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

Cardiovascular Medications: OtherVasodilating DrugsADCIRCATier 5 P Aepoprostenol sodium Tier 2LETAIRISTier 5 L P A, N M OREMODULINTier 5 L P A, H I T, N M OREVATIO INJECTIONTier 5 P A, H I Tsildenafil tabletTier 2 P ATRACLEERTier 5 L P A, N M OTYVASO M BveletriTier 2 N M OVENTAVIS M B N M OCardiovascular Medications:Potassium Sparing Diureticsamiloride hcl tablet Tier 2amiloride-hydrochlorothiazide Tier 1eplerenone Tier 2spironolactone tablet Tier 1spironolactone-hctz Tier 1triamterene-hctz Tier 1triamterene-hydrochlorothiazid Tier 1Cardiovascular Medications: Thiazideand Related Drugschlorothiazide Tier 2chlorothiazide sodiumTier 5 H I Tchlorthalidone Tier 1hydrochlorothiazide capsule, -tablet Tier 1indapamide Tier 1methyclothiazide Tier 2metolazone Tier 2Cardiovascular Medications:Vasodilator Antihypertensivesdoxazosin mesylate 1 mg tab Tier 1 Q C D (34/30)doxazosin mesylate 2 mg tab, -4 mg tab, Tier 1 Q C D (68/30)-8 mg tabhydralazine hcl injectionTier 2 H I Thydralazine hcl tablet Tier 2minoxidil tablet Tier 2prazosin hcl Tier 1terazosin 1 mg capsule, -5 mg capsule Tier 1 Q C D (34/30)terazosin 2 mg capsule, -10 mg capsule Tier 1 Q C D (68/30)36Q 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.