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

Antineoplastic/Immunosuppressant Drugs (continued)CELLCEPT INJECTIONTier 3 P A, H I TCELLCEPT ORAL SUSPTier 5 P AcerubidineTier 2 H I TcisplatinTier 2 H I TcladribineTier 5 H I TCLOLARTier 5 H I TCOMETRIQ Tier 5cyclophosphamide injectionTier 2 H I Tcyclophosphamide tablet Tier 2cyclosporine 50 mg/ml ampTier 2 P A, H I Tcyclosporine capsule, -50 mg/ml vial, Tier 2 P A-solutioncyclosporine modifiedTier 2 P AcytarabineTier 2 H I TdacarbazineTier 2 H I TDACOGENTier 5 H I TdaunorubicinTier 2 H I TDEPOCYT Tier 3dexrazoxaneTier 5 H I TDOCEFREZTier 5 H I Tdocetaxel 160 mg/16 ml vial, -20 mg/2 Tier 5 H I Tml vial, -20 mg/0.5 ml vial, -80 mg/2ml vialdocetaxel 20 mg/ml vialTier 2 H I Tdocetaxel 80 mg/8 ml vial, -80 mg/4 ml Tier 5 H I TvialAntineoplastic/Immunosuppressant Drugs (continued)DOXILTier 5 H I TdoxorubicinTier 2 H I TELIGARD Tier 3ELITEKTier 5 H I TELSPARTier 3 H I TEMCYT Tier 3ENBREL 25 MG KIT Tier 5 Q C D (16/30),P AENBREL 25 MG/0.5 ML SYRINGE, Tier 5 P A-50 MG/ML SURECLICK SYRENBREL 50 MG/ML SYRINGE Tier 5 Q C D (8/30), P AepirubicinTier 2 H I TERBITUXTier 5 H I TERIVEDGE Tier 5ETOPOPHOSTier 5 H I Tetoposide injectionTier 2 H I Texemestane Tier 2FARESTON Tier 3FASLODEX Tier 5FIRMAGON Tier 3floxuridine Tier 2fludarabine 50mg vialTier 2 H I Tfludarabine 50 mg/2 ml vial Tier 5fluorouracilTier 2 H I Tflutamide Tier 2FOLOTYNTier 5 H I T, N M O16Q 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.