PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication. Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information: http://www.kdheks.gov/hcf/pharmacy/pa_criteria.htm TO QUICKLY FIND A DRUG, USE THE [CTRL +F] SEARCH OPTION. Page 1 of 26 Last Updated: July 1, 2020 INHALATION AGENTS Anticholinergics for the Maintenance Treatment of COPD Preferred Non-Preferred, Prior Authorization Required Atrovent® HFA (ipratropium bromide) Ipratropium Bromide nebulizer solution Incruse Ellipta® (umeclidinium bromide) Spiriva® Handihaler® (tiotropium) Lonhala™ Magnair™ (glycopyrrolate) Seebri Neohaler® (glycopyrrolate) Spiriva® Respimat (tiotropium) Tudorza PressAir® (aclidinium) Yupelri™ (Revefenacin) Beta2-Agonists - Long-Acting Preferred Non-Preferred, Prior Authorization Required Brovana® (arformoterol) for ages ≥ 65 years old Serevent® Diskus® (salmeterol) Arcapta® (indacaterol) Brovana® (arformoterol) Striverdi® Respimat® (olodaterol) Beta2-Agonists - Short-Acting Preferred Non-Preferred, Prior Authorization Required AccuNeb® (albuterol) ProAir HFA® (albuterol) Proventil® HFA (albuterol) Proventil® Inhalation Solution (albuterol) Ventolin® Inhalation Solution (albuterol) ProAir RespiClick® (albuterol) ProAir® Digihaler™(albuterol) Ventolin HFA® (albuterol) Xopenex® Inhalation Solution (levalbuterol) Xopenex HFA® (levalbuterol) Beta2-Agonists - Long-Acting/Anticholinergics Preferred Non-Preferred, Prior Authorization Required Anoro Ellipta® (umeclidinium/vilanterol) Bevespi Aerosphere™ (glycopyrrolate/formoterol) Duaklir® Pressair® (aclidinium/formoterol) Stiolto® Respimat® (tiotropium/olodaterol) Utibron™ Neohaler® (indacaterol/glycopyrrolate) Beta2-Agonists - Long-Acting/Corticosteroids Preferred Non-Preferred, Prior Authorization Required Advair Diskus® (fluticasone/salmeterol) Airduo™ Respiclick® (fluticasone/salmeterol) Advair® HFA (fluticasone/salmeterol) Breo Ellipta® (fluticasone/vilanterol) Dulera® (formoterol/mometasone) Symbicort® (budesonide/formoterol)
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Anticholinergics for the Maintenance Treatment of …Differin® (adapalene) cream Differin® (adapalene) 0.3% gel pump Differin® (adapalene) lotion Differin® (adapalene) 0.1% solution
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PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
Adrenaclick® (epinephrine auto inject) + Symjepi®(epinephrine) + Epinephrine auto injectors Epipen® (epinephrine auto inject) Epipen Jr® (epinephrine auto inject)
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
The following drugs are covered for KBH only: Allegra-D® (fexofenadine/pseudoephedrine) Allegra-D24® (fexofenadine/pseudoephedrine) Clarinex-D 12-hour® (desloratadine/pseudoephedrine) Clarinex-D 24-hour® (desloratadine/pseudoephedrine)
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
Hydrocortisone base (all generics of brand products on the PDL) Capex® (fluocinolone acetonide) Synalar® (fluocinolone acetonide) Derma-Smoothe/FS Body & Scalp® (fluocinolone
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information:
PREFERRED DRUG LIST When a generic product is available, for a preferred or non-preferred agent, the pharmacy will
receive a lower reimbursement rate for the branded product unless a DAW PA is obtained. Products listed in RED have changed from the previous month’s publication.
Medications marked with an asterisk (*) may be opened and sprinkled into 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 have clinical prior authorization requirements. Please see the link below for additional information: