Drug Benefit List

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

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, HYDROCORTISONE

Limited use benefit (prior approval required).

For treatment of acute diffuse bacterial external otitis. Criteria for coverage include:
a. - failure to respond to other listed topical antibiotics, or
b. - contraindications to other listed topical antibiotics.

2MG & 10MG/ML Otic Suspension

02240035     CIPRO HC     ALC

ERYTHROMYCIN

5MG/G Ophth Ointment

02141574     DIOMYCIN     DKT

02212935     ERYTHROMYCIN     RIV

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

02212927     R.O. GENTYCIN     RVX

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

02239148     TOBRAMYCIN     BSH

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

02213672     FLONASE     GSK

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

1% Ophth Solution

02213079     PREDNISOLONE     RIV

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

52:10.00 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

52:20.00 EENT - MIOTICS

CARBACHOL

0.01% Ophth Solution

00042544     MIOSTAT     ALC

1.5% Ophth Solution

00000655     ISOPTO CARBACHOL     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

52:24.00 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

00529117     PROPINE     ALL

02032376     RATIO-DIPIVEFRIN     RPH

HOMATROPINE HBR

2% Ophth Solution

02148420     HOMATROPINE     NVR

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:
a. - treatment of radiation mucositis and oral ulcerative complications of chemotherapy.
b. - use in immunocompromised patients who are at risk of mucosal breakdown.

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     ZIL

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

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

52:92.00 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

BETAXOLOL HCL

0.5% Ophth Solution

02235971     SANDOZ-BETAXOLOL     SDZ

0.25% Ophth Suspension

01908448     BETOPTIC S     ALC

BIMATOPROST

0.03% Ophth Solution

02245860     LUMIGAN     ALL

BRIMONIDINE TARTRATE

0.2% Ophth Solution

02236876     ALPHAGAN     ALL

02260077     APO-BRIMONIDINE     APX

02246284     PMS-BRIMONIDINE     PMS

02243026     RATIO-BRIMONIDINE     RPH

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

BRIMONIDINE TARTRATE, TIMOLOL MALEATE

0.2% & 0.5% Ophth Solution

02248347     COMBIGAN     ALL

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

02246083     APO-IPRAVENT     APX

02163705     ATROVENT     BOE

02240508     DOM-IPRATROPIUM     DPC

02239627     PMS-IPRATROPIUM     PMS

0.06% Nasal Spray

02246084     APO-IPRAVENT     APX

02163713     ATROVENT     BOE

LATANOPROST

0.005% Ophth Solution

02231493     XALATAN     PFI

LEVOBUNOLOL HCL

0.25% Ophth Solution

02241575     APO-LEVOBUNOLOL     APX

00751286     BETAGAN     ALL

02231714     LEVOBUNOLOL     BSH

02197456     NOVO-LEVOBUNOLOL     NOP

02031159     RATIO-LEVOBUNOLOL     RPH

02241715     SANDOZ-LEVOBUNOLOL     SDZ

0.5% Ophth Solution

02241574     APO-LEVOBUNOLOL     APX

00637661     BETAGAN     ALL

02231715     LEVOBUNOLOL     BSH

02197464     NOVO-LEVOBUNOLOL     NOP

02237991     PMS-LEVOBUNOLOL     PMS

02031167     RATIO-LEVOBUNOLOL     RPH

02241716     SANDOZ-LEVOBUNOLOL     SDZ

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

02067412     SALINE NASAL     SDR

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% 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     ALC

0.5% Ophth Gel Solution

02242276     TIMOLOL MALEATE     ALC

0.25% Ophth Solution

00755826     APO-TIMOP     APX

02238770     DOM-TIMOLOL     DPC

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

02238771     DOM-TIMOLOL     DPC

00893781     GEN-TIMOLOL     GEN

02084325     MED-TIMOLOL     MEC

02083345     PMS-TIMOLOL     PMS

02166720     SANDOZ-TIMOLOL     SDZ

00451207     TIMOPTIC     FRS

TRAVOPROST

0.004% Ophth Solution

02244896     TRAVATAN     ALC

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