5-Tier Preferred Drug List - Health Plan of Nevada

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Generic Name Brand NameTierNotescortisone acetate *CORTONE 1dexamethasone *DECADRON 1fludrocortisone *FLORINEF 1hydrocortisone acetate *CORTEF 1methylprednisolone *MEDROL 1prednisolone MILIPRED DP PAK 3prednisolone *PRELONE 1prednisolone PREDNISOLONE 5MG 2prednisolone sod phosphate VERIPRED 3prednisolone sodium *ORAPRED 1prednisolone sodium *PEDIAPRED 1prednisone 16-B AndrogensGeneric Name Brand NameTierNotesdanazol *DANOCRINE 1methyltestosterone ANDROID 3methyltestosterone METHITEST 3testosterone ANDRODERM 3 QL (30 patches/month) PAtestosterone FORTESTA 3 PAtestosterone TESTIM 3 PAtestosterone TD sol AXIRON 3 PAtestosterone buccal system STRIANT 3 PA QL (60 patches/month)6-C EstrogensGeneric Name Brand NameTierNotesesterified estrogens 1esterified estrogens MENEST 3estradiol *ESTRACE 1estradiol gel ESTROGEL 3 QL (93gm/month)estradiol patch *CLIMARA 1 QL (4 patches/month)estradiol patch VIVELLE 2 QL (8 patches/month)estradiol patch VIVELLE DOT 2 QL (8 patches/month)estradiol patch ALORA 3 QL (8 patches/month)estradiol patch ESCLIM 3estradiol patch ESTRADERM 3 QL (8 patches/month)estradiol patch MENOSTAR 3 QL (4 patches/month)estradiol spray EVAMIST 3 QL (9 ml/month)estradiol TD gel DIVIGEL 2 QL (1 tube/month)estradiol transdermal ESTRASORB 3 QL (56 packets/month)estradiol-levonorgestrel patch CLIMARA PRO 3 QL (4 patches/month)estradiol-norethindrone ACTIVELLA 3 QL (1 dialpak/month)estradiol-norethindrone patch COMBIPATCH 3 QL (8 patches/month)estradiol-norgestimate ORTHO-PREFEST 2estrogen-medroxyprogesterone PREMPHASE 2 QL (1 dialpak/month)estrogen-medroxyprogesterone PREMPRO 2 QL (1 dialpak/month)estrogens (conjugated synthetic) CENESTIN 2 QL (30 tablets/month)estrogens (conjugated synthetic) ENJUVIA 2 QL (30 tablets/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 225-Tier Drug Benefit Guide09/01/13
estrogens (conjugated) PREMARIN 3 QL (30 tablets/month)estrogens-methyltestosterone *ESTRATEST 1estrogens-methyltestosterone *ESTRATEST HS 1estropipate *OGEN 1ethinyl estradiol-norethindrone FEMHRT 3 QL (1 dialpak/month)ospemifene OSPHENA 36-D ContraceptivesGeneric Name Brand NameTierNotesMONOPHASIC PRODUCTSethinyl estradiol (EE) /desogestrel productsApri, Emoquette, Reclipsen, Solia *ORTHO CEPT 1 QL (28 tablets/21 days)DESOGEN 2 QL (28 tablets/21 days)mestranol/norethindroneNecon 1/150 *NORINYL 1 QL (28 tablets/21 days)EE/norgestimate productsORTHO CYCLEN 1 QL (28 tablets/21 days)Sprintec, Previfem, Mononessa 3 QL (28 tablets/21 days) STSprintec, Previfem, Mononessa ST = requires trial of brand Ortho Cyclen within the last 120 daysEE/norethindrone productsrtrel,Cyclafem,Necon,Norinyl,Alyacen *ORTHO NOVUM 1/35 1 QL (28 tablets/21 days)LOESTRIN 24 3 QL (28 tablets/month)Junel Fe, Gildess Fe, Microgestin Fe *LOESTRIN FE 1 QL (28 tablets/21 days)Microgestin, Junel *LOESTRIN 3 QL (28 tablets/21 days)Balziva, Zenchent FE, Briellyn *OVCON-35 3 QL (28 tablets/21 days)Nortrel, Necon, Brevicon *MODICON 1 QL (28 tablets/21 days)EE/drospirenone productsYAZ 2 QL (28 tablets/21 days)Gianvi, Loryna, 3 QL (28 tablets/21 days) STGianvi, Loryna, ST = requires trial of brand Yaz within the last 120 daysYASMIN 1 QL (28 tablets/21 days)Ocella, Zarah, Syeda 3 QL (28 tablets/21 days) STOcella , Zarah, Syeda ST = requires trial of brand Yasmin in past 120 daysEE/norgestrel productsLow-ogestrel, Cryselle *LO/OVRAL 1 QL (28 tablets/21 days)EE/ethynodiol productsKelnor 1 QL (28 tablets/21 days)Zovia 1/35 1 QL (28 tablets/21 days)EE/levonorgestrel productsAltavera, Levora, Marlissa, Portia *NORDETTE 1 QL (28 tablets/21 days)Aviane,Lessina,Lutera,Sronyx,Orsythia *ALESSE 1 QL (28 tablets/21 days)Jolessa, Introvale, Quasense *SEASONALE 1 QL (91 tablets/3 months)Amethyst *LYBREL 1 QL (28 tablets/21 days)BIPHASIC PRODUCTSEE-desogestrel/EEKariva, Azurette, Viorele *MIRCETTE 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 23QL (28 tablets/month)5-Tier Drug Benefit Guide09/01/13
Page 1 and 2: Preferred Drug List 5-Tier21NVHPN09
Page 3 and 4: Five-Tier Drug Benefit GuideIntrodu
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: halobetasol *ULTRAVATE 1halobetasol
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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