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

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BD PEN NEEDLE NANO32GX5/32 ............. 55BD PEN NEEDLE ORIG29GX1/2 .............. 55BD PEN NEEDLE SHORT31GX5/16 ............. 55BD SAFETYGLIDE SYRINGE27GX5/8 .............. 55BD SAFTGLD INS 0.3 ML31GX5/16 ............. 55BD SAFTGLD INS SYR 0.3 ML29G. .................. 55BD SAFTGLD INS SYR 0.5 ML30G. .................. 55BD SINGLE USE ALCOHOLSWAB. ................ 55BD SINGLE USE SWAB .. 55BD SYR 0.3 ML 31GX5/16(1/2) .................. 55BD SYR 0.3 ML 31GX15/64(1/2) .................. 55BD ULTRA FINE LANCETS 55benazepril hcl tablet ....... 31benazeprilhydrochlorothiazide...... 35BENLYSTA 120 MG VIAL .. 15BENLYSTA 400 MG VIAL .. 15benztropine injection ...... 20benztropine tablet. ........ 20betamethasone acetate-sodphos .................. 42betamethasone dipropionatecream, -gel, -lotion, -oint .. 38betamethasone valerate cream,-lotion, -oint, -foam ....... 38BETASERON ............ 50betaxolol hcl ophth drops. .. 90betaxolol hcl tablet ........ 32bethanechol chloride tablet . 95bicalutamide ............. 15BICNU. ................. 15bisoprolol fumarate ........ 32bisoprololhydrochlorothiazide...... 35BL ALCOHOL PREPSWABS ............... 55bleomycin sulfate injection. . 15BL INSULIN 0.3 MLSYRINGE. ............. 55BL INSULIN 0.5 MLSYRINGE. ............. 55BL INSULIN 1 MLSYRINGE. ............. 55BL LANCETS ............ 55BLOOD GLUCOSE CONTROLSOLUTION ............ 55BOOSTRIX. ............. 48BOSULIF TABLET ........ 15BOTOX ................. 91bp 10-1 ................. 37BREEZE 2 SOLUTION. ... 55briellyn .................. 83brimonidine tartrate. ....... 90bromfenac sodium ........ 91bromocriptine mesylate capsule,-tablet ................. 28BROVANA. .............. 93budeprion sr ............. 28budesonide ec ........... 46budesonide nebs ......... 94BULLSEYE MINI SAFETY21G. .................. 55BULLSEYE MINI SAFETY 28GLANCT ................ 55BULLSEYE MINI SAFETYLANCETS. ............. 55bumetanide injection ...... 34bumetanide tablet. ........ 34BUPHENYL TABLET ...... 40bupivacaine-dextrose ....... 7bupivacaine hcl-epinephrine . 7bupivacaine hcl injection .... 7buprenorphine. ........... 20buprenorphine hcl tab, sl ... 25buprenorphine-naloxon. .... 25buproban ................ 30bupropion hcl sr .......... 28bupropion hcl tablet ....... 28bupropion xl. ............. 28buspirone hcl tablet ....... 23BUSULFEX. ............. 15butalb-caff-acetaminophcodein................. 26butalbital compound-codeine 26butorphanol tartrate aerosol. 26butorphanol tartrate injection 20BYDUREON ............. 42BYETTA . . . . . . . . . . . . . . . . . 42Ccabergoline .............. 44caffeine citrate injection .... 25caffeine citrate solution .... 93calcipotriene ............. 37calcitonin-salmon ......... 44calcitriol capsule, -solution. . 83calcitriol injection ......... 83CALCITRIOL OINT ....... 37calcium acetate. .......... 83calcium chloride injection. .. 79calcium folinate injection ... 15camila. .................. 89CAMPATH ............... 15CAMPHOR. ............. 39CAMPRAL. .............. 29camrese ................. 83camrese lo. .............. 83CANCIDAS .............. 12candesartan- hctz ......... 35candin .................. 48CAPASTAT SULFATE. ...... 9CAPRELSA. ............. 15captopril-hydrochlorothiazide 35captopril tablet ........... 31CARBAGLU ............. 40carbamazepine capsulesustained action, -oral susp 23carbamazepine chew tab,-tablet ................. 23carbamazepine er ......... 23carbamazepine xr ......... 23carbidopa-levodopa ....... 28carbidopa-levodopaentacapone............. 28carbinoxamine maleate. .... 92carboplatin. .............. 15CAREONE INS SYR 1 ML30GX5/16 ............. 55CAREONE THIN LANCET . 55CAREONE ULTRA THINLANCET ............... 55CAREONE UNIFINE PENTIP5MM 31G. ............. 55CAREONE UNIFINE PENTIP6MM 31G. ............. 55100
