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

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Your Medicare Prescription Drug CostsMedicare HMO Blue ValueRxMedicare HMO Blue PlusRxDrug CoverageYou pay:Annual DeductibleInitial Coverage$0 for Tiers 1 and 2$220 for Tiers 3, 4 and 5$0 for Tiers 1 and 2$150 for Tiers 3, 4 & 5You pay the following until total yearly drug costs reach $2,970 for:30-day supplyat a networkretail pharmacy90-day supplyat networkretail pharmacy 190-day supplythrough networkmail-order pharmacy30-day supplyat a networkretail pharmacy90-day supplyat networkretail pharmacy 190-day supplythrough networkmail-order pharmacyTier 1: Preferred Generic drugs $6 $18 $6 $6 $18 $6Tier 2: Non-Preferred Generic drugs $12 $36 $24 $12 $36 $24Tier 3: Preferred Brand drugs $45 $135 $90 $45 $135 $90Tier 4: Non-Preferred Brand drugs $90 $270 $180 $90 $270 $180Tier 5: Specialty Tier drugs 27% 27% 27% 30% 30% 30%Coverage GapAfter your total yearly drug costs reach $2,970 and untilyour yearly out-of-pocket drug costs reach $4,750 you pay no more than:79% of the cost of generic drugs and 47.5% of the negotiated price(excluding dispensing and vaccine administration fees) for brand name drugs.Catastrophic CoverageAfter your yearly out-of-pocket drug costs reach $4,750 you pay the greater of:Generic (including brand drugstreated as generic)$2.65 or 5%All other drugs 2 $6.60 or 5%1. Available at retail pharmacies that have agreed to allow members to fill 90-daysupplies of their prescriptions.2. All covered drugs are on the formulary/drug list.6
Anesthetics: Local Anestheticsbupivacaine hcl injection Tier 2bupivacaine hcl-epinephrine Tier 2bupivacaine-dextrose Tier 2chloroprocaine hcl Tier 2droperidol injection Tier 2ketamine hcl Tier 2lidocaine hcl injectionTier 2 H I Tlidocaine hcl-dextroseTier 2 H I Tlidocaine hcl-epinephrine Tier 2Anesthetics: Topical Anestheticslidocaine hcl cream, -oint, -dental, -gel, Tier 2-lotionlidocaine hcl viscous Tier 2lidocaine-prilocaine Tier 2LIDODERM Tier 3pre-attached lta kit Tier 2Antiinfectives: AminoglycosidesamikacinTier 2 H I TgentamicinTier 2 H I Tiso gentamicinTier 2 H I Tkanamycin sulfate injectionTier 2 H I Tneomycin sulfate tablet Tier 2TOBITier 5 P ATOBI PODHALER Tier 5tobramycinTier 2 H I TAntiinfectives: AnthelminticsALBENZA Tier 3STROMECTOL Tier 3Antiinfectives: Specialized IndicationsDAPSONE TABLET Tier 3metronidazole capsule, -tablet Tier 2metronidazole injectionTier 2 H I Tparomomycin sulfate capsule Tier 2tinidazole tablet 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. 7
Page 1: Medicare HMO Blue SM ValueRx (HMO)M
Page 4 and 5: How do I use the Formulary?There ar
Page 6 and 7: What do I do before I can talk to m
Page 10 and 11: Antiinfectives: Antiretrovirals and
Page 12 and 13: Antiinfectives: Oral Antifungal Dru
Page 14 and 15: Antiinfectives: Other Antiviral Dru
Page 16 and 17: Antiinfectives: Sulfonamideserythro
Page 18 and 19: Antineoplastic/Immunosuppressant Dr
Page 20 and 21: Antineoplastic/Immunosuppressant Dr
Page 22 and 23: Autonomic and CNS Medications: Anal
Page 24: Autonomic and CNS Medications:Antiv
Page 28 and 29: 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 56 and 57: Medical (Miscellaneous) Supplies:Di
Page 58 and 59:
Medical (Miscellaneous) Supplies:Di
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Page 80 and 81:
Musculoskeletal Medications: Non-St
Page 82 and 83:
Nutrition, Blood Modifiers, Electro
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Nutrition, Blood Modifiers, Electro
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Obstetrical and Gynecological Medic
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Obstetrical and GynecologicalMedica
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Obstetrical and Gynecological Medic
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Ophthalmic Medications: Antiglaucom
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Ophthalmic Medications: OtherOphtha
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Respiratory Medications: Other Drug
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IndexSymbols1ST CHOICE SUPER THINLA
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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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