84:00. Skin and Mucous Membrane Agents. 84:00 Skin and Mucous Membrane Agents
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1 Skin and Mucous Membrane Agents Skin and Mucous Membrane Agents
2 COMPOUND PRESCRIPTION COMPOUND - RETINOIC ACID (TRETINOIN) () MISCELLANEOUS COMPOUND To be used when the compound has been prepared and dispensed by a licensed community pharmacy COMPOUND - RETINOIC ACID (TRETINOIN) () MISCELLANEOUS COMPOUND To be used when the compound has been procured from a licensed compound and repackaging pharmacy and dispensed by a licensed community pharmacy. UNIT OF ISSUE - REFER TO PRICE POLICY 187 EFFECTIVE APRIL 1, 2018
3 84:04 ANTI-INFECTIVES COMPOUND PRESCRIPTION COMPOUND-ANTI-INFECTIVE () To be used when the compound has been prepared and dispensed by a licensed community pharmacy COMPOUND-ANTI-INFECTIVE () To be used when the compound has been procured from a licensed compound and repackaging pharmacy and dispensed by a licensed community pharmacy. PRODUCT IS NOT INTERCHANGEABLE 188 EFFECTIVE APRIL 1, 2018
4 84:04.04 ANTI-INFECTIVES (ANTIBACTERIALS) FUSIDIC ACID 2 % CREAM FUCIDIN LEO METRONIDAZOLE 1 % CREAM NORITATE 1 % GEL METROGEL 10 % VAGINAL CREAM FLAGYL GAL SAV METRONIDAZOLE/ NYSTATIN 500 MG * 100,000 UNIT VAGINAL OVULE FLAGYSTATIN SAV MUPIROCIN 2 % OINTMENT O-MUPIROCIN SODIUM FUSIDATE 2 % OINTMENT FUCIDIN LEO : ANTI-INFECTIVES ANTIFUNGALS (ALLYLAMINES) TERBINAFINE HCL 1 % CREAM LAMISIL 1 % SOLUTION LAMISIL NOV NOV : ANTI-INFECTIVES ANTIFUNGALS (AZOLES) KETOCONAZOLE 2 % CREAM KETODERM UNIT OF ISSUE - REFER TO PRICE POLICY 189 EFFECTIVE APRIL 1, 2018
5 84: ANTI-INFECTIVES ANTIFUNGALS (HYDROXYPYRIDONES) CICLOPIROX OLAMINE 1 % CREAM LOPROX :04.92 ANTI-INFECTIVES (MISCELLANEOUS LOCAL ANTI-INFECTIVES) SILVER SULFADIAZINE 1 % CREAM FLAMAZINE SNE :06 AMCINONIDE 0.1 % CREAM O-AMCINONIDE CYCLOCORT GSK BECLOMETHASONE DIPROPIONATE 250 MCG / G CREAM PROPADERM BETAMETHASONE DIPROPIONATE 0.05 % (BASE) CREAM RATIO-TOPISONE DIPROSONE 0.05 % (BASE) GLYCOL CREAM DIPROLENE GLYCOL RATIO-TOPILENE 0.05 % (BASE) OINTMENT RATIO-TOPISONE DIPROSONE 0.05 % (BASE) GLYCOL OINTMENT DIPROLENE GLYCOL RATIO-TOPILENE 0.05 % (BASE) LOTION RATIO-TOPISONE DIPROSONE 0.05 % (BASE) GLYCOL LOTION RATIO-TOPILENE BETAMETHASONE DIPROPIONATE/ SALICYLIC ACID 0.5 MG / G (BASE) * 30 MG / G OINTMENT DIPROSALIC 0.5 MG / ML (BASE) * 20 MG / ML LOTION RATIO-TOPISALIC DIPROSALIC PRODUCT IS NOT INTERCHANGEABLE 190 EFFECTIVE APRIL 1, 2018
