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Formulary changes

The chart below indicates current and future changes to the formulary used by Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx. These changes may include the removal of a drug from the formulary or a change in copayment or coinsurance level. Changes will be posted 60 days before a change takes place and will remain displayed until the revised formulary is published on an annual basis.

Blue Medicare Rx Standard

Drug Name Change Type Reason for Change Alternative Options Estimated Cost of Alternative
Leukine 500 mcg This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Freamine III 8.5% This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Elspar This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Astramorph This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Azathioprine injection This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Oxandrin 2.5mg and 10mg This drug has been removed from the formulary. This drug manufacturer has discontinued participation in the Coverage Gap Discount Program. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Krystexxa inj 8mg/ml This drug has been removed from the formulary. This drug manufacturer has discontinued participation in the Coverage Gap Discount Program. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.

For the most up to date formulary information please use our drug search.

Blue Medicare HMO/PPO and Blue Medicare Rx Enhanced

Drug Name Change Type Reason for Change Alternative Options Estimated Cost of Alternative
Tyzine 0.1% This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Leukine 500 mcg This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Cimetidine injection This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Tobramycin injection 1.2 mg/ml in saline This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Celestone solution 0.6 mg/5 ml This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Freamine III 8.5% This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Onsolis This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Elspar This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Astramorph This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Azathioprine injection This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Allopurinol injection This drug has been removed from the formulary. This drug has been withdrawn or discontinued by the manufacturer. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Oxandrin 2.5mg and 10mg This drug has been removed from the formulary. This drug manufacturer has discontinued participation in the Coverage Gap Discount Program. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.
Krystexxa inj 8mg/ml This drug has been removed from the formulary. This drug manufacturer has discontinued participation in the Coverage Gap Discount Program. Please ask your doctor to prescribe a drug that is on the formulary (drug list) to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor.

For the most up to date formulary information please use our drug search.

Important Legal Information and Disclaimers

The information on this page is current as of 04/27/14.

Y0079_6246 CMS Approved 10222013

®, SM Mark of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina.