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Connecticut Medicaid ACNE AGENTS, TOPICAL ‡ ANGIOTENSIN MODULATOR COMBINATIONS ANTICONVULSANTS, CONT. CONNECTICUT MEDICAID (STEP THERAPY CATEGORY) AMLODIPINE / BENAZEPRIL (ORAL) LAMOTRIGINE CHEW DISPERS TAB (not ODT) (ORAL) (DX CODE REQUIRED - DIFFERIN, EPIDUO and RETIN-A) AMLODIPINE / OLMESARTAN (ORAL) LAMOTRIGINE TABLET (IR) (not ER) (ORAL) Preferred Drug List (PDL) ACNE MEDICATION LOTION (BENZOYL PEROXIDE) (TOPICAL)AMLODIPINE / VALSARTAN (ORAL) LEVETIRACETAM SOLUTION, IR TABLET (not ER) (ORAL) • The Connecticut Medicaid Preferred Drug List (PDL) is a BENZOYL PEROXIDE CREAM, WASH (not FOAM) (TOPICAL) OXCARBAZEPINE TABLET (ORAL) listing of prescription products selected by the BENZOYL PEROXIDE 5% and 10% GEL (OTC) (TOPICAL) ANTHELMINTICS PHENOBARBITAL ELIXIR, TABLET (ORAL) Pharmaceutical and Therapeutics Committee as efficacious, BENZOYL PEROXIDE 6% CLEANSER (OTC) (TOPICAL) ALBENDAZOLE TABLET (ORAL) PHENYTOIN CHEW TABLET, SUSPENSION (ORAL) safe and cost effective choices when prescribing for HUSKY CLINDAMYCIN PH 1% PLEGET (TOPICAL) BILTRICIDE TABLET (ORAL) PHENYTOIN SOD EXT CAPSULE (ORAL) A, HUSKY C, HUSKY D, Tuberculosis (TB) and Family CLINDAMYCIN PH 1% SOLUTION (not GEL or LOTION) (TOPICAL)IVERMECTIN TABLET (ORAL) PRIMIDONE (ORAL) Planning (FAMPL) clients. CLINDAMYCIN / BENZOYL PEROXIDE 1.2%-5% (DUAC) (TOPICAL) SABRIL 500 MG POWDER PACK (ORAL) • Preferred or Non-preferred status only applies to DIFFERIN 0.1% CREAM (TOPICAL) (not OTC GEL) (DX CODE REQ.) ANTI-ALLERGENS, ORAL SABRIL TABLET (ORAL) those medications that fall within the drug classes DIFFERIN 0.1% LOTION (TOPICAL) (DX CODE REQ.) All agents require non-PDL PA TEGRETOL SUSPENSION (ORAL) listed on this PDL DIFFERIN 0.3% GEL PUMP (TOPICAL) (DX CODE REQ.) TEGRETOL XR (ORAL) • HIV medications are excluded from the PDL and do EPIDUO FORTE 0.3-2.5% GEL PUMP (TOPICAL) (DX CODE REQ.)* ANTIBIOTICS, GI TOPIRAMATE SPRINKLE CAPSULE (ORAL) not require prior authorization ERYTHROMYCIN 2% SOLUTION (not GEL) (TOPICAL) FIRVANQ SOLUTION (ORAL) TOPIRAMATE TABLET (not ER) (ORAL) • The brand-name of a generically available medication PANOXYL 10% ACNE FOAMING WASH (OTC) (TOPICAL) METRONIDAZOLE TABLET (not CAPSULE) (ORAL) TRILEPTAL SUSPENSION (ORAL) will not be covered without a PA, unless the brand is RETIN-A CREAM (TOPICAL) (DX CODE REQ.) TINIDAZOLE TABLET (ORAL)* VALPROIC ACID CAPSULE, SOLUTION (ORAL) listed on the PDL RETIN-A GEL (not MICRO)(TOPICAL) (DX CODE REQ.) VANCOMYCIN CAPSULE (ORAL)* VIMPAT SOLUTION, TABLET (not STARTER KIT) (ORAL) ANTIBIOTICS, INHALED ZONISAMIDE CAPSULE (ORAL) • Preferred brand-name medications with non- ALZHEIMER'S AGENTS BETHKIS AMPULE (INHALATION) preferred generic equivalents are listed in BOLD DONEPEZIL ODT (ORAL) KITABIS PAK 300 MG/5 ML (INHALATION) ANTIDEPRESSANTS, OTHER • DX CODE REQUIRED NOTATION will appear for DONEPEZIL 5MG & 10MG TABLET (not 23MG) (ORAL) TOBI PODHALER 28MG INHALE CAPSULE (INHALATION) BUPROPION TABLET (ORAL) preferred agents that require ICD-10 code for EXELON PATCH (TRANSDERMAL) BUPROPION SR, BUPROPION XL (NOT 450MG) (ORAL) reimbursement MEMANTINE IR TABLET (not ER CAPSULES) (ORAL) ANTIBIOTICS, TOPICAL DESVENLAFAXINE SUC ER (generic PRISTIQ) (ORAL) HUSKY Therapeutic Class ICD-10 Diagnosis List MEMANTINE 5-10MG TITRATION PACK (ORAL) GENTAMICIN 0.1% CREAM (TOPICAL) MIRTAZAPINE TABLET, ODT (ORAL) • UPDATED NOTATIONS: CHEWABLE notation will RIVASTIGMINE CAPSULES (ORAL) GENTAMICIN 0.1% OINTMENT (TOPICAL) TRAZODONE TABLET (ORAL) appear for preferred agents ANALGESICS, NARCOTICS SHORT MUPIROCIN 2% OINTMENT (not CREAM) (TOPICAL) TRINTELLIX (BRINTELLIX) (ORAL) ** New Therapeutic Class added to PDL effective 7/1/21 APAP / CODEINE 300-30 MG/12.5 ML SOLUTION (ORAL) VENLAFAXINE ER CASPULES (not TABLET) (ORAL) * New Drug added to the PDL effective 7/1/21 APAP / CODEINE 120-12 MG/5 ML SOLUTION (ORAL) ANTIBIOTICS, VAGINAL VIIBRYD TABLET (not STARTER PACK) (ORAL) Non - PDL PA Requirements APAP / CODEINE #2, #3, #4 TABLET (ORAL) CLEOCIN OVULES (VAGINAL) CONNECTICUT MEDICAID PDL PA FORM HYDROCODONE / APAP SOLUTION (ORAL) CLINDESSE 2% CREAM (VAGINAL) • Intolerance of the preferred agents HYDROCODONE / APAP TABLET (ORAL) METRONIDAZOLE VAGINAL 0.75% GEL (VAGINAL)* ANTIDEPRESSANTS, SSRIs • Adverse reaction to the preferred agents HYDROMORPHONE TABLET (IR) (ORAL) NUVESSA VAGINAL 1.3% GEL (VAGINAL) CITALOPRAM TABLET, SOLUTION (ORAL) • Inadequate response from the preferred agents MORPHINE CONC, SOLUTION, SYRUP (ORAL) ESCITALOPRAM TABLET, SOLUTION (ORAL) • Determined medically necessary appropriate MORPHINE IR TABLET (ORAL) ANTICOAGULANTS FLUOXETINE 20 MG/5 ML SOLUTION (ORAL) • Absence of appropriate formulation of the preferred OXYCODONE / APAP CAPSULE, TABLET (ORAL) ELIQUIS STARTER PACK (ORAL) FLUOXETINE CAPSULE (not 90 MG) (ORAL) agent OXYCODONE