84:00 Skin and mucous membrane agents

84:04.04 SMMA - ANTIBIOTICS

BACITRACIN ZINC

Table: BACITRACIN ZINC
Drug strength and dosage form DIN Brand name Manufacturer code
500IU Ointment 00584908 BACITIN PED
500IU Ointment 02351714 JAMP-BACITRACINE JMP

CLINDAMYCIN PHOSPHATE

Table: CLINDAMYCIN PHOSPHATE
Drug strength and dosage form DIN Brand name Manufacturer code
2% Cream 02060604 DALACIN PFI
1% Solution 02483769 CLINDAMYCIN PHOSPHATE TOPICAL TEL
1% Solution 02243659 CLINDA-T VAE
1% Solution 00582301 DALACIN T PFI
1% Solution 02266938 TARO-CLINDAMYCIN TAR
pDIN For Extemporaneous Mixture 99502000 CLINDAMYCIN IN DILUSOL OR DUONALC UNK

CLINDAMYCIN PHOSPHATE, BENZOYL PEROXIDE

Table: CLINDAMYCIN PHOSPHATE, BENZOYL PEROXIDE
Drug strength and dosage form DIN Brand name Manufacturer code
1% & 3% Gel 02382822 CLINDOXYL ADV GSK
1% & 5% Gel 02248472 BENZACLIN VAE
1% & 5% Gel 02243158 CLINDOXYL GSK
1% & 5% Gel 02464519 TARO-BENZOYL PEROXIDE / CLINDAMYCIN KIT TAR
1% & 5% Gel 02440180 TARO-CLINDAMYCIN/BENZOYL PEROXIDE TAR

ERYTHROMYCIN, BENZOYL PEROXIDE

Table: ERYTHROMYCIN, BENZOYL PEROXIDE
Drug strength and dosage form DIN Brand name Manufacturer code
3% & 5% Gel 02225271 BENZAMYCIN VAE

FUSIDATE SODIUM

Table: FUSIDATE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
2% Ointment 00586676 FUCIDIN LEO

FUSIDIC ACID

Table: FUSIDIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
2% Cream 00586668 FUCIDIN LEO

FUSIDIC ACID, HYDROCORTISONE ACETATE

Table: FUSIDIC ACID, HYDROCORTISONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
2% & 1% Cream 02238578 FUCIDIN H LEO

METRONIDAZOLE

Table: METRONIDAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
1% Cream 02156091 NORITATE BSH
0.75% Gel 02092832 METROGEL GAC
0.75% Gel 02125226 NIDAGEL VAE
1% Gel 02297809 METROGEL GAC
0.75% Lotion 02248206 METROLOTION GAC

METRONIDAZOLE, NYSTATIN

Table: METRONIDAZOLE, NYSTATIN
Drug strength and dosage form DIN Brand name Manufacturer code
500MG & 100,000IU Suppository 01926829 FLAGYSTATIN SAC

MUPIROCIN

Table: MUPIROCIN
Drug strength and dosage form DIN Brand name Manufacturer code
2% Ointment 02279983 TARO-MUPIROCIN TAR

MUPIROCIN CALCIUM

Table: MUPIROCIN CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code
2% Cream 02239757 BACTROBAN GSK

POLYMYXIN B SULFATE, BACITRACIN ZINC

Table: POLYMYXIN B SULFATE, BACITRACIN ZINC
Drug strength and dosage form DIN Brand name Manufacturer code
10,000IU & 500IU Ointment 02304473 ANTIBIOTIC OINT PMS
10,000IU & 500IU Ointment 00876488 BACIMYXIN ONGUENT PMS
10,000IU & 500IU Ointment 00621366 BIODERM ODN
10,000IU & 500IU Ointment 02357569 JAMPOLYCIN JMP
10,000IU & 500IU Ointment 02237227 POLYSPORIN ANTIBIOTIC JAJ
10,000IU & 500IU Ointment 01942921 POLYTOPIC SDZ
10000U & 500U Ointment 02181908 POLYDERM TAR

POLYMYXIN B SULFATE, BACITRACIN ZINC, GRAMICIDIN

Table: POLYMYXIN B SULFATE, BACITRACIN ZINC, GRAMICIDIN
Drug strength and dosage form DIN Brand name Manufacturer code
10,000U & 500U & 0.25MG Ointment 02237226 POLYSPORIN TRIPLE JAJ

POLYMYXIN B SULFATE, GRAMICIDIN

Table: POLYMYXIN B SULFATE, GRAMICIDIN
Drug strength and dosage form DIN Brand name Manufacturer code
0.25MG & 10,000IU Cream 02230844 POLYSPORIN ANTIBIOTIC JAJ

