Standard Health Pals Formulary
Clotrimazole 1% / Betamethasone Dipropionate 0.05% Cream (Generic for Lotrisone)
Coverage Level – 100%
Copay – $0
Limitations – No more than 90 days’ supply; Limit 50 grams in 30 days; Limit 150 grams in 90 days
Restrictions – Health Pals Mail Order Pharmacy Network
Comments – Generic for Lotrisone