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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11-I Otic (Ear) MedicationsGeneric Name Brand Name<strong>Tier</strong>chloroxylenol-pramoxine-zinc acetate otic ZINOTIC 3chloroxylenol-pramoxine-zinc acetate otic ZINOTIC ES 3cipr<strong>of</strong>loxacin-dexamethasone CIPRODEX 3cipr<strong>of</strong>loxacin-HC otic CETRAXAL 3cipr<strong>of</strong>loxacin-HC otic CIPRO HC OTIC 3hydrocortisone-acetic acid otic *VOSOL-HC 1neomycin-polymyxin-HC otic *CORTISPORIN otic 1neomycin-colistin-HC-thonzonium otic CORTISPORIN-TC 3<strong>of</strong>loxacin otic *FLOXIN OTIC 111-J Mouth and ThroatGeneric Name Brand Name<strong>Tier</strong>amlexanox oral paste APHTHASOL 3cevimeline *EVOXAC 3chlorhexidine *PERIDEX 1clotrimazole troche *MYCELEX TROCHE 1lidocaine *VISCOUS LIDOCAINE 1oral hydrogel wafer MUCOTROL 3pilocarpine *SALAGEN 5mg 1pilocarpine *SALAGEN 7.5mg 1sodium fluoride *KARIGEL 1sodium fluoride *KARIGEL-N 1triamcinolone/orabase *KENALOG-ORABASE 1NotesQL (15 ml/month)QL (15 ml/month)QL (8 ml/month)QL (10 ml/month)QL (10 ml/month)NotesQL (90 capsules/month)QL (120 wafers/month)QL (180 tablets/month)QL (120 tablets/month)RESPIRATORY (drugs to treat breathing conditions, ie asthma and allergies)12-A AntihistaminesGeneric Name Brand Name<strong>Tier</strong>Notescyproheptadine *PERIACTIN 1promethazine *PHENERGAN 1pyrilamine tannate PYRLEX SYRUP 3 QL (120 ml/month)triprolidine tannate ZYMINE XR SYRUP 3 QL (120 ml/month)12-B Topical Nasal ProductsGeneric Name Brand Name<strong>Tier</strong>Notesazelastine nasal *ASTELIN 1 QL (1 inhaler/month)azelastine nasal ASTEPRO 2 QL (1 inhaler/month)beclomethasone nasal BECONASE AQ 3 QL (2 inhalers/month)budesonide nasal RHINOCORT AQUA 3 QL (2 inhalers/month)ciclesonide nasal OMNARIS 3 QL (1 inhaler/month)flunisolide nasal *NASALIDE 1 QL (3 inhalers/month)flunisolide nasal *NASAREL 1 QL (3 inhalers/month)fluticasone nasal *FLONASE 1ipratropium nasal *ATROVENT 0.03% NASAL 1 QL (1 inhaler/month)ipratropium nasal *ATROVENT 0.06% NASAL 1 QL (2 inhalers/month)mometasone nasal NASONEX 3 QL (1 inhaler/month)olopatadine nasal PATANASE 3 QL (1 inhaler/month)triamcinolone nasal NASACORT 3 QL (1 inhaler/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty <strong>Drug</strong>s 405-<strong>Tier</strong> <strong>Drug</strong> Benefit Guide09/01/13
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