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

Musculoskeletal Medications: Drugsto Prevent and Treat Goutallopurinol sodiumTier 2 H I Tallopurinol tablet Tier 1COLCRYS Tier 3KRYSTEXXA Tier 4probenecid Tier 2probenecid-colchicine Tier 2ULORICTier 4 S TMusculoskeletal Medications: Non-Steroidal Antiinflammatory AgentsCELEBREX Tier 4 Q C D (68/30),P Adiclofenac- misoprost Tier 2diclofenac potassium Tier 2diclofenac sodium e.c. tab, -tablet Tier 2sustained actionetodolac capsule, -tablet, -tablet Tier 2sustained actionfenoprofen calcium tablet Tier 2FLECTOR Tier 4flurbiprofen tablet Tier 2ibuprofen oral susp Tier 2ibuprofen tablet Tier 1indomethacin capsule, -capsule Tier 2sustained action, -injectionketoprofen capsule, -capsule sustained Tier 2actionketorolac tablet Tier 2ketorolac injectionTier 2 H I Tmeclofenamate sodium capsule Tier 2mefenamic acid capsule Tier 2meloxicam oral susp Tier 2meloxicam tablet Tier 1 Q C D (34/30)nabumetone Tier 2naproxen e.c. tab, -tablet Tier 1Q 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. 77