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

Obstetrical and Gynecological Medications:Prenatal Vitamins (continued)ultimatecare one nf Tier 2vemavite-prx 2 Tier 2vena-bal dha Tier 2venatal complete dha Tier 2venatal-fa Tier 2vinacal Tier 2vinate az Tier 2vinate az extra Tier 2vinate c Tier 2vinate calcium Tier 2vinate care Tier 2vinate gt Tier 2vinate ic Tier 2vinate ii Tier 2vinate one Tier 2vinate pn care Tier 2vinate ultra Tier 2vinate-m Tier 2virt-bal dha Tier 2virt-pn Tier 2virt-pn dha Tier 2vitafol-ob Tier 2vitafol-pn Tier 2vitaspire Tier 2Obstetrical and Gynecological Medications:Prenatal Vitamins (continued)vol-nate Tier 2vol-plus Tier 2vol-tab rx Tier 2vp-ch-pnv Tier 2vp-era ob plus Tier 2vp-ggr-b6 Tier 2zatean-ch Tier 2zatean-pn Tier 2zatean-pn dha Tier 2zatean-pn plus Tier 288Q 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.