2013 Medicare HMO Blue ValueRx/PlusRx Formulary - Blue Cross ...

Autonomic and CNS Medications:Antipsychotic DrugsABILIFY 20 MG TABLET, -30 MG Tier 5TABLET, -300 MG ER INJECTIONABILIFY DISCMELT Tier 4ABILIFY INJECTION, -SOLUTION, -2 Tier 3MG TABLET, -5 MG TABLET, -10 MGTABLET, -15 MG TABLETchlorpromazine hcl injectionTier 2 H I Tchlorpromazine hcl tablet Tier 2clozapine Tier 2FANAPT Tier 4FAZACLO Tier 4fluphenazine decanoate injection Tier 2fluphenazine hcl Tier 2GEODON INJECTION Tier 3haloperidol decanoate Tier 2haloperidol decanoate 100 Tier 2haloperidol injection Tier 2haloperidol lactate Tier 2haloperidol tablet Tier 1INVEGA Tier 4INVEGA SUSTENNA 117 MG PREF Tier 5SY, -156 MG PREF SY, -234 MGPREF SYINVEGA SUSTENNA 39 MG PREF Tier 4SYR, -78 MG PREF SYRAutonomic and CNS Medications:Antipsychotic Drugs (continued)LATUDA Tier 4loxapine Tier 2olanzapine 20 mg tablet Tier 5olanzapine injection, -2.5 mg tablet, Tier 2-5 mg tablet, -7.5 mg tablet, -10 mgtablet, -15 mg tabletolanzapine odt Tier 2olanzapine-fluoxetine hcl Tier 2 Q C D (34/30)ORAP Tier 3perphenazine Tier 2quetiapine fumarate Tier 2RISPERDAL CONSTA 12.5 MG SYR, Tier 3-25 MG SYRRISPERDAL CONSTA 37.5 MG SYR, Tier 5-50 MG SYRrisperidone Tier 2risperidone m-tab Tier 2risperidone odt Tier 2SAPHRIS Tier 4SEROQUEL XR Tier 3thioridazine hcl Tier 2thiothixene Tier 1trifluoperazine hcl Tier 2ziprasidone hcl Tier 2ZYPREXA RELPREVV Tier 4Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 21