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

Nutrition, Blood Modifiers, Electrolytes:Electrolytes, Irrigating Solutions, etc. (continued)dextrose 5%-1/4ns iv solution, -5%-sod Tier 2 H I Tchloride 0.2%, -5%-1/3ns iv solution,-d10%-1/2ns soln/excel cont, -5%-1/2ns iv solution, -2.5%-1/2ns iv soln,-5%-ns iv solutiondextrose 5%-electrolyte #48 Tier 2dextrose 5%-ns-kclTier 2 H I Tdextrose 5%-water iv soln, -10%-water Tier 2 H I Tiv solutiondextrose in lactated ringersTier 2 H I Tdextrose in ringers injection Tier 2kcl 10 meq in d5w-1/4 ns, -kcl 10 meq Tier 2 H I Tin d5w-1/4 ns, -kcl 20 meq in d5w-1/4 ns, -kcl 5 meq in d5w-1/4 nslactated ringers injectionTier 2 H I Tlactated ringers solution Tier 2liposyn iii Tier 2LYSINE HCL Tier 2magnesium sulfate injection Tier 2mannitol injection Tier 2MONOJECT PREFILL 0.9% FLUSH M BMONOJECT PREFILL 0.9% NA SYR M Bnormal saline flush M BNORMOSOL-M AND DEXTROSE Tier 4NORMOSOL-R Tier 4NORMOSOL-R AND DEXTROSE Tier 4Nutrition, Blood Modifiers, Electrolytes:Electrolytes, Irrigating Solutions, etc. (continued)NORMOSOL-R PH 7.4 Tier 4nutrilyte Tier 2nutrilyte ii Tier 2potassium chl-normal saline M Bpotassium chloride-nacl M Bringers injection M Bringers irrigation Tier 2saline 0.45% soln-excel con, -0.45% Tier 2 H I Tsoln, -saline 0.9% soln-excel cont,-0.9% solution, -cl 2.5 meq/ml vial,-3% iv soln, -5% iv solnsaline flush M Bsodium acetate Tier 2sodium bicarbonate Tier 2sodium chloride 0.9% soln, -0.9% soln.,-4 meq/ml vl, -solutionsodium lactateTier 2Tier 2 H I Tsodium phosphate Tier 2sterile water for injection, -for injection Tier 2ampul, -for injection vialsyrex M Btri-vitamin with fluoride Tier 280Q 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.