CAREONE UNIFINE PENTIP8MM 31G. ............. 55CAREONE UNIFINE PNTP12MM 29G ............ 55CARESENS CONTROLSOLUTION ............ 55carisoprodol-aspirin ....... 76carisoprodol-aspirin-codeine 76carisoprodol compound .... 76carisoprodol compoundcodeine................ 76carisoprodol tablet ........ 76carteolol hcl. ............. 90cartia xt ................. 32carvedilol ................ 32cavan-alpha kit ........... 86cavan-ec sod dha ......... 86cavan-heme ob ........... 86cavan one omega . . . . . . . . . 86CAYSTON ............... 10caziant .................. 83CEENU . . . . . . . . . . . . . . . . . 15cefaclor .................. 9cefaclor er . . . . . . . . . . . . . . . . 9cefadroxil ................. 9cefazolin. ................. 9cefdinir ................... 9cefepime ................. 9cefotaxime ................ 9cefotetan . . . . . . . . . . . . . . . . . 9cefoxitin .................. 9cefpodoxime proxetil. ....... 9cefprozil .................. 9ceftazidime ............... 9ceftriaxone ................ 9cefuroxime ................ 9cefuroxime axetil ........... 9cefuroxime sodium ......... 9CELEBREX. ............. 77CELLCEPT INJECTION ... 16CELLCEPT ORAL SUSP .. 16CELONTIN .............. 30cephalexin ................ 9CEREZYME ............. 44cerubidine ............... 16CERVARIX .............. 48cesia. ................... 83cetirizine hcl. ............. 92cevimeline hcl ............ 41CHANTIX. ............... 30CHEMET. ............... 40chloramphenicol sodsuccinate .............. 10chlordiazepoxide-amitriptyline 28chlordiazepoxide hcl ....... 23chlorhexidine gluconate dental/mucous membrn products 41chloroprocaine hcl ......... 7chloroquine phosphate tablet 13chlorothiazide ............ 36chlorothiazide sodium. ..... 36chlorpromazine hcl injection. 21chlorpromazine hcl tablet ... 21chlorpropamide ........... 43chlorthalidone ............ 36chlorzoxazone ............ 76cholestyramine ........... 33cholestyramine light ....... 33choline mag trisalicylate .... 78chorionic gonadotropininjection ............... 89ciclodan ................. 12ciclopirox . . . . . . . . . . . . . . . . 12cidofovir vial. ............. 11cilostazol ................ 78cimetidine injection. ....... 46cimetidine solution, -tablet .. 46CINRYZE ............... 48CIPRODEX. ............. 41ciprofloxacin-d5w injection . 13ciprofloxacin er ........... 13ciprofloxacin hcl ophth drops 91ciprofloxacin injection ...... 13ciprofloxacin tablet ........ 13cisplatin ................. 16citalopram hbr solution. .... 30citalopram hbr tablet. ...... 30cladribine ................ 16claravis. ................. 38clarithromycin er .......... 12clarithromycin suspension,-tablet ................. 12clemastine fumarate syrup,-tablet ................. 92clenia emulsion ........... 37CLEOCIN 100 MG VAGINALOVULE . . . . . . . . . . . . . . . . 85CLEVER CHEK 30GLANCETS. ............. 56CLEVER CHEK CONTROLSOLUTION ............ 56CLEVER CHEK ULTRA THINLANCETS. ............. 56CLICKFINE 31G X 1/4NEEDLES ............. 56CLICKFINE 31G X 5/16NEEDLES ............. 56CLICKFINE UNIVERSAL 31G X1/4. ................... 56CLICKFINE UNIVERSAL31GX5/16 ............. 56CLIMARA PRO. .......... 85clinda-benzoyl perox 1-5%gel .................... 37clindacin p ............... 37clindamycin-benzoyl peroxgel .................... 37clindamycin-d5w .......... 10clindamycin hcl capsule .... 10clindamycin injection ...... 10clindamycin palmitate hcl ... 10clindamycin phos-benzoylperox .................. 37clindamycin phosphate foam(non-contraceptive), -gel,-lotion, -soln, top, -swabs,applicators ............. 37clindamycin phosphate vaginalproducts ............... 85CLINIMIX 2.75%-5%SOLUTION, -4.25%-20%SOLUTION, -4.25%-25%SOLUTION, -4.25%-5%SOLUTION, -5%-15%SOLUTION, -5%-20%SOLUTION, -5%-25%SOLUTION ............ 79CLINIMIX 4.25%-10%SOLUTION ............ 79101
