2-Tier Open Preferred Drug List - Health Plan of Nevada
2-Tier Open Preferred Drug List - Health Plan of Nevada
2-Tier Open Preferred Drug List - Health Plan of Nevada
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travaprost ophth 1 QL (2.5 ml/month)11-E Ophthalmic CycloplegicsGeneric Name Brand Name<strong>Tier</strong>Notesatropine ophth *ISOPTO ATROPINE 1cyclopentolate ophth *CYCLOGYL 1homatropine ophth *ISOPTO HOMATROPINE 1scopolamine ophth ISOPTO HYOSCINE 2tropicamide ophth *MYDRIACYL 111-F Ophthalmics MioticsGeneric Name Brand Name<strong>Tier</strong>Notespilocarpine ophth *ISOPTO CARPINE 1pilocarpine ophth PILOPINE HS 211-G Ophthalmics Adrenergic AgentsGeneric Name Brand Name<strong>Tier</strong>Notesapraclonidine 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 2dicl<strong>of</strong>enac ophth *VOLTAREN ophth 1dicl<strong>of</strong>enac ophth VOLTAREN ophth gel 2dorzolamide ophth *TRUSOPT 1flurbipr<strong>of</strong>en 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 2<strong>Tier</strong>NotesQL (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 Name<strong>Tier</strong>Noteschloroxylenol-pramoxine-zinc acetate otic ZINOTIC 2 QL (15 ml/month)chloroxylenol-pramoxine-zinc acetate otic ZINOTIC ES 2 QL (15 ml/month)cipr<strong>of</strong>loxacin-dexamethasone CIPRODEX 2 QL (8 ml/month)cipr<strong>of</strong>loxacin-HC otic CETRAXAL 2cipr<strong>of</strong>loxacin-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 2<strong>of</strong>loxacin otic *FLOXIN OTIC 1 QL (10 ml/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty <strong>Drug</strong>s 39 2-<strong>Tier</strong> (open) <strong>Drug</strong> BenefitGuide 09/01/13
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