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

Antineoplastic/Immunosuppressant Drugs (continued)TEMODAR CAPSULE M BTEMODAR INJECTION Tier 3THERACYS Tier 3thiotepa injectionTier 2 H I TtoposarTier 2 H I Ttopotecan hclTier 5 H I TTORISELTier 5 H I TTREANDA 100 MG VIALTier 3 H I TTREANDA 25 MG VIAL Tier 5TRELSTAR Tier 5TRELSTAR DEPOT Tier 5TRELSTAR LA Tier 5tretinoin capsule Tier 5TRISENOXTier 3 H I TTYKERB Tier 5TYSABRITier 5 L P A, H I T, N M OUVADEX Tier 3VALSTAR Tier 3VANDETANIBTier 5 N M OVANTAS Tier 3VECTIBIXTier 5 H I TVELCADETier 5 H I TVIDAZA Tier 5vinblastineTier 2 H I Tvincasar pfs Tier 2vincristineTier 2 H I TAntineoplastic/Immunosuppressant Drugs (continued)vinorelbineTier 2 H I TVORAXAZE Tier 5VOTRIENT Tier 5VUMON Tier 5XALKORI Tier 5XELODA M BXTANDI Tier 5YERVOYTier 5 H I T, N M OZALTRAP Tier 5ZANOSARTier 5 H I TZELBORAF Tier 5ZOLADEX Tier 3ZOLINZA Tier 5ZORTRESS 0.25 MG TABLET Tier 3ZORTRESS 0.5 MG TABLET, -0.75 MG Tier 5TABLETZYTIGA Tier 5Q 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. 19