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

Antiinfectives: Sulfonamideserythromycin-sulfisoxazole Tier 2sulfadiazine tablet Tier 2sulfamethoxazole-trimethoprim injectionsulfamethoxazole-trimethoprim oralsusp, -tabletAntiinfectives: TetracyclinesTier 2 H I TTier 2demeclocycline hcl tablet Tier 2doxycycline hyclate capsule, -e.c. cap, Tier 2-e.c. tab, -100 mg tabdoxycycline hyclate injectionTier 2 H I Tdoxycycline monohydrate Tier 2minocycline hcl capsule, -tablet, -tablet Tier 2sustained actiontetracycline hcl capsule Tier 2Antiinfectives: Topical Antibacterial Drugsgentamicin sulfate cream, -0.1% Tier 2ointmentmafenide acetate Tier 2mupirocin cream Tier 2mupirocin oint Tier 2silver sulfadiazine cream Tier 2ssd Tier 2SULFAMYLON Tier 3thermazene Tier 2Antiinfectives: Topical Antifungal-Corticosteroid Comb.clotrimazole-betamethasone Tier 2nystatin-triamcinolone Tier 2Antiinfectives: Urinary Antiinfectivesmethenamine hippurate Tier 2methenamine mandelate e.c. tab, -tablet Tier 2nitrofurantoin macrocrystal capsule Tier 2nitrofurantoin mono-macro Tier 2nitrofurantoin oral susp Tier 2trimethoprim Tier 2urogesic-blue Tier 214Q 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.