Drug Benefit List - April 2009

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:02.00 EENT - ANTIALLERGIC AGENTS

LEVOCABASTINE HCL

0.05% Nasal Spray

02020017 LIVOSTIN JNO

0.05% Ophth Suspension

02131625 LIVOSTIN NVR

SODIUM CROMOGLYCATE

2% Nasal Solution

02231390 APO-CROMOLYN APX

52:04.04 EENT - ANTIBACTERIALS

BACITRACIN ZINC, POLYMYXIN B SULFATE

500IU & 10,000IU/G Ophth Ointment

02160889 OPTIMYXIN SDZ

02239157 POLYSPORIN PFI

CHLORAMPHENICOL

1% Ophth Ointment

02026260 DIOCHLORAM DKT

01980564 PENTAMYCETIN SDZ

0.25% Ophth Solution

01980556 PENTAMYCETIN SDZ

0.5% Ophth Solution

02023857 DIOCHLORAM DKT

02164051 PENTAMYCETIN SDZ

CIPROFLOXACIN HCL

0.3% Ophth Solution

02263130 APO-CIPROFLOX APX

01945270 CILOXAN ALC

02253933 PMS-CIPROFLOXACIN PMS

CIPROFLOXACIN HCL, DEXAMETHASONE

0.3%/0.1% Otic Solution

02252716 CIPRODEX ALC

CIPROFLOXACIN HCL, HYDROCORTISONE

2MG & 10MG/ML Otic Suspension

02240035 CIPRO HC ALC

ERYTHROMYCIN

5MG/G Ophth Ointment

02237041 ERYTHROMYCIN PHH

01912755 PMS-ERYTHROMYCIN PMS

FRAMYCETIN SULFATE

0.5% Ophth Ointment

02224895 SOFRAMYCIN STERILE EYE ERF

0.5% Ophth Solution

02224887 SOFRAMYCIN ERF

FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE

5MG & 0.05MG/G & 0.5MG Ointment

02224631 SOFRACORT EYE/EAR SAC

GENTAMICIN SULFATE

0.3% Ophth Ointment

02023776 DIOGENT DKT

00028339 GARAMYCIN SCH

02230888 SANDOZ-GENTAMICIN SDZ

0.3% Solution

02023822 DIOGENT DKT

00512192 GARAMYCIN SCH

00512184 GARAMYCIN OTIC SCH

02219581 GENTAMICIN SPH

00776521 PMS-GENTAMICIN PMS

02230889 PMS-GENTAMICIN OTIC PMS

02229440 SANDOZ-GENTAMICIN SDZ

02229441 SANDOZ-GENTAMICIN OTIC SDZ

GRAMICIDIN, NEOMYCIN SULFATE, POLYMYXIN B SULFATE

0.025MG & 2.5MG & 10,000U/ML Solution

00694371 NEOSPORIN EYE/EAR GSK

00807435 OPTIMYXIN PLUS EYE/EAR SDZ

GRAMICIDIN, POLYMYXIN B SULFATE

0.025MG & 10,000U/ML Solution

00701785 OPTIMYXIN EYE/EAR SDZ

02239156 POLYSPORIN EYE/EAR WLA

OFLOXACIN

0.3% Ophth Solution

02248398 APO-OFLOXACIN APX

02143291 OCUFLOX ALL

02252570 PMS-OFLOXACIN PMS

POLYMYXIN B SULFATE, TRIMETHOPRIM SULFATE

10,000U & 1MG/ML Ophth Solution

02240363 PMS-POLYTRIMETHOPRIM PMS

02011956 POLYTRIM ALL

SULFACETAMIDE SODIUM

10% Ophth Solution

02023830 DIOSULF DKT

TOBRAMYCIN

0.3% Ophth Ointment

00614254 TOBREX ALC

0.3% Ophth Solution

02239577 PMS-TOBRAMYCIN PMS

02241755 SANDOZ-TOBRAMYCIN SDZ

00513962 TOBREX ALC

52:04.20 EENT - ANTIVIRALS

TRIFLURIDINE

1% Ophth Solution

