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

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emtricitabine-tenofovir TRUVADA 2enfuvirtide FUZEON 2entecavir BARACLUDE 2etravirine INTELENCE 2Intelence ST = requires 30 day trial fill of other NNRTI (Sustiva, Viramune, Rescriptor) within past 2 yearsfosamprenavir LEXIVA 2 QL (120 tablets/month) SPindinavir sulfate CRIXIVAN 2 SPlamivudine EPIVIR 2 SPlamivudine-zidovudine *Combivir 1 SPlopinavir-ritonavir KALETRA 2 SPmaraviroc SELZENTRY 150mg 2 QL (60 tablets/month) PA SPmaraviroc SELZENTRY 300mg 2 QL (120 tablets/month) PA SPnelfinavir mesylate VIRACEPT 2 SPnevirapine *VIRAMUNE 1 SPnevirapine XR VIRAMUNE XR 2 SPraltegravir ISENTRESS 2 QL (60 tablets/month) SPrilpivirine EDURANT 2 SPritonavir NORVIR 2 SPsaquinavir INVIRASE 2 SPstavudine *ZERIT 1 SPtelbivudine TYZEKA 2 SPtenofovir VIREAD 2 SPtipranavir APTIVUS capsules 2 QL (120 capsules/month) SPtipranavir APTIVUS suspension 2 QL (300 mls/month) SPzidovudine *RETROVIR 1 SP1-J AntimalarialsGeneric Name Brand NameTierartemether-lumefantrine COARTEM 2atovaquone-proguanil HCL MALARONE 2chloroquine *ARALEN 1hydroxychloroquine *PLAQUENIL 1mefloquine *LARIAM 1primaquine *PRIMAQUINE 1pyrimethamine DARAPRIM 2quinine sulfate 11-K AnthelminticsGeneric Name Brand NameTieralbendazole ALBENZA 2ivermectin STROMECTOL 2mebendazole VERMOX 2praziquantel BILTRICIDE 2thiabendazole MINTEZOL 2QL (30 tablets/month) SPSIO SPQL (30 tablets/month) SPQL 120 tablets/month) ST SPNotesQL (24 tablets/60 days)Notes1-L Misc Anti-InfectivesGeneric Name Brand NameTieratovaquone MEPRON 2QL - Quantity LimitsAL - Age LimitsNotesPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 4 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: griseofulvin ultramicrosize *GRIS-P
Page 11 and 12: mycophenolate mofetil *CELLCEPT 1si
Page 14 and 15: prazosin *MINIPRESS 1reserpine 1sil
Page 16 and 17: Generic Name Brand NameTierisosorbi
Page 18 and 19: venlafaxine *EFFEXOR 1 QL (90 table
Page 20 and 21: methylphenidate METHYLIN (chewable)
Page 22 and 23: topiramate *TOPAMAX SPRINKLES 1valp
Page 24 and 25: Generic Name Brand NameTierNotesaci
Page 26 and 27: prednisolone PREDNISOLONE 5MG 2pred
Page 28 and 29: Aranelle, Leena *TRI-NORINYL 1 QL (
Page 30 and 31: osiglitazone-metformin AVANDAMET 2/
Page 32 and 33: ACCU-CHEK COMPACT CARE KIT 1ACCU-CH
Page 34 and 35: ondansetron *ZOFRAN ODT 4mg 1ondans
Page 36 and 37: citric acid-D-gluconic acid RENACID
Page 38 and 39: tramadol ER ULTRAM ER 200mg 2tramad
Page 40 and 41: metaxalone SKELAXIN 2methocarbamol
Page 42 and 43: gatifloxacin ophth ZYMAR 2 QL (5 ml
Page 44 and 45: 11-J Mouth and ThroatGeneric Name B
Page 46 and 47: oflumilast DALIRESP 2 PA QL (30 tab
Page 48 and 49: Generic Name Brand NameTierNotesada
Page 50 and 51: diclofenac potassium ZIPSORdiclofen
Page 52 and 53: sulfacetamide sodium-sulfur susp SU
Page 54 and 55: Alphabetical IndexDrug Name PDL Sec
Page 56 and 57: Alphabetical IndexDrug Name PDL Sec
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Alphabetical IndexDrug Name PDL Sec
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2-Tier Open Preferred Drug List - Health Plan of Nevada

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