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

Antineoplastic/Immunosuppressant Drugs (continued)FUSILEVTier 3 H I Tgemcitabine 1 gram/26.3 ml vl Tier 5 H I Tgemcitabine 200 mg/5.26 ml vl, -200 Tier 2 H I Tmg vialgemcitabine hcl 1 gram vial, -2 Tier 5 H I Tgram/52.6 ml vl, -2 gram vialgengrafTier 2 P AGLEEVEC Tier 5HALAVENTier 5 H I Thecoria 0.5 mg capsule, -1 mg capsule Tier 2 P Ahecoria 5 mg capsuleTier 5 P AHERCEPTINTier 5 H I THEXALEN Tier 5HUMIRA 20 MG/0.4 ML SYRINGE Tier 5 P AHUMIRA 40 MG/0.8 ML PEN, -40MG/0.8 ML SYRINGE, -CROHN’SSTARTER PACK, -PSORIASISSTARTER PACKTier 5 Q C D (6syringes/30),P AHYCAMTIN CAPSULE M Bhydroxyurea capsule Tier 2ICLUSIG Tier 5idarubicin hclTier 5 H I Tifosfamide 1 gm vialTier 2 H I Tifosfamide 1 gm/ 20 ml vial, -3 gm vial, Tier 5 H I T-3 gm/ 60 ml vialifosfamide-mesnaTier 5 H I TINLYTA Tier 5Antineoplastic/Immunosuppressant Drugs (continued)IRESSAirinotecan hclISTODAXIXEMPRATier 5 N M OTier 2 H I TTier 5 H I TTier 3 H I TJAKAFI Tier 5JEVTANATier 5 H I TKADCYLA Tier 5leflunomide Tier 2 Q C D (34/30)letrozole Tier 2leucovorin calcium injectionTier 2 H I Tleucovorin calcium tablet Tier 2LEUKERAN Tier 3LIPODOX Tier 5LIPODOX 50 Tier 5LUPRON DEPOT 45 MG 6MO KIT Tier 5LYSODREN Tier 3MATULANETier 5 N M Omegestrol acetate oral susp, -tablet Tier 2melphalan hclTier 2 H I Tmercaptopurine tablet Tier 2mesnaTier 2 H I TMESNEX TABLET Tier 5methotrexate injectionTier 2 P A, H I Tmethotrexate tabletTier 2 P AmitomycinTier 2 H I TQ 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. 17