84:04.06 SMMA - ANTIVIRALS

ACYCLOVIR

Table: ACYCLOVIR
Drug strength and dosage form DIN Brand name Manufacturer code
5% Cream 02039524 ZOVIRAX VAE
5% Ointment 02477130 APO-ACYCLOVIR APX
5% Ointment 00569771 ZOVIRAX VAE

SINECATECHINS

Table: SINECATECHINS
Drug strength and dosage form DIN Brand name Manufacturer code
10% Ointment 02411849 VEREGEN PAL

84:04.08 SMMA - ANTIFUNGALS

BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE

Table: BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% & 1% Cream 00611174 LOTRIDERM FRS

CICLOPIROX OLAMINE

Table: CICLOPIROX OLAMINE
Drug strength and dosage form DIN Brand name Manufacturer code
1% Cream 02221802 LOPROX VAE
1% Lotion 02221810 LOPROX VAE

CLOTRIMAZOLE

Table: CLOTRIMAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
1% Cream 02150867 CANESTEN BAY
1% Cream 02150891 CANESTEN BAY
1% Cream 00812382 CLOTRIMADERM TAR
1% Cream 00812366 CLOTRIMADERM VAGINAL 6 TAR
1% Cream 02229380 CLOTRIMAZOLE TAR
1% Cream 00874043 NEO-ZOL PPI
1% Cream 00874051 NEO-ZOL PPI
2% Cream 02150905 CANESTEN BAY
2% Cream 00812374 CLOTRIMADERM VAGINAL 3 TAR
1% & 200MG Tablet (Controlled Release) 02264099 CANESTEN COMBI-PAK COMFORTAB 3 BAY
1% & 500MG Tablet (Controlled Release) 02264102 CANESTEN COMBI-PAK COMFORTAB 1 BAY
500MG Vaginal Tablet 02150859 CANESTEN COMFORTAB 1 BAY

KETOCONAZOLE

Table: KETOCONAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
2% Cream 02245662 KETODERM TPT
2% Shampoo 02182920 NIZORAL UNK

MICONAZOLE NITRATE

Table: MICONAZOLE NITRATE
Drug strength and dosage form DIN Brand name Manufacturer code
2% Cream 02085852 MICATIN MICONAZOLE NITRATE WPC
2% Cream 02231106 MICOZOLE TAR
2% Cream 02084309 MONISTAT 7 INS
2% Cream 02126567 MONISTAT DERM INS
2% & 100MG Cream/Vaginal Suppository 02126257 MONISTAT 7 DUAL-PAK INS
2% & 400MG Cream/Vaginal Suppository 02126249 MONISTAT 3 DUAL-PAK INS
400MG Ovule 02126605 MONISTAT 3 INS
400MG Suppository 02171775 MICONAZOLE 3 DAY OVULE TREATMENT VTH

NYSTATIN

Table: NYSTATIN
Drug strength and dosage form DIN Brand name Manufacturer code
25,000IU Cream 00716901 NYADERM TAR
100,000IU Cream 00716871 NYADERM TAR
100,000IU Cream 02194236 RATIO-NYSTATIN TEV
100,000IU Cream 02194163 TEVA-NYSTATIN TEV
100,000IU Ointment 02194228 RATIO-NYSTATIN TEV

TERBINAFINE HYDROCHLORIDE

Table: TERBINAFINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
1% Cream 02031094 LAMISIL NVR

TERCONAZOLE

Table: TERCONAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
0.4% Cream 02247651 TARO-TERCONAZOLE TAR

TOLNAFTATE

Table: TOLNAFTATE
Drug strength and dosage form DIN Brand name Manufacturer code
1% Aerosol 00576050 TINACTIN AEROSOL BAY
1% Cream 00576034 TINACTIN BAY
1% Powder 01919245 DRSCHOLL'S ATHLETE'S FOOT SPRAY BAY
1% Powder 00576042 TINACTIN BAY

84:04.12 SMMA - SCABICIDES AND PEDICULICIDES

CROTAMITON

Table: CROTAMITON
Drug strength and dosage form DIN Brand name Manufacturer code
10% Cream 00623377 EURAX CLC

DIMETHICONE

Table: DIMETHICONE
Drug strength and dosage form DIN Brand name Manufacturer code
50% Solution 02373785 NYDA GPB

ISOPROPYL MYRISTATE

Table: ISOPROPYL MYRISTATE
Drug strength and dosage form DIN Brand name Manufacturer code
50% Solution 02279592 RESULTZ MDF

