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

Autonomic and CNS Medications: SelectiveSerotonin Reuptake Inhibitorscitalopram hbr solution Tier 2citalopram hbr tablet Tier 1 Q C D (51/30)escitalopram oxalate solution Tier 2escitalopram oxalate tablet Tier 2 Q C D (51/30)fluoxetine dr Tier 2 Q C D (5/30)fluoxetine hcl 10 mg capsule, -20 mg Tier 2 Q C D (34/30)capsulefluoxetine hcl 10 mg tablet Tier 2 Q C D (51/30)fluoxetine hcl 20 mg tablet Tier 2 Q C D (120/30)fluoxetine hcl 40 mg capsule Tier 2 Q C D (68/30)fluoxetine hcl solution Tier 2fluvoxamine maleate 100 mg tab Tier 2 Q C D (102/30)fluvoxamine maleate 25 mg tab Tier 2 Q C D (51/30)fluvoxamine maleate 50 mg tab Tier 2 Q C D (68/30)paroxetine cr 12.5 mg tablet, -cr 37.5 Tier 2 Q C D (68/30)mg tablet, -er 37.5 mg tabletparoxetine cr 25 mg tablet Tier 2 Q C D (102/30)paroxetine hcl 10 mg tablet, -40 mg Tier 1 Q C D (51/30)tabletparoxetine hcl 20 mg tablet, -30 mg Tier 1 Q C D (68/30)tabletPAXIL ORAL SUSP Tier 4sertraline hcl 100 mg tablet Tier 1 Q C D (68/30)sertraline hcl 25 mg tablet, -50 mgtabletTier 1 Q C D (51/30)Autonomic and CNS Medications: SelectiveSerotonin Reuptake Inhibitors (continued)sertraline hcl solution Tier 2VIIBRYD 10 MG TABLET, -20 MGTABLET, -40 MG TABLETTier 4 Q C D (34/30),S TVIIBRYD TITRATION PACK Tier 4 Q C D (30/30),S TAutonomic and CNS Medications:Smoking Cessation Productsbuproban Tier 2CHANTIX Tier 3 Q C D (408/365)NICOTROL Tier 3NICOTROL NS Tier 3 Q C D (160/30)Autonomic and CNS Medications: SuccinimidesCELONTIN Tier 3ethosuximide capsule, -syrup Tier 2Autonomic and CNS Medications: Tertiary Aminesamitriptyline hcl tablet Tier 2clomipramine hcl capsule Tier 2doxepin hcl capsule, -solution Tier 2imipramine hcl tablet Tier 2imipramine pamoate Tier 2trimipramine maleate capsule Tier 230Q 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.