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Drug Benefit List 2012

class 86:00

class 80:00

Pharmacologic-Therapeutic Classification List of Drugs

84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:04.04 SMMA - ANTIBIOTICS

BACITRACIN

500IU Ointment: 00584908 BACITIN PMS

BACITRACIN ZINC, POLYMYXIN B SULFATE

500IU & 10,000IU Ointment: 02237227 POLYSPORIN ANTIBIOTIC PFI

CLINDAMYCIN PHOSPHATE

1% Solution: 00582301 DALACIN T PFI; 02266938 TARO-CLINDAMYCIN TAR

1% Solution: 02243659 CLINDA-T VAO

2% Vaginal Cream: 02060604 DALACIN PMJ

ERYTHROMYCIN, TRETINOIN

4% & 0.01% Gel: 02015994 STIEVAMYCIN MILD STI

4% & 0.025% Gel: 01905112 STIEVAMYCIN STI

4% & 0.05% Gel: 01945262 STIEVAMYCIN FORTE STI

FUSIDATE SODIUM

2% Ointment: 00586676 FUCIDIN LEO

FUSIDIC ACID

2% Cream: 00586668 FUCIDIN LEO

GRAMICIDIN, POLYMYXIN B SULFATE

0.25mg & 10,000IU Cream: 02230844 POLYSPORIN ANTIBIOTIC PFI

MUPIROCIN

2% Cream: 02239757 BACTROBAN GSK

2% Ointment: 01916947 BACTROBAN GSK; 02279983 TARO-MUPIROCIN TAR

POLYMYXIN B SULFATE, BACITRACIN

10,000IU & 500IU Ointment: 00876488 BACIMYXIN PMS; 00621366 BIODERM ODN; 01942921 POLYTOPIC SDZ

84:04.06 SMMA - ANTIVIRALS

ACYCLOVIR

5% Cream: 02039524 ZOVIRAX GSK

5% Ointment: 00569771 ZOVIRAX GSK

IDOXURIDINE

0.1% Topical Solution: 02237187 SANDOZ-IDOXURIDINE SDZ

84:04.08 SMMA - ANTIFUNGALS

CLOTRIMAZOLE

1% Cream: 02150867 CANESTEN BCD; 00812382 CLOTRIMADERM TAR

1% & 200mg Cream & Vaginal Suppository: 02264099 CANESTEN 3 COMFORT COMBI PAK BCD

1% & 500mg Cream & Vaginal Suppository: 02264102 CANESTEN 1 COMFORT COMBI PAK BCD

