5-Tier Preferred Drug List - Health Plan of Nevada

6-K Diabetic Suppliesulipristal ELLA 3ACCU-CHEK ACTIVE CARE KIT 1ACCU-CHEK ACTIVE TEST STRIPS 1ACCU-CHEK ADVANTAGE CARE KIT 1ACCU-CHEK AVIVA CARE KIT 1ACCU-CHEK AVIVA TEST STRIPS 1ACCU-CHEK COMFORT CURVE TEST STRIPS 1ACCU-CHEK COMPACT CARE KIT 1ACCU-CHEK COMPACT TEST STRIPS 1ACCU-CHEK METER 1ASCENSIA AUTODISC TEST STRIPS 3ASCENSIA BREEZE 2 TEST STRIPS 3ASCENSIA ELITE TEST STRIPS 3CONTOUR TEST STRIPS 3FREESTYLE FLASH SYSTEM 3FREESTYLE FREEDOM LITE METER 3FREESTYLE FREEDOM METER 3FREESTYLE LITE METER 3FREESTYLE SYSTEM 3FREESTYLE TEST STRIPS 3GLUCOMETER DEX TEST STRIPS 3ONE TOUCH SYSTEM 1ONE TOUCH TEST STRIPS 1ONE TOUCH ULTRA 2 SYSTEM 1ONE TOUCH ULTRA MINI SYSTEM 1ONE TOUCH ULTRA SYSTEM 1ONE TOUCH ULTRA TEST STRIPS 1PRECISION XTRA METER 3PRECISION XTRA TEST STRIPS 3SMARTVIEW TEST STRIPS 1SURESTEP SYSTEM 3SURESTEP TEST STRIPS 3VERIO STRIPS 1VERIO IQ STRIPS 1GASTROINTESTINAL (drugs to treat stomach or intestinal conditions, ie reflux, constipation, etc)7-A LaxativesGeneric Name Brand NameTierlactulose 1na sulf-k sulf-mg sulf & peg 3350 SUCLEAR 3PEG electrolyte *COLYTE 1PEG electrolyte GOLYTELY 2PEG 3350 MOVIPREP 3peg(high)-electrolyte *NULYTELY 1sod sulf-pot sulf-mag sulfate SUPREP 3sod phos mon-sod phos di VISICOL 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 28Notes5-Tier Drug Benefit Guide09/01/13