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

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SAPHRIS ............... 21SAVELLA. ............... 28SB INS SYR 0.5 ML29GX1/2 .............. 69SB INS SYR 0.5 ML30GX5/16 ............. 69SB INS SYR 1 ML29GX1/2 .............. 69SB INS SYRINGE 1 ML30GX5/16 ............. 69SB INSULIN SYR 1 ML31GX5/16 ............. 70SB INSULN SYR 0.5 ML30GX5/16 ............. 70SB LANCETS THIN. ...... 70SB LANCETS ULTRA THIN 70SCHNUCKS SYR 0.5 ML29GX1/2 .............. 70SCHNUCKS SYR 0.5 ML30GX5/16 ............. 70se-care. ................. 87se-care conceive. ......... 87se-care gesture ........... 87selegiline hcl capsule, -tablet 28selenium sulfide 2.5% lotion 37selenium sulfide 2.25%shampoo. .............. 37SELZENTRY. ............. 8SEMPREX-D. ............ 92se-natal 19. .............. 87se-natal 90 .............. 87se-natal one. ............. 87SENSIPAR 30 MG TABLET 45SENSIPAR 60 MG TABLET, -90MG TABLET. ........... 45se-plete dha. ............. 87SEREVENT DISKUS ...... 93SEROMYCIN . . . . . . . . . . . . . 9SEROQUEL XR. ......... 21sertraline hcl 25 mg tablet, -50mg tablet. .............. 30sertraline hcl 100 mg tablet. 30sertraline hcl solution ...... 30se-tan dha ............... 87setonet. ................. 87setonet-ec . . . . . . . . . . . . . . . 87sf 81sf 5000 plus ............. 81sildenafil tablet ........... 36silver sulfadiazine cream. ... 14SIMULECT .............. 18simvastatin tablet ......... 33SINGLE-LET LANCETS ... 70SM ALCOHOL 70% PREPPADS ................. 70SM ALCOHOL PREP PADS 70SMARTDIABETES VANTAGE30G. .................. 70SMARTEST CONTROLSOLUTION ............ 70SMARTEST LANCET. ..... 70SMART SENSE COLOR 33GLANCETS. ............. 70SMART SENSE STANDARD21G. .................. 70SMART SENSE SUPER THIN30G. .................. 70SMART SENSE THIN 26GLANCETS. ............. 70SM COLORED LANCETS . 70SM INS SYR 0.5 ML29GX1/2 .............. 70SM INS SYR 0.5 ML30GX5/16 ............. 70SM INS SYR 1 ML29GX1/2 .............. 70SM INS SYRING 0.3 ML30GX5/16 ............. 70SM INS SYRINGE 1 ML28GX1/2 .............. 70SM INS SYRINGE 1 ML30GX5/16 ............. 70SM INSULIN SYR 0.3 ML29GX1/2 .............. 70SM INSULIN SYR 0.5 ML28GX1/2 .............. 70SM INSULIN SYR 1 ML31GX5/16 ............. 70SM INSUL SYR 0.3 ML31GX5/16 ............. 70SM INSUL SYR 0.5 ML31GX5/16 ............. 70SM LANCETS. ........... 70SM MICRO THIN 33GLANCETS. ............. 70SMS GLUCOSE CONTROLSOL NORMAL ......... 70SM SUPER THIN LANCETS 70SM THIN LANCETS ...... 70sodium acetate ........... 80sodium bicarbonate ....... 80sodium chloride 0.9% soln,-0.9% soln., -4 meq/ml vl,-solution ............... 80sodium chloride nebs ...... 94sodium citrate & citric acid. . 82sodium fluoride . . . . . . . . . . . 81sodium lactate. ........... 80sodium phenylbutyratepowder ................ 40sodium phosphate ........ 80sodium polystyrene sulfonate 35sodium sulfacetamide pad,medicated pad .......... 37sodium sulfacetamidesolution ................ 37sodium sulfacetamide-sulfurcream, -sulf-sulfur cleanser,-sulfacetamide-sulfur 8-4%susp .................. 37sodium sulfacetamide-sulfurfoam (non-contraceptive),-lotion, -sulfacet-sulfur wash,-sulf-sulfur cleanser, -pad,medicated pad, -sod.sulfacetsulfursusp ............. 37SOFTCLIX LANCETS ..... 70SOFT TOUCH LANCETS. . 70SOFT TOUCH SAFE-T-PRO 70SOLARAZE. ............. 39solia .................... 84SOLO V2 30G LANCETS. . 70SOLO V2 CONTROLSOLUTION HIGH. ...... 70SOLO V2 CONTROLSOLUTION LOW ....... 70SOLTAMOX. ............. 18SOMATULINE DEPOT .... 18SOMAVERT ............. 45SORBITOL .............. 95SORIATANE ............. 37SORIATANE CK .......... 37sorine ................... 34sotalol .................. 34122
