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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oxycodone-APAP *PERCOCET 10-650mg 1oxycodone-ASA *PERCODAN 1oxycodone-ibupr<strong>of</strong>en COMBUNOX 3oxymorphone *OPANA 3oxymorphone ER OPANA ER 2pentazocine-naloxone *TALWIN NX 1propoxyphene-APAP DARVOCET A 3propoxyphene napsylate DARVON-N 3tapentadol NUCYNTA 3tapentadol SR NUCYNTA ER 3tramadol *ULTRAM 1tramadol ER ULTRAM ER 100mg 3tramadol ER ULTRAM ER 200mg 3tramadol ER ULTRAM ER 300mg 3tramadol-APAP ULTRACET 29-C Non-Steroidal Anti-Inflammatory <strong>Drug</strong>s (NSAIDS)Generic Name Brand Name<strong>Tier</strong>celecoxib CELEBREX 50mg 3celecoxib CELEBREX 100mg 3celecoxib CELEBREX 200mg 3celecoxib CELEBREX 400mg 3dicl<strong>of</strong>enac *VOLTAREN 25mg 1dicl<strong>of</strong>enac *VOLTAREN 50mg 1dicl<strong>of</strong>enac *VOLTAREN 75mg 1dicl<strong>of</strong>enac potassium *CATAFLAM 1dicl<strong>of</strong>enac SR *VOLTAREN XR 1dicl<strong>of</strong>enac-misoprostol *ARTHROTEC 3etodolac *LODINE 200mg 1etodolac *LODINE 300mg 1etodolac *LODINE 400mg 1etodolac *LODINE 500mg 1etodolac SR *LODINE XL 600mg 1fenopr<strong>of</strong>en *NALFON 1flurbipr<strong>of</strong>en *ANSAID 1ibupr<strong>of</strong>en *MOTRIN 1indomethacin *INDOCIN 1indomethacin CR *INDOCIN SR 1ketopr<strong>of</strong>en ORUDIS 2ketopr<strong>of</strong>en SR ORUVAIL 3ketorolac *TORADOL 1lansoprazole-naproxen PREVACID NAP KIT 3mecl<strong>of</strong>enamate *MECLOMEN 1mefenamic acid *PONSTEL 3meloxicam *MOBIC 7.5mg 1meloxicam *MOBIC 15mg 1nabumetone *RELAFEN 1naproxen *NAPROSYN 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty <strong>Drug</strong>s 34QL (180 tablets/month)QL (360 tablets/month)QL (7 day treatment; 4 tablets/day)QL (180 tablets/month)QL (60 tablets/month)QL (240 tablets/month)QL (180 tablets/month)QL (180 tablets/month)QL (60 tablets/month)QL (240 tablets/month)QL (90 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (240 tablets/month)NotesQL (60 capsules/month)QL (60 capsules/month)QL (60 capsules/month)QL (30 capsules/month)QL (240 tablets/month)QL (120 tablets/month)QL (90 tablets/month)QL (120 tablets/month)QL (120 tablets/month)QL (90 capsules/month)QL (90 capsules/month)QL (90 tablets/month)QL (90 tablets/month)QL (60 tablets/month)QL (60 capsules/month)QL (20 tablets/month)QL (60 tablets/month)QL (30 tablets/month)5-<strong>Tier</strong> <strong>Drug</strong> Benefit Guide09/01/13
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