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Therapeutic Class

Generic Name

Pioglitazone

TEST STRIPS

Pituitary

SYRINGES Desmopressin Acetate

Thyroid & Anti- Thyroid Agents

LEVOTHYROXINE SODIUM

CHP

Relative Cost

R

$$$$

QL

$

QL PA

$ $$$$

NTI

$

DDAVP

Tab

SYNTHROID, LEVOTHROID, LEVOXYL

Tab

VERSION 05/2004

CHP Restrictions

Restricted to patients with inadequate control by a sulfonylurea or metformin; or use

One-Touch- Preferred; Qty. Limited to 120 strips per

di i Qty. Limited to 120 syringes per

dispensing

ONE TOUCH

0.1mg, 0.2mg, 100,cg/mL,

1/ ALL

Actos

Brand Name

Strength

15mg

Tab

Form

METHIMAZOLE

TAPAZOLE

Tab

5mg, 10mg

x

$$$$

PROPYLTHIOURACIL

PTU

Tab

50mg

x

$

Thyroid

Armour Thyroid

Tab Plain

ALL

90

$

Alendronate Sodium

Fosamax

Tab

70mg

R

$$$

Risedronate Sodium

Actonel

Tab

5mg, 30mg

R

$$$

Bisphosphonates

Restricted to Treatment of

Osteoporosis Restricted to treatment of

osteoporosis and Paget's Disease

POLYMYXIN/ BACITRACIN

POLYSPORIN

TOBRAMYCIN

TOBREX

TRIMETHOPRIM SULFATE & POLYMYXIN

POLYTRIM

Trifluridine

Viroptic Vira A BLEPH 10

Vidarabine SULFACETAMIDE SODIUM

DEXAMETHASONE/ NEOMYCIN/ POLYMYXIN

MAXITROL

DEXAMETHASONE/ TOBRAMYCIN

TOBRADEX

DICLOFENAC FLUOROMETHOLONE

VOLTAREN FML

Ketorolac Tromethamine PREDNISOLONE

Acular PRED FORTE

PREDNISOLONE/ NEOMYCIN/ POLYMYXIN B

POLY PRED

PREDNISOLONE/ SULFACETAMIDE

BLEPHAMIDE

Brinzolamide

Azopt

EYE, EAR, NOSE & THROAT PREPARATIONS

Anti-Virals-Eye

Sulfanomides-Eye

Anti- Inflammatory- Eye

Carbonic Anhydrase Inhibitor Eye

AK-TRACIN AK-POLY-BAC Chloromycetin, AK-Chlor

Ciloxan ILOTYCIN GARAMYCIN