PERMETHRIN

Table: PERMETHRIN
Drug strength and dosage form DIN Brand name Manufacturer code
1% Cream 00771368 NIX INS
5% Cream 02219905 NIX DERMAL GSK
1% Liquid 02231480 KWELLADA-P MTC
5% Lotion 02231348 KWELLADA-P MTC

PIPERONYL BUTOXIDE, PYRETHRINS

Table: PIPERONYL BUTOXIDE, PYRETHRINS
Drug strength and dosage form DIN Brand name Manufacturer code
3% & 0.3% Shampoo 02125447 R & C SHAMPOO WITH CONDITIONER MTC

84:04.92 SMMA - MISCELLANEOUS LOCAL ANTI-INFECTIVES

ISOPROPYL ALCOHOL

Table: ISOPROPYL ALCOHOL
Drug strength and dosage form DIN Brand name Manufacturer code
70% Liquid 00426539 DUONALC ICN

METRONIDAZOLE

Table: METRONIDAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
10% Cream 01926861 FLAGYL SAC

POVIDONE-IODINE

Table: POVIDONE-IODINE
Drug strength and dosage form DIN Brand name Manufacturer code
10% Solution 00158348 BETADINE PFR

SELENIUM SULFIDE

Table: SELENIUM SULFIDE
Drug strength and dosage form DIN Brand name Manufacturer code
2.5% Lotion 00594601 VERSEL VAE
2.5% Shampoo 00243000 EXTRA STRENGTH SELSUN SAC

SILVER SULFADIAZINE

Table: SILVER SULFADIAZINE
Drug strength and dosage form DIN Brand name Manufacturer code
1% Cream 00323098 FLAMAZINE SNE
1% Cream 09854037 FLAMAZINE SMW

84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS

AMCINONIDE

Table: AMCINONIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Cream 02246714 TARO-AMCINONIDE TAR
0.1% Lotion 02247097 RATIO-AMCINONIDE TEV
0.1% Ointment 02247096 RATIO-AMCINONIDE TEV

BECLOMETHASONE DIPROPIONATE

Table: BECLOMETHASONE DIPROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.025% Cream 02089602 PROPADERM VAE

BETAMETHASONE DIPROPIONATE

Table: BETAMETHASONE DIPROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% Cream 00323071 DIPROSONE FRS
0.05% Cream 02122073 ROLENE RIV
0.05% Cream 02122049 ROSONE RIV
0.05% Cream 01925350 TARO-SONE TAR
0.05% Cream 00849650 TEVA-TOPILENE TEV
0.05% Cream 00804991 TEVA-TOPISONE TEV
0.05% Lotion 00417246 DIPROSONE FRS
0.05% Lotion 02122065 ROLENE RIV
0.05% Lotion 02122030 ROSONE RIV
0.05% Lotion 01927914 TEVA-TOPILENE TEV
0.05% Lotion 00809187 TEVA-TOPISONE TEV
0.05% Ointment 00629367 DIPROLENE FRS
0.05% Ointment 00344923 DIPROSONE FRS
0.05% Ointment 02122081 ROLENE RIV
0.05% Ointment 02122057 ROSONE RIV
0.05% Ointment 00849669 TEVA-TOPILENE TEV
0.05% Ointment 00805009 TEVA-TOPISONE TEV

BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE

Table: BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% & 1% Cream 02496410 TARO-CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE TAR

BETAMETHASONE DIPROPIONATE, SALICYLIC ACID

Table: BETAMETHASONE DIPROPIONATE, SALICYLIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% & 2% Lotion 02245688 RATIO-TOPISALIC TEV
0.05% & 3% Ointment 00578436 DIPROSALIC FRS
pDIN For Extemporaneous Mixture 99500003 SALICYLIC ACID IN CORTICOSTEROID CREAM UNK
pDIN For Extemporaneous Mixture 99501001 SALICYLIC ACID IN NON-MEDICATED OINTMENT UNK

BETAMETHASONE VALERATE

Table: BETAMETHASONE VALERATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% Cream 00716618 BETADERM TAR
0.05% Cream 02357860 CELESTODERM V VAE
0.05% Cream 00535427 RATIO-ECTOSONE TEV
0.1% Cream 00716626 BETADERM TAR
0.1% Cream 02357844 CELESTODERM V VAE
0.1% Cream 00535435 RATIO-ECTOSONE TEV
0.05% Lotion 00653209 RATIO-ECTOSONE TEV
0.1% Lotion 00716634 BETADERM TAR
0.1% Lotion 00750050 RATIO-ECTOSONE TEV
0.1% Lotion 01940112 RIVASONE RIV
0.1% Lotion 00027944 VALISONE VAE
0.05% Ointment 00716642 BETADERM TAR
0.05% Ointment 02357879 CELESTODERM V VAE
0.1% Ointment 00716650 BETADERM TAR
0.1% Ointment 02357852 CELESTODERM V VAE

