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

Aranelle, Leena *TRI-NORINYL 1 QL (28 tablets/21 days)ORTHO-NOVUM 7/7/7 1 QL (28 tablets/21 days), Necon 7/7/7, Nortrel 7/7/7, Cyclafem 2 QL (28 tablets/21 days) STAlyacen, Necon 7/7/7, Nortrel 7/7/7, Cyclafem ST = requires failure of brand Ortho Novum 7/7/7Tilia FE, Tri Legest FE *ESTROSTEP (FE) 1 QL (28 tablets/21 days)EE/levonogestrel-EE/Levonorgestrel-EE/LevonorgestrelTrivora, Myzilra *ENPRESSE 1/desogestrel-EE/desogestrel-EE/desogestrelCesia, Velivet, Caziant *CYCLESSA 1orgestimate-EE/norgestimate-EE/norgestimateORTHO TRI CYCLEN 1Tri-Sprintec,Tri-Previfem,Trinessa 2Tri-Sprintec, Tri-Previfem, Trinessa ST= requires trial of brand Ortho Tri Cyclenwithin the last 120 daysORTHO TRI CYCLEN LO 2 QL (28 tablets/21 days)4-PHASIC PRODUCTSestradiol-estradiol/dienogest-estradiol/dienogest-estradiolNATAZIA 1 QL (28 tablets/21 days)PROGESTIN ONLY-PRODUCTSNorethindroneORTHO MICRONOR 1 QL (28 tablets/month)Camila, Errin, Heather, Jolivette, Nora Be 2 QL (28 tablets/month) STCamila, Errin, Heather, Jolivette, Nora Be requires failure to brand Ortho MicronorMISCELLANEOUSLevonorgestrelUlipristalEtonogestrel/EENorelgestromin/EENext choice *PLAN B 1PLAN B ONE-STEP 1ELLA 1NUVARING 2ORTHO EVRA 2DIAPHRAMS 1FEMCAP 2QL (28 tablets/21 days)QL (28 tablets/21 days)QL (28 tablets/21 days)QL (28 tablets/21 days) STQL (28 tablets/21 days)QL (1 ring/month)QL (3 patches/month)QL (1 cap/year)6-E ProgestinsGeneric Name Brand NameTierNoteshydroxyprogesterone caproate MAKENA 2 PAmedroxyprogesterone *PROVERA 1norethindrone *AYGESTIN 1progesterone micronized *PROMETRIUM 2progesterone vaginal CRINONE 2 PA6-F Oral Antidiabetics (diabetes)Generic Name Brand NameTierNotesacarbose *PRECOSE 1 QL (90 tablets/month)alogliptin benzoate NESINA 2 STQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 24 2-Tier (open) Drug BenefitGuide 09/01/13