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

Generic Name Brand NameTierNotesacitretin *SORIATANE 2acitretin *SORIATANE CK kit 2 QL (1 kit/month)anthralin *PSORIATEC 1calcipotriene *DOVONEX 1 QL (1 tube/month)calcitriol ointment *VECTICAL 1 QL (100 gm/month)methoxsalen OXSORALEN-ULTRA 2tazarotene TAZORAC ** 2 QL (1 tube/month) AL** Larger tube sizes (60 grams or above) will be subject to a 60-day supply limit and 2 copays will apply5-G Scabicides and PediculicidesGeneric Name Brand NameTierNotescrotamiton EURAX 2lindane shampoo *KWELL 1permethrin *ELIMITE 1spinosad *NATROBA 25-H Topical CorticosteroidsGeneric Name Brand NameTierNotesalclometasone *ACLOVATE 1amcinonide *CYCLOCORT 1augmented betamethasone *DIPROLENE 1augmented betamethasone *DIPROLENE AF 1betamethasone dipropionate *DIPROSONE 1betamethasone foam *LUXIQ 2betamethasone valerate *VALISONE 1clobetasol foam *OLUX 1clobetasol propionate *TEMOVATE 1clocortolone CLODERM 2desonide *DESOWEN 1desonide foam VERDESO 2 QL (50 gm/60 days)desoximetasone *TOPICORT 1diclofenac gel VOLTAREN GEL 2 QL (500 gm/month)diflorasone diacetate PSORCON 2 QL (60 gm/month)flucinolone oil DERMA-SMOOTH FS 2fluocinolone acetonide *SYNALAR 1fluocinolone shampoo CAPEX 2fluocinonide *LIDEX 1fluocinonide VANOS 2 QL (1 tube/month)flurandrenolide patch CORDRAN 2fluticasone *CUTIVATE ** 1halcinonide HALOG 2halobetasol *ULTRAVATE 1halobetasol ULTRAVATE KIT 2 QL (1 kit/month)hc lot 2% sal acid sulfur 2-2% SCALACORT DK KIT 2hydrocortisone butyrate *LOCOID CREAM 1 QL (45 gm/month)hydrocortisone butyrate LOCOID LOTION 2hydrocortisone valerate *WESTCORT 1mometasone *ELOCON 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 20 2-Tier (open) Drug BenefitGuide 09/01/13