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5-Tier Preferred Drug List - Health Plan of Nevada

5-Tier Preferred Drug List - Health Plan of Nevada

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pregabalin LYRICA 300mg 3 QL (60 capsules/month) STpregabalin LYRICA SOLUTION 3 QL STLyrica ST = requires 30 day trial <strong>of</strong> Gabapentin in the past 2 yearsprimidone *MYSOLINE 1 Mrufinamide BANZEL 3rufinamide BANZEL suspension 3tiagabine *GABITRIL 1topiramate *TOPAMAX SPRINKLES 1 QL (120 capsules/month)topiramate *TOPAMAX 1 QL (90 tablets/month)valproic acid *DEPAKENE 1valproic acid STAVZOR 3 QL (60 capsules/month)vigabatrin SABRIL 3 QL (180 tablets/month)zonisamide *ZONEGRAN 25mg 1 QL (120 capsules/month)zonisamide *ZONEGRAN 50mg 1 QL (120 capsules/month)zonisamide *ZONEGRAN 100mg 1 QL (180 capsules/month)4-H Antiparkinsonian AgentsGeneric Name Brand Name<strong>Tier</strong>NotesAMANTADINE (Symmetrel) 2apomorphine APOKYN 4 SIO SPbenztropine *COGENTIN 1bromocriptine (tablets) *PARLODEL 1carbidopa-levodopa *SINEMET 1carbidopa-levodopa *PARCOPA 1carbidopa-levodopa CR *SINEMET CR 1carbidopa-levodopa-entacapone STALEVO 3 QL (240 tablets/month)entacapone *COMTAN 2 QL (240 tablets/month)pramipexole *MIRAPEX 1 QL (90 tablets/month)ropinirole *REQUIP 1 QL (90 tablets/month)trihexyphenidyl *ARTANE 1*SELEGILINE 1DERMATOLOGICALS (drugs to treat skin disorders or conditions)5-A AnorectalGeneric Name Brand Name<strong>Tier</strong>Noteshydrocortisone rectal *ANUSOL-HC 1hydrocortisone-pramoxine rectal *ANALPRAM-HC 1hydrocortisone-pramoxine rectal PROCTOFOAM-HC 25-B Acne ProductsGeneric Name Brand Name<strong>Tier</strong>Notesadapalene DIFFERIN 0.1% cream 3 QL (45 gm/60 days) ALadapalene DIFFERIN 0.1% lotion 3 QL (1 bottle/60 days) ALadapalene *DIFFERIN 0.1% cream/gel 3 STDifferin 0.1% generic ST = requires trial <strong>of</strong> BRAND Differin cream/gel the past 120 daysazelaic acid AZELEX 3azelaic acid FINACEA 3benzoyl peroxide-vit E INOVA KIT 3benzoyl peroxide-salicylic acid-vit E INOVA 4/1 KIT 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty <strong>Drug</strong>s 185-<strong>Tier</strong> <strong>Drug</strong> Benefit Guide09/01/13

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