Section 7 Preferred Drug List

Kansas State Group Health Insurance Program Member Preferred Drug List

2007

The drug representation on the Preferred Drug List is subject to continuing review by the Caremark National Pharmacy and Therapeutics Committee solely as it relates to safety and efficacy.

If you have questions or need additional information, contact Kansas State Employees Prescription Drug Program toll-free at 1-800-294-6324 or access the Web site at:: http://khpa.ks.gov/subject/benelink

The Preferred Drug List is subject to change. You may access the most current drug list at the State of Kansas Web site at: http://khpa.ks.gov/subject/benelink to locate covered prescriptions on-line.

What is a Preferred Drug List? A Preferred Drug List is a list of safe and cost effective drugs, chosen by a committee of physicians and pharmacists. Drug lists have been used in hospitals for many years to help ensure quality drug use. The Kansas State Employees Preferred Drug List will be continually revised to reflect the changing drug market.

Should I ask my physician to switch my current medications to a medication that is on the Preferred Drug List? Many of your medications will already be on the Preferred Drug List. However, if you have a medication that is not, ask your physician to choose a similar Preferred Drug List product for you to use.

Should I use generics? There are many medications on the market that do not come in generic form. For those drugs that do, your pharmacist should suggest safe and effective generic alternatives.

The following drug categories contain medications your doctor may prescribe. You should present this member Preferred Drug List to your physician at each office visit.

KSE-CDL-0107 Your Kansas State Employees Preferred Drug List As Of January 2007

ANALGESICS Second Generation NSAIDs cefaclor * $$ ibuprofen * $ cefuroxime axetil * $$$ naproxen * $ Third Generation naproxen sodium * $$ cefdinir (OMNICEF) $$$$ indomethacin * $$ * salsalate $$$$ Erythromycins/Macrolides * etodolac $$$$ erythromycin stearate * $ * oxaprozin $$$$ erythromycin/sulfisoxazole * $ * sulindac $$$$ erythromycin ethylsuccinate * $ * diflunisal $$$$$ erythromycin delayed-rel * $ * diclofenac sodium delayed-rel $$$$$ azithromycin susp * $$ * nabumetone $$ $$$$$ azithromycin tabs * $$ * indomethacin ext-rel $$$ $$$$$ clarithromycin * $$$ clarithromycin ext-rel (BIAXIN XL) $$$ COX-2 INHIBITORS celecoxib (CELEBREX) $ $$$$$ Fluoroquinolones ciprofloxacin ext-rel (CIPRO XR) $$ GOUT ciprofloxacin susp (CIPRO susp) $$$$ allopurinol * $ moxifloxacin (AVELOX) $$$$$ colchicine * $$$$ ciprofloxacin tabs * $$$$$ probenecid * $ $$$$$ levofloxacin (LEVAQUIN) $$$$$ NARCOTIC ANALGESICS Penicillins hydrocodone/acetaminophen * $$ amoxicillin * $ codeine/acetaminophen * $$ ampicillin * $ NARCOTIC ANALGESICS, CII penicillin VK * $ oxycodone/acetaminophen 5/325 * $ dicloxacillin * $ oxycodone soln * $$$$ amoxicillin/clavulanate * $$$ oxycodone * $$$$$ hydromorphone * $ $$$$$ Sulfonamides morphine * $$ $$$$$ acetyl sulfisoxazole susp (GANTRISIN) $ morphine ext-rel (AVINZA) $$$ $$$$$ Tetracyclines oxycodone ext-rel * $$$ $$$$$ doxycycline hyclate * $ fentanyl transdermal * $$$ $$$$$ tetracycline * $ morphine supp * $$$$$ $$$$$ minocycline * $$ NON-NARCOTIC ANALGESICS ANTIFUNGALS tramadol * $$ nystatin * $$$ butalbital/acetaminophen/caffeine * $$$ ketoconazole * $$$$ butalbital/aspirin/caffeine * $$$ clotrimazole troches * $$$$$ griseofulvin ultramicrosize $$$$$ ANTI-INFECTIVES (GRIS-PEG) ANTIBACTERIALS fluconazole * $$$$$ Cephalosporins terbinafine tabs (LAMISIL) $ $$$$$ First Generation itraconazole * $$ $$$$$ cephalexin * $ voriconazole (VFEND) $$$$$ $$$$$ cefadroxil * $$

* = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

ANTIMALARIALS ANTITUBERCULAR AGENTS chloroquine * $$ isoniazid * $ mefloquine * $$ pyrazinamide * $$$$ atovaquone/proguanil (MALARONE) $$$$$ rifampin * $$$$$ ethambutol * $$$$$ ANTIRETROVIRAL AGENTS Non-Nucleoside Reverse- ANTIVIRALS Transcriptase Inhibitors Cytomegalovirus Agents delavirdine (RESCRIPTOR) $ $$$$$ valganciclovir (VALCYTE) $$ nevirapine (VIRAMUNE) $$ $$$$$ ganciclovir * $$$$ $$$$$ efavirenz (SUSTIVA) $$ $$$$$ Hepatitis Agents Nucleoside Reverse-Transcriptase Inhibitors lamivudine (EPIVIR-HBV) $$$$$ zalcitabine (HIVID) $ $$$$$ adefovir dipivoxil (HEPSERA) $$ $$$$$ didanosine (VIDEX) $ $$$$$ ribavirin * $$ $$$$$ emtricitabine (EMTRIVA) $ $$$$$ entecavir (BARACLUDE) $$$ $$$$$ lamivudine (EPIVIR) $ $$$$$ ribavirin oral soln (REBETOL) $$$ $$$$$ didanosine delayed-rel * $ $$$$$ stavudine (ZERIT) $ $$$$$ Herpes Agents zidovudine (RETROVIR) $$ $$$$$ acyclovir * $ abacavir (ZIAGEN) $$ $$$$$ valacyclovir (VALTREX) $$

