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

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Musculoskeletal Medications: Non-SteroidalAntiinflammatory Agents (continued)naproxen oral susp Tier 2naproxen sodium tablet Tier 2oxaprozin Tier 2piroxicam capsule Tier 2sulindac tablet Tier 2tolmetin sodium Tier 2Nutrition, Blood Modifiers,Electrolytes: Antiplatelet DrugsAGGRENOX Tier 4cilostazol Tier 2clopidogrel Tier 2dipyridamole tablet Tier 2EFFIENT Tier 3ticlopidine hcl Tier 2Musculoskeletal Medications:Other Drugs for Arthritischoline mag trisalicylate Tier 2CUPRIMINE Tier 3diflunisal tablet Tier 2HYALGAN M BRIDAURA Tier 3salsalate tablet Tier 1SUPARTZ M BSYNVISC M BSYNVISC-ONE M BSYPRINE Tier 5Nutrition, Blood Modifiers,Electrolytes: Blood Detoxicantsconstulose Tier 2enulose Tier 2generlac Tier 2lactulose Tier 2RENVELA Tier 378Q 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.
Nutrition, Blood Modifiers, Electrolytes:Electrolytes, Irrigating Solutions, etc.amino acids Tier 2AMINOSYN 3.5% IV SOLUTION, -7% Tier 4 H I TIV SOLUTION, -10% IV SOLUTIONAMINOSYN 8.5% IV SOLUTION Tier 4 H I TAMINOSYN IITier 4 H I TAMINOSYN II 5% IN 25% DEXTROSE Tier 4 H I TAMINOSYN MTier 4 H I TAMINOSYN WITH ELECTROLYTES Tier 4 H I TAMINOSYN-HBCTier 4 H I TAMINOSYN-HFTier 4 H I TAMINOSYN-PFTier 4 H I TAMINOSYN-RFTier 4 H I Tbacteriostatic saline vial, -0.9% syringe, M B-0.9% vial, -0.9% zr syrbacteriostatic water vial M Bcalcium chloride injection Tier 2CLINIMIX 2.75%-5% SOLUTION, Tier 4 H I T-4.25%-20% SOLUTION, -4.25%-25% SOLUTION, -4.25%-5%SOLUTION, -5%-15% SOLUTION,-5%-20% SOLUTION, -5%-25%SOLUTIONCLINIMIX 4.25%-10% SOLUTION Tier 4 H I TNutrition, Blood Modifiers, Electrolytes:Electrolytes, Irrigating Solutions, etc. (continued)CLINIMIX E 2.75%-10% SOLUTION,-2.75%-5% SOLUTION, -4.25%-25%SOLUTION, -4.25%-5% SOLUTION,-5%-15% SOLUTION, -5%-20%SOLUTION, -5%-25% SOLUTIONCYSTAGONd5%-1/4ns-kcl 10 meq/l iv sol, -d5%-1/4ns-kcl 30 meq/l iv sol, -d5%-1/4ns-kcl 40 meq/l iv solTier 4 H I TTier 3 L P A, N M OTier 2 H I Td5w-kcl 30 meq/l iv solution, -d5w/kcl Tier 2 H I T30 meq/l iv solutiondelflex with 1.5% dextrose Tier 2delflex with 2.5% dextrose Tier 2delflex with 4.25% dextrose Tier 2dextrose 10%-1/4nsTier 2 H I Tdextrose 10%-ns iv solution Tier 2dextrose 2.5%-water iv soln,-25%-water syringe, -30%-water ivsoln, -40%-water iv soln, -50%-waterabboject, -50%-water iv soln,-50%-water syringe, -50%-water vial,-70%-water iv solndextrose 5%-1/2ns-kcldextrose 5%-1/3ns-kclTier 2Tier 2 H I TTier 2 H I TQ 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. 79
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Medicare HMO Blue SM ValueRx (HMO)M
Page 4 and 5:
How do I use the Formulary?There ar
Page 6 and 7:
What do I do before I can talk to m
Page 8 and 9:
Your Medicare Prescription Drug Cos
Page 10 and 11:
Antiinfectives: Antiretrovirals and
Page 12 and 13:
Antiinfectives: Oral Antifungal Dru
Page 14 and 15:
Antiinfectives: Other Antiviral Dru
Page 16 and 17:
Antiinfectives: Sulfonamideserythro
Page 18 and 19:
Antineoplastic/Immunosuppressant Dr
Page 20 and 21:
Antineoplastic/Immunosuppressant Dr
Page 22 and 23:
Autonomic and CNS Medications: Anal
Page 24:
Autonomic and CNS Medications:Antiv
Page 28 and 29:
Autonomic and CNS Medications: CNSS
Page 30 and 31: Autonomic and CNS Medications:Other
Page 32 and 33: Autonomic and CNS Medications: Sele
Page 34 and 35: Cardiovascular Medications: Beta-Ad
Page 36 and 37: Cardiovascular Medications: Loop Di
Page 38 and 39: Cardiovascular Medications: OtherVa
Page 40 and 41: Dermatological Medications: OralDer
Page 42 and 43: Dermatological Medications: Topical
Page 44 and 45: Endocrine Medications: Glucocortico
Page 46 and 47: Endocrine Medications: Oral Hypogly
Page 48 and 49: Gastrointestinal Medications: Antis
Page 50 and 51: Immunologicals and VaccinesACTHIB T
Page 52 and 53: Immunologicals and Vaccines: Interf
Page 54 and 55: Medical (Miscellaneous) Supplies:Di
Page 82 and 83: Nutrition, Blood Modifiers, Electro
Page 84 and 85: Nutrition, Blood Modifiers, Electro
Page 86 and 87: Obstetrical and Gynecological Medic
Page 88 and 89: Obstetrical and GynecologicalMedica
Page 90 and 91: Obstetrical and Gynecological Medic
Page 92 and 93: Ophthalmic Medications: Antiglaucom
Page 94 and 95: Ophthalmic Medications: OtherOphtha
Page 96 and 97: Respiratory Medications: Other Drug
Page 98 and 99: IndexSymbols1ST CHOICE SUPER THINLA
Page 100 and 101: aminophylline 250 mg/10 mlvl ......
Page 102 and 103: BD PEN NEEDLE NANO32GX5/32 ........
Page 104 and 105: CLINIMIX E 2.75%-10%SOLUTION, -2.75
Page 106 and 107: disulfiram ................ 29dival
Page 108 and 109: ESTRACE VAGINALPRODUCTS. ..........
Page 110 and 111: GAMASTAN S-D. ......... 48GAMMAGARD
Page 112 and 113: IN CONTROL PEN NEEDLE6MM 31G. .....
Page 114 and 115: lactulose ................ 78LADY L
Page 116 and 117: metaproterenol sulfate syrup,-table
Page 118 and 119: NILANDRON ............ 18nimodipine
Page 120 and 121: PEGASYS PROCLICK 180MCG/0.5 .......
Page 122 and 123: PUB INSUL SYR 0.3 ML31GX5/16 ......
Page 124 and 125: SAPHRIS ............... 21SAVELLA.
Page 126 and 127: SUSTIVA ................. 8SUTENT .
Page 128 and 129: ULT CFT 0.3 ML 29GX1/2(1/2) .......
Page 130 and 131:
venlafaxine hcl ............ 28venl
Page 133:
®, SM Registered and Service Marks
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