Tier 2 cover - Health Plan of Nevada

Certain medications may have quantity, age or therapeutic supply limitations based on FDA
approved dosages, literature documentation or P&T Committee decisions. See your plan
documents for a complete list of covered benefits, limitations and exclusions.
Mandatory Generic Substitution Policy
Most of our prescription drug plans include a mandatory generic requirement, therefore, if a
preferred brand name drug is dispensed when a preferred generic equivalent is available, you will
be required to pay the difference between the contracted cost of the generic and brand name drug in
addition to the preferred generic (tier 1) copayment. Please note that not all dosage forms or
strengths may be available in a generic form. The asterisk (*) indicates that at least one form or
strength of the drug is available as a generic at the time of printing. Check with your pharmacist
for more information.
Pharmacy Exceptions
The Medical Necessity/Exceptions Policy allows members and practitioners to request, on the basis
of medical necessity, that Health Plan of Nevada cover a certain pharmaceutical not on the current
Preferred Drug List. This Policy is applicable to members with a closed or 2-tier prescription drug
benefit where no coverage for non-preferred drugs is available. It is anticipated that such
exceptions will be rare and that preferred medications will be appropriate to treat the vast majority
of medical conditions.
Requests for medical necessity or exceptions may be submitted by members, pharmacists or
providers; however, the prescribing practitioner must provide the appropriate information to support
the request on the basis of medical necessity. Pharmacy Services uses pharmacists, practitioners of
appropriate specialists and/or medical guidelines to review exception requests. Each request is
evaluated on an individual basis to determine if the patient meets criteria based on current medical
literature, drug information, opinion or medical professionals and patient specific information.
Exception requests are processed within 24 hours of receipt of all necessary clinical information,
with exception of weekend and holidays. The member and the prescribing practitioner are notified
of the decision by fax, phone or letter. If the exception request is denied, the practitioner or the
member may choose to appeal through the HPN appeal process.
To request an exception, members should contact Member Services at (702) 242-7300 or (800) 777-
1840.
Since this list is to be used in the decision-making process and does not represent standards of care
for an individual, we encourage you to take this reference to all doctor appointments and verify that
the drug he/she prescribes is included on this list. You and your provider should discuss the best
possible treatment plan and medications to meet your needs. Because a drug is included on our
Preferred Drug List does not guarantee that the provider will prescribe that medication.
If you have any questions regarding HPN’s Preferred Drug List, please contact our Member
Services Department at (702) 242-7300 or (800) 777-1840. We are proud to be your healthcare
provider of choice. Working together, we can achieve our common goal – to keep you healthy!
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