BUDESONIDE, SODIUM CHLORIDE

Table: BUDESONIDE, SODIUM CHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.02MG/ML Enema 02052431 ENTOCORT TIL

CALCIPOTRIOL, BETAMETHASONE DIPROPIONATE

Table: CALCIPOTRIOL, BETAMETHASONE DIPROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MCG & 0.5MG Aerosol (Foam) 02457393 ENSTILAR LEO
0.5MG & 50MCG Gel 02319012 DOVOBET LEO
0.5MG & 50MCG Ointment 02244126 DOVOBET LEO

CLOBETASOL PROPIONATE

Table: CLOBETASOL PROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% Cream 02213265 DERMOVATE TPT
0.05% Cream 02024187 MYLAN-CLOBETASOL MYL
0.05% Cream 02232191 PMS-CLOBETASOL PMS
0.05% Cream 02309521 PMS-CLOBETASOL PMS
0.05% Cream 02245523 TARO-CLOBETASOL TAR
0.05% Cream 01910272 TEVA-CLOBETASOL TEV
0.05% Lotion 02213281 DERMOVATE TPT
0.05% Lotion 02216213 MYLAN-CLOBETASOL MYL
0.05% Lotion 02232195 PMS-CLOBETASOL PMS
0.05% Lotion 02245522 TARO-CLOBETASOL TAR
0.05% Lotion 01910299 TEVA-CLOBETASOL TEV
0.05% Ointment 02213273 DERMOVATE TPT
0.05% Ointment 02026767 MYLAN-CLOBETASOL MYL
0.05% Ointment 02309548 PMS-CLOBETASOL PMS
0.05% Ointment 02245524 TARO-CLOBETASOL TAR
0.05% Ointment 01910280 TEVA-CLOBETASOL TEV

CLOBETASONE BUTYRATE

Table: CLOBETASONE BUTYRATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% Cream 02214415 SPECTRO ECZEMACARE GSK

DESONIDE

Table: DESONIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% Cream 02229315 PDP-DESONIDE PED
0.05% Cream 02154862 TRIDESILON PER
0.05% Ointment 02229323 PDP-DESONIDE PED
0.05% Ointment 02154870 TRIDESILON PER

DESOXIMETASONE

Table: DESOXIMETASONE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% Cream 02221918 TOPICORT MILD BSH
0.25% Cream 02221896 TOPICORT BSH
0.05% Gel 02221926 TOPICORT BSH
0.25% Ointment 02221934 TOPICORT BSH

ESCULIN, FRAMYCETIN SULFATE, DIBUCAINE HYDROCHLORIDE, HYDROCORTISONE ACETATE

Table: ESCULIN, FRAMYCETIN SULFATE, DIBUCAINE HYDROCHLORIDE, HYDROCORTISONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
1% & 1% & 0.5% & 0.5% Ointment 02247322 PROCTOL ODN
1% & 1% & 0.5% & 0.5% Ointment 02223252 PROCTOSEDYL APC
1% & 1% & 0.5% & 0.5% Ointment 02242527 SANDOZ PROCTOMYXIN HC SDZ
10MG & 10MG & 5MG & 5MG Ointment 02226383 TEVA-PROCTOSONE TEV
10MG & 10MG & 5MG & 5MG Suppository 02247882 PROCTOL ODN
10MG & 10MG & 5MG & 5MG Suppository 02242528 SANDOZ PROCTOMYXIN HC SDZ
10MG & 10MG & 5MG & 5MG Suppository 02226391 TEVA-PROCTOSONE TEV

FLUOCINONIDE

Table: FLUOCINONIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% Cream 02163152 LIDEMOL VAE
0.05% Cream 02161923 LIDEX VAE
0.05% Cream 00716863 LYDERM TPT
0.05% Cream 00598933 TIAMOL TPT
0.05% Gel 02161974 LIDEX VAE
0.05% Gel 02236997 LYDERM TPT
0.01% Lotion 00873292 DERMA-SMOOTHE HIL
0.025% Ointment 02162512 SYNALAR VAE
0.05% Ointment 02161966 LIDEX VAE
0.05% Ointment 02236996 LYDERM TPT
0.01% Solution 02162504 SYNALAR VAE

HALOBETASOL PROPIONATE

Table: HALOBETASOL PROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% Cream 01962701 ULTRAVATE UNK
0.05% Ointment 01962728 ULTRAVATE UNK

