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

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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.
Nutrition, Blood Modifiers, Electrolytes:Therapeutic Vitamins and Mineralscalcitriol capsule, -solution Tier 2calcitriol injectionTier 2 H I Tcalcium acetate Tier 2eliphos Tier 2levocarnitine injectionTier 2 H I Tlevocarnitine solution, -tablet Tier 2ZEMPLAR CAPSULE Tier 3ZEMPLAR INJECTIONTier 3 H I TObstetrical and GynecologicalMedications: Androgen DrugsANADROL-50 Tier 5androxy Tier 2AXIRON Tier 4danazol capsule Tier 2FORTESTA Tier 4METHITEST Tier 3oxandrolone tablet Tier 2TESTIM Tier 3testosterone cypionate injection Tier 2testosterone enanthate injection Tier 2Obstetrical and GynecologicalMedications: Contraceptivesaltavera Tier 2alyacen Tier 2amethia Tier 2amethia lo Tier 2amethyst Tier 2apri Tier 2aranelle Tier 2aviane Tier 2azurette Tier 2balziva Tier 2briellyn Tier 2camrese Tier 2camrese lo Tier 2caziant Tier 2cesia Tier 2cryselle Tier 2cyclafem Tier 2drospirenone-eth estradiol Tier 2ELLA Tier 4emoquette Tier 2enpresse Tier 2gianvi Tier 2gildagia Tier 2gildess fe Tier 2Q 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. 83
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Medicare HMO Blue SM ValueRx (HMO)M
Page 4 and 5:
How do I use the Formulary?There ar
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What do I do before I can talk to m
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Your Medicare Prescription Drug Cos
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Antiinfectives: Antiretrovirals and
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Antiinfectives: Oral Antifungal Dru
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Antiinfectives: Other Antiviral Dru
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Antiinfectives: Sulfonamideserythro
Page 18 and 19:
Antineoplastic/Immunosuppressant Dr
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Antineoplastic/Immunosuppressant Dr
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Autonomic and CNS Medications: Anal
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Autonomic and CNS Medications:Antiv
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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 80 and 81: Musculoskeletal Medications: Non-St
Page 82 and 83: 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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2013 Medicare HMO Blue ValueRx/PlusRx Formulary - Blue Cross ...

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