52:00 Eye, Ear, Nose and Throat Preparations

52:02.00 EENT - ANTIALLERGIC AGENTS

CROMOLYN SODIUM

Table: CROMOLYN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
2% Ophthalmic Solution 02009277 CROMOLYN PED
2% Ophthalmic Solution 02230621 OPTICROM ALL

DICLOFENAC SODIUM

Table: DICLOFENAC SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Solution 02475065 DICLOFENAC UNK

KETOTIFEN FUMARATE

Table: KETOTIFEN FUMARATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.25MG Solution 02489651 JAMP-KETOTIFEN JMP
0.25MG Solution 02400871 KETOTIFEN RAX

LEVOCABASTINE HYDROCHLORIDE

Table: LEVOCABASTINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% Nasal Spray 02020017 LIVOSTIN JSO

LODOXAMIDE TROMETHAMINE

Table: LODOXAMIDE TROMETHAMINE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Solution 00893560 ALOMIDE NVR

OLOPATADINE HYDROCHLORIDE

Table: OLOPATADINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Ophthalmic Solution 02403986 ACT OLOPATADINE ACG
0.1% Ophthalmic Solution 02305054 APO-OLOPATADINE APX
0.1% Ophthalmic Solution 02422727 MINT-OLOPATADINE MIN
0.1% Ophthalmic Solution 02233143 PATANOL NVR
0.1% Ophthalmic Solution 02358913 SANDOZ OLOPATADINE SDZ
0.2% Ophthalmic Solution 02404095 ACT OLOPATADINE ACG
0.2% Ophthalmic Solution 02402823 APO-OLOPATADINE APX
0.2% Ophthalmic Solution 02420171 SANDOZ OLOPATADINE SDZ
0.1% Solution 02458411 JAMP-OLOPATADINE JMP

52:04.04 EENT - ANTIBACTERIALS

CIPROFLOXACIN HYDROCHLORIDE

Table: CIPROFLOXACIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.3% Ointment 02200864 CILOXAN NVR
0.3% Solution 02263130 APO-CIPROFLOX APX
0.3% Solution 01945270 CILOXAN NVR
0.3% Solution 02387131 SANDOZ CIPROFLOXACIN SDZ

CIPROFLOXACIN HYDROCHLORIDE, DEXAMETHASONE

Table: CIPROFLOXACIN HYDROCHLORIDE, DEXAMETHASONE
Drug strength and dosage form DIN Brand name Manufacturer code
0.3%/0.1% Suspension 02252716 CIPRODEX NVR

ERYTHROMYCIN

Table: ERYTHROMYCIN
Drug strength and dosage form DIN Brand name Manufacturer code
5MG Ointment 00641324 ODAN-ERYTHROMYCIN ODN
5MG/G Ointment 02326663 ERYTHROMYCIN STG
5MG/G Ointment 01912755 PDP-ERYTHROMYCIN PED

FUSIDIC ACID

Table: FUSIDIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
1% Drop 02243862 FUCITHALMIC AMD

GATIFLOXACIN

Table: GATIFLOXACIN
Drug strength and dosage form DIN Brand name Manufacturer code
0.3% Solution 02257270 ZYMAR ALL

GATIFLOXACIN (GATIFLOXACIN HEMIHYDRATE)

Table: GATIFLOXACIN (GATIFLOXACIN HEMIHYDRATE)
Drug strength and dosage form DIN Brand name Manufacturer code
0.3% Solution 02327260 APO-GATIFLOXACIN APX

MOXIFLOXACIN HYDROCHLORIDE

Limited use benefit (prior approval not required).

Coverage will be limited to 14 tablets every 14 days, followed by a 14 day lockout.

