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

Nutrition, Blood Modifiers,Electrolytes: Fluoride Productsdenta 5000 plus Tier 2dentagel Tier 2epiflur Tier 2fluor-a-day chew tab Tier 2FLUOR-A-DAY ORAL DROPS Tier 3fluoride Tier 2fluoridex daily defense Tier 2fluoritab chew tab Tier 2lozi-flur Tier 2ludent fluoride Tier 2neutragard advanced Tier 2perio med Tier 2sf Tier 2sf 5000 plus Tier 2sodium fluoride Tier 2stannous fluoride dental/mucousmembrn productsTier 2Nutrition, Blood Modifiers, Electrolytes:Injectable Anticoagulantsenoxaparin 100 mg/ml syr Tier 2 Q C D (60/30)enoxaparin 120 mg/0.8 ml syr Tier 5 Q C D (48/30)enoxaparin 150 mg/ml syr Tier 5 Q C D (60/30)enoxaparin 30 mg/0.3 ml syr Tier 2 Q C D (18/30)enoxaparin 300 mg/3 ml vial Tier 2 Q C D (180/30)enoxaparin 40 mg/0.4 ml syr Tier 2 Q C D (24/30)enoxaparin 60 mg/0.6 ml syr Tier 2 Q C D (36/30)enoxaparin 80 mg/0.8 ml syr Tier 2 Q C D (48/30)fondaparinux 10 mg/0.8 ml syr Tier 5 Q C D (24/30)fondaparinux 2.5 mg/0.5 ml syr Tier 2 Q C D (15/30)fondaparinux 5 mg/0.4 ml syr Tier 5 Q C D (12/30)fondaparinux 7.5 mg/0.6 ml syr Tier 5 Q C D (18/30)heparin iv flush 1 unit/ml syr, -iv flush10 unit/ml sy, -lock flush 10 units/ml,-iv flush 100 units/ml, -lock flush 100unit/mlheparin lock 10 units/ml vial, -flush 10units/ml, -100 units/ml vial, -flush 100unit/mlheparin sod 1,000 unit/ml vial, -sod5,000 unit/ml vial, -sod 10,000 unit/mlvl, -sod 20,000 unit/ml vlheparin sod 2,000 unit/ml vial, -sod2,500 unit/ml vial, -sod 5,000 unit/ml syr, -sod 5,000 unit/ 0.5 ml, -sod5,000 unit/0.5 mlM BM BH I TH I TTier 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. 81