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

Endocrine Medications: Glucocorticoid Drugsa-methapred Tier 2baycadron Tier 2betamethasone acetate-sod phos Tier 2cortisone acetate tablet Tier 2dexamethasone elix Tier 2dexamethasone intensol Tier 2dexamethasone sodium phosphate Tier 2 H I Tinjectiondexamethasone tablet Tier 1hydrocortisone tablet Tier 2methylprednisolone injectionTier 2 H I Tmethylprednisolone tab(in convenience Tier 1package), -tabletMILLIPRED DP Tier 3millipred tablet Tier 1prednisolone 15 mg/5 ml soln Tier 2prednisolone 5 mg/5 ml soln, -6.7 mg/5 Tier 2ml soln, -15 mg/5 ml soln, 25mg/5mlsolnprednisone intensol Tier 2prednisone solution Tier 2prednisone tab(in convenience Tier 1package), -tabletRAYOS Tier 4veripred 20 Tier 2Endocrine Medications: Glucose Elevating DrugsGLUCAGEN Tier 3GLUCAGON EMERGENCY KIT Tier 3PROGLYCEM Tier 3Endocrine Medications: Hypoglycemic DrugsBYDUREON Tier 3BYETTA Tier 3SYMLIN Tier 3SYMLINPEN 120 Tier 3SYMLINPEN 60 Tier 3VICTOZA 2-PAKTier 4 S TVICTOZA 3-PAKTier 4 S T42Q 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.