5-Tier Preferred Drug List - Health Plan of Nevada

oxiconazole OXISTAT 3setraconazole ERTACZO 3 QL (1 tube/month)5-E Topical AntiviralsGeneric Name Brand NameTierNotesacyclovir topical *ZOVIRAX topical 1penciclovir DENAVIR 3 QL (1 tube/month)5-F AntipsoriaticsGeneric Name Brand NameTierNotesanthralin *PSORIATEC 1acitretin *SORIATANE 3acitretin *SORIATANE CK kit 3 QL (1 kit/month)calcipotriene *DOVONEX 1 QL (1 tube/month)calcitriol ointment *VECTICAL 1 QL (100 gm/month)methoxsalen OXSORALEN-ULTRA 3tazarotene TAZORAC ** 3 QL (1 tube/month) AL** Larger tube sizes (60 grams or above) will be subject to a 60-day supply limit and 2 copays will apply5-G Scabicides and PediculicidesGeneric Name Brand NameTierNotescrotamiton EURAX 3lindane shampoo *KWELL 1permethrin *ELIMITE 1spinosad *NATROBA 35-H Topical CorticosteroidsGeneric Name Brand Namealclometasone *ACLOVATE 1amcinonide *CYCLOCORT 3augmented betamethasone *DIPROLENE 1augmented betamethasone *DIPROLENE AF 1betamethasone dipropionate *DIPROSONE 1betamethasone foam *LUXIQ 3betamethasone valerate *VALISONE 1clobetasol foam *OLUX 1clobetasol propionate *TEMOVATE 1clocortolone CLODERM 3desonide *DESOWEN 1desonide foam VERDESO 3desoximetasone *TOPICORT 1diclofenac gel VOLTAREN GEL 3diflorasone diacetate PSORCON 2flucinolone oil DERMA-SMOOTH FS 3fluocinolone acetonide *SYNALAR 1fluocinolone shampoo CAPEX 3fluocinonide *LIDEX 1fluocinonide VANOS 3flurandrenolide patch CORDRAN 3fluticasone *CUTIVATE ** 1halcinonide HALOG 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 20TierQL (50 gm/60 days)QL (500 gm/month)QL (60 gm/month)QL (1 tube/month)Notes5-Tier Drug Benefit Guide09/01/13