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

Immunologicals and VaccinesACTHIB Tier 3ADACEL Tier 3AFLURIA 2011-2012 M BAFLURIA 2011-2012 (PF) M BARANESP 100 MCG/0.5 MLTier 5 Q C D (2/30), P ASYRINGEARANESP 100 MCG/ML VIAL, -200 Tier 5 Q C D (4/30), P AMCG/ML VIAL, -300 MCG/ML VIAL,-500 MCG/1 ML SYRINGEARANESP 150 MCG/0.3 MLSYRINGEARANESP 150 MCG/0.75 ML VIALARANESP 200 MCG/0.4 MLSYRINGETier 5 Q C D (1.2/30),P ATier 5 P ATier 5 Q C D (1.6/30),P AARANESP 25 MCG/0.42 ML SYRING Tier 3 Q C D (1.68/30),P AARANESP 25 MCG/ML VIAL, -40 Tier 3 Q C D (4/30), P AMCG/ML VIAL, -60 MCG/ML VIALARANESP 300 MCG/0.6 MLSYRINGETier 5 Q C D (2.4/30),P AARANESP 40 MCG/0.4 ML SYRINGE Tier 3 Q C D (1.6/30),P AARANESP 60 MCG/0.3 ML SYRINGE Tier 3 Q C D (1.2/30),P ABOOSTRIX Tier 3candin Tier 2CERVARIX Tier 3CINRYZETier 5 H I TImmunologicals and Vaccines (continued)COMVAX Tier 3DAPTACEL Tier 3DECAVAC Tier 3DIPHTHERIA-TETANUS TOXOID Tier 3ENGERIX-B M BEPOGEN 10,000 UNITS/ML VIAL Tier 3 P AEPOGEN 2,000 UNITS/ML VIAL,-3,000 UNITS/ML VIAL, -4,000UNITS/ML VIAL, -20,000 UNITS/2 MLVIAL, -20,000 UNITS/ML VIALTier 3 Q C D (12/30),P AFIRAZYR Tier 5FLUARIX 2011-2012 M BFLULAVAL 2011-2012 M BFLUMIST NASAL 2011-12 VACCINE M BFLUVIRIN 2011-2012 M BFLUZONE 2011-2012 M BFLUZONE 2011-2012 (PF) M BFLUZONE 2012-2013 M BFLUZONE HIGH-DOSE 2011-12 (PF) M BFLUZONE HIGH-DOSE 2012-13 M BFLUZONE INTRADERMAL M BFLUZONE INTRADERMAL 2012-2013 M BFLUZONE PEDI 2012-2013 M BGAMASTAN S-DTier 3 P AGAMMAGARD LIQUIDTier 5 P A, H I TGAMMAGARD S-DTier 5 P A48Q 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.