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

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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.
Antiinfectives: Antiretrovirals and Protease Inh (continued)zidovudine Tier 2Antiinfectives: Antituberculosis DrugsCAPASTAT SULFATETier 3 H I Tethambutol hcl Tier 2isonarif Tier 2isoniazid injection, -syrup, -tablet Tier 2MYCOBUTIN Tier 3PASER Tier 3PRIFTIN Tier 3pyrazinamide Tier 2rifampin capsule Tier 2rifampin injectionTier 2 H I TSEROMYCIN Tier 3TRECATOR Tier 3Antiinfectives: Cephalosporinscefaclor Tier 2cefaclor er Tier 2cefadroxil Tier 2cefazolinTier 2 H I Tcefdinir Tier 2cefepimecefotaximecefotetancefoxitinTier 2 H I TTier 2 H I TTier 2 H I TTier 2 H I Tcefpodoxime proxetil Tier 2cefprozil Tier 2ceftazidimeceftriaxoneTier 2 H I TTier 2 H I Tcefuroxime Tier 2cefuroxime axetil Tier 2cefuroxime sodiumTier 2 H I Tcephalexin Tier 2SUPRAX Tier 3Antiinfectives: Erythromycinsery-tab Tier 2ERYTHROCIN VIAL FOR INJECTION Tier 3 H I Terythrocin stearate Tier 2erythromycin e.c. cap, -tablet Tier 2erythromycin ethylsuccinate tablet Tier 2Q 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. 9
Page 1: 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
Page 12 and 13: Antiinfectives: Oral Antifungal Dru
Page 14 and 15: Antiinfectives: Other Antiviral Dru
Page 16 and 17: Antiinfectives: Sulfonamideserythro
Page 18 and 19: Antineoplastic/Immunosuppressant Dr
Page 20 and 21: Antineoplastic/Immunosuppressant Dr
Page 22 and 23: Autonomic and CNS Medications: Anal
Page 24: Autonomic and CNS Medications:Antiv
Page 28 and 29: Autonomic and CNS Medications: CNSS
Page 30 and 31: 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 60 and 61:
Medical (Miscellaneous) Supplies:Di
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
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Page 70 and 71:
Page 72 and 73:
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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 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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