02248529 SANDOZ-TRIFLURIDINE SDZ

00687456 VIROPTIC GSK

52:08.08 EENT - CORTICOSTEROIDS

BECLOMETHASONE DIPROPIONATE

50MCG/DOSE Nasal Spray

02238796 APO-BECLOMETHASONE APX

02172712 GEN-BECLO AQ GEN

02237379 MED-BECLOMETHASONE AQ MEC

02238577 NU-BECLOMETHASONE NXP

00872318 RATIO-BECLOMETHASONE AQ RPH

02228300 RIVANASE AQ RIV

BETAMETHASONE SODIUM PHOSPHATE, GENTAMICIN SULFATE

0.1% & 0.3% Ophth Ointment

00586706 GARASONE SCH

0.1% & 0.3% Solution

00682217 GARASONE OPHTH/OTIC SCH

02244999 SANDOZ-PENTASONE OPHTH/OTIC SDZ

BUDESONIDE

64MCG/DOSE Nasal Spray

02241003 GEN-BUDESONIDE AQ GEN

02231923 RHINOCORT AQ AZC

100MCG/DOSE Nasal Spray

02230648 GEN-BUDESONIDE AQ GEN

100MCG/DOSE Powder

02035324 RHINOCORT TURBUHALER AZC

DEXAMETHASONE

0.1% Ophth Ointment

00042579 MAXIDEX ALC

0.1% Ophth Solution

02023865 DIODEX DKT

00785261 PMS-DEXAMETHASONE PMS

00739839 SANDOZ-DEXAMETHASONE SDZ

0.1% Ophth Suspension

00042560 MAXIDEX ALC

DEXAMETHASONE, TOBRAMYCIN

0.1% & 0.3% Ophth Ointment

00778915 TOBRADEX ALC

0.1% & 0.3% Ophth Suspension

00778907 TOBRADEX ALC

FLUMETHASONE PIVALATE, CLIOQUINOL

0.02% & 1% Otic Solution

00074454 LOCACORTEN VIOFORM PAL

FLUNISOLIDE

0.025% Nasal Solution

00878790 RATIO-FLUNISOLIDE RPH

02162687 RHINALAR IVX

0.025% Nasal Spray

02239288 APO-FLUNISOLIDE APX

01927167 PMS-FLUNISOLIDE PMS

FLUOROMETHOLONE

0.1% Ophth Solution

02238568 PMS-FLUOROMETHOLONE PMS

0.1% Ophth Suspension

00247855 FML ALL

0.25% Ophth Suspension

00707511 FML FORTE ALL

FLUOROMETHOLONE ACETATE

0.1% Ophth Solution

00756784 FLAREX ALC

FLUTICASONE PROPIONATE

50MCG/DOSE Nasal Spray

02294745 APO-FLUTICASONE APX

02213672 FLONASE GSK

02296071 RATIO-FLUTICASONE RPH

FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE

5MG & 0.05MG/ML & 0.5MG Ophth/Otic Solution

02247920 SANDOZ-OPTICORT SDZ

02224623 SOFRACORT EYE/EAR SAC

HYDROCORTISONE, NEOMYCIN SULFATE, POLYMYXIN B SULFATE

10MG & 3.5MG & 10,000U/ML Otic Solution

01912828 CORTISPORIN GSK

02230386 SANDOZ-CORTIMYXIN SDZ

10MG & 5MG & 10,000U/ML Suspension

02025736 CORTISPORIN EYE/EAR GSK

MOMETASONE FUROATE

50MCG Nasal Spray

02238465 NASONEX SCH

PREDNISOLONE ACETATE

0.12% Ophth Suspension

00299405 PRED MILD ALL

01916181 SANDOZ-PREDNISOLONE SIL

1% Ophth Suspension

02023768 DIOPRED DKT

00301175 PRED FORTE ALL

00700401 RATIO-PREDNISOLONE RPH

01916203 SANDOZ-PREDNISOLONE SDZ

PREDNISOLONE ACETATE, SULFACETAMIDE SODIUM

0.2% & 10% Ophth Ointment

