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

Dermatological Medications: TopicalDermatological Drugs (continued)urea 40% cream, -45% cream, -50% Tier 2cream, -foam (non-contraceptive),-gel, -40% lotion, -soln, top, -50%emulsion, -50% topical suspensionx-viate Tier 2ZONALON Tier 3ZYCLARA Tier 3Diagnostic and MiscellaneousMedications: Diagnostic ProductsCHEMET Tier 3EXJADE 125 MG TABLETTier 3 L P A, N M OEXJADE 250 MG TABLET, -500 MG Tier 5 L P A, N M OTABLETFERRIPROX Tier 5METHACHOLINE CHLORIDE Tier 2Diagnostic and MiscellaneousMedications: Miscellaneous DrugsADAGENaminocaproic acid injection, -syrup,-500 mg tabTier 5 L P A, N M OTier 2AMPYRA Tier 5 Q C D (68/30),P A, L P A, N M OAUBAGIO TABLET Tier 5BUPHENYL TABLET Tier 5CARBAGLUTier 5 N M OCOPAXONE Tier 5 Q C D (30/30)CYKLOKAPRONTier 3 H I Tergoloid mesylates tablet Tier 2fomepizoleTier 2 H I TGILENYA Tier 5 Q C D (30/30),P AORFADINTier 5 L P A, N M Osodium phenylbutyrate powder Tier 2THALOMID Tier 5tranexamic acidTier 2 H I Ttranexamic tab Tier 2 Q C D (30/30)40Q 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.