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VERSION 05/2004

Therapeutic Class

Generic Name

Local Anesthetic

Proparacaine HCL

Eye Miotics

Carbachol

Physostigmine Salicylate PILOCARPINE

Mydriactics

Atropine Sulfate

Cyclopentolate

DIPIVEFRIN HCL Epinephrine

Vasoconstrictors

Homatropine Phenylephrine (viscous) NAPHAZOLINE

Other Anti- Glaucoma Agents

Naphazoline/ Antazoline LEVOBUNOLOL HCL

Methazolamide

Brimonidine acetonide TIMOLOL MALEATE

TIMOLOL MALEATE

Misc.-Eye

ARTIFICIAL TEARS SODIUM CHLORIDE OPHTH

Otic Preps

TYLOXAPOL Acetic Acid/ Aluminum Acetate

Antipyine/ Benzocaine Soln ACETIC ACID/ HYDROCORTISONE

Ophth Soln

0.5%

Ophth Drop

0.75%, 1.5%,

Ophth Oint

2 25% 3% 0.25%

Ophth Gel, Soln

4%, 0.25%, 0.5%, 1%, 2%, 3%, 5%, 6%, 0.5%, 1%, 2%,

Ophth Oint,

Soln Ophth Soln

3% 0.2%, 1%, 2%

Ophth Soln Ophth Drop

0.1% 0.1%, 0.5%, 1%,

Ophth Soln

2% 2%, 5%

Ophth Soln

2.5%, 10%

Ophth Soln

0.1%

Ophth Soln Ophth Drop,

0.05%-0.5% 0.25%, 0.5%

Soln Tab

25mg, 50mg

Opth Soln Ophth Soln,

0.15% 0.25%, 0.5%

Gel Ophth Soln

0.25%, 0.5%

Soln, Oint Ophth Soln,

1%, 5%

Oint Soln

0.25%

Otic Drop

2%-10%

Otic Soln Otic Drop

5.4%-1.4% 2%-3%-1%

Brand Name

Ophthaine Isopto Carbachol

Eserine PILOCAR

Atropine

AK-Pentolate PROPINE Epifrin

Isopto Homatropine Neosynephrine VASOCON Vasocon- A BETAGAN, AKBETA

Neptazane Alphagan P TIMOPTIC, TIMOPTIC-X

BETIMOL

LIQUIFILM MURO 128

ENUCLENE Otic Domeboro Auralgan VOSOL- HC

Form

Strength

CHP

Relative Cost

x x

$ $

x x

$ $

CHP Restrictions

x

$

x

$

x

$$

x

$$$

x

$

x

$

x

$

x

$

x

$$

x

$

x

$$

x

$$

x

$$

x

$

x

$

x

$

x

$

x

$

x

$

Cover RX only

Cover RX only

Otic Drop Otic Soln

6.5% 0.5%

x x x

$

Otic Drop

0.5%- 10,000units/

$$

Otic Soln,

L 1%, 3.5mg/mL

x

$

Susp Otic Drop,

0.3%

x

$$$

SDV Nasal Spray

0.084%, 42mcg,

x

$$

Nasal Spray Nasal Soln

84mcg 25mcg

x x

$$$$

0.125%, 0.25%,

Nasal Spray

1% 0.4%, 0.6%,

x

$

Nasal Spray

0 65% 0 9% 100mcg

x

$

x

$

x

$

CARBAMIDE PEROXIDE Chloramphenicol

DEBROX

HYDROCORTISONE/ POLYMYXIN B

OTOBIOTIC

NEOMYCIN-POLYMYXIN-HC

Ofloxacin

Floxin

Beclomethasone Diproprionate

Beconase AQ

Flunisolide Phenylephrine

Nasalide, Nasarel

SODIUM CHLORIDE

OCEAN

Triamcinolone

Nasacort AQ

Tab

300mg, 500mg, 600mg, 400mg, 600mg/5mL, 320mg/5mL,

Chew, Liq

450mg/mL 600-300mg, 600-

300mg/5mL, 225- 200mg/5mL

ALUMINUM/ MAGNESIUM HYDROXIDE GEL

MAALOX

Nasal Spray

Antacids GASTROINTESTINAL AGENTS ALUMINUM HYDROXIDE GEL

AMPHOGEL

12

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