6 84:06 BETAMETHASONE SODIUM PHOSPHATE 5 MG / ENM (BASE) RECTAL ENEMA BETNESOL (5MG/100ML) PAL BETAMETHASONE VALERATE 0.05 % (BASE) CREAM BETADERM MILD RATIO-ECTOSONE MILD 0.1 % (BASE) CREAM BETADERM REGULAR RATIO-ECTOSONE REGULAR 0.05 % (BASE) OINTMENT BETADERM MILD 0.1 % (BASE) OINTMENT BETADERM REGULAR 0.05 % (BASE) LOTION RATIO-ECTOSONE MILD 0.1 % (BASE) LOTION RATIO-ECTOSONE REGULAR 0.1 % (BASE) SCALP LOTION RATIO-ECTOSONE SCALP BUDESONIDE 2.3 MG / ENM RECTAL ENEMA ENTOCORT (115 ML) TPG CLOBETASOL 17-PROPIONATE 0.05 % CREAM MYLAN-CLOBETASOL RATIO-CLOBETASOL O-CLOBETASOL DERMOVATE 0.05 % OINTMENT MYLAN-CLOBETASOL RATIO-CLOBETASOL O-CLOBETASOL DERMOVATE 0.05 % SCALP LOTION MYLAN-CLOBETASOL RATIO-CLOBETASOL O-CLOBETASOL DERMOVATE MYP MYP MYP UNIT OF ISSUE - REFER TO PRICE POLICY 191 EFFECTIVE APRIL 1, 2018
7 84:06 COMPOUND PRESCRIPTION COMPOUND-CORTICOSTEROIDS - To be used when the compound has been prepared and dispensed by a licensed community pharmacy COMPOUND-CORTICOSTEROIDS - To be used when the compound has been procured from a licensed compound and repackaging pharmacy and dispensed by a licensed community pharmacy. DESONIDE 0.05 % CREAM PDP-DESONIDE 0.05 % OINTMENT PDP-DESONIDE PPH PPH PRODUCT IS NOT INTERCHANGEABLE 192 EFFECTIVE APRIL 1, 2018
8 84:06 DESOXIMETASONE 0.05 % CREAM TOPICORT MILD 0.25 % CREAM TOPICORT FLUOCINONIDE 0.05 % CREAM LIDEX LYDERM 0.05 % EMOLLIENT CREAM LIDEMOL TIAMOL 0.05 % OINTMENT LYDERM LIDEX 0.05 % GEL LYDERM LIDEX HALOBETASOL PROPIONATE 0.05 % CREAM ULTRAVATE HYDROCORTISONE 1 % CREAM EMO-CORT 1 % OCCLUSIVE CREAM PREVEX HC 0.5 % OINTMENT CORTODERM MILD 1 % OINTMENT CORTODERM REGULAR 1 % LOTION JAMP-HYDROCORTISONE 100 MG / ENM RECTAL ENEMA CORTENEMA (100MG/60ML) GSK GSK JPC AXC HYDROCORTISONE 17-VALERATE 0.2 % CREAM HYDROVAL 0.2 % OINTMENT HYDROVAL HYDROCORTISONE ACETATE 0.5 % CREAM HYDERM 1 % CREAM HYDERM DERMAFLEX HC 1 % LOTION DERMAFLEX HC 10 % RECTAL FOAM CORTIFOAM PAL PAL PAL UNIT OF ISSUE - REFER TO PRICE POLICY 193 EFFECTIVE APRIL 1, 2018
9 84:06 HYDROCORTISONE ACETATE/ PRAMOXINE HCL 1 % * 1 % RECTAL FOAM PROCTOFOAM-HC DUI HYDROCORTISONE ACETATE/ PRAMOXINE HCL/ ZINC SULFATE 10 MG * 20 MG * 10 MG RECTAL SUPPOSITORY PROCTODAN-HC SANDOZ ANUZINC HC PLUS ANUGESIC-HC 0.5 % * 1 % * 0.5 % RECTAL OINTMENT PROCTODAN-HC ANUGESIC-HC SDZ MCL MCL HYDROCORTISONE ACETATE/ ZINC SULFATE 10 MG * 10 MG RECTAL SUPPOSITORY ANODAN-HC SANDOZ ANUZINC HC ANUSOL-HC 0.5 % * 0.5 % RECTAL OINTMENT ANODAN-HC JAMPZINC-HC SANDOZ ANUZINC HC ANUSOL-HC SDZ CHD JPC SDZ CHD MOMETASONE FUROATE 0.1 % CREAM O-MOMETASONE ELOCOM 0.1 % OINTMENT RATIO-MOMETASONE ELOCOM 0.1 % LOTION O-MOMETASONE ELOCOM TRIAMCINOLONE ACETONIDE 0.1 % CREAM TRIADERM REGULAR ARISTOCORT R 0.5 % CREAM ARISTOCORT C 0.1 % OINTMENT ARISTOCORT R 0.1 % DENTAL PASTE ORACORT PRODUCT IS NOT INTERCHANGEABLE 194 EFFECTIVE APRIL 1, 2018
