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

Obstetrical and GynecologicalMedications: Prenatal Vitaminsbal-care dha Tier 2cavan one omega Tier 2cavan-alpha kit Tier 2cavan-ec sod dha Tier 2cavan-heme ob Tier 2complete natal dha Tier 2completenate Tier 2co-natal fa Tier 2elite ob dha Tier 2elite-ob Tier 2elite-ob 400 Tier 2fe c Tier 2folbecal Tier 2folcal dha Tier 2folcaps omega-3 Tier 2folinatal plus b Tier 2folivane-ec calcium dha nf Tier 2folivane-ob Tier 2folivane-prx dha nf Tier 2gentex ade Tier 2hemenatal ob Tier 2hemenatal ob + dha Tier 2inatal advance Tier 2inatal gt Tier 2Obstetrical and Gynecological Medications:Prenatal Vitamins (continued)inatal ultra Tier 2levomefolate dha Tier 2levomefolatepnv Tier 2macnatal cn dha Tier 2multinatal plus Tier 2mynatal Tier 2mynatal advance Tier 2mynatal plus Tier 2mynatal-z Tier 2mynate 90 plus Tier 2nutri-tab ob Tier 2nutri-tab ob + dha Tier 2ob-natal one Tier 2pnv ob+dha Tier 2pnv-dha Tier 2pnv-dha + docusate Tier 2pnv-omega Tier 2pnv-select Tier 2pnv-total Tier 2pr natal 400 Tier 2pr natal 400 ec Tier 2pr natal 430 Tier 2pr natal 430 ec Tier 2prenafirst Tier 286Q 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.