1% Vaginal Cream: 02150891 CANESTEN BCD; 00812366 CLOTRIMADERM TAR

2% Vaginal Cream: 02150905 CANESTEN BCD; 00812374 CLOTRIMADERM TAR

KETOCONAZOLE

2% Cream: 02245662 KETODERM TAR

2% Shampoo: 02182920 NIZORAL MCL

MICONAZOLE NITRATE

2% Cream: 02085852 MICATIN MCL; 02126567 MONISTAT-DERM MCL

2% & 100mg Cream & Vaginal Suppository: 02126257 MONISTAT 7 DUAL PAK MCL

2% & 400mg Cream & Vaginal Suppository: 02126249 MONISTAT 3 DUAL PAK MCL

2% Vaginal Cream: 02231106 MICOZOLE TAR; 02084309 MONISTAT 7 MCL

400mg Vaginal Suppository: 02171775 MICONAZOLE VTH; 02126605 MONISTAT 3 MCL

NYSTATIN

100,000IU Cream: 00716871 NYADERM TAR; 02194236 RATIO-NYSTATIN RPH

100,000IU Ointment: 02194228 RATIO-NYSTATIN RPH

25,000IU Vaginal Cream: 00716901 NYADERM TAR

100,000IU Vaginal Cream: 02194163 RATIO-NYSTATIN RPH

TERBINAFINE HCL

1% Cream: 02031094 LAMISIL NVR

TERCONAZOLE

0.4% Vaginal Cream: 02247651 TARO-TERCONAZOLE TAR; 00894729 TERAZOL 7 JNO

0.8% & 80mg Vaginal Cream & Vaginal Suppository: 02130874 TERAZOL 3 DUAL PAK JNO

TOLNAFTATE

1% Cream: 00576034 TINACTIN SCH

1% Powder: 01919245 ATHLETES FOOT SPRAY SCH; 00576042 TINACTIN SCH; 02029081 ZEASORB AF STI

1% Spray: 00576050 TINACTIN AEROSOL SCH

84:04.12 SMMA - SCABICIDES AND PEDICULICIDES

CROTAMITON

10% Cream: 00623377 EURAX NVC

ISOPROPYL MYRISTATE

50% Solution: 02279592 RESULTZ NYC

LINDANE

1% Lotion: 00703591 PMS-LINDANE PMS

1% Shampoo: 00430617 HEXIT ODN; 00703605 PMS-LINDANE PMS

PERMETHRIN

5% Cream: 02219905 NIX DERMAL GSK

5% Lotion: 02231348 KWELLADA-P GSK

1% Rinse: 02231480 KWELLADA-P GSK; 00771368 NIX WLA

PIPERONYL BUTOXIDE, PYRETHRINS

3% & 0.3% Shampoo: 02125447 R & C GSK

84:04.92 SMMA - MISCELLANEOUS LOCAL ANTI-INFECTIVES

BENZOYL PEROXIDE

5% Gel (Alcohol Base): 02162113 BENZAGEL NVC; 00263702 PANOXYL-5 STI

10% Gel (Alcohol Base): 00263699 PANOXYL-10 STI

20% Gel (Alcohol Base): 00373036 PANOXYL-20 STI

2.5% Gel (Water Base): 02214830 PANOXYL AQUAGEL STI

4% Gel (Water Base): 01975382 SOLUGEL STI

5% Gel (Water Base): 00899453 BENZAC AC GAC; 01925180 BENZAC W5 GAC *; 02214849 PANOXYL AQUAGEL STI

8% Gel (Water Base): 02019825 SOLUGEL STI

10% Gel (Water Base): 01912437 BENZAC AC GAC

2.5% Lotion: 02046539 OXY 5 GSK

5% Lotion: 02166607 BENZAGEL 5 NVC; 00374326 OXYDERM VAE

10% Lotion: 00370568 BENOXYL STI

5% Soap: 00483184 PANOXYL-5 STI

10% Soap: 00527661 PANOXYL-10 STI

5% Wash: 00896276 BENZAC W GAC; 02162121 BENZAGEL NVC; 02214857 PANOXYL STI

10% Wash: 01925199 BENZAC W GAC

CHLORHEXIDINE ACETATE

0.5% Dressing: 00433497 BACTIGRAS SNE

CHLORHEXIDINE GLUCONATE

2% Liquid: 01938991 STANHEXIDINE OMG

4% Liquid: 01938983 STANHEXIDINE OMG

HYDROGEN PEROXIDE

3% Liquid: 00167703 HYDROGEN PEROXIDE 10V RWP; 00485721 HYDROGEN PEROXIDE 10V RPH *; 00579297 PEROXIDE D'HYDROGENE ATL

METRONIDAZOLE

0.75% Cream: 02226839 METROCREAM GAC

1% Cream: 02156091 NORITATE SAC

0.75% Gel: 02092832 METROGEL GAC

1% Gel: 02297809 METROGEL GAC

