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

Antiinfectives: Vaginal Antifungalsmiconazole 3 Tier 2nystatin vaginal products Tier 2terconazole Tier 2Antineoplastic/Immunosuppressant Drugsadriamycin injectionTier 2 H I Tadrucil Tier 2AFINITOR Tier 5ALIMTATier 5 H I TALKERAN TABLET M BamifostineTier 5 H I Tanagrelide hcl Tier 2anastrozole tablet Tier 2ARRANONTier 5 H I TARZERRATier 5 H I T, N M OAVASTINTier 5 H I Tazathioprine sodiumTier 2 P A, H I Tazathioprine tabletTier 2 P ABENLYSTA 120 MG VIALTier 3 H I TBENLYSTA 400 MG VIALTier 5 H I Tbicalutamide Tier 2BICNUTier 3 H I Tbleomycin sulfate injectionTier 2 H I TBOSULIF TABLET Tier 5BUSULFEXTier 5 H I Tcalcium folinate injection Tier 2CAMPATHTier 5 H I TCAPRELSATier 5 L P A, N M OcarboplatinTier 2 H I TCEENU Tier 3Q 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. 15