HYDROCORTISONE ACETATE

Table: HYDROCORTISONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
2.5% Cream 02469421 SANDOZ HYDROCORTISONE SDZ

HYDROCORTISONE ACETATE, UREA

Table: HYDROCORTISONE ACETATE, UREA
Drug strength and dosage form DIN Brand name Manufacturer code
1% & 10% Cream 00681989 DERMAFLEX HC PAL
1% Cream 80073645 M-HC UREA MAN
1% Lotion 80073689 M-HC UREA MAN
1.00% Lotion 00681997 DERMAFLEX HC PAL

HYDROCORTISONE ACETATE, ZINC SULFATE

Table: HYDROCORTISONE ACETATE, ZINC SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% & 0.5% Ointment 02128446 ANODAN-HC ODN
0.5% & 0.5% Ointment 00505773 ANUSOL HC CHU
0.5% & 0.5% Ointment 02209764 EGOZINC-HC PMS
0.5% & 0.5% Ointment 00607789 RATIO-HEMCORT-HC TEV
0.5% & 0.5% Ointment 02179547 RIVA-HC RIV
0.5% & 0.5% Ointment 02247691 SANDOZ ANUZINC HC SDZ
10MG & 10MG Suppository 02236399 ANODAN-HC ODN
10MG & 10MG Suppository 00476285 ANUSOL HC CHU
10MG & 10MG Suppository 02210517 EGOZINC-HC PMS
10MG & 10MG Suppository 02240112 RIVASOL-HC RIV
10MG & 10MG Suppository 02242798 SANDOZ ANUZINC HC SDZ

HYDROCORTISONE ACETATE, ZINC SULFATE MONOHYDRATE

Table: HYDROCORTISONE ACETATE, ZINC SULFATE MONOHYDRATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% & 0.5% Ointment 02387239 JAMP-ZINC-HC JMP

HYDROCORTISONE ACETATE, ZINC SULFATE, PRAMOXINE HYDROCHLORIDE

Table: HYDROCORTISONE ACETATE, ZINC SULFATE, PRAMOXINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% & 0.5% & 1% Ointment 00505781 ANUGESIC HC MCL
0.5% & 0.5% & 1% Ointment 02234466 PROCTODAN-HC ODN
10MG & 10MG & 20MG Suppository 00476242 ANUGESIC HC MCL
10MG & 10MG & 20MG Suppository 02240851 PROCTODAN-HC ODN
10MG & 10MG & 20MG Suppository 02242797 SANDOZ ANUZINC HC PLUS SDZ

HYDROCORTISONE ACETATE-UREA

Table: HYDROCORTISONE ACETATE-UREA
Drug strength and dosage form DIN Brand name Manufacturer code
1% Cream 80061501 JAMP-HYDROCORTISONE UREA MAN

HYDROCORTISONE VALERATE

Table: HYDROCORTISONE VALERATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.2% Cream 02242984 HYDROVAL TPT
0.2% Ointment 02242985 HYDROVAL TPT

MOMETASONE FUROATE

Table: MOMETASONE FUROATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Cream 00851744 ELOCOM FRS
0.1% Cream 02367157 TARO-MOMETASONE TAR
0.1% Lotion 00871095 ELOCOM FRS
0.1% Ointment 00851736 ELOCOM FRS
0.1% Ointment 02244769 PMS-MOMETASONE PMS
0.1% Ointment 02270862 PMS-MOMETASONE PMS
0.1% Ointment 02266385 TARO-MOMETASONE TAR
0.1% Ointment 02248130 TEVA-MOMETASONE TEV
pDIN For Extemporaneous Mixture 99500008 MOMETASONE CREAM UNK

TRIAMCINOLONE ACETONIDE

Table: TRIAMCINOLONE ACETONIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Cream 02194058 ARISTOCORT R VAE
0.1% Cream 00716960 TRIADERM TAR
0.5% Cream 02194066 ARISTOCORT C VAE
0.1% Ointment 02194031 ARISTOCORT R VAE
0.1% Paste 01964054 ORACORT DENTAL PASTE TAR

