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

Autonomic and CNS Medications:Antivertigo and Antiemetic Drugscompro Tier 2dimenhydrinate injection Tier 2dronabinol 10 mg capsule Tier 5dronabinol 2.5 mg capsule, -5 mg Tier 2capsuleEMEND 40 MG CAPSULE, -125 MG Tier 3 Q C D (1/1)CAPSULEEMEND 80 MG CAPSULE Tier 3 Q C D (2/1)EMEND INJECTION Tier 3EMEND TRIFOLD PACK Tier 3 Q C D (3/1)granisetron hcl 0.1 mg/ml vial, -4 mg/4 Tier 2 H I Tml vialgranisetron hcl 1 mg/ml vial Tier 2granisetron hcl tablet Tier 2 Q C D (4/3)granisolTier 2 Q C D (30 ml/3)meclizine hcl tablet Tier 2ondansetron 40 mg/20 ml vial, -4 mg/2 Tier 2ml syr, -4 mg/2 ml ampuleondansetron hcl 24 mg tablet Tier 2 Q C D (2/1)ondansetron hcl 4 mg tablet, -8 mg Tier 2 Q C D (12/1)tabletondansetron hcl 4 mg/2 ml vial Tier 2 H I Tondansetron hcl in dextrose Tier 2ondansetron hcl solutionTier 2 Q C D (150 ml/1)ondansetron in sodium chloride Tier 2Autonomic and CNS Medications: Antivertigoand Antiemetic Drugs (continued)ondansetron odt Tier 2 Q C D (12/1)phenadoz Tier 2prochlorperazine edisylate injection Tier 2prochlorperazine maleate rectal Tier 2prochlorperazine maleate tablet Tier 1promethazine hcl rectal Tier 2promethegan Tier 2TRANSDERM-SCOP Tier 4trimethobenzamide hcl capsule,-injectionTier 222Q 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.