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

Immunologicals and Vaccines (continued)GAMUNEXTier 5 P A, H I TGAMUNEX-CTier 5 P AGARDASIL Tier 3HAVRIX Tier 3HIBERIX Tier 3IMOVAX RABIES VACCINE Tier 3INFANRIX Tier 3INFLUENZA A (H1N1) 2009 M BIPOL Tier 3IXIARO Tier 3JE-VAX Tier 3KEPIVANCETier 5 L P A, H I T, N M OKINRIX Tier 3MENACTRA Tier 3MENOMUNE-A-C-Y-W-135 Tier 3MENVEO A-C-Y-W-135-DIP Tier 3M-M-R II VACCINE Tier 3MOZOBIL Tier 5NPLATETier 5 N M OOCTAGAMTier 5 P APEDIARIX Tier 3PEDVAXHIB Tier 3PENTACEL Tier 3PNEUMOVAX 23 VIAL M BPREVNAR 13 M BImmunologicals and Vaccines (continued)PROCRIT 2,000 UNITS/ML VIAL,-3,000 UNITS/ML VIAL, -4,000UNITS/ML VIAL, -10,000 UNITS/MLVIALPROCRIT 20,000 UNITS/ML VIAL,-40,000 UNITS/ML VIALPROMACTAPROQUAD Tier 3RABAVERT Tier 3RECOMBIVAX HB M BROTARIX Tier 3ROTATEQ Tier 3TENIVAC Tier 3TETANUS DIPHTHERIA TOXOIDS Tier 3tetanus toxoid adsorbed Tier 2TETANUS-DIPHTERIA-DECAVAC Tier 3TRIHIBIT Tier 3TRIPEDIA Tier 3TWINRIX Tier 3TYPHIM VI Tier 3VAQTA Tier 3VARIVAX VACCINE Tier 3YF-VAX Tier 3ZOSTAVAX Tier 3Tier 3 Q C D (12/30),P ATier 5 Q C D (12/30),P ATier 5 L P A, N M OQ 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. 49