00307246 BLEPHAMIDE ALL

0.5% & 10% Ophth Solution

02023814 DIOPTIMYD DKT

0.2% & 10% Ophth Suspension

00807788 BLEPHAMIDE ALL

PREDNISOLONE SODIUM PHOSPHATE

0.5% Ophth Solution

02148498 PREDNISOLONE CUV

TRIAMCINOLONE ACETONIDE

55MCG/DOSE Nasal Spray

02213834 NASACORT AQ SAC

52:08.20 EENT - NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

DICLOFENAC SODIUM

0.1% Ophth Solution

01940414 VOLTAREN NVR

FLURBIPROFEN SODIUM

0.03% Ophth Solution

00766046 OCUFEN ALL

KETOROLAC TROMETHAMINE

0.5% Ophth Solution

01968300 ACULAR ALL

02245821 APO-KETOROLAC APX

02247461 RATIO-KETOROLAC RPH

52:20.00 EENT - MIOTICS

CARBACHOL

1.5% Ophth Solution

00000655 ISOPTO CARBACHOL ALC

52:24.00 EENT - MYDRIATICS

ATROPINE SULFATE

1% Ophth Ointment

00252484 ATROPINE ALC

1% Ophth Solution

02023695 ATROPINE DKT

02148358 ATROPINE SULPHATE MINIMS NVR

00035017 ISOPTO ATROPINE ALC

CYCLOPENTOLATE HCL

0.5% Ophth Solution

02148331 CYCLOPENTOLATE NVR

1% Ophth Solution

00252506 CYCLOGYL ALC

02148382 CYCLOPENTOLATE MINIMS NVR

02023644 DIOPENTOLATE DKT

DIPIVEFRIN HCL

0.1% Ophth Solution

02242232 APO-DIPIVEFRIN APX

02237868 PMS-DIPIVEFRIN PMS

HOMATROPINE HBR

2% Ophth Solution

00000779 ISOPTO HOMATROPINE ALC

5% Ophth Solution

00000787 ISOPTO HOMATROPINE ALC

52:28.00 EENT - MOUTHWASHES AND GARGLES

BENZYDAMINE HCL

0.15% Rinse

02239044 APO-BENZYDAMINE APX

02239537 DOM-BENZYDAMINE DPC

02229799 NOVO-BENZYDAMINE NOP

02229777 PMS-BENZYDAMINE PMS

02230170 RATIO-BENZYDAMINE RPH

01966065 TANTUM MMH

CHLORHEXIDINE GLUCONATE

0.12% Rinse

02240433 PERICHLOR PMS

02237452 PERIDEX MMH

02207796 PERIOGARD COP

52:32.00 EENT - VASOCONSTRICTORS

ANTAZOLINE PHOSPHATE, NAPHAZOLINE HCL

0.5% & 0.05% Ophth Solution

00433519 ALBALON A ALL

NAPHAZOLINE HCL

0.1% Ophth Solution

00001147 ALBALON ALL

00390283 NAPHCON FORTE ALC

PHENYLEPHRINE HCL

0.12% Ophth Solution

00395161 PREFRIN LIQUIFILM ALL

2.5% Ophth Solution

02027100 DIONEPHRINE DKT

00465763 MYDFRIN ALC

02148447 PHENYLEPHRINE MINIMS NVR

10% Ophth Solution

02148455 PHENYLEPHRINE NVR

52:40.04 EENT - ALPHA-ADRENERGIC AGONISTS

BRIMONIDINE TARTRATE

0.2% Ophth Solution

02236876 ALPHAGAN ALL

02260077 APO-BRIMONIDINE APX

02246284 PMS-BRIMONIDINE PMS

02243026 RATIO-BRIMONIDINE RPH

02305429 SANDOZ BRIMONIDINE 0.2% OP SOL SDZ

BRIMONIDINE TARTRATE (ALPHAGAN P)

Limited use benefit (prior approval required).

For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride.

