Clickable Table
| Generic Name | Brand Name | Strength | Dosing | 90 Day Cost | Coverage | Comments | Category 1 | Category 2 |
|---|---|---|---|---|---|---|---|---|
| Minocycline | Minocin | 100 mg | QD x 90 days | $35 | BC - Covered / IA - SA | L Topicals | Acne Treatments | |
| Tretinoin Cream | Stieva-A (25g tube) | 0.025% | As dir | $25 | BC - SA / IA Covered | L Topicals | Acne Treatments | |
| Permethrin | Nix | 1% | As dir | $25 | BC / IA - Covered | L Topicals | Lice | |
| Dimethicone | Nyda | 50% | As dir | $40 | BC / IA - Covered | L Topicals | Lice | |
| Pyrethrins/Piperonyl Butoxide | R&C | 0.33%/3% | As dir | $25 | BC / IA - Covered | L Topicals | Lice | |
| Isopropyl Myristate | Resultz | 50% | As dir | $30 | BC / IA - Covered | L Topicals | Lice | |
| Imiquimod | Aldara (24x250mg) | 5% | As dir | $300 | BC / IA - SA | L Topicals | Miscellaneous Topicals | |
| Betamethasone/Calcipotriol | Dovobet (60g tube) | 0.05/0.005% | As dir | $115 | BC / IA - Covered | L Topicals | Miscellaneous Topicals | |
| Tacrolimus | Protopic (30g tube) | 0.03% | As dir | $90 | BC / IA - SA | L Topicals | Miscellaneous Topicals | |
| Betamethasone Valerate | Betaderm/Betnovate | 0.10% | As dir | $15 | BC / IA - Covered |
Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. |
L Topicals | Topical Corticosteroids |
| Hydrocortisone | Cortate | 1.00% | As dir | $20 | BC / IA - Covered |
Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. |
L Topicals | Topical Corticosteroids |
| Amcinonide | Cyclocort | 0.10% | As dir | $20 | BC / IA - Covered |
Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. |
L Topicals | Topical Corticosteroids |
| Clobetasol 17-propionate | Dermovate | 0.05% | As dir | $20 | BC / IA - Covered |
Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. |
L Topicals | Topical Corticosteroids |
| Desonide | Desonate | 0.05% | As dir | $25 | BC / IA - Covered |
Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. |
L Topicals | Topical Corticosteroids |
| Betamethasone Dipropionate Glycol | Diprolene | 0.05% | As dir | $30 | BC / IA - Covered |
Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. |
L Topicals | Topical Corticosteroids |
| Betamethasone Dipropionate | Diprosone | 0.05% | As dir | $20 | BC / IA - Covered |
Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. |
L Topicals | Topical Corticosteroids |
| Mometasone Furoate | Elocom | 0.10% | As dir | $35 | BC / IA - Covered |
Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. |
L Topicals | Topical Corticosteroids |
| Isotretinoin | Accutane | 40 mg | QD x 90 days | $205 | BC / IA - Covered | L Topicals | Acne Treatments | |
| Benzoyl Peroxide/Clindamycin | Clindoxyl (45g tube) | 5%/1% | As dir | $50 | BC - SA / IA Covered | L Topicals | Acne Treatments | |
| Adapalene | Differin (60g tube) | 0.10% | As dir | $150 | BC - NC; IA - Covered | L Topicals | Acne Treatments |