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

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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
pramoxine-HC cream *PRAMOSONE 1pramoxine-HC foam EPIFOAM 2prednicarbate *DERMATOP 1sodium hyaluronate *HYLIRA 1triamcinolone acetonide *KENALOG 1** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply5-I Miscellaneous TopicalsGeneric Name Brand NameTierNotesalefacept AMEVIVE 2aluminum chloride *DRYSOL 1aluminum chloride-alcohol XERAC-AC 2becaplermin REGRANEX 2 PAcollagenase SANTYL 2fluorouracil *EFUDEX 1fluorouracil CARAC 2fluorouracil FLUOROPLEX 2imiquimod *ALDARA 1 QL (12 packets/month)lidocaine (topical) *XYLOCAINE 1lidocaine patch LIDODERM 2 PAlidocaine-hydrocortisone *ANAMANTLE 1lidocaine-tetracaine SYNERA PATCH 2 QL (4 patches/month)lidocaine-prilocaine *EMLA cream 1 QL (30 gm/month)pimecrolimus ELIDEL 2 QL (1 tube/month)podofilox *CONDYLOX 2podophyllum resin PODOCON 2selenium sulfide shampoo *SELSUN 1sulfacetamide *OVACE 1sulfacetamide *OVACE PLUS SHAMPOO 1% 1sulfacetamide-urea lotion *CARMOL SCALP 1tacrolimus topical PROTOPIC 2 QL (1 tube/month)trypsin-castor oil-peruvian balsam *XENADERM 1urea *KERALAC 1urea *VANAMIDE 1urea KERAFOAM 2 QL (60 gm/month)urea (carbamide) *CARMOL 40 1urea in zinc KEROL AD 2ENDOCRINE AND HORMONES (drugs to treat metabolic or hormone conditions, ie diabetes)6-A CorticosteroidsGeneric Name Brand NameTiercortisone acetate *CORTONE 1dexamethasone *DECADRON 1fludrocortisone *FLORINEF 1hydrocortisone acetate *CORTEF 1methylprednisolone *MEDROL 1prednisolone MILIPRED DP PAK 2prednisolone *PRELONE 1QL - Quantity LimitsAL - Age LimitsNotesPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 21 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 and 20: lithium carbonate CR *ESKALITH CR 1
Page 21 and 22: carbamazepine SR *TEGRETOL XR 1clob
Page 23: clindamycin-benzoyl peroxide gel *D
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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