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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clonidine SR NEXICLON XR (tablet)clotrimazole LOTRIMIN 1%dermatological GENADUR KITdesloratadine CLARINEXdesonide DESONILdesoximetasone TOPICORT SPRAYdesvenlafaxine er DESVENLAFAXdextroamphetamine sulfate ZENZEDIdicl<strong>of</strong>enac CAMBIAdicl<strong>of</strong>enac patch FLECTORdicl<strong>of</strong>enac potassium ZIPSORdicl<strong>of</strong>enac sol PENNSAIDdonepezil ARICEPT 23mgdoxepin SILENORdoxycycline hyclate DORYXdoxycycline hyclate MORGIDOXdoxycycline monohydrate ADOXAdoxycycline monohydrate Brand MONODOXdrospirenone-ethyinal-levomefolate BEYAZdrospirenone-ethyinyl SAFYRALdutasteride-tamsulosin JALYNemedastine EMADINEepinastine ELESTATepinephrine inj ADRENACLICKesomeprazole NEXIUMezetimibe-atorvastatin LIPTRUZETfelbamate FELBATOLfen<strong>of</strong>ibrate TRICORfen<strong>of</strong>ibric acid TRILIPIXferric subsulfate soln MONSELSfex<strong>of</strong>enadine ALLEGRAfex<strong>of</strong>enadine-pseudoephedrine ALLEGRA Dfluocinolone acetonide soln SYNALAR TSfluticasone furoate nasal VERAMYSTgabapentin GRALISEgabapentin enacarbil HORIZANTgranisetron patch SANCUSOhc-pramoxine cr-diet manage prod tab-cleans wipe kit ANALPRAM ADVANCED KIThydrocortisone topical HYTONEhydrocortisone topical NUCORThydrocortisone topical HYDROCORTISONE 0.05%hydrocortisone topical HYDROCORTISONE 1%hydrocortisone-pramoxine PROCORTibupr<strong>of</strong>en-famotidine DUEXISicosapent ethyl VASCEPAimiquimod ZYCLARAinterferon beta-1B EXTAVIAQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty <strong>Drug</strong>s 465-<strong>Tier</strong> <strong>Drug</strong> Benefit Guide09/01/13
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