Tier 2 cover - Health Plan of Nevada

ONE TOUCH ULTRA SYSTEM 1
ONE TOUCH ULTRA TEST STRIPS 1
GASTROINTESTINAL (drugs to treat stomach or intestinal conditions, ie reflux, constipation, etc)
7-A Laxatives
Generic Name Brand Name
Tier
Notes
lactulose 1
PEG electrolyte *COLYTE 1
PEG electrolyte GOLYTELY 2
peg (high)-electrolyte *NULYTELY 1
7-B Antidiarrheals
Generic Name Brand Name
Tier
Notes
diphenoxylate-atropine *LOMOTIL 1
7-C Miscelleanous Ulcer Drugs
Generic Name Brand Name
Tier
Notes
dicyclomine *BENTYL 1
glycopyrrolate *ROBINUL 1
glycopyrrolate *ROBINUL FORTE 1
hyoscyamine *LEVSIN 1
hyoscyamine *LEVBID 1
hyoscyamine *NULEV 1
hyoscyamine SR *LEVSINEX 1
misoprostol *CYTOTEC 1 QL (120 tablets/month)
phenobarbital-belladonna *DONNATAL 1
propantheline PRO-BANTHINE 2
sucralfate CARAFATE 2
7-D H2 Blockers
Generic Name Brand Name
Tier
Notes
cimetidine *TAGAMET 1 M
famotidine *PEPCID 1 M
nizatadine *AXID 1 M
ranitidine *ZANTAC 1 M
7-E Proton Pump Inhibitors (PPI)
Generic Name Brand Name
Tier
Notes
omeprazole *PRILOSEC 20mg capsules 1 QL (60 capsules/month)
omeprazole *PRILOSEC 20mg tablets 1 QL (30 tablets/month)
omeprazole *PRILOSEC 40mg 1 QL (30 capsules/month)
omeprazole-sodium bicarb ZEGERID (brand) 2 QL (30 capsules/month)
pantoprazole *PROTONIX 1 QL (30 tablets/month)
7-F Antiemetics
Generic Name Brand Name
Tier
Notes
granisetron *KYTRIL 1 QL (2 tablets/fill; 2 fills/month)
ondansetron *ZOFRAN 4mg 1 QL (30 tablets/fill; 2 fills/month)
ondansetron *ZOFRAN 8mg 1 QL (30 tablets/fill; 2 fills/month)
ondansetron *ZOFRAN 24mg 1 QL (15 tablets/fill; 2 fills/month)
ondansetron *ZOFRAN ODT 4mg 1 QL (30 tablets/fill; 2 fills/month)
ondansetron *ZOFRAN ODT 8mg 1 QL (30 tablets/fill; 2 fills/month)
QL - Quantity Limits
AL - Age Limits
PA - Prior Authorization Required
ST - Step Therapy Required M - Mail-order/Maintenance drug
SIO - Self-Injectable Orphan 17 2-Tier (closed) Drug Benefit Guide 01/04/12