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GENTAMICIN

GARAMYCIN

Mupirocin

Bactroban

POLYMYXIN B SULFATE/

POLYSPORIN

BACITRACIN ZINC

POLYMYXIN B SULFATE/

NEOSPORIN

BACITRACIN ZINC/ NEOMYCIN

SULFATE

CLOTRIMAZOLE

GYNE-LOTRIMIN

Therapeutic Class

AntiFungal Topical Agents

Generic Name

Brand Name

Econazole Nitrate MICONAZOLE NITRATE

Spectazole Various

Terbinafine

Lamisil

TERCONAZOLE

TERAZOL

Scabicides &

TOLNAFTATE Crotamiton

Pediculicides

PERMETHRIN PYRETHRINS

Corticosteroids Topical

BETAMETHASONE DIPROPIONATE Augmented

TINACTIN Eurax ACTICIN A-200 SHAMPOO, RID DIPROLENE

BETAMETHASONE DIPROPIONATE

DIPROSONE

BETAMETHASONE VALERATE

VALISONE

CLOBETASOL PROPIONATE

TEMOVATE

FLUOCINOLONE

FLUOCINOLONE ACETONIDE

SYNALAR, LIDEX, LIDEX-E Derma-SmootheF/S

HEMORRHOIDAL PRODUCTS-RX ANUSOL-HC

HYDROCORTISONE

HYTONE

HYDROCORTISONE VALERATE LIDOCAINE

WESTCORT ELA-Max

Mometasone

Elocon

TRIAMCINOLONE ACETONIDE

KENALOG

PETROLATUM/ MINERAL OIL

EUCERIN

Podofilox

Condylox

SUNSCREEN

VARIOUS

VITMAINS & NUTRITIONAL AGENTS

Misc. Topical Agents

Aluminum Acetate/ Calcium AcetateDomeboro

CALAMINE LOTION

CALAMINE

COAL TAR

T/Gel

18

CHP

Relative Cost

x

$

PA x

$$$ $

x

$

x

$

x x

$$$ $

x x

$$$$$ $$$

x x x x x

$ $$ $ $ $$$

x

$$$

x

$$

x

$$

x

$/$$$

PA

$/$$$

PA

$

x

$

x x

$ $$

PA

$$$

x

$

x

$

x x

$ $$$

x x

$ $$$$

PA

x

Supp

80mg

Top Liq, Crm

1%

Top Crm,

0.1%

Oint Top Oint

2%

Top Oint

10,000units- 500units/g

Top Oint

5000units- 400units- 3.5mg/g

Vag Tab, Crm, Trouche, Top Crm, Lot Cream

100mg, 200mg, 500mg, 1%, 10mg

1%

Top Crm, Vag Crm, Dual Pkg, Crm

100mg, 200mg, 2%

1%

Vag Crm,

0.4%, 0.8%,

Crm, Lot

10%

Crm, Rinse Shampoo

5%, 1% 0.3%

Crm, Lot, Gel, Oint

0.05%

Crm, Lot, Oint

0.05%

Crm, Lot, Oint

0.1%

Crm, Gel,

0.05%

Oint Soln Crm, Oint,

0.025%, 0.05%, 0.01%

Oil, Soln, Gel

Top Oil

0.01%

Supp, Rectal, Oint, Crm ,

25mg, 1%, 2.5%

Lt Crm, Lot,

0.5%,1%, 2.5%, 100mg, 25mg,

Enema, Supp

Oint

0 0.2%

Crm, Gel, Liq

4%, 2%

Crm, Lot,

0.1%

Oint Crm, Lot,

0.025%, 0.05%, 0.01%, 0.1%,

Oint, Soln

Pwd

0 5% 1:40

Lot

Gel, Shampoo,

5%, 2%-2%

l Oint

Top Soln, Gel

0.5%

Lot

SPF15

OTC- Non-Formulary

Restricted to Dermatology

(Except low sensitizing)

Medically necessary- protection due to photosensitivity

DX- Impetigo

Form

Strength

VERSION 05/2004

CHP Restrictions

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