Table: MOXIFLOXACIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% Solution 02472120 JAMP-MOXIFLOXACIN JMP

MOXIFLOXACIN HYDROCHLORIDE (OPHTHALMIC)

Table: MOXIFLOXACIN HYDROCHLORIDE (OPHTHALMIC)
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% Solution 02404656 ACT MOXIFLOXACIN TEV
0.5% Solution 02406373 APO-MOXIFLOXACIN APX
0.5% Solution 02432218 PMS-MOXIFLOXACIN PMS
0.5% Solution 02411520 SANDOZ MOXIFLOXACIN SDZ
0.5% Solution 02252260 VIGAMOX NVR

OFLOXACIN

Table: OFLOXACIN
Drug strength and dosage form DIN Brand name Manufacturer code
0.3% Solution 02248398 APO-OFLOXACIN APX
0.3% Solution 02143291 OCUFLOX ALL

POLYMYXIN B SULFATE, BACITRACIN ZINC

Table: POLYMYXIN B SULFATE, BACITRACIN ZINC
Drug strength and dosage form DIN Brand name Manufacturer code
500IU & 10,000IU/G Ointment 02160889 OPTIMYXIN SDZ
500IU & 10,000IU/G Ointment 02239157 POLYSPORIN JAJ

POLYMYXIN B SULFATE, GRAMICIDIN

Table: POLYMYXIN B SULFATE, GRAMICIDIN
Drug strength and dosage form DIN Brand name Manufacturer code
0.025MG & 10,000U/ML Drop 00701785 OPTIMYXIN SDZ
0.025MG & 10,000U/ML Drop 02239156 POLYSPORIN EYE AND EAR JAJ

POLYMYXIN B SULFATE, TRIMETHOPRIM SULFATE

Table: POLYMYXIN B SULFATE, TRIMETHOPRIM SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
10,000U & 1MG/ML Solution 02011956 POLYTRIM ALL
10,000U & 1MG/ML Solution 02239234 SANDOZ POLYTRIMETHOPRIM SDZ

TOBRAMYCIN (OPHTHALMIC)

Table: TOBRAMYCIN (OPHTHALMIC)
Drug strength and dosage form DIN Brand name Manufacturer code
0.3% Ointment 00614254 TOBREX NVR
0.3% Solution 02241755 SANDOZ TOBRAMYCIN SDZ
0.3% Solution 00513962 TOBREX NVR

52:04.20 EENT - ANTIVIRALS

TRIFLURIDINE

Table: TRIFLURIDINE
Drug strength and dosage form DIN Brand name Manufacturer code
1% Solution 00687456 VIROPTIC VAE

52:04.92 EENT - MISCELLANEOUS ANTI-INFECTIVES

CHLORHEXIDINE GLUCONATE

Table: CHLORHEXIDINE GLUCONATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.12% Mouthwash 02462842 CHLORHEXIDINE EUR
0.12% Mouthwash 02384272 GUM PAROEX SUS
0.12% Mouthwash 02240433 PERICHLOR PED
0.12% Mouthwash 02237452 PERIDEX MAK

52:08.00 

FLUTICASONE PROPIONATE

Table: FLUTICASONE PROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MCG Spray 02248307 FLONASE ALLERGY RELIEF GSK

52:08.08 EENT - CORTICOSTEROIDS

BECLOMETHASONE DIPROPIONATE

Table: BECLOMETHASONE DIPROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MCG/DOSE Nasal Spray 02238796 APO-BECLOMETHASONE APX
50MCG/DOSE Nasal Spray 02172712 MYLAN-BECLO AQ MYL

BUDESONIDE

Table: BUDESONIDE
Drug strength and dosage form DIN Brand name Manufacturer code
64MCG/DOSE Spray 02241003 MYLAN-BUDESONIDE AQ MYL
64MCG/DOSE Spray 02231923 RHINOCORT AQUA MCL
100MCG/DOSE Spray 02230648 MYLAN-BUDESONIDE AQ MYL

DEXAMETHASONE

Table: DEXAMETHASONE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Ointment 00042579 MAXIDEX NVR
0.1% Suspension 00042560 MAXIDEX NVR

DEXAMETHASONE PHOSPHATE

Table: DEXAMETHASONE PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Solution 02023865 DEXAMETHASONE UNK
0.1% Solution 00785261 PMS-DEXAMETHASONE PMS

DEXAMETHASONE, TOBRAMYCIN

Table: DEXAMETHASONE, TOBRAMYCIN
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% & 0.3% Ointment 00778915 TOBRADEX NVR
0.1% & 0.3% Suspension 00778907 TOBRADEX NVR

