5-Tier Preferred Drug List - Health Plan of Nevada
5-Tier Preferred Drug List - Health Plan of Nevada
5-Tier Preferred Drug List - Health Plan of Nevada
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
propranolol HCL CR *INDERAL LA 1propranolol HCL SR INNOPRAN XL 3sotalol *BETAPACE 1sotalol AF *BETAPACE AF 1timolol maleate *BLOCADREN 1QL (30 capsules/month)3-D Calcium Channel BlockersGeneric Name Brand Name<strong>Tier</strong>Notesamlodipine *NORVASC 1cartia XT 1 QL (60 capsules/month)diltiazem *CARDIZEM 1 Mdiltiazem SR *TIAZAC 1 Mdiltiazem SR 12HR *CARDIZEM SR 1 Mdiltiazem SR 24HR CARDIZEM LA 3 QL (30 tablets/month)felodipine *PLENDIL 1 QL (60 tablets/month)isradipine *DYNACIRC 1 QL (60 tablets/month)isradipine DYNACIRC CR 5mg 3 QL (30 tablets/month)isradipine DYNACIRC CR 10mg 3 QL (60 tablets/month)nicardipine *CARDENE 1nicardipine CARDENE SR 3nifedipine CR *ADALAT CC 1nifedipine CR *PROCARDIA XL 1nifedipine IR *ADALAT CC 1nifedipine IR *PROCARDIA 1nisoldipine SR *SULAR 8.5mg 3 QL (30 tablets/month)nisoldipine SR *SULAR 10mg 3 QL (30 tablets/month)nisoldipine SR *SULAR 17mg 3 QL (30 tablets/month)nisoldipine SR *SULAR 20mg 3 QL (30 tablets/month)nisoldipine SR *SULAR 25.5mg 3 QL (60 tablets/month)nisoldipine SR *SULAR 30mg 3 QL (60 tablets/month)nisoldipine SR *SULAR 34mg 3 QL (30 tablets/month)nisoldipine SR *SULAR 40mg 3 QL (30 tablets/month)verapamil *CALAN 1verapamil CR (controlled onset) COVERA HS 3 QL (60 tablets/month)verapamil SR *CALAN SR 1verapamil SR *VERELAN PM 13-E AntiarrhythmicsGeneric Name Brand Name<strong>Tier</strong>Notesamiodarone *CORDARONE 1disopyramide *NORPACE 1d<strong>of</strong>etilide TIKOSYN 3 QL (60 capsules/month)dronedarone MULTAQ 3 QL (60 tablets/month)flecainide *TAMBOCOR 1mexiletine *MEXITIL 1propafenone *RYTHMOL 1propafenone *RYTHMOL SR 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty <strong>Drug</strong>s 85-<strong>Tier</strong> <strong>Drug</strong> Benefit Guide09/01/13