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

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ULT CFT 0.3 ML 29GX1/2(1/2) .................. 72ULT CFT 0.3 ML 30GX5/16(1/2) .................. 72ULT CFT 0.3 ML 31GX5/16(1/2) .................. 72ULTICARE 30GX0.3 MLSYRINGE. ............. 73ULTICARE 30GX0.5 MLSYRINGE. ............. 73ULTICARE 30GX1 MLSYRINGE. ............. 73ULTICARE 31GX0.3 MLSYRINGE. ............. 73ULTICARE 31GX0.5 MLSYRINGE. ............. 73ULTICARE 31GX1 MLSYRINGE. ............. 73ULTICARE INS 0.5 ML29GX1/2 .............. 73ULTICARE INS SYR 1 ML28GX1/2 .............. 73ULTICARE INS SYR 1 ML29GX1/2 .............. 73ULTICARE INSULIN SYR U1001 ML .................. 73ULTICARE INSUL SYR U1000.3 ML ................ 73ULTICARE INSUL SYR U1000.5 ML ................ 73ULTICARE PEN NEEDLES4MM 32G. ............. 73ULTICARE PEN NEEDLES 6MM 31 G .............. 73ULTICARE PEN NEEDLES6MM 31G. ............. 73ULTICARE PEN NEEDLES 8MM 31 G .............. 73ULTICARE PEN NEEDLES8MM 31G. ............. 73ULTICARE PEN NEEDLES12MM 29G ............ 73ULTICARE SYR 0.3 ML31GX5/16 ............. 73ULTICARE SYR 0.5 ML30GX5/16 ............. 73ULTICARE SYR 0.5 ML31GX5/16 ............. 73ULTICARE SYRIN 0.3 ML29GX1/2 .............. 73ULTICARE SYRIN 0.5 ML28GX1/2 .............. 73ULTICARE THIN 28GLANCETS. ............. 73ULTICARE THIN 30GLANCETS. ............. 73ULTICARE U100 0.3 ML30GX5/16 ............. 73ULTICARE U100 0.5 ML29GX1/2 .............. 73ULTI-LANCE AUTO-ADDEVICE ............... 73ULTILET 28G LANCETS ... 73ULTILET 30G LANCETS ... 73ULTILET ALCOHOL STERLSWAB. ................ 73ULTILET ALCOHOL SWAB 73ULTILET BASIC 30GLANCETS. ............. 73ULTILET CLASSIC 26GLANCETS. ............. 73ULTILET CLASSIC 28GLANCETS. ............. 73ULTILET CLASSIC 30GLANCETS. ............. 73ULTILET INSULIN SYRINGE0.3 ML ................ 73ULTILET INSULIN SYRINGE0.5 ML ................ 73ULTILET INSULIN SYRINGE 1ML. ................... 73ULTILET LANCETS ....... 73ULTILET SAFETY LANCETS 73ultimatecare advantage .... 87ultimatecare one .......... 87ultimatecare one nf ........ 88ultimate ob dha ........... 87ULTRA COMFORT 0.3 ML29GX1/2 .............. 73ULTRA COMFORT 0.3 MLSYRINGE. ............. 73ULTRA COMFORT 0.5 ML28GX1/2 .............. 73ULTRA COMFORT 0.5 ML29GX1/2 .............. 73ULTRA COMFORT 0.5 ML30GX5/16 ............. 73ULTRA COMFORT 0.5 ML31GX5/16 ............. 73ULTRA COMFORT 0.5 MLSYRINGE. ............. 73ULTRA COMFORT 1 ML28GX1/2 .............. 74ULTRA COMFORT 1 ML29GX1/2 .............. 74ULTRA COMFORT 1 ML30GX5/16 ............. 74ULTRA COMFORT 1 ML31GX5/16 ............. 74ULTRA COMFORT 1 MLSYRINGE. ............. 74ULTRA COMFORT 3/10 MLSYR................... 74ULTRACOMFORT 30GX0.5 MLSYR................... 74ULTRACOMFORT 30GX1 MLSYRINGE. ............. 74ULTRACOMFORT 31GX0.5 MLSYR................... 74ULTRACOMFORT 31GX1 MLSYRINGE. ............. 74ULTRACOMFORT INSULINSYR 1 ML. ............. 74ULTRACOMFORT INSUL SYR0.5 ML ................ 74ULTRACOMFORT PENNEEDLES 6MM ........ 74ULTRACOMFORT PENNEEDLES 8MM ........ 74ULTRALANCE 26GLANCETS. ............. 74ULTRALANCE 28GLANCETS. ............. 74ULTRA THIN 28 G LANCET 74ULTRA THIN 28GLANCETS. ............. 74ULTRA THIN 31GLANCETS. ............. 74ULTRA THIN 33GLANCETS. ............. 74ULTRA-THIN II 26GLANCET ............... 74126
