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

Ophthalmic Medications: OtherOphthalmic Drugs (continued)RESTASIS Tier 3 Q C D (64vials/30)trifluridine ophth drops Tier 2ZIRGAN Tier 4Respiratory Medications: Antihistamineand Decongestant Drugsarbinoxa Tier 2carbinoxamine maleate Tier 2cetirizine hcl Tier 2clemastine fumarate syrup, -tablet Tier 2cyproheptadine hcl syrup, -tablet Tier 2desloratadine Tier 2desloratadine odt Tier 2 Q C D (34/30)dexchlorpheniramine maleate Tier 2diphenhydramine 50 mg/ml vial Tier 2 H I Tdiphenhydramine hcl capsuleTier 2 P Adiphenhydramine hcl elix, -50 mg/ml Tier 2syrngfexofenadine hcl Tier 2levocetirizine dihydrochloride solution Tier 2levocetirizine dihydrochloride tablet Tier 2 Q C D (34/30)palgic Tier 2promethazine hcl injection Tier 2promethazine hcl syrup, -tablet Tier 2 P Apromethazine vcTier 2 P ASEMPREX-D Tier 4zoden pd Tier 292Q 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.