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

Generic Name Brand NameTierNotesadalimumab HUMIRA 2 PA SIO SP STHumira ST = requires trial of 1 formulary alternative: Enbrel, Simponi, and/or Cimziaanakinra subcutaneous KINERET 2 PA SIO SPcertolizumab pegol CIMZIA 2 PA SIO SPetanercept for subcutaneous ENBREL 2 PA SIO SPgolimumab SIMPONI 2 QL (1 unit/month) PA SIO SPtofacitinib XELJANZ 2 PA STXELJANZ ST- requires trial of 2 formulary alternatives: Enbrel, Simponi, and/or Cimzia13-I Miscellaneous SpecialtyGeneric Name Brand NameTierNotesabatacept ORENCIA 2 PA SPcorticotropin ACTHAR HP 2 PA SIO SPicatibant acetate FIRAZYR 2 PA SPinterferon alfa-2B INTRON-A 2 PA SIOinterferon gamma-1B ACTIMMUNE 2 PA SIO SPleuprolide acetate ELIGARD 2 PA SIOleuprolide acetate LUPRON 2 SIOleuprolide acetate LUPRON DEPOT 2 SIOleuprolide acetate LUPRON DEPOT-PED 2 SIOnitisinone ORFADIN 2 PAoprelvekin NEUMEGA 2 PA SPoxandralone OXANDRALONE 2 PAoxymetholone ANADROL-50 2 PApalonosetron ALOXI (tablets) 2 PApeginterferon alfa-2B SYLATRON 2 PA SIO SPpeginterferon alfa-2B SYLATRON 4-PACK 2 PA SIO SPrilonacept ARCALYST 2 PA SIOEXCLUSIONS (excluded drugs)14-A Excluded From CoverageGeneric Name Brand Nameacyclovir hydrocortisone XERESEalcaftadine LASTACAFTalendronate BINOSTOamilodipine-atorvastatin CADUETamlodipine-aliskiren TEKAMLOamlodipine-aliskiren-hctz AMTURNIDEamlodipine-olmesartan AZORamlodipine-valsartan EXFORGEamlodipine-valsartan-hctz EXFORGE HCTantipyrine-benzocaine-polycosanol OTIC CAREantiseborrheic PROMISEB COMPLETE KITAPAP-caffeine-butalbital ORBIVANAPAP-codeine COCET PLUSAPAP-hydrocodone ZOLVITazelastine OPTIVARQL - Quantity LimitsAL - Age LimitsTierNotesPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 44 2-Tier (open) Drug BenefitGuide 09/01/13