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

1 Connecticut Medicaid preferred Drug List (PDL) Changes **Effective 1/1/2019**. Therapeutic Classes Additions ( preferred ) Removals (non- preferred ). ALZHEIMER'S AGENTS GALANTAMINE ER (ORAL). ANTICONVULSANTS SABRIL POWDER PACK (ORAL) CELONTIN (ORAL). LAMOTRIGINE TABLET DOSE PACK (ORAL). PEGANONE (ORAL). ANTIDEPRESSANTS, EMSAM (TRANSDERMAL). OTHER FETZIMA (ORAL). MARPLAN (ORAL). NEFAZODONE (ORAL). ANTIHYPERTENSIVES, METHYLDOPA/HYDROCHLOROTHIAZIDE. SYMPATHOLYTICS (ORAL). ANTIHYPERURICEMICS MITIGARE (ORAL) COLCHICINE CAPSULE (ORAL). ANTIPARKINSON'S CARBIDOPA / LEVODOPA ODT (ORAL). AGENTS SELEGILINE CAPSULE (ORAL). ANTIPSORIATICS, ORAL METHOXSALEN RAPID (ORAL). ANTIPSYCHOTICS ARISTADA INITIO (INTRAMUSC) ABILIFY DISCMELT (ORAL).

2 BRONCHODILATORS, TERBUTALINE (ORAL). BETA AGONIST. COLONY STIMULATING FULPHILA (SUBCUTANEOUS) GRANIX (INJECTION). FACTORS NIVESTYM (SUBCUTANEOUS) NEULASTA SYRINGE (INJECTION). COPD AGENTS COMBIVENT RESPIMAT (INHALATION). CYTOKINE AND CAM COSENTYX PEN INJECTER (SUBCUTANE.). ANTAGONISTS COSENTYX SYRINGE (SUBCUTANE.). ERYTHROPOIESIS RETACRIT (INJECTION). STIMULATING PROTEINS. PDL Changes Effective: 1/1/2019. Connecticut Medicaid preferred Drug List (PDL) Changes **Effective 1/1/2019**. Therapeutic Classes Additions ( preferred ) Removals (non- preferred ). HEMOPHILIA ADVATE (INTRAVEN.). TREATMENT* ADYNOVATE (INTRAVEN). AFSTYLA (INTRAVEN). ALPHANATE (INTRAVEN.).

3 ALPHANINE SD (INTRAVEN.). ALPROLIX (INTRAVEN). BEBULIN (INTRAVEN). BENEFIX KIT (INTRAVEN.). COAGADEX (INTRAVEN). CORIFACT KIT (INTRAVEN). ELOCTATE (INTRAVEN). FEIBA NF (INTRAVEN). HELIXATE FS (INTRAVEN.). HEMLIBRA (SUBCUTANE.). HEMOFIL-M (INTRAVEN.). HUMATE-P KIT (INTRAVEN.). IDELVION (INTRAVEN). IXINITY (INTRAVEN). JIVI (INTRAVEN). KOATE-DVI KIT (INTRAVEN.). KOATE-DVI VIAL (INTRAVEN). KOGENATE FS (INTRAVEN.). KOVALTRY (INTRAVEN.). MONOCLATE-P KIT (INTRAVEN.). MONONINE KIT (INTRAVEN). NOVOEIGHT (INTRAVEN). NOVOSEVEN RT (INTRAVEN). NUWIQ (INTRAVEN). OBIZUR (INTRAVEN). PROFILNINE SD (INTRAVEN). REBINYN (INTRAVEN). RECOMBINATE (INTRAVEN.). RIXUBIS (INTRAVEN).

4 TRETTEN (INTRAVEN). VONVENDI (INTRAVEN). WILATE (INTRAVEN). XYNTHA KIT (INTRAVEN). XYNTHA SOLOFUSE SYRINGE KIT. (INTRAVEN.). INTRANASAL RHINITIS OLOPATADINE (NASAL). AGENTS. IRON, ORAL NOVAFERRUM DROPS OTC (ORAL) FERROUS FUMARATE/FA TABLET (ORAL). HEMOCYTE PLUS CAPSULE (ORAL). INTEGRA CAPSULE OTC (ORAL). INTEGRA PLUS CAPSULE (ORAL). TANDEM DUAL ACTION CAPSULE OTC (ORAL). TANDEM PLUS CAPSULE (ORAL). MOVEMENT DISORDERS AUSTEDO (ORAL). NSAIDS DICLOFENAC SR (ORAL). PDL Changes Effective: 1/1/2019. Connecticut Medicaid preferred Drug List (PDL) Changes **Effective 1/1/2019**. Therapeutic Classes Additions ( preferred ) Removals (non- preferred ). ONCOLOGY, ORAL - IMBRUVICA TABLET (ORAL).

5 HEMATOLOGIC. OPHTHALMIC VIGAMOX (OPHTHALMIC). ANTIBIOTICS. OPHTHALMIC PRED-G DROPS SUSP (OPHTHALMIC). ANTIBIOTIC-STEROID PRED-G OINT. (OPHTHALMIC). COMBINATIONS. OPHTHALMICS, ANTI- FLAREX (OPHTHALMIC). INFLAMMATORIES FML (OPHTHALMIC). MAXIDEX (OPHTHALMIC). PREDNISOLONE SOD PHOSPHATE. (OPHTHALMIC). PROGESTATIONAL MAKENA AUTO INJECTOR AYGESTIN (ORAL). AGENTS* (SUBCUTANEOUS) CRINONE (VAGINAL). MAKENA MDV (INTRAMUSCULAR) DEPO-PROVERA 400 MG/ML (INJECTION). MAKENA SDV (INTRAMUSCULAR) HYDROXYPROGESTERONE CAPROATE. MEDROXYPROGESTERONE ACETATE (INTRAMUSCULAR). (ORAL) HYDROXYPROGESTERONE CAPROATE VIAL. NORETHINDRONE ACETATE (ORAL) (AG) (INTRAMUSCULAR). PROGESTERONE (INTRAMUSC) HYDROXYPROGESTERONE CAPROATE VIAL.

6 PROGESTERONE CAPSULE (ORAL) (INTRAMUSCULAR). PROMETRIUM (ORAL). PROVERA (ORAL). STEROIDS, TOPICAL BETAMET DIPROP / PROP GLY CREAM. HIGH (TOPICAL). STEROIDS, TOPICAL LOW DESONIDE OINTMENT (TOPICAL). STIMULANTS AND KAPVAY (ORAL). RELATED AGENTS. * New Therapeutic Class added to PDL effective 1/1/2019. Please Note: The Additions and Removals listed refer to all strengths and dosage forms unless otherwise stated. PDL Changes Effective: 1/1/2019.