FLUMETHASONE PIVALATE, CLIOQUINOL

Table: FLUMETHASONE PIVALATE, CLIOQUINOL
Drug strength and dosage form DIN Brand name Manufacturer code
0.02% & 1% Drop 00074454 LOCACORTEN VIOFORM PAL

FLUOROMETHOLONE

Table: FLUOROMETHOLONE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Drop 00247855 FML ALL
0.1% Suspension 00756784 FLAREX NVR
0.1% Suspension 00432814 SANDOZ FLUOROMETHOLONE SDZ

FLUTICASONE FUROATE

Table: FLUTICASONE FUROATE
Drug strength and dosage form DIN Brand name Manufacturer code
100MCG Powder 02446561 ARNUITY ELLIPTA GSK
200MCG Powder 02446588 ARNUITY ELLIPTA GSK

FLUTICASONE PROPIONATE

Table: FLUTICASONE PROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MCG Pump 02453738 TEVA-FLUTICASONE TEV
50MCG/DOSE Spray 02294745 APO-FLUTICASONE APX
50MCG/DOSE Spray 02296071 RATIO-FLUTICASONE TEV

FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE

Table: FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE
Drug strength and dosage form DIN Brand name Manufacturer code
5MG & 0.05MG/ML & 0.5MG Drop 02224623 SOFRACORT EAR/EYE SAC

MOMETASONE FUROATE

Table: MOMETASONE FUROATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MCG Spray 02403587 APO-MOMETASONE APX
50MCG Spray 02238465 NASONEX FRS
50MCG Spray 02475863 TEVA-MOMETASONE TEV
500MCG/ML Spray 02449811 SANDOZ MOMETASONE SDZ

PREDNISOLONE ACETATE

Table: PREDNISOLONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.12% Drop 00299405 PRED MILD ALL
1% Drop 00301175 PRED FORTE ALL
1% Suspension 01916203 SANDOZ PREDNISOLONE SDZ
1% Suspension 00700401 TEVA-PREDNISOLONE TEV

PREDNISOLONE ACETATE, SULFACETAMIDE SODIUM

Table: PREDNISOLONE ACETATE, SULFACETAMIDE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
0.2% & 10% Drop 00807788 BLEPHAMIDE ALL
0.5% & 10% Suspension 02023814 PREDNISOLONE/SULFACETAMIDE UNK

PREDNISOLONE SODIUM PHOSPHATE

Table: PREDNISOLONE SODIUM PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% Drop 02148498 MINIMS PREDNISOLONE VAE

TRIAMCINOLONE ACETONIDE

Table: TRIAMCINOLONE ACETONIDE
Drug strength and dosage form DIN Brand name Manufacturer code
55MCG Spray 02437635 APO-TRIAMCINOLONE AQ APX
55MCG/DOSE Spray 02213834 NASACORT AQ SAC

52:08.20 EENT - NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

DICLOFENAC SODIUM

Table: DICLOFENAC SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Solution 01940414 VOLTAREN OPHTHA NVR

DICLOFENAC SODIUM (TOPICAL)

Limited use benefit (prior approval required).

For the treatment of osteoarthritis when:

  • pain is inadequately controlled with acetaminophen and a non-steroidal anti-inflammatory (NSAID); or
  • there is contraindication to acetaminophen and NSAID; or
  • there is intolerance to acetaminophen and NSAID.
Table: DICLOFENAC SODIUM (TOPICAL)
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Solution 02441020 APO-DICLOFENAC APX
0.1% Solution 02454807 SANDOZ DICLOFENAC OPHTHA SDZ

KETOROLAC TROMETHAMINE

Table: KETOROLAC TROMETHAMINE
Drug strength and dosage form DIN Brand name Manufacturer code
0.45% Solution 02369362 ACUVAIL ALL
0.5% Solution 01968300 ACULAR ALL
0.5% Solution 02245821 APO-KETOROLAC AAP

NEPAFENAC

Table: NEPAFENAC
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Suspension 02308983 NEVANAC NVR
0.3% Suspension 02411393 ILEVRO NVR

