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

Antiinfectives: Antiretrovirals and Protease Inhabacavir Tier 2APTIVUS Tier 5ATRIPLA Tier 5COMBIVIR Tier 5COMPLERA Tier 5CRIXIVAN Tier 3didanosine Tier 2EDURANT Tier 5EMTRIVA Tier 3EPIVIR SOLUTION Tier 3EPZICOM Tier 5FUZEON Tier 5INCIVEKTier 5 P AINTELENCE 100 MG TABLET, -200 Tier 5MG TABLETINTELENCE 25 MG TABLET Tier 3INVIRASE CAPSULE Tier 3INVIRASE TABLET Tier 5ISENTRESS Tier 5KALETRA 100-25 MG TABLET Tier 3KALETRA SOLUTION, -200-50 MG Tier 5TABLETlamivudine Tier 2lamivudine-zidovudine Tier 2LEXIVA ORAL SUSP Tier 3LEXIVA TABLET Tier 5Antiinfectives: Antiretrovirals and Protease Inh (continued)nevirapine Tier 2NORVIR Tier 3PREZISTA 150 MG TABLET, -400 MG Tier 5TABLET, -600 MG TABLETPREZISTA 75 MG TABLET, -800MG Tier 3TABLET, -100MG SUSPRESCRIPTOR Tier 3RETROVIR INJECTIONTier 3 H I TREYATAZ 100 MG CAPSULE Tier 3REYATAZ 150 MG CAPSULE, -200 MG Tier 5CAPSULE, -300 MG CAPSULESELZENTRY Tier 5stavudine Tier 2STRIBILD Tier 5SUSTIVA Tier 3TRIZIVIR Tier 5TRUVADA Tier 5VICTRELISTier 5 P AVIDEX Tier 3VIRACEPT POWDER, -250 MG Tier 3TABLETVIRACEPT 625 MG TABLET Tier 5VIRAMUNE ORAL SUSP Tier 3VIRAMUNE XR Tier 3VIREAD Tier 5ZIAGEN SOLUTION Tier 38Q 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.