Pharmacy Information

This page is for pharmacy and health care providers, pharmaceutical company government affairs representatives, and others who have an interest in pharmacy-specific program information of the Connecticut Medical Assistance Program of DSS. Here you will find information and links to pharmacy program information.

Pharmacy Program Publications

Prior Authorization Form Directory Drug and Diabetic Product SEARCH LINK (*NEW 1/1/2026*)
- Evrysdi PA Form
- Insulin Pump PA Form
- Opioid PA Form (Long Acting and Short Acting)
- PCSK9i PA Form
- Pharmacy Prior Authorization Form - For Non-Preferred, Brand Medically Necessary, Early Refill and Optimal Dose Requirements
- Pharmacy Continuous Glucose Monitoring PA Form
- Spravato PA Form (Pharmacy)
- Spravato PA Form (Professional)
- Step Therapy PA Form Step Therapy required for the following drug classes: Acne Agents (Topical), Antimigraine (Triptans), Proton Pump Inhibitors, and Statins
- Wegovy for MACE Risk Reduction Prior Authorization Form
- Wegovy for MASH Prior Authorization Form
- Zepbound for Treatment of Obstructive Sleep Apnea Prior Authorization Form
- Clinical Criteria PA Forms - Effective 1/1/2026
Diagnosis Lists
- ICD-10-CM Therapeutic Class Product Diagnosis List
- ICD-10-CM Enteral Nutrition Products Diagnosis List
Alternate Formularies
Pharmacy Prescription Attachment Notices
Drug Manufacturer Rebate Lists
- HUSKY A, HUSKY C, HUSKY D, Family Planning and Tuberculosis
- HUSKY B
Pharmacy Pricing Resources
- NADAC and FUL Drug Price Lookup
- Pricing Logic for CT Claims-Pharmacy, UB-04, and CMS-1500
Additional Supplemental Pharmacy Publications
Pharmacy Provider Directory
- Pharmacy Provider Directory

CADAP and CIPA Programs: The State of Connecticut CADAP and CIPA Services are being administered by the Connecticut Department of Public Health beginning November 1, 2018. All Applications and information about the Connecticut CADAP and CIPA programs can be found on line at this Web location: https://ctdph.primetherapeutics.com/ or email CTMyRxEnroll@primetherapeutics.com with specific questions.

	Preferred Drug List Information
The Connecticut Medicaid Preferred Drug Lists (PDL) are a listing of prescription products recommended by the Pharmaceutical and Therapeutics Committee as efficacious, safe, and cost effective choices when prescribing for Medicaid patients. Most FDA approved drugs that are not listed are available, with prior authorization by calling Gainwell Technologies toll-free at 1-866-409-8386. Drug classes will be added as the Pharmaceutical & Therapeutics Committee review additional classes. The PDLs are not an all-inclusive list of covered Medicaid drugs. Approximately 100 classes of drugs are on the PDL at any time and represent a portion of the total number of classes of drugs available to clients. HIV medications are excluded from the PDL legislation and will always be preferred drugs and not require a Prior Authorization for PDL. Current Medicaid Preferred Drug List Alphabetized Preferred Drug List Preferred Drug List Changes Previous Preferred Drug Lists Diabetic Supplies Preferred Product List Previous Diabetic Supplies Preferred Product List

	Pharmaceutical and Therapeutics Committee
The purpose of the Medicaid Pharmaceutical & Therapeutics Committee is to develop and implement a voluntary Medicaid preferred prescribed drug designation program, as stipulated in the Connecticut General Statute Chapter 319V, section 17b-274d. Committee Members Committee Bylaws Committee Ethics Statement Meeting Schedule Meeting Agenda, Minutes and Recommendations Meeting Guidelines for Submission or Presentation to Committee TOP$ Therapeutic Class Review Schedule Legislation Addressing the Preferred Drug List Links to Connecticut General StatuteChapter 319V, section 17b-274d. Please refer to the history section of the statute for a listing of amendments.You can e-mail or call the PDL coordinator, at 1-571-348-0187 with your questions, comments, or concerns.

	Pharmacy Prior Authorization Program
The Pharmacy Prior Authorization (PA) program is a state-mandated pharmacy initiative. The Pharmacy Prior Authorization program allows DSS to assure appropriate prescribing and utilization of prescribed medications in a cost-effective manner. Click on the links below for further information regarding Pharmacy PA. State Law Requirements for PA Current PA Criteria - Gainwell Technologies Brand Medically Necessary Cystic Fibrosis Early Refill (Over Utilization) Opioid Medication (Long and Short Acting) Non-Preferred Medication Optimal Dosage PCSK9i Step Therapy Clinical Prior Authorization for Non-Preferred Drugs (new effective 1/1/2026) Anticonvulsants Anti-Migraine Agents – Other, CGRP Antagonists, 5‑HT1F Receptor Agonists Bladder Relaxant Preparations CNS: Multiple Sclerosis Agents, Oral CNS: Multiple Sclerosis Agents, Injectable Colony Stimulating Factors Cytokine and CAM Antagonists: CAPs Agents IL‑17 Antibody / IL‑17 Receptor Antagonists IL‑23 and IL‑12/23 Inhibitors IL‑6 Receptor Antagonists JAK Inhibitors CAM Antagonists: Miscellaneous TNF Inhibitors Growth Hormone GLP‑1/GIP Agonists (Diabetes) Immunomodulators: Asthma & Allergy PAH: Endothelin Receptor Antagonists PAH: Inhaled Prostacyclins PAH: Oral Prostacyclins PAH: PDE‑5 Inhibitors & GCS Topical Antipsoriatics Current PA Criteria - CTBHP (Carelon) Spravato Coverage Guidelines Claim Processing with Prior Authorization Request for Back‑Dated Prior Authorization Prior Authorization Forms Prior Authorization forms can be downloaded from the Publications page. Optimal Dose List Frequently Asked Questions

	Retrospective Drug Utilization Review Program
The Omnibus Budget Reconciliation Act of 1990 (OBRA '90) requires state Medicaid programs to conduct a comprehensive Drug Utilization Review program. This does not include Connecticut Medical Assistance clients with third party insurance. The RetroDUR program collects and analyzes claims data against predetermined, DUR Board approved criteria to identify and correct aberrant prescribing practices, client misuse, and provider fraud. The RetroDUR program also has functionality to identify potential pharmacy restriction candidates and to specify a pharmacy and/or physician provider to assist in correcting client abuse or misuse. The DUR Board is required to implement corrective action to modify practices via appropriate interventions and demonstrate cost savings. Concurrent with RetroDUR and using the resulting data, the DUR contractor also conducts a pharmacy restriction program. Through RetroDUR, provider, and the medical audit division’s input the contractor identifies certain clients who demonstrate the potential to abuse or misuse of prescription drugs. These clients are offered the opportunity to change their behavior and demonstrate appropriate use of prescription drugs. If the clients continue inappropriate behavior, they are restricted to the use of a single pharmacy for a one-year period per Connecticut State law. Clients and providers with questions should contact Acentra Health concerning the RetroDUR program operations or pharmacy restriction by calling toll-free to 1-877-719-3123 or by fax to 1-866-743-9788. Further information about the RetroDUR program is available through the following links: DUR Board Purpose DUR Board Bylaws DUR Board Schedule DUR Board Agendas DUR Board Minutes DUR Board Newsletters

	Drug Rebate
CT Drug Rebate Policies Pricing Logic for CT Claims-Pharmacy, UB-04, and CMS-1500 Non-Qualified SPAP Agreement for Rebate Participation (Husky B) SPAP documentation from CMS Governor Bill to Maximize Rebates

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