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PREFERRED DRUG LISTGeneric drugs and interchangeable biologic products are required when available on themarket, for both preferred or non-preferred agents, unless a Brand Medical Necessity priorauthorization request is approved.Products listed in RED have changed from the previousmonth’s publication. Medications marked with an asterisk (*) may be opened and sprinkledinto soft food or dissolved in water, as per product labeling. Products marked with a ( )indicate that the brand name product is no longer available. Some PDL drugs also haveclinical prior authorization requirements. Please see the link below for additional information:http://www.kdheks.gov/hcf/pharmacy/pa criteria.htmTO QUICKLY FIND A DRUG, USE THE [CTRL F] SEARCH OPTION.INHALATION AGENTSAnticholinergics for the Maintenance Treatment of COPDPreferredNon-Preferred, Prior Authorization RequiredAtrovent HFA (ipratropium bromide)Lonhala Magnair (glycopyrrolate)Ipratropium Bromide nebulizer solutionSeebri Neohaler (glycopyrrolate)Incruse Ellipta (umeclidinium bromide)Tudorza PressAir (aclidinium)Spiriva Handihaler (tiotropium)Yupelri (revefenacin)Spiriva Respimat (tiotropium)Beta2-Agonists - Long-ActingPreferredNon-Preferred, Prior Authorization RequiredBrovana (arformoterol) for ages 65 years oldArcapta (indacaterol)Serevent Diskus (salmeterol)Brovana (arformoterol)Striverdi Respimat (olodaterol)PreferredAccuNeb (albuterol)ProAir HFA (albuterol)Proventil HFA (albuterol)Proventil (albuterol) Inhalation SolutionVentolin HFA (albuterol)Ventolin (albuterol) Inhalation SolutionBeta2-Agonists - Short-ActingNon-Preferred, Prior Authorization RequiredProAir Digihaler (albuterol)ProAir RespiClick (albuterol)Xopenex (levalbuterol) Inhalation SolutionXopenex HFA (levalbuterol)Beta2-Agonists - , Prior Authorization RequiredAnoro Ellipta (umeclidinium/vilanterol)Duaklir Pressair (aclidinium/formoterol)Bevespi Aerosphere (glycopyrrolate/formoterol)Stiolto Respimat (tiotropium/olodaterol)Utibron Neohaler (indacaterol/glycopyrrolate)Beta2-Agonists - Long-Acting/CorticosteroidsPreferredNon-Preferred, Prior Authorization RequiredAdvair Diskus (fluticasone/salmeterol)Airduo Digihaler (fluticasone/salmeterol)Advair HFA (fluticasone/salmeterol)Airduo Respiclick (fluticasone/salmeterol)Breo Ellipta (fluticasone/vilanterol)Dulera (formoterol/mometasone)Symbicort (budesonide/formoterol)COPD Agents – Triple TherapyPreferredNon-Preferred, Prior Authorization RequiredTrelegy (fluticasone/umeclidinium/vilanterol)Breztri (budesonide/glycopyrrolate/formoterol)Page 1 of 2807/01/2021

PREFERRED DRUG LISTGeneric drugs and interchangeable biologic products are required when available on themarket, for both preferred or non-preferred agents, unless a Brand Medical Necessity priorauthorization request is approved.Products listed in RED have changed from the previousmonth’s publication. Medications marked with an asterisk (*) may be opened and sprinkledinto soft food or dissolved in water, as per product labeling. Products marked with a ( )indicate that the brand name product is no longer available. Some PDL drugs also haveclinical prior authorization requirements. Please see the link below for additional information:http://www.kdheks.gov/hcf/pharmacy/pa criteria.htmTO QUICKLY FIND A DRUG, USE THE [CTRL F] SEARCH OPTION.INHALATION AGENTS (CONTINUED)PreferredArnuity Ellipta (fluticasone)Asmanex (mometasone)Flovent Diskus (fluticasone)Flovent HFA (fluticasone)Pulmicort Flexhaler (budesonide)Pulmicort Respules (budesonide)QVAR (beclomethasone)QVAR RediHaler (beclomethasone)CorticosteroidsNon-Preferred, Prior Authorization RequiredAerospan (flunisolide)Alvesco (ciclesonide)ArmonAir Digihaler (fluticasone)ArmonAir RespiClick (fluticasone)Asmanex HFA (mometasone)Tobramycin ProductsPreferredNon-Preferred, Prior Authorization RequiredGeneric tobramycin 300 mg/5 mL nebulization solutionBethkis (tobramycin)Kitabis pak (tobramycin nebulizer) BRAND ONLYTobi (tobramycin)Tobi Podhaler (tobramycin)INTRANASAL AGENTSPreferredAstelin (azelastine) PreferredFlonase (fluticasone)AntihistaminesNon-Preferred, Prior Authorization RequiredAstepro (azelastine)Patanase (olopatadine)CorticosteroidsNon-Preferred, Prior Authorization RequiredBeconase AQ (beclomethasone)Nasacort AQ (triamcinolone)Nasarel (flunisolide) Nasonex (mometasone)Omnaris (ciclesonide)Qnasl (beclomethasone)Xhance (fluticasone)Zetonna (ciclesonide)OPHTHALMIC AGENTSPreferredAlphagan P (brimonidine) 0.1%Brimonidine 0.2%Iopidine (apraclonidine)Page 2 of 28Alpha-Adrenergic AgonistsNon-Preferred, Prior Authorization RequiredAlphagan P (brimonidine) 0.15%07/01/2021

PREFERRED DRUG LISTGeneric drugs and interchangeable biologic products are required when available on themarket, for both preferred or non-preferred agents, unless a Brand Medical Necessity priorauthorization request is approved.Products listed in RED have changed from the previousmonth’s publication. Medications marked with an asterisk (*) may be opened and sprinkledinto soft food or dissolved in water, as per product labeling. Products marked with a ( )indicate that the brand name product is no longer available. Some PDL drugs also haveclinical prior authorization requirements. Please see the link below for additional information:http://www.kdheks.gov/hcf/pharmacy/pa criteria.htmTO QUICKLY FIND A DRUG, USE THE [CTRL F] SEARCH OPTION.OPHTHALMIC AGENTS (CONTINUED)PreferredAlaway (ketotifen)Cromolyn (cromolyn)Optivar (azelastine)Patanol (olopatadine)Refresh (ketotifen)Zaditor (ketotifen)Antihistamines/Mast Cell StabilizersNon-Preferred, Prior Authorization RequiredAlocril (nedocromil)Alomide (lodoxamide)Bepreve (bepotastine)Elestat (epinastine)Emadine (emedastine)Lastacaft (alcaftadine)Pataday (olopatadine)Pazeo (olopatadine)Zerviate (cetirizine)Anti-Infective/Steroid CombinationsPreferredNon-Preferred, Prior Authorization RequiredBlephamide (sulfacetamide/prednisolone)Blephamide S.O.P. (sulfacetamide/prednisolone)Maxitrol (neomycin/polymyxin/dexamethasone)TobraDex (tobramycin/dexamethasone)Pred-G (prednisolone/gentamicin)TobraDex ST (tobramycin/dexamethasone)Pred-G S.O.P. (prednisolone/gentamicin)Zylet (loteprednol/tobramycin)PreferredBetagan (levobunolol)Betimol (timolol)Betoptic (betaxolol) Betoptic -S (betaxolol)CarteololOptiPranolol (metipranolol) Timoptic (timolol)Timoptic-XE (timolol)PreferredAzopt (brinzolamide)Page 3 of 28Beta-BlockersNon-Preferred, Prior Authorization RequiredIstalol (timolol)Timoptic Ocudose (timolol)Carbonic Anhydrase InhibitorsNon-Preferred, Prior Authorization RequiredTrusopt (dorzolamide)07/01/2021

