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

Ophthalmic Medications: Antiglaucoma Drugsacetazolamide capsule sustained action, Tier 2-tabletacetazolamide sodiumTier 2 H I Tapraclonidine hcl Tier 2betaxolol hcl ophth drops Tier 2brimonidine tartrate Tier 1carteolol hcl Tier 1dorzolamide hcl Tier 2dorzolamide-timolol Tier 2latanoprost Tier 2levobunolol hcl Tier 1methazolamide tablet Tier 2metipranolol Tier 2PHOSPHOLINE IODIDE Tier 3pilocarpine hcl ophth drops Tier 1timolol maleate ophth drops Tier 1TRAVATAN Z Tier 3travoprost ophth drops Tier 2Ophthalmic Medications: OphthalmicAntiinfective/Corticosteroidsneomycin-bacitracin-poly-hc Tier 2neomycin-polymyxin-dexameth Tier 1neomycin-polymyxin-hc ophth drops Tier 2poly-dex Tier 1sulfacetamide-prednisolone Tier 2tobramycin-dexamethasone Tier 2Ophthalmic Medications: OphthalmicCorticosteroid Drugsdexamethasone sodium phosphate Tier 2ophth dropsfluorometholone ophth drops Tier 2PRED MILD Tier 3prednisolone acetate ophth drops Tier 2prednisolone sodium phosphate ophthdropsTier 290Q 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.