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

Respiratory Medications: Other Drugs for Asthmaacetylcysteine nebsTier 2 P AADVAIR DISKUS Tier 4 Q C D (60doses/30), P AADVAIR HFA Tier 4 Q C D (24gm/30), P AATROVENT HFA Tier 3 Q C D (38.7gm/30)budesonide nebs Tier 2 Q C D (140/30),P ACOMBIVENT Tier 3 Q C D (29.4gm/30)COMBIVENT RESPIMATTier 3 Q C D (8 gm/30)cromolyn sodium nebsTier 2 P Acromolyn sodium solution Tier 2DULERA Tier 3 Q C D (26gm/30), P Aepinephrine 0.1 mg/ml syringe, -1 mg/ Tier 2ml ampul, -1 mg/ml vialEPINEPHRINE 0.15 MG AUTO-INJCT, Tier 4-0.3 MG AUTO-INJECTEPIPEN Tier 3EPIPEN JR Tier 3FLOVENT DISKUS Tier 3 Q C D (120doses/30)FLOVENT HFA 110 MCG INHALER Tier 3 Q C D (12gm/30)FLOVENT HFA 220 MCG INHALER Tier 3 Q C D (36gm/30)Respiratory Medications: OtherDrugs for Asthma (continued)FLOVENT HFA 44 MCG INHALER Tier 3 Q C D (21.2gm/30)HYPER-SAL M Bipratropium bromide nebsTier 2 P Aipratropium-albuterolTier 2 P Amontelukast Tier 2QVAR Tier 3 Q C D (26.1/30)sodium chloride nebs M BSPIRIVA Tier 3 Q C D (60capsules/30)SYMBICORT 160-4.5 MCG INHALER Tier 3 Q C D (20.4/30),P ASYMBICORT 80-4.5 MCG INHALER Tier 3 Q C D (13.8/30),P ATUDORZA Tier 3XOLAIRTier 5 P A, L P A, N M OzafirlukastTier 2 P A94Q 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.