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

Cardiovascular Medications: Beta-Adrenergic Antagonist Drugsacebutolol hcl capsule Tier 2atenolol tablet Tier 1betaxolol hcl tablet Tier 2bisoprolol fumarate Tier 2carvedilol Tier 1labetalol hcl tablet Tier 2labetalol hcl injectionTier 2 H I Tmetoprolol succinate Tier 2metoprolol tartrate injectionTier 2 H I Tmetoprolol tartrate tablet Tier 1nadolol tablet Tier 1pindolol Tier 2propranolol hcl capsule sustained Tier 1action, -tabletpropranolol hcl injectionTier 2 H I Tpropranolol hcl solution Tier 2timolol maleate tablet Tier 1Cardiovascular Medications: Calcium Antagonistsafeditab cr Tier 2amlodipine besylate 10 mg tab Tier 1 Q C D (34/30)amlodipine besylate 2.5 mg tab, -5 mg Tier 1 Q C D (51/30)tabcartia xt Tier 2dilt-cd Tier 2diltiazem 125 mg/25 ml vial, -50 mg/10 Tier 2ml vialdiltiazem 24hr cd Tier 2diltiazem 24hr er Tier 2diltiazem injectionTier 2 H I Tdiltiazem er Tier 2diltiazem hcl tablet Tier 1dilt-xr Tier 2diltzac er Tier 2felodipine er Tier 2isradipine Tier 2matzim la Tier 2nicardipine injectionTier 2 H I Tnicardipine hcl capsule Tier 2nifediac cc Tier 2nifedical xl Tier 2nifedipine capsule Tier 2nifedipine er Tier 2nimodipine Tier 232Q 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.