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

Autonomic and CNS Medications:Other AnticonvulsantsBANZEL 400 MG TABLET Tier 5BANZEL ORAL SUSP, -200 MG Tier 3TABLETclonazepam tabletTier 2 P Adiazepam rectalTier 2 P Afelbamate Tier 2gabapentin capsule, -tablet Tier 1gabapentin solution Tier 2GABITRIL 12 MG TABLET -16 MG Tier 3TABLETHORIZANT Tier 4lamotrigine Tier 2lamotrigine er Tier 2levetiracetam injectionTier 2 H I Tlevetiracetam solution, -tablet, -tablet Tier 2sustained actionLYRICATier 4 P AONFITier 4 P Aphenobarbital elix, -tablet Tier 2POTIGA Tier 3primidone tablet Tier 2SABRILTier 5 L P A, N M Otiagabine tablet Tier 2topiragen Tier 2topiramate sprinkle, -tablet Tier 2Autonomic and CNS Medications: OtherAnticonvulsants (continued)VIMPAT INJECTIONTier 3 H I TVIMPAT SOLUTION, -TABLET Tier 3zonisamide Tier 2Q 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. 27