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

venlafaxine *EFFEXOR 1 QL (90 tablets/month)venlafaxine SR *EFFEXOR XR (cap) 37.5mg 1 QL (90 capsules/month)venlafaxine SR *EFFEXOR XR (cap) 75mg 1 QL (90 capsules/month)venlafaxine SR *EFFEXOR XR (cap) 150mg 1 QL (60 capsules/month)venlafaxine SR *EFFEXOR XR (cap) 225mg 1 QL (30 capsules/month)venlafaxine SR *VENLAFAXINE XR (tab) 37.5mg 1 QL (90 tablets/month)venlafaxine SR *VENLAFAXINE XR (tab) 75mg 1 QL (90 tablets/month)venlafaxine SR *VENLAFAXINE XR (tab) 150mg 1 QL (60 tablets/month)venlafaxine SR *VENLAFAXINE XR (tab) 225mg 1 QL (30 tablets/month)vilazodone VIIBRYD 2 QL (30 tablets/month) STViibryd ST = requires 60 day consistent trial of 2 the following agents (fluoxetine, paroxetine, citalopram,sertraline, bupropion/SR, venlafaxine) in the past 2 years4-C Hypnotics (Sleep Aids)Generic Name Brand NameTierNoteschloral hydrate SOMNOTE 2estazolam *PROSOM 1eszopiclone LUNESTA 2 QL (30 tablets/month) STLunesta ST = requires 30 day fill of zolpidem in the past 2 yearsflurazepam *DALMANE 1phenobarbital 1ramelteon ROZEREM 2 QL (30 tablets/month) STRozerem ST = requires 30 day fill of zolpidem in the past 2 yearstemazepam *RESTORIL 1 QL (30 capsules/month)triazolam *HALCION 1 QL (15 tablets/fill; 2 fills/month)zaleplon *SONATA 5mg 1 QL (30 capsules/month)zaleplon *SONATA 10mg 1 QL (60 capsules/month)zolpidem *AMBIEN 1 QL (30 tablets/month)zolpidem CR *AMBIEN CR 1 QL (30 tablets/month)4-D AntipsychoticsGeneric Name Brand NameTierNotesaripiprazole ABILIFY 2 QL (30 tablets/month)asenapine SAPHRIS 2 PA ST QL (60 tablets/month)Saphris ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearschlorpromazine *THORAZINE 1clozapine *FAZACLO 2 PA STFazaclo ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearsclozapine *CLOZARIL (NTI) 2 PA STClozaril ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearsfluphenazine *PROLIXIN 1haloperidol *HALDOL 1iloperidone FANAPT 2 QL (60 tablets/month) PA STFanapt ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis inpast 2 yearslithium carbonate *ESKALITH 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 14 2-Tier (open) Drug BenefitGuide 09/01/13