2-Tier Open Preferred Drug List - Health Plan of Nevada

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fludarabine OFORTA 2flutamide *EULEXIN 1gefitinib IRESSA 2hydroxyurea *HYDREA 1imatinib mesylate GLEEVEC 2lapatinib ditosylate TYKERB 2lenalidomide REVLIMID 2letrozole *FEMARA 1leucovorin calcium *LEUCOVORIN CALCIUM 1leucovorin calcium *WELLCOVORIN 1lomustine CEENU 2megestrol *MEGACE 1megestrol MEGACE ES 2melphalan ALKERAN 2mercaptopurine *PURINETHOL 1mesna MESNEX 2methotrexate 1methotrexate TREXALL 2mitotane LYSODREN 2nilotinib TASIGNA 2nilutamide NILANDRON 2pazopanib VOTRIENT 2pomalidomide POMALYST 2ponatinib hcl ICLUSIG 2procarbazine HCL MATULANE 2regorafenib STIVARGA 2sorafenib tosylate NEXAVAR 2sunitinib SUTENT 2tamoxifen *NOLVADEX 1tamoxifen SOLTAMOX 2temozolomide *TEMODAR 2thalidomide THALOMID 2thioguanine THIOGUANINE 2topotecan HYCAMTIM 2toremifene citrate FARESTON 2trametinib dimethyl sulfoxide MEKINIST 2tretinoin *VESANOID 1vemurafenib ZELBORAF 2vismodegib ERIVEDGE 2vorinostat ZOLINZA 22-B ImmunosuppressivesGeneric Name Brand NameTierazathioprine *IMURAN 1cyclosporine *SANDIMMUNE (NTI) 2cyclosporine modified *GENGRAF 1cyclosporine modified *NEORAL (NTI) 2mycophenolate MYFORTIC 2QL - Quantity LimitsAL - Age LimitsPA SPQL (30 tablets/month)PA SPPA SPPA SPQL (30 tablets/month)SIOPAPA SPPA SPPA SPPAPA SPPA SPPA SPPA SPPA SPPAQL (30 tablets/month)PA SPSPPA SPQL PA SPPA SPNotesSPSPSPQL (120 tablets/month) SPPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 6 2-Tier (open) Drug BenefitGuide 09/01/13
mycophenolate mofetil *CELLCEPT 1sirolimus RAPAMUNE 2tacrolimus *PROGRAF 1SPSPSPCARDIOVASCULAR (drugs to treat heart conditions)3-A CardiotonicsGeneric Name Brand NameTierdigoxin *LANOXIN (NTI) 23-B AntianginalsGeneric Name Brand NameTierisosorbide dinitrate *ISORDIL 1isosorbide mononitrate *IMDUR 1nitroglycerin ointment *NITROBID 1nitroglycerin patch *MINITRAN 1nitroglycerin patch *NITRO-DUR 1nitroglycerin spray *NITROLINGUAL PUMPSPRAY 1nitroquick *NITROSTAT 2NotesNotesGeneric Name Brand NameTierNotesacebutolol *SECTRAL 1atenolol *TENORMIN 1betaxolol *KERLONE 1bisoprolol *ZEBETA 1carteolol HCL CARTROL 2carvedilol *COREG 3.125mg 1 QL (60 tablets/month)carvedilol *COREG 6.25mg 1 QL (60 tablets/month)carvedilol *COREG 12.5mg 1 QL (60 tablets/month)carvedilol *COREG 25mg 1 QL (120 tablets/month)labetalol *NORMODYNE 1 Mlabetalol *TRANDATE 1 Mmetoprolol *LOPRESSOR 1 Mmetoprolol succinate SR *TOPROL XL 1 QL (45 tablets/month)nadolol *CORGARD 20mg 1 QL (90 tablets/month)nadolol *CORGARD 40mg 1 QL (60 tablets/month)nadolol *CORGARD 80mg 1 QL (90 tablets/month)nadolol *CORGARD 120mg 1 QL (60 tablets/month)nebivolol BYSTOLIC 2.5mg 2 QL (30 tablets/month)nebivolol BYSTOLIC 5mg 2 QL (30 tablets/month)nebivolol BYSTOLIC 10mg 2 QL (120 tablets/month)nebivolol BYSTOLIC 20mg 2 QL (60 tablets/month)penbutolol sulfate LEVATOL 2pindolol *VISKEN 1propranolol *INDERAL 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 7 2-Tier (open) Drug BenefitGuide 09/01/13
Page 1 and 2: Preferred Drug List 2-Tier Open21NV
Page 3 and 4: Two-Tier (OPEN) Drug Benefit GuideI
Page 5 and 6: TWO-TIER OPEN Preferred Drug ListTh
Page 7 and 8: griseofulvin ultramicrosize *GRIS-P
Page 12: propranolol HCL CR *INDERAL LA 1pro
Page 15 and 16: methazolamide *NEPTAZANE 1methyclot
Page 17 and 18: equires 30 day trial of Gabapentin
Page 19 and 20: lithium carbonate CR *ESKALITH CR 1
Page 21 and 22: carbamazepine SR *TEGRETOL XR 1clob
Page 23 and 24: clindamycin-benzoyl peroxide gel *D
Page 25 and 26: pramoxine-HC cream *PRAMOSONE 1pram
Page 27 and 28: MONOPHASIC PRODUCTSethinyl estradio
Page 29 and 30: NESINA ST = requires fill of metfor
Page 31 and 32: propylthiouracil *PTU 1thyroid ARMO
Page 33 and 34: ismuth subcit-metronidazole-tetracy
Page 35 and 36: sulfasalazine EC *AZULFIDINE EN 1ur
Page 37 and 38: dihydrocodeine compound SYNALGOS DC
Page 39 and 40: penicillamine CUPRIMINE 2penicillam
Page 41 and 42: 10-C MineralsGeneric Name Brand Nam
Page 43 and 44: travaprost ophth 1 QL (2.5 ml/month
Page 45 and 46: chlorpheniramine *ED CHLORPED 1chlo
Page 47 and 48: 13-C Hematopoietic AgentsGeneric Na
Page 49 and 50: azelastine hcl-fluticasone DYMISTAa
Page 51 and 52: lidocaine gel LIDORXloperamide IMOD
Page 53 and 54: Alphabetical IndexDrug Name PDL Sec
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2-Tier Open Preferred Drug List - Health Plan of Nevada

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