ULTRA-THIN II 28GLANCETS. ............. 74ULTRA-THIN II 30GLANCETS. ............. 74ULTRA-THIN II 31G SHORTNEEDLE. .............. 74ULTRA-THIN II INS 0.3 ML29G. .................. 74ULTRA-THIN II INS 0.3 ML30G. .................. 74ULTRA-THIN II INS 0.3 ML31G. .................. 74ULTRA-THIN II INS 0.5 ML29G. .................. 74ULTRA-THIN II INS 0.5 ML30G. .................. 74ULTRA-THIN II INS 0.5 ML31G. .................. 74ULTRA-THIN II INS SYR 1 ML29G. .................. 74ULTRA-THIN II INS SYR 1 ML30G. .................. 74ULTRA-THIN II PEN NDL29GX1/2 .............. 74ULTRA-THIN II PEN NDL31GX5/16 ............. 74ULTRA THIN LANCETS. ... 74ULTRATRAK CONTROL SOLNORMAL . . . . . . . . . . . . . . 74ULTRATRAK CONTROLSOLUTION ............ 74ULTRATRAK PRO CNTRLSOLUTION ............ 74ULTRATRAK ULTIMATE CNTRLSOLN . . . . . . . . . . . . . . . . . 74UNIFINE PENTIP 0.5CCNEEDLE. .............. 74UNIFINE PENTIPNEEDLES ............. 74UNIFINE PENTIPS 6MM31G. .................. 74UNIFINE PENTIPS 6MMNEEDLE. .............. 75UNIFINE PENTIPS 6MMNEEDLES ............. 75UNIFINE PENTIPS 8MM31G. .................. 75UNIFINE PENTIPS 8MMNEEDLE. .............. 75UNIFINE PENTIPS 8MMNEEDLES ............. 75UNIFINE PENTIPS 12MM29G. .................. 74UNIFINE PENTIPS 12MMNEEDLE. .............. 74UNIFINE PENTIPS31GX3/16 ............. 74UNIFINE PENTIPS32GX5/32 ............. 74UNIFINE PENTIPS NEEDLES29G. .................. 75UNIFINE PENTIPS NEEDLES31G. .................. 75UNILET COMFORTOUCH 26GLANCETS. ............. 75UNILET COMFORTOUCHLANCET ............... 75UNILET EXCELITE IILANCET ............... 75UNILET EXCELITE LANCET 75UNILET GP LANCET. ..... 75UNILET GP LANCETSUPERLITE ............ 75UNILET LANCET . . . . . . . . . 75UNILET LANCET 28G. .... 75UNILET LANCETSUPERLITE ............ 75UNILET SUPER THIN 30GLANCETS. ............. 75UNILET ULTRA THIN 28GLANCETS. ............. 75UNISTIK 3 COMFORTLANCET ............... 75UNISTIK 3 EXTRA 21GLANCETS. ............. 75UNISTIK 3 NORMAL 23GLANCETS. ............. 75UNISTIK 3 SAFETY 21GLANCETS. ............. 75UNISTIK CZT COMFORTLANCET ............... 75UNISTIK CZT NORMAL 23GLANCETS. ............. 75unithroid. ................ 45UNIVERSAL 1 33GLANCETS. ............. 75urea 39% cream, -45% lotion,-40% nail film susp ...... 39urea 40% cream, -45% cream,-50% cream, -foam (noncontraceptive),-gel, -40%lotion, -soln, top, -50%emulsion, -50% topicalsuspension ............. 40urogesic-blue. ............ 14ursodiol capsule, -tablet. ... 47UVADEX ................ 19VVAGIFEM ............... 85valacyclovir .............. 12VALCYTE. ............... 12valproate sodium injection .. 31valproic acid capsule, -syrup 31valsartan-hctz ............ 35VALSTAR ................ 19VALUE PLUS STANDARDLANCETS. ............. 75VALUE PLUS SUPER THINLANCETS. ............. 75VALUEPLUS SYR 0.3 ML29GX1/2 .............. 75VALUE PLUS THINLANCETS. ............. 75VANCOMYCIN-D5W ..... 11vancomycin hcl capsule .... 11vancomycin vial ........... 10vandazole. ............... 85VANDETANIB ............ 19VANISHPOINT 0.5 ML30GX1/2 SY ........... 75VANISHPOINT U-100 29X1/2SYR................... 75VANTAS. ................ 19VAQTA .................. 49VARIVAX VACCINE ....... 49VECTIBIX ............... 19VELCADE ............... 19veletri . . . . . . . . . . . . . . . . . . . 36velivet ................... 84vemavite-prx 2 ............ 88vena-bal dha ............. 88venatal complete dha ...... 88venatal-fa ................ 88127
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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 78 and 79: 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 124 and 125: SAPHRIS ............... 21SAVELLA.
Page 126 and 127: SUSTIVA ................. 8SUTENT .
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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