English: Criteria for coverage include: a. - failure to respond to other listed topical antibiotics, or b. - contraindications to other listed topical antibiotics. 2MG & 10MG/ML Otic Suspension 02240035 CIPRO HC ALC ERYTHROMYCIN 5MG/G Ophth Ointment 02237041 ERYTHROMYCIN PHH 01912755 PMS-ERYTHROMYCIN PMS FRAMYCETIN SULFATE 0.5% Ophth Ointment 02224895 SOFRAMYCIN STERILE EYE ERF 0.5% Ophth Solution 02224887 SOFRAMYCIN ERF FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE 5MG & 0.05MG/G & 0.5MG Ointment 02224631 SOFRACORT EYE/EAR SAC GENTAMICIN SULFATE 0.3% Ophth Ointment 02023776 DIOGENT DKT 00028339 GARAMYCIN SCH 02230888 SANDOZ-GENTAMICIN SDZ 0.3% Solution 02023822 DIOGENT DKT 00512192 GARAMYCIN SCH 00512184 GARAMYCIN OTIC SCH 02219581 GENTAMICIN SPH 00776521 PMS-GENTAMICIN PMS 02230889 PMS-GENTAMICIN OTIC PMS 02229440 SANDOZ-GENTAMICIN SDZ 02229441 SANDOZ-GENTAMICIN OTIC SDZ GRAMICIDIN, NEOMYCIN SULFATE, POLYMYXIN B SULFATE 0.025MG & 2.5MG & 10,000U/ML Solution 00694371 NEOSPORIN EYE/EAR GSK 00807435 OPTIMYXIN PLUS EYE/EAR SDZ GRAMICIDIN, POLYMYXIN B SULFATE 0.025MG & 10,000U/ML Solution 00701785 OPTIMYXIN EYE/EAR SDZ 02239156 POLYSPORIN EYE/EAR WLA OFLOXACIN 0.3% Ophth Solution 02248398 APO-OFLOXACIN APX 02143291 OCUFLOX ALL 02252570 PMS-OFLOXACIN PMS POLYMYXIN B SULFATE, TRIMETHOPRIM SULFATE 10,000U & 1MG/ML Ophth Solution 02240363 PMS-POLYTRIMETHOPRIM PMS 02011956 POLYTRIM ALL SULFACETAMIDE SODIUM 10% Ophth Solution 02023830 DIOSULF DKT TOBRAMYCIN 0.3% Ophth Ointment 00614254 TOBREX ALC 0.3% Ophth Solution 02239577 PMS-TOBRAMYCIN PMS 02241755 SANDOZ-TOBRAMYCIN SDZ 00513962 TOBREX ALC Top of Page 52:04.20 EENT - ANTIVIRALS TRIFLURIDINE 1% Ophth Solution 02248529 SANDOZ-TRIFLURIDINE SDZ 00687456 VIROPTIC GSK 52:08.08 EENT - CORTICOSTEROIDS BECLOMETHASONE DIPROPIONATE 50MCG/DOSE Nasal Spray 02238796 APO-BECLOMETHASONE APX 02172712 GEN-BECLO AQ GEN 02237379 MED-BECLOMETHASONE AQ MEC 02238577 NU-BECLOMETHASONE NXP 00872318 RATIO-BECLOMETHASONE AQ RPH 02228300 RIVANASE AQ RIV BETAMETHASONE SODIUM PHOSPHATE, GENTAMICIN SULFATE 0.1% & 0.3% Ophth Ointment 00586706 GARASONE SCH 0.1% & 0.3% Solution 00682217 GARASONE OPHTH/OTIC SCH 02244999 SANDOZ-PENTASONE OPHTH/OTIC SDZ BUDESONIDE 64MCG/DOSE Nasal Spray 02241003 GEN-BUDESONIDE AQ GEN 02231923 RHINOCORT AQ AZC 100MCG/DOSE Nasal Spray 02230648 GEN-BUDESONIDE AQ GEN 100MCG/DOSE Powder 02035324 RHINOCORT TURBUHALER AZC DEXAMETHASONE 0.1% Ophth Ointment 00042579 MAXIDEX ALC 0.1% Ophth Solution 02023865 DIODEX DKT 00785261 PMS-DEXAMETHASONE PMS 00739839 SANDOZ-DEXAMETHASONE SDZ 0.1% Ophth Suspension 00042560 MAXIDEX ALC DEXAMETHASONE, TOBRAMYCIN 0.1% & 0.3% Ophth Ointment 00778915 TOBRADEX ALC 0.1% & 0.3% Ophth Suspension 00778907 TOBRADEX ALC FLUMETHASONE PIVALATE, CLIOQUINOL 0.02% & 1% Otic Solution 00074454 LOCACORTEN VIOFORM PAL FLUNISOLIDE 