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

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Autonomic and CNS Medications: AnalgesicsbuprenorphineTier 2 H I Tbutorphanol tartrate injectionTier 2 H I TnalbuphineTier 2 H I Tpentazocine-acetaminophen Tier 2pentazocine-naloxone hcl Tier 2sufenta Tier 2sufentanil citrate injection Tier 2tramadol hcl Tier 2tramadol hcl er Tier 2tramadol hcl-acetaminophen Tier 2Autonomic and CNS Medications:Antiparkinson Anticholinergic Drugsbenztropine injectionTier 2 H I Tbenztropine tablet Tier 1trihexyphenidyl hcl elix Tier 2trihexyphenidyl hcl tablet Tier 1Autonomic and CNS Medications:Antidementia DrugsARICEPT 23 MG TABLET Tier 3donepezil hcl Tier 2EXELON ADH. PATCH, -SOLUTION Tier 3galantamine hbr Tier 2NAMENDA Tier 3rivastigmine Tier 220Q 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.
Autonomic and CNS Medications:Antipsychotic DrugsABILIFY 20 MG TABLET, -30 MG Tier 5TABLET, -300 MG ER INJECTIONABILIFY DISCMELT Tier 4ABILIFY INJECTION, -SOLUTION, -2 Tier 3MG TABLET, -5 MG TABLET, -10 MGTABLET, -15 MG TABLETchlorpromazine hcl injectionTier 2 H I Tchlorpromazine hcl tablet Tier 2clozapine Tier 2FANAPT Tier 4FAZACLO Tier 4fluphenazine decanoate injection Tier 2fluphenazine hcl Tier 2GEODON INJECTION Tier 3haloperidol decanoate Tier 2haloperidol decanoate 100 Tier 2haloperidol injection Tier 2haloperidol lactate Tier 2haloperidol tablet Tier 1INVEGA Tier 4INVEGA SUSTENNA 117 MG PREF Tier 5SY, -156 MG PREF SY, -234 MGPREF SYINVEGA SUSTENNA 39 MG PREF Tier 4SYR, -78 MG PREF SYRAutonomic and CNS Medications:Antipsychotic Drugs (continued)LATUDA Tier 4loxapine Tier 2olanzapine 20 mg tablet Tier 5olanzapine injection, -2.5 mg tablet, Tier 2-5 mg tablet, -7.5 mg tablet, -10 mgtablet, -15 mg tabletolanzapine odt Tier 2olanzapine-fluoxetine hcl Tier 2 Q C D (34/30)ORAP Tier 3perphenazine Tier 2quetiapine fumarate Tier 2RISPERDAL CONSTA 12.5 MG SYR, Tier 3-25 MG SYRRISPERDAL CONSTA 37.5 MG SYR, Tier 5-50 MG SYRrisperidone Tier 2risperidone m-tab Tier 2risperidone odt Tier 2SAPHRIS Tier 4SEROQUEL XR Tier 3thioridazine hcl Tier 2thiothixene Tier 1trifluoperazine hcl Tier 2ziprasidone hcl Tier 2ZYPREXA RELPREVV Tier 4Q 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. 21
Page 1: Medicare HMO Blue SM ValueRx (HMO)M
Page 4 and 5: How do I use the Formulary?There ar
Page 6 and 7: What do I do before I can talk to m
Page 8 and 9: Your Medicare Prescription Drug Cos
Page 10 and 11: Antiinfectives: Antiretrovirals and
Page 12 and 13: Antiinfectives: Oral Antifungal Dru
Page 14 and 15: Antiinfectives: Other Antiviral Dru
Page 16 and 17: Antiinfectives: Sulfonamideserythro
Page 18 and 19: Antineoplastic/Immunosuppressant Dr
Page 20 and 21: Antineoplastic/Immunosuppressant Dr
Page 24: Autonomic and CNS Medications:Antiv
Page 28 and 29: Autonomic and CNS Medications: CNSS
Page 30 and 31: Autonomic and CNS Medications:Other
Page 32 and 33: Autonomic and CNS Medications: Sele
Page 34 and 35: Cardiovascular Medications: Beta-Ad
Page 36 and 37: Cardiovascular Medications: Loop Di
Page 38 and 39: Cardiovascular Medications: OtherVa
Page 40 and 41: Dermatological Medications: OralDer
Page 42 and 43: Dermatological Medications: Topical
Page 44 and 45: Endocrine Medications: Glucocortico
Page 46 and 47: Endocrine Medications: Oral Hypogly
Page 48 and 49: Gastrointestinal Medications: Antis
Page 50 and 51: Immunologicals and VaccinesACTHIB T
Page 52 and 53: Immunologicals and Vaccines: Interf
Page 54 and 55: Medical (Miscellaneous) Supplies:Di
Page 72 and 73:
Medical (Miscellaneous) Supplies:Di
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Musculoskeletal Medications: Non-St
Page 82 and 83:
Nutrition, Blood Modifiers, Electro
Page 84 and 85:
Nutrition, Blood Modifiers, Electro
Page 86 and 87:
Obstetrical and Gynecological Medic
Page 88 and 89:
Obstetrical and GynecologicalMedica
Page 90 and 91:
Obstetrical and Gynecological Medic
Page 92 and 93:
Ophthalmic Medications: Antiglaucom
Page 94 and 95:
Ophthalmic Medications: OtherOphtha
Page 96 and 97:
Respiratory Medications: Other Drug
Page 98 and 99:
IndexSymbols1ST CHOICE SUPER THINLA
Page 100 and 101:
aminophylline 250 mg/10 mlvl ......
Page 102 and 103:
BD PEN NEEDLE NANO32GX5/32 ........
Page 104 and 105:
CLINIMIX E 2.75%-10%SOLUTION, -2.75
Page 106 and 107:
disulfiram ................ 29dival
Page 108 and 109:
ESTRACE VAGINALPRODUCTS. ..........
Page 110 and 111:
GAMASTAN S-D. ......... 48GAMMAGARD
Page 112 and 113:
IN CONTROL PEN NEEDLE6MM 31G. .....
Page 114 and 115:
lactulose ................ 78LADY L
Page 116 and 117:
metaproterenol sulfate syrup,-table
Page 118 and 119:
NILANDRON ............ 18nimodipine
Page 120 and 121:
PEGASYS PROCLICK 180MCG/0.5 .......
Page 122 and 123:
PUB INSUL SYR 0.3 ML31GX5/16 ......
Page 124 and 125:
SAPHRIS ............... 21SAVELLA.
Page 126 and 127:
SUSTIVA ................. 8SUTENT .
Page 128 and 129:
ULT CFT 0.3 ML 29GX1/2(1/2) .......
Page 130 and 131:
venlafaxine hcl ............ 28venl
Page 133:
®, SM Registered and Service Marks
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2013 Medicare HMO Blue ValueRx/PlusRx Formulary - Blue Cross ...

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