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

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