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

Autonomic and CNS Medications: Class II Narcoticsalfentanil hydrochloride Tier 2codeine phosphate injection Tier 2codeine sulfate Tier 2diskets Tier 2duramorph 0.5mg/ml ampul, -1mg/ml Tier 2 H I Tampulduramorph 5mg/10ml ampul,Tier 2 H I T-10mg/10ml ampulendocet Tier 2endodan Tier 2fentanyl Tier 2 Q C D (15/30)fentanyl 0.05 mg/ml ampul, -0.05 mg/ml Tier 2syringe, -0.05 mg/ml vial, -1 mg/20 mlvial, -100 mcg/2 ml vial, -250 mcg/5ml vialfentanyl 2,500 mcg/50 ml vial Tier 2fentanyl citrate lozenge Tier 5 Q C D (120/30),P Ahydromorphone hcl injection, -rectal, Tier 2-solution, -tabletlevorphanol tartrate tablet Tier 2meperidine hcl injection, -solution, Tier 2-tabletmeperitab Tier 2methadone hcl injectionTier 2 H I Tmethadone hcl solution, -tablet Tier 2methadone intensol Tier 2Autonomic and CNS Medications:Class II Narcotics (continued)methadose Tier 2morphine sulfate er capsule sustained Tier 2 Q C D (90/30)actionmorphine sulfate er tablet sustained Tier 2 Q C D (120/30)actionmorphine sulfate in dextrose Tier 2morphine sulfate injection, -rectal, Tier 2-solution, -tabletOPIUM TINCTURE Tier 3oxycodone concentrate Tier 2oxycodone hcl Tier 2oxycodone hcl-acetaminophen Tier 2oxycodone hcl-aspirin Tier 2oxycodone hcl-ibuprofen Tier 2oxycodone-acetaminophen Tier 2OXYCONTIN 10 MG TABLET, -15 MG Tier 3 Q C D (90/30)TABLET, -20 MG TABLET, -30 MGTABLET, -40 MG TABLETOXYCONTIN 60 MG TABLET Tier 3 Q C D (120/30)OXYCONTIN 80 MG TABLET Tier 5 Q C D (120/30)oxymorphone hcl tablet Tier 2oxymorphone hcl er tablet Tier 2 Q C D (90/30)ROXICET SOLUTION Tier 3roxicet tablet Tier 2sublimaze Tier 224Q 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.