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

Obstetrical and Gynecological Medications:Contraceptives (continued)vestura Tier 2viorele Tier 2zarah Tier 2zenchent Tier 2zenchent fe Tier 2zeosa Tier 2zovia 1-35e Tier 2zovia 1-50e Tier 2Obstetrical and GynecologicalMedications: Estrogen DrugsESTRACE VAGINAL PRODUCTS Tier 3estradiol adh. patch Tier 2 Q C D (5/30)estradiol tablet Tier 2estradiol valerate injection Tier 2estropipate Tier 2MENEST Tier 3PREMARIN INJECTIONTier 4 H I TPREMARIN TABLET, -VAGINAL Tier 4PRODUCTSVAGIFEM Tier 3Obstetrical and Gynecological Medications:Estrogen/Progestin CombinationsCLIMARA PRO Tier 3 Q C D (5/30)estradiol-norethindrone acetat Tier 2FEMHRT 0.5 MG-2.5 MCG TABLET Tier 3jevantique Tier 2jinteli Tier 2mimvey Tier 2Obstetrical and Gynecological Medications:Ob/Gyn Topical AntiinfectivesCLEOCIN 100 MG VAGINAL OVULE Tier 3clindamycin phosphate vaginal products Tier 2fem ph Tier 2metronidazole vaginal products Tier 2vandazole 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. 85