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

Antiinfectives: Other Antiinfective Drugs (continued)vancomycin hcl capsule Tier 5VANCOMYCIN-D5WTier 3 H I TVIBATIV 250 MG VIALTier 3 H I TVIBATIV 750 MG VIALTier 5 H I TZYVOX ORAL SUSP, -TABLET Tier 5ZYVOX IV SOLUTIONTier 5 H I TAntiinfectives: Other Antiviral Drugsacyclovir Tier 2acyclovir injectionTier 2 H I Tacyclovir ointment Tier 2amantadine Tier 2BARACLUDE SOLUTION Tier 3BARACLUDE TABLET Tier 5cidofovir vial Tier 2DENAVIR Tier 3EPIVIR HBV Tier 3famciclovir 125 mg tablet, -500 mg Tier 2 Q C D (21/30)tabletfamciclovir 250 mg tablet Tier 2 Q C D (68/30)foscarnet sodiumTier 2 H I Tganciclovir injectionTier 2 H I THEPSERA Tier 5RELENZA Tier 3 Q C D (60inhalations/180), N M Oribapak 200-400 mg dosepack Tier 2ribapak 400-400 mg dosepack, -400- Tier 5600 mg, -600-400 mg, -600-600 mgribasphere 600 mg tablet Tier 5ribasphere capsule, -200 mg tablet, Tier 2-400 mg tabletribavirin capsule, -tablet Tier 2rimantadine hcl 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. 11