sotalol af ................ 34sotret ................... 38SPIRIVA. ................ 94spironolactone-hctz ....... 36spironolactone tablet ...... 36sprintec ................. 84SPRYCEL ............... 18sps ..................... 35sronyx. .................. 84ssd ..................... 14stagesic ................. 25stannous fluoride dental/mucousmembrn products. ....... 81stavudine ................. 8STERILANCE TL TWIST 30GLANCET ............... 70STERILANCE TL TWIST 32GLANCET ............... 70sterile water for injection, -forinjection ampul, -for injectionvial .................... 80STIMATE ................ 45STIVARGA. .............. 18STRATTERA 10 MG CAPSULE,-18 MG CAPSULE, -25MG CAPSULE, -80 MGCAPSULE, -100 MGCAPSULE ............. 29STRATTERA 40 MG CAPSULE,-60 MG CAPSULE ...... 29STRIBILD ................ 8STROMECTOL. ........... 7sublimaze. ............... 24SUBOXONE. ............ 25SUCRAID ............... 47sucralfate oral susp, -tablet . 46sufenta .................. 20sufentanil citrate injection .. 20sulfacetamide-prednisolone. 90sulfacetamide sodium lotion 37sulfacetamide sodium oint .. 91sulfacetamide sodium ophthdrops. ................. 91sulfacetamide sodium-sulfur 37sulfacleanse 8-4 .......... 37sulfadiazine tablet ......... 14sulfamethoxazole-trimethopriminjection ............... 14sulfamethoxazole-trimethoprimoral susp, -tablet ........ 14sulfamide ................ 91SULFAMYLON . . . . . . . . . . . 14sulfasalazine dr . . . . . . . . . . . 47sulfasalazine tablet ........ 47sulfazine. ................ 47sulfazine ec .............. 47sulindac tablet. ........... 78sumatriptan 4 mg/0.5 ml cart,-4 mg/0.5 ml inject, -4 mg/0.5ml kit, -4 mg/0.5 ml refill, -4mg/0.5 ml vial, -6 mg/0.5 mlrefill, -6 mg/0.5 ml syrng .. 26sumatriptan 6 mg/0.5 ml inject,-6 mg/0.5 ml vial ........ 26sumatriptan succinate tablet 26SUPARTZ ............... 78SUPER THIN 28GLANCETS. ............. 70SUPER THIN 30GLANCETS. ............. 70SUPER THIN 33GLANCETS. ............. 70SUPER THIN LANCETS. .. 70SUPRAX . . . . . . . . . . . . . . . . . 9SUPREME II CONTROLSOLUTION ............ 70SURECHEK GLUCOSECONTROL SOLN. ...... 71SURE COMFORT 0.3 MLSYRINGE. ............. 70SURE COMFORT 0.5 MLSYRINGE. ............. 71SURE COMFORT 1 MLSYRINGE. ............. 71SURE COMFORT 3/10 MLSYRINGE. ............. 71SURE COMFORT 28GLANCETS. ............. 71SURE COMFORT 30GLANCETS. ............. 71SURE COMFORT 31G PENNEEDLE. .............. 71SURE COMFORT ALCOHOLPREP PADS. ........... 71SURE COMFORT PEN NDL29GX1/2 .............. 71SURE COMFORT PEN NDL31GX3/16 ............. 71SURE EDGE GLUCOSECONTROL SOLN. ...... 71SURE-FINE PEN NEEDLES5MM .................. 71SURE-FINE PEN NEEDLES8MM .................. 71SURE-FINE PEN NEEDLES12.7MM ............... 71SURE-JECT INSULIN SYR 0.3ML. ................... 71SURE-JECT INSULIN SYR 0.5ML. ................... 71SURE-JECT INSULINSYRINGE 1 ML. ........ 71SURE-JECT INSUL SYR U1001 ML .................. 71SURE-JECT INSU SYR U1000.3 ML ................ 71SURE-JECT INSU SYR U1000.5 ML ................ 71SURE-JECT INSU SYR U100 1ML. ................... 71SURE-LANCE 26GLANCETS. ............. 71SURE-LANCE FLATLANCETS. ............. 71SURE-LANCE THINLANCET ............... 71SURE-LANCE ULTRA THIN30G. .................. 71SURELITE LANCET REGBODY ................. 71SURE-PREP ALCOHOL PREPPADS ................. 71SURESTEP GLUC CONTROLSOLN . . . . . . . . . . . . . . . . . 71SURESTEP PRO CONTROLSOLN . . . . . . . . . . . . . . . . . 71SURESTEP PRO LINEARITYKIT. ................... 71SURESTEP PRO TESTSTRIPS. ............... 71SURESTEP TEST STRIPS . 71SURE-TEST EASYPLUS MINISOLN . . . . . . . . . . . . . . . . . 71SURE-TOUCH LANCET ... 71123
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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
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Medical (Miscellaneous) Supplies:Di
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Page 74 and 75: 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 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 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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