84:06.08 

HYDROCORTISONE ACETATE

Table: HYDROCORTISONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% Cream 80021088 CORTATE BAY
0.5% Cream 00716820 HYDERM TAR
0.5% Cream 02242930 HYDROCORTISONE ACETATE TAR
1% Cream 00192597 EMOCORT GSK
1% Cream 02412926 EUROHYDROCORTISONE EUR
1% Cream 00716839 HYDERM TAR
1% Cream 00564281 HYDROSONE TEV
1% Cream 80057178 JAMP-HC JMP
1% Cream 80057189 JAMP-HYDROCORTISONE JMP
1% Cream 80066164 M-HC MAN
1% Cream 00804533 PREVEX HC GSK
0.5% Lotion 80021087 CORTATE BAY
1% Lotion 80057191 JAMP-HYDROCORTISONE JMP
1% Lotion 80066168 M-HC MAN
1% Lotion 00578541 SARNA HC GSK
0.5% Ointment 80021085 CORTATE BAY
0.5% Ointment 00716685 CORTODERM TAR
1% Ointment 00716693 CORTODERM TAR

84:08.00 SMMA - ANTIPRURITICS AND LOCAL ANESTHETICS

LIDOCAINE

Limited use benefit (prior approval not required).

Coverage will be limited to 35 grams every 30 days.

Table: LIDOCAINE
Drug strength and dosage form DIN Brand name Manufacturer code
5% Ointment 02386836 JAMPOCAINE JMP
5% Ointment 01963988 LIDODAN ODN
5% Ointment 02083795 LIDODAN ODN
5% Ointment 00001961 XYLOCAINE UNK

LIDOCAINE HCL

Table: LIDOCAINE HCL
Drug strength and dosage form DIN Brand name Manufacturer code
5% Ointment 00811475 XYLOCAINE UNK

LIDOCAINE HYDROCHLORIDE

Table: LIDOCAINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
2% Solution 02427745 JAMPOCAINE VISCOUS JMP

LIDOCAINE, PRILOCAINE

Table: LIDOCAINE, PRILOCAINE
Drug strength and dosage form DIN Brand name Manufacturer code
2.5% & 2.5% Cream 00886858 EMLA UNK
2.5% & 2.5% Patch 02057794 EMLA UNK

PHENAZOPYRIDINE HYDROCHLORIDE

Table: PHENAZOPYRIDINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Tablet 00476714 PYRIDIUM ERF

84:16.00 SMMA - CELL STIMULANTS AND PROLIFERANTS

TRETINOIN

Table: TRETINOIN
Drug strength and dosage form DIN Brand name Manufacturer code
0.01% Cream 00897329 RETIN-A UNK
0.01% Cream 00657204 STIEVA-A GSK
0.025% Cream 00897310 RETIN-A UNK
0.025% Cream 00578576 STIEVA-A GSK
0.05% Cream 00443794 RETIN-A UNK
0.05% Cream 00518182 STIEVA-A GSK
0.01% Gel 00870013 RETIN-A UNK
0.01% Gel 01926462 VITAMIN A ACID VAE
0.025% Gel 00443816 RETIN-A UNK
0.025% Gel 01926470 VITAMIN A ACID VAE
0.05% Gel 01926489 VITAMIN A ACID VAE

84:24.00 EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

UREA

Table: UREA
Drug strength and dosage form DIN Brand name Manufacturer code
10% Cream 80079497 UREMOL 10 ODN
10% Cream 80005397 URISEC10 ODN
20% Cream 80083394 UREMOL ODN
22% Cream 00396125 URISEC 22 ODN
10% Lotion 80079498 UREMOL 10 ODN
12% Lotion 00514896 URISEC 12 ODN

84:24.12 BASIC OINTMENTS AND PROTECTANTS

DIMETHICONE

Table: DIMETHICONE
Drug strength and dosage form DIN Brand name Manufacturer code
20% Cream 02060841 BARRIERE WPC

WHITE PETROLATUM

Table: WHITE PETROLATUM
Drug strength and dosage form DIN Brand name Manufacturer code
71.5% Ointment 02277778 CRITIC-AID CLEAR UNK

ZINC OXIDE

Table: ZINC OXIDE
Drug strength and dosage form DIN Brand name Manufacturer code
15% Cream 02215799 ZINC OXIDE HJS
25% Paste 00532576 PATE D'IHLE TEV
25% Paste 00886327 PÂTE D'IHLE ATL

ZINC OXIDE, WHITE PETROLATUM

Table: ZINC OXIDE, WHITE PETROLATUM
Drug strength and dosage form DIN Brand name Manufacturer code
15% & 80.3% Cream 02337452 DIAPER RASH HJS
40% Ointment 02239160 ZINCOFAX EXTRA STRENGTH PAL

84:28.00 KERATOLYTIC AGENTS

BENZOYL PEROXIDE

Table: BENZOYL PEROXIDE
Drug strength and dosage form DIN Brand name Manufacturer code
5% Gel 02162113 BENZAGEL CLC
4% Lotion 02413353 SPECTRO ACNECARE WASH GSK
5% Lotion 02166607 BENZAGEL 5 CLC
5% Solution 02162121 BENZAGEL CLC

