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

Obstetrical and Gynecological Medications:Contraceptives (continued)introvale Tier 2jolessa Tier 2junel Tier 2junel fe Tier 2kariva Tier 2kelnor 1-35 Tier 2leena Tier 2lessina Tier 2levonest Tier 2levonorgestrel Tier 2levonorg-eth estrad eth estrad Tier 2levonorgestrel-eth estradiol Tier 2levora-28 Tier 2loryna Tier 2low-ogestrel Tier 2lutera Tier 2marlissa Tier 2microgestin Tier 2microgestin fe Tier 2mononessa Tier 2myzilra Tier 2necon Tier 2next choice Tier 2next choice one dose Tier 2Obstetrical and Gynecological Medications:Contraceptives (continued)norethindrone-ethin estradiol Tier 2norgestimate-ethinyl estradiol Tier 2norgestrel-ethiny estra Tier 2nortrel Tier 2ocella Tier 2ogestrel Tier 2orsythia Tier 2ORTHO EVRA Tier 4philith Tier 2portia Tier 2previfem Tier 2quasense Tier 2reclipsen Tier 2solia Tier 2sprintec Tier 2sronyx Tier 2syeda Tier 2tilia fe Tier 2tri-legest fe Tier 2trinessa Tier 2tri-previfem Tier 2tri-sprintec Tier 2trivora-28 Tier 2velivet Tier 284Q 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.