5-Tier Preferred Drug List - Health Plan of Nevada

pravastatin *PRAVACHOL 1rosuvastatin CRESTOR 2simvastatin *ZOCOR 13-M Miscellaneous CardiovascularGeneric Name Brand NameTierisosorbide dinitrate-hydralazine BIDIL 3ranolazine RANEXA 2QL (30 tablets/month)QL (30 tablets/month)NotesQL (60 tablets/month)CENTRAL NERVOUS SYSTEM (drugs that affect the brain)4-A Antianxiety AgentsGeneric Name Brand NameTierNotesalprazolam *XANAX 1alprazolam SR *XANAX XR 0.5mg 1 QL (30 tablets/month)alprazolam SR *XANAX XR 1mg 1 QL (30 tablets/month)alprazolam SR *XANAX XR 2mg 1 QL (30 tablets/month)alprazolam SR *XANAX XR 3mg 1 QL (60 tablets/month)alprazolam *NIRAVAM 3buspirone BUSPAR (7.5mg) 2buspirone *BUSPAR 10mg 1 QL (60 tablets/month)buspirone *BUSPAR 15mg 1 QL (120 tablets/month)chlordiazepoxide *LIBRIUM 1clorazepate *TRANXENE 1diazepam *VALIUM 1hydroxyzine HCL *ATARAX 1hydroxyzine pamoate *VISTARIL 1lorazepam *ATIVAN 1meprobamate 1oxazepam *SERAX 14-B AntidepressantsGeneric Name Brand NameTierNotesamitriptyline *ELAVIL 1amoxapine *ASENDIN 1bupropion *WELLBUTRIN 75mg 1 QL (180 tablets/month)bupropion *WELLBUTRIN 100mg 1 QL (120 tablets/month)bupropion SR *WELLBUTRIN SR 100mg 1 QL (60 tablets/month)bupropion SR *WELLBUTRIN SR 150mg 1 QL (60 tablets/month)bupropion SR *WELLBUTRIN SR 200mg 1 QL (60 tablets/month)bupropion XL *WELLBUTRIN XL 1 QL (30 tablets/month)citalopram *CELEXA 1 QL (45 tablets/month)clomipramine *ANAFRANIL 1desipramine *NORPRAMIN 1desvenlafaxine PRISTIQ 3 QL (30 tablets/month) STPristiq ST = requires 60 day consistent trial of 2 the following agents (fluoxetine, paroxetine, citalopram,sertraline, bupropion/SR, venlafaxine) in the past 2 yearsdoxepin *SINEQUAN 1duloxetine CYMBALTA 20mg 3 QL (60 capsules/month) STduloxetine CYMBALTA 30mg 3 QL (60 capsules/month) STQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 125-Tier Drug Benefit Guide09/01/13