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

Ear-Nose-Throat Medications:Drugs Affecting the Earacetasol hc Tier 2acetic acid otic drops Tier 2acetic acid-aluminum Tier 2antipyrine-benzocaine Tier 2aurodex Tier 2auroguard Tier 2CIPRODEX Tier 3fluocinolone acetonide oil Tier 2hydrocortisone-acetic acid Tier 2neomycin-polymyxin-hc suspensions, Tier 2(not oral)neomycin-polymyxin-hydrocort Tier 2ofloxacin otic drops Tier 2Ear-Nose-Throat Medications:Drugs Affecting the Noseazelastine hcl nasal drops/sprays Tier 2 Q C D (60 ml/30)flunisolide 0.025% sprayTier 2 Q C D (50 ml/30)flunisolide 29 mcg-0.025% spr Tier 2fluticasone propionate nasal inhaledsteroidsipratropium 0.03% sprayipratropium 0.06% spraytriamcinolone acetonide nasal inhaledsteroidsTYZINE Tier 3Ear-Nose-Throat Medications: DrugsAffecting the Throat and Mouthcevimeline hcl Tier 2chlorhexidine gluconate dental/mucous Tier 2membrn productsdoxycycline hyclate 20 mg tab Tier 2periogard Tier 2pilocarpine hcl tablet Tier 2triamcinolone acetonide paste Tier 2Tier 2 Q C D (32gm/30)Tier 2 Q C D (60 ml/30)Tier 2 Q C D (15 ml/30)Tier 2 Q C D (33gm/30)Endocrine Medications: Antithyroid Drugsmethimazole tablet Tier 2propylthiouracil tablet Tier 1Q 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. 41