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

Autonomic and CNS Medications: CNSStimulant Drugs (continued)modafinil tabletTier 2 P AAutonomic and CNS Medications: Drugsto Prevent and Treat Headachesascomp with codeine Tier 2butalb-caff-acetaminoph-codein Tier 2butalbital compound-codeine Tier 2butorphanol tartrate aerosolTier 2 Q C D (5 ml/30)dihydroergotamine mesylate injection Tier 2migergot Tier 2naratriptan hcl Tier 2 Q C D (9/30)rizatriptan Tier 2 Q C D (18/30)sumatriptan 4 mg/0.5 ml cart, -4 mg/0.5ml inject, -4 mg/0.5 ml kit, -4 mg/0.5ml refill, -4 mg/0.5 ml vial, -6 mg/0.5ml refill, -6 mg/0.5 ml syrngsumatriptan 6 mg/0.5 ml inject, -6mg/0.5 ml vialTier 2Tier 2 Q C D (4vials/30)sumatriptan succinate tablet Tier 2 Q C D (9/30)ZOMIG NASAL DROPS/SPRAYS Tier 3 Q C D (6 nasalsprayers/30)Autonomic and CNS Medications: HydantoinsDILANTIN 30 MG CAPSULE Tier 3fosphenytoinTier 2 H I TPEGANONE Tier 3phenytoin injectionTier 2 H I Tphenytoin oral susp Tier 2phenytoin sodium extended Tier 2phenytoin tablet chew Tier 2Autonomic and CNS Medications: MAO InhibitorsEMSAM Tier 4MARPLAN Tier 3phenelzine sulfate tablet Tier 2tranylcypromine sulfate Tier 226Q 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.