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

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