Nucleoside Reverse-Transcriptase Influenza Agents Inhibitor Combinations amantadine * $ lamivudine/zidovudine $$$ $$$$$ rimantadine * $$$ (COMBIVIR) oseltamivir (TAMIFLU) $$$$$ emtricitabine/tenofovir $$$ $$$$$ (TRUVADA) MISCELLANEOUS abacavir/lamivudine $$$ $$$$$ metronidazole * $ (EPZICOM) sulfamethoxazole/trimethoprim * $ abacavir/lamivudine/ $$$ $$$$$ mebendazole * $ zidovudine (TRIZIVIR) dapsone $ trimethoprim * $ Nucleotide Reverse- nitrofurantoin ext-rel * $$ Transcriptase Inhibitors clindamycin * $$ tenofovir (VIREAD) $$ $$$$$ nitrofurantoin macrocrystals * $$

Protease Inhibitors ANTINEOPLASTIC AGENTS fosamprenavir (LEXIVA) $ $$$$$ HORMONAL ANTINEOPLASTIC AGENTS indinavir (CRIXIVAN) $$ $$$$$ Antiandrogens nelfinavir (VIRACEPT) $$$ $$$$$ bicalutamide (CASODEX) lopinavir/ritonavir (KALETRA) $$$ $$$$$ flutamide * amprenavir (AGENERASE) $$$ $$$$$ saquinavir mesylate (INVIRASE) $$$ $$$$$ Antiestrogens atazanavir (REYATAZ) $$$ $$$$$ fulvestrant (FASLODEX) darunavir (PREZISTA) $$$$ $$$$$ tamoxifen * tipranavir (APTIVUS) $$$$$ $$$$$ toremifene (FARESTON) ritonavir (NORVIR) $$$$$ $$$$$

* = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

Aromatase Inhibitors ACE INHIBITOR/CALCIUM CHANNEL anastrozole (ARIMIDEX) BLOCKER COMBINATIONS exemestane (AROMASIN) trandolapril/verapamil ext-rel $ $$$$$ letrozole (FEMARA) (TARKA) amlodipine/benazepril (LOTREL) $$ $$$$$ Luteinizing Hormone-Releasing Hormone (LHRH) Agonists ACE INHIBITOR/ goserelin acetate (ZOLADEX) DIURETIC COMBINATIONS leuprolide acetate * benazepril/hydrochlorothiazide * $$ triptorelin pamoate (TRELSTAR) captopril/hydrochlorothiazide * $$ lisinopril/hydrochlorothiazide * $$ Progestins enalapril/hydrochlorothiazide * $$$ megestrol acetate * fosinopril/hydrochlorothiazide * $$$$ quinapril/hydrochlorothiazide * $$$$ ORAL AGENTS Alkylating Agents ADRENOLYTICS, CENTRAL busulfan (MYLERAN) clonidine * $ chlorambucil (LEUKERAN) guanfacine * $$ cyclophosphamide * lomustine (CEENU) ALPHA BLOCKERS melphalan (ALKERAN) doxazosin * $ temozolomide (TEMODAR) terazosin * $

Antimetabolites ANGIOTENSIN II RECEPTOR ANTAGONISTS capecitabine (XELODA) candesartan (ATACAND†) $$$$ mercaptopurine * irbesartan (AVAPRO) $$$$$ thioguanine losartan (COZAAR) $$$$$

† Atacand should be reserved for participants who meet Multi Kinase Inhibitors CHARM (Candesartan in Heart Failure - Assessment of sorafenib (NEXAVAR) Reduction in Mortality and Morbidity) trial criteria. sunitinib (SUTENT) ANGIOTENSIN II RECEPTOR Tyrosine Kinase Inhibitors ANTAGONIST COMBINATIONS erlotinib (TARCEVA) candesartan/hydrochlorothiazide $$$$$ imatinib mesylate (GLEEVEC) (ATACAND HCT) irbesartan/hydrochlorothiazide $ $$$$$ Miscellaneous (AVALIDE) altretamine (HEXALEN) losartan/hydrochlorothiazide $$ $$$$$ bexarotene (TARGRETIN) (HYZAAR) etoposide * hydroxyurea * ANTIARRHYTHMICS mitotane (LYSODREN) mexiletine * $$$$ procarbazine (MATULANE) disopyramide ext-rel * $ $$$$$ tretinoin caps (VESANOID) amiodarone * $$ $$$$$ flecainide * $$ $$$$$ CARDIOVASCULAR propafenone * $$$ $$$$$ ACE INHIBITORS disopyramide * $$$ $$$$$ lisinopril * $ dofetilide (TIKOSYN) $$$ $$$$$ benazepril * $$ sotalol * $$$$ $$$$$ fosinopril * $$$ quinapril * $$$$$ ramipril (ALTACE) $$$$$ * = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

