5-Tier Preferred Drug List - Health Plan of Nevada

Generic Name Brand NameTierNotesteriparatide (recombinant) FORTEO 4 PA SIO SP13-G Somatostatin AnalogsGeneric Name Brand NameTierNoteslanreotide acetate SOMATULINE DEPOT 4 PA SIOnafarelin SYNAREL 4 PAoctreotide acetate *OCTREOTIDE 4 PA SIO SPoctreotide acetate release SANDOSTATIN LAR 4 PA SIO SPpegvisomant SOMAVERT 4 PA SIO SP13-H ImmunomodulatorsGeneric Name Brand NameTierNotesadalimumab HUMIRA 5 PA SIO SP STHumira ST = requires trial of 1 formulary alternative: Enbrel, Simponi, and/or Cimziaanakinra subcutaneous KINERET 5 PA SIO SPcertolizumab pegol CIMZIA 4 PA SIO SPetanercept for subcutaneous ENBREL 4 PA SIO SPgolimumab SIMPONI 4 QL (1 unit/month) PA SIO SPtofacitinib XELJANZ 3 PA STXELJANZ ST- requires trial of 2 formulary alternatives: Enbrel, Simponi, and/or Cimzia13-I Miscellaneous SpecialtyGeneric Name Brand NameTierNotesabatacept ORENCIA 3 PA SPcorticotropin ACTHAR HP 4 PA SIO SPicatibant acetate FIRAZYR 5 PA SPinterferon alfa-2B INTRON-A 5 PA SIOinterferon gamma-1B ACTIMMUNE 4 PA SIO SPleuprolide acetate ELIGARD 5 PA SIOleuprolide acetate LUPRON 2 SIOleuprolide acetate LUPRON DEPOT 2 SIOleuprolide acetate LUPRON DEPOT-PED 2 SIOnitisinone ORFADIN 4 PAoprelvekin NEUMEGA 4 PA SPoxandralone OXANDRALONE 4 PAoxymetholone ANADROL-50 4palonosetron ALOXI (tablets) 4 PApeginterferon alfa-2B SYLATRON 5 PA SIO SPpeginterferon alfa-2B SYLATRON 4-PACK 5 PA SIO SPrilonacept ARCALYST 4 PA SIO14-A Excluded From CoverageGeneric Name Brand Nameacyclovir hydrocortisone XERESEalcaftadine LASTACAFTalendronate BINOSTOamilodipine-atorvastatin CADUETamlodipine-aliskiren TEKAMLOEXCLUSIONS (excluded drugs)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 44TierNotes5-Tier Drug Benefit Guide09/01/13