DERMATOLOGICALS/TOPICAL THERAPY TOPICAL CORTICOSTEROIDS ** Ingredient Cost Per Therapy Click on notes for additional information Brand/Generic Name Dosage/Strength Status Notes Ingredient Cost Aclovate Alclometasone Dipropionate     Unknown Anusol-HC Hydrocortisone Acetate Suppository - 25 mg     $10-$20 Aristocort A Triamcinolone Acetonide     $10-$20 Aristocort R Triamcinolone Acetonide Cream     < $10 Aristocort R Triamcinolone Acetonide Ointment     < $10 Betamethasone Valerate Betamethasone Valerate     $10-$20 Clobex Clobetasol Propionate Lotion     Unknown Clobex Spray Clobetasol Propionate     Unknown Cloderm Clocortolone Pivalate     Unknown Cordran Flurandrenolide Tape   $60-$70 Cordran Flurandrenolide     $50-$60 Cordran SP Flurandrenolide     Unknown Cormax Clobetasol Propionate     Unknown Cutivate Fluticasone Propionate     Unknown Cyclocort Amcinonide     Unknown Dermacort Hydrocortisone     $20-$30 Desonate Desonide     Unknown DesOwen Desonide Cream     $10-$20 DesOwen Desonide Lotion     $30-$40 DesOwen Desonide Ointment     $10-$20 Diprolene Aug Betamethasone Dipropionate Ointment     $40-$50 Diprolene Aug Betamethasone Dipropionate     Unknown Diprolene Aug Betamethasone Dipropionate Lotion     Unknown Diprolene AF Aug Betamethasone Dipropionate     Unknown Diprosone Betamethasone Dipropionate Aerosol Soln     $20-$30 Diprosone Betamethasone Dipropionate Cream     $10-$20 Diprosone Betamethasone Dipropionate Lotion     $40-$50 Diprosone Betamethasone Dipropionate Ointment     < $10 Elocon Mometasone Furoate Cream     $30-$40 Elocon Mometasone Furoate Lotion     $30-$40 Elocon Mometasone Furoate Ointment     $30-$40 Halog Halcinonide     Unknown Hytone Hydrocortisone Cream - 2.5 %   $10-$20 Hytone Hydrocortisone Lotion - 2.5 %   $10-$20 Hytone Hydrocortisone Ointment - 2.5 %   $10-$20 Kenalog Triamcinolone Acetonide     $40-$50 Kerol Redi-Cloths Urea     Unknown Lidex Fluocinonide     $10-$20 Lidex-E Fluocinonide Emulsified Base     $10-$20 Locoid Hydrocortisone Butyrate     Unknown Maxivate Betamethasone Dipropionate Cream     $10-$20 Maxivate Betamethasone Dipropionate Lotion     $10-$20 Maxivate Betamethasone Dipropionate Ointment     < $10 Nutracort Hydrocortisone Lotion - 2.5 %     $10-$20 Olux Clobetasol Propionate     Unknown Olux-E Clobetasol Propionate Emulsion Foam - 0.05 %     Unknown Pandel Hydrocortisone Probutate     Unknown Psorcon Diflorasone Diacetate     Unknown Psorcon E Diflorasone Diacet Emoll Base     Unknown Synalar Fluocinolone Acetonide     < $10 Temovate Clobetasol Propionate     $30-$40 Topicort Desoximetasone     $30-$40 Topicort LP Desoximetasone     $30-$40 Tridesilon Desonide Ointment     Unknown Ultravate Halobetasol Propionate     Unknown Vanos Fluocinonide Cream     Unknown Verdeso Desonide Foam     Unknown Westcort Hydrocortisone Valerate     $20-$30 Key for Product(s) Listed Above (click on symbol for full definition) Formulary (Brand non-formulary if Generic available)   Prior Authorization Required (Once approved Brand and Generic, if available, are formulary) Non-Formulary (Brand and Generic, if available, are non-formulary)  Not Reimbursed  Generic Available Notes or Restrictions    Brand and Generic are Formulary   Disclaimer: This is not a comprehensive list of all products covered on the formulary. Formulary status, ingredient cost, and/or copay may vary subject to availability of newly approved dosage forms and/or strengths. If you have additional questions regarding your prescription drug benefit, please contact Member Services.

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