TABLET (not CAPSULE) (ORAL) ELIQUIS TABLET (ORAL) FLUOXETINE TABLET (ORAL) 10 MG only Step Therapy PA Requirements OXYCODONE 5 MG/5 ML SOLUTION (ORAL) ENOXAPARIN SYRINGE (SUBCUTANEOUS) FLUVOXAMINE TABLET (IR) (ORAL) STEP THERAPY PA FORM PROLATE TABLET (ORAL) ENOXAPARIN VIAL (SUBCUTANEOUS) PAROXETINE TABLET (IR only) (ORAL) ‡ Agents from the following FIVE categories: TRAMADOL 50 MG TABLET (not 100 MG) (ORAL) PRADAXA CAPSULE (ORAL) SERTRALINE TABLET, ORAL CONC (ORAL) ACNE AGENTS, TOPICAL, ANTIMIGRAINE TRAMADOL / APAP (ORAL) WARFARIN TABLET (ORAL) AGENTS, CYTOKINE/CAM ANTAGONISTS, XARELTO TABLET (ORAL) LIPOTROPICS, STATINS, PROTON PUMP ANDROGENIC AGENTS XARELTO STARTER PACK (ORAL) ANTIEMETIC / ANTIVERTIGO AGENTS INHIBITORS ANDROGEL 1.62% GEL PUMP (TRANSDERMAL)* APREPITANT CAPSULE (not PACK) (ORAL) Important Connecticut Medicaid Phone Numbers ANTICONVULSANTS DICLEGIS (ORAL) ANGIOTENSIN MODULATORS CARBAMAZEPINE TAB CHEW, TABLET (ORAL) DRONABINOL CAPSULE (ORAL) Gainwell Technologies Pharmacy Prior Authorization Center BENAZEPRIL TABLET (ORAL)* CARBATROL (ORAL) EMEND 80 MG CAPSULE (not TRIPACK) (ORAL)* Phone #: 1-866-409-8386 (toll-free) Fax #: 1-866-759-4110 (toll-free) DIOVAN TABLET (ORAL) CLOBAZAM TABLET (ORAL) ONDANSETRON ODT, SOLUTION, TABLET (ORAL) ENALAPRIL, ENALAPRIL / HCTZ (ORAL) CLONAZEPAM IR TABLET (not ODT or ER) (ORAL) PA forms are available on our website: ENTRESTO TABLET (ORAL) DEPAKOTE SPRINKLE (ORAL) http://www.CTDSSMAP.com IRBESARTAN, IRBESARTAN / HCTZ (ORAL) DIAZEPAM (RECTAL) (generic DIASTAT) ANTIFUNGALS, ORAL Navigate to: Pharmacy Information LISINOPRIL, LISINOPRIL / HCTZ (ORAL) DIAZEPAM DEVICE (RECTAL) (generic DIASTAT ACUDIAL) CLOTRIMAZOLE 10 MG TROCHE (MUCOUS MEM) or: information > publications > forms LOSARTAN, LOSARTAN / HCTZ (ORAL) DIVALPROEX ER (ORAL) FLUCONAZOLE SUSPENSION, TABLET (ORAL) Gainwell Technologies Provider Assistance Center OLMESARTAN, OLMESARTAN / HCTZ (ORAL)* DIVALPROEX SOD DR TABLET (ORAL) GRISEOFULVIN SUSPENSION (not TABLET) (ORAL) 1-800-842-8440 (toll-free) QUINAPRIL, QUINIPRIL / HCTZ (ORAL) EPIDIOLEX (ORAL) NOXAFIL DR 100 MG TABLET (ORAL)* Dept of Social Services Rx Consultant RAMIPRIL CAPSULE (ORAL) ETHOSUXIMIDE CAPSULE, SOLUTION (ORAL) NYSTATIN SUSPENSION (not TABLET) (ORAL) 1-860-424-5150 VALSARTAN / HCTZ (ORAL) GABITRIL TABLET (ORAL) TERBINAFINE TABLET (ORAL) Updated September 8, 2021 ANTIFUNGALS, TOPICAL ANTIPARKINSON'S AGENTS, CONT. ANTIVIRALS, TOPICAL