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

Endocrine Medications: InsulinHUMALOG Tier 3HUMALOG MIX 50-50 Tier 3HUMALOG MIX 75-25 Tier 3HUMULIN 70-30 Tier 3HUMULIN N Tier 3HUMULIN R Tier 3LANTUS Tier 3LANTUS SOLOSTAR Tier 3LEVEMIR Tier 3NOVOLIN 70-30 Tier 3NOVOLIN N Tier 3NOVOLIN R Tier 3NOVOLOG Tier 3NOVOLOG MIX 70-30 Tier 3Endocrine Medications: OralHypoglycemics and Combosacarbose Tier 2ACTOS 15 MG TABLET Tier 4 Q C D (51/30),S TACTOS 30 MG TABLET, -45 MGTABLETTier 4 Q C D (34/30),S TAVANDAMET Tier 4 Q C D (68/30),S T, L P A, N M OAVANDIA 2 MG TABLET, -4 MGTABLETTier 4 Q C D (68/30),S T, L P A, N M OAVANDIA 8 MG TABLET Tier 4 Q C D (34/30),S T, L P A, N M Ochlorpropamide Tier 2glimepiride Tier 1glipizide er Tier 2glipizide tablet Tier 1glipizide xl Tier 2glipizide-metformin Tier 2glyburide micronized Tier 2glyburide tablet Tier 1glyburide-metformin hcl Tier 2JANUMETTier 3 S TJANUMET XRTier 3 S TJANUVIATier 3 S TJUVISYNCTier 4 S TKOMBIGLYZE XRTier 3 S TQ 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. 43