5-Tier Preferred Drug List - Health Plan of Nevada

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emtricitabine-tenofovir TRUVADA 5 QL (30 tablets/month) SPenfuvirtide FUZEON 4 SIO SPentecavir BARACLUDE 4 QL (30 tablets/month) SPetravirine INTELENCE 4 QL 120 tablets/month) ST SPIntelence ST = requires 30 day trial fill of other NNRTI (Sustiva, Viramune, Rescriptor) within past 2 yearsfosamprenavir LEXIVA 5 QL (120 tablets/month) SPindinavir sulfate CRIXIVAN 2 SPlamivudine EPIVIR 5 SPlamivudine-zidovudine *Combivir 1 SPlopinavir-ritonavir KALETRA 2 SPmaraviroc SELZENTRY 150mg 4 QL (60 tablets/month) PAmaraviroc SELZENTRY 300mg 4 QL (120 tablets/month) PAnelfinavir mesylate VIRACEPT 5 SPnevirapine *VIRAMUNE 1 SPnevirapine XR VIRAMUNE XR 2 SPraltegravir ISENTRESS 4 QL (60 tablets/month) SPrilpivirine EDURANT 5 SPritonavir NORVIR 5 SPsaquinavir INVIRASE 5 SPstavudine *ZERIT 1 SPtelbivudine TYZEKA 5 QL (30 tablets/month) SPtenofovir VIREAD 2 SPtipranavir APTIVUS capsules 5 QL (120 capsules/month) SPtipranavir APTIVUS suspension 5 QL (300 mls/month) SPzidovudine *RETROVIR 1 SP1-J AntimalarialsGeneric Name Brand NameTierartemether-lumefantrine COARTEM 3atovaquone-proguanil HCL MALARONE 3chloroquine *ARALEN 1hydroxychloroquine *PLAQUENIL 1mefloquine *LARIAM 1primaquine *PRIMAQUINE 1pyrimethamine DARAPRIM 2quinine sulfate 11-K AnthelminticsGeneric Name Brand NameTieralbendazole ALBENZA 3ivermectin STROMECTOL 3mebendazole VERMOX 2praziquantel BILTRICIDE 3thiabendazole MINTEZOL 3NotesQL (24 tablets/60 days)Notes1-L Misc Anti-InfectivesGeneric Name Brand NameTieratovaquone MEPRON 4QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 4Notes5-Tier Drug Benefit Guide09/01/13
dapsone DAPSONE 2dornase alfa PULMOZYME 4EES-sulfisoxazole *PEDIAZOLE 1fidaxomicin DIFICID 3iodoquinol *YODOXIN 1linezolid ZYVOX 3loracarbef LORABID 3metronidazole *FLAGYL tablets 1metronidazole *FLAGYL capsule 1metronidazole CR FLAGYL ER 3neomycin *MYCIFRADIN 1nitazoxanide ALINIA tablets 3nitazoxanide ALINIA suspension 3refaximin XIFAXAN 3XIFAXAN ST = requires failure of lactulose within the past 2 yearsSMZ-TMP *BACTRIM 1SMZ-TMP *SEPTRA 1sulfadiazine 1tobramycin TOBI 4tobramycin TOBI PODHALER 5trimethoprim *TRIMPEX 1vancomycin *VANCOCIN 4PAPAQL (7 tablets/fill)QL (6 tablets/fill)QL (60 mls/fill)QL (60 tablets/month) STPA SPPA SPQL (56 capsules/14 days) PACANCER and TRANSPLANT (drugs to treat cancers and prevent organ rejection)2-A Antineoplastics (cancer drugs)Generic Name Brand NameTierNotesabiraterone acetate ZYTIGA 3 PA SPaltretamine HEXALEN 2anastrozole *ARIMIDEX 1 QL (30 tablets/month)axitinib INLYTA 3 QL PA SPbexarotene TARGRETIN 3 SPbicalutamide *CASODEX 1bosutinib BOSULIF 3 PA SPbusulfan MYLERAN 2cabozantinib COMETRIQ 3 PAcapecitabine XELODA 3 PA SPchlorambucil LEUKERAN 2crizotinib XALKORI 3 PAcyclophosphamide CYTOXAN 2dabrafenib mesylat TAFINLAR 3 PA SPdasatinib SPRYCEL 3 PA SPenzalutamide XTANDI 3 PA SPerlotinib TARCEVA 3 PA SPestramustine EMCYT 2etoposide *VEPESID 1everolimus AFINITOR 3 PA SPexemestane *AROMASIN 1 QL (30 tablets/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 55-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 and 6: FIVE-TIER Drug Benefit GuideThis dr
Page 7: griseofulvin ultramicrosize *GRIS-P
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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