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

Autonomic and CNS Medications:Valproic Acid and Derivativesdivalproex sodium Tier 2divalproex sodium er Tier 2valproate sodium injectionTier 2 H I Tvalproic acid capsule, -syrup Tier 2Cardiovascular Medications: AngiotensinII Receptor AntagonistsDIOVANTier 3 S Teprosartan mesylate Tier 2irbesartan Tier 2losartan potassium Tier 2Cardiovascular Medications: AngiotensinConverting Enzyme Inhibitorsbenazepril hcl tablet Tier 1captopril tablet Tier 1enalapril maleate tablet Tier 1enalaprilat Tier 2fosinopril sodium Tier 2lisinopril tablet Tier 1moexipril hcl Tier 2perindopril erbumine Tier 2quinapril hcl Tier 1ramipril Tier 1trandolapril Tier 2Cardiovascular Medications: Antidysrhythmic Drugsdisopyramide phosphate Tier 2flecainide acetate Tier 2mexiletine hcl capsule Tier 2procainamide hcl injectionTier 2 H I Tpropafenone hcl Tier 2quinidine gluconate injectionquinidine gluconate tablet sustainedactionquinidine sulfate tablet, -tablet sustainedactionTier 2 H I TTier 2Tier 2Q 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. 31