Tier 2 cover - Health Plan of Nevada

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carbamazepine SR *TEGRETOL XR 1 clonazepam *KLONOPIN 1 divalproex sodium EC *DEPAKOTE 1 ethosuximide *ZARONTIN 1 gabapentin *GABARONE 1 gabapentin *NEURONTIN 100mg 1 gabapentin *NEURONTIN 300mg 1 gabapentin *NEURONTIN 400mg 1 gabapentin *NEURONTIN 600mg 1 gabapentin *NEURONTIN 800mg 1 lamotrigine *LAMICTAL 1 lamotrigine *LAMICTAL STARTER KIT 1 levetiracetam *KEPPRA 1 oxcarbazepine *TRILEPTAL 100mg 1 oxcarbazepine *TRILEPTAL 300mg 1 oxcarbazepine *TRILEPTAL 600mg 1 phenytoin *DILANTIN (NTI) 2 primidone *MYSOLINE 1 topiramate *TOPAMAX 1 topiramate *TOPAMAX SPRINKLES 1 valproic acid *DEPAKENE 1 zonisamide *ZONEGRAN 25mg 1 zonisamide *ZONEGRAN 50mg 1 zonisamide *ZONEGRAN 100mg 1 4-H Antiparkinsonian Agents Generic Name Brand Name AMANTADINE (Symmetrel) 2 apomorphine APOKYN 2 benztropine *COGENTIN 1 bromocriptine (tablets) *PARLODEL 1 carbidopa-levodopa *PARCOPA 1 carbidopa-levodopa *SINEMET 1 carbidopa-levodopa CR *SINEMET CR 1 entacapone COMTAN 2 pergolide *PERMAX 1 pramipexole *MIRAPEX 1 ropinirole *REQUIP 1 trihexyphenidyl *ARTANE 1 *SELEGILINE 1 Tier M SIO M M 5-A Anorectal Generic Name Brand Name Tier hydrocortisone rectal *ANUSOL-HC 1 hydrocortisone-pramoxine rectal *ANALPRAM-HC 1 hydrocortisone-pramoxine rectal PROCTOFOAM-HC 2 5-B Acne Products QL - Quantity Limits M M M M QL (240 capsules/month) M QL (360 capsules/month) M QL (270 capsules/month) M QL (180 tablets/month) M QL (120 tablets/month) M M QL (1 kit/month) M QL (60 tablets/month)M QL (90 tablets/month)M QL (120 tablets/month)M M M QL (90 tablets/month) QL (120 capsules/month) M QL (120 capsules/month) QL (120 capsules/month) QL (180 capsules/month) Notes M M QL (240 tablets/month) M M QL (90 tablets/month) QL (90 tablets/month) M M M DERMATOLOGICALS (drugs to treat skin disorders or conditions) AL - Age Limits Notes PA - Prior Authorization Required ST - Step Therapy Required M - Mail-order/Maintenance drug SIO - Self-Injectable Orphan 11 2-Tier (closed) Drug Benefit Guide 01/04/12
Generic Name Brand Name Tier Notes benzoyl peroxide-erythromycin gel *BENZAMYCIN 1 QL (60 gm/month) clindamycin topical *CLEOCIN-T 1 erythromycin topical *ERYGEL 1 metronidazole cream *METROCREAM 1 QL (60 gm/month) metronidazole cream NORITATE** 2 QL (60 gm/month) metronidazole lotion *METROLOTION 1 sulfacetamide lotion (acne) *KLARON 1 sulfacetamide-sulfur emulsion *PLEXION 1 tretinoin *RETIN-A ** 1 AL ** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply 5-C Topical Antibiotics Generic Name Brand Name Tier Notes bac-polymy-neomycin HC oint CORTISPORIN OINTMENT 2 gentamicin topical *GARAMYCIN 1 mupirocin *BACTROBAN 1 mupirocin BACTROBAN CREAM 2 mupirocin BACTROBAN NASAL OINTMENT 2 neomycin-polymyxin-HC cream CORTISPORIN CREAM 2 silver sulfadiazine *SILVADENE 1 5-D Topical Antifungals Generic Name Brand Name Tier Notes ciclopirox *LOPROX 1 ciclopirox solution *PENLAC 1 QL (7 ml/month) clotrimazole-betamethasone *LOTRISONE 1 QL (30 ml/month) econazole *SPECTAZOLE 1 ketoconazole shampoo *NIZORAL SHAMPOO 1 ketoconazole topical 1 nystatin topical *MYCOSTATIN topical 1 nystatin-triamcinolone *MYCOLOG II 1 5-E Topical Antivirals Generic Name Brand Name Tier Notes acyclovir topical ZOVIRAX topical 2 5-F Antipsoriatics Generic Name Brand Name Tier Notes anthralin *PSORIATEC 1 calcipotriene DOVONEX 2 QL (1 tube/month) calcitriol ointment VECTICAL 2 QL (100 gm/month) ** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply 5-G Scabicides and Pediculicides Generic Name Brand Name Tier Notes lindane shampoo *KWELL 1 permethrin *ELIMITE 1 5-H Topical Corticosteroids Generic Name Brand Name Tier Notes alclometasone *ACLOVATE 1 augmented betamethasone *DIPROLENE 1 QL - Quantity Limits AL - Age Limits PA - Prior Authorization Required ST - Step Therapy Required M - Mail-order/Maintenance drug SIO - Self-Injectable Orphan 12 2-Tier (closed) Drug Benefit Guide 01/04/12
Page 1 and 2: Preferred Drug List 2-Tier Closed
Page 3 and 4: TWO-Tier (CLOSED) Preferred Drug Li
Page 5 and 6: This summary is not an offer of cov
Page 7 and 8: erythromycin ethylsuccinate *EES 1
Page 9 and 10: Generic Name Brand Name Tier Notes
Page 11 and 12: verapamil SR *VERELAN PM 1 M 3-E An
Page 13 and 14: gemfibrozil *LOPID 1 M lovastatin *
Page 15: quetiapine fumarate SEROQUEL 300mg
Page 19 and 20: hydrocortisone acetate *CORTEF 1 M
Page 21 and 22: GLUCAGON 2 QL (2 kits/month 6-I Thy
Page 23 and 24: ondansetron *ZOFRAN ODT 24mg 1 scop
Page 25 and 26: Generic Name Brand Name Tier Notes
Page 27 and 28: sumatriptan SUMATRIPTAN INJ 2 QL (2
Page 29 and 30: metipranolol ophth *OPTIPRANOLOL 1
Page 31 and 32: promethazine VC PHENERGAN VC 2 prom
Page 33 and 34: oxymetholone ANADROL-50 2 palonoset
Page 35 and 36: naproxen esomeprazole VIMOVO noreth
Page 37 and 38: Preferred Alternatives DYNACIRC ESC
Page 39 and 40: Alphabetical Index Drug Name PDL Se

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