5-Tier Preferred Drug List - Health Plan of Nevada
5-Tier Preferred Drug List - Health Plan of Nevada
5-Tier Preferred Drug List - Health Plan of Nevada
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epaglinide-metformin PRANDIMET 2rosiglitazone AVANDIA 3 QL (30 tablets/month) STAvandia ST = requires 90 day trial <strong>of</strong> either sulfonylurea or biguanide in past 2 yearsrosiglitazone maleate-glimepiride AVANDARYL 4/1mg 3 QL (60 tablets/month) STrosiglitazone maleate-glimepiride AVANDARYL 4/2mg 3 QL (60 tablets/month) STrosiglitazone maleate-glimepiride AVANDARYL 4/4mg 3 QL (30 tablets/month) STAvandaryl ST = requires 90 day trial <strong>of</strong> either Avandia or glimipride in past 2 yearsrosiglitazone-metformin AVANDAMET 1/500mg 3 QL (120 tablets/month) STrosiglitazone-metformin AVANDAMET 2/500mg 3 QL (120 tablets/month) STrosiglitazone-metformin AVANDAMET 4/500mg 3 QL (120 tablets/month) STrosiglitazone-metformin AVANDAMET 2/1000mg 3 QL (60 tablets/month) STrosiglitazone-metformin AVANDAMET 4/1000mg 3 QL (60 tablets/month) STAvandamet ST = requires 90 day trial <strong>of</strong> either Avandia or metformin in past 2 yearssaxagliptin ONGLYZA 2 QL (30 tablets/month)saxagliptin-metformin KOMBIGLYZE XR 2 QL (30 tablets/month)sitaglipin JANUVIA 3 QL (30 tablets/month) STJanuvia ST = requires fill <strong>of</strong> metformin within the past 2 yearssitaglipin-metformin JANUMET 3 QL (60 tablets/month) STJanumet ST = requires fill <strong>of</strong> metformin within the past 2 yearssitaglipin-metformin JANUMET XR 3 QL (30 tablets/month) STJanumet ST = requires fill <strong>of</strong> metformin within the past 2 yearstolazamide *TOLINASE 1tolbutamide *TOLBUTAMIDE 16-G InsulinsGeneric Name Brand Name<strong>Tier</strong>Notesinsulin (human) NOVOLIN 3 STNOVOLIN ST = requires failure <strong>of</strong> a Lilly product within the last 2 yearsinsulin (human) HUMULIN 1insulin (human) HUMULIN PEN 2insulin (human) RELION 3insulin aspart NOVOLOG 3 STNOVOLOG ST = requires failure <strong>of</strong> a Lilly product within the last 2 yearsinsulin aspart mix NOVOLOG MIX 3 STNOVOLOG MIX ST = requires failure <strong>of</strong> a Lilly product within the last 2 yearsinsulin detemir LEVEMIR 2insulin glargine LANTUS 2insulin glulisine APIDRA 3insulin lispro HUMALOG 1insulin lispro HUMALOG PEN 2insulin lispro mix HUMALOG MIX 1insulin lispro mix HUMALOG MIX PEN 26-H GlucagonGeneric Name Brand Name<strong>Tier</strong>NotesGLUCAGON 2 QL (2 kits/month6-I Thyroid AgentsGeneric Name Brand Name<strong>Tier</strong>Noteslevothroid 1 QL (60 tablets/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty <strong>Drug</strong>s 265-<strong>Tier</strong> <strong>Drug</strong> Benefit Guide09/01/13
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