ANTILIPEMICS CALCIUM CHANNEL BLOCKER/ Antilipemic Combinations ANTILIPEMIC COMBINATIONS ezetimibe/simvastatin (VYTORIN) $$ $$$$$ amlodipine/atorvastatin $$$ $$$$$ (CADUET) Bile Acid Resins cholestyramine $ $$$$$ DIGITALIS GLYCOSIDES (cans cost preferred) * digoxin ped elixir * $ colesevelam (WELCHOL) $$$$ $$$$$ digoxin * $

Cholesterol Absorption Inhibitors DIURETICS ezetimibe (ZETIA) $$ $$$$$ hydrochlorothiazide * $ amiloride/hydrochlorothiazide * $ Fibrates chlorthalidone * $ gemfibrozil * $$$ triamterene/hydrochlorothiazide * $ fenofibrate * $$$ $$$$$ indapamide * $ fenofibrate (TRICOR) $$$ $$$$$ furosemide * $ bumetanide * $ HMG-CoA Reductase Inhibitors amiloride * $$ lovastatin * $$$ spironolactone/hydrochlorothiazide * $$$ pravastatin * $$ $$$$$ torsemide * $$$ atorvastatin (LIPITOR) $$$ $$$$$ spironolactone * $$$ metolazone * $$$$$ Niacins niacin ext-rel (NIASPAN) $$ $$$$$ NITRATES Oral BETA-BLOCKERS isosorbide dinitrate oral * $ atenolol * $ isosorbide mononitrate ext-rel * $ metoprolol * $ isosorbide dinitrate ext-rel tabs * $$ pindolol * $ isosorbide mononitrate * $$$ propranolol * $$ nadolol * $$ Sublingual bisoprolol * $$$ nitroglycerin sublingual * $$ labetalol * $$$$ metoprolol ext-rel (TOPROL-XL) $$$$$ Transdermal carvedilol (COREG) $$$ $$$$$ nitroglycerin transdermal * $ $$$$$

BETA-BLOCKER/DIURETIC COMBINATIONS NITRATE/VASODILATOR COMBINATIONS atenolol/chlorthalidone * $ isosorbide dinitrate/hydralazine $$$$ $$$$$ bisoprolol/hydrochlorothiazide * $ (BIDIL) metoprolol/hydrochlorothiazide * $$$$$ MISCELLANEOUS CALCIUM CHANNEL BLOCKERS hydralazine * $ Dihydropyridines methyldopa * $$$ nifedipine ext-rel * $$$$ midodrine * $$$$$ $$$$$ felodipine ext-rel * $$$$ amlodipine (NORVASC) $$$$$ CENTRAL NERVOUS SYSTEM ANTIANXIETY Nondihydropyridines Benzodiazepines verapamil * $ clonazepam tabs * $ verapamil ext-rel * $$ alprazolam * $ diltiazem * $$ diazepam * $ diltiazem ext-rel * $ $$$$$ lorazepam * $$ * = Generic available oxazepam * $$$ Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

Miscellaneous Tricyclic Antidepressants (TCAs) buspirone * $$ amitriptyline * $ clomipramine * $$$ doxepin * $ fluvoxamine * $$$ $$$$$ nortriptyline * $ desipramine * $$ ANTICONVULSANTS imipramine HCl * $$$ phenobarbital * $ phenytoin (DILANTIN INFATABS) $ Miscellaneous Agents carbamazepine * $ trazodone * $ phenytoin sodium extended * $$ mirtazapine * $$$ primidone * $$$$ bupropion * $$$$ ethosuximide * $$$$$ bupropion ext-rel * $$ $$$$$ valproic acid * $ $$$$$ bupropion ext-rel $$ $$$$$ divalproex sodium ext-rel $ $$$$$ (WELLBUTRIN XL) (DEPAKOTE ER) gabapentin * $$ $$$$$ ANTIPARKINSONIAN AGENTS zonisamide * $$ $$$$$ benztropine * $ oxcarbazepine (TRILEPTAL) $$ $$$$$ trihexyphenidyl * $ levetiracetam (KEPPRA) $$$ $$$$$ selegiline * $$ divalproex sodium $$$ $$$$$ amantadine * $$$ delayed-rel (DEPAKOTE) carbidopa/levodopa * $$$ topiramate (TOPAMAX) $$$$ $$$$$ carbidopa/ $$ $$$$$ lamotrigine (LAMICTAL) $$$$ $$$$$ levodopa ext-rel * diazepam rectal gel (DIASTAT) $$$$ $$$$$ carbidopa/levodopa/ $$ $$$$$ entacapone (STALEVO) ANTIDEMENTIA pramipexole (MIRAPEX) $$ $$$$$ memantine (NAMENDA) $ $$$$$ bromocriptine * $$ $$$$$ donepezil (ARICEPT) $ $$$$$ entacapone (COMTAN) $$$ $$$$$ galantamine (RAZADYNE) $ $$$$$ ropinirole (REQUIP) $$$ $$$$$ rivastigmine (EXELON) $ $$$$$ pergolide * $$$ $$$$$

