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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acl<strong>of</strong>en *LIORESAL 1carisoprodol *SOMA 1 QL (120 tablets/month)carisoprodol-ASA *SOMA COMPOUND 1 QL (120 tablets/month)carisoprodol-ASA-codeine *SOMA CPD w/CODEINE 1 QL (120 tablets/month)chlorzoxazone *PARAFON FORTE 1cyclobenzaprine *FLEXERIL 5mg 1 QL (90 tablets/month)cyclobenzaprine *FLEXERIL 10mg 1cyclobenzaprine *AMRIX 1 QL (30 capsules/month)cyclobenzaprine *FEXMID 3 QL (90 tablets/month) STFexmid ST = requires 2 fills <strong>of</strong> generic cyclobenzaprine in past 2 yearsdantrolene *DANTRIUM 1metaxalone SKELAXIN 3 QL (240 tablets/month)methocarbamol *ROBAXIN 1orphenadrine citrate *NORFLEX 1tizanidine *ZANAFLEX 19-H Miscelleanous Neuromuscular AgentsGeneric Name Brand Name<strong>Tier</strong>Notespyridostigmine *MESTINON 1riluzole *RILUTEK 3 QL (60 tablets/month)VITAMINS & HEMATOLOGICALS (drugs to treat vitamin deficiencies and other blood disorders)10-A VitaminsGeneric Name Brand Name<strong>Tier</strong>Notescalcitriol *ROCALTROL 1docercalciferol HECTOROL 3ergocalciferol [vitamin D] *CALCIFEROL 1paricalcitol [vitamin D] ZEMPLAR 2 QL (30 capsules/month) SPphytonadione MEPHYTON 2potassium aminobenzoate POTABA 210-B MultivitaminsGeneric Name Brand Name<strong>Tier</strong>NotesB complex-vit C-FA *NEPHROCAPS 1fe bisglycin-fe polysac NIFEREX GOLD 3 QL (30 tablets/month)multi vitamin TANDEM F 3ped multi vitamin-fluoride *POLY-VI-FLOR 1ped multi vitamin-fluoride-FE *POLY-VI-FLOR-FE 1ped vitamins ACD-fluoride *TRI-VI-FLOR 1ped vitamins ACD-fluoride-FE *TRI-VI-FLOR-FE 1pnv-select 1prenatal FE-CBN-DSS-Methylfol-FA *PRENATE ELITE 1prenatal low iron 1prenat-fe poly cmplx-fe heme PREFERA OB 3 QL (30 tablets/month)prenat-fe poly cmplx-fe heme PREFERA OB + DHA 3 QL (60 tablets/month)prenatal mv w/fe poly-fa SELECT-OB+DHA 3prenatal vitamin-FE-bisglycinate-FA *NATELLE C 1 QL (30 tablets/month)prenatal vitamins-fe- bis-fe prot succ-fa-ca- *DUET DHA EC 1prenatal vitamins-FE-FA *STUARTNATAL 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty <strong>Drug</strong>s 365-<strong>Tier</strong> <strong>Drug</strong> Benefit Guide09/01/13
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