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

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Gastrointestinal Medications: Antispasmodics/Drugs Affect GI MotilityCUVPOSATier 4 N M Odicyclomine hcl capsule, -syrup, -tablet Tier 2glycopyrrolate injection, -tablet Tier 2methscopolamine bromide tablet Tier 2metoclopramide syrup Tier 2metoclopramide injectionTier 2 H I Tmetoclopramide hcl tablet Tier 1propantheline bromide tablet Tier 2Gastrointestinal Medications: Antiulcer Drugscimetidine injectionTier 2 H I Tcimetidine solution, -tablet Tier 2famotidine oral susp Tier 2famotidine injectionTier 2 H I Tfamotidine tablet Tier 1nizatidine Tier 2ranitidine syrup Tier 2ranitidine hcl injectionTier 2 H I Tranitidine hcl capsule, -tablet Tier 1Gastrointestinal Medications: Other Antiulcer Drugsmisoprostol Tier 2sucralfate oral susp, -tablet Tier 2Gastrointestinal Medications: Other GI DrugsAMITIZA Tier 3 Q C D (68/30)APRISO Tier 3ASACOL Tier 3ASACOL HD Tier 3balsalazide disodium Tier 2budesonide ec Tier 5DELZICOL Tier 3gavilyte-c Tier 2gavilyte-g Tier 2gavilyte-n Tier 2hydrocortisone rectal Tier 2lidocaine-hydrocortisone rectal Tier 2LINZESS CAPSULE Tier 3 Q C D (34/30)LOTRONEX Tier 5 Q C D (68/30)mesalamine kit, -rectal Tier 2OSMOPREP Tier 4PANCREAZE Tier 4PANCRELIPASE 5,000 Tier 3peg 3350-electrolyte Tier 2peg-3350 and electrolytes Tier 2peg-3350 with flavor packs Tier 2PENTASA Tier 3polyethylene glycol 3350 Tier 2procto-pak Tier 2proctosol-hc Tier 246Q 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.
Gastrointestinal Medications: Other GI Drugs (continued)proctozone-hc Tier 2PYLERA Tier 3RECTIV Tier 4RELISTOR Tier 3SUCRAID Tier 5sulfasalazine dr Tier 2sulfasalazine tablet Tier 2sulfazine Tier 2sulfazine ec Tier 2trilyte with flavor packets Tier 2ursodiol capsule, -tablet Tier 2VISICOL Tier 4ZENPEP Tier 3Immunologicals and Vaccines: GrowthHormones and Related DrugsHUMATROPENUTROPINNUTROPIN AQNUTROPIN AQ NUSPINSAIZENZORBTIVETier 5 P ATier 5 P ATier 5 P ATier 5 P ATier 5 P ATier 5 P A, L P A, N M OGastrointestinal Medications: Proton Pump Inhibitorslansoprazole capsule sustained action Tier 2 Q C D (34/30),S Tomeprazole dr 10 mg capsule, -dr 40 Tier 2 Q C D (34/30)mg capsuleomeprazole dr 20 mg capsule Tier 2 Q C D (68/30)omeprazole-sodium bicarbonate Tier 2 Q C D (34/30),S Tpantoprazole sodium Tier 2 Q C D (34/30),S Tpantoprazole sodium vial 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. 47
Page 1: Medicare HMO Blue SM ValueRx (HMO)M
Page 4 and 5: How do I use the Formulary?There ar
Page 6 and 7: What do I do before I can talk to m
Page 8 and 9: Your Medicare Prescription Drug Cos
Page 10 and 11: Antiinfectives: Antiretrovirals and
Page 12 and 13: Antiinfectives: Oral Antifungal Dru
Page 14 and 15: Antiinfectives: Other Antiviral Dru
Page 16 and 17: Antiinfectives: Sulfonamideserythro
Page 18 and 19: Antineoplastic/Immunosuppressant Dr
Page 20 and 21: Antineoplastic/Immunosuppressant Dr
Page 22 and 23: Autonomic and CNS Medications: Anal
Page 24: Autonomic and CNS Medications:Antiv
Page 28 and 29: Autonomic and CNS Medications: CNSS
Page 30 and 31: Autonomic and CNS Medications:Other
Page 32 and 33: Autonomic and CNS Medications: Sele
Page 34 and 35: Cardiovascular Medications: Beta-Ad
Page 36 and 37: Cardiovascular Medications: Loop Di
Page 38 and 39: Cardiovascular Medications: OtherVa
Page 40 and 41: Dermatological Medications: OralDer
Page 42 and 43: Dermatological Medications: Topical
Page 44 and 45: Endocrine Medications: Glucocortico
Page 46 and 47: Endocrine Medications: Oral Hypogly
Page 50 and 51: Immunologicals and VaccinesACTHIB T
Page 52 and 53: Immunologicals and Vaccines: Interf
Page 54 and 55: Medical (Miscellaneous) Supplies:Di
Page 80 and 81: Musculoskeletal Medications: Non-St
Page 82 and 83: Nutrition, Blood Modifiers, Electro
Page 84 and 85: Nutrition, Blood Modifiers, Electro
Page 86 and 87: Obstetrical and Gynecological Medic
Page 88 and 89: Obstetrical and GynecologicalMedica
Page 90 and 91: Obstetrical and Gynecological Medic
Page 92 and 93: Ophthalmic Medications: Antiglaucom
Page 94 and 95: Ophthalmic Medications: OtherOphtha
Page 96 and 97: Respiratory Medications: Other Drug
Page 98 and 99:
IndexSymbols1ST CHOICE SUPER THINLA
Page 100 and 101:
aminophylline 250 mg/10 mlvl ......
Page 102 and 103:
BD PEN NEEDLE NANO32GX5/32 ........
Page 104 and 105:
CLINIMIX E 2.75%-10%SOLUTION, -2.75
Page 106 and 107:
disulfiram ................ 29dival
Page 108 and 109:
ESTRACE VAGINALPRODUCTS. ..........
Page 110 and 111:
GAMASTAN S-D. ......... 48GAMMAGARD
Page 112 and 113:
IN CONTROL PEN NEEDLE6MM 31G. .....
Page 114 and 115:
lactulose ................ 78LADY L
Page 116 and 117:
metaproterenol sulfate syrup,-table
Page 118 and 119:
NILANDRON ............ 18nimodipine
Page 120 and 121:
PEGASYS PROCLICK 180MCG/0.5 .......
Page 122 and 123:
PUB INSUL SYR 0.3 ML31GX5/16 ......
Page 124 and 125:
SAPHRIS ............... 21SAVELLA.
Page 126 and 127:
SUSTIVA ................. 8SUTENT .
Page 128 and 129:
ULT CFT 0.3 ML 29GX1/2(1/2) .......
Page 130 and 131:
venlafaxine hcl ............ 28venl
Page 133:
®, SM Registered and Service Marks
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2013 Medicare HMO Blue ValueRx/PlusRx Formulary - Blue Cross ...

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