10 84:06.00 BETAMETHASONE DIPROPIONATE/ CLOTRIMAZOLE 0.05 % (BASE) * 1 % CREAM LOTRIDERM COMPOUND PRESCRIPTION (COMBINATION ANTI-INFECTIVE/ANTI-INFLAMMATORY AGENTS) COMBINATION ANTI-INFECTIVE /CORTICOSTEROID To be used when the compound has been prepared and dispensed by a licensed community pharmacy COMBINATION ANTI- INFECTIVE/CORTICOSTEROID To be used when the compound has been procured from a licensed compound and repackaging pharmacy and dispensed by a licensed community pharmacy. UNIT OF ISSUE - REFER TO PRICE POLICY 195 EFFECTIVE APRIL 1, 2018
11 84:06.00 HYDROCORTISONE/ CINCHOCAINE HCL/ FRAMYCETIN SULFATE/ ESCULIN 5 MG * 5 MG * 10 MG * 10 MG RECTAL SUPPOSITORY PROCTOL RATIO-PROCTOSONE SANDOZ PROCTOMYXIN HC 5 MG / G * 5 MG / G * 10 MG / G * 10 MG / G RECTAL OINTMENT PROCTOL RATIO-PROCTOSONE SANDOZ PROCTOMYXIN HC PROCTOSEDYL 84:08 (COMBINATION ANTI-INFECTIVE/ANTI-INFLAMMATORY AGENTS) SDZ SDZ AXC ANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE 5 % OINTMENT LIDODAN XYLOCAINE APC LIDOCAINE HCL 2 % JELLY LIDODAN XYLOCAINE JELLY APC PRODUCT IS NOT INTERCHANGEABLE 196 EFFECTIVE APRIL 1, 2018
12 84:28 KERATOLYTIC AGENTS COMPOUND PRESCRIPTION COMPOUND- SALICYLIC ACID () To be used when the compound has been prepared and dispensed by a licensed community pharmacy COMPOUND- SALICYLIC ACID () To be used when the compound has been procured from a licensed compound and repackaging pharmacy and dispensed by a licensed community pharmacy. 84:92 MISCELLANEOUS 5-FLUOROURACIL 50 MG / G CREAM EFUDEX UNIT OF ISSUE - REFER TO PRICE POLICY 197 EFFECTIVE APRIL 1, 2018
13 84:92 MISCELLANEOUS ACITRETIN 10 MG ORAL CAPSULE SORIATANE 25 MG ORAL CAPSULE SORIATANE ACV ACV AZELAIC ACID 15 % GEL FINACEA BAI CALCIPOTRIOL 50 MCG / G OINTMENT DOVONEX LEO CALCIPOTRIOL MONOHYDRATE/ BETAMETHASONE DIPROPIONATE 50 MCG / G (BASE) * 0.5 MG / G (BASE) OINTMENT DOVOBET 50 MCG / G (BASE) * 0.5 MG / G (BASE) GEL DOVOBET LEO LEO COLLAGENASE 250 UNIT / G OINTMENT SANTYL SNE ISOTRETINOIN 10 MG ORAL CAPSULE CLARUS ACCUTANE 40 MG ORAL CAPSULE CLARUS ACCUTANE MYP HLR MYP HLR TAZAROTENE 0.05 % GEL TAZORAC 0.1 % GEL TAZORAC ALL ALL PRODUCT IS NOT INTERCHANGEABLE 198 EFFECTIVE APRIL 1, 2018
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