2-Tier Open Preferred Drug List - Health Plan of Nevada
2-Tier Open Preferred Drug List - Health Plan of Nevada
2-Tier Open Preferred Drug List - Health Plan of Nevada
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Generic Name Brand Name<strong>Tier</strong>isosorbide dinitrate-hydralazine BIDIL 2ranolazine RANEXA 2NotesQL (60 tablets/month)CENTRAL NERVOUS SYSTEM (drugs that affect the brain)4-A Antianxiety AgentsGeneric Name Brand Name<strong>Tier</strong>Notesalprazolam *NIRAVAM 2alprazolam *XANAX 1alprazolam SR *XANAX XR 0.5mg 1 QL (30 tablets/month)alprazolam SR *XANAX XR 1mg 1 QL (30 tablets/month)alprazolam SR *XANAX XR 2mg 1 QL (30 tablets/month)alprazolam SR *XANAX XR 3mg 1 QL (60 tablets/month)buspirone BUSPAR (7.5mg) 2buspirone *BUSPAR 10mg 1 QL (60 tablets/month)buspirone *BUSPAR 15mg 1 QL (120 tablets/month)chlordiazepoxide *LIBRIUM 1clorazepate *TRANXENE 1diazepam *VALIUM 1hydroxyzine HCL *ATARAX 1hydroxyzine pamoate *VISTARIL 1lorazepam *ATIVAN 1meprobamate 1oxazepam *SERAX 14-B AntidepressantsGeneric Name Brand Name<strong>Tier</strong>Notesamitriptyline *ELAVIL 1amoxapine *ASENDIN 1bupropion *WELLBUTRIN 75mg 1 QL (180 tablets/month)bupropion *WELLBUTRIN 100mg 1 QL (120 tablets/month)bupropion SR *WELLBUTRIN SR 100mg 1 QL (60 tablets/month)bupropion SR *WELLBUTRIN SR 150mg 1 QL (60 tablets/month)bupropion SR *WELLBUTRIN SR 200mg 1 QL (60 tablets/month)bupropion XL *WELLBUTRIN XL 1 QL (30 tablets/month)citalopram *CELEXA 1 QL (45 tablets/month)clomipramine *ANAFRANIL 1desipramine *NORPRAMIN 1desvenlafaxine PRISTIQ 2 QL (30 tablets/month) STPristiq ST = requires 60 day consistent trial <strong>of</strong> 2 the following agents (fluoxetine, paroxetine, citalopram,sertraline, bupropion/SR, venlafaxine) in the past 2 yearsdoxepin *SINEQUAN 1duloxetine CYMBALTA 20mg 2 QL (60 capsules/month) STduloxetine CYMBALTA 30mg 2 QL (60 capsules/month) STduloxetine CYMBALTA 60mg 2 QL (30 capsules/month) STCymbalta ST = (depression) requires 60 day consistent trial <strong>of</strong> 2 the following agents (fluoxetine,paroxetine, citalopram, sertraline, bupropion/SR, venlafaxine) in the past 2 years; (fibromyalgia, DPN)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty <strong>Drug</strong>s 12 2-<strong>Tier</strong> (open) <strong>Drug</strong> BenefitGuide 09/01/13