0.025% Nasal Solution 00878790 RATIO-FLUNISOLIDE RPH 02162687 RHINALAR IVX 0.025% Nasal Spray 02239288 APO-FLUNISOLIDE APX 01927167 PMS-FLUNISOLIDE PMS FLUOROMETHOLONE 0.1% Ophth Solution 02238568 PMS-FLUOROMETHOLONE PMS 0.1% Ophth Suspension 00247855 FML ALL 0.25% Ophth Suspension 00707511 FML FORTE ALL FLUOROMETHOLONE ACETATE 0.1% Ophth Solution 00756784 FLAREX ALC FLUTICASONE PROPIONATE 50MCG/DOSE Nasal Spray 02294745 APO-FLUTICASONE APX 02213672 FLONASE GSK 02296071 RATIO-FLUTICASONE RPH FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE 5MG & 0.05MG/ML & 0.5MG Ophth/Otic Solution 02247920 SANDOZ-OPTICORT SDZ 02224623 SOFRACORT EYE/EAR SAC HYDROCORTISONE, NEOMYCIN SULFATE, POLYMYXIN B SULFATE 10MG & 3.5MG & 10,000U/ML Otic Solution 01912828 CORTISPORIN GSK 02230386 SANDOZ-CORTIMYXIN SDZ 10MG & 5MG & 10,000U/ML Suspension 02025736 CORTISPORIN EYE/EAR GSK MOMETASONE FUROATE 50MCG Nasal Spray 02238465 NASONEX SCH PREDNISOLONE ACETATE 0.12% Ophth Suspension 00299405 PRED MILD ALL 01916181 SANDOZ-PREDNISOLONE SIL 1% Ophth Suspension 02023768 DIOPRED DKT 00301175 PRED FORTE ALL 00700401 RATIO-PREDNISOLONE RPH 01916203 SANDOZ-PREDNISOLONE SDZ PREDNISOLONE ACETATE, SULFACETAMIDE SODIUM 0.2% & 10% Ophth Ointment 00307246 BLEPHAMIDE ALL 0.5% & 10% Ophth Solution 02023814 DIOPTIMYD DKT 0.2% & 10% Ophth Suspension 00807788 BLEPHAMIDE ALL PREDNISOLONE SODIUM PHOSPHATE 0.5% Ophth Solution 02148498 PREDNISOLONE CUV TRIAMCINOLONE ACETONIDE 55MCG/DOSE Nasal Spray 02213834 NASACORT AQ SAC Top of Page 52:08.20 EENT - NONSTEROIDAL ANTI-INFLAMMATORY AGENTS DICLOFENAC SODIUM 0.1% Ophth Solution 01940414 VOLTAREN NVR FLURBIPROFEN SODIUM 0.03% Ophth Solution 00766046 OCUFEN ALL KETOROLAC TROMETHAMINE 0.5% Ophth Solution 01968300 ACULAR ALL 02245821 APO-KETOROLAC APX 02247461 RATIO-KETOROLAC RPH 52:20.00 EENT - MIOTICS CARBACHOL 1.5% Ophth Solution 00000655 ISOPTO CARBACHOL ALC 52:24.00 EENT - MYDRIATICS ATROPINE SULFATE 1% Ophth Ointment 00252484 ATROPINE ALC 1% Ophth Solution 02023695 ATROPINE DKT 02148358 ATROPINE SULPHATE MINIMS NVR 00035017 ISOPTO ATROPINE ALC CYCLOPENTOLATE HCL 0.5% Ophth Solution 02148331 CYCLOPENTOLATE NVR 1% Ophth Solution 00252506 CYCLOGYL ALC 02148382 CYCLOPENTOLATE MINIMS NVR 02023644 DIOPENTOLATE DKT DIPIVEFRIN HCL 0.1% Ophth Solution 02242232 APO-DIPIVEFRIN APX 02237868 PMS-DIPIVEFRIN PMS HOMATROPINE HBR 2% Ophth Solution 00000779 ISOPTO HOMATROPINE ALC 5% Ophth Solution 00000787 ISOPTO HOMATROPINE ALC 52:28.00 EENT - MOUTHWASHES AND GARGLES BENZYDAMINE HCL Limited use benefit (prior approval required).
