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

Autonomic and CNS Medications:Other Antidepressantsbudeprion sr Tier 2 Q C D (68/30)bupropion hcl sr Tier 2 Q C D (68/30)bupropion hcl tablet Tier 2bupropion xl Tier 2 Q C D (34/30)chlordiazepoxide-amitriptyline Tier 2CYMBALTA 20 MG CAPSULE, -60 MGCAPSULETier 4 Q C D (68/30),S TCYMBALTA 30 MG CAPSULE Tier 4 Q C D (34/30),S TDESVENLAFAXINE ER Tier 4FORFIVO XL TABLET Tier 4maprotiline hcl Tier 2mirtazapine 15 mg tablet Tier 2 Q C D (51/30)mirtazapine 7.5 mg tablet, -15 mg odt, Tier 2 Q C D (34/30)-30 mg odt, -30 mg tablet, -45 mg odt,-45 mg tabletnefazodone hcl Tier 2perphenazine-amitriptyline Tier 2PRISTIQ ER Tier 4 Q C D (34/30),S TSAVELLA Tier 3trazodone hcl tablet Tier 1venlafaxine hcl Tier 2venlafaxine hcl er 150 mg cap, -150 mgtabTier 2 Q C D (68/30)Autonomic and CNS Medications: OtherAntidepressants (continued)VENLAFAXINE HCL ER 225 MG TAB Tier 4 Q C D (34/30)(BRAND)venlafaxine hcl er 225 mg tab (generic) Tier 2 Q C D (34/30)venlafaxine hcl er 37.5 mg cap, -75 mgcap, -37.5 mg tab, -75 mg tabAutonomic and CNS Medications:Other Antiparkinson DrugsTier 2 Q C D (34/30)APOKYNTier 5 L P A, N M OAZILECT Tier 3bromocriptine mesylate capsule, -tablet Tier 2carbidopa-levodopa Tier 2carbidopa-levodopa-entacapone Tier 2COMTAN Tier 4entacapone Tier 2LODOSYN Tier 3pramipexole dihydrochloride Tier 2ropinirole hcl Tier 2selegiline hcl capsule, -tablet Tier 2TASMAR Tier 5ZELAPAR Tier 428Q 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.