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

Obstetrical and GynecologicalMedications: Progestin Drugscamila Tier 2errin Tier 2heather Tier 2jolivette Tier 2MAKENATier 4 P Amedroxyprogesterone acetate injection, Tier 2-tabletnora-be Tier 2norethindrone Tier 2norethindrone acetate tablet Tier 2progesterone capsule, -oil 50 mg/ml vl Tier 2progesterone oil 50 mg/ml vl Tier 2Obstetrical and Gynecological Medications:Specialized Ob/Gyn Drugschorionic gonadotropin injection Tier 2leuprolide acetate injection Tier 2LUPRON DEPOT 11.25 MG 3MO KIT Tier 5LUPRON DEPOT 3.75 MG KIT, -7.5 MG Tier 5KIT, -22.5 MG 3MO KIT, --4 MONTHKITLUPRON DEPOT-PED Tier 5methylergonovine maleate Tier 2novarel injection Tier 2oxytocin injection Tier 2SYNAREL Tier 5Q 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. 89