0.75% Lotion: 02248206 METROLOTION GAC

10% Vaginal Cream: 01926861 FLAGYL SAC

0.75% Vaginal Gel: 02125226 NIDAGEL MMH

METRONIDAZOLE, AVOBENZONE, OCTINOXATE

1% & 2% & 7.5% Cream: 02242919 ROSASOL STI

METRONIDAZOLE, NYSTATIN

100mg & 20,000U/g Vaginal Cream: 01926845 FLAGYSTATIN SAC

500mg & 100,000IU Vaginal Suppository: 01926829 FLAGYSTATIN SAC

POVIDONE-IODINE

10% Liquid: 00158348 BETADINE PFR

SELENIUM SULFIDE

2.5% Lotion: 00243000 SELSUN ABB; 00594601 VERSEL VAO

SILVER SULFADIAZINE

1% Cream: 02010917 DERMAZIN PMS; 00323098 FLAMAZINE SNE; 09854037 FLAMAZINE 50G SNE *

TRICLOSAN

0.5% Liquid: 00632317 TERSASEPTIC STI

84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS

AMCINONIDE

0.1% Cream: 02192284 CYCLOCORT STI; 02247098 RATIO-AMCINONIDE RPH; 02246714 TARO-AMCINONIDE TAR

0.1% Lotion: 02192276 CYCLOCORT STI; 02247097 RATIO-AMCINONIDE RPH

0.1% Ointment: 02192268 CYCLOCORT STI; 02247096 RATIO-AMCINONIDE RPH

BECLOMETHASONE DIPROPIONATE

0.025% Cream: 02089602 PROPADERM SHI

BETAMETHASONE DIPROPIONATE

0.05% Cream: 00323071 DIPROSONE SCH; 00804991 RATIO-TOPISONE RPH; 02122049 ROSONE RIV; 01925350 TARO-SONE TAR

0.05% Lotion: 00417246 DIPROSONE SCH; 00809187 RATIO-TOPISONE RPH; 02122030 ROSONE RIV

0.05% Ointment: 00344923 DIPROSONE SCH; 00805009 RATIO-TOPISONE RPH; 02122057 ROSONE RIV

BETAMETHASONE DIPROPIONATE IN PROPYLENE GLYCOL

0.05% Cream: 00688622 DIPROLENE SCH; 00849650 RATIO-TOPILENE GLYCOL RPH; 02122073 ROLENE RIV

0.05% Lotion: 00862975 DIPROLENE SCH; 01927914 RATIO-TOPILENE GLYCOL RPH; 02122065 ROLENE RIV

0.05% Ointment: 00629367 DIPROLENE SCH; 00849669 RATIO-TOPILENE GLYCOL RPH; 02122081 ROLENE RIV

BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE

0.05% & 1% Cream: 00611174 LOTRIDERM SCH

BETAMETHASONE DIPROPIONATE, SALICYLIC ACID

0.05% & 2% Lotion: 00578428 DIPROSALIC SCH; 02245688 RATIO-TOPISALIC RPH

0.05% & 3% Ointment: 00578436 DIPROSALIC SCH

BETAMETHASONE DISODIUM PHOSPHATE

0.05mg/mL Enema: 02060884 BETNESOL SHI

BETAMETHASONE VALERATE

0.05% Cream: 00535427 RATIO-ECTOSONE RPH

0.1% Cream: 00716626 BETADERM TAR; 00804541 PREVEX B STI; 00535435 RATIO-ECTOSONE RPH

0.05% Lotion: 00653209 RATIO-ECTOSONE RPH

0.1% Lotion: 00750050 RATIO-ECTOSONE RPH

0.05% Ointment: 00716642 BETADERM TAR

0.1% Ointment: 00716650 BETADERM TAR

0.1% Scalp Lotion: 00716634 BETADERM TAR; 01940112 RIVASONE RIV; 00027944 VALISONE SCH

BUDESONIDE

0.02mg/mL Enema: 02052431 ENTOCORT AZC

CLOBETASOL PROPIONATE

0.05% Cream: 02213265 DERMOVATE TAR; 02024187 MYLAN-CLOBETASOL MYL; 02232191 PMS-CLOBETASOL PMS; 01910272 RATIO-CLOBETASOL RPH; 02245523 TARO-CLOBETASOL TAR; 02093162 TEVA-CLOBETASOL TEV

0.05% Ointment: 02213273 DERMOVATE TAR; 02026767 MYLAN-CLOBETASOL MYL; 02309548 PMS-CLOBETASOL PMS; 01910280 RATIO-CLOBETASOL RPH; 02245524 TARO-CLOBETASOL TAR; 02126192 TEVA-CLOBETASOL TEV

0.05% Scalp Lotion: 02213281 DERMOVATE TAR; 02216213 MYLAN-CLOBETASOL MYL; 02232195 PMS-CLOBETASOL PMS; 01910299 RATIO-CLOBETASOL RPH

