To order additional copies, please call Massachusetts Medical
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Xxxxxx Anti-infectives Xxxxxx (Antifungals)<br />
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP<br />
CLOTRIMAzOLE TROCHE X* X* X X X X X<br />
CLOTRIMAzOLE TROCHE<br />
[Mycelex Troche]<br />
FE X X NC X<br />
ECONAzOLE topical X* X* X X X X X X X X<br />
FLUCONAzOLE PA* X1 X DL X X X X X X*<br />
FLUCONAzOLE (150 mg) DL* DL* X DL X X DL2 X X X<br />
FLUCONAzOLE [Diflucan] PA X PA X NC PA X<br />
FLUCONAzOLE [Diflucan 150 mg] DL DL PA X NC X<br />
gRIsEOFULVIN microsize X* X X X X X X X X X<br />
gRIsEOFULVIN ultramicrosize X* X* X X X X X X X X<br />
ITRACONAzOLE capsules PA* DL PA DL PA PA DL PA DL DL PA X X PA<br />
ITRACONAzOLE [sporanox] solution FE PA NC DL<br />
PA<br />
DL PA X X X X<br />
KETOCONAzOLE oral X* X* X X X X X X X X<br />
MICONAzOLE (OTC) NC NC X NC NC X X X<br />
NysTATIN oral X* X* X X X X X X X X<br />
TERBINAFINE oral PA* DL* PA DL PA DL DL PA DL3 DL4 PA DL X PA*<br />
TERBINAFINE oral [Lamisil] FE PA DL PA DL PA DL DL PA NC PA PA<br />
TERBINAFINE oral granules FE PA DL PA DL PA PA DL PA PA PA DL PA5 [Lamisil oral granules] sT<br />
VORICONAzOLE [Vfend] FE X* X PA X PA DL<br />
Anti-infectives (Antivirals)<br />
ACyCLOVIR X* X* X X X X X X X X*<br />
ADEFOVIR [Hepsera] X* X* X PA X X DL6 X PA7 X<br />
AMANTADINE X* X* X X X X X X X X*<br />
ENTECAVIR [Baraclude] FE X* X X DL6 X PA7 X<br />
ENTECAVIR solution [Baraclude] FE X* X X DL8 X PA9 X<br />
FAMCICLOVIR X* DL* X X X X X X X X*<br />
1 150 mg tabs limited to 5 tabs /30 days<br />
2 6 tabs/30 days<br />
3 90 tablets/12 months<br />
4 84 tabs/12 months<br />
5 ST for
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