52:12.00 EENT - CONTACT LENS SOLUTION

HYDROXYPROPYLMETHYLCELLULOSE

Table: HYDROXYPROPYLMETHYLCELLULOSE
Drug strength and dosage form DIN Brand name Manufacturer code
3MG Solution 02231289 GENTEAL ALC

52:16.00 EENT - LOCAL ANESTHETICS

LIDOCAINE HYDROCHLORIDE

Table: LIDOCAINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
2% Solution 00001686 XYLOCAINE VISCOUS UNK

52:24.00 EENT - MYDRIATICS

ATROPINE SULFATE

Table: ATROPINE SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
1% Solution 02023695 ATROPINE UNK
1% Solution 00035017 ISOPTO ATROPINE ALC
1% Solution 02148358 MINIMS ATROPINE VAE

CYCLOPENTOLATE HYDROCHLORIDE

Table: CYCLOPENTOLATE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% Drop 02148331 MINIMS CYCLOPENTOLATE VAE
1% Drop 00252506 CYCLOGYL ALC
1% Drop 02148382 MINIMS CYCLOPENTOLATE VAE

DIPIVEFRIN HYDROCHLORIDE

Table: DIPIVEFRIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Liquid 02242232 APO-DIPIVEFRIN APX

PHENYLEPHRINE HYDROCHLORIDE

Table: PHENYLEPHRINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
2.5% Drop 02148447 MINIMS PHENYLEPHRINE VAE
2.5% Drop 00465763 MYDFRIN ALC
2.5% Drop 02027100 PHENYLEPHRINE UNK
10% Drop 02148455 MINIMS PHENYLEPHRINE VAE

TROPICAMIDE

Table: TROPICAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% Solution 00000981 MYDRIACYL ALC
1% Solution 00001007 MYDRIACYL ALC

52:28.00 EENT - MOUTHWASHES AND GARGLES

BENZYDAMINE HYDROCHLORIDE

Limited use benefit (prior approval required).

For the treatment of radiation mucositis and oral ulcerative complications of chemotherapy; or

For use in immunocompromised patients who are at risk of mucosal breakdown.

Table: BENZYDAMINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.15% Mouthwash 02239044 APO-BENZYDAMINE APX
0.15% Mouthwash 02229777 PHARIXIA PED
0.15% Mouthwash 02239537 PMS-BENZYDAMINE PMS

52:32.00 EENT - VASOCONSTRICTORS

EPINEPHRINE

Table: EPINEPHRINE
Drug strength and dosage form DIN Brand name Manufacturer code
1MG/ML Solution 00155365 ADRENALIN ERF

NAPHAZOLINE HYDROCHLORIDE

Table: NAPHAZOLINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Drop 00001147 ALBALON ALL

52:40.04 EENT - ALPHA-ADRENERGIC AGONISTS

BRIMONIDINE TARTRATE

Table: BRIMONIDINE TARTRATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.15% Solution 02248151 ALPHAGAN P ALL
0.15% Solution 02301334 BRIMONIDINE P AAP
0.2% Solution 02236876 ALPHAGAN ALL
0.2% Solution 02260077 APO-BRIMONIDINE APX
0.2% Solution 02246284 PMS-BRIMONIDINE PMS
0.2% Solution 02305429 SANDOZ BRIMONIDINE SDZ

TIMOLOL MALEATE, BRIMONIDINE TARTRATE

Table: TIMOLOL MALEATE, BRIMONIDINE TARTRATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.2% & 0.5% Solution 02248347 COMBIGAN ALL

52:40.08 EENT - BETA-ADRENERGIC BLOCKING AGENTS

BETAXOLOL HYDROCHLORIDE

Table: BETAXOLOL HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.25% Ophthalmic Solution 01908448 BETOPTIC S NVR

LEVOBUNOLOL HYDROCHLORIDE

Table: LEVOBUNOLOL HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.25% Ophthalmic Solution 02241575 APO-LEVOBUNOLOL APX

