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

Immunologicals and Vaccines: InterferonsACTIMMUNETier 5 P A, L P A, N M OAVONEXTier 5 Q C D (4 kits/30)AVONEX ADMINISTRATION PACK Tier 5 Q C D (4 kits/30)AVONEX PEN Tier 5BETASERON Tier 5 Q C D (15/30)INFERGEN 15 MCG/0.5 ML VIAL Tier 5 P AINFERGEN 9 MCG/0.3 ML VIAL Tier 5 P AINTRON A 3 MILLION UNIT/ML Tier 3 P APEN, -6 MILLION UNIT/ML VL, -10MILLION UNIT PEN, -10 MILLIONUNIT/ML, -10 MILLION UNITS VIALINTRON A 5 MILLION UNIT/ML Tier 5 P APEN, -18 MILLION UNITS VIAL, -50MILLION UNITS VIALPEGASYS 180 MCG/0.5 ML SYRINGE Tier 5 Q C D (4syringes/30),P APEGASYS 180 MCG/ML VIAL Tier 5 Q C D (4vials/30), P APEGASYS PROCLICK 135 MCG/0.5 Tier 5 Q C D (4/30), P APEGASYS PROCLICK 180 MCG/0.5 Tier 5 Q C D (4/30), P APEGINTRON 50 MCG KITTier 5 Q C D (5 kits/30),P APEGINTRON 80 MCG KIT, -120 MCG Tier 5 P AKIT, -150 MCG KITPEGINTRON REDIPEN Tier 5 Q C D (4pens/30), P AImmunologicals and Vaccines: Interferons (continued)REBIF 22 MCG/0.5 ML SYRINGE, -44 Tier 5 Q C D (7.5 ml/30)MCG/0.5 ML SYRINGEREBIF TITRATION PACK Tier 5 Q C D (4.2syringes/30)SYLATRONTier 5 P ASYLATRON 4-PACKTier 5 P AImmunologicals and Vaccines:Interleukin Recptr AntagonistACTEMRAARCALYSTILARISKINERETTier 5 P ATier 5 L P A, N M OTier 5 P A, L P A, N M OTier 5 P AImmunologicals and Vaccines: InterleukinsNEUMEGA Tier 5PROLEUKINTier 5 P A, H I T50Q 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.