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

Ophthalmic Medications: OphthalmicTopical Antibacterial Drugsak-poly-bac Tier 2bacitracin oint Tier 2bacitracin-polymyxin Tier 2ciprofloxacin hcl ophth drops Tier 2erythromycin oint Tier 1garamycin ophth drops Tier 1gentak Tier 1gentamicin 3 mg/gm eye oint, -ophth Tier 1dropslevofloxacin ophth drops Tier 2neomycin-bacitracin-polymyxin Tier 2neomycin-polymyxin-gramicidin Tier 2neo-polycin Tier 2ofloxacin ophth drops Tier 2polycin-b Tier 2polymyxin b sul-trimethoprim Tier 1romycin Tier 1sulfacetamide sodium oint Tier 2sulfacetamide sodium ophth drops Tier 1sulfamide Tier 1tobramycin sulfate ophth drops Tier 1Ophthalmic Medications: Other Ophthalmic Drugsak-con Tier 2akorn balanced salt Tier 2altafrin Tier 2atropine care Tier 2atropine sulfate oint, -ophth drops Tier 2azelastine hcl ophth drops Tier 2BOTOXTier 4 P Abromfenac sodium Tier 2cromolyn sodium ophth drops Tier 2cyclopentolate hcl ophth drops Tier 2diclofenac sodium ophth drops Tier 2epinastine hcl Tier 2flurbiprofen sodium Tier 2homatropaire Tier 2homatropine Tier 2ketorolac 0.4% ophth solution Tier 2ketorolac 0.5% ophth solution Tier 2 Q C D (10/30)LACRISERT Tier 3mydral Tier 2NATACYN Tier 3neofrin Tier 2parcaine Tier 2phenylephrine hcl ophth drops Tier 2proparacaine hcl ophth drops Tier 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. 91