ORAL), PROAIR HFA (INHALATION), SEREVENT (INHALATION) COLONY STIMULATING FACTORS ON PDL: FULPHILA (SUBCUTANEOUS), NEUPOGEN DISP SYRIN (INJECTION), NEUPOGEN VIAL (INJECTION), UDENYCA (SUBCUTANEOUS) COPD AGENTS ON PDL: ANORO ELLIPTA (INHALATION), ATROVENT HFA (INHALATION), COMBIVENT RESPIMAT (INHALATION), DALIRESP (ORAL), IPRATROPIUM / ALBUTEROL (INHALATION), IPRATROPIUM NEBULIZER (INHALATION), SPIRIVA (INHALATION), STIOLTO RESPIMAT (INHALATION) CYTOKINE AND CAM ANTAGONISTS ON PDL: ENBREL KIT (INJECTION), ENBREL MINI CARTRIDGE (SUBCUTANE.), ENBREL PEN (INJECTION), ENBREL SYRINGE (INJECTION), ENBREL VIAL (SUBCUTANEOUS), HUMIRA KIT (INJECTION), HUMIRA PEN KIT (INJECTION), OTEZLA (ORAL) EMOLLIENTS ON PDL: AMMONIUM LACTATE CREAM/LOTION (TOPICAL) ENZYME REPLACEMENT, GAUCHERS DISEASE ON PDL: ZAVESCA (ORAL) EPINEPHRINE, SELF-INJECTED ON PDL: EPINEPHRINE 0.15 MG (EPIPEN JR) (49502-0101-02) (INJECTION), EPINEPHRINE 0.3 MG (EPIPEN) (49502-0102-02) (INJECTION) ERYTHROPOIESIS STIMULATING PROTEINS ON PDL: ARANESP DISP SYRIN (INJECTION), ARANESP VIAL (INJECTION), RETACRIT (INJECTION) GLUCOCORTICOIDS, INHALED ON PDL: ADVAIR DISKUS (INHALATION), ADVAIR HFA (INHALATION), ASMANEX (INHALATION), BREO ELLIPTA (INHALATION), DULERA (INHALATION), FLOVENT DISKUS (INHALATION), FLOVENT HFA (INHALATION), PULMICORT 0.25, 0.5 MG RESPULES (INHALATION), PULMICORT 1 MG RESPULES (INHALATION), PULMICORT FLEXHALER (INHALATION), SYMBICORT (INHALATION), TRELEGY ELLIPTA (INHALATION) GLUCOCORTICOIDS, ORAL ON PDL: BUDESONIDE EC (ORAL), DEXAMETHASONE TABLET (ORAL), HYDROCORTISONE (ORAL), METHYLPREDNISOLONE TAB DS PK (ORAL), PREDNISOLONE SODIUM PHOSPHATE (ORAL), PREDNISOLONE SOLUTION (ORAL), PREDNISONE TABLET (ORAL) HEMOPHILIA TREATMENT ON PDL: ALPHANATE (INTRAVEN.), BENEFIX KIT (INTRAVEN.), COAGADEX (INTRAVEN), CORIFACT KIT (INTRAVEN), FEIBA NF (INTRAVEN), HEMLIBRA (SUBCUTANE.), HUMATE-P KIT (INTRAVEN.), NOVOEIGHT (INTRAVEN), NUWIQ (INTRAVEN), SEVENFACT (INTRAVEN), WILATE (INTRAVEN), XYNTHA KIT (INTRAVEN), XYNTHA SOLOFUSE SYRINGE KIT (INTRAVEN.) HISTAMINE II RECEPTOR BLOCKER ON PDL: CIMETIDINE TABLET OTC (ORAL), FAMOTIDINE SUSPENSION (ORAL), FAMOTIDINE TABLET (ORAL), FAMOTIDINE TABLET OTC (ORAL) IDIOPATHIC PULMONARY FIBROSIS ON PDL: OFEV (ORAL) IMMUNOMODULATORS, ASTHMA ON PDL: FASENRA PEN (SUBCUTANEOUS), FASENRA SYRINGE (SUBCUTANEOUS), XOLAIR SYRINGE (SUB-Q), XOLAIR VIAL (SUB-Q) IMMUNOMODULATORS, ATOPIC DERMATITIS ON PDL: ELIDEL (TOPICAL), EUCRISA (TOPICAL), PROTOPIC (TOPICAL) IMMUNOMODULATORS, TOPICAL ON PDL: IMIQUIMOD (ALDARA) (TOPICAL), PODOFILOX SOLUTION (TOPICAL) INTRANASAL RHINITIS AGENTS ON PDL: AZELASTINE (ASTELIN) (NASAL), FLUTICASONE (NASAL), FLUTICASONE OTC (NASAL), IPRATROPIUM (NASAL), TRIAMCINOLONE OTC (NASAL) IRON, ORAL ON PDL: BIFERA TABLET OTC (ORAL), FERROUS FUMARATE TABLET OTC (ORAL), FERROUS GLUCONATE TABLET OTC (ORAL), FERROUS SULFATE DROPS OTC (ORAL), FERROUS SULFATE SOLUTION OTC (ORAL),FERROUS SULFATE TABLET OTC (ORAL),FERROUS SULFATE, DRIED TABLET ER OTC (ORAL), IRON CARBONYL/ASCORBIC ACID TABLET OTC (ORAL), IRON POLYSACCHARIDES CAPSULE OTC (ORAL), IRON POLYSACCHARIDES/B12/FA CAPSULE (ORAL) LEUKOTRIENE MODIFIERS ON PDL: MONTELUKAST CHEWABLE TABLET (ORAL), MONTELUKAST TABLET (ORAL) METHOTREXATE ON PDL: METHOTREXATE PF VIAL (INJECTION), METHOTREXATE TABLET (ORAL), METHOTREXATE VIAL (INJECTION) MOVEMENT DISORDERS ON PDL: AUSTEDO (ORAL), TETRABENAZINE (ORAL) NEUROPATHIC PAIN ON PDL: CAPSAICIN OTC (TOPICAL), DULOXETINE (CYMBALTA) (ORAL), GABAPENTIN CAPSULE (ORAL), GABAPENTIN TABLET (ORAL), LIDODERM (TOPICAL), LYRICA CAPSULE (ORAL), PREGABALIN CAPSULE (AG) (ORAL), PREGABALIN CAPSULE (ORAL), ZTLIDO (TOPICAL) NSAIDS ON PDL: DICLOFENAC GEL (TOPICAL), DICLOFENAC SODIUM (ORAL), IBUPROFEN SUSPENSION (ORAL), IBUPROFEN SUSPENSION OTC (ORAL), IBUPROFEN TABLET (ORAL), INDOMETHACIN CAPSULE (ORAL), MELOXICAM TABLET (ORAL), NABUMETONE (ORAL), NAPROXEN SUSPENSION (ORAL), NAPROXEN TABLET (ORAL), SULINDAC (ORAL), VOLTAREN (TOPICAL) ONCOLOGY, ORAL – BREAST ON PDL: ANASTROZOLE (ORAL), CYCLOPHOSPHAMIDE (ORAL), EXEMESTANE (ORAL), IBRANCE CAPSULE (ORAL), LETROZOLE (ORAL), TAMOXIFEN CITRATE (ORAL), XELODA (ORAL) ONCOLOGY, ORAL – HEMATOLOGIC ON PDL: ALKERAN (ORAL), BOSULIF (ORAL), BRUKINSA (ORAL), CALQUENCE (ORAL), COPIKTRA
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