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

11-J Mouth and ThroatGeneric Name Brand NameTieramlexanox oral paste APHTHASOL 2cevimeline *EVOXAC 2chlorhexidine *PERIDEX 1clotrimazole troche *MYCELEX TROCHE 1lidocaine *VISCOUS LIDOCAINE 1oral hydrogel wafer MUCOTROL 2pilocarpine *SALAGEN 5mg 1pilocarpine *SALAGEN 7.5mg 1sodium fluoride *KARIGEL 1sodium fluoride *KARIGEL-N 1triamcinolone/orabase *KENALOG-ORABASE 1NotesQL (90 capsules/month)QL (120 wafers/month)QL (180 tablets/month)QL (120 tablets/month)RESPIRATORY (drugs to treat breathing conditions, ie asthma and allergies)12-A AntihistaminesGeneric Name Brand NameTierNotescyproheptadine *PERIACTIN 1promethazine *PHENERGAN 1pyrilamine tannate PYRLEX SYRUP 2 QL (120 ml/month)triprolidine tannate ZYMINE XR SYRUP 2 QL (120 ml/month)12-B Topical Nasal ProductsGeneric Name Brand NameTierNotesazelastine nasal *ASTELIN 1 QL (1 inhaler/month)beclomethasone nasal BECONASE AQ 2 QL (2 inhalers/month)budesonide nasal RHINOCORT AQUA 2 QL (2 inhalers/month)ciclesonide nasal OMNARIS 2 QL (1 inhaler/month)flunisolide nasal *NASALIDE 1 QL (3 inhalers/month)flunisolide nasal *NASAREL 1 QL (3 inhalers/month)fluticasone nasal *FLONASE 1ipratropium nasal *ATROVENT 0.03% NASAL 1 QL (1 inhaler/month)ipratropium nasal *ATROVENT 0.06% NASAL 1 QL (2 inhalers/month)mometasone nasal NASONEX 2 QL (1 inhaler/month)olopatadine nasal PATANASE 2 QL (1 inhaler/month)triamcinolone nasal NASACORT 2 QL (1 inhaler/month)triamcinolone nasal NASACORT AQ 2 QL (2 inhalers/month)triamcinolone nasal TRI-NASAL 2 QL (1 inhaler/month)12-C Cough/Cold/AllergyGeneric Name Brand NameTierNotesacetylcysteine *MUCOMYST 1acrivastine-PSE SEMPREX-D 2benzonatate *TESSALON 1bromphen-PSE-DM BROMOXAFED 2cardec DM *RONDEC DM 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 40 2-Tier (open) Drug BenefitGuide 09/01/13