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

Nutrition, Blood Modifiers, Electrolytes:Injectable Anticoagulants (continued)heparin sodium in 0.45% naclTier 2 H I Theparin-d5w 20,000 unit/500 ml Tier 2 H I Theparin-d5w 25,000 unit/500 ml, --d5w Tier 2 H I T25,000 unit/250 mlheparin-ns 1,000 unit/500 mlTier 2 H I Theparin-ns 2,000 unit/1,000 ml Tier 2 H I Tmonoject heparin 10 units/ml M B H I Tmonoject heparin 10 units/ml, -heparin100 units/mlM BNutrition, Blood Modifiers, Electrolytes:Oral Anticoagulants, Vitamin Kjantoven Tier 1PRADAXA Tier 4warfarin sodium tablet Tier 1XARELTO Tier 3H I TNutrition, Blood Modifiers, Electrolytes:Potassium Supplementscytra-2 Tier 2effer-k 25 meq tablet eff Tier 2k effervescent Tier 2kcl 20 meq in d5w solution, -d5w/kcl Tier 2 H I T40 meq/l iv solution, -kcl 40 meq ind5w solutionkcl 20 meq in d5w-lact ringerTier 2 H I Tkcl 40 meq in d5w-lact ringerTier 2 H I Tklor-con 10 Tier 1klor-con 20 meq packet Tier 1klor-con 8 Tier 1klor-con m10 Tier 1klor-con m15 Tier 2klor-con m20 Tier 1klor-con-ef Tier 2phospha 250 neutral Tier 2potassium acetate injection Tier 2potassium bicarbonate Tier 2potassium chloride sa capsule, -sa Tier 1tabletpotassium cl injectionTier 2 H I Tpotassium cl solution Tier 2sodium citrate & citric acid Tier 282Q 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.