5-Tier Preferred Drug List - Health Plan of Nevada

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fludarabine OFORTA 3flutamide *EULEXIN 1gefitinib IRESSA 3hydroxyurea *HYDREA 1imatinib mesylate GLEEVEC 3lapatinib ditosylate TYKERB 3lenalidomide REVLIMID 3letrozole *FEMARA 2leucovorin calcium *LEUCOVORIN CALCIUM 1leucovorin calcium *WELLCOVORIN 1lomustine CEENU 2megestrol *MEGACE 1megestrol MEGACE ES 3melphalan ALKERAN 2mercaptopurine *PURINETHOL 1mesna MESNEX 4methotrexate 1methotrexate TREXALL 3mitotane LYSODREN 2nilotinib TASIGNA 3nilutamide NILANDRON 3pazopanib VOTRIENT 3pomalidomide POMALYST 3ponatinib hcl ICLUSIG 3procarbazine HCL MATULANE 2regorafenib STIVARGA 3sorafenib tosylate NEXAVAR 3sunitinib SUTENT 3tamoxifen *NOLVADEX 1tamoxifen SOLTAMOX 3temozolomide *TEMODAR 3thalidomide THALOMID 3thioguanine THIOGUANINE 2topotecan HYCAMTIM 3toremifene citrate FARESTON 3trametinib dimethyl sulfoxide MEKINIST 3tretinoin *VESANOID 1vemurafenib ZELBORAF 3vismodegib ERIVEDGE 3vorinostat ZOLINZA 32-B ImmunosuppressivesGeneric Name Brand NameTierazathioprine *IMURAN 1cyclosporine *SANDIMMUNE (NTI) 2cyclosporine modified *GENGRAF 1cyclosporine modified *NEORAL (NTI) 2mycophenlate MYFORTIC 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 6PAQL (30 tablets/month)PA SPPA SPPA SPQL (30 tablets/month)SIOPAPA SPPA SPPA SPPA SPPA SPPA SPPA SPPA SPPA SPPAQL (30 tablets/month)PA SPSPPA SPQL PA SPPA SPNotesSPSPSPQL (120 tablets/month) SP5-Tier Drug Benefit Guide09/01/13
mycophenolate mofetil *CELLCEPT 1sirolimus RAPAMUNE 2tacrolimus *PROGRAF 1SPSPSPCARDIOVASCULAR (drugs to treat heart conditions)3-A CardiotonicsGeneric Name Brand NameTierdigoxin *LANOXIN (NTI) 23-B AntianginalsGeneric Name Brand NameTierisosorbide dinitrate *ISORDIL 1isosorbide mononitrate *IMDUR 1nitroglycerin ointment *NITROBID 1nitroglycerin patch *MINITRAN 1nitroglycerin patch *NITRO-DUR 1nitroglycerin spray *NITROLINGUAL PUMPSPRAY 1nitroquick *NITROSTAT 23-C Beta BlockersGeneric Name Brand NameTieracebutolol *SECTRAL 1atenolol *TENORMIN 1betaxolol *KERLONE 1bisoprolol *ZEBETA 1carteolol HCL CARTROL 3carvedilol *COREG 3.125mg 1carvedilol *COREG 6.25mg 1carvedilol *COREG 12.5mg 1carvedilol *COREG 25mg 1labetalol *NORMODYNE 1labetalol *TRANDATE 1metoprolol *LOPRESSOR 1metoprolol succinate SR *TOPROL XL 1nadolol *CORGARD 20mg 1nadolol *CORGARD 40mg 1nadolol *CORGARD 80mg 1nadolol *CORGARD 120mg 1nebivolol BYSTOLIC 2.5mg 2nebivolol BYSTOLIC 5mg 2nebivolol BYSTOLIC 10mg 2nebivolol BYSTOLIC 20mg 2penbutolol sulfate LEVATOL 3pindolol *VISKEN 1propranolol *INDERAL 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 7NotesNotesNotesQL (60 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (120 tablets/month)QL (45 tablets/month)QL (90 tablets/month)QL (60 tablets/month)QL (90 tablets/month)QL (60 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (120 tablets/month)QL (60 tablets/month)5-Tier Drug Benefit Guide09/01/13
Page 1 and 2: Preferred Drug List 5-Tier21NVHPN09
Page 3 and 4: Five-Tier Drug Benefit GuideIntrodu
Page 5 and 6: FIVE-TIER Drug Benefit GuideThis dr
Page 7 and 8: griseofulvin ultramicrosize *GRIS-P
Page 9: dapsone DAPSONE 2dornase alfa PULMO
Page 13 and 14: quinidine gluconate 1quinidine sulf
Page 15 and 16: indapamide *LOZOL 1methazolamide *N
Page 17 and 18: duloxetine CYMBALTA 60mg 3QL (30 ca
Page 19 and 20: iloperidone FANAPT 3 QL (60 tablets
Page 21 and 22: ivastigmine *EXELON 1rivastigmine E
Page 23 and 24: enzoyl peroxide-adapalene EPIDUO 3
Page 25 and 26: halobetasol *ULTRAVATE 1halobetasol
Page 27 and 28: estrogens (conjugated) PREMARIN 3 Q
Page 29 and 30: medroxyprogesterone *PROVERA 1noret
Page 31 and 32: levothyroxine 1levothyroxine TIROSI
Page 33 and 34: 7-B AntidiarrhealsGeneric Name Bran
Page 35 and 36: mesalamine CANASA 2mesalamine LIALD
Page 37 and 38: APAP-hydrocodone *VICODIN ES 1 QL (
Page 39 and 40: naproxen sodium *ANAPROX 1oxaprozin
Page 41 and 42: prenatal vitamins-FE-FA *PRECARE 1p
Page 43 and 44: tobramycin-dexamethasone ophth *TOB
Page 45 and 46: triamcinolone nasal NASACORT AQ 3tr
Page 47 and 48: mecasermin INCRELEX 5 PA SIO SPsoma
Page 49 and 50: amlodipine-aliskiren-hctz AMTURNIDE
Page 51 and 52: isotretinoin ABSORICAitraconazole O
Page 53 and 54: Alphabetical IndexDrug Name PDL Sec
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5-Tier Preferred Drug List - Health Plan of Nevada

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