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

Dermatological Medications: Antiacne Drugsadapalene Tier 2bp 10-1 Tier 2clenia emulsion Tier 2clinda-benzoyl perox 1-5% gel Tier 2clindacin p Tier 2clindamycin phos-benzoyl perox Tier 2clindamycin phosphate foam (noncontraceptive),-gel, -lotion, -soln, top,Tier 2-swabs, applicatorsclindamycin-benzoyl perox gel Tier 2ery Tier 2erythromycin gel, -soln, top, -swabs, Tier 2applicatorserythromycin-benzoyl peroxide Tier 2metronidazole cream, -gel, -lotion Tier 2prascion Tier 2prascion fc Tier 2rosadan cream, -gel Tier 2sodium sulfacetamide pad, medicatedpadsodium sulfacetamide-sulfur cream,-sulf-sulfur cleanser, -sulfacetamidesulfur8-4% suspTier 2Tier 2Dermatological Medications: Antiacne Drugs (continued)sodium sulfacetamide-sulfur foam Tier 2(non-contraceptive), -lotion, -sulfacetsulfurwash, -sulf-sulfur cleanser, -pad,medicated pad, -sod.sulfacet-sulfursuspsulfacetamide sodium-sulfur Tier 2sulfacleanse 8-4 Tier 2tretinoin cream, -gelTier 2 P Avitazol Tier 2Dermatological Medications: Antipsoriasisand Antieczema Drugscalcipotriene Tier 2CALCITRIOL OINT Tier 4DRITHOCREME HP Tier 3selenium sulfide 2.25% shampoo Tier 2selenium sulfide 2.5% lotion Tier 2sodium sulfacetamide solution Tier 2SORIATANE Tier 5SORIATANE CK Tier 5sulfacetamide sodium lotion Tier 2TAZORAC Tier 4ZITHRANOL-RR Tier 4Q 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. 37