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Therapeutic Class

Generic Name

Triphasic

NORETHINDRONE/ ETHINYL ESTRADIOL

NORGESTIMATE/ETHINYL ESTRADIOL

NORGESTIMATE/ETHINYL ESTRADIOL

LEVONORGESTREL/ ETHINYL ESTRADIOL

Progestins

MEDROXYPROGESTERONE ACETATE

Contraceptives Non- Oral

Norethindrone CONDOMS

CONTRACEPTIVE SPONGES CONTRACEPTIVE FOAM w/ APPLICATOR

CONTRACEPTIVE VAGINAL SUPPOSITORIES

Estrogens

DIAPHRAGM COIL SPRING DIAPHRAGM JELLY Chlorotrianisene

Conjugated estrogens/ Medroxyprogesterone acetate Dienestrol

Diethylstilbestrol

ESTRADIOL

Estramustine Phosphate Estrogens Conjugated

ESTROPIPATE

Ethinyl Estradiol

ANTI-DIABETIC AGENTS Insulin Glargine Insulins

Insulin Lispro Insulin, Human

Sulfonylureas

Acetohexamide CHLORPROPAMIDE GLIPIZIDE GLYBURIDE

TOLAZAMIDE

TOLBUTAMIDE

Other AntiDiabetic Glucometer

At gen s METFORMIN HCL

Brand Name

Form

NECON 7-7-7

Tab

ORTHO TRI-CYCLEN

Tab

ORTHO TRI-CYCLEN LO

Tab

TRI-LEVLEN

Tab

PROVERA

Tab

Nor-QD

Tab

TODAY SPONGES EMKO FOAM

SEMICID

ORTHO GLYNOL

Tace

Cap

Prempro

Tab

Ortho Dienestrol

Vag Crm

Des

Tab, TabEC

ESTRACE

Tab

Emcyt

Cap

Premarin

Tab, Vag

Crm

Humalog

Inj

Iletin I, II, Novolin,

Inj

Humulin L, N, R, U,

50/50, 70/30

Dylemor

Tab

DIABINESE

Tab

GLUCOTROL

Tab

DIABETA, MICRONASE

Tab

OGEN

Tab, Vag Crm

Estinyl

Tab

TOLINASE

Tab

ORINASE

Tab

One Touch

GLUCOPHAGE

Tab

Lantus

Inj

10

VERSION 05/2004

CHP

Relative

Cost

90

$

Strength

CHP Restrictions

90

$$$

91

$$$

90

$

2.5mg, 5mg, 10mg

90

$

0.35mg/5mg

90 QL

$ $

x x

Qty. Limited to max. 24 condoms/ dispensing

x

x

x

x

$$

x

$$$

x

$$$

90

$

90

$$$

90

$

90

$

90

$

90

$

PA

$$/$$$$

PA

$$/$$$$

x

$$/$$$$

x

$$

90

$

90

$

90

$

90

$

90

$

PA

$$$

x

$$$

12mg, 25mg

    • 0.625

      -2.5mg,

    • 0.625

      -5mg,

04 0.01%

/1

1mg, 2.5mg,

5mg 50mg 0.5mg, 1mg,

2mg 140mg

    • 0.3

      mg,

    • 0.625

      mg,

    • 0.9

      mg, 1.25mg,

    • 2.5

      mg,

    • 0.75

      mg, 1.5mg,

3mg, 6mg,

01 % 0.02mg,

  • 0

    05mg 0 5mg

Approval by an Endocrinologist and documentation of "nocturnal

h l i" PA- for Lispro (Humalog), Pen Vials

and Cartridges

Sustained Release- Non-Formulary

One-Touch Basic

500mg, 850mg, 1000mg

250mg, 500mg

100mg, 250mg

5mg, 10mg

500mg 250mg, 500mg

1.25mg, 2.5mg, 5mg

100mg, 250mg,

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