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

Respiratory Medications: Other Respiratory DrugsARALAST NP 500 MG VIAL Tier 5 P A, L P A, H I T,N M OGLASSIA Tier 5 P A, L P A, H I T,N M OKALYDECO TABLETTier 5 P APROLASTIN CTier 5 P A, H I T, N M OPULMOZYMETier 5 P AUrological Medications: AnticholinergicAntispasmodicsDETROLTier 4 S TDETROL LATier 4 S TENABLEXTier 3 S Tflavoxate hcl Tier 2oxybutynin chloride er Tier 2oxybutynin chloride syrup, -tablet Tier 2tolterodine tartrate Tier 2trospium chloride Tier 2Urological Medications: Other Genitourinary Productsacetic acid 0.25% irrig soln Tier 2alfuzosin hcl Tier 2bethanechol chloride tablet Tier 2CYSTADANETier 3 N M Ocytra-3 Tier 2cytra-k Tier 2finasteride 5mg tablet Tier 2glycine Tier 2K-PHOS M.F. Tier 3K-PHOS NO.2 Tier 3K-PHOS ORIGINAL Tier 3neomycin-polymyxin b Tier 2potassium citrate TABLET SUSTAINED Tier 2ACTIONpotassium citrate-citric acid Tier 2SORBITOL Tier 3tamsulosin hcl Tier 2taron-crystals Tier 2tricitrates 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. 95