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

Dermatological Medications: OralDermatological Drugs8-MOP Tier 3amnesteem Tier 2claravis Tier 2myorisan Tier 2sotret Tier 2Dermatological Medications: Scabicidesacticin Tier 2EURAX Tier 3lindane Tier 2malathion Tier 2permethrin cream Tier 2ULESFIA Tier 4Dermatological Medications: TopicalCorticosteroid Drugsalclometasone dipropionate Tier 2amcinonide Tier 2betamethasone dipropionate cream, Tier 2-gel, -lotion, -ointbetamethasone valerate cream, -lotion, Tier 2-oint, -foamclobetasol emollient Tier 2clobetasol propionate cream, -foam Tier 2(non-contraceptive), -gel, -lotion,-oil,shampoo,cleanser, -oint, -soln, topcormax Tier 2desonide cream, -lotion, -oint Tier 2desoximetasone cream, -gel, -oint Tier 2diflorasone diacetate Tier 2fluocinolone acetonide cream,Tier 2-oil,shampoo,cleanser, -oint, -soln, topfluocinonide cream, -gel, -oint, -soln, top Tier 2fluocinonide emollient Tier 2fluocinonide-e Tier 2fluticasone propionate cream, -lotion, Tier 2-ointhalobetasol propionate Tier 2halonate pac Tier 2hydrocortisone 1% cream Tier 238Q 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.