CANTHARIDIN

Table: CANTHARIDIN
Drug strength and dosage form DIN Brand name Manufacturer code
1% Liquid 80028872 CANTHACUR 07 PAL

CANTHARIDIN, PODOPHYLLIN, SALICYLIC ACID

Table: CANTHARIDIN, PODOPHYLLIN, SALICYLIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
1% & 2% & 30% Liquid 00772011 CANTHARONE PLUS DOR

CLINDAMYCIN PHOSPHATE, TRETINOIN

Table: CLINDAMYCIN PHOSPHATE, TRETINOIN
Drug strength and dosage form DIN Brand name Manufacturer code
1.2% & 0.025% Gel 02359685 BIACNA TOPICAL BSH

SALICYLIC ACID

Table: SALICYLIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
170MG/ML Gel 00614246 COMPOUND W GEL UNK
20% Liquid 00690333 SOLUVER DPT
26% Liquid 00754951 OCCLUSAL HP VAE
27% Liquid 00837733 SOLUVER PLUS DPT
40% Plaster 01967878 DR SCHOLLS CLEAR AWAY PLANTAR WART REMOVER SYSTEM BAY
40% Plaster 01974335 DR SCHOLLS CLEAR AWAY WART REMOVER SYSTEM BAY
4% Shampoo 00666106 SEBCUR DPT

84:32.00 KERATOPLASTIC AGENTS

COAL TAR

Table: COAL TAR
Drug strength and dosage form DIN Brand name Manufacturer code
10% Gel 00344508 TARGEL ODN
0.5% Shampoo 02240645 NEUTROGENA JAJ
1% Shampoo 02307146 T/ THERAPEUTIC SHAMPOO EXTRA STRENGTH JAJ
20% Solution 00358495 ODAN LIQUOR CARBONIS DETERGENT ODN

COAL TAR, SALICYLIC ACID

Table: COAL TAR, SALICYLIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
10% & 3% Gel 00510335 TARGEL SA ODN
10% & 4% Shampoo 00666114 SEBCUR-T DPT

84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

ACITRETIN

Open benefit (prior approval not required).

Soriatane should be used with caution in clients of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings should be consulted prior to prescribing or dispensing this drug.

Table: ACITRETIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Capsule 02468840 MINT-ACITRETIN MIN
ST10MG Capsule 02070847 SORIATANE ALL
ST10MG Capsule 02466074 TARO-ACITRETIN TAR
ST25MG Capsule 02468859 MINT-ACITRETIN MIN
ST25MG Capsule 02070863 SORIATANE ALL
ST25MG Capsule 02466082 TARO-ACITRETIN TAR

ADAPALENE

Table: ADAPALENE
Drug strength and dosage form DIN Brand name Manufacturer code
0.1% Cream 02231592 DIFFERIN GAC
0.1% Gel 02148749 DIFFERIN GAC
0.3% Gel 02274000 DIFFERIN XP GAC

AZELAIC ACID

Table: AZELAIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
15% Gel 02270811 FINACEA LEO

BRODALUMAB

Limited use benefit (prior approval required).

For the treatment of:

  • psoriasis according to established criteria.

(Please refer to Appendix A).

Table: BRODALUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
210MG Solution 02473623 SILIQ VAE

CALCIPOTRIOL

Table: CALCIPOTRIOL
Drug strength and dosage form DIN Brand name Manufacturer code
50MCG/G Ointment 01976133 DOVONEX LEO

CAPSAICIN

Table: CAPSAICIN
Drug strength and dosage form DIN Brand name Manufacturer code
0.025% Cream 02157101 CAPSAICIN VAE
0.025% Cream 02244952 ZODERM EUR
0.025% Cream 00740306 ZOSTRIX VAE
0.075% Cream 02157128 CAPSAISIN VAE
0.075% Cream 02004240 ZOSTRIX HP VAE

COLLAGENASE

Table: COLLAGENASE
Drug strength and dosage form DIN Brand name Manufacturer code
250U Ointment 02063670 SANTYL SNE

DUPILUMAB

Limited use benefit (prior approval required).

Initial coverage criteria (4 months):

For adult patient with chronic moderate to severe atopic dermatitis who meet all the following criteria:

  • patient has a score greater than or equal to 16 on the Eczema Area and Severity Index (EASI); and
  • patient has a score greater than or equal to 8 on the Dermatology Life Quality Index (DLQI); and
  • body surface area (BSA) of 10% or more is affected; and
  • the disease is insufficiently controlled despite the use of topical treatments including at least two medium or high-potency topical corticosteroids and one topical calcineurin inhibitor; and
  • intolerance or lack of response to phototherapy or inability to access phototherapy.

