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
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sertraline HCL *ZOLOFT 100mg 1 QL (60 tablets/month)trazodone *DESYREL 1trimipramine maleate *SURMONTIL 1trimipramine maleate SURMONTIL 3venlafaxine *EFFEXOR 1 QL (90 tablets/month)venlafaxine SR *EFFEXOR XR (cap) 37.5mg 1 QL (90 capsules/month)venlafaxine SR *EFFEXOR XR (cap) 75mg 1 QL (90 capsules/month)venlafaxine SR *EFFEXOR XR (cap) 150mg 1 QL (60 capsules/month)venlafaxine SR *EFFEXOR XR (cap) 225mg 1 QL (30 capsules/month)venlafaxine SR *VENLAFAXINE XR (tab) 37.5mg 1 QL (90 tablets/month)venlafaxine SR *VENLAFAXINE XR (tab) 75mg 1 QL (90 tablets/month)venlafaxine SR *VENLAFAXINE XR (tab) 150mg 1 QL (60 tablets/month)venlafaxine SR *VENLAFAXINE XR (tab) 225mg 1 QL (30 tablets/month)vilazodone VIIBRYD 3 QL (30 tablets/month) STViibryd ST = requires 60 day consistent trial <strong>of</strong> 2 the following agents (fluoxetine, paroxetine, citalopram,sertraline, bupropion/SR, venlafaxine) in the past 2 years4-C Hypnotics (Sleep Aids)Generic Name Brand Name<strong>Tier</strong>Noteschloral hydrate SOMNOTE 2estazolam *PROSOM 1eszopiclone LUNESTA 3 QL (30 tablets/month) STLunesta ST = requires 30 day fill <strong>of</strong> zolpidem in the past 2 yearsflurazepam *DALMANE 1phenobarbital 1ramelteon ROZEREM 3 QL (30 tablets/month) STRozerem ST = requires 30 day fill <strong>of</strong> zolpidem in the past 2 yearstemazepam *RESTORIL 22.5mg 1 QL (30 capsules/month)triazolam *HALCION 1 QL (15 tablets/fill; 2 fills/month)zaleplon *SONATA 5mg 1 QL (30 capsules/month)zaleplon *SONATA 10mg 1 QL (60 capsules/month)zolpidem *AMBIEN 1 QL (30 tablets/month)zolpidem CR *AMBIEN CR 3 QL (30 tablets/month)4-D AntipsychoticsGeneric Name Brand Name<strong>Tier</strong>Notesaripiprazole ABILIFY 3 QL (30 tablets/month)asenapine SAPHRIS 3 QL (60 tablets/month) PA STSaphris ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearschlorpromazine *THORAZINE 1clozapine *FAZACLO 3 PA STFazaclo ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearsclozapine *CLOZARIL (NTI) 2 PA STClozaril ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearsfluphenazine *PROLIXIN 1haloperidol *HALDOL 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty <strong>Drug</strong>s 145-<strong>Tier</strong> <strong>Drug</strong> Benefit Guide09/01/13
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