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

Dermatological Medications: TopicalCorticosteroid Drugs (continued)hydrocortisone 1% cream, -plus 1% Tier 2cream, -2.5% cream, -lotion, -oint, -solhydrocortisone butyrate Tier 2hydrocortisone valerate Tier 2lidocaine-hydrocortisone cream, -kit Tier 2mometasone furoate Tier 2prednicarbate Tier 2triamcinolone acetonide cream, -lotion, Tier 2-ointtrianex Tier 2triderm Tier 2Dermatological Medications: TopicalDermatological Drugsammonium lactate cream, -lotion Tier 2CAMPHOR Tier 2CONDYLOX GEL Tier 3ELIDELTier 4 P AFLUOROPLEX Tier 3fluorouracil cream, -soln, top Tier 2hpr plus Tier 2hypercare Tier 2imiquimod cream Tier 2methyl salicylate Tier 2METVIXIA Tier 4PANRETIN Tier 5PICATO Tier 4podofilox Tier 2PROTOPICTier 4 P Aprudoxin Tier 2REGRANEX Tier 3remeven Tier 2salicylic acid soln, top Tier 2SANTYL Tier 3SOLARAZE Tier 3u-kera e urea emollient Tier 2urea 39% cream, -45% lotion, -40%nail film suspTier 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. 39