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

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Antiinfectives: Other Antiviral Drugs (continued)TAMIFLU 30 MG GELCAP Tier 3 Q C D (84/180),N M OTAMIFLU 45 MG GELCAP, -75 MGGELCAPTier 3 Q C D (42/180),N M OTAMIFLU SUSPENSION Tier 3 Q C D (263ml/180), N M OTYZEKA Tier 5valacyclovir Tier 2 Q C D (34/30)VALCYTE Tier 5ZOVIRAX CREAM, -OINT Tier 3Antiinfectives: Other Macrolidesazithromycin injectionTier 2 H I Tazithromycin packet, -suspension, -tablet Tier 2clarithromycin er Tier 2clarithromycin suspension, -tablet Tier 2Antiinfectives: Other Topical Antifungalsciclodan Tier 2ciclopirox Tier 2clotrimazole Tier 2econazole nitrate Tier 2ketoconazole Tier 2ketodan foam Tier 2LAMISIL SOLUTION Tier 3nyamyc Tier 2nystatin Tier 2nystop Tier 2pedi-dri Tier 2Antiinfectives: Parenteral Antifungalsamphotericin b injectionTier 2 H I TCANCIDASTier 5 H I TfluconazoleTier 2 H I TMYCAMINETier 5 H I Tvoriconazole Tier 212Q 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: Penicillinsamox tr-potassium clavulanate Tier 2amoxicillin Tier 2amoxicillin-clavulanate er Tier 2ampicillin injectionTier 2 H I Tampicillin trihydrate Tier 2ampicillin-sulbactam injectionTier 2 H I Tdicloxacillin sodium Tier 2nafcillin 1 gm add-van vialTier 2 H I Tnafcillin 1 gm vialTier 2 H I Tnafcillin 1 gm/ 50 ml injTier 5 H I Tnafcillin 10 gm bulk vial, -10 gm vial Tier 5 H I Tnafcillin 2 gm add-vant vial, -2 gm vial Tier 5 H I Tnafcillin 2 gm/ 100 ml injTier 5 H I Toxacillin 1 gm vialTier 2 H I Toxacillin 1 gm/ 50 ml injTier 2 H I Toxacillin 10 gm vialTier 5 H I Toxacillin 2 gm add-vantage vl, -2 gm vial Tier 5 H I Toxacillin 2 gm/ 50 ml injTier 5 H I Tpenicillin g k 5 million unitTier 2 H I Tpenicillin g procaineTier 2 H I Tpenicillin g sodiumTier 2 H I Tpenicillin gk 20 million unitTier 2 H I Tpenicillin v potassium Tier 2piperacil-tazobact injectionTier 2 H I TAntiinfectives: Plasmodicidesatovaquone-proguanil hcl Tier 2chloroquine phosphate tablet Tier 2COARTEM Tier 3DARAPRIM Tier 3hydroxychloroquine sulfate tablet Tier 2mefloquine hcl Tier 2PRIMAQUINE Tier 4QUALAQUIN Tier 4 Q C D (42/30),N M Oquinine sulfate 324mg capsule Tier 2 Q C D (42/30),N M OAntiinfectives: Quinolonesciprofloxacin injectionTier 2 H I Tciprofloxacin-d5w injectionTier 2 H I Tciprofloxacin er Tier 2ciprofloxacin tablet Tier 2levofloxacin injectionTier 2 H I Tlevofloxacin solution, -tablet Tier 2levofloxacin-d5w injectionTier 2 H I Tofloxacin 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. 13
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 10 and 11: Antiinfectives: Antiretrovirals and
Page 12 and 13: Antiinfectives: Oral Antifungal 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 64 and 65:
Medical (Miscellaneous) Supplies:Di
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
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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