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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)WAVESENSE CONTROL SOLN M BNORMALWD MEDIC SYR 0.3 ML 30GX5/16 Tier 3WD MEDIC SYR 0.5 ML 29GX1/2 Tier 3WD MEDIC SYR 0.5 ML 30GX5/16 Tier 3WD MEDIC SYR 1 ML 29GX1/2 Tier 3WDMEDIC INS SYR 1 ML 30GX5/16 Tier 3WDMEDIC SYRING 0.3 ML 29GX1/2 Tier 3WEBCOL ALCOHOL PREPS Tier 3XPRES CONTROL SOLUTION M BNORMALMusculoskeletal Medications: CNS Muscle Relaxantscarisoprodol compound Tier 2carisoprodol compound-codeine Tier 2carisoprodol tablet Tier 2carisoprodol-aspirin Tier 2carisoprodol-aspirin-codeine Tier 2chlorzoxazoneTier 2 P Acyclobenzaprine hcl capsule sustained Tier 2action, -tabletmetaxalone Tier 2methocarbamol tabletTier 2 P Aorphenadrine citrate injection Tier 2orphenadrine citrate tablet sustained Tier 2 P Aactionorphenadrine compoundTier 2 P Aorphenadrine compound forteTier 2 P ARILUTEK Tier 5Musculoskeletal Medications:Direct Muscle Relaxantsbaclofen tablet Tier 2dantrolene sodium capsule Tier 2DYSPORTTier 4 P Arevonto Tier 2tizanidine hcl capsule, -tablet Tier 2XEOMINTier 4 P A76Q 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.