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

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gatifloxacin ophth ZYMAR 2 QL (5 ml/month)gatifloxacin ophth ZYMAXID 2 QL (2.5 ml/month)gentamycin sulfate ophth *GENTAMICIN OINT 3% 1levofloxacin ophth *QUIXIN 1moxifloxacin ophth MOXEZA 2 QL (3 ml/month)moxifloxacin ophth VIGAMOX 2 QL (3 ml/month)neomycin-polymyxin B-gramacidin ophth *NEOSPORIN ophth 1ofloxacin ophth *OCUFLOX 1 QL (10 ml/month)sulfacetamide sodium ophth *BLEPH-10 1tobramycin ophth *TOBREX 1trifluridine ophth *VIROPTIC 1trimethoprim-polymy B ophth *POLYTRIM ophth 111-B Ophthalmics Beta-BlockerGeneric Name Brand NameTierNotesbetaxolol HCL ophth BETOPTIC-S 2brimonidine timolol ophth COMBIGAN 2 QL (5 ml/month)carteolol ophth *OCUPRESS 1dorzolamide-timolol ophth *COSOPT 1dorzolamide-timolol ophth COSOPT PF 2 QL (60 sing-use vials per month)levobunolol ophth *BETAGAN 1metipranolol ophth *OPTIPRANOLOL 1timolol ophth BETIMOL 2 QL (5 ml/month)timolol maleate ophth *TIMOPTIC 1timolol maleate ophth *TIMOPTIC XE 111-C Ophthalmic SteroidsGeneric Name Brand NameTierNotesdexamethasone ophth MAXIDEX 2dexamethasone phosphate ophth *DECADRON ophth 1difluprednate ophth DUREZOL 2fluorometholone ophth FML FORTE 2fluorometholone ophth *FML LIQUIFILM 1fluorometholone ophth FML SOP 2fluorometholone ophth FLAREX 2loteprednol etb-tobramycin ophth ZYLET 2 QL (5 ml/month)loteprednol ophth ALREX 2 QL (5 ml/month)loteprednol ophth LOTEMAX 2 QL (10 ml/month)neomycin-polymyxin-HC ophth *CORTISPORIN OPHTH 1prednisolone ophth *PRED FORTE 1rimexolone ophth VEXOL 2sulfacetamide-prednisolone ophth *BLEPHAMIDE 1tobramycin-dexamethasone ophth *TOBRADEX 1 QL (5 ml/month)11-D Ophthalmic ProstaglandinGeneric Name Brand NameTierNotesbimatoprost ophth LUMIGAN 2 QL (2.5 ml/month)latanoprost ophth *XALATAN 1 QL (2.5 ml/month)tafluprost opth soln ZIOPTAN 2 QL (1 carton (30 vials) per month (QD)travaprost ophth TRAVATAN Z 2 QL (2.5 ml/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 38 2-Tier (open) Drug BenefitGuide 09/01/13
travaprost ophth 1 QL (2.5 ml/month)11-E Ophthalmic CycloplegicsGeneric Name Brand NameTierNotesatropine ophth *ISOPTO ATROPINE 1cyclopentolate ophth *CYCLOGYL 1homatropine ophth *ISOPTO HOMATROPINE 1scopolamine ophth ISOPTO HYOSCINE 2tropicamide ophth *MYDRIACYL 111-F Ophthalmics MioticsGeneric Name Brand NameTierNotespilocarpine ophth *ISOPTO CARPINE 1pilocarpine ophth PILOPINE HS 211-G Ophthalmics Adrenergic AgentsGeneric Name Brand NameTierNotesapraclonidine ophth *IOPIDINE 1brimonidine ophth ALPHAGAN P 0.1% 2 QL (10ml per month)brimonidine ophth *ALPHAGAN P 0.2% 1 QL (10ml per month)brimonidine ophth *ALPHAGAN P 0.15% 1 QL (10ml per month)11-H Ophthalmics MiscelleanousGeneric Name Brand Namebrinzolamide ophth AZOPT 2bromfenac ophth *XIBROM 2cromolyn sodium ophth *CROLOM ophth 1cyclosporine ophth RESTASIS 2cysteamine CYSTARAN 2diclofenac ophth *VOLTAREN ophth 1diclofenac ophth VOLTAREN ophth gel 2dorzolamide ophth *TRUSOPT 1flurbiprofen ophth *OCUFEN 1ketorolac ophth *ACULAR 1ketorolac ophth *ACULAR LS 1lidocaine ophth AKTEN GEL 2lodoxamide ophth ALOMIDE 2nedocromil ophth ALOCRIL 2nepafenac ophth NEVANAC 2pemirolast ophth ALAMAST 2TierNotesQL (10 ml/month)QL (2.5 ml/month)PA QL (60 vials(1 box)/month)QL (5ml per month)QL (3 ml/month)11-I Otic (Ear) MedicationsGeneric Name Brand NameTierNoteschloroxylenol-pramoxine-zinc acetate otic ZINOTIC 2 QL (15 ml/month)chloroxylenol-pramoxine-zinc acetate otic ZINOTIC ES 2 QL (15 ml/month)ciprofloxacin-dexamethasone CIPRODEX 2 QL (8 ml/month)ciprofloxacin-HC otic CETRAXAL 2ciprofloxacin-HC otic CIPRO HC OTIC 2 QL (10 ml/month)hydrocortisone-acetic acid otic *VOSOL-HC 1neomycin-polymyxin-HC otic *CORTISPORIN otic 1neomycin-colistin-HC-thonzonium otic CORTISPORIN-TC 2ofloxacin otic *FLOXIN OTIC 1 QL (10 ml/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 39 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 and 40: penicillamine CUPRIMINE 2penicillam
Page 41: 10-C MineralsGeneric Name Brand Nam
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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