Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Cyclomydril cyclopentolate-phenylephrine Drops     Not Applicable Lacrisert hydroxypropyl cellulose 5 mg Insert     Not Applicable Lastacaft alcaftadine 0.25 % Drops   Not Applicable Latisse bimatoprost Drops with Applicator     Not Applicable Restasis cyclosporine 0.05 % Dropperette   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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