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

More documents

Recommendations

Info

prednisolone PREDNISOLONE 5MG 2prednisolone sodium *ORAPRED 1prednisolone sodium *PEDIAPRED 1prednisolone sodium phosphate VERIPRED 2prednisone 16-B AndrogensGeneric Name Brand NameTierdanazol *DANOCRINE 1methyltestosterone ANDROID 2methyltestosterone METHITEST 2testosterone ANDRODERM 2testosterone FORTESTA 2testosterone TESTIM 2testosterone buccal system STRIANT 2testosterone TD sol AXIRON 26-C EstrogensGeneric Name Brand Nameesterified estrogens 1esterified estrogens MENEST 2estradiol *ESTRACE 1estradiol gel ESTROGEL 2estradiol patch *CLIMARA 1estradiol patch VIVELLE 2estradiol patch VIVELLE DOT 2estradiol patch ALORA 2estradiol patch ESCLIM 2estradiol patch ESTRADERM 2estradiol patch MENOSTAR 2estradiol spray EVAMIST 2estradiol TD gel DIVIGEL 2estradiol transdermal ESTRASORB 2estradiol-levonorgestrel patch CLIMARA PRO 2estradiol-norethindrone ACTIVELLA 2estradiol-norethindrone patch COMBIPATCH 2estradiol-norgestimate ORTHO-PREFEST 2estrogens (conjugated) PREMARIN 2estrogens (conjugated synthetic) CENESTIN 2estrogens (conjugated synthetic) ENJUVIA 2estrogen-medroxyprogesterone PREMPHASE 2estrogen-medroxyprogesterone PREMPRO 2estrogens-methyltestosterone *ESTRATEST 1estrogens-methyltestosterone *ESTRATEST HS 1estropipate *OGEN 1ethinyl estradiol-norethindrone FEMHRT 2ospemifene OSPHENA 26-D ContraceptivesGeneric Name Brand NameQL - Quantity LimitsAL - Age LimitsTierTierNotesQL (30 patches/month) PAPAPAPA QL (60 patches/month)PANotesMMQL (93gm/month)QL (4 patches/month)QL (8 patches/month)QL (8 patches/month)QL (8 patches/month)QL (8 patches/month)QL (4 patches/month)QL (9 ml/month)QL (1 tube/month)QL (56 packets/month)QL (4 patches/month)QL (1 dialpak/month)QL (8 patches/month)QL (30 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (1 dialpak/month)QL (1 dialpak/month)QL (1 dialpak/month)NotesPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 22 2-Tier (open) Drug BenefitGuide 09/01/13
MONOPHASIC PRODUCTSethinyl estradiol (EE) /desogestrel productsApri, Emoquette, Reclipsen, Solia *ORTHO CEPT 1 QL (28 tablets/21 days)DESOGEN 2 QL (28 tablets/21 days)mestranol/norethindroneNecon 1/150 *NORINYL 1 QL (28 tablets/21 days)EE/norgestimate productsORTHO CYCLEN 1 QL (28 tablets/21 days)Sprintec, Previfem, Mononessa 2 QL (28 tablets/21 days) STSprintec, Previfem, Mononessa ST = requires trial of brand Ortho Cyclen within the last 120 daysEE/norethindrone productsrtrel,Cyclafem,Necon,Norinyl,Alyacen *ORTHO NOVUM 1/35 1 QL (28 tablets/21 days)LOESTRIN 24 2 QL (28 tablets/month)Junel Fe, Gildess Fe, Microgestin Fe *LOESTRIN FE 1 QL (28 tablets/21 days)Microgestin, Junel *LOESTRIN 2 QL (28 tablets/21 days)Balziva, Zenchent FE, Briellyn *OVCON-35 2 QL (28 tablets/21 days)Nortrel, Necon, Brevicon *MODICON 1 QL (28 tablets/21 days)EE/drospirenone productsYAZ 2 QL (28 tablets/21 days)Gianvi, Loryna, 2 QL (28 tablets/21 days) STGianvi, Loryna, ST = requires trial of brand Yaz within the last 120 daysYASMIN 1 QL (28 tablets/21 days)Ocella, Zarah, Syeda 2 QL (28 tablets/21 days) STOcella , Zarah, Syeda ST = requires trial of brand Yasmin in past 120 daysEE/norgestrel productsLow-ogestrel, Cryselle *LO/OVRAL 1 QL (28 tablets/21 days)EE/ethynodiol productsKelnor 1 QL (28 tablets/21 days)Zovia 1/35 1 QL (28 tablets/21 days)EE/levonorgestrel productsAltavera, Levora, Marlissa, Portia *NORDETTE 1 QL (28 tablets/21 days)Aviane,Lessina,Lutera,Sronyx,Orsythia *ALESSE 1 QL (28 tablets/21 days)Jolessa, Introvale, Quasense *SEASONALE 1 QL (91 tablets/3 months)Amethyst *LYBREL 1 QL (28 tablets/21 days)BIPHASIC PRODUCTSEE-desogestrel/EEKariva, Azurette, Viorele *MIRCETTE 2EE-levonorgestrel/EECamrese Lo, Amethia Lo *LOSEASONIQUE 1Camrese, Amethia, *SEASONIQUE 1EE/norethindrone-EE/norethindroneNecon 10/11 *ORTHO NOVUM 10/11 1LO LOESTRIN FE 2TRIPHASIC PRODUCTSEE/norethindrone-EE/norethindrone-EE/norethindroneQL - Quantity LimitsAL - Age LimitsQL (28 tablets/month)QL (28 tablets/21 days)QL (91 tablets/3 months)QL (28 tablets/21 days)QL (28 tablets/month)PA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 23 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 and 24: clindamycin-benzoyl peroxide gel *D
Page 25: pramoxine-HC cream *PRAMOSONE 1pram
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
Page 77 and 78:
Alphabetical IndexDrug Name PDL Sec
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?