ANTIDEPRESSANTS ANTIPSYCHOTICS Monoamine Oxidase Inhibitors (MAOIs) Atypicals phenelzine (NARDIL) $$$$ clozapine * $$$$ $$$$$ tranylcypromine (PARNATE) $$$$$ quetiapine (SEROQUEL) $$$$ $$$$$ ziprasidone HCl (GEODON) $$$$ $$$$$ Selective Serotonin Reuptake Inhibitors olanzapine (ZYPREXA) $$$$$ $$$$$ (SSRIs) aripiprazole (ABILIFY) $$$$$ $$$$$ fluoxetine * $ risperidone (RISPERDAL) $$$$$ $$$$$ paroxetine HCl * $$$ citalopram * $$$$ Miscellaneous sertraline * $$$$$ haloperidol * $ escitalopram (LEXAPRO) $$$$$ fluphenazine * $ paroxetine HCl ext-rel (PAXIL CR) $ $$$$$ thiothixene * $ thioridazine * $$ Serotonin Norepinephrine Reuptake trifluoperazine * $$$$ Inhibitors (SNRIs)** chlorpromazine * $$$$ **Indicates the proposed mechanism of action, based on the American Psychiatric Association Summary of perphenazine * $$$$ Treatment Recommendations. venlafaxine * $ $$$$$ venlafaxine ext-rel (EFFEXOR XR) $$ $$$$$

* = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

ATTENTION DEFICIT HYPERACTIVITY MUSCULOSKELETAL THERAPY AGENTS DISORDER chlorzoxazone * $ methylphenidate * $$ carisoprodol * $ dexmethylphenidate (FOCALIN) $$$ methocarbamol * $ dextroamphetamine ext-rel * $$$ cyclobenzaprine * $$ dextroamphetamine * $$$$ orphenadrine/aspirin/caffeine * $$$ methylphenidate ext-rel $$$$$ baclofen * $$$ (METADATE CD) dantrolene * $$$$$ methylphenidate ext-rel $$$$$ tizanidine * $$$$$ (RITALIN LA) methocarbamol/aspirin * $ $$$$$ dexmethylphenidate ext-rel $ $$$$$ (FOCALIN XR) MYASTHENIA GRAVIS methylphenidate ext-rel * $ $$$$$ pyridostigmine * $$$$$ methylphenidate ext-rel $ $$$$$ NARCOLEPSY/CATAPLEXY (CONCERTA) modafinil (PROVIGIL) $$$$ $$$$$ amphetamine/ $$ $$$$$ sodium oxybate (XYREM) $$$$$ $$$$$ dextroamphetamine mixed salts ext-rel (ADDERALL XR) PSYCHOTHERAPEUTIC-MISCELLANEOUS Narcotic Antagonists HYPNOTICS naltrexone * $$ $$$$$ Benzodiazepines temazepam * $ triazolam * $ ENDOCRINE AND METABOLIC ANDROGENS Non-Benzodiazepines testosterone gel (ANDROGEL) $$$ $$$$$ zolpidem (AMBIEN) $ $$$$$ eszopiclone (LUNESTA) $$ $$$$$ ANTIDIABETICS Alpha-Glucosidase Inhibitors MIGRAINE acarbose (PRECOSE) $$ $$$$$ Ergotamine Derivatives ergotamine/caffeine * $ Amylin Analogs dihydroergotamine inj * $ $$$$$ pramlintide (SYMLIN) $$$ $$$$$

Selective Serotonin Agonists Biguanides sumatriptan (IMITREX) $$$ metformin * $$$ rizatriptan (MAXALT) $$$$ metformin ext-rel * $$ $$$$$ zolmitriptan (ZOMIG) $$$$ Biguanide/Sulfonylurea Combinations MOOD STABILIZERS glipizide/metformin * $$ $$$$$ lithium carbonate * $ glyburide/metformin * $$ $$$$$ lithium carbonate ext-rel * $$$ Incretin Mimetic Agents MULTIPLE SCLEROSIS AGENTS exenatide (BYETTA) $$$ $$$$$ glatiramer (COPAXONE) $$$$$ $$$$$ interferon beta-1a (REBIF) $$$$$ $$$$$ interferon beta-1a (AVONEX) $$$$$ $$$$$

* = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

Insulins BISPHOSPHONATES insulin isophane human 70%/ $$ risedronate (ACTONEL) $$ $$$$$ regular 30% (NOVOLIN 70/30) alendronate (FOSAMAX) $$ $$$$$ insulin isophane human $$ risedronate + calcium carbonate $$ $$$$$ (NOVOLIN N) (ACTONEL WITH CALCIUM) insulin human (NOVOLIN R) $$ alendronate/vitamin D3 $$ $$$$$ insulin human (HUMULIN R) $$ (FOSAMAX PLUS D) insulin isophane human $$ (HUMULIN N) CONTRACEPTIVES insulin isophane human 50%/ $$ EE = ethinyl estradiol regular 50% (HUMULIN 50/50) ME = mestranol insulin isophane human 70%/ $$ Monophasic regular 30% (HUMULIN 70/30) 20 mcg Estrogen insulin glargine (LANTUS) $ $$$$$ levonorgestrel/EE 0.1/20 * $ insulin aspart (NOVOLOG) $$ $$$$$ norethindrone acetate/ $$ insulin lispro (HUMALOG) $$ $$$$$ EE/iron 1/20 * insulin lispro protamine/ $$ $$$$$ norethindrone acetate/EE 1/20 * $$$$ insulin lispro (HUMALOG MIX) drospirenone/EE 3/20 (YAZ) $ $$$$$ insulin detemir (LEVEMIR) $$ $$$$$ insulin aspart protamine 70%/ $$ $$$$$ 30 mcg Estrogen insulin aspart 30% norgestrel/EE 0.3/30 * $$ (NOVOLOG MIX 70/30) (LOW-OGESTREL) levonorgestrel/EE 0.15/30 * $$ Insulin Sensitizers (LEVORA) rosiglitazone (AVANDIA) $$$ $$$$$ desogestrel/EE 0.15/30 * $$$ pioglitazone (ACTOS) $$$ $$$$$ levonorgestrel/EE 0.15/30 * $$$ Insulin Sensitizer/Biguanide Combinations drospirenone/EE 3/30 (YASMIN) $$$ rosiglitazone/metformin $$$ $$$$$ norethindrone acetate/EE 1.5/30 * $$$$ (AVANDAMET) norethindrone acetate/ $ $$$$$ pioglitazone/metformin $$$ $$$$$ EE/iron 1.5/30 * (ACTOPLUS MET) 30 mcg Estrogen, Extended Cycle Insulin Sensitizer/Sulfonylurea Combinations levonorgestrel/EE 0.15/30 * $ rosiglitazone/glimepiride $$$ $$$$$ (AVANDARYL) 35 mcg Estrogen ethynodiol diacetate/EE 1/35 * $$ Meglitinides (ZOVIA 1/35) repaglinide (PRANDIN) $$$ $$$$$ norgestimate/EE 0.25/35 * $$$ norethindrone/EE 0.5/35 * $$$$ Sulfonylureas ethynodiol diacetate/EE 1/35 * $$$$ glipizide * $ norethindrone/EE 1/35 * $$$$ glyburide * $ glyburide, micronized * $ 50 mcg Estrogen glimepiride * $$$$ norethindrone/ME 1/50 * $$ glipizide ext-rel * $$$$$ ethynodiol diacetate/EE 1/50 * $$$ (ZOVIA 1/50) Supplies ethynodiol diacetate/EE 1/50 * $ $$$$$ Accu-Chek kits and test strips OneTouch kits and test strips Biphasic lancets norethindrone/EE * $$$ BD insulin syringes and needles desogestrel/EE * $$$

* = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

Triphasic ESTROGEN/PROGESTIN levonorgestrel/EE * $ Oral levonorgestrel/EE * (TRIVORA) $$ estrogens, conjugated/ $$$$$ desogestrel/EE * $$$$ medroxyprogesterone norethindrone/EE * $$$$ (PREMPHASE) norgestimate/EE * $$$$ estrogens, conjugated/ $$$$$ norgestimate/EE $$$$$ medroxyprogesterone (ORTHO TRI-CYCLEN LO) (PREMPRO)

Progestin Only Transdermal norethindrone * $$$$$ estradiol/levonorgestrel $$$$$ (CLIMARA PRO) Emergency Contraception levonorgestrel (PLAN B) $$ GLUCOCORTICOIDS prednisone * $ Injectables dexamethasone * $ medroxyprogesterone $ prednisolone syrup * $ acetate 150 mg/mL * methylprednisolone * $ fludrocortisone * $$$ Transdermal hydrocortisone * $$$$ norelgestromin/EE (ORTHO EVRA) $$$$$ prednisolone sodium phosphate * $ $$$$$

Vaginal GLUCOSE ELEVATING AGENTS etonogestrel/EE ring (NUVARING) $$$$ glucagon, human recombinant $$ $$$$$ (GLUCAGON) ESTROGENS Oral HUMAN GROWTH HORMONES estropipate * $ somatropin $$$$ $$$$$ estradiol * $ (NORDITROPIN) estrogens, conjugated, $$ somatropin $$$$$ $$$$$ synthetic A (CENESTIN) (GENOTROPIN) estrogens, conjugated (PREMARIN) $$ somatropin (SAIZEN) $$$$$ $$$$$ estrogens, conjugated, synthetic B $$$$$ somatropin $$$$$ $$$$$ (ENJUVIA) (NUTROPIN/NUTROPIN AQ) somatropin $$$$$ $$$$$ Transdermal (HUMATROPE) estradiol * $ estradiol (VIVELLE/VIVELLE-DOT) $$$$$ PARATHYROID HORMONES estradiol (ESTRADERM) $$$$$ teriparatide (FORTEO) $$$$ $$$$$

Vaginal PHOSPHATE BINDER AGENTS estradiol vaginal ring (FEMRING) $$$$ calcium acetate (PHOSLO) $$$$$ estrogens, conjugated crm $$$$ sevelamer (RENAGEL) $$$ $$$$$ (PREMARIN crm) estradiol vaginal crm $$ $$$$$ PROGESTINS (ESTRACE) medroxyprogesterone acetate * $ norethindrone acetate * $ progesterone, micronized $ (PROMETRIUM)

* = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

SELECTIVE ESTROGEN RECEPTOR INFLAMMATORY BOWEL DISEASE MODULATORS Oral Agents raloxifene (EVISTA) $$ $$$$$ sulfasalazine * $$$ sulfasalazine delayed-rel * $$$$$ THYROID AGENTS mesalamine delayed-rel $ $$$$$ Antithyroid Agents tabs (ASACOL) propylthiouracil * $ budesonide (ENTOCORT EC) $$$ $$$$$ methimazole * $ $$$$$ Rectal Agents Thyroid Supplements mesalamine supp (CANASA) $$ $$$$$ levothyroxine * (SYNTHROID) $ hydrocortisone enema * $$$ $$$$$ levothyroxine * (LEVOXYL) $ hydrocortisone acetate foam $$$ $$$$$ levothyroxine * $ (CORTIFOAM) mesalamine rectal susp * $$$$$ $$$$$ VASOPRESSINS desmopressin spray * $$$ $$$$$ LAXATIVES polyethylene glycol 3350 * $ MISCELLANEOUS peg 3350/electrolytes * $$$ levocarnitine * $ $$$$$ peg 3350/sodium bicarbonate/ $$$ cabergoline (DOSTINEX) $$$ $$$$$ sodium chloride/potassium chloride (NULYTELY) GASTROINTESTINAL lactulose (KRISTALOSE) $$$$ ANTIDIARRHEALS sodium phosphates (VISICOL) $$$$ diphenoxylate/atropine * $ lactulose * $$$$$ loperamide * $ peg 3350/sodium bicarbonate/ $$$$$ sodium chloride/ ANTIEMETICS potassium chloride + bisacodyl meclizine * $ (HALFLYTELY) metoclopramide * $ prochlorperazine * $$ PANCREATIC ENZYMES promethazine * $$ pancrelipase (VIOKASE) $ $$$$$ trimethobenzamide * $$$ pancrelipase delayed-rel (CREON) $$ $$$$$ scopolamine (TRANSDERM SCOP) $$$$ pancrelipase delayed-rel $$$ $$$$$ dronabinol (MARINOL) $ $$$$$ (ULTRASE) ondansetron (ZOFRAN) $$$$$ $$$$$ pancrelipase delayed-rel $$$$$ $$$$$ (ULTRASE MT) ANTISPASMODICS hyoscyamine sulfate * $ PROSTAGLANDINS dicyclomine * $$ misoprostol * $$$ $$$$$ chlordiazepoxide/clidinium * $$ hyoscyamine sulfate ext-rel * $$$$ PROTON PUMP INHIBITORS lansoprazole delayed-rel $$$$$ CHOLELITHOLYTICS (PREVACID) ursodiol * $$$ $$$$$ omeprazole delayed-rel * $$$$$ ursodiol (URSO) $$$ $$$$$ esomeprazole delayed-rel $ $$$$$ (NEXIUM) H2-RECEPTOR ANTAGONISTS ranitidine * $ STEROIDS, RECTAL cimetidine * $$ hydrocortisone rectal crm * $ famotidine * $$

* = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

MISCELLANEOUS MISCELLANEOUS lidocaine viscous * $ cilostazol * $$$ $$$$$ triamcinolone paste * $$ sucralfate * $$$$ IMMUNOLOGIC AGENTS DISEASE-MODIFYING GENITOURINARY ANTI-RHEUMATIC DRUGS (DMARDs) BENIGN PROSTATIC HYPERPLASIA hydroxychloroquine * $$$$$ tamsulosin (FLOMAX) $ $$$$$ methotrexate * $$$$$ dutasteride (AVODART) $$ $$$$$ penicillamine (CUPRIMINE) $$ $$$$$ finasteride * $$$ $$$$$ auranofin (RIDAURA) $$$$ $$$$$ adalimumab (HUMIRA) $$$$$ $$$$$ URINARY ANTISPASMODICS etanercept (ENBREL) $$$$$ $$$$$ oxybutynin * $ oxybutynin transdermal $$ $$$$$ IMMUNOMODULATORS (OXYTROL) Interferons tolterodine ext-rel $$ $$$$$ interferon alfa-2a (ROFERON-A) $$ $$$$$ (DETROL LA) interferon alfacon-1 $$ $$$$$ oxybutynin ext-rel $$$ $$$$$ (INFERGEN) (DITROPAN XL) tolterodine (DETROL) $$$ $$$$$ peginterferon alfa-2a $$$$ $$$$$ (PEGASYS) VAGINAL ANTI-INFECTIVES peginterferon alfa-2b $$$$ $$$$$ terconazole * $$$ (PEG-INTRON) clindamycin crm * $ $$$$$ interferon alfa-2b $$$$$ $$$$$ metronidazole $ $$$$$ (INTRON A) (METROGEL-VAGINAL) Interferon/Antiviral Combinations MISCELLANEOUS ribavirin + interferon $$$$$ $$$$$ phenazopyridine * $ alfa-2b (REBETRON) potassium citrate (UROCIT-K) $$$ bethanechol * $$$ $$$$$ IMMUNOSUPPRESSANTS pentosan polysulfate sodium $$$ $$$$$ Antimetabolites (ELMIRON) azathioprine * $$$

HEMATOLOGIC Calcineurin Inhibitors ANTICOAGULANTS cyclosporine * $$$ $$$$$ warfarin * $$ tacrolimus (PROGRAF) $$$ $$$$$ warfarin (COUMADIN) $$$ cyclosporine, modified * $$$ $$$$$

HEMATOPOIETIC GROWTH FACTORS Rapamycin Derivatives filgrastim (NEUPOGEN) $$$$$ $$$$$ sirolimus (RAPAMUNE) $$ $$$$$ darbepoetin alfa (ARANESP) $$$$$ $$$$$ epoetin alfa (PROCRIT) $$$$$ $$$$$ NUTRITIONAL/SUPPLEMENTS pegfilgrastim (NEULASTA) $$$$$ $$$$$ ELECTROLYTES Potassium PLATELET AGGREGATION INHIBITORS potassium chloride liquid * $ dipyridamole * $$$$$ potassium chloride ext-rel * $ $$$$$ clopidogrel (PLAVIX) $$$$$ $$$$$

