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

Endocrine Medications: Oral Hypoglycemicsand Combos (continued)metformin hcl Tier 1metformin hcl er 500 mg tab, -750 mg Tier 1tabletmetformin hcl er 500 mg tablet, -1,000 Tier 2mg tabnateglinide Tier 2ONGLYZATier 3 S Tpioglitazone hcl 15mg tablet Tier 2 Q C D (51/30),S Tpioglitazone hcl 30mg tablet, -45mg tab Tier 2 Q C D (34/30),S Tpioglitazone-glimepirideTier 2 S Tpioglitazone-metformin Tier 2 Q C D (68/30),S TPRANDIN Tier 3tolazamide Tier 2tolbutamide Tier 2Endocrine Medications: Other Endocrine DrugsALDURAZYMEalendronate sodium 35 mg tab, -70 mgtabTier 5 L P A, H I T, N M OTier 1 Q C D (5/30)alendronate sodium 5 mg tablet, -10 mg Tier 1 Q C D (34/30)tab, -40 mg tabcabergoline Tier 2 Q C D (16/30)calcitonin-salmon Tier 2CEREZYME Tier 5 P A, L P A, H I T,N M Odesmopressin ac nasal drops/sprays, Tier 2-solution, -tabletdesmopressin ac injectionTier 2 H I TELELYSO Tier 5etidronate disodium Tier 2EVISTA Tier 3FABRAZYME 35 MG VIALTier 5 L P A, H I T, N M Ofludrocortisone acetate tablet Tier 2FORTEO Tier 5 Q C D (2.4pens/30), P Afortical Tier 2ibandronate sodium Tier 2 Q C D (1/30)INCRELEXTier 5 P A, L P A, N M OKORLYMTier 5 P AKUVANTier 5 L P A, N M OMIACALCIN INJECTION Tier 4NAGLAZYMETier 5 L P A, H I T, N M O44Q 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.