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

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CLINIMIX E 2.75%-10%SOLUTION, -2.75%-5%SOLUTION, -4.25%-25%SOLUTION, -4.25%-5%SOLUTION, -5%-15%SOLUTION, -5%-20%SOLUTION, -5%-25%SOLUTION ............ 79clobetasol emollient ....... 38clobetasol propionate cream,-foam (non-contraceptive), -gel,-lotion, -oil,shampoo,cleanser,-oint, -soln, top .......... 38CLOLAR ................ 16clomipramine hcl capsule. .. 30clonazepam tablet. ........ 27clonidine ................ 33clonidine hcl injection. ..... 33clonidine hcl tablet . . . . . . . . 33clopidogrel. .............. 78clorazepate dipotassium ... 23CLOSERCARE LANCETS . 56clotrimazole .............. 12clotrimazole-betamethasone 14clotrimazole lozenge ....... 10clozapine . . . . . . . . . . . . . . . . 21COAGUCHEK LANCETS . 56COARTEM .............. 13codeine phosphate injection 24codeine sulfate ........... 24co-gesic. ................ 25COLCRYS. .............. 77colestipol hcl ............. 33colistimethate 150 mg vial .. 10COMBIVENT ............ 94COMBIVENT RESPIMAT .. 94COMBIVIR ............... 8COMETRIQ ............. 16COMFORT EZ INS 0.3ML30GX1/2 .............. 56COMFORT EZ INS 0.3ML30GX5/16 ............. 56COMFORT EZ INSULIN SYR0.3 ML ................ 56COMFORT EZ INSULIN SYR0.5 ML ................ 56COMFORT EZ PEN NEEDLES5MM 31G. ............. 56COMFORT EZ PEN NEEDLES6MM 31G. ............. 56COMFORT EZ PEN NEEDLES8MM 31G. ............. 56COMFORT EZ SYR 0.3 ML29GX1/2 .............. 56COMFORT EZ SYR 0.5 ML28GX1/2 .............. 56COMFORT EZ SYR 0.5 ML29GX1/2 .............. 56COMFORT EZ SYR 0.5 ML30GX1/2 .............. 56COMFORT EZ SYR 1 ML28GX1/2 .............. 56COMFORT EZ SYR 1 ML29GX1/2 .............. 56COMFORT EZ SYR 1 ML30GX1/2 .............. 56COMFORT EZ SYR 1 ML30GX5/16 ............. 56COMFORT EZ SYR 1 ML31GX5/16 ............. 56COMFORT LANCETS. .... 56COMPLERA .............. 8complete natal dha ........ 86completenate. ............ 86compro. ................. 22COMTAN. ............... 28COMVAX. ............... 48co-natal fa ............... 86CONDYLOX GEL. ........ 39constulose ............... 78CONTOUR NEXT LEV 1CONTROL SOL ........ 56CONTOUR NEXT LEV 2CONTROL SOL ........ 56CONTOUR SOLUTION ... 56CONTROL SOLUTIONNORMAL . . . . . . . . . . . . . . 56COPAXONE ............. 40cormax .................. 38CORNWALL METAL PIPETHOLDER .............. 56cortisone acetate tablet .... 42CRESTOR. .............. 33CRIXIVAN ................ 8cromolyn sodium nebs ..... 94cromolyn sodium ophthdrops. ................. 91cromolyn sodium solution .. 94cryselle. ................. 83CUBICIN. ............... 10CUPRIMINE. ............ 78CURITY ALCOHOL PREPS 56CURITY ALCOHOLSWABS ............... 56CUVPOSA .............. 46CVS ALCOHOL 70% PREPSWABS ............... 56CVS ALCOHOL SWABS .. 56CVS INSULIN SYR 1 ML29GX1/2 .............. 56CVS ISOPROPYL ALCOHOL70% WIPE ............. 56CVS LANCETS. .......... 56CVS LANCETS-ORIGINAL 56CVS LANCETS-THIN. ..... 56CVS LANCING DEVICE ... 56CVS MICRO THIN 33GLANCETS. ............. 56CVS SYRINGE 1/2 ML .... 56CVS SYRINGE 3/10 ML. .. 57CVS THIN LANCETS ..... 57CVS ULTRA THINLANCETS. ............. 57cyclafem. ................ 83cyclobenzaprine hcl capsulesustained action, -tablet .. 76cyclopentolate hcl ophthdrops. ................. 91cyclophosphamide injection 16cyclophosphamide tablet ... 16cyclosporine 50 mg/ml amp 16cyclosporine capsule, -50 mg/mlvial, -solution. ........... 16cyclosporine modified ..... 16CYKLOKAPRON ......... 40CYMBALTA 20 MG CAPSULE,-60 MG CAPSULE ...... 28CYMBALTA 30 MGCAPSULE ............. 28cyproheptadine hcl syrup,-tablet ................. 92CYSTADANE. ............ 95CYSTAGON ............. 79cytarabine ............... 16102
cytra-2 .................. 82cytra-3 .................. 95cytra-k .................. 95Dd5%-1/4ns-kcl 10 meq/l iv sol,-d5%-1/4ns-kcl 30 meq/l ivsol, -d5%-1/4ns-kcl 40 meq/liv sol .................. 79d5w-kcl 30 meq/l iv solution,-d5w/kcl 30 meq/l ivsolution ................ 79dacarbazine .............. 16DACOGEN .............. 16danazol capsule .......... 83dantrolene sodium capsule . 76DAPSONE TABLET ........ 7DAPTACEL .............. 48DARAPRIM .............. 13daunorubicin . . . . . . . . . . . . . 16DECAVAC ............... 48delflex with 1.5% dextrose. . 79delflex with 2.5% dextrose. . 79delflex with 4.25% dextrose. 79DELZICOL .............. 46demeclocycline hcl tablet. .. 14DEMSER. ............... 33DENAVIR. ............... 11denta 5000 plus .......... 