BRONCHODILATORS, BETA AGONIST, CONT. CLOTRIMAZOLE 1% CREAM (RX and OTC) (TOPICAL) CARBIDOPA / LEVODOPA / ENTACAPONE TABLET (ORAL) ZOVIRAX 5% CREAM (TOPICAL) PROAIR HFA (INHALATION) CLOTRIMAZOLE 1% SOLUTION (RX ONLY) (TOPICAL) PRAMIPEXOLE (IR) (ORAL) ZOVIRAX 5% OINTMENT (TOPICAL) SEREVENT DISKUS (INHALATION) CLOTRIMAZOLE-BETAMETHASONE CREAM (TOPICAL) ROPINIROLE (IR) (ORAL) KETOCONAZOLE CREAM (TOPICAL) SELEGILINE CAPSULE, TABLET (ORAL) ANXIOLYTICS CALCIUM CHANNEL BLOCKERS KETOCONAZOLE 2% SHAMPOO (TOPICAL) TRIHEXYPHENIDYL ELIXIR, TABLET (ORAL) ALPRAZOLAM IR TABLET (not ER or ODT) (ORAL) AMLODIPINE TABLET (ORAL) MICONAZOLE 2% CREAM (OTC) (TOPICAL) BUSPIRONE TABLET (ORAL) DILTIAZEM 12HR ER CAPSULE (ORAL) MICONAZOLE POWDER (not POWDER SPRAY) (OTC) (TOPICAL) CHLORDIAZEPOXIDE CAPSULE (ORAL) DILTAIZEM 24HR ER CAPSULE (not TABLET) (ORAL) NYSTATIN CREAM, OINTMENT, POWDER (TOPICAL) ANTIPSORIATICS, ORAL DIAZEPAM 5 MG/5 ML SOLUTION (not 5 MG/ML CONC) (ORAL)DILTIAZEM TABLET (ORAL) NYSTATIN-TRIAMCINOLONE CREAM, OINTMENT (TOPICAL)* ACITRETIN CAPSULE (ORAL) DIAZEPAM TABLET (ORAL) FELODIPINE ER (ORAL) ANTIHISTAMINES, MINIMALLY SEDATING LORAZEPAM TABLET, 2MG/ML INTENSOL (ORAL) NIFEDIPINE ER (ORAL) CETIRIZINE SOFTGEL (not TABLETS) (OTC) (ORAL) ANTIPSORIATICS, TOPICAL VERAPAMIL TABLET (ORAL) CETIRIZINE SOLUTION, SYRUP (RX ONLY) (ORAL) CALCIPOTRIENE 0.005% OINTMENT, SOLUTION (TOPICAL) BETA-BLOCKERS VERAPAMIL TABLET ER TABLET (not CAPSULE) (ORAL) CETIRIZINE-D TABLET (OTC) (ORAL) DOVONEX 0.005% CREAM (TOPICAL) ATENOLOL TABLET (ORAL) FEXOFENADINE 30 MG/5 ML SUSP (OTC) (ORAL) TACLONEX OINTMENT (TOPICAL) ATENOLOL / CHLORTHALIDONE (ORAL) CEPHALOSPORINS AND RELATED ANTIBIOTICS FEXOFENADINE-D TABLET (OTC) (ORAL) VECTICAL 3 MCG/G OINTMENT (TOPICAL) BISOPROLOL (ORAL) AMOXICILLIN / CLAV SUSPENSION (ORAL) LEVOCETIRIZINE TABLETS (RX & OTC) (ORAL) CARVEDILOL TABLET (not ER) (ORAL) AMOXICILLIN / CLAV TABLET (not CHEW TAB or ER) (ORAL) LORATADINE SOLUTION, SYRUP (OTC) (ORAL) ANTIPSYCHOTICS LABETALOL TABLET (ORAL) CEFACLOR CAPSULE (not SUSPENSION) (ORAL) LORATADINE OTC TABLET (not ODT) (ORAL) ABILIFY MAINTENA ER (INTRAMUSC.) METOPROLOL TARTRATE (ORAL) CEFADROXIL CAPSULE, SUSPENSION (not TABLET) (ORAL) ADASUVE (INHALATION) METOPROLOL SUCCINATE ER (ORAL) CEFDINIR CAPSULE, SUSPENSION (ORAL) ANTIHYPERTENSIVES, SYMPATHOLYTICS ARIPIPRAZOLE SOLUTION, TABLET (not ODT) (ORAL)
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