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

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