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

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metaxalone SKELAXIN 2methocarbamol *ROBAXIN 1orphenadrine citrate *NORFLEX 1tizanidine *ZANAFLEX 19-H Miscelleanous Neuromuscular AgentsGeneric Name Brand NameTierpyridostigmine *MESTINON 1riluzole *RILUTEK 2QL (240 tablets/month)NotesQL (60 tablets/month)VITAMINS & HEMATOLOGICALS (drugs to treat vitamin deficiencies and other blood disorders)10-A VitaminsGeneric Name Brand NameTierNotescalcitriol *ROCALTROL 1docercalciferol HECTOROL 2ergocalciferol [vitamin D] *CALCIFEROL 1paricalcitol [vitamin D] ZEMPLAR 2 QL (30 capsules/month) SPphytonadione MEPHYTON 2potassium aminobenzoate POTABA 2 M10-B MultivitaminsGeneric Name Brand NameTierNotesB complex-vit C-FA *NEPHROCAPS 1fe bisglycin-fe polysac NIFEREX GOLD 2 QL (30 tablets/month)multi vitamin TANDEM F 2ped multi vitamin-fluoride *POLY-VI-FLOR 1ped multi vitamin-fluoride-FE *POLY-VI-FLOR-FE 1ped vitamins ACD-fluoride *TRI-VI-FLOR 1ped vitamins ACD-fluoride-FE *TRI-VI-FLOR-FE 1pnv-select 1prenatal FE-CBN-DSS-Methylfol-FA *PRENATE ELITE 1prenatal low iron 1prenat-fe poly cmplx-fe heme PREFERA OB 2 QL (30 tablets/month)prenat-fe poly cmplx-fe heme PREFERA OB + DHA 2 QL (60 tablets/month)prenatal mv w/fe poly-fa SELECT-OB+DHA 2prenatal vitamin-FE-bisglycinate-FA *NATELLE C 1 QL (30 tablets/month)prenatal vitamins-fe- bis-fe prot succ-fa-ca- *DUET DHA EC 1prenatal vitamins-FE-FA *STUARTNATAL 1prenatal vitamins-FE-FA *PRECARE 1prenatal vitamins-iron carbonyl-FA *NESTABS 1prenatal w/dss iron carbonyl-fa ATABEX EC 2prenatal w/fe fum-l methylfolate NEEVO DHA 2prenate w/fe fum-fe poly-fa omega 3 CONCEPT DHA 2prenate w/o a w/fe fum-fe poly-fa CONCEPT OB 2prenate w/o Vit A w/ FE NATELLE ONE 2prenate vitamin FE-Fum-Lmethylfol-FA-CA *PRENATE DHA 1 QL (30 tablets/month)prenate w/o a w/fecbn-egl-dss-fa & dha CITRANATAL ASSURE PAK 2 QL (60 tablets/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 36 2-Tier (open) Drug BenefitGuide 09/01/13
10-C MineralsGeneric Name Brand NameTiercyanocobalamin (nasal) NASCOBAL 2cyanocobalamin inj 1FA-vit B6-vit B12 *FOLBEE 1FA-vit B6-vit B12 *FOLGARD RX 1FA-vit B6-vit B12 *FOLTX TABLETS 1FE fum-FA-DSS-B complex-vit C NEPHRON FA 2FE fum-fe poly-fa-c-b3 INTEGRA F 2FE fum-iron polysacch complex INTEGRA PLUS 2FE fum-vit C-vit B12-FA *CHROMAGEN FORTE 2folic acid 1L-methylfolate ZERVALX 2L-methylfolate B12 B6 METANX CAPSULES 2L-methylfolate B12 B6 *METANX TABLETS 1L-methylfolate B12 B6 B2 CEREFOLIN 2NotesQL (30 tablets/month)QL (30 tablets/month)QL (60 tablets/month)MQL (30 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (30 tablets/month)10-D AnticoagulantsGeneric Name Brand NameTierNotesapixaban ELIQUIS 2 PAdibigatran PRADAXA 2 PArivaroxaban XARELTO 2 QLwarfarin *COUMADIN (NTI) 210-E Miscelleanous HematologicalsGeneric Name Brand NameTierNotesaminocaproic acid *AMICAR 1anagrelide *AGRYLIN 1cilostazol *PLETAL 1 QL (60 tablets/month)clopidogrel *PLAVIX 1 Mdipyridamole *PERSANTINE 1 Mdipyridamole-aspirin SR AGGRENOX 2 QL (60 capsules/month)pentoxifylline *TRENTAL 1 QL (90 tablets/month)prasugrel EFFIENT 2 QL (30 tablets/month)sodium polystyrene sulfonate *KAYEXALATE 1ticagrelor BRILINTA 2ticlopidine *TICLID 1 QL (60 tablets/month)tranexamic acid *LYSTEDA 1 QL (5 days therapy/28 days)EYE, EAR AND THROAT (drugs to treat eye, ear and throat conditions)11-A Ophthalmic Anti-infectivesGeneric Name Brand NameTierNotesazithromycin ophth AZASITE 2 QL (5 ml/month)bacitracin ophth 1bacitracin-polymyxin B ophth *POLYSPORIN ophth 1besifloxacin ophth BESIVANCE 2 QL (5 ml/month)ciprofloxacin ophth *CILOXAN 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 37 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 and 38: dihydrocodeine compound SYNALGOS DC
Page 39: penicillamine CUPRIMINE 2penicillam
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

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

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