Criteria for renewal or for initial coverage in patients currently maintained on Dupixent (12 months):

  • patient has an improvement of at least 75% in the EASI score compared to the baseline level; or
  • patient has an improvement of at least 50% in the EASI score; and
  • patient has had a decrease of at least five points on the DLQI questionnaire compared to the baseline.
Table: DUPILUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Solution 02470365 DUPIXENT SAC

FLUOROURACIL

Table: FLUOROURACIL
Drug strength and dosage form DIN Brand name Manufacturer code
5% Cream 00330582 EFUDEX VAE

IMIQUIMOD

Table: IMIQUIMOD
Drug strength and dosage form DIN Brand name Manufacturer code
5% Cream 02239505 ALDARA P BSH
5% Cream 02407825 APO-IMIQUIMOD APX
5% Cream 02482983 TARO-IMIQUIMOD PUMP TAR

ISOTRETINOIN

Open benefit (prior approval not required).

Soriatane should be used with caution in clients of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings should be consulted prior to prescribing or dispensing this drug.

Table: ISOTRETINOIN
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Capsule 00582344 ACCUTANE ROCHE HLR
ST10MG Capsule 02257955 CLARUS MYL
10MG Capsule 02396971 EPURIS CIP
20MG Capsule 02396998 EPURIS CIP
30MG Capsule 02397005 EPURIS CIP
ST40MG Capsule 00582352 ACCUTANE ROCHE HLR
ST40MG Capsule 02257963 CLARUS MYL
40MG Capsule 02397013 EPURIS CIP

IXEKIZUMAB

Limited use benefit (prior approval required).

For the treatment of:

  • psoriatic arthritis according to established criteria.
  • psoriasis according to established criteria.

(Please refer to Appendix A).

Table: IXEKIZUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
80MG Solution 02455102 TALTZ LIL
80MG Solution 02455110 TALTZ LIL

LUBRICANT

Table: LUBRICANT
Drug strength and dosage form DIN Brand name Manufacturer code
Vaginal Gel 09991643 CAYA DIAPHRAGM TSN
Vaginal Gel 09991644 CONTRAGEL GREEN TSN

PIMECROLIMUS

Limited use benefit (prior approval required).

For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment.

Table: PIMECROLIMUS
Drug strength and dosage form DIN Brand name Manufacturer code
1% Cream 02247238 ELIDEL VAE

PODOFILOX

Table: PODOFILOX
Drug strength and dosage form DIN Brand name Manufacturer code
0.5% Solution 01945149 CONDYLINE SAC

PODOPHYLLIN

Table: PODOPHYLLIN
Drug strength and dosage form DIN Brand name Manufacturer code
25% Liquid 00598208 PODOFILM PAL

RISANKIZUMAB

Limited use benefit (prior approval required).

For the treatment of patients with moderate to severe psoriasis

(Please refer to Appendix A).

Table: RISANKIZUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
90MG Solution 02487454 SKYRIZI ABV

SALICYLIC ACID, FLUOROURACIL

Table: SALICYLIC ACID, FLUOROURACIL
Drug strength and dosage form DIN Brand name Manufacturer code
10% & 0.5% Solution 02428946 ACTIKERALL CIP

SECUKINUMAB

Limited use benefit (prior approval required).

For the treatment of:

  • psoriasis according to established criteria.
  • psoriatic arthritis according to established criteria.
  • ankylosing spondylitis according to established criteria.

(Please refer to Appendix A).

Table: SECUKINUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
150MG/ML Injection 99101215 COSENTYX (STYLO) NVC
150MG/ML Injection 09857548 COSENTYX PEN (ON) NVC
150MG Solution 02438070 COSENTYX NVR

TACROLIMUS (PROTOPIC)

Limited use benefit (prior approval required).

For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment.

Note: Contraindicated in children less than 2 years of age.

Table: TACROLIMUS (PROTOPIC)
Drug strength and dosage form DIN Brand name Manufacturer code
0.03% Ointment 02244149 PROTOPIC LEO
0.1% Ointment 02244148 PROTOPIC LEO

TAZAROTENE

Table: TAZAROTENE
Drug strength and dosage form DIN Brand name Manufacturer code
0.05% Cream 02243894 TAZORAC ALL
0.1% Cream 02243895 TAZORAC ALL
0.05% Gel 02230784 TAZORAC ALL
0.1% Gel 02230785 TAZORAC ALL
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