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

Antineoplastic/Immunosuppressant Drugs (continued)mitoxantroneMUSTARGENmycophenolate mofetilMYFORTICTier 2 H I TTier 3 H I TTier 2 P ATier 3 P AMYLERAN M BNEXAVARTier 5 L P A, N M ONILANDRON Tier 3NULOJIXTier 5 P A, H I Toctreotide acet 200 mcg/ml vl, -acet Tier 5500 mcg/ml amp, -acet 500 mcg/mlsyr, -acet 500 mcg/ml vl, -1,000 mcg/ml vialoctreotide acet 50 mcg/ml amp, -acet Tier 250 mcg/ml syr, -acet 50 mcg/ml vial,-acet 100 mcg/ml amp, -acet 100mcg/ml syr, -acet 100 mcg/ml vlONCASPAR Tier 5ONTAKTier 5 H I TORENCIA 125 MG/ML SYRINGE Tier 5 P AORENCIA 250 MG VIALTier 5 P A, H I Toxaliplatin 100 mg vialTier 2 H I Toxaliplatin 100 mg/20 ml vialTier 5 H I Toxaliplatin 50 mg/10 ml vialTier 5 H I Tpaclitaxel 100 mg/16.7 ml vial, -30mg/5 ml vialpaclitaxel 300 mg/50 ml vialpentostatinTier 5 H I TTier 2 H I TTier 2 H I TAntineoplastic/Immunosuppressant Drugs (continued)PERJETA Tier 5POMALYST Tier 5PROGRAF INJECTIONTier 3 P A, H I TQUADRAMET Tier 5RAPAMUNE 2 MG TABLETTier 5 P ARAPAMUNE SOLUTION, -0.5 MG Tier 3 P ATABLET, -1 MG TABLETREMICADETier 5 P A, H I TREVLIMIDTier 5 L P A, N M ORITUXANTier 5 P A, H I TSANDOSTATIN LAR Tier 5SIMULECTTier 3 P A, H I TSOLTAMOX Tier 4SOMATULINE DEPOT Tier 5SPRYCEL Tier 5STIVARGA Tier 5SUTENT Tier 5SYNRIBO Tier 5TABLOID Tier 3tacrolimus 0.5 mg capsule, -1 mg Tier 2 P Acapsuletacrolimus 5 mg capsuleTier 5 P Atamoxifen citrate tablet Tier 2TARCEVA Tier 5TARGRETIN Tier 5TASIGNA Tier 518Q 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.