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Ergotamine Tartrate Ergotamine Tartrate/ Caffeine

Ergomar, Ergostat Cafergot, Ercaf,

PROPRANOLOL

Wigraine INDERAL

Therapeutic Class

Generic Name

Brand Name

Bicalutamide Fluoxymesterone

Casodex Halotestin

FLUTAMIDE ETHYNODIOL DIACETATE/ ETHINYL ESTRADIOL

EULEXIN ZOVIA

LEVONORGESTREL/ ETHINYL ESTRADIOL

APRI

LEVONORGESTREL/ ETHINYL ESTRADIOL

LEVORA

NORETHINDRONE/ ETHINYL ESTRADIOL

NECON 0.5/35

NORETHINDRONE/ ETHINYL ESTRADIOL

NECON 1/35

NORGESTREL/ ETHINYL ESTRADIOL

OGESTREL

NORGESTREL/ ETHINYL ESTRADIOL

LOW-OGESTREL

ETHINYLl ESTRADIOL/DROSPIRENONE

YASMIN

HORMONES & SYNTHETIC SUBSTITUTES Adrenals

DEXAMETHASONE

DECADRON

HYDROCORTISONE

CORTEF

VALPROIC ACID

ENDOCRINE & HORMONES ALLOPURINOL COLCHICINE INDOMETHACIN Anti-Gout

PROBENECID PROBENEMID/ COLCHICINE

Contraceptives Monophasic

DEPAKENE

ZYLOPRIM COLCHICINE INDOCIN

BENEMID PROBENEMID

CORTENEMA

PRELONE

ORASONE

Androgens

HYDROCORTISONE RETENTION ENEMA

PREDNISOLONE

PREDNISONE

ETHINYLl ESTRADIOL/ETONOGESTREL

Nuva Ring

9

VERSION 05/2004

Tab, Elixir

0.25mg, 0.5mg, 0.75mg, 1mg, 1.5mg, 2mg,

x

$

Tab

4mg, 6mg, 5mg, 10mg,

x

$

Enema

20mg 100mg/60cc

x

$

CHP

Relative Cost

x x

$ $

90

90

$$$$

90 90 x

$ $$ $

90 x

$$$ $

Tab

0 50mg

0

x

>$$$$$

Tab

2mg, 5mg, 10mg

x

$$$

Cap

125mg

x

$$$

Tab

1mg/50mcg

90

$

Tab

0.1mg/0.02mg

90

$

Tab

0.15mg/0.03mg

90

$

Tab

0.5mg/0.035mg

90

$

Tab

0.035mg/ 1mg

90

$

Tab

0.5mg/ 50mcg

90

$$

Tab

0.3/0.03mg

90

$/$$

Tab

0.03mg/3mg.

90

$$$$

Restricted/ call plan

Form

Tab, TabSL Tab, Supp

Tab, Soln

Cap, Syr

Tab

Tab Cap, CapCR

Tab

Tab

Tab, Syr,

1mg, 5mg, 1%,

Tab Susp

15mg/5mL 1mg, 2.5mg,

5mg, 10mg,

x

$$$

90

$

Strength

1mg, 2mg

1/100mg, 2/100mg

10mg, 20mg, 40mg, 60mg, 80mg, 4mg/mL, 8mg/mL,

80mg/mL 250mg,

250mg/5mL

CHP Restrictions

Except Long Acting

100mg, 300mg

0.5mg, 0.6mg 25mg, 50mg,

75mg 500mg

90

$$$$

Vaginal Ring

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