Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

clotrimazole clotrimazole 1 % Cream; 1 % Cream     Not Applicable Ertaczo sertaconazole Cream     Not Applicable Exelderm sulconazole 1 % Cream     $$$ Exelderm sulconazole 1 % Solution     $$$ Extina ketoconazole Foam     Not Applicable Loprox ciclopirox Cream     $ Loprox ciclopirox Shampoo     $ Lotrisone clotrimazole-betamethasone Cream     $$ Lotrisone clotrimazole-betamethasone Lotion     Not Applicable Mentax butenafine Cream     Not Applicable Mycolog II nystatin-triamcinolone 100,000-0.1 unit/g-% Cream     $ Mycolog II nystatin-triamcinolone 100,000-0.1 unit/gram-% Ointment     $ Mycostatin nystatin 100,000 unit/g Cream     $ Naftin naftifine 1 % Cream   Not Applicable Naftin naftifine 1 % Gel   Not Applicable Nizoral ketoconazole 2 % Shampoo     $$$ Oxistat oxiconazole 1 % Cream     Not Applicable Oxistat oxiconazole 1 % Lotion     Not Applicable Pedipirox-4 ciclopirox-nail lacq-foot no.4 8 % Kit     Not Applicable Penlac ciclopirox Solution     $ Spectazole econazole 1 % Cream     $$ Xolegel ketoconazole 2 % Gel     Not Applicable

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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