' Neomycin-Polymyxin-Dexameth
Ophthalmic Medications
Anti-Inflammatory Agents, Corticosteroids

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Maxitrol generic.gif (400 bytes)
neomycin-polymyxin-dexameth		 3.5-10,000-0.1 mg-unit/g-% Ointment   approved.gif (510 bytes)  

$
Maxitrol generic.gif (400 bytes)
neomycin-polymyxin-dexameth		 3.5-10,000-0.1 mg/mL-unit/mL-% Drops, Suspension   approved.gif (510 bytes)  

$

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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