5-Tier Preferred Drug List - Health Plan of Nevada

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clarithromycin *BIAXIN 1 QL (28 tablets/month)clarithromycin SR *BIAXIN XL 1 QL (28 tablets/month)clindamycin *CLEOCIN 1erythromycin PCE 3erythromycin EC ERY-TAB 2erythromycin ethylsuccinate *EES 1erythromycin ethylsuccinate *ERYPED 1erythromycin stearate ERYTHROCIN 2telithromycin KETEK 3 QL (20 tablets/month) STKetek ST = requires failure/contraindication to erythromycin or azithromycin within the past 60 daysERYTHROMYCIN BASE 21-D TetracyclinesGeneric Name Brand NameTierNotesdoxycycline *VIBRAMYCIN 1doxycycline ORACEA 3doxycycline hyclate *PERIOSTAT 1 QL (60 tablets/month)doxycycline monohyclate *VIBRATABS 1 QL (60 tablets/month)doxycycline monohydrate *MONODOX 75mg 3 QL (28 tablets/month)doxycycline monohydrate *MONODOX 100mg 3 QL (28 tablets/month)minocycline *MINOCIN 1 QL (60 tablets/month)tetracycline *SUMYCIN 11-E FluoroquinolonesGeneric Name Brand Nameciprofloxacin *CIPRO 1ciprofloxacin SR *CIPRO XR 1levofloxacin *LEVAQUIN 1moxifloxacin *LEVAQUIN 3norfloxacin NOROXIN 3ofloxacin *FLOXIN 1TierNotesQL (60 tablets/month)QL (14 tablets/month)QL (14 tablets/month)1-F Antimycobacterial AgentsGeneric Name Brand NameTierNotesbedaquiline fumarate SIRTURO 3ethambutol *MYAMBUTOL 1ethionamide TRECATOR-SC 3isoniazid 1isoniazid-rifampin RIFAMATE 3isoniazid-rifampin-pyrazinamide RIFATER 3pyrazinamide 1rifabutin MYCOBUTIN 3rifampin *RIFADIN 11-G AntifungalsGeneric Name Brand NameTierNotesfluconazole *DIFLUCAN 50mg 1 QL (30 tablets/month)fluconazole *DIFLUCAN 100mg 1 QL (30 tablets/month)fluconazole *DIFLUCAN 150mg 1 QL (1 tablet/fill)fluconazole *DIFLUCAN 200mg 1 QL (30 tablets/month)griseofulvin microsize *GRIFULVIN V 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 25-Tier Drug Benefit Guide09/01/13
griseofulvin ultramicrosize *GRIS-PEG 2itraconazole *SPORANOX 1ketoconazole *NIZORAL 1miconazole-zinc oxide-white petroleum VUSION 3nystatin BIO-STATIN 2nystatin *MYCOSTATIN susp 1posaconazole NOXAFIL 3terbinafine HCL *LAMISIL 1terbinafine HCL LAMISIL GRANULE PACKET 3voriconazole *VFEND 50mg 1voriconazole *VFEND 200mg 11-H Miscelleanous AntiviralsGeneric Name Brand NameTieracyclovir *ZOVIRAX 1famciclovir *FAMVIR 125mg 1famciclovir *FAMVIR 250mg 1famciclovir *FAMVIR 500mg 1ganciclovir ZIRGAN 3oseltamivir TAMIFLU capsules 3oseltamivir TAMIFLU suspension 3ribavirin *REBETOL capsules/tablets 1ribavirin REBETOL solution 3rimantadine *FLUMADINE 1valacyclovir *VALTREX 500mg 3valacyclovir *VALTREX 1gm 3valganciclovir HCL VALCYTE 4zanamivir RELENZA 3QL (14 capsules/month)QL (50 gms/50 days)QL (90 tablets/year)QL (30 packets/month)QL (180 tablets/month)QL (60 tablets/month)NotesQL (60 tablets/month)QL (60 tablets/month)QL (21 tablets/month)QL (5 gm/month)QL (10 capsules/3 months)QL (50 mls/months)QL (180 capsules/tabletsmonth) PAPAQL (14 pills/fill)QL (60 tablets/month)QL (30 tablets/month)QL (60 tablets/month)QL (1 diskhaler/month)1-I AntiretroviralsGeneric Name Brand NameTierNotesabacavir sulfate ZIAGEN 2 SPabacavir-lamivudine EPZICOM 5 QL (30 tablets/month) SPabacavir-lamivudine-zidovudine TRIZIVIR 5 SPatazanavir REYATAZ 5 SPdarunavir PREZISTA 75mg 5 QL (60 tablets/month) ST SPdarunavir PREZISTA 150mg 5 QL (60 tablets/month) ST SPdarunavir PREZISTA 300mg 5 QL (120 tablets/month) ST SPdarunavir PREZISTA 400mg 5 QL (120 tablets/month) ST SPdarunavir PREZISTA 600mg 5 QL (60 tablets/month) ST SPPrezista ST = must be > 6 years old; requires at least a 30 day fill of Protease Inhibitor within last 2 yearsdarunavir PREZISTA SUSP 3 QL (12ml/day)delavirdine RESCRIPTOR 5 SPdidanosine 1 SPdidanosine *VIDEX EC 1 SPefavirenz SUSTIVA 5 SPefavirenz-emtricitabine-tenofovir ATRIPLA 4 SPemtricitabine EMTRIVA 2 QL (30 capsules/month)emtricitabine-rilpivirine-tenofovir COMPLERA 3 SPQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 35-Tier Drug Benefit Guide09/01/13
Page 1 and 2: Preferred Drug List 5-Tier21NVHPN09
Page 3 and 4: Five-Tier Drug Benefit GuideIntrodu
Page 5: FIVE-TIER Drug Benefit GuideThis dr
Page 9 and 10: dapsone DAPSONE 2dornase alfa PULMO
Page 11 and 12: mycophenolate mofetil *CELLCEPT 1si
Page 13 and 14: quinidine gluconate 1quinidine sulf
Page 15 and 16: indapamide *LOZOL 1methazolamide *N
Page 17 and 18: duloxetine CYMBALTA 60mg 3QL (30 ca
Page 19 and 20: iloperidone FANAPT 3 QL (60 tablets
Page 21 and 22: ivastigmine *EXELON 1rivastigmine E
Page 23 and 24: enzoyl peroxide-adapalene EPIDUO 3
Page 25 and 26: halobetasol *ULTRAVATE 1halobetasol
Page 27 and 28: estrogens (conjugated) PREMARIN 3 Q
Page 29 and 30: medroxyprogesterone *PROVERA 1noret
Page 31 and 32: levothyroxine 1levothyroxine TIROSI
Page 33 and 34: 7-B AntidiarrhealsGeneric Name Bran
Page 35 and 36: mesalamine CANASA 2mesalamine LIALD
Page 37 and 38: APAP-hydrocodone *VICODIN ES 1 QL (
Page 39 and 40: naproxen sodium *ANAPROX 1oxaprozin
Page 41 and 42: prenatal vitamins-FE-FA *PRECARE 1p
Page 43 and 44: tobramycin-dexamethasone ophth *TOB
Page 45 and 46: triamcinolone nasal NASACORT AQ 3tr
Page 47 and 48: mecasermin INCRELEX 5 PA SIO SPsoma
Page 49 and 50: amlodipine-aliskiren-hctz AMTURNIDE
Page 51 and 52: isotretinoin ABSORICAitraconazole O
Page 53 and 54: Alphabetical IndexDrug Name PDL Sec
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5-Tier Preferred Drug List - Health Plan of Nevada

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