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

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Generic Name Brand NameTierisosorbide dinitrate-hydralazine BIDIL 2ranolazine RANEXA 2NotesQL (60 tablets/month)CENTRAL NERVOUS SYSTEM (drugs that affect the brain)4-A Antianxiety AgentsGeneric Name Brand NameTierNotesalprazolam *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 NameTierNotesamitriptyline *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 of 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 of 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 Drugs 12 2-Tier (open) Drug BenefitGuide 09/01/13
equires 30 day trial of Gabapentin in the past 2 years; (chronic pain) requires 30 day trial of genericNSAIDS and generic narcotics in the past 2 yearsescitalopram *LEXAPRO 5mg 1 QL (45 tablets/month)escitalopram *LEXAPRO 10mg 1 QL (45 tablets/month)escitalopram *LEXAPRO 20mg 1 QL (30 tablets/month)fluoxetine *PROZAC 10mg 1 QL (30 capsules/month)fluoxetine *PROZAC 20mg 1 QL (120 capsules/month)fluoxetine *PROZAC 40mg 1 QL (60 capsules/month)fluoxetine *PROZAC WEEKLY 2 QL (4 capsules/month) STProzac Weekly ST = requires 60 day consistent trial of 2 of the following agents (fluoxetine, paroxetine,citalopram, sertraline, bupropion/SR, venlafaxine) in the past 2 yearsfluoxetine SARAFEM 2 QL (30 capsules/month) STSarafem ST = requires 60 day consistent trial of 2 of the following agents (fluoxetine, paroxetine,citalopram, sertraline, bupropion/SR, venlafaxine) in the past 2 yearsfluvoxamine *LUVOX 1fluvoxamine *LUVOX CR 100mg 1fluvoxamine *LUVOX CR 150mg 1imipramine *TOFRANIL 1imipramine pamoate TOFRANIL PM 2maprotiline *LUDIOMIL 1mirtazapine *REMERON 1mirtazapine soltabs *REMERON SOLTABS 1nefazodone HCL *SERZONE 1 Mnortriptyline *PAMELOR 1 Mparoxetine HCL *PAXIL 10mg 1paroxetine HCL *PAXIL 20mg 1paroxetine HCL *PAXIL 30mg 1paroxetine HCL *PAXIL 40mg 1paroxetine HCL SR *PAXIL CR 12.5mg 1paroxetine HCL SR *PAXIL CR 25mg 1paroxetine HCL SR *PAXIL CR 37.5mg 1QL (90 tablets/month)QL (30 capsules/month)QL (60 capsules/month)QL (30 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (60 tablets/month)QL (45 tablets/month)QL (30 tablets/month) STQL (60 tablets/month) STQL (60 tablets/month) STPaxil CR ST = requires 60 day consistent trial of 2 of the following agents (fluoxetine, paroxetine,citalopram, sertraline, bupropion/SR, venlafaxine) in the past 2 yearsparoxetine mes PEXEVA 10mg 2 QL (30 tablets/month) STparoxetine mes PEXEVA 20mg 2 QL (30 tablets/month) STparoxetine mes PEXEVA 30mg 2 QL (60 tablets/month) STparoxetine mes PEXEVA 40mg 2 QL (45 tablets/month) STPexeva ST = requires 60 day consistent trial of 2 of the following agents (fluoxetine, paroxetine,citalopram, sertraline, bupropion/SR, venlafaxine) in the past 2 yearsphenelzine sulfate *NARDIL 1protriptyline *VIVACTIL 1sertraline HCL *ZOLOFT 25mg 1sertraline HCL *ZOLOFT 50mg 1sertraline HCL *ZOLOFT 100mg 1trazodone *DESYREL 1trimipramine maleate *SURMONTIL 1trimipramine maleate SURMONTIL 2QL - Quantity LimitsAL - Age LimitsQL (45 tablets/month)QL (45 tablets/month)QL (60 tablets/month)PA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 13 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 10 and 11: fludarabine OFORTA 2flutamide *EULE
Page 12: propranolol HCL CR *INDERAL LA 1pro
Page 15: methazolamide *NEPTAZANE 1methyclot
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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Alphabetical IndexDrug Name PDL Sec
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2-Tier Open Preferred Drug List - Health Plan of Nevada

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