Drug Benefit List 2012

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

52:02.00 EENT - ANTIALLERGIC AGENTS

LEVOCABASTINE HCL

0.05% Nasal Spray

02020017 LIVOSTIN JNO

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 Ointment

02200864 CILOXAN ALC

0.3% Ophth Solution

02263130 APO-CIPROFLOX APX

01945270 CILOXAN ALC

02253933 PMS-CIPROFLOXACIN PMS

CIPROFLOXACIN HCL, DEXAMETHASONE

Limited use benefit (prior approval required).

1. for children 16 years old and under
2. for acute otitis media with otorrhea through tympanostomy tubes who require treatment
3. for acute otitis externa in the presence of tympanostomy tube or known perforation of the tympanic membrane

0.3%/0.1% Otic Solution

02252716 CIPRODEX ALC

ERYTHROMYCIN

5mg/g Ointment

02326663 ERYTHROMYCIN STG

5mg/g Ophth Ointment

01912755 PMS-ERYTHROMYCIN PMS

FRAMYCETIN SULFATE

0.5% Ophth Ointment

02224895 SOFRAMYCIN STERILE EYE ERF

0.5% Ophth Solution

02224887 SOFRAMYCIN ERF

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

02229440 SANDOZ-GENTAMICIN SDZ

02229441 SANDOZ-GENTAMICIN OTIC SDZ

GRAMICIDIN, NEOMYCIN SULFATE, POLYMYXIN B SULFATE

0.025mg & 2.5mg & 10,000U/mL Solution

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 MYLAN-BECLO AQ MYL

02238577 NU-BECLOMETHASONE NXP

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 MYLAN-BUDESONIDE AQ MYL

02231923 RHINOCORT AQ AZC

100mcg/Dose Nasal Spray

02230648 MYLAN-BUDESONIDE AQ MYL

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 Spray

02239288 APO-FLUNISOLIDE APX

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

MOMETASONE FUROATE

50mcg Nasal Spray

02238465 NASONEX SCH

PREDNISOLONE ACETATE

0.12% Ophth Suspension

00299405 PRED MILD ALL

01916181 SANDOZ PREDNISOLONE SDZ

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

0.2% & 10% Ophth Suspension

00807788 BLEPHAMIDE ALL

0.5% & 10% Ophth Suspension

02023814 DIOPTIMYD DKT

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

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 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

Limited use benefit (prior approval required).

For:

1. treatment of radiation mucositis and oral ulcerative complications of chemotherapy.
2. use in immunocompromised patients who are at risk of mucosal breakdown.

0.15% Rinse

02239044 APO-BENZYDAMINE APX

02239537 DOM-BENZYDAMINE DPC

02229777 PMS-BENZYDAMINE PMS

02229799 TEVA-BENZYDAMINE TEV

02310422 TEVA-BENZYDAMINE TEV

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 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

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 ALC

0.5% Ophth Gel Solution

02290812 APO-TIMOP APX

02242276 TIMOLOL MALEATE-EX ALC

0.25% Ophth Solution

00755826 APO-TIMOP APX

02238770 DOM-TIMOLOL DPC

00893773 MYLAN-TIMOLOL MYL

02048523 NOVO-TIMOL TEV

02083353 PMS-TIMOLOL PMS

02166712 SANDOZ-TIMOLOL SDZ

0.5% Ophth Solution

00755834 APO-TIMOP APX

02238771 DOM-TIMOLOL DPC

02083345 PMS-TIMOLOL PMS

02166720 SANDOZ-TIMOLOL SDZ

00451207 TIMOPTIC FRS

52:40.12 EENT - CARBONIC ANHYDRASE INHIBITORS

ACETAZOLAMIDE

250mg Tablet

00545015 ACETAZOLAMIDE AAP

BRINZOLAMIDE

1% Ophth Suspension

02238873 AZOPT ALC

BRINZOLAMIDE/TIMOLOL MALEATE

1%/0.5% Ophth Solution

02331624 AZARGA ALC

DORZOLAMIDE HCL

20mg/mL Ophth Solution

02316307 SANDOZ DORZOLAMIDE SDZ

02216205 TRUSOPT FRS

DORZOLAMIDE HCL, TIMOLOL MALEATE

20mg & 5mg/mL Ophth Solution

02299615 APO-DORZO-TIMOP APX

02240113 COSOPT FRS

02344351 SANDOZ SDZ

DORZOLAMIDE/TIMOLOL

METHAZOLAMIDE

50mg Tablet

02245882 METHAZOLAMIDE AAP

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

52:40.28 EENT - PROSTAGLANDIN AGENTS

BIMATOPROST

0.01% Ophth Solution

02324997 LUMIGAN ALL

0.03% Ophth Solution

02245860 LUMIGAN ALL

LATANOPROST

0.005% Ophth Solution

02296527 APO-LATANOPROST APX

02231493 XALATAN PFI

TIMOLOL MALEATE, TRAVOPROST

0.5% & 0.004% Ophth Solution

02278251 DUO TRAV ALC

TRAVOPROST

0.004% Ophth Solution

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

HYDROXYPROPYL CELLULOSE

5mg Ophth Solution

02250624 LACRISERT FRS

HYDROXYPROPYLMETHYLCELLULOSE

0.5% Ophth Solution

00000809 ISOPTO TEARS ALC

00889806 SANDOZ EYELUBE SDZ

1% Ophth Solution

00000817 ISOPTO TEARS ALC

00874965 SANDOZ EYELUBE SDZ

LODOXAMIDE TROMETHAMINE

0.1% Ophth Solution

00893560 ALOMIDE ALC

MACROGOL, PROPYLENE GLYCOL

15% & 20% Nasal Gel

02220806 LUBRICATING NASAL GEL PMS

00551805 SECARIS PMS

15% & 20% Nasal Spray

00732230 LUBRICATING NASAL MIST 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

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

9mg/mL Nasal Solution

80024901 SALINEX DROPS SDZ

80024381 SALINEX NASAL SPRAY SDZ

0.7% Nasal Spray

00810436 OTRIVIN SALINE NVC

5% Ophth Ointment

00750816 MURO-128 BSH

5% Ophth Solution

00750824 MURO-128 BSH

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