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Medicare HMO Blue SM ValueRx (HMO)M
Page 4 and 5:
How do I use the Formulary?There ar
Page 6 and 7:
What do I do before I can talk to m
Page 8 and 9:
Your Medicare Prescription Drug Cos
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Antiinfectives: Antiretrovirals and
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Antiinfectives: Oral Antifungal Dru
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Antiinfectives: Other Antiviral Dru
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Antiinfectives: Sulfonamideserythro
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Antineoplastic/Immunosuppressant Dr
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Antineoplastic/Immunosuppressant Dr
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Autonomic and CNS Medications: Anal
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Autonomic and CNS Medications:Antiv
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Autonomic and CNS Medications: CNSS
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Autonomic and CNS Medications:Other
Page 32 and 33:
Autonomic and CNS Medications: Sele
Page 34 and 35:
Cardiovascular Medications: Beta-Ad
Page 36 and 37:
Cardiovascular Medications: Loop Di
Page 38 and 39:
Cardiovascular Medications: OtherVa
Page 40 and 41:
Dermatological Medications: OralDer
Page 42 and 43:
Dermatological Medications: Topical
Page 44 and 45:
Endocrine Medications: Glucocortico
Page 46 and 47:
Endocrine Medications: Oral Hypogly
Page 48 and 49:
Gastrointestinal Medications: Antis
Page 50 and 51:
Immunologicals and VaccinesACTHIB T
Page 52 and 53: Immunologicals and Vaccines: Interf
Page 54 and 55: Medical (Miscellaneous) Supplies:Di
Page 80 and 81: Musculoskeletal Medications: Non-St
Page 82 and 83: Nutrition, Blood Modifiers, Electro
Page 84 and 85: Nutrition, Blood Modifiers, Electro
Page 86 and 87: Obstetrical and Gynecological Medic
Page 88 and 89: Obstetrical and GynecologicalMedica
Page 90 and 91: Obstetrical and Gynecological Medic
Page 92 and 93: Ophthalmic Medications: Antiglaucom
Page 94 and 95: Ophthalmic Medications: OtherOphtha
Page 96 and 97: Respiratory Medications: Other Drug
Page 98 and 99: IndexSymbols1ST CHOICE SUPER THINLA
Page 100 and 101: aminophylline 250 mg/10 mlvl ......
Page 104 and 105: CLINIMIX E 2.75%-10%SOLUTION, -2.75
Page 106 and 107: disulfiram ................ 29dival
Page 108 and 109: ESTRACE VAGINALPRODUCTS. ..........
Page 110 and 111: GAMASTAN S-D. ......... 48GAMMAGARD
Page 112 and 113: IN CONTROL PEN NEEDLE6MM 31G. .....
Page 114 and 115: lactulose ................ 78LADY L
Page 116 and 117: metaproterenol sulfate syrup,-table
Page 118 and 119: NILANDRON ............ 18nimodipine
Page 120 and 121: PEGASYS PROCLICK 180MCG/0.5 .......
Page 122 and 123: PUB INSUL SYR 0.3 ML31GX5/16 ......
Page 124 and 125: SAPHRIS ............... 21SAVELLA.
Page 126 and 127: SUSTIVA ................. 8SUTENT .
Page 128 and 129: ULT CFT 0.3 ML 29GX1/2(1/2) .......
Page 130 and 131: venlafaxine hcl ............ 28venl
Page 133: ®, SM Registered and Service Marks
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2013 Medicare HMO Blue ValueRx/PlusRx Formulary - Blue Cross ...

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