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Cyclophosphamide

Cytoxan

Etoposide

Vepesid

Fluorouracil (5-FU)

Efudex

HYDROXYUREA

HYDREA

LEUCOVORIN CALCIUM

WELLCOVORIN

Lomustine

CeeNU

MEGESTEROL ACETATE

MEGACE

Melphalan

Alkeran

Mercaptopurine

Purinethol

Therapeutic Class

Generic Name

Brand Name

METHOTREXATE Procarbazine

TAMOXIFEN CITRATE Thioguanine CARDIOVASCULAR AGENTS AMIODARONE DISOPYRAMIDE PHOSPHATE Antiarrhythmics

RHEUMATREX Matulane NOLVADEX

CORDARONE NORPACE

Top Crm,

1%, 2%, 5%

Cap Top Soln

500mg

Tab

25mg, 50mg

Cap

50mg

Tab, Susp

20mg, 40mg,

Tab

2mg 40mg/mL

Form

Strength

Tab

5mg, 10mg,

Cap Dosepak

15mg 25mg 10-40-100mg

Tab

50mg

Tab

2.5mg

Cap

50mg

Tab

10mg, 20mg

Tab

40mg

x

$$$

Oncology Restricted

x

$$

Oncology Restricted

x

$$$

Oncology Restricted

x

$

Oncology Restricted

x

$

Oncology Restricted

x

$$

Oncology Restricted

x

$

Oncology Restricted

x

>$$$$$

Oncology

Restricted

to Hematology/

Oncology & Restricted

Gastroenterology to Hematology/ Oncology

Restricted

to Hematology/ Oncology

VERSION 05/2004

R

$

x

$$$

x

$

x

$

x

$

to Hematology/

to Hematology/

to Hematology/

to Hematology/

to Hematology/

to Hematology/

to Hematology/

CHP

Relative Cost

CHP Restrictions

Restricted

to Hematology/

Tab

200mg

90

$$$$

Cap, CapSA

100mg, 150mg

90

$$$

Anticoagulants & Blood Modifiers

Antihyperlipemics

MEXILETINE HCL

PROCAINAMIDE

PROPRANOLOL

QUINIDINE GLUCONATE

QUINIDINE SULFATE Aspirin & Extended-Release

Dipyridamole DIPYRIDAMOLE

PENTOXIFYLLINE

WARFARIN SODIUM CHOLESTYRAMINE COLESTIPOL

GEMFIBROZIL Nicotinic Acid

Atorvastatin Calcium

QUINAGLUTE QUINIDEX, QUINORA Aggrenox

Tab

80mg/mL 324mg

90 90 PA

Tab, TabSA Cap

200mg, 300mg 25mg/200mg

PERSANTINE

Tab

25mg, 50mg,

90

TRENTAL

Tab

75mg 400mg

R

MEXTIL

Cap

150mg, 200mg,

90

PROCAN, PRONESTYL

Cap, Tab,

250mg 250mg, 375mg,

90

TabSR

500mg, 750mg,

INDERAL

Tab, Soln

1000 10mg, 20mg,

90

40mg, 60mg, 80mg, 4mg/mL, 8mg/mL,

Tab Pwd

ALL 210gm, 378gm

Granules

300g, 500g, 5g

Tab Tab

pkt 600mg

25mg, 50mg,

Tab

100mg 500mg 80mg

COUMADIN

NTI

QUESTRAN

x

COLESTID

x

LOPID

90

Niacin

x

Lipitor

R

$$$

Restricted to Cardiology

$$$

$

Except Long Acting

$$ $$ $$$$

Restricted to secondary prevention in patients with

$

i

h

i

t

k

TIA

$$

Restricted to use for patients 65 years of age or older diagnosed with intermittent claudication, or for diabetic patients of any age diagnosed with intermittent

$$ $$$ $$$

(Reg & Light)

$ $

$$$$

Restricted to Cardiology and Endocrinology for first prescriptionsand simvastatin

LOVASTATIN

Pravastatin

Simvastatin

MEVACOR

Tab

10mg, 20mg,

x

$$

Pravachol

Tab

40mg 10mg, 20mg,

x

$$$$

Zocor

Tab

40mg 5mg, 10mg,

x

$$$$

20mg, 40mg, 0

Generic Only

4

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