TIMOLOL MALEATE

Table: TIMOLOL MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.25% Ophthalmic Gel Solution 02242275 TIMOLOL MALEATE-EX SDZ
0.5% Ophthalmic Gel Solution 02242276 TIMOLOL MALEATE-EX SDZ
0.5% Ophthalmic Gel Solution 00451207 TIMOPTIC PFR
0.25% Ophthalmic Solution 00755826 APO-TIMOP APX
0.25% Ophthalmic Solution 02238770 DOM-TIMOLOL DPC
0.25% Ophthalmic Solution 02083353 PMS-TIMOLOL PMS
0.5% Ophthalmic Solution 00755834 APO-TIMOP APX
0.5% Ophthalmic Solution 02238771 DOM-TIMOLOL DPC
0.5% Ophthalmic Solution 02447800 JAMP-TIMOLOL JMP
0.5% Ophthalmic Solution 02083345 PMS-TIMOLOL PMS
0.5% Ophthalmic Solution 02166720 SANDOZ TIMOLOL SDZ
0.50% Ophthalmic Solution 99113735 TIMOLOL MALEATE (QC) UNK
0.5% Solution (Extended Release) 02171899 TIMOPTIC-XE PFR

52:40.12 EENT - CARBONIC ANHYDRASE INHIBITORS

ACETAZOLAMIDE

Table: ACETAZOLAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Tablet 00545015 ACETAZOLAMIDE AAP

BRINZOLAMIDE

Table: BRINZOLAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
1% Suspension 02238873 AZOPT NVR

BRINZOLAMIDE, BRIMONIDINE TARTRATE

Table: BRINZOLAMIDE, BRIMONIDINE TARTRATE
Drug strength and dosage form DIN Brand name Manufacturer code
1% & 0.2% Suspension 02435411 SIMBRINZA NVR

BRINZOLAMIDE, TIMOLOL MALEATE

Table: BRINZOLAMIDE, TIMOLOL MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
1%/0.5% Suspension 02331624 AZARGA NVR

DORZOLAMIDE HYDROCHLORIDE

Table: DORZOLAMIDE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
2% Ophthalmic Solution 02216205 TRUSOPT FRS
2% Ophthalmic Solution 02269090 TRUSOPT FRS
20MG/ML Ophthalmic Solution 02316307 SANDOZ DORZOLAMIDE SDZ

DORZOLAMIDE HYDROCHLORIDE, TIMOLOL MALEATE

Table: DORZOLAMIDE HYDROCHLORIDE, TIMOLOL MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
20MG & 5MG Ophthalmic Solution 02437686 MED-DORZOLAMIDE-TIMOLOL GMP
20MG & 5MG/ML Ophthalmic Solution 02404389 ACT DORZOTIMOLOL TEV
20MG & 5MG/ML Ophthalmic Solution 02299615 APO-DORZO-TIMOP APX
20MG & 5MG/ML Ophthalmic Solution 02240113 COSOPT FRS
20MG & 5MG/ML Ophthalmic Solution 02441659 RIVA-DORZOLAMIDE/TIMOLOL RIV
20MG & 5MG/ML Ophthalmic Solution 02344351 SANDOZ DORZOLAMIDE/TIMOLOL SDZ
20MG & 5MG Solution 02457539 JAMP DORZOLAMIDE-TIMOLOL JMP

METHAZOLAMIDE

Table: METHAZOLAMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Tablet 02245882 METHAZOLAMIDE AAP

52:40.20 EENT - MIOTICS

CARBACHOL

Table: CARBACHOL
Drug strength and dosage form DIN Brand name Manufacturer code
0.01% Ophthalmic Solution 00042544 MIOSTAT ALC

PILOCARPINE HYDROCHLORIDE

Table: PILOCARPINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
2% Ophthalmic Solution 00000868 ISOPTO CARPINE NVR
4% Ophthalmic Solution 00000884 ISOPTO CARPINE NVR
4% Ophthalmic Solution 02023733 PILOCARPINE UNK

PILOCARPINE NITRATE

Table: PILOCARPINE NITRATE
Drug strength and dosage form DIN Brand name Manufacturer code
2% Drop 02148463 MINIMS PILOCARPINE VAE