PLATELET SYNTHESIS INHIBITORS anagrelide * $$$$$ $$$$$

* = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

VITAMINS AND MINERALS ANTIHISTAMINE/DECONGESTANT Folic Acid Agents COMBINATIONS folic acid * $ chlorpheniramine/ $$ folic acid/vitamin B6/ $ pseudoephedrine ext-rel vitamin B12 (FOLTX) 8 mg/120 mg * brompheniramine/ $$ Prenatal Vitamins pseudoephedrine ext-rel prenatal vitamins w/folic acid * $ 12 mg/120 mg * prenatal vitamins w/folic acid $$ brompheniramine/ $$$ (PRENATE ELITE) pseudoephedrine ext-rel Miscellaneous 6 mg/60 mg * cyanocobalamin inj * $ cetirizine/pseudoephedrine $ $$$$$ fluoride tabs * $ ext-rel (ZYRTEC-D 12 Hour) multivitamins/fluoride/± iron drops, tabs * $ brompheniramine/ $ $$$$$ vitamin ADC/fluoride/±iron drops * $ pseudoephedrine fluoride drops * $ 4 mg/45 mg per 5 mL * ergocalciferol (D2) * $$$ fexofenadine/ $$ $$$$$ calcitriol (1,25-D3) * $$$$ pseudoephedrine ext-rel (ALLEGRA-D) RESPIRATORY carbinoxamine/ $$$ $$$$$ ANAPHYLAXIS TREATMENT AGENTS pseudoephedrine epinephrine (EPIPEN JR.) $ $$$$$ 1 mg/15 mg per mL * epinephrine (EPIPEN) $ $$$$$ ANTITUSSIVES ANTICHOLINERGICS benzonatate * $ ipratropium soln * $ $$$$$ ANTITUSSIVE COMBINATIONS tiotropium (SPIRIVA) $$$ $$$$$ Narcotic hydrocodone/homatropine * $ ANTICHOLINERGIC/BETA AGONIST codeine/guaifenesin * $ COMBINATIONS codeine/promethazine * $ ipratropium/albuterol $$ $$$$$ codeine/guaifenesin/ $ (COMBIVENT) pseudoephedrine * ipratropium/albuterol soln $$$$ $$$$$ codeine/chlorpheniramine/ $ (DUONEB) pseudoephedrine * hydrocodone/chlorpheniramine/ $ ANTIHISTAMINES, LOW SEDATING phenylephrine * cetirizine (ZYRTEC) $ $$$$$ codeine/promethazine/ $$ phenylephrine ANTIHISTAMINES, NONSEDATING (PROMETHAZINE VC w/CODEINE) fexofenadine * $ $$$$$

Non-Narcotic ANTIHISTAMINES, SEDATING dextromethorphan/promethazine * $ clemastine 2.68 mg * $$$ dextromethorphan/ $$ cyproheptadine * $$$$ brompheniramine/ hydroxyzine HCl * $$ $$$$$ pseudoephedrine * dextromethorphan/carbinoxamine/ $$$ pseudoephedrine drops *

* = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

BETA AGONISTS STEROID INHALANTS Inhalants budesonide (PULMICORT) $$$$$ albuterol inhaler * $$ mometasone (ASMANEX) $$$ $$$$$ albuterol soln * $$$ fluticasone (FLOVENT) $$$ $$$$$ albuterol sulfate, $$$$ CFC-free aerosol XANTHINES (PROVENTIL HFA) theophylline * $$$$ levalbuterol tartrate $$$$$ theophylline ext-rel tabs * $$$$$ (XOPENEX HFA) MISCELLANEOUS formoterol inhalation caps $$$ $$$$$ ipratropium spray * $$$$$ (FORADIL) salmeterol xinafoate $$$ $$$$$ (SEREVENT) TOPICAL albuterol soln (ACCUNEB) $$$$ $$$$$ DERMATOLOGY levalbuterol soln (XOPENEX) $$$$$ $$$$$ Acne Oral Oral Agents isotretinoin * $$$$$ $$$$$ albuterol * $$$ terbutaline * $$$$$ Topical albuterol ext-rel (VOSPIRE ER) $ $$$$$ erythromycin soln * $ benzoyl peroxide * $$$ DECONGESTANT/EXPECTORANT erythromycin gel 2% * $$$ COMBINATIONS clindamycin gel, lotion, soln * $$$ pseudoephedrine/ $ sulfacetamide/sulfur * $$$ guaifenesin ext-rel (ENTEX PSE) tretinoin * $ $$$$$ tretinoin gel microsphere $$ $$$$$ LEUKOTRIENE RECEPTOR ANTAGONISTS (RETIN-A MICRO) montelukast (SINGULAIR) $$$ $$$$$ clindamycin/benzoyl $$$ $$$$$ peroxide (BENZACLIN) MAST CELL STABILIZERS clindamycin/benzoyl $$$ $$$$$ cromolyn soln * $$$$$ peroxide (DUAC) cromolyn (INTAL) $$$ $$$$$ adapalene (DIFFERIN) $$$ $$$$$ erythromycin/ $$$$ $$$$$ NASAL ANTIHISTAMINES benzoyl peroxide * azelastine spray (ASTELIN) $$$$ $$$$$ Actinic Keratosis NASAL STEROIDS fluorouracil (CARAC) $$$ $$$$$ flunisolide spray * $ $$$$$ mometasone spray (NASONEX) $$ $$$$$ Antibiotics fluticasone spray * $$$ $$$$$ gentamicin * $ triamcinolone acetonide $$$ $$$$$ silver sulfadiazine * $ spray (NASACORT AQ) mupirocin * $ $$$$$ budesonide spray $$$ $$$$$ Antifungals (RHINOCORT AQUA) nystatin * $ STEROID/BETA AGONIST COMBINATIONS clotrimazole * $$$ fluticasone/salmeterol $$$$ $$$$$ ketoconazole * $$$$ (ADVAIR) econazole * $$$$$ ciclopirox * $$ $$$$$

* = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

Antipsoriatics Emollients tazarotene (TAZORAC) $$$ $$$$$ ammonium lactate 12% * $$$$ calcipotriene (DOVONEX) $$$$ $$$$$ Immunomodulators Antiseborrheics pimecrolimus (ELIDEL) $$ $$$$$ selenium sulfide shampoo 2.5% * $$ tacrolimus (PROTOPIC) $$ $$$$$ ketoconazole shampoo 2% * $$$$ Local Anesthetics Corticosteroids lidocaine/prilocaine * $$$$$ Low Potency hydrocortisone lotion 1% * $ Rosacea hydrocortisone crm 2.5% * $ azelaic acid gel (FINACEA) $$ $$$$$ desonide crm, lotion, oint 0.05% * $ sulfacetamide/sulfur * $$ $$$$$ fluocinolone acetonide soln 0.01% * $$ metronidazole crm * $$$ $$$$$ alclometasone oint 0.05% * $$$$ Scabicides and Pediculicides Medium Potency permethrin 5% * $$$$ triamcinolone acetonide $ malathion (OVIDE) $$$$ $$$$$ crm, lotion 0.025% * Miscellaneous Skin and Mucous Membrane triamcinolone acetonide $ podofilox * $$$$ $$$$$ crm, lotion, oint 0.1% * fluocinolone acetonide $ OPHTHALMIC crm, oint 0.025% * Antiallergics betamethasone valerate $ cromolyn sodium * $$$$ crm, lotion, oint 0.1% * ketotifen (ZADITOR) $ $$$$$ hydrocortisone valerate $$ azelastine (OPTIVAR) $$$ $$$$$ crm, oint 0.2% * mometasone oint 0.1% * $$$ Anti-infectives desoximetasone crm 0.05% * $$$ bacitracin * $ fluticasone propionate $$$$ gentamicin * $ crm 0.05%, oint 0.005% * erythromycin * $ sulfacetamide 10% * $ High Potency neomycin/polymyxin B/gramicidin * $$$$ fluocinonide crm, gel, oint 0.05% * $ polymyxin B/bacitracin * $$$$ betamethasone dipropionate $ ciprofloxacin * $$$$$ crm, lotion, oint 0.05% * triamcinolone acetonide crm 0.5% * $ Anti-infective/Anti-inflammatory desoximetasone crm, $$ Combinations oint 0.25%, gel 0.05% * neomycin/polymyxin B/ $ diflorasone diacetate crm 0.05% * $ $$$$$ dexamethasone * betamethasone dipropionate $ $$$$$ sulfacetamide/prednisolone $$$ augmented crm 0.05% * phosphate 10%/0.25% * sulfacetamide/prednisolone $$$$$ Very High Potency acetate oint 10%/0.2% clobetasol propionate $$ (BLEPHAMIDE SOP) crm, oint 0.05% * neomycin/polymyxin B/ $ $$$$$ diflorasone diacetate oint 0.05% * $$$$ hydrocortisone * halobetasol propionate $$$$ tobramycin/ $$ $$$$$ crm, oint 0.05% * dexamethasone (TOBRADEX) betamethasone $ $$$$$ dipropionate augmented gel, oint 0.05% * * = Generic available Please note this may affect your coinsurance. Your Kansas State Employees Preferred Drug List As Of January 2007

Anti-inflammatories Topical Nonsteroidal dorzolamide (TRUSOPT) $$$$$ ketorolac 0.5% (ACULAR) $$ $$$$$ Parasympathomimetics Steroidal pilocarpine * $ fluorometholone * $$ prednisolone phosphate 1% * $$$ Prostaglandins dexamethasone sodium phosphate * $$$ latanoprost (XALATAN) $$$$$ prednisolone acetate 0.12% $$$ travoprost (TRAVATAN) $$$$$ (PRED MILD) bimatoprost (LUMIGAN) $$ $$$$$ prednisolone acetate 1% * $$$$ Sympathomimetics loteprednol 0.5% (LOTEMAX) $$$$ brimonidine 0.2% * $$$$$ Antivirals brimonidine 0.15% $$ $$$$$ trifluridine * $$$$$ $$$$$ (ALPHAGAN P)

Beta-Blockers OTIC Nonselective Anti-infectives timolol maleate * $ acetic acid/aluminum acetate * $ levobunolol * $$ acetic acid * $$ timolol maleate gel * $$ ofloxacin otic (FLOXIN OTIC) $$$ $$$$$ metipranolol * $$ Anti-infective/Anti-inflammatory timolol hemihydrate (BETIMOL) $$$ Combinations Selective acetic acid/hydrocortisone * $$$ betaxolol (BETOPTIC S) $$$$$ neomycin/polymyxin B/ $$$$ hydrocortisone * Carbonic Anhydrase Inhibitors ciprofloxacin/ $$$$$ $$$$$ Oral dexamethasone (CIPRODEX) acetazolamide * $$ methazolamide * $$$$ Miscellaneous benzocaine/antipyrine * $

* = Generic available Please note this may affect your coinsurance.