5-Tier Preferred Drug List - Health Plan of Nevada

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FIVE-Tier Drug Benefit GuideTable of ContentsIntroduction .............................................................. iDrug Benefit Guide .................................................. 1Section 1 Anti-InfectivesSection 2 Cancer and TransplantSection 3 CardiovascularSection 4 Central Nervous SystemSection 5 DermatologicalsSection 6 Endocrine and HormonesSection 7 GastrointestinalsSection 8 GenitourinarySection 9 Musculoskeletal and PainSection 10 Vitamins and HematologicalsSection 11 Eye, Ear, and ThroatSection 12 RespiratorySection 13 SpecialtySection 14 ExclusionsPreferred Alternatives............................................... 48Alphabetical Index ................................................... 51
Five-Tier Drug Benefit GuideIntroductionAs a member of a health plan that includes outpatient prescription drug coverage, you haveaccess to a wide range of effective and affordable medications. The health plan utilizes aPreferred Drug List (PDL) (also known as a drug formulary) as a tool to guide providers toprescribe clinically sound yet cost-effective drugs. This list was established to give you access tothe prescription drugs you need at a reasonable cost. Your out-of-pocket prescription cost islower when you use preferred medications. Please refer to your Prescription Drug Benefit Rideror Evidence of Coverage for specific pharmacy benefit information.The PDL is a list of FDA-approved generic and brand name medications recommended for useby your health plan. The list is developed and maintained by a Pharmacy and Therapeutics(P&T) Committee comprised of actively practicing primary care and specialty physicians,pharmacists and other healthcare professionals. Patient needs, scientific data, drug effectiveness,availability of drug alternatives currently on the PDL and cost are all considerations in selecting"preferred" medications. Due to the number of drugs on the market and the continuousintroduction of new drugs, the PDL is a dynamic and routinely updated document screenedregularly to ensure that it remains a clinically sound tool for our providers.Reading the Drug Benefit GuidePreferred generic and brand name medications are available for the applicable preferred generic(tier 1) or preferred brand name (tier 2) copayment. Non-preferred medications, as well assome medications not listed on the HPN PDL are also covered for a higher (tier 3) copayment. Inaddition, specialty medications are available for the applicable preferred specialty (tier 4) andnon-preferred specialty (tier 5) copayments. Certain medications may have quantity, age ortherapeutic supply limitations based on FDA approved dosages, literature documentation or P&TCommittee decisions. See your plan documents for a complete list of covered benefits,limitations and exclusions.For your convenience, medications are grouped together based on their therapeutic category (i.e.,Anti-Infectives, Cardiovascular, etc.) and further separated into drug classes (i.e.,Antidepressants, Contraceptives, etc.). Each drug class has a designated section number (i.e., 1-A, 1-B, etc.) and is the reference point noted in the index.The generic or chemical name is listed to the left of the brand or trade name for each drug.Drugs with a generic equivalent available are identified by an asterisk (*) before the commonbrand name of the product (for example, in the listing for ampicillin.....*PRINCIPEN, indicatesthat PRINCIPEN is available as a generic and ampicillin would be dispensed by the pharmacy).Drugs that are not available generically have the brand-name listed in BOLD print (for example,the listing for rivaroxaban.....XARELTO, indicates that there is no generic for XARELOT andthe brand name product will be dispensed).Other abbreviations used throughout the PDL are:• AL = age limitations• NTI = narrow therapeutic index (generic not required)• PA = prior authorizationi
Page 1: Preferred Drug List 5-Tier21NVHPN09
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 and 12: mycophenolate mofetil *CELLCEPT 1si
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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