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

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