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

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Cardiovascular Medications: Loop Diureticsbumetanide injectionTier 2 H I Tbumetanide tablet Tier 2furosemide solution Tier 2furosemide injectionTier 2 H I Tfurosemide tablet Tier 1torsemide injectionTier 2 H I Ttorsemide tablet Tier 2Cardiovascular Medications: Nitratesisoditrate Tier 2isosorbide dinitrate Tier 2isosorbide mononitrate Tier 1isosorbide mononitrate er Tier 1nitro-bid Tier 2nitroglycerin in d5w Tier 2nitroglycerin injectionTier 2 H I Tnitroglycerin patch Tier 2NITROSTAT Tier 3Cardiovascular Medications: Other Antiarrhythmicsadenosine injection Tier 2amiodarone injectionTier 2 H I Tamiodarone tablet Tier 2ibutilide fumarate Tier 2MULTAQ Tier 4pacerone Tier 2sorine Tier 2sotalol Tier 2sotalol af Tier 2TIKOSYN Tier 334Q 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.
Cardiovascular Medications: Other Antihypertensivesamlodipine besylate-benazepril Tier 2atenolol-chlorthalidone Tier 1benazepril-hydrochlorothiazide Tier 1bisoprolol-hydrochlorothiazide Tier 1candesartan- hctz Tier 2captopril-hydrochlorothiazide Tier 1enalapril-hydrochlorothiazide Tier 1EXFORGETier 4 S TEXFORGE HCTTier 4 S Tfosinopril-hydrochlorothiazide Tier 2irbesartan-hydrochlorothiazide Tier 2lisinopril-hydrochlorothiazide Tier 1losartan-hydrochlorothiazide Tier 2methyldopa-hydrochlorothiazide Tier 2metoprolol-hydrochlorothiazide Tier 2moexipril-hydrochlorothiazide Tier 2nadolol-bendroflumethiazide Tier 2propranolol-hydrochlorothiazid Tier 1quinapril-hydrochlorothiazide Tier 2reserpine tablet Tier 2TEKAMLO Tier 4TEKTURNA Tier 4TEKTURNA HCT Tier 4valsartan-hctz Tier 2Cardiovascular Medications: OtherCardiovascular Drugsalprostadil injection Tier 2digoxin injectionTier 2 H I Tdigoxin solution Tier 2digoxin tablet Tier 1dobutamine hcl Tier 2dobutamine hcl in dextrose Tier 2dopamine hcl in 5% dextrose Tier 2dopamine hcl injection Tier 2kalexate Tier 2kionex oral susp Tier 2LANOXIN TABLET Tier 4midodrine hcl Tier 2milrinone in 5% dextrose Tier 2milrinone lactate Tier 2norepinephrine bitartrate Tier 2pentoxifylline tablet sustained action Tier 2RANEXA Tier 3sodium polystyrene sulfonate Tier 2sps Tier 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. 35
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 22 and 23: Autonomic and CNS Medications: Anal
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 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 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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