52:40.28 EENT - PROSTAGLANDIN AGENTS

BIMATOPROST

Table: BIMATOPROST
Drug strength and dosage form DIN Brand name Manufacturer code
0.01% Ophthalmic Solution 02324997 LUMIGAN RC ALL
0.01% Ophthalmic Solution 09857368 LUMIGAN RC (ON) ALL
0.01% Ophthalmic Solution 09857398 LUMIGAN RC (ON) ALL
0.03% Ophthalmic Solution 02429063 VISTITAN SDZ

LATANOPROST

Table: LATANOPROST
Drug strength and dosage form DIN Brand name Manufacturer code
0.005% Solution 02296527 APO-LATANOPROST APX
0.005% Solution 02373041 GD-LATANOPROST UNK
0.005% Solution 02426935 MED-LATANOPROST GMP
0.005% Solution 02317125 PMS-LATANOPROST PMS
0.005% Solution 02341085 RIVA-LATANOPROST RIV
0.005% Solution 02367335 SANDOZ LATANOPROST SDZ
0.005% Solution 02254786 TEVA-LATANOPROST TEV
0.005% Solution 02231493 XALATAN UNK
50MCG Solution 02453355 JAMP LATANOPROST JMP

LATANOPROST, TIMOLOL MALEATE

Table: LATANOPROST, TIMOLOL MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.005% & 0.5% Solution 02436256 ACT LATANOPROST/TIMOLOL ACG
0.005% & 0.5% Solution 02414155 APO-LATANOPROST-TIMOP APX
0.005% & 0.5% Solution 02373068 GD-LATANOPROST/TIMOLOL UNK
0.005% & 0.5% Solution 02404591 PMS-LATANOPROST-TIMOLOL PMS
0.005% & 0.5% Solution 02394685 SANDOZ LATANOPROST/TIMOLOL SDZ
0.005% & 0.5% Solution 02246619 XALACOM UNK
50MCG & 5MG Solution 02453770 JAMP-LATANOPROST/TIMOLOL JMP
50MCG & 5MG Solution 02454505 MED-LATANOPROST-TIMOLOL GMP

LATANOPROSTENE BUNOD

Table: LATANOPROSTENE BUNOD
Drug strength and dosage form DIN Brand name Manufacturer code
0.024% Solution 02484218 VYZULTA BSH

TIMOLOL MALEATE, TRAVOPROST

Table: TIMOLOL MALEATE, TRAVOPROST
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% & 0.004% Solution 02415305 APO-TRAVOPROST-TIMOP PQ APX
0.5% & 0.004% Solution 02278251 DUOTRAV PQ NVR
0.5% & 0.004% Solution 02413817 SANDOZ TRAVOPROST / TIMOLOL PQ SDZ

TRAVOPROST

Table: TRAVOPROST
Drug strength and dosage form DIN Brand name Manufacturer code
0.003% Solution 02457997 IZBA NVR
0.004% Solution 02415739 APO-TRAVOPROST Z APX
0.004% Solution 02413167 SANDOZ TRAVOPROST SDZ
0.004% Solution 02318008 TRAVATAN Z NVR

TRAVOPROST-TIMOLOL

Table: TRAVOPROST-TIMOLOL
Drug strength and dosage form DIN Brand name Manufacturer code
0.0040.5/% Ophthalmic Solution 09857513 DUOTRAV PQ OP ALC

52:92.00 MISCELLANEOUS EENT DRUGS

AFLIBERCEPT

Limited use benefit (prior approval required).

For the treatment of:

  • diabetic macular edema (DME)
  • wet age-related macular degeneration (w-AMD)
  • retinal vein occlusion (RVO)

(Please refer to Appendix A).

