5-Tier Preferred Drug List - Health Plan of Nevada

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Generic Name Brand NameTierdolasetron ANZEMET 4doxylamine-pyridoxine DICLEGIS 3dronabinol *MARINOL 4granisetron *KYTRIL 1ondansetron *ZOFRAN 4mg 1ondansetron *ZOFRAN 8mg 1ondansetron *ZOFRAN 24mg 1ondansetron *ZOFRAN ODT 4mg 1ondansetron *ZOFRAN ODT 8mg 1scopolamine patch TRANSDERM-SCOP 3trimethobenzamide *TIGAN 17-G Digestive AidsGeneric Name Brand NameTieramylase-lipase-protease PANCREASE MT 2amylase-lipase-protease KU-ZYME 3amylase-lipase-protease KU-ZYME-HP 3amylase-lipase-protease CREON 2amylase-lipase-protease VIOKASE 2amy-lip-prot dr ULTRASE 2amy-lip-prot dr ULTRASE MT 2miglustat ZAVESCA 4pancrelipase ZENPEP 2pegademase ADAGEN 4sacrosidase SUCRAID 4sodium phenylbutyrate BUPHENYL 4NotesQL (1 tablet/fill; 2 fills/month)PAQL (2 tablets/fill; 2 fills/month)QL (30 tablets/fill; 2 fills/month)QL (30 tablets/fill; 2 fills/month)QL (15 tablets/fill; 2 fills/month)QL (30 tablets/fill; 2 fills/month)QL (30 tablets/fill; 2 fills/month)QL (10 patches/month)Notes7-H Miscelleanous GastrointestinalGeneric Name Brand NameTierNotesBXN MOUTHWASH 3balsalazide *COLAZAL 1 QL (270 capsules/month)adefovir HEPSERA 5 QL (30 tablets/month) SPalosetron LOTRONEX 3 QL (60 tablets/month) PAbudesonide SR *ENTOCORT EC 1 QL (90 capsules/month)budesonide SR UCERIS 3 PAcalcium acetate (phosphate binder) *PHOSLO 1calcium acetate (phosphate binder) ELIPHOS 2crofelemer FULYZAQ 3 PAcysteamine bitartrate PROCYSBI 3 PA SPglycopyrroate CUVPOSA 3 AL (limited to 16 years of age and under)hycosamine-phenyltoloxamine DIGEX NF 3lamivudine (hepatitis) EPIVIR HBV 2 QL (30 tablets/month) SPlanthanum FOSRENOL 500mg 2 QL (150 tablets/month)lanthanum FOSRENOL 750mg 2 QL (150 tablets/month)lanthanum FOSRENOL 1000mg 2 QL (120 tablets/month)linaclotide LINZESS 3lubiprostone AMITIZA 2 QLQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 305-Tier Drug Benefit Guide09/01/13
mesalamine CANASA 2mesalamine LIALDA 3mesalamine CR APRISO 2mesalamine CR PENTASA 3mesalamine enema *ROWASA 1methylnaltrexone bromide RELISTOR 3metoclopramide *REGLAN 1sevelamer RENAGEL 3sevelamer RENVELA 3sulfasalazine *AZULFIDINE 1sulfasalazine EC *AZULFIDINE EN 1ursodiol *ACTIGALL 1ursodiol *URSO 3ursodiol *URSO FORTE 3DIPENTUM 3QL (120 tablets/month)PAGENITOURINARY (drugs to treat genital and bladder or kidney conditions)8-A Urinary Anti-InfectivesGeneric Name Brand NameTierNotesfosfomycin MONUROL 2 QL (1 Packet/month)methenamine-NA biphosphate *UROQID 1nitrofurantoin macro *MACROBID 1nitrofurantoin macrocrystals *MACRODANTIN 1nitrofurantoin susp FURADANTIN 28-B Urinary AntispasmodicsGeneric Name Brand NameTierNotesbethanechol *URECHOLINE 1darifenacin ENABLEX 3 QL (30 tablets/month)fexoterodine TOVIAZ 3 QL (30 tablets/month)flavoxate *URISPAS 1 QL (240 tablets/month)mirabegron MYRBETRIQ 3oxybutynin *DITROPAN 1 QL (240 tablets/month)oxybutynin CR *DITROPAN XL 5mg 1 QL (30 tablets/month)oxybutynin CR *DITROPAN XL 10mg 1 QL (60 tablets/month)oxybutynin CR *DITROPAN XL 15mg 1 QL (60 tablets/month)oxybutynin patches OXYTROL 3 QL (8 patches/month)solifenacin VESICARE 3 QL (30 tablets/month)tolterodine DETROL 3 QL (60 tablets/month)trospium *SANCTURA 3 QL (60 tablets/month)8-C Vaginal ProductsGeneric Name Brand NameTierNotesclindamycin vaginal *CLEOCIN vaginal cream 1clindamycin vaginal CLINDESSE 3 QL (6 gm/fill)estradiol vaginal ESTRACE vaginal 2estradiol vaginal VAGIFEM 3estradiol vaginal ring ESTRING 3 QL (1 ring/3 months)estradiol vaginal ring FEMRING 3 QL (1 ring/3 months)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 315-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 and 26: halobetasol *ULTRAVATE 1halobetasol
Page 27 and 28: estrogens (conjugated) PREMARIN 3 Q
Page 29 and 30: medroxyprogesterone *PROVERA 1noret
Page 31 and 32: levothyroxine 1levothyroxine TIROSI
Page 33: 7-B AntidiarrhealsGeneric Name Bran
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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