Ear, Nose and Throat
Ear Preparations, Miscellaneous

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
A/B Otic generic.gif (400 bytes)
antipyrine-benzocaine		 5.4-1.4 % Drops   approved.gif (510 bytes)  

$
Auralgan
Benzocaine-Antipyrine		   nonform.gif (625 bytes)  

Not Applicable
Domeboro generic.gif (400 bytes)
calcium acetate-aluminum sulf		 952-1,347 mg Powder in Packet   approved.gif (510 bytes)  

$
TriOxin
chloroxylenol-benzoc-hydrocort		 Drops, Suspension   nonform.gif (625 bytes)  

Not Applicable
VoSol generic.gif (400 bytes)
acetic acid		 2 % Solution   approved.gif (510 bytes)  

$

Key for Product(s) Listed Above
Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary
(Third tier coverage applies for selected plans)		 Not Reimbursed
Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans.
Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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