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

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ondansetron *ZOFRAN ODT 4mg 1ondansetron *ZOFRAN ODT 8mg 1scopolamine patch TRANSDERM-SCOP 2trimethobenzamide *TIGAN 17-G Digestive AidsGeneric Name Brand NameTieramylase-lipase-protease PANCREASE MT 2amylase-lipase-protease KU-ZYME 2amylase-lipase-protease KU-ZYME-HP 2amylase-lipase-protease CREON 2amylase-lipase-protease VIOKASE 2amy-lip-prot dr ULTRASE 2amy-lip-prot dr ULTRASE MT 2miglustat ZAVESCA 2pancrelipase ZENPEP 2pegademase ADAGEN 2sacrosidase SUCRAID 2sodium phenylbutyrate BUPHENYL 27-H Miscelleanous GastrointestinalGeneric Name Brand Nameadefovir HEPSERA 2alosetron LOTRONEX 2balsalazide *COLAZAL 1budesonide SR *ENTOCORT EC 1budesonide SR UCERIS 2calcium acetate (phosphate binder) *PHOSLO 1calcium acetate (phosphate binder) ELIPHOS 2crofelemer FULYZAQ 2cysteamine bitartrate PROCYSBI 2glycopyrroate CUVPOSA 2hycosamine-phenyltoloxamine DIGEX NF 2lamivudine (hepatitis) EPIVIR HBV 2lanthanum FOSRENOL 500mg 2lanthanum FOSRENOL 750mg 2lanthanum FOSRENOL 1000mg 2linaclotide LINZESS 2lubiprostone AMITIZA 2mesalamine CANASA 2mesalamine LIALDA 2mesalamine CR APRISO 2mesalamine CR PENTASA 2mesalamine enema *ROWASA 1methylnaltrexone bromide RELISTOR 2metoclopramide *REGLAN 1sevelamer RENAGEL 2sevelamer RENVELA 2sulfasalazine *AZULFIDINE 1QL - Quantity LimitsAL - Age LimitsQL (30 tablets/fill; 2 fills/month)QL (30 tablets/fill; 2 fills/month)QL (10 patches/month)TierNotesQL (30 tablets/month) SPQL (60 tablets/month) PAQL (270 capsules/month)QL (90 capsules/month)PAQLPANotesPAPA SPAL (limited to 16 years of age and under)QL (30 tablets/month) SPQL (150 tablets/month)QL (150 tablets/month)QL (120 tablets/month)QL (120 tablets/month)PA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 30 2-Tier (open) Drug BenefitGuide 09/01/13
sulfasalazine EC *AZULFIDINE EN 1ursodiol *ACTIGALL 1ursodiol *URSO 1ursodiol *URSO FORTE 1BXN MOUTHWASH 2DIPENTUM 2GENITOURINARY (drugs to treat genital and bladder or kidney conditions)8-A Urinary Anti-InfectivesGeneric Name Brand NameTierNotesfosfomycin MONUROL 2 QL (1 packet/month)methenamine-NA biphosphate *UROQID 1nitrofurantoin macro *MACROBID 1nitrofurantoin macrocrystals *MACRODANTIN 1nitrofurantoin susp FURADANTIN 28-B Urinary AntispasmodicsGeneric Name Brand NameTierNotesbethanechol *URECHOLINE 1darifenacin ENABLEX 2 QL (30 tablets/month)fexoterodine TOVIAZ 2 QL (30 tablets/month)flavoxate *URISPAS 1 QL (240 tablets/month)mirabegron MYRBETRIQ 2oxybutynin *DITROPAN 1 QL (240 tablets/month)oxybutynin CR *DITROPAN XL 5mg 1 QL (30 tablets/month)oxybutynin CR *DITROPAN XL 10mg 1 QL (60 tablets/month)oxybutynin CR *DITROPAN XL 15mg 1 QL (60 tablets/month)oxybutynin patches OXYTROL 2 QL (8 patches/month)solifenacin VESICARE 2 QL (30 tablets/month)tolterodine DETROL 2 QL (60 tablets/month)trospium *SANCTURA 1 QL (60 tablets/month)8-C Vaginal ProductsGeneric Name Brand NameTierNotesclindamycin vaginal *CLEOCIN vaginal cream 1clindamycin vaginal CLINDESSE 2 QL (6 gm/fill)estradiol vaginal ESTRACE vaginal 2estradiol vaginal VAGIFEM 2estradiol vaginal ring ESTRING 2 QL (1 ring/3 months)estradiol vaginal ring FEMRING 2 QL (1 ring/3 months)estrogens (conjugated) vaginal PREMARIN vaginal 2metronidazole vaginal *METROGEL vaginal 1metronidazole vaginal *VANDAZOLE 1nystatin vaginal 1sulfanilamide vaginal AVC vaginal 2terconazole vaginal TERAZOL 2triple sulfas vaginal 18-D Miscelleanous Genitourinary AgentsGeneric Name Brand NameTierNotesQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 31 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 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: ismuth subcit-metronidazole-tetracy
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 85 and 86:
Alphabetical IndexDrug Name PDL Sec
Page 87 and 88:
Page 89:
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2-Tier Open Preferred Drug List - Health Plan of Nevada

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