$

product A least expensive

$$

product B more expensive than A

$$$

product C more expensive than B

$$$$

product D more expensive than C

$$$$$

product E more expensive than D

!!!!!

product F is substantially more expensive than A-E

Non-Formulary

product G not part of the formulary

MAC

Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand.

Drug Name (Generic Name)

The BRAND NAME of the drug followed by generic in parentheses or the generic name only.

Drug and/or Generic Comments

Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc.

Strength and/or Dosage

The dosage of a drug covered if not all strengths are formulary as in half-strength program.

Strength and/or Dosage Comments

Comments related to dosage/quantity limitations.

Table of Contents     Index     Policy Information


 

ANTIACNE DRUGS

Relative Cost

MAC

Drug Name (Generic Name)

Drug and/or Generic Comments

Strength and/or Dosage

Strength and/or Dosage Comments

 

 

CLINDAMAX (clindamycin phosphate)

lotion

 

 

clindamycin phosphate (clindamycin phosphate)

gel

 

 

clindamycin phosphate (clindamycin phosphate)

lotion

 

 

clindamycin phosphate (clindamycin phosphate)

soln

 

 

clindamycin phosphate (clindamycin phosphate)

top

 

 

del-aqua-5 (benzoyl peroxide)

 

 

 

DEL-MYCIN (erythromycin base)

 

 

 

erythromycin (erythromycin base)

 

 

 

metronidazole (metronidazole)

cream

 

 

metronidazole (metronidazole)

gel

 

 

metronidazole (metronidazole)

lotion

 

 

tretinoin (tretinoin)

0.025 % cream

 

 

tretinoin (tretinoin)

0.05 % cream

 

 

tretinoin (tretinoin)

0.1 % cream

 

 

tretinoin (tretinoin)

gel

$

 

DESQUAM-X (benzoyl peroxide)

 

$$

 

benzoyl peroxide (benzoyl peroxide)

5 % gel

$$

 

benzoyl peroxide (benzoyl peroxide)

10 % gel

$$

 

benzoyl peroxide (benzoyl peroxide)

soln

$$

 

benzoyl peroxide (benzoyl peroxide)

10 % top

$$

 

CLEOCIN T (clindamycin phosphate)

gel

$$

 

CLEOCIN T (clindamycin phosphate)

lotion

$$

 

CLEOCIN T (clindamycin phosphate)

soln

$$

 

CLEOCIN T (clindamycin phosphate)

top

$$

 

clinda-derm (clindamycin phosphate)

 

$$

 

EMGEL (erythromycin base)

 

$$

 

ethexderm (benzoyl peroxide)

10 % soln, top

$$

 

NUOX (benzoyl peroxide/sulfur)

 

$$

 

sulfatol-m (sulfacetamide/sulfur)

 

$$

 

ZETACET (sulfacetamide/sulfur)

suspensions

$$

 

ZETACET (sulfacetamide/sulfur)

not oral

$$$

 

BENZASHAVE (benzoyl peroxide)

5 % cream

$$$

 

ery (erythromycin base)

 

$$$

 

METROCREAM (metronidazole)

 

$$$$

 

AKNE-MYCIN (erythromycin base)

 

$$$$

 

BENZAC AC (benzoyl peroxide)

gel

$$$$

 

BENZAC AC (benzoyl peroxide)

soln

$$$$

 

BENZAC AC (benzoyl peroxide)

10 % top

$$$$

 

BENZAC W WASH (benzoyl peroxide)

10 % soln, top

$$$$

 

BENZAMYCIN (erythromycin base/benz per)

 

$$$$

 

erythromycin-benzoyl peroxide (erythromycin base/benz per)

 

$$$$

 

FINACEA (azelaic acid)

 

$$$$

 

METROLOTION (metronidazole)

 

$$$$

 

RETIN-A (PAR age > 29) (tretinoin)

 

$$$$

 

sodium sulfacetamide-sulfur (sulfacetamide/sulfur)

lotion

$$$$

 

sulfatol (sulfacetamide sod/sulfur/ure)

lotion

$$$$$

 

BENZACLIN (clindamycin phos/benz per)

 

$$$$$

 

BENZAMYCINPAK (erythromycin base/benz per)

 

$$$$$

 

CLINDAGEL (clindamycin phosphate)

 

$$$$$

 

DIFFERIN (PAR age > 29) (adapalene)

 

$$$$$

 

NORITATE (metronidazole)

 

$$$$$

 

RETIN-A MICRO (PAR age > 29) (tretinoin)

 

$$$$$

 

RETIN-A MICRO PUMP (tretinoin)

 

$$$$$

 

