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

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TWO-Tier (OPEN) Drug Benefit GuideTable of ContentsIntroduction .............................................................. iDrug Benefit Guide .................................................. 1Section 1Section 2Section 3Section 4Section 5Section 6Section 7Section 8Section 9Section 10Section 11Section 12Section 13Section 14Anti-InfectivesCancer and TransplantCardiovascularCentral Nervous SystemDermatologicalsEndocrine and HormonesGastrointestinalsGenitourinaryMusculoskeletal and PainVitamins and HematologicalsEye, Ear, and ThroatRespiratorySelf-Injectable/SpecialtyExclusionsAlphabetical Index ................................................... 48
Two-Tier (OPEN) Drug Benefit GuideIntroductionAs a member of a health plan that includes outpatient prescription drug coverage, you haveaccess to a wide range of effective and affordable medications. The health plan utilizes aPreferred Drug List (PDL) (also known as a drug formulary) as a tool to guide providers toprescribe clinically sound yet cost-effective drugs. This list was established to give you access tothe prescription drugs you need at a reasonable cost. Your out-of-pocket prescription cost islower when you use preferred medications. Please refer to your Prescription Drug Benefit Rideror Evidence of Coverage for specific pharmacy benefit information.The PDL is a list of FDA-approved generic and brand name medications recommended for useby your health plan. The list is developed and maintained by a Pharmacy and Therapeutics(P&T) Committee comprised of actively practicing primary care and specialty physicians,pharmacists and other healthcare professionals. Patient needs, scientific data, drug effectiveness,availability of drug alternatives currently on the PDL and cost are all considerations in selecting"preferred" medications. Due to the number of drugs on the market and the continuousintroduction of new drugs, the PDL is a dynamic and routinely updated document screenedregularly to ensure that it remains a clinically sound tool for our providers.Reading the Drug Benefit GuidePreferred generic and brand name medications are available for the applicable preferred generic(tier 1) or preferred brand name (tier 2) copayment. Certain medications may have quantity, ageor therapeutic supply limitations based on FDA approved dosages, literature documentation orP&T Committee decisions. See your plan documents for a complete list of covered benefits,limitations and exclusions.For your convenience, medications are grouped together based on their therapeutic category (i.e.,Anti-Infectives, Cardiovascular, etc.) and further separated into drug classes (i.e.,Antidepressants, Contraceptives, etc.). Each drug class has a designated section number (i.e., 1-A, 1-B, etc.) and is the reference point noted in the index.The generic or chemical name is listed to the left of the brand or trade name for each drug.Drugs with a generic equivalent available are identified by an asterisk (*) before the commonbrand name of the product (for example, in the listing for ampicillin.....*PRINCIPEN, indicatesthat PRINCIPEN is available as a generic and ampicillin would be dispensed by the pharmacy).Drugs that are not available generically have the brand-name listed in BOLD print (for example,the listing for rivaroxaban.....XARELTO, indicates that there is no generic for XARELTO andthe brand name product will be dispensed).Other abbreviations used throughout the PDL are:• AL = age limitations• NTI = narrow therapeutic index (generic not required)• PA = prior authorization• QL = quantity limitations• SIO = self-injectable/orphan drug• ST = step therapyi
Page 1: Preferred Drug List 2-Tier Open21NV
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 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
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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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