0.15% Ophth Solution

02248151 ALPHAGAN P ALL

02301334 APO-BRIMONIDINE P APX

BRIMONIDINE TARTRATE, TIMOLOL MALEATE

0.2% & 0.5% Ophth Solution

02248347 COMBIGAN ALL

52:40.08 EENT - BETA-ADRENERGIC BLOCKING AGENTS

BETAXOLOL HCL

0.5% Ophth Solution

02235971 SANDOZ-BETAXOLOL SDZ

0.25% Ophth Suspension

01908448 BETOPTIC S ALC

LEVOBUNOLOL HCL

0.25% Ophth Solution

02241575 APO-LEVOBUNOLOL APX

00751286 BETAGAN ALL

02031159 RATIO-LEVOBUNOLOL RPH

02241715 SANDOZ-LEVOBUNOLOL SDZ

0.5% Ophth Solution

00637661 BETAGAN ALL

02237991 PMS-LEVOBUNOLOL PMS

02031167 RATIO-LEVOBUNOLOL RPH

02241716 SANDOZ-LEVOBUNOLOL SDZ

TIMOLOL MALEATE

0.25% Long Acting Ophth Solution

02171880 TIMOPTIC-XE FRS

0.5% Long Acting Ophth Solution

02171899 TIMOPTIC-XE FRS

0.25% Ophth Gel Solution

02242275 TIMOLOL MALEATE-EX PMS

0.5% Ophth Gel Solution

02290812 APO-TIMOP APX

02242276 TIMOLOL MALEATE-EX PMS

0.25% Ophth Solution

00755826 APO-TIMOP APX

00893773 GEN-TIMOLOL GEN

02084317 MED-TIMOLOL MEC

02048523 NOVO-TIMOL NOP

02083353 PMS-TIMOLOL PMS

02240248 RATIO-TIMOLOL RPH

02166712 SANDOZ-TIMOLOL SDZ

0.5% Ophth Solution

00755834 APO-TIMOP APX

00893781 GEN-TIMOLOL GEN

02084325 MED-TIMOLOL MEC

02083345 PMS-TIMOLOL PMS

00451207 TIMOPTIC FRS

52:40.12 EENT - CARBONIC ANHYDRASE INHIBITORS

ACETAZOLAMIDE

250MG Tablet

00545015 APO-ACETAZOLAMIDE APX

BRINZOLAMIDE

1% Ophth Suspension

02238873 AZOPT ALC

DORZOLAMIDE HCL

2% Ophth Solution

02216205 TRUSOPT FRS

DORZOLAMIDE HCL, TIMOLOL MALEATE

20MG & 5MG/ML Ophth Solution

02240113 COSOPT FRS

METHAZOLAMIDE

50MG Tablet

02245882 APO-METHAZOLAMIDE APX

52:40.20 EENT - MIOTICS

CARBACHOL

0.01% Ophth Solution

00042544 MIOSTAT ALC

3% Ophth Solution

00000663 ISOPTO CARBACHOL ALC

PILOCARPINE HCL

4% Ophth Gel

00575240 PILOPINE HS ALC

1% Ophth Solution

00000841 ISOPTO CARPINE ALC

02229556 PILOCARPINE SCN

2% Ophth Solution

00000868 ISOPTO CARPINE ALC

4% Ophth Solution

02023733 DIOCARPINE DKT

00000884 ISOPTO CARPINE ALC

PILOCARPINE NITRATE

2% Ophth Solution

02148463 PILOCARPINE NITRATE MINIMS NVR

4% Ophth Solution

02148471 PILOCARPINE NITRATE MINIMS NVR

52:40.28 EENT - PROSTAGLANDIN AGENTS

BIMATOPROST

0.03% Ophth Solution

02245860 LUMIGAN ALL

LATANOPROST

0.005% Ophth Solution

02231493 XALATAN PFI

TIMOLOL MALEATE, TRAVOPROST

0.5% & 0.004% Ophth Solution

02278251 DUO TRAV ALC

TRAVOPROST

0.004% Ophth Solution

02244896 TRAVATAN ALC

02318008 TRAVATAN Z ALC

52:92.00 MISCELLANEOUS EENT DRUGS

