5-Tier Preferred Drug List - Health Plan of Nevada

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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 NameTierNotesamlodipine *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 NameTierNotesamiodarone *CORDARONE 1disopyramide *NORPACE 1dofetilide 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 Drugs 85-Tier Drug Benefit Guide09/01/13
quinidine gluconate 1quinidine sulfate 13-F Angiotensin Converting Enzyme (ACE) InhibitorsGeneric Name Brand NameTierNotesbenazepril *LOTENSIN 1 QL (60 tablets/month)captopril *CAPOTEN 1enalapril *VASOTEC 1 QL (60 tablets/month)fosinopril *MONOPRIL 1 QL (60 tablets/month)lisinopril *PRINIVIL 1 QL (60 tablets/month)lisinopril *ZESTRIL 1 QL (60 tablets/month)moexipril *UNIVASC 1 QL (60 tablets/month)perindopril *ACEON 3 QL (60 tablets/month)quinapril *ACCUPRIL 1 QL (60 tablets/month)ramipril *ALTACE 1 QL (60 capsules/month)trandolapril *MAVIK 1 QL (60 tablets/month)3-G Angiotensin II Receptor Blockers (ARB's)Generic Name Brand NameTierNotesazilsartan medoxomil EDARBI 3 QL (30 tablets/month)candesartan *ATACAND 3 QL (60 tablets/month)eprosartan TEVETEN 400mg 3 QL (60 tablets/month)eprosartan *Teveten 600mg 1 QL (30 tablets/month)irbesartan *AVAPRO 1 QL (30 tablets/month)losartan *COZAAR 25mg 1 QL (60 tablets/month)losartan *COZAAR 50mg 1 QL (60 tablets/month)losartan *COZAAR 100mg 1 QL (30 tablets/month)olmesartan BENICAR 2 QL (30 tablets/month)telmisartan MICARDIS 3 QL (30 tablets/month)valsartan *DIOVAN 40mg 3 QL (30 tablets/month)valsartan *DIOVAN 80mg 3 QL (30 tablets/month)valsartan *DIOVAN 160mg 3 QL (60 tablets/month)valsartan *DIOVAN 320mg 3 QL (30 tablets/month)3-H Miscellaneous AntihypertensivesGeneric Name Brand NameTierNotesaliskiren fumarate TEKTURNA 3 QL (30 tablets/month)ambrisentan LETAIRIS 5 PA SPbosentan TRACLEER 4 QL (60 tablets/month) PA SPclonidine *CATAPRES 1clonidine patch *CATAPRES-TTS 1 QL (8 patches/month)deserpidine-methyclothiazide ENDURONYL 3doxazosin *CARDURA 1 QL (60 tablets/month)guanfacine *TENEX 1hydralazine *APRESOLINE 1iloprost VENTAVIS 4 PA SPmecamylamine VECAMYL 3methyldopa *ALDOMET 1minoxidil *LONITEN 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 95-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 and 10: dapsone DAPSONE 2dornase alfa PULMO
Page 11: mycophenolate mofetil *CELLCEPT 1si
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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