81dentagel. ................ 81depade. ................. 29DEPOCYT. .............. 16desipramine hcl tablet ..... 29desloratadine. ............ 92desloratadine odt ......... 92desmopressin ac injection .. 44desmopressin ac nasal drops/sprays, -solution, -tablet .. 44desonide cream, -lotion, -oint 38desoximetasone cream, -gel,-oint ................... 38DESVENLAFAXINE ER. ... 28DETROL ................ 95DETROL LA ............. 95dexamethasone elix. ....... 42dexamethasone intensol. ... 42dexamethasone sodiumphosphate injection ...... 42dexamethasone sodiumphosphate ophth drops. .. 90dexamethasone tablet ..... 42dexchlorpheniramine maleate 92dexmethylphenidate hcl .... 25dexrazoxane. ............. 16dextroamphetamineamphetamineer 10mg cap, -er15mg cap, -er 25mg cap, -er5mg cap ............... 25dextroamphetamineamphetamineer 20mg cap, -er30mg cap .............. 25dextroamphetamine sulfatecapsule sustained action,-tablet ................. 25dextrose 2.5%-wateriv soln, -25%-watersyringe, -30%-water ivsoln, -40%-water iv soln,-50%-water abboject,-50%-water iv soln,-50%-water syringe,-50%-water vial, -70%-water ivsoln . . . . . . . . . . . . . . . . . . . 79dextrose 5%-1/2ns-kcl. .... 79dextrose 5%-1/3ns-kcl. .... 79dextrose 5%-1/4ns iv solution,-5%-sod chloride 0.2%, -5%-1/3ns iv solution, -d10%-1/2nssoln/excel cont, -5%-1/2ns ivsolution, -2.5%-1/2ns iv soln,-5%-ns iv solution ....... 80dextrose 5%-electrolyte #48 80dextrose 5%-ns-kcl. ....... 80dextrose 5%-water iv soln,-10%-water iv solution. ... 80dextrose 10%-1/4ns. ...... 79dextrose 10%-ns iv solution. 79dextrose in lactated ringers . 80dextrose in ringers injection . 80diazepam injection, -solution,-tablet ................. 23diazepam rectal. .......... 27DIBENZYLINE ........... 33diclofenac- misoprost ...... 77diclofenac potassium ...... 77diclofenac sodium e.c. tab,-tablet sustained action. .. 77diclofenac sodium ophthdrops. ................. 91dicloxacillin sodium. ....... 13dicyclomine hcl capsule, -syrup,-tablet ................. 46didanosine ................ 8DIFICID ................. 10diflorasone diacetate ...... 38diflunisal tablet ........... 78digoxin injection .......... 35digoxin solution ........... 35digoxin tablet. ............ 35dihydroergotamine mesylateinjection ............... 26DILANTIN 30 MGCAPSULE ............. 26dilt-cd ................... 32diltiazem 24hr cd ......... 32diltiazem 24hr er .......... 32diltiazem 125 mg/25 ml vial, -50mg/10 ml vial ........... 32diltiazem er .............. 32diltiazem hcl tablet ........ 32diltiazem injection . . . . . . . . . 32dilt-xr. ................... 32diltzac er ................ 32dimenhydrinate injection. ... 22DIOVAN. ................ 31diphenhydramine 50 mg/mlvial .................... 92diphenhydramine hcl capsule 92diphenhydramine hcl elix, -50mg/ml syrng ............ 92diphenoxylate-atropine ..... 45DIPHTHERIA-TETANUSTOXOID ............... 48dipyridamole tablet ........ 78diskets .................. 24disopyramide phosphate ... 31103
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Medicare HMO Blue SM ValueRx (HMO)M
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How do I use the Formulary?There ar
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What do I do before I can talk to m
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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
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Autonomic and CNS Medications: Sele
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Cardiovascular Medications: Beta-Ad
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Cardiovascular Medications: Loop Di
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Cardiovascular Medications: OtherVa
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Dermatological Medications: OralDer
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Dermatological Medications: Topical
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Endocrine Medications: Glucocortico
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Endocrine Medications: Oral Hypogly
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Gastrointestinal Medications: Antis
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Immunologicals and VaccinesACTHIB T
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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 102 and 103: BD PEN NEEDLE NANO32GX5/32 ........
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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