0.05% Solution: 02245522 TARO-CLOBETASOL TAR

CLOBETASONE BUTYRATE

0.05% Cream: 02214415 EUMOVATE GSK

DESONIDE

0.05% Cream: 02229315 PMS-DESONIDE PMS; 02154862 TRIDESILON SCN

0.05% Ointment: 02229323 PMS-DESONIDE PMS; 02154870 TRIDESILON SCN

DESOXIMETASONE

0.05% Cream: 02221918 TOPICORT SAC

0.25% Cream: 02221896 TOPICORT SAC

0.05% Gel: 02221926 TOPICORT SAC

0.25% Ointment: 02221934 TOPICORT SAC

DIFLUCORTOLONE VALERATE

0.1% Cream: 00587826 NERISONE STI; 00587818 NERISONE OILY STI

0.1% Ointment: 00587834 NERISONE STI

DIFLUCORTOLONE VALERATE, SALICYLIC ACID

0.1% & 3% Cream: 02028719 NERISALIC OILY STI

FLUOCINOLONE ACETONIDE

0.025% Ointment: 02162512 SYNALAR MDC

0.01% Scalp Lotion: 00873292 DERMA-SMOOTHE HIL

0.01% Shampoo: 02242738 CAPEX GAC

FLUOCINONIDE

0.05% Cream: 02161923 LIDEX VAO; 00716863 LYDERM OPT

0.05% Emollient Cream: 02163152 LIDEMOL MDC; 00598933 TIAMOL TAR

0.05% Gel: 02161974 LIDEX VAO; 02236997 LYDERM OPT

0.05% Ointment: 02161966 LIDEX VAO; 02236996 LYDERM OPT

FLUTICASONE PROPIONATE

0.05% Cream: 02089912 CUTIVATE GSK

HALOBETASOL PROPIONATE

0.05% Cream: 01962701 ULTRAVATE WSB

0.05% Ointment: 01962728 ULTRAVATE WSB

HYDROCORTISONE

1% Cream: 02086034 BARRIERE HC SHI; 00192597 EMO CORT STI; 00804533 PREVEX HC STI

2.5% Cream: 00595799 EMO CORT STI

0.5% Cream: 80021088 CORTATE SCH

100mg/60mL Enema: 02112736 CORTENEMA AXC; 00230316 HYCORT VAE

1% Lotion: 00192600 EMO CORT STI; 00578541 SARNA HC STI

2.5% Lotion: 00595802 EMO CORT STI; 00641154 EMO CORT SCALP STI; 00856711 SARNA HC STI

0.5% Lotion: 80021087 CORTATE SCH

0.5% Ointment: 00716685 CORTODERM TAR

1% Ointment: 00716693 CORTODERM TAR

0.5% Ointment: 80021085 CORTATE SCH

HYDROCORTISONE ACETATE

10% Aerosol Foam: 00579335 CORTIFOAM SQU

0.5% Cream: 00716820 HYDERM TAR

1% Cream: 00716839 HYDERM TAR

2% Cream: 00749834 NEO-HC NEO

1% Lotion: 00681997 DERMAFLEX HC NEO

HYDROCORTISONE ACETATE, ZINC SULFATE

0.5% & 0.5% Ointment: 02128446 ANODAN-HC ODN; 00505773 ANUSOL HC PFI; 02209764 EGOZINC-HC PMS; 00607789 RATIO-HEMCORT HC RPH; 02179547 RIVASOL HC RIV; 02247691 SANDOZ-ANUZINC HC SDZ

10mg & 10mg Suppository: 02236399 ANODAN-HC ODN; 00476285 ANUSOL HC PFI; 02210517 EGOZINC HC PMS; 00607797 RATIO-HEMCORT HC RPH; 02240112 RIVASOL-HC RIV; 02242798 SANDOZ ANUZINC HC SDZ

HYDROCORTISONE ACETATE, ZINC SULFATE, PRAMOXINE HCL

0.5% & 0.5% & 1% Ointment: 00505781 ANUGESIC HC PFI; 02234466 PROCTODAN HC ODN; 02247692 SANDOZ-ANUZINC HC PLUS SDZ

10mg & 10mg & 20mg Suppository: 00476242 ANUGESIC HC PFI; 02240851 PROCTODAN HC ODN; 02242797 SANDOZ ANUZINC HC PLUS SDZ

