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

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tramadol ER ULTRAM ER 200mg 2tramadol ER ULTRAM ER 300mg 2CODEINE SULFATE 2METHADONE 29-C Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)Generic Name Brand Namecelecoxib CELEBREX 50mg 2celecoxib CELEBREX 100mg 2celecoxib CELEBREX 200mg 2celecoxib CELEBREX 400mg 2diclofenac *VOLTAREN 25mg 1diclofenac *VOLTAREN 50mg 1diclofenac *VOLTAREN 75mg 1diclofenac misoprostol *ARTHROTEC 2diclofenac potassium *CATAFLAM 1diclofenac SR *VOLTAREN XR 1etodolac *LODINE 200mg 1etodolac *LODINE 300mg 1etodolac *LODINE 400mg 1etodolac *LODINE 500mg 1etodolac SR *LODINE XL 600mg 1fenoprofen *NALFON 1flurbiprofen *ANSAID 1ibuprofen *MOTRIN 1indomethacin *INDOCIN 1indomethacin CR *INDOCIN SR 1ketoprofen ORUDIS 2ketoprofen SR ORUVAIL 2ketorolac *TORADOL 1lansoprazole-naproxen PREVACID NAP KIT 2meclofenamate *MECLOMEN 1mefenamic acid *PONSTEL 1meloxicam *MOBIC 7.5mg 1meloxicam *MOBIC 15mg 1nabumetone *RELAFEN 1naproxen *NAPROSYN 1naproxen sodium *ANAPROX 1oxaprozin *DAYPRO 1piroxicam *FELDENE 1sulindac *CLINORIL 1tolmetin sodium *TOLECTIN 1QL (30 tablets/month)QL (30 tablets/month)TierNotesQL (60 capsules/month)QL (60 capsules/month)QL (60 capsules/month)QL (30 capsules/month)QL (240 tablets/month)QL (120 tablets/month)QL (90 tablets/month)QL (120 tablets/month)QL (120 tablets/month)QL (90 capsules/month)QL (90 capsules/month)QL (90 tablets/month)QL (90 tablets/month)QL (60 tablets/month)QL (60 capsules/month)QL (20 tablets/month)QL (60 tablets/month)QL (30 tablets/month)QL (90 tablets/month)9-D Anti-Rheumatic AgentsGeneric Name Brand NameTierNotesauranofin RIDAURA 2deferasirox EXJADE 2 PA SPleflunomide *ARAVA 1 QL (30 tablets/month)methotrexate 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 34 2-Tier (open) Drug BenefitGuide 09/01/13
penicillamine CUPRIMINE 2penicillamine DEPEN 29-E Migraine ProductsGeneric Name Brand NameTierNotesalmotriptan AXERT 2 QL (6 tablets/fill; 2 fills/month) STAxert ST = requires one fill of sumatriptan AND Relpax in past 2 yearsAPAP-isometh-caffeine PRODRIN 2 QL (240 tablets/month)APAP-isometh-dichlor hydrate *MIDRIN 1dihydroergotamine (nasal) *MIGRANAL 2divalproex sodium (migraine) *DEPAKOTE ER 1eletriptan RELPAX 2 QL (6 tablets/fill; 2 fills/month)ergotamine-caffeine *CAFERGOT 1 QL (40 tablets/month)ergotamine-phenobarb-belladona 1frovatriptan FROVA 2 QL (6 tablets/fill; 2 fills/month) STFrova ST = requires one fill of sumatriptan AND Relpax in past 2 yearsnaratriptan *AMERGE 1 QL (6 tablets/fill; 2 fills/month)rizatriptan *MAXALT 2 QL (6 tablets/fill; 2 fills/month)rizatriptan *MAXALT MLT 2 QL (6 tablets/fill; 2 fills/month)sumatriptan *IMITREX 2 QL (9 tablets/fill; 2 fills/month)sumatriptan *IMITREX NASAL 1 QL (6 vials/month)sumatriptan SUMATRIPTAN INJ 2 QL (2 kits/fill; 2 fills/month)zolmitriptan *ZOMIG 2 QL (6 tablets/fill; 2 fills/month)zolmitriptan ZOMIG NASAL 2 QL (6 vials/month)Zomig Nasal ST = requires one fill of sumatriptan AND Relpax in past 2 yearszolmitriptan *ZOMIG ZMT 2 QL (6 tablets/fill; 2 fills/month)9-F GoutGeneric Name Brand NameTierNotesallopurinol *ZYLOPRIM 1colchicine COLCRYS 2colchicine-probenecid *COLBENEMID 1febuxostat ULORIC 2 QL (30 tablets/month) STUloric ST = requires fill of 2 consecutive months of allopurinol in past 120 daysglycerol phenylbutyrate RAVICTI 2probenecid *BENEMID 19-G Musculoskeletal Therapy AgentsGeneric Name Brand NameTierNotesbaclofen *LIORESAL 1carisoprodol *SOMA 1 QL (120 tablets/month)carisoprodol-ASA *SOMA COMPOUND 1 QL (120 tablets/month)carisoprodol-ASA-codeine *SOMA CPD w/CODEINE 1 QL (120 tablets/month)chlorzoxazone *PARAFON FORTE 1cyclobenzaprine *FLEXERIL 5mg 1 QL (90 tablets/month)cyclobenzaprine *FLEXERIL 10mg 1cyclobenzaprine *AMRIX 1 QL (30 capsules/month)cyclobenzaprine *FEXMID 2 QL (90 tablets/month) STFexmid ST = requires 2 fills of generic cyclobenzaprine in past 2 yearsdantrolene *DANTRIUM 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 35 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 and 36: sulfasalazine EC *AZULFIDINE EN 1ur
Page 37: dihydrocodeine compound SYNALGOS DC
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 89:
Alphabetical IndexDrug Name PDL Sec
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2-Tier Open Preferred Drug List - Health Plan of Nevada

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