5-Tier Preferred Drug List - Health Plan of Nevada

EE-levonorgestrel/EECamrese Lo, Amethia Lo *LOSEASONIQUE 1Camrese, Amethia, *SEASONIQUE 1EE/norethindrone-EE/norethindroneNecon 10/11 *ORTHO NOVUM 10/11 1LO LOESTRIN FE 3TRIPHASIC PRODUCTSEE/norethindrone-EE/norethindrone-EE/norethindroneAranelle, Leena *TRI-NORINYL 1ORTHO-NOVUM 7/7/7 1, Necon 7/7/7, Nortrel 7/7/7, Cyclafem 3Alyacen, Necon 7/7/7, Nortrel 7/7/7, Cyclafem ST = requires failure of brand Ortho Novum 7/7/7Tilia FE, Tri Legest FE *ESTROSTEP (FE) 1 QL (28 tablets/21 days)EE/levonogestrel-EE/Levonorgestrel-EE/LevonorgestrelTrivora, Myzilra *ENPRESSE 1 QL (28 tablets/21 days)/desogestrel-EE/desogestrel-EE/desogestrelCesia, Velivet, Caziant *CYCLESSA 1 QL (28 tablets/21 days)orgestimate-EE/norgestimate-EE/norgestimateORTHO TRI CYCLEN 1 QL (28 tablets/21 days)Tri-Sprintec,Tri-Previfem,Trinessa 3 QL (28 tablets/21 days) STTri-Sprintec, Tri-Previfem, Trinessa ST= requires trial of brand Ortho Tri Cyclenwithin the last 120 daysORTHO TRI CYCLEN LO 2 QL (28 tablets/21 days)4-PHASIC PRODUCTSestradiol-estradiol/dienogest-estradiol/dienogest-estradiolNATAZIA 1 QL (28 tablets/21 days)PROGESTIN ONLY-PRODUCTSNorethindroneORTHO MICRONOR 1 QL (28 tablets/month)Camila, Errin, Heather, Jolivette, Nora Be 3 QL (28 tablets/month) STCamila, Errin, Heather, Jolivette, Nora Be requires failure to brand Ortho MicronorMISCELLANEOUSLevonorgestrelUlipristalEtonogestrel/EENorelgestromin/EENext choice *PLAN B 1PLAN B ONE-STEP 1ELLA 1NUVARING 2ORTHO EVRA 3DIAPHRAMS 1FEMCAP 3QL (28 tablets/21 days)QL (91 tablets/3 months)QL (28 tablets/21 days)QL (28 tablets/month)QL (28 tablets/21 days)QL (28 tablets/21 days)QL (28 tablets/21 days) STQL (28 tablets/21 days)QL (1 ring/month)QL (3 patches/month)QL (1 cap/year)6-E ProgestinsGeneric Name Brand NameTierhydroxyprogesterone caproate MAKENA 3 PAQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 24Notes5-Tier Drug Benefit Guide09/01/13