HYDROCORTISONE VALERATE

0.2% Cream: 02242984 HYDROVAL TAR

0.2% Ointment: 02242985 HYDROVAL TAR

HYDROCORTISONE, DIBUCAINE HCL, ESCULIN, FRAMYCETIN SULFATE

5mg & 5mg & 10mg & 10mg Ointment: 02247322 PROCTOL ODN; 02223252 PROCTOSEDYL AXC; 02226383 RATIO-PROCTOSONE RPH; 02242527 SANDOZ-PROCTOMYXIN HC SDZ

5mg & 5mg & 10mg & 10mg Suppository: 02247882 PROCTOL ODN; 02223260 PROCTOSEDYL AXC; 02226391 RATIO-PROCTOSONE RPH; 02242528 SANDOZ PROCTOMYXIN HC SDZ

HYDROCORTISONE, UREA

1% & 10% Cream: 00503134 UREMOL HC STI

1% & 10% Lotion: 00560022 UREMOL HC STI

MOMETASONE FUROATE

0.1% Cream: 00851744 ELOCOM SCH; 02367157 TARO-MOMETASONE TAR

0.1% Lotion: 00871095 ELOCOM SCH; 02266385 TARO-MOMETASONE TAR

0.1% Ointment: 00851736 ELOCOM SCH; 02244769 PMS-MOMETASONE PMS; 02270862 PMS-MOMETASONE PMS; 02248130 RATIO-MOMETASONE RPH; 02264749 TARO-MOMETASONE TAR

