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

Obstetrical and Gynecological Medications:Prenatal Vitamins (continued)prenaissance Tier 2prenaissance balance Tier 2prenaissance next Tier 2prenaissance plus Tier 2prenaplus Tier 2prenatabs fa Tier 2prenatabs rx Tier 2prenatal 19 Tier 2prenatal ad Tier 2prenatal low iron Tier 2prenatal plus Tier 2prenatal-u Tier 2prenate plus Tier 2relnate dha Tier 2se-care Tier 2se-care conceive Tier 2se-care gesture Tier 2se-natal 19 Tier 2se-natal 90 Tier 2se-natal one Tier 2se-plete dha Tier 2se-tan dha Tier 2setonet Tier 2setonet-ec Tier 2Obstetrical and Gynecological Medications:Prenatal Vitamins (continued)taron a prenatal Tier 2taron ec calcium Tier 2taron-bc Tier 2taron-c dha Tier 2taron-duo ec Tier 2taron-ec cal Tier 2taron-prex prenatal Tier 2tl-assure one Tier 2tl-select Tier 2tri rx Tier 2triadvance Tier 2trimesis rx Tier 2trinatal gt Tier 2trinatal rx 1 Tier 2trinatal ultra Tier 2trinate Tier 2triveen-duo dha Tier 2triveen-one Tier 2triveen-prx rnf Tier 2triveen-ten Tier 2triveen-u Tier 2ultimate ob dha Tier 2ultimatecare advantage Tier 2ultimatecare one 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. 87