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

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Ophthalmic Medications: OtherOphthalmic Drugs (continued)RESTASIS Tier 3 Q C D (64vials/30)trifluridine ophth drops Tier 2ZIRGAN Tier 4Respiratory Medications: Antihistamineand Decongestant Drugsarbinoxa Tier 2carbinoxamine maleate Tier 2cetirizine hcl Tier 2clemastine fumarate syrup, -tablet Tier 2cyproheptadine hcl syrup, -tablet Tier 2desloratadine Tier 2desloratadine odt Tier 2 Q C D (34/30)dexchlorpheniramine maleate Tier 2diphenhydramine 50 mg/ml vial Tier 2 H I Tdiphenhydramine hcl capsuleTier 2 P Adiphenhydramine hcl elix, -50 mg/ml Tier 2syrngfexofenadine hcl Tier 2levocetirizine dihydrochloride solution Tier 2levocetirizine dihydrochloride tablet Tier 2 Q C D (34/30)palgic Tier 2promethazine hcl injection Tier 2promethazine hcl syrup, -tablet Tier 2 P Apromethazine vcTier 2 P ASEMPREX-D Tier 4zoden pd Tier 292Q 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.
Respiratory Medications: Beta-2 Adrenergic Drugsalbuterol sulfate nebsTier 2 P Aalbuterol sulfate syrup, -tablet, -tablet Tier 2sustained actionARCAPTA NEOHALER Tier 4 Q C D (30/30)BROVANATier 3 P AFORADIL Tier 3 Q C D (120/30)levalbuterol concentrateTier 2 P Ametaproterenol sulfate syrup, -tablet Tier 2PERFOROMISTTier 3 P APROAIR HFA Tier 3 Q C D (25.5gm/30)PROVENTIL HFA Tier 3 Q C D (20.1gm/30)SEREVENT DISKUS Tier 3 Q C D (60doses/30)terbutaline sulfate injection, -tablet Tier 2XOPENEXTier 3 P ARespiratory Medications: Methyl Xanthine Drugsaminophylline 250 mg/10 ml vl Tier 2 H I Taminophylline tablet Tier 2caffeine citrate solution Tier 2dylix Tier 2theochron Tier 2theophylline Tier 2theophylline anhydrous tablet sustainedactionTier 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. 93
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Medicare HMO Blue SM ValueRx (HMO)M
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How do I use the Formulary?There ar
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What do I do before I can talk to m
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Your Medicare Prescription Drug Cos
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Antiinfectives: Antiretrovirals and
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Antiinfectives: Oral Antifungal Dru
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Antiinfectives: Other Antiviral Dru
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Antiinfectives: Sulfonamideserythro
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Antineoplastic/Immunosuppressant Dr
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Antineoplastic/Immunosuppressant Dr
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Autonomic and CNS Medications: Anal
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Autonomic and CNS Medications:Antiv
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Autonomic and CNS Medications: CNSS
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Autonomic and CNS Medications:Other
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Autonomic and CNS Medications: Sele
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Cardiovascular Medications: Beta-Ad
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Cardiovascular Medications: Loop Di
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Cardiovascular Medications: OtherVa
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Dermatological Medications: OralDer
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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 80 and 81: Musculoskeletal Medications: Non-St
Page 82 and 83: Nutrition, Blood Modifiers, Electro
Page 84 and 85: Nutrition, Blood Modifiers, Electro
Page 86 and 87: Obstetrical and Gynecological Medic
Page 88 and 89: Obstetrical and GynecologicalMedica
Page 90 and 91: Obstetrical and Gynecological Medic
Page 92 and 93: Ophthalmic Medications: Antiglaucom
Page 96 and 97: Respiratory Medications: Other Drug
Page 98 and 99: IndexSymbols1ST CHOICE SUPER THINLA
Page 100 and 101: 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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