5-Tier Preferred Drug List - Health Plan of Nevada

estrogens (conjugated) vaginal PREMARIN vaginal 2metronidazole vaginal *METROGEL vaginal 1metronidazole vaginal *VANDAZOLE 1nystatin vaginal 1sulfanilamide vaginal AVC vaginal 2terconazole vaginal TERAZOL 2triple sulfas vaginal 18-D Miscelleanous Genitourinary AgentsGeneric Name Brand NameTiercitric acid-sodium citrate *BICITRA 1citric acid-D-gluconic acid RENACIDIN 3dutasteride AVODART 3finasteride *PROSCAR 1methylergonovine METHERGINE 3oxybutynin gel GELNIQUE 3pentosan polysulfate sodium ELMIRON 2phenazopyridine *PYRIDIUM 1potassium citrate CR *UROCIT-K 1potassium phosphate K-PHOS 2POTASSIUM CHLORIDE 2silodosin RAPAFLO 3tadalafil CIALIS 3tamsulosin *FLOMAX 1tiopronin THIOLA 3NotesQL (30 capsules/month)QL (30 tablets/month)QL (30 packets/month)QL (90 capsules/month)QL (30 capsules/month)PAQL (60 capsules/month)MUSCULOSKELETAL AND PAIN (drugs to treat pain and muscle conditions)9-A Analgesics-Non-NarcoticGeneric Name Brand NameTierNotesAPAP-butalbital *PHRENILIN 1 QL (360 tablets/month)DIFLUNISAL 2APAP-caffeine-butalbital *ESGIC PLUS 1 QL (360 tablets/month)APAP-caffeine-butalbital *FIORICET 1 QL (360 tablets/month)ASA-caffeine-butalbital *FIORINAL 1choline-mag salicylates *TRILISATE 1salsalate *DISALCID 19-B Analgesics-NarcoticGeneric Name Brand NameTierNotesCODEINE SULFATE 2METHADONE 2APAP-codeine *TYLENOL w/CODEINE 1 QL (390 tablets/month)APAP-hydrocodone *LORCET 10/650mg 1 QL (180 tablets/month)APAP-hydrocodone *LORTAB 1 QL (240 tablets/month)APAP-hydrocodone *MAXIDONE 1 QL (150 tablets/month)APAP-hydrocodone *NORCO 1 QL (360 tablets/month)APAP-hydrocodone *VICODIN 1 QL (240 tablets/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 325-Tier Drug Benefit Guide09/01/13