ALUMINUM ACETATE, BENZETHONIUM CHLORIDE

0.5% & 0.03% Otic Solution

00674222 BURO-SOL STI

APRACLONIDINE HCL

0.5% Ophth Solution

02076306 IOPIDINE ALC

DEXTRAN 70, HYDROXYPROPYLMETHYLCELLULOSE

0.1% & 0.3% Ophth Solution

00390291 TEARS NATURALE ALC

01943308 TEARS NATURALE FREE ALC

00743445 TEARS NATURALE II ALC

DIPIVEFRIN HCL, LEVOBUNOLOL HCL

0.1% & 0.5% Ophth Solution

02209071 PROBETA ALL

HYDROXYPROPYLMETHYLCELLULOSE

0.5% Ophth Solution

00000809 ISOPTO TEARS ALC

00889806 SANDOZ EYELUBE SDZ

1% Ophth Solution

00000817 ISOPTO TEARS ALC

00874965 SANDOZ EYELUBE SDZ

IPRATROPIUM BROMIDE

0.03% Nasal Spray

02163705 ATROVENT BOE

0.06% Nasal Spray

02163713 ATROVENT BOE

LODOXAMIDE TROMETHAMINE

0.1% Ophth Solution

00893560 ALOMIDE ALC

MACROGOL, PROPYLENE GLYCOL

15% & 20% Nasal Gel

02220806 PMS-RHINARIS PMS

00551805 SECARIS PMS

15% & 20% Nasal Spray

00732230 RHINARIS PMS

MINERAL OIL, PETROLATUM

80% & 20% Ophth Ointment

02125706 DUOLUBE BSH

MINERAL OIL, WHITE PETROLATUM

55.5% & 42.5% Ophth Ointment

00210889 LACRI LUBE ALL

PETROLATUM, LANOLIN, MINERAL OIL

94% & 3% & 3% Ophth Ointment

02082519 TEARS NATURALE P.M. ALC

PETROLATUM, PETROLATUM LIQUID

85% & 15% Ophth Ointment

02133288 HYPOTEARS NVR

POLYVINYL ALCOHOL

1% Ophth Solution

02133253 HYPOTEARS NVR

1.4% Ophth Solution

02229570 ARTIFICIAL TEARS PMS

00045616 LIQUIFILM TEARS ALL

00579408 TEARS PLUS ALL

POLYVINYL ALCOHOL, POVIDONE

1.4% & 0.6% Ophth Solution

02229632 ARTIFICIAL TEARS EXTRA PMS

SODIUM CARBOXYMETHYL CELLULOSE

0.5% Ophth Solution

02049260 REFRESH PLUS ALL

1% Ophth Solution

00870153 CELLUVISC ALL

10MG/ML Ophth Solution

02244650 REFRESH LIQUIGEL ALL

0.5% Ophth Solution (Multi-Dose)

02231008 REFRESH TEARS ALL

SODIUM CHLORIDE

0.7% Nasal Solution

00857777 OTRIVIN SALINE NVC

0.7% Nasal Spray

00810436 OTRIVIN SALINE NVC

0.9% Nasal Spray

02231476 HYDRA SENSE (ISOTONIC, STERILE SEAWATER) SCH

02030861 NASAL SALINE PDD

00489530 SALINEX SDZ

5% Ophth Ointment

00750816 MURO-128 BSH

5% Ophth Solution

00750824 MURO-128 BSH

02245735 SANDOZ-SODIUM CHLORIDE SDZ

TIMOLOL MALEATE

0.25% Ophth Solution

02238770 DOM-TIMOLOL DPC

0.5% Ophth Solution

02238771 DOM-TIMOLOL DPC

02166720 SANDOZ-TIMOLOL SDZ

VERTEPORFIN

Limited use benefit (prior approval required).

For treatment of age related macular degeneration for patients with this diagnosis who are being treated by a certified ophthalmologist.

15MG/VIAL Injection

02242367 VISUDYNE QLT