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

Antiinfectives: Oral Antifungal Drugsclotrimazole lozenge Tier 2fluconazole 150 mg tablet Tier 2 Q C D (5/30)fluconazole suspension, -50 mg tablet, Tier 2-100 mg tablet, -200 mg tabletflucytosine capsule Tier 5griseofulvin micro tablet Tier 2griseofulvin oral susp Tier 2griseofulvin ultra tablet Tier 2itraconazole capsule Tier 2 Q C D (120/30)ketoconazole tablet Tier 2LAMISIL 125 MG GRANULES Tier 4 Q C D (68/30)PACKETLAMISIL 187.5 MG GRANULES PACK Tier 4 Q C D (34/30)NOXAFIL Tier 5nystatin Tier 2terbinafine hcl tablet Tier 2 Q C D (34/30)VFEND SUSPENSION Tier 5voriconazole 200 mg tablet Tier 5voriconazole 50 mg tablet Tier 2Antiinfectives: Other Antiinfective DrugsALINIA Tier 3AZACTAM-ISO-OSMOT 1 GM/50 ML Tier 3 H I TAZACTAM-ISO-OSMOT 2 GM/50 ML Tier 5 H I Taztreonam vialTier 2 H I Tbaciim Tier 2bacitracin injection Tier 2CAYSTONTier 5 L P A, N M Ochloramphenicol sod succinate Tier 2 H I Tclindamycin-d5w Tier 2clindamycin injectionTier 2 H I Tclindamycin hcl capsule Tier 2clindamycin palmitate hcl Tier 2colistimethate 150 mg vialTier 2 H I TCUBICINTier 5 H I TDIFICID Tier 5DORIBAX VIALTier 3 H I Timipenem-cilastatin sodiumTier 2 H I TINVANZ VIALTier 3 H I TKETEK Tier 3MEPRON Tier 5meropenem vialTier 2 H I TNEBUPENTTier 3 P Apolymyxin b sulfate injectionTier 2 H I TTYGACILTier 3 H I Tvancomycin vialTier 2 H I T10Q 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.