52:00 Eye, Ear, Nose and Throat Preparations
52:02.00 EENT - ANTIALLERGIC AGENTS
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.1% Solution | 02475065 | DICLOFENAC | UNK |
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.05% Nasal Spray | 02020017 | LIVOSTIN | JSO |
LODOXAMIDE TROMETHAMINE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.1% Solution | 00893560 | ALOMIDE | NVR |
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
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.3%/0.1% Suspension | 02252716 | CIPRODEX | NVR |
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
1% Drop | 02243862 | FUCITHALMIC | AMD |
GATIFLOXACIN
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.3% Solution | 02257270 | ZYMAR | ALL |
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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.5% Solution | 02472120 | JAMP-MOXIFLOXACIN | JMP |
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
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
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
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
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)
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
1% Solution | 00687456 | VIROPTIC | VAE |
52:04.92 EENT - MISCELLANEOUS ANTI-INFECTIVES
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
50MCG Spray | 02248307 | FLONASE ALLERGY RELIEF | GSK |
52:08.08 EENT - CORTICOSTEROIDS
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
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.1% Ointment | 00042579 | MAXIDEX | NVR |
0.1% Suspension | 00042560 | MAXIDEX | NVR |
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
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.02% & 1% Drop | 00074454 | LOCACORTEN VIOFORM | PAL |
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
100MCG Powder | 02446561 | ARNUITY ELLIPTA | GSK |
200MCG Powder | 02446588 | ARNUITY ELLIPTA | GSK |
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
5MG & 0.05MG/ML & 0.5MG Drop | 02224623 | SOFRACORT EAR/EYE | SAC |
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
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
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.5% Drop | 02148498 | MINIMS PREDNISOLONE | VAE |
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
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.
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
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
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
3MG Solution | 02231289 | GENTEAL | ALC |
52:16.00 EENT - LOCAL ANESTHETICS
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
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
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.1% Liquid | 02242232 | APO-DIPIVEFRIN | APX |
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
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.
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
1MG/ML Solution | 00155365 | ADRENALIN | ERF |
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
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
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.25% Ophthalmic Solution | 01908448 | BETOPTIC S | NVR |
LEVOBUNOLOL HYDROCHLORIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.25% Ophthalmic Solution | 02241575 | APO-LEVOBUNOLOL | APX |
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
250MG Tablet | 00545015 | ACETAZOLAMIDE | AAP |
BRINZOLAMIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
1% Suspension | 02238873 | AZOPT | NVR |
BRINZOLAMIDE, BRIMONIDINE TARTRATE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
1% & 0.2% Suspension | 02435411 | SIMBRINZA | NVR |
BRINZOLAMIDE, TIMOLOL MALEATE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
1%/0.5% Suspension | 02331624 | AZARGA | NVR |
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
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
50MG Tablet | 02245882 | METHAZOLAMIDE | AAP |
52:40.20 EENT - MIOTICS
CARBACHOL
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.01% Ophthalmic Solution | 00042544 | MIOSTAT | ALC |
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
2% Drop | 02148463 | MINIMS PILOCARPINE | VAE |
52:40.28 EENT - PROSTAGLANDIN AGENTS
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
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
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.024% Solution | 02484218 | VYZULTA | BSH |
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
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
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).
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
40MG Solution | 02415992 | EYLEA | BAY |
ANETHOLE TRITHIONE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST25MG Tablet | 02240344 | SIALOR | PMS |
APRACLONIDINE HYDROCHLORIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.5% Ophthalmic Solution | 02076306 | IOPIDINE | NVR |
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
5MG Insert | 02250624 | LACRISERT | ATO |
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
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
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
55.5% & 42.5% Ointment | 00210889 | REFRESH LACRI-LUBE | ALL |
NATURAL HEALTH PRODUCT
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
100% Spray | 80069578 | SALINEX | UNK |
PETROLATUM, MINERAL OIL
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
80% & 20% Ointment | 02125706 | SOOTHE NIGHT TIME | BSH |
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).
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
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
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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
15MG/VIAL Powder For Solution | 02242367 | VISUDYNE | CHE |
WHITE PETROLATUM, LANOLIN, MINERAL OIL
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
94% & 3% & 3% Ointment | 02444062 | SYSTANE | ALC |