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

Autonomic and CNS Medications:Other CNS/Autonomic Drugsatropine sulfate injection Tier 2CAMPRAL Tier 3depade Tier 2disulfiram Tier 2flumazenil Tier 2guanidine hcl Tier 2INTUNIV Tier 4lithium Tier 2lithium carbonate capsule, -tablet, -tablet Tier 1sustained actionMESTINON SYRUP, -TABLETTier 3SUSTAINED ACTIONnaloxone hcl injection Tier 2naltrexone hcl tablet Tier 2neostigmine methylsulfate injection Tier 2NUEDEXTATier 3 P Aphysostigmine salicylate injection Tier 2PROSTIGMIN Tier 3pyridostigmine bromide tablet Tier 2STRATTERA 10 MG CAPSULE, -18MG CAPSULE, -25 MG CAPSULE,-80 MG CAPSULE, -100 MGCAPSULESTRATTERA 40 MG CAPSULE, -60MG CAPSULETier 3 Q C D (34/30),P ATier 3 Q C D (68/30),P AAutonomic and CNS Medications: OtherCNS/Autonomic Drugs (continued)XENAZINEXYREMTier 5 L P A, N M OTier 5 L P A, N M OAutonomic and CNS Medications: Secondary Aminesamoxapine Tier 2desipramine hcl tablet Tier 2nortriptyline hcl capsule, -solution Tier 2protriptyline hcl Tier 2Autonomic and CNS Medications:Sedative/Hypnotic Drugsestazolamflurazepam hcltemazepamtriazolamTier 2 P ATier 2 P ATier 2 P ATier 2 P Azaleplon Tier 2 Q C D (30/30)zolpidem tartrate Tier 2 Q C D (30/30)zolpidem tartrate er Tier 2 Q C D (30/30)Q 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. 29