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FLUPHENAZINE

PROLIXIN

HALOPERIDOL

HALDOL

Pergolide Mesylate

Permax

Pramipexole

Mirapex

MESORIDAZINE

SERENTIL

Molindone HCL

Moban

PROCHLORPERAZINE

COMPAZINE

Rivastigmine

Exelon

Galantamine

Reminyl

Therapeutic Class

Generic Name

Brand Name

SELEGILINE

ELDEPRYL

TRIHEXYPHENIDYL HCL

ARTANE

ANTI-PSYCHOTIC AGENTS CHLORPROMAZINE

THORAZINE

ALZHEIMER AGENTS

ALPRAZOLAM

XANAX

CLORAZEPATE DIPOTASSIUM

TRANXENE

DIAZEPAM

VALIUM

FLURAZEPAM

DALMANE

LORAZEPAM

ATIVAN

OXAZEPAM

SERAX

TEMAZEPAM

RESTORIL

TRIAZOLAM

HALCION

CHLORAL HYDRATE

HYDROXYZINE HCL

ATARAX

HYDROXYZINE PAMOATE

VISTARIL

ACETAMINOPHEN/

MIDRIN

DICHLORALPHENAZONE/

ISOMETHEPTENE

ASPIRIN/ CAFFEINE/

FIORNAL

BUTALBITAL

ACETAMINOPHEN/ CAFFEINE/

FIORCET

BUTALBITAL

ERGOLOID MESYLATES

HYDERGINE

ANXIOLYTICS, SEDATIVES & HYPNOTICS

Benzodiapines

Misc. Anxiolytics, Sedatives & Hypnotics

Migraine & Headache Agents

8

CHP

Relative Cost

x

$$$$$

x

$$$

x xC

$$$ $

x

>$$$$$

x

$$$$

xC

$$$

xC

$$$

xC

$

xC

$

xC

$$$$

xC

$$

x

$

x

$$$$

R

$

R x

$ $$

x

$$

R x

$ $$

x

$

x

$$

x x

$$ $

x

$$

x

$$

x

$

Tab, CapSA, ALL Oral Conc, Syr, Supp Tab, Elixir 1mg, 2.5mg,

/ 5 m g , 1 0 m g , Tab, Oral Conc 25mg, 50mg, 100mg, Tab, CapSA, 2.5mg, 5mg,

VERSION 05/2004

CHP Restrictions

Restricted to Psychiatry

Restricted to Psychiatry

Restricted to Psychiatry

Restricted to Psychiatry

Restricted to Psychiatry

Restricted to Psychiatry

Restricted to Psychiatry

Restricted to Cerebral Palsy, Athetoid States or Spinal Cord

D ti Restricted to use in the treatment

of Insomnia

Restricted to use in the treatment of Insomnia

Tab

0.5mg, 1mg,

Tab, Cap

2mg 10mg, 15mg,

Cap

30mg 15mg, 30mg

Tab, Cap

325/40/50mg

Tab

325/40/50mg, 500-40-50mg

SL

1mg

Tab, Oral Conc

Tab, Liq

10mg 5mg/mL 0.5mg, 1mg,

2mg, 5mg, 10mg, 20mg, 10mg, 25mg, 50mg, 100mg,

Syr, Supp

10mg, 15mg, 25mg, 30mg,

Cap

1.5mg, 3mg,

Tab

4 5mg 6mg 4mg, 8mg, 12mg

Tab

0.125mg,

Cap, Supp,

0 25mg 500mg,

Syr

250mg/5mL,

Tab, Syr

00 / 10mg, 25mg,

50mg, 100mg,

Cap

10 / 25mg, 50mg

Cap

65/100/325mg

Form

Strength

Cap

15mg, 30mg

Tab, Soln

0.25mg, 0.5mg, 1mg, 2mg, 0.5mg/mL, 3.75mg, 7.5mg, 15mg, 11.25mg,

Tab, Cap, Single Dose

Tab

22 5 2mg, 5mg, 10mg

Tab

Tab

Tab, Cap Tab, Liq

0.05mg,

0 25mg 1mg 0.125mg,

0.25mg, 1mg,

1 5mg

2mg, 5mg, 2mg/5mL

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