ROSULA (sulfacetamide sod/sulfur/ure)

lotion

Non-Formulary

 

10-1

 

Non-Formulary

 

ATRALIN

 

Non-Formulary

 

AVAR

 

Non-Formulary

 

AVAR

 

Non-Formulary

 

AVAR-E

 

Non-Formulary

 

AVITA

 

Non-Formulary

 

AZELEX

 

Non-Formulary

 

BENPROX

 

Non-Formulary

 

BENZAC AC

 

Non-Formulary

 

BENZAC W WASH

 

Non-Formulary

 

BENZASHAVE

 

Non-Formulary

 

BENZIQ

 

Non-Formulary

 

BENZIQ LS

 

Non-Formulary

 

BENZOYL PEROXIDE

 

Non-Formulary

 

BENZOYL PEROXIDE

 

Non-Formulary

 

BENZOYL PEROXIDE

 

Non-Formulary

 

BENZOYL PEROXIDE

 

Non-Formulary

 

BREVOXYL-4

 

Non-Formulary

 

BREVOXYL-4

 

Non-Formulary

 

BREVOXYL-4

 

Non-Formulary

 

BREVOXYL-8

 

Non-Formulary

 

BREVOXYL-8

 

Non-Formulary

 

BREVOXYL-8

 

Non-Formulary

 

BREZE

 

Non-Formulary

 

CLARIFOAM EF

 

Non-Formulary

 

CLEANSE AND TREAT

 

Non-Formulary

 

CLEANSING WASH

 

Non-Formulary

 

CLENIA

 

Non-Formulary

 

CLENIA

 

Non-Formulary

 

CLEOCIN T

 

Non-Formulary

 

CLINAC BPO

 

Non-Formulary

 

CLINDAMAX

 

Non-Formulary

 

CLINDAMYCIN PHOSPHATE

 

Non-Formulary

 

CLINDAREACH

 

Non-Formulary

 

CLINDETS

 

Non-Formulary

 

DUAC CS

 

Non-Formulary

 

ETHEXDERM

 

Non-Formulary

 

EVOCLIN

 

Non-Formulary

 

INOVA

 

Non-Formulary

 

INOVA 4-1

 

Non-Formulary

 

INOVA 8-2

 

Non-Formulary

 

LAVOCLEN-4

 

Non-Formulary

 

LAVOCLEN-4

 

Non-Formulary

 

LAVOCLEN-4

 

Non-Formulary

 

LAVOCLEN-8

 

Non-Formulary

 

LAVOCLEN-8

 

Non-Formulary

 

LAVOCLEN-8

 

Non-Formulary

 

METROGEL

 

Non-Formulary

 

METROGEL

 

Non-Formulary

 

NEOBENZ MICRO

 

Non-Formulary

 

NEOBENZ MICRO SD

 

Non-Formulary

 

NYDAMAX

 

Non-Formulary

 

OSCION

 

Non-Formulary

 

PERODERM

 

Non-Formulary

 

PLEXION

 

Non-Formulary

 

PLEXION SCT

 

Non-Formulary

 

PRASCION

 

Non-Formulary

 

PRASCION FC

 

Non-Formulary

 

PRASCION RA

 

Non-Formulary

 

PRASCION TS

 

Non-Formulary

 

ROSAC

 

Non-Formulary

 

ROSAC

 

Non-Formulary

 

ROSADERM

 

Non-Formulary

 

ROSANIL

 

Non-Formulary

 

ROSULA

 

Non-Formulary

 

ROSULA CLK

 

Non-Formulary

 

ROSULA NS

 

Non-Formulary

 

SOD SULFACETAMIDE-SULFUR WASH

 

Non-Formulary

 

SODIUM SULFA-SULFUR-MERATAN

 

Non-Formulary

 

SODIUM SULFACETAMIDE

 

Non-Formulary

 

SODIUM SULFACETAMIDE-SULFUR

 

Non-Formulary

 

SODIUM SULFACETAMIDE-SULFUR

 

Non-Formulary

 

SOLUCLENZ RX

 

Non-Formulary

 

SULFATOL

 

Non-Formulary

 

SUPHERA

 

Non-Formulary

 

TOPISULF

 

Non-Formulary

 

TRETIN-X

 

Non-Formulary

 

TRETIN-X

 

Non-Formulary

 

TRIAZ

 

Non-Formulary

 

ZACARE

 

Non-Formulary

 

ZACLIR

 

Non-Formulary

 

ZETACET

 

Non-Formulary

 

ZIANA

 

Non-Formulary

 

ZODERM

 

Non-Formulary

 

ZODERM

 


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Formulary Date: 10/07/2008    Update Date: 10/09/2008    V1.3.0