Table: AFLIBERCEPT
Drug strength and dosage form DIN Brand name Manufacturer code
40MG Solution 02415992 EYLEA BAY

ANETHOLE TRITHIONE

Table: ANETHOLE TRITHIONE
Drug strength and dosage form DIN Brand name Manufacturer code
ST25MG Tablet 02240344 SIALOR PMS

APRACLONIDINE HYDROCHLORIDE

Table: APRACLONIDINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% Ophthalmic Solution 02076306 IOPIDINE NVR

DEXTRAN 70, HYDROXYPROPYLMETHYLCELLULOSE

Table: DEXTRAN 70, HYDROXYPROPYLMETHYLCELLULOSE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% & 0.3% Drop 01943308 TEARS NATURALE FREE ALC
0.1% & 0.3% Drop 00743445 TEARS NATURALE II ALC

HYDROXYPROPYL CELLULOSE

Table: HYDROXYPROPYL CELLULOSE
Drug strength and dosage form DIN Brand name Manufacturer code
5MG Insert 02250624 LACRISERT ATO

HYDROXYPROPYLMETHYLCELLULOSE

Table: HYDROXYPROPYLMETHYLCELLULOSE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% Solution 00000809 ISOPTO TEARS ALC
1% Solution 00000817 ISOPTO TEARS ALC

MACROGOL, PROPYLENE GLYCOL

Table: MACROGOL, PROPYLENE GLYCOL
Drug strength and dosage form DIN Brand name Manufacturer code
15% & 20% Gel 02220806 LUBRICATING PMS
15% & 20% Gel 02352699 RHINARIS NASAL PED
15% & 20% Gel 00551805 SECARIS PED
15% & 20% Spray 00732230 LUBRICATING NASAL MIST PMS
15% & 20% Spray 02354551 RHINARIS NASAL MIST PED

MINERAL OIL, WHITE PETROLATUM

Table: MINERAL OIL, WHITE PETROLATUM
Drug strength and dosage form DIN Brand name Manufacturer code
55.5% & 42.5% Ointment 00210889 REFRESH LACRI-LUBE ALL

NATURAL HEALTH PRODUCT

Table: NATURAL HEALTH PRODUCT
Drug strength and dosage form DIN Brand name Manufacturer code
100% Spray 80069578 SALINEX UNK

PETROLATUM, MINERAL OIL

Table: PETROLATUM, MINERAL OIL
Drug strength and dosage form DIN Brand name Manufacturer code
80% & 20% Ointment 02125706 SOOTHE NIGHT TIME BSH

POLYVINYL ALCOHOL

Table: POLYVINYL ALCOHOL
Drug strength and dosage form DIN Brand name Manufacturer code
1.4% Ophthalmic Solution 02229570 ARTIFICIAL TEARS PED
1.4% Ophthalmic Solution 00579408 TEARS PLUS ALL

RANIBIZUMAB

Limited use benefit (prior approval required).

For the treatment of:

  • diabetic macular edema (DME)
  • wet age-related macular degeneration (w-AMD)
  • retinal vein occlusion (RVO)
  • choroidal neovascularization secondary to pathologic myopia (mCNV)

(Please refer to Appendix A).

Table: RANIBIZUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
10MG/ML Solution 02296810 LUCENTIS NVR
10MG/ML Solution 02425629 LUCENTIS PFS NVR

SODIUM CARBOXYMETHYL CELLULOSE

Table: SODIUM CARBOXYMETHYL CELLULOSE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% Drop 02049260 REFRESH PLUS ALL
0.5% Drop 02231008 REFRESH TEARS ALL
1% Drop 00870153 REFRESH CELLUVISC ALL
10MG/ML Solution 02244650 REFRESH LIQUIGEL ALL

SODIUM CHLORIDE

Table: SODIUM CHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
9MG/ML Nasal Drops 80024901 SALINEX SDZ
5% Ointment 00750816 MURO 128 BSH
5% Ophthalmic Ointment 80046696 ODAN SODIUM CHLORIDE ODN
5% Solution 00750824 MURO 128 BSH
5% Solution 80046737 ODAN-SODIUM CHLORIDE ODN
9MG/ML Spray 80024381 SALINEX SDZ

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.

Table: VERTEPORFIN
Drug strength and dosage form DIN Brand name Manufacturer code
15MG/VIAL Powder For Solution 02242367 VISUDYNE CHE

WHITE PETROLATUM, LANOLIN, MINERAL OIL

Table: WHITE PETROLATUM, LANOLIN, MINERAL OIL
Drug strength and dosage form DIN Brand name Manufacturer code
94% & 3% & 3% Ointment 02444062 SYSTANE ALC
Date modified: