5-Tier Preferred Drug List - Health Plan of Nevada

11-A Ophthalmic Anti-infectivesGeneric Name Brand NameTierazithromycin ophth AZASITE 3bacitracin ophth 1bacitracin-polymyxin B ophth *POLYSPORIN ophth 1besifloxacin ophth BESIVANCE 3ciprofloxacin ophth *CILOXAN 1gatifloxacin ophth ZYMAR 3gatifloxacin ophth ZYMAXID 3gentamycin sulfate ophth *GENTAMICIN OINT 3% 1levofloxacin ophth *QUIXIN 1moxifloxacin ophth MOXEZA 3moxifloxacin ophth VIGAMOX 3neomycin-polymyxin B-gramacidin ophth *NEOSPORIN ophth 1ofloxacin ophth *OCUFLOX 1sulfacetamide sodium ophth *BLEPH-10 1tobramycin ophth *TOBREX 1trifluridine ophth *VIROPTIC 1trimethoprim-polymy B ophth *POLYTRIM ophth 111-B Ophthalmics Beta-BlockerGeneric Name Brand NameTierbetaxolol HCL ophth BETOPTIC-S 3brimonidine timolol ophth COMBIGAN 2carteolol ophth *OCUPRESS 1dorzolamide-timolol ophth *COSOPT 1dorzolamide-timolol ophth COSOPT PF 3levobunolol ophth *BETAGAN 1metipranolol ophth *OPTIPRANOLOL 1timolol ophth BETIMOL 2timolol maleate ophth *TIMOPTIC 1timolol maleate ophth *TIMOPTIC XE 111-C Ophthalmic SteroidsGeneric Name Brand NameTierdexamethasone ophth MAXIDEX 3dexamethasone phosphate ophth *DECADRON ophth 1difluprednate ophth DUREZOL 3fluorometholone ophth FML FORTE 2fluorometholone ophth *FML LIQUIFILM 1fluorometholone ophth FML SOP 2fluorometholone ophth FLAREX 3loteprednol etb-tobramycin ophth ZYLET 3loteprednol ophth ALREX 3loteprednol ophth LOTEMAX 3neomycin-polymyxin-HC ophth *CORTISPORIN OPHTH 1prednisolone ophth *PRED FORTE 1rimexolone ophth VEXOL 2sulfacetamide-prednisolone ophth *BLEPHAMIDE 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 38NotesQL (5 ml/month)QL (5 ml/month)QL (5 ml/month)QL (5 ml/month)QL (3 ml/month)QL (3 ml/month)QL (10 ml/month)QL (5 ml/month)NotesQL (60 sing-use vials per month)QL (5 ml/month)QL (5 ml/month)QL (5 ml/month)QL (10 ml/month)Notes5-Tier Drug Benefit Guide09/01/13