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

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methylphenidate METHYLIN (chewable) 10mg 2methylphenidate METHYLIN (suspension) 5mg/ml 2methylphenidate METHYLIN (suspension) 10mg/ml 2methylphenidate *METHYLIN (tablets) 5mg 1methylphenidate *METHYLIN (tablets) 10mg 1methylphenidate *METHYLIN (tablets) 20mg 1methylphenidate *METHYLIN ER 1methylphenidate *RITALIN 5mg 1methylphenidate *RITALIN 10mg 1methylphenidate *RITALIN 20mg 1methylphenidate CR *RITALIN SR 1methylphenidate CR *METADATE CD 2methylphenidate SA *CONCERTA 18mg 2methylphenidate SA *CONCERTA 27mg 2methylphenidate SA *CONCERTA 36mg 2methylphenidate SA *CONCERTA 54mg 2methylphenidate SR *Ritalin LA 10mg 1methylphenidate SR *Ritalin LA 20mg 1methylphenidate SR *Ritalin LA 30mg 1methylphenidate SR *Ritalin LA 40mg 1modafinil *PROVIGIL 100mg 2modafinil *PROVIGIL 200mg 2sodium oxybate XYREM 24-F Misc Psychotherapeutic and Neurological AgentsGeneric Name Brand NameTieramitriptyline-chlordiazepoxide LIMBITROL 2disulfiram *ANTABUSE 1dextromethorphan quindine NUEDEXTA 2donepezil *ARICEPT 1ergoloid mesylates *HYDERGINE 1galantamine *RAZADYNE 1galantamine *RAZADYNE ER 1guanfacine INTUNIV 2menantine NAMENDA 2olanzapine-fluoxetine *SYMBYAX 2QL (180 tablets/month)QL (1800 mls/month)QL (900 mls/month)QL (180 tablets/month)QL (180 tablets/month)QL (60 tablets/month)QL (90 tablets/month)QL (180 tablets/month)QL (180 tablets/month)QL (90 tablets/month)QL (90 tablets/month)QL (30 capsules/month)QL (30 tablets/month)QL (30 tablets/month)QL (60 tablets/month)QL (30 tablets/month)QL (30 capsules/month)QL (30 capsules/month)QL (60 capsules/month)QL (30 capsules/month)PA QL (30 tablets/month)PA QL (60 tablets/month)PANotesQL (30 tablets/month)QL (60 tablets/month)QL (30 capsules/month)QL (30 tablets/month)QL (60 tablets/month)STSymbyax ST = requires failure of either Risperidone and Quetiapine or Seroquel XR OR failure to two preferredantidepressants (depending on diagnosis)perphenazine-amitriptyline *ETRAFON 1pimozide ORAP 2rivastigmine *EXELON 1 QL (60 capsules/month)rivastigmine EXELON PATCH 2 QL (30 patches/month)tacrine COGNEX 2tetrabenazine XENAZINE 24-G AnticonvulsantsGeneric Name Brand NameTierNotescarbamazepine *TEGRETOL (NTI) 2carbamazepine SR *CARBATROL 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 16 2-Tier (open) Drug BenefitGuide 09/01/13
carbamazepine SR *TEGRETOL XR 1clobazam ONFI 2clonazepam *KLONOPIN 1diazepam rectal *DIASTAT 1divalproex sodium EC *DEPAKOTE 1ethosuximide *ZARONTIN 1ethotoin PEGANONE 2ezogabine POTIGA 2gabapentin *GABARONE 1gabapentin *NEURONTIN 100mg 1gabapentin *NEURONTIN 300mg 1gabapentin *NEURONTIN 400mg 1gabapentin *NEURONTIN 600mg 1gabapentin *NEURONTIN 800mg 1gabapentin NEURONTIN (solution) 2lacosamide VIMPAT 2lacosamide VIMPAT (solution) 2lamotrigine *LAMICTAL 1lamotrigine LAMICTAL ODT 2lamotrigine LAMICTAL ODT KIT 2lamotrigine *LAMICTAL STARTER KIT 1lamotrigine *LAMICTAL XR 1lamotrigine *LAMICTAL XR KIT 1levetiracetam *KEPPRA 1levetiracetam *KEPPRA XR 2methsuximide CELONTIN 2milnacipran SAVELLA 2milnacipran SAVELLA TITRATION PAK 2oxcarbazepine *TRILEPTAL 100mg 1oxcarbazepine *TRILEPTAL 300mg 1oxcarbazepine *TRILEPTAL 600mg 1phenytoin *DILANTIN (NTI) 2pregabalin LYRICA 25mg 2pregabalin LYRICA 50mg 2pregabalin LYRICA 75mg 2pregabalin LYRICA 100mg 2pregabalin LYRICA 150mg 2pregabalin LYRICA 200mg 2pregabalin LYRICA 225mg 2pregabalin LYRICA 300mg 2pregabalin LYRICA SOLUTION 2QL - Quantity LimitsLyrica ST = requires 30 day trial of Gabapentin in the past 2 yearsprimidone *MYSOLINE 1rufinamide BANZEL 2rufinamide BANZEL suspension 2 QL (80 mls/day)tiagabine *GABITRIL 1topiramate *TOPAMAX 1AL - Age LimitsPAQL (1 kit/month)QL (240 capsules/month)QL (360 capsules/month)QL (270 capsules/month)QL (180 tablets/month)QL (120 tablets/month)QL (60 tablets/month)QL (1 kit/month)QL (1 kit/month)QL (1 kit/month)QL (60 capsules/month)QL (1 kit/month)QL (60 tablets/month)QL (90 tablets/month)QL (120 tablets/month)QL (90 capsules/month) STQL (90 capsules/month) STQL (90 capsules/month) STQL (90 capsules/month) STQL (90 capsules/month) STQL (90 capsules/month) STQL (60 capsules/month) STQL (60 capsules/month) STQL STQL (90 tablets/month)PA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 17 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 and 16: methazolamide *NEPTAZANE 1methyclot
Page 17 and 18: equires 30 day trial of Gabapentin
Page 19: lithium carbonate CR *ESKALITH CR 1
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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