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

Endocrine Medications: OtherEndocrine Drugs (continued)pamidronateTier 2 H I TPROLIATier 4 P ARECLASTTier 4 H I TSAMSCA Tier 5SENSIPAR 30 MG TABLET Tier 3SENSIPAR 60 MG TABLET, -90 MG Tier 5TABLETSOMAVERTTier 5 L P A, N M OSTIMATE Tier 3XGEVATier 5 P AZAVESCATier 5 L P A, N M Ozoledronic acid Tier 5ZOMETATier 5 H I TEndocrine Medications: Thyroid Supplementslevothroid Tier 1LEVOTHYROXINE 100 MCG VIAL Tier 3levothyroxine 500 mcg vial Tier 2levothyroxine sodium tablet Tier 1levoxyl Tier 1liothyronine sodium injectionTier 2 H I Tliothyronine sodium tablet Tier 2lugol’s solution Tier 2nature-throid Tier 2SYNTHROID Tier 4unithroid Tier 1Gastrointestinal Medications: Antidiarrheal Drugsdiphenoxylate-atropine Tier 2loperamide capsule Tier 2paregoric Tier 2Q 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. 45