Tier 2 cover - Health Plan of Nevada

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TWO-Tier (CLOSED) Preferred Drug List Table of Contents Introduction .............................................................. i Drug Benefit Guide .................................................. 1 Section 1 Anti-Infectives Section 2 Cancer and Transplant Section 3 Cardiovascular Section 4 Central Nervous System Section 5 Dermatologicals Section 6 Endocrine and Hormones Section 7 Gastrointestinals Section 8 Genitourinary Section 9 Musculoskeletal and Pain Section 10 Vitamins and Hematologicals Section 11 Eye, Ear, and Throat Section 12 Respiratory Section 13 Self-Injectable/Specialty Section 14 Exclusions Preferred Alternatives............................................... 31 Alphabetical Index ................................................... 34
TWO-Tier (CLOSED) Preferred Drug List Introduction As a member of Health Plan of Nevada (HPN), you have access to a wide range of effective and affordable medications. HPN utilizes a Preferred Drug List (PDL) as a tool to guide providers to prescribe clinically sound yet cost-effective drugs. This list was established to give you access to the prescription drugs you need at a reasonable cost. Your out-of-pocket prescription cost is lower when you use preferred medications. Please refer to your plan documents for specific pharmacy benefit information. The PDL is a list of FDA-approved generic and brand name medications recommended for use by HPN. The list is developed and maintained by a Pharmacy and Therapeutics (P&T) Committee comprised of actively practicing primary care and specialty physicians, pharmacists and other healthcare professionals. Patient needs, scientific data, drug effectiveness, availability of drug alternatives currently on the PDL and cost are all considerations in selecting "preferred" medications. Due to the number of drugs on the market and the continuous introduction of new drugs, the PDL is a dynamic and routinely updated document screened regularly to ensure that it remains a clinically sound tool for our providers. Reading the Preferred Drug List For your convenience, medications are grouped together based on their therapeutic category (i.e., Anti-Infectives, Cardiovascular, etc.) and further separated into drug classes (i.e., Antidepressants, Contraceptives, etc.). Each drug class has a designated section number (i.e., 1-A, 1-B, etc.) and is the reference point noted in the index. The generic or chemical name is listed to the left of the brand or trade name for each drug. Drugs with a generic equivalent available are identified by an asterisk (*) before the common brand name of the product (for example, in the listing for ampicillin.....*PRINCIPEN, indicates that PRINCIPEN is available as a generic and ampicillin would be dispensed by the pharmacy). Drugs that are not available generically have the brand-name listed in BOLD print (for example, the listing for atorvastatin.....LIPITOR, indicates that there is no generic for LIPITOR and the brand name product will be dispensed). Other abbreviations used throughout the PDL are: • AL = age limitations • M = mail-order/maintenance drug • NTI = narrow therapeutic index (generic not required) • PA = prior authorization • QL = quantity limitations • SIO = self-injectable/orphan drug • ST = step therapy The amount of your copayment for a preferred prescription drug will vary, depending upon whether you select a generic drug, a brand name drug or a brand name when a generic is available. i
Page 1: Preferred Drug List 2-Tier Closed
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 and 16: 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 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
Page 53 and 54:
Alphabetical Index Drug Name PDL Se
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
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Tier 2 cover - Health Plan of Nevada

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