Medicaid Formulary 2024 Payment Form. The connecticut medicaid preferred drug lists (pdl) are a listing of prescription products recommended by the pharmaceutical and therapeutics committee as efficacious, safe,. Complete this printable form to ask us for a decision about a prescription drug and your specific plan coverage.

Members should fax form to 1. The health first colorado (colorado’s medicaid program) preferred drug list includes clinically effective medications that you can get without needing prior authorization or.