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

Cardiovascular Medications: CalciumAntagonists (continued)nisoldipine Tier 2taztia xt Tier 2verapamil injectionTier 2 H I Tverapamil er 120 mg tablet, -180 mg Tier 1tablet, -240 mg tabletverapamil er pm Tier 2verapamil hcl capsule sustained action,-tablet, -er 120 mg tablet, -er 240 mgtabletTier 1Cardiovascular Medications: CentrallyActing Antihypertensivesclonidine Tier 2 Q C D (5/30)clonidine hcl injection Tier 2clonidine hcl tablet Tier 1guanfacine hcl Tier 1methyldopa Tier 1methyldopate hclCardiovascular Medications: Drugsfor PheochromocytomaTier 2 H I TDEMSER Tier 3DIBENZYLINE Tier 3Cardiovascular Medications: HMG-COA Reductase Inhibitorsamlodipine-atorvastatin Tier 2atorvastatin calcium Tier 2 Q C D (34/30)CRESTOR Tier 3 Q C D (34/30),S Tfluvastatin sodium 20 mg cap Tier 2 Q C D (34/30)fluvastatin sodium 40 mg cap Tier 2 Q C D (68/30)lovastatin 10 mg tablet Tier 1 Q C D (34/30)lovastatin 20 mg tablet, -40 mg tablet Tier 1 Q C D (68/30)pravastatin sodium Tier 1 Q C D (34/30)simvastatin tablet Tier 1 Q C D (34/30)Cardiovascular Medications: Hypolipoproteinemicscholestyramine Tier 2cholestyramine light Tier 2colestipol hcl Tier 2fenofibrate Tier 2gemfibrozil tablet Tier 2LOVAZA Tier 4NIASPAN Tier 3prevalite Tier 2WELCHOL Tier 4ZETIA Tier 3 Q C D (34/30),S TQ 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. 33