Topical Agents
Scabicides/Pediculocides

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Elimite generic.gif (400 bytes)
permethrin		 5 % Cream   approved.gif (510 bytes)  

$$$
Eurax
crotamiton		 10 % Cream   approved.gif (510 bytes)  

$$$
Eurax
crotamiton		 10 % Lotion   approved.gif (510 bytes)  

$$$
lindane
lindane		 1 % Lotion   approved.gif (510 bytes)

ql.gif

$
lindane
lindane		 1 % Shampoo   approved.gif (510 bytes)

ql.gif

$
Lioresal generic.gif (400 bytes)
baclofen		 500 mcg/mL Solution   approved.gif (510 bytes)  

$$
Natroba generic.gif (400 bytes)
spinosad		 0.9 % Suspension   nonform.gif (625 bytes)  

Not Applicable
Ovide generic.gif (400 bytes)
malathion		 0.5 % Lotion   nonform.gif (625 bytes)

ql.gif

Not Applicable
Ulesfia
benzyl alcohol		 5 % Lotion   nonform.gif (625 bytes)

ql.gif

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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