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

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citric acid-D-gluconic acid RENACIDIN 2citric acid-sodium citrate *BICITRA 1dutasteride AVODART 2finasteride *PROSCAR 1methylergonovine METHERGINE 2oxybutynin gel GELNIQUE 2pentosan polysulfate sodium ELMIRON 2phenazopyridine *PYRIDIUM 1potassium citrate CR *UROCIT-K 1potassium phosphate K-PHOS 2silodosin RAPAFLO 2tadalafil CIALIS 2tamsulosin *FLOMAX 1tiopronin THIOLA 2POTASSIUM CHLORIDE 2QL (30 capsules/month)QL (30 tablets/month)QL (30 packets/month)QL (90 capsules/month)QL (30 capsules/month)PAQL (60 capsules/month)MUSCULOSKELETAL AND PAIN (drugs to treat pain and muscle conditions)9-A Analgesics-Non-NarcoticGeneric Name Brand NameTierNotesAPAP-butalbital *PHRENILIN 1 QL (360 tablets/month)APAP-caffeine-butalbital *ESGIC PLUS 1 QL (360 tablets/month)APAP-caffeine-butalbital *FIORICET 1 QL (360 tablets/month)ASA-caffeine-butalbital *FIORINAL 1choline-mag salicylates *TRILISATE 1salsalate *DISALCID 1DIFLUNISAL 29-B Analgesics-NarcoticGeneric Name Brand NameTierNotesAPAP-codeine *TYLENOL w/CODEINE 1 QL (390 tablets/month)APAP-hydrocodone *LORCET 10/650mg 1 QL (180 tablets/month)APAP-hydrocodone *LORTAB 1 QL (240 tablets/month)APAP-hydrocodone *MAXIDONE 1 QL (150 tablets/month)APAP-hydrocodone *NORCO 1 QL (360 tablets/month)APAP-hydrocodone *VICODIN 1 QL (240 tablets/month)APAP-hydrocodone *VICODIN ES 1 QL (150 tablets/month)APAP-hydrocodone *VICODIN HP 1 QL (180 tablets/month)APAP-hydrocodone ZAMICET 2 QL (360 mls/month)APAP-hydrocodone ZYDONE 2 QL (300 mls/month)ASA-codeine *EMPIRIN w/CODEINE 1ASA-caffeine-but-codeine *FIORINAL w/CODEINE 1buprenorphine BUTRANS 2 STButrans ST = Requires a 30 day trial of at least 2 of the following within the past 6 months:hydrocodone/apap, tramadol, apap with codeine, oxycodone/apap,and/or morphine IR.buprenorphine *SUBUTEX 1 PAbuprenorphine naloxone SUBOXONE FILM TAB 2 PAbuprenorphine naloxone SUBOXONE TABLETS 2 PAbutorphanol *STADOL NS 1 QL (1 bottle/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 32 2-Tier (open) Drug BenefitGuide 09/01/13
dihydrocodeine compound SYNALGOS DC 2fentanyl citrate nasal LAZANDA 2fentanyl citrate SL ABSTRAL 2fentanyl lollipop *ACTIQ 1fentanyl patch *DURAGESIC 1PAPAQL (120 lozenges/month) PAQL (10 patches/month) STDuragesic ST = requires 30 day trial fill of MSSR in past 2 yearsPAQL (120 lozenges/month) PAQL (360 tablets/month)QL (360 tablets/month)QL (360 tablets/month)QL (30 tablets/month)QL (480 tablets/month)QL (480 tablets/month)fentanyl transmucosal film ONSOLIS 2fentanyl transmucosal lozenge FENTORA 2hydromorphone *DILAUDID 2mg 1hydromorphone *DILAUDID 4mg 1hydromorphone *DILAUDID 8mg 1hydromorphone ER EXALGO 2ibuprofen-hydrocodone *VICOPROFEN 1ibuprofen-hydrocodone *REPREXAIN 1ketorolac tromethamine nasal SPRIX NASAL 2meperidine *DEMEROL 1morphine AVINZA 30mg 2morphine AVINZA 60mg 2morphine AVINZA 90mg 2morphine AVINZA 120mg 2QL (1 bottle/day; 1 box/5 bottles per month )QL (360 tablets/month)QL (30 capsules/month) STQL (30 capsules/month) STQL (60 capsules/month) STQL (90 capsules/month) STAvinza ST = requires 30 day trial fill of BOTH MSSR and Opana ER in the past 2 yearmorphine sulfate *ROXANOL 1morphine sulfate SR *MS CONTIN 1naltrexone *REVIA 1naltrexone VIVITROL 2 PAoxycodone *OXYIR 1oxycodone *ROXICODONE 1 QL (360 tablets/month)oxycodone SR OXYCONTIN 2 QL (60 tablets/month) STOxycontin ST = requires 30 day trial fill of BOTH MSSR and Opana ER in the past 2 yearoxycodone-APAP *PERCOCET 2.5-325mg 1 QL (360 tablets/month)oxycodone-APAP *PERCOCET 5-325mg 1 QL (360 tablets/month)oxycodone-APAP *PERCOCET 7.5-325mg 1 QL (360 tablets/month)oxycodone-APAP *PERCOCET 10-325mg 1 QL (360 tablets/month)oxycodone-APAP *PERCOCET 7.5-500mg 1 QL (240 tablets/month)oxycodone-APAP *PERCOCET 10-650mg 1 QL (180 tablets/month)oxycodone-ASA *PERCODAN 1 QL (360 tablets/month)oxycodone-ibuprofen COMBUNOX 2 QL (7 day treatment; 4 tablets/day)oxymorphone *OPANA 2 QL (180 tablets/month)oxymorphone ER OPANA ER 2 QL (60 tablets/month)pentazocine-naloxone *TALWIN NX 1propoxyphene-APAP DARVOCET A 2 QL (240 tablets/month)propoxyphene napsylate DARVON-N 2 QL (180 tablets/month)tapentadol NUCYNTA 3 QL (180 tablets/month)tapentadol SR NUCYNTA ER 3 QL (60 tablets/month)tramadol *ULTRAM 1 QL (240 tablets/month)tramadol-APAP ULTRACET 2 QL (240 tablets/month)tramadol ER ULTRAM ER 100mg 2 QL (90 tablets/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 33 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 and 34: ismuth subcit-metronidazole-tetracy
Page 35: sulfasalazine EC *AZULFIDINE EN 1ur
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 87 and 88:
Alphabetical IndexDrug Name PDL Sec
Page 89:
Alphabetical IndexDrug Name PDL Sec
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2-Tier Open Preferred Drug List - Health Plan of Nevada

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