Acne
Acne Formulary for Passport for patients 18yo and under
| Drug Name | Formulary Status |
|---|---|
|
ADAPALENE |
|
|
Adapalene Cream 0.1% |
Non-formulary |
|
Adapalene Gel 0.1% |
OTC covered, RX version requires PA |
|
Adapalene Gel 0.3% |
Non-formulary |
|
Adapalene Lotion 0.1% |
Non-formulary |
|
AZELAIC ACID |
|
|
Azelaic Acid Cream, Foam |
Non-formulary |
|
BENZOYL PEROXIDE |
|
|
Benzoyl Peroxide Liq- 4%, 5% , 10% |
Formulary |
|
Benzoyl Peroxide Cream-10% |
Formulary |
|
Benzoyl Peroxide Gel-2.5%, 5%, 10% |
Formulary |
|
Benzoyl Peroxide Foam-5.3%, 5.5%, 9.5%, 9.8% |
Non-formulary |
|
Benzoyl Peroxide Liquid-5.25%, 7% |
Non-Formulary |
|
Benzoyl Peroxide Gel-2.75%, 5.25% |
Non-formulary |
|
Benzoyl Peroxide Cloth 6% |
Non-formulary |
|
CLINDAMYCIN |
|
|
Clindamycin Phos Soln 1% |
Formulary |
|
Clindamycin Phos Swab, 1% |
Formulary |
|
Clindamycin Phos Gel-1%, Lotion-1% |
Formulary, Requires PA |
|
Clindamycin Phos Foam-1% |
Non-formulary |
|
DAPSONE |
|
|
Dapsone Gel 5% |
Non-formulary |
|
ERYTHROMYCIN |
|
|
Erythromycin Soln-2% |
Formulary |
|
Erythromycin Gel, Pads-2% |
Non-formulary |
|
SULFACETAMIDE SODIUM, SULFACETAMIDE W/SULFUR PRODUCTS, BRIMONIDINE PRODUCTS |
|
|
All products |
Non-formulary |
|
TAZAROTENE |
|
|
Tazarotene Cream-0.05%, 0.1 % |
Formulary, Requires PA |
|
Tazarotene Gel-0.05%, 0.1%, Foam-0.1% |
Non-formulary |
|
TRETINOIN |
|
|
Tretinoin Cream-0.025%, 0.05%, 0.1% |
Generic requires PA, Brand-Non-formulary |
|
Tretinoin Gel-0.1%, 0.025% |
Generic requires PA, Brand-Non-formulary |
|
Tretinoin Gel-0.05% |
Non-formulary |
|
Tretinoin Microsphere Gel-0.04%, 0.1% |
Non-formulary |
|
COMBO AGENTS |
|
|
Adapalene/Benzoyl Peroxide Gel-0.1/2.5%, 0.3/2.5% |
Non-formulary |
|
Benzoyl Peroxide/Erythromycin Gel-5/3% |
Generic requires PA, Brand-Non-formulary |
|
Clindamycin Phos/Benzoyl Peroxide (Refrig) Gel-1.2-5.0% |
Formulary, Requires PA |
|
Clindamycin Phos/Benzoyl Peroxide Gel-1.2-2.5%, 1.2-3.75%, 1-5% |
Non-formulary |
|
Clindamycin Phos/Tretinoin Gel-1.2-0.025% |
Non-formulary |
|
ORAL AGENTS - ISOTRETINOIN CAPS |
|
|
Isotretinoin Caps-10mg, 20mg, 30mg, 40mg Amnesteem Claravis Isotretinoin Myorisan Zenatane |
Formulary, Requires PA |
|
Absorica Caps-10mg, 20mg, 25mg, 30mg, 35mg, 40mg |
Non-formulary |
- All acne agents for 19yo and older are non-formulary
- Updated 3/2019