PREFERRED DRUG LISTGeneric drugs and interchangeable biologic products are required when available on themarket, for both preferred or non-preferred agents, unless a Brand Medical Necessity priorauthorization request is approved.Products listed in RED have changed from the previousmonth’s publication. Medications marked with an asterisk (*) may be opened and sprinkledinto soft food or dissolved in water, as per product labeling. Products marked with a ( )indicate that the brand name product is no longer available. Some PDL drugs also haveclinical prior authorization requirements. Please see the link below for additional information:http://www.kdheks.gov/hcf/pharmacy/pa criteria.htmTO QUICKLY FIND A DRUG, USE THE [CTRL F] SEARCH OPTION.OPHTHALMIC AGENTS (CONTINUED)Corticosteroids - OphthalmicPreferredNon-Preferred, Prior Authorization RequiredDexamethasone Sodium Phosphate 0.1% SolutionAlrex (loteprednol etabonate) SuspensionDurezol (difluprednate) EmulsionEysuvis (loteprednol etabonate) SuspensionFML Forte (fluorometholone) SuspensionFlarex (fluorormetholone) SuspensionFML Liquifilm (fluorometholone) SuspensionInveltys (loteprednol etabonate) SuspensionFML (fluorometholone) OintmentLotemax (loteprednol etabonate) GelFML (fluorometholone) SuspensionLotemax (loteprednol etabonate) OintmentMaxidex (dexamethasone sodium phosphate)Lotemax (loteprednol etabonate) SuspensionSuspensionLotemax SM (loteprednol etabonate) GelOmnipred (prednisolone acetate) SuspensionPred Forte (prednisolone acetate) SuspensionPred Mild (prednisolone acetate) SuspensionPrednisolone Sodium Phosphate 1% SolutionPreferredCombigan (brimonidine/timolol)Cosopt (dorzolamide/timolol)PreferredAcular (ketorolac)Ocufen (flurbiprofen) Voltaren ophthalmic (diclofenac) PreferredXalatan (latanoprost)Page 4 of 28Glaucoma Combination ProductsNon-Preferred, Prior Authorization RequiredCosopt PF (dorzolamide/timolol PF)Simbrinza (brinzolamide/brimonidine)Non-Steroidal Anti-Inflammatory DrugsNon-Preferred, Prior Authorization RequiredAcular LS (ketorolac)Acuvail (ketorolac)Bromday (bromfenac)BromSite (bromfenac)Ilevro (nepafenac)Prolensa (bromfenac)Nevanac (nepafenac)Prostaglandin AnalogsNon-Preferred, Prior Authorization RequiredLumigan (bimatoprost)Travatan Z (travoprost)Vyzulta (latanoprostene bunod)Xelpros (latanoprost)Zioptan (tafluprost)Zioptan droperette (tafluprost)07/01/2021

PREFERRED DRUG LISTGeneric drugs and interchangeable biologic products are required when available on themarket, for both preferred or non-preferred agents, unless a Brand Medical Necessity priorauthorization request is approved.Products listed in RED have changed from the previousmonth’s publication. Medications marked with an asterisk (*) may be opened and sprinkledinto soft food or dissolved in water, as per product labeling. Products marked with a ( )indicate that the brand name product is no longer available. Some PDL drugs also haveclinical prior authorization requirements. Please see the link below for additional information:http://www.kdheks.gov/hcf/pharmacy/pa criteria.htmTO QUICKLY FIND A DRUG, USE THE [CTRL F] SEARCH OPTION.OTIC AGENTSAnti-Infective/Steroid CombinationsPreferredNon-Preferred, Prior Authorization RequiredCipro HC (ciprofloxacin/hydrocortisone) suspensionAcetasol HC (acetic acid/hydrocortisone) solutionCiprodex (ciprofloxacin/dexameth) suspensionCortisporin Otic (neomycin/polymyxin B/hc) suspensionCortisporin Otic (neomycin/polymyxin b/hc) solutionCortisporin TC (neomycin/col/hc/thon) suspensionOtovel (ciprofloxacin/fluocinolone) solutionORAL/INJECTABLE/TOPICAL AGENTSACE InhibitorsNon-Preferred, Prior Authorization RequiredAceon (perindopril)Capoten (captopril) Epaned (enalapril) solutionMavik ( trandolapril) Qbrelis (lisinopril solution)Univasc (moexipril) PreferredAccupril (quinapril)Altace (ramipril)*Lotensin (benazepril)Monopril (fosinopril) Prinivil (lisinopril)Vasotec (enalapril)Zestril (lisinopril)ACE Inhibitor/Calcium Channel Blocker CombinationsPreferredNon-Preferred, Prior Authorization RequiredLotrel (benazepril/amlodipine)Prestalia (perindopril/amlodipine)Tarka (trandolapril/verapamil)PreferredAcne Agents – Antibiotics- TopicalNon-Preferred, Prior Authorization RequiredCleocin-T (clindamycin) gelCleocin-T (clindamycin) lotionCleocin-T (clindamycin) solutionCleocin-T (clindamycin) swabEry (erythromycin) padsErygel (erythromycin) gelErythromycin solutionKlaron (sulfacetamide) lotion (suspension)Sumadan Wash (sulfacetamide-sulfur cleanser)Page 5 of 28Amzeeq (minocycline)Avar (sulfacetamide-sulfur) padsAvar-E Emollient (sulfacetamide-sulfur) creamAvar-E Green (sulfacetamide-sulfur) creamAvar LS (sulfacetamide-sulfur) padsBP 10-1 (sulfacetamide/sulfur cleanser)Clindacin ETZ (clindamycin) swabClindacin-P (clindamycin) swabClindacin Pac (clindamycin) kitClindagel (clindamycin) gelEvoclin (clindamycin phosphate) foamRosanil Cleanser (sulfacetamide-sulfur) emulsionSSS 10-5 (sulfacetamide-sulfur) creamSulfacetamide-Sulfur lotionSumadan , Sumadan XLT (sulfacetamide-sulfur) kitSumaxin (sulfacetamide-sulfur) padsSumaxin TS (sulfacetamide-sulfur) suspensionSumaxin Wash (sulfacetamide-sulfur) liquid07/01/2021

PREFERRED DRUG LISTGeneric drugs and interchangeable biologic products are required when available on themarket, for both preferred or non-preferred agents, unless a Brand Medical Necessity priorauthorization request is approved.Products listed in RED have changed from the previousmonth’s publication. Medications marked with an asterisk (*) may be opened and sprinkledinto soft food or dissolved in water, as per product labeling. Products marked with a ( )indicate that the brand name product is no longer available. Some PDL drugs also haveclinical prior authorization requirements. Please see the link below for additional information:http://www.kdheks.gov/hcf/pharmacy/pa criteria.htmTO QUICKLY FIND A DRUG, USE THE [CTRL F] SEARCH OPTION.ORAL/INJECTABLE/TOPICAL AGENTS (CONTINUED)Acne Agents – Combination Agents- TopicalPreferredNon-Preferred, Prior Authorization RequiredDuac (benzoyl peroxide-clindamycin) gelAcanya (benzoyl peroxide-clindamycin) gelEpiduo (benzoyl peroxide-adapalene) gelAktipak (benzoyl peroxide-erythromycin) gelBenzaclin (benzoyl peroxide – clindamycin) gelBenzamycin (benzoyl peroxide-erythromycin) gelEpiduo Forte (adapalene/benzoyl peroxide)Neuac (clindamycin/benzoyl peroxide)Onexton (benzoyl peroxide-clindamycin) gelVeltin (clindamycin-tretinoin)Ziana (clindamycin-tretinoin)PreferredAmnesteem (isotretinoin)Claravis (isotretinoin)Myorisan (isotretinoin)Zenatane (isotretinoin)PreferredAczone (dapsone) 5% gelAcne Agents – Isotretinoin ProductsNon-Preferred, Prior Authorization RequiredAbsorica (isotretinoin)Absorica LD (isotretinoin)Acne Agents- Other - TopicalNon-Preferred, Prior Authorization RequiredAczone (dapsone) 7.5% gelAzelex (azelaic acid) creamAcne Agents – Retinoids- TopicalPreferredNon-Preferred, Prior Authorization RequiredAtralin (tretinoin) gelAklief (trifarotene) creamAvita (tretinoin) gelAltreno (tretinoin) lotionDifferin (adapalene) 0.1% and 0.3% gel tubeArazlo (tazarotene) lotionRetin-A