TRIAMCINOLONE ACETONIDE

0.1% Cream: 02194058 ARISTOCORT R VAO

0.5% Cream: 02194066 ARISTOCORT C VAO

0.1% Ointment: 02194031 ARISTOCORT R VAO

0.1% Paste: 01964054 ORACORT TAR

84:08.00 SMMA - ANTIPRURITICS AND LOCAL ANESTHETICS

LIDOCAINE HCL

2% Liquid: 01968823 LIDODAN VISCOUS ODN; 00811874 PMS-LIDOCAINE VISCOUS PMS; 00001686 XYLOCAINE VISCOUS AZC

LIDOCAINE, PRILOCAINE

2.5% & 2.5% Cream: 00886858 EMLA AZC

2.5% & 2.5% Patch: 02057794 EMLA AZC

84:16.00 SMMA - CELL STIMULANTS AND PROLIFERANTS

TRETINOIN

0.01% Cream: 00897329 RETIN A JAJ; 00657204 STIEVA-A STI

0.025% Cream: 00897310 RETIN A JAJ; 00578576 STIEVA-A STI

0.05% Cream: 00443794 RETIN A JAJ; 00518182 STIEVA-A STI

0.1% Cream: 00870021 RETIN A JAJ; 00662348 STIEVA-A FORTE STI

0.01% Gel: 01926462 VITAMIN A ACID SAC

0.025% Gel: 00587966 STIEVA-A STI; 01926470 VITAMIN A ACID SAC

0.05% Gel: 00641863 STIEVA-A STI; 01926489 VITAMIN A ACID SAC

0.025% Solution: 00578568 STIEVA-A STI

84:24.12 BASIC OINTMENTS AND PROTECTANTS

DIMETHICONE

20% Cream: 02060841 BARRIERE WPC

PETROLATUM

67% Cream: 00635189 PREVEX STI

ZINC OXIDE

15% Cream: 02215799 ZINC OXIDE CREAM 15% HJS

25% Ointment: 00532576 IHLES PASTE RPH

40% Ointment: 02239160 ZINCOFAX EXTRA STRENGTH GSK

84:28.00 KERATOLYTIC AGENTS

ADAPALENE

0.1% Cream: 02231592 DIFFERIN GAC

0.1% Gel: 02148749 DIFFERIN GAC

CANTHARIDIN, PODOPHYLLIN, SALICYLIC ACID

1% & 2% & 30% Liquid: 00772011 CANTHARONE PLUS DOR

1% & 5% & 30% Liquid: 00589500 CANTHACUR PS PMS

DITHRANOL

0.1% Cream: 00537594 ANTHRANOL MTI

0.2% Cream: 00537608 ANTHRANOL MTI

0.4% Lotion: 00695351 ANTHRASCALP MTI

1% Ointment: 00566756 ANTHRAFORTE 1 MTI

2% Ointment: 00566748 ANTHRAFORTE 2 MTI

FORMALDEHYDE, LACTIC ACID, SALICYLIC ACID

5% & 10% & 25% Ointment: 00513091 DUOPLANT STI

LACTIC ACID, SALICYLIC ACID

17% & 17% Liquid: 00370576 DUOFILM STI

PODOFILOX

0.5% Solution: 01945149 CONDYLINE CDX

PODOPHYLLIN

25% Liquid: 00598208 PODOFILM PMS

SALICYLIC ACID

27% Gel: 01939645 DUOFORTE 27 STI

170mg/mL Gel: 00614246 COMPOUND W

20% Liquid: 00690333 SOLUVER DER

26% Liquid: 00754951 OCCLUSAL HP MDC

27% Liquid: 00837733 SOLUVER PLUS DER

40% Plaster: 01974335 CLEAR AWAY SCH

4% Shampoo: 00666106 SEBCUR DER

84:32.00 KERATOPLASTIC AGENTS

COAL TAR

10% Gel: 00344508 TARGEL ODN

20% Liquid: 00358495 ODANS LIQUOR CARBONIS DETERGENT ODN

1% Shampoo: 00632295 TERSA-TAR MILD STI

3% Shampoo: 00632309 TERSA-TAR STI

4.3% Shampoo: 00740314 PENTRAX MDC

COAL TAR, JUNIPER TAR, PINE TAR

1% Shampoo: 00249866 POLYTAR STI

COAL TAR, JUNIPER TAR, PINE TAR, ZINC PYRITHIONE

0.166% & 0.166% & 0.166% & 1% Shampoo: 00628042 MULTI-TAR PLUS MILD VAE *

0.33% & 0.33% & 0.33% & 1% Shampoo: 02240942 MULTITAR PLUS VAE

COAL TAR, SALICYLIC ACID

8% & 2% Gel: 00560448 P&S PLUS BAK *

10% & 3% Liquid: 00510335 TARGEL SA ODN

10% & 4% Shampoo: 00666114 SEBCUR-T DER

COAL TAR, SALICYLIC ACID, SULFUR

2% & 2% & 2% Shampoo: 00444448 STEREX IDE

84:50.06 PIGMENTING AGENTS

METHOXSALEN

10mg Capsule: 00252654 OXSORALEN VAE; 01946374 OXSORALEN VAE

1% Lotion: 01907476 OXSORALEN VAE

84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

ACITRETIN

Soriatane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings, should be consulted prior to prescribing or dispensing this drug.

10mg Capsule: 02070847 SORIATANE ACG

25mg Capsule: 02070863 SORIATANE ACG

AZELAIC ACID

15% Gel: 02270811 FINACEA BAY

CALCIPOTRIOL

50mcg/g Cream: 02150956 DOVONEX LEO

50mcg/g Ointment: 01976133 DOVONEX LEO

50mcg/mL Solution: 02194341 DOVONEX LEO

CAPSAICIN

0.025% Cream: 02157101 CAPSAICIN VAO; 02244952 ZODERM EUR; 00740306 ZOSTRIX MDC

0.075% Cream: 02157128 CAPSAICIN HP VAO; 02004240 ZOSTRIX HP MDC

COLLAGENASE

250U Ointment: 02063670 SANTYL HPC

FLUOROURACIL

5% Cream: 00330582 EFUDEX VAE

ISOTRETINOIN

Accutane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings should be consulted prior to prescribing or dispensing this drug.

10mg Capsule: 00582344 ACCUTANE HLR; 02257955 CLARUS MYL

40mg Capsule: 00582352 ACCUTANE HLR; 02257963 CLARUS MYL

PIMECROLIMUS

Limited use benefit (prior approval required).

For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment.

Note: Contraindicated in children less than 2 years of age.

1% Cream: 02247238 ELIDEL NVC

TACROLIMUS (PROTOPIC)