French: Les critères d'utilisation comprennent: a. - inefficacité des autres antibiotiques topiques de la liste, ou b. - contre-indications aux autres antibiotiques topiques de la liste . 2MG & 10MG/ML Suspension otique 02240035 CIPRO HC ALC ÉRYTHROMYCINE 5MG/G Onguent ophtalmique 02237041 ERYTHROMYCIN PHH 01912755 PMS-ERYTHROMYCIN PMS FRAMYCÉTINE (SULFATE DE) 0.5% Onguent ophtalmique 02224895 SOFRAMYCIN ERF 0.5% Solution ophtalmique 02224887 SOFRAMYCIN ERF FRAMYCÉTINE (SULFATE DE), GRAMICIDINE, DEXAMÉTHASONE 5MG & 0.05MG/G & 0.5MG Onguent 02224631 SOFRACORT OPH./OT. SAC GENTAMICINE (SULFATE DE) 0.3% Onguent ophtalmique 02023776 DIOGENT DKT 00028339 GARAMYCIN SCH 02230888 SANDOZ-GENTAMICIN SDZ 0.3% Solution 02023822 DIOGENT DKT 00512192 GARAMYCIN SCH 00512184 GARAMYCIN OTIC SCH 02219581 GENTAMICIN SPH 00776521 PMS-GENTAMICINE PMS 02230889 PMS-GENTAMICINE OTIC PMS 02229440 SANDOZ-GENTAMICIN SDZ 02229441 SANDOZ-GENTAMICIN OTIC SDZ GRAMICIDINE, NÉOMYCINE (SULFATE DE), POLYMYXINE B (SULFATE DE) 0.025MG & 2.5MG & 10,000U/ML Solution 00694371 NEOSPORINE OPH./OT. GSK 00807435 OPTIMYXIN PLUS OPH./OT. SDZ GRAMICIDINE, POLYMYXINE B (SULFATE DE) 0.025MG & 10,000U/ML Solution 00701785 OPTIMYXIN OPH./OT. SDZ 02239156 POLYSPORIN OPH./OT. WLA OFLOXACINE 0.3% Solution ophtalmique 02248398 APO-OFLOXACIN APX 02143291 OCUFLOX ALL 02252570 PMS-OFLOXACIN PMS POLYMYXINE B (SULFATE DE), TRIMÉTHOPRIME (SULFATE DE) 10,000U & 1MG/ML Solution ophtalmique 02240363 PMS-POLYTRIMETHOPRIM PMS 02011956 POLYTRIM ALL SULFACÉTAMIDE SODIQUE 10% Solution ophtalmique 02023830 DIOSULF DKT TOBRAMYCINE 0.3% Onguent ophtalmique 00614254 TOBREX ALC 0.3% Solution ophtalmique 02239577 PMS-TOBRAMYCIN PMS 02241755 SANDOZ-TOBRAMYCIN SDZ 00513962 TOBREX ALC Haut de la page 52:04.20 O.R.L.O. - ANTIVIRAUX TRIFLURIDINE 1% Solution ophtalmique 02248529 SANDOZ-TRIFLURIDINE SDZ 00687456 VIROPTIC GSK 52:08.08 ORLO - CORTICOSTÉROïDE BUDÉSONIDE 100MCG/DOSE Poudre 02035324 RHINOCORT TURBUHALER AZC 64MCG/DOSE Vaporisateur nasal 02241003 GEN-BUDESONIDE AQ GEN 02231923 RHINOCORT AQ AZC 100MCG/DOSE Vaporisateur nasal 02230648 GEN-BUDESONIDE AQ GEN BÉCLOMÉTHASONE (DIPROPIONATE DE) 50MCG/DOSE Vaporisateur nasal 02238796 APO-BECLOMETHASONE APX 02172712 GEN-BECLO AQ GEN 02237379 MED-BECLOMETHASONE AQ MEC 02238577 NU-BECLOMETHASONE NXP 00872318 RATIO-BECLOMETHASONE AQ RPH 02228300 RIVANASE AQ RIV BÉTAMÉTHASONE (PHOSPHATE SODIQUE DE), GENTAMICINE (SULFATE DE) 0.1% & 0.3% Onguent ophtalmique 00586706 GARASONE SCH 0.1% & 0.3% Solution 00682217 GARASONE OPH./OT. SCH 02244999 SANDOZ-PENTASONE OPH./OT. SDZ DEXAMÉTHASONE 0.1% Onguent ophtalmique 00042579 MAXIDEX ALC 0.1% Solution ophtalmique 02023865 DIODEX DKT 00785261 PMS-DEXAMETHASONE PMS 00739839 SANDOZ-DEXAMETHASONE SDZ 0.1% Suspension ophtalmique 00042560 MAXIDEX ALC DEXAMÉTHASONE, TOBRAMYCINE 0.1% & 0.3% Onguent ophtalmique 00778915 TOBRADEX ALC 0.1% & 0.3% Suspension ophtalmique 00778907 TOBRADEX ALC FLUMÉTHASONE (PIVALATE DE), CLIOQUINOL 0.02% & 1% Solution otique 00074454 LOCACORTEN-VIOFORM PAL FLUNISOLIDE 0.025% Solution nasale 00878790 RATIO-FLUNISOLIDE RPH 02162687 RHINALAR IVX 0.025% Vaporisateur nasal 02239288 APO-FLUNISOLIDE APX 01927167 PMS-FLUNISOLIDE PMS FLUOROMÉTHOLONE 0.1% Solution ophtalmique 02238568 PMS-FLUOROMETHOLONE PMS 0.1% Suspension ophtalmique 00247855 FML ALL 0.25% Suspension ophtalmique 00707511 FML FORTE ALL FLUOROMÉTHOLONE (ACÉTATE DE) 0.1% Solution ophtalmique 00756784 FLAREX ALC FLUTICASONE (PROPIONATE DE) 50MCG/DOSE Vaporisateur nasal 02294745 APO-FLUTICASONE APX 02213672 FLONASE GSK 02296071 RATIO-FLUTICASONE RPH FRAMYCÉTINE (SULFATE DE), GRAMICIDINE, DEXAMÉTHASONE 5MG & 0.05MG/ML & 0.5MG Solution oto-ophtalmique 02247920 SANDOZ-OPTICORT SDZ 02224623 SOFRACORT OPH./OT. SAC HYDROCORTISONE, NÉOMYCINE (SULFATE DE), POLYMYXINE B (SULFATE DE) 10MG & 3.5MG & 10,000U/ML Solution otique 01912828 CORTISPORIN GSK 02230386 SANDOZ-CORTIMYXIN SDZ 10MG & 5MG & 10,000U/ML Suspension 02025736 CORTISPORIN OPH./OT. GSK MOMÉTASONE (FUROATE DE) 50MCG Vaporisateur nasal 02238465 NASONEX SCH PREDNISOLONE (ACÉTATE DE) 0.12% Suspension ophtalmique 00299405 PRED MILD ALL 01916181 SANDOZ-PREDNISOLONE SIL 1% Suspension ophtalmique 02023768 DIOPRED DKT 00301175 PRED FORTE ALL 00700401 RATIO-PREDNISOLONE RPH 01916203 SANDOZ-PREDNISOLONE SDZ PREDNISOLONE (ACÉTATE DE), SULFACÉTAMIDE SODIQUE 0.2% & 10% Onguent ophtalmique 00307246 BLEPHAMIDE ALL 0.5% & 10% Solution ophtalmique 02023814 DIOPTIMYD DKT 0.2% & 10% Suspension ophtalmique 00807788 BLEPHAMIDE ALL PREDNISOLONE (PHOSPHATE SODIQUE DE) 0.5% Solution ophtalmique 02148498 PREDNISOLONE CUV TRIAMCINOLONE (ACÉTONIDE DE) 55MCG/DOSE Vaporisateur nasal 02213834 NASACORT AQ SAC Haut de la page 52:08.20 ORLO - ANTI-INFLAMMATOIRE NON STÉROïDAL DICLOFÉNAC SODIQUE 0.1% Solution ophtalmique 01940414 VOLTAREN NVR FLURBIPROFÈNE SODIQUE 0.03% Solution ophtalmique 00766046 OCUFEN ALL KÉTOROLAC (TROMÉTHAMINE DE) 0.5% Solution ophtalmique 01968300 ACULAR ALL 02245821 APO-KETOROLAC APX 02247461 RATIO-KETOROLAC RPH 52:20.00 O.R.L.O.- MYOTIQUES CARBACHOL 1.5% Solution ophtalmique 00000655 ISOPTO CARBACHOL ALC 52:24.00 O.R.L.O. - MYDRIATIQUES ATROPINE (SULFATE D') 1% Onguent ophtalmique 00252484 ATROPINE ALC 1% Solution ophtalmique 02023695 ATROPINE DKT 02148358 ATROPINE SULPHATE MINIMS NVR 00035017 ISOPTO ATROPINE ALC CYCLOPENTOLATE (CHLORHYDRATE DE) 0.5% Solution ophtalmique 02148331 CYCLOPENTOLATE NVR 1% Solution ophtalmique 00252506 CYCLOGYL ALC 02148382 CYCLOPENTOLATE MINIMS NVR 02023644 DIOPENTOLATE DKT DIPIVÉFRINE (CHLORHYDRATE DE) 0.1% Solution ophtalmique 02242232 APO-DIPIVEFRIN APX 02237868 PMS-DIPIVEFRIN PMS HOMATROPINE (BROMHYDRATE D') 2% Solution ophtalmique 00000779 ISOPTO HOMATROPINE ALC 5% Solution ophtalmique 00000787 ISOPTO HOMATROPINE ALC Haut de la page 52:28.00 O.R.L.O. - RINCE-BOUCHE ET GARGARISMES BENZYDAMINE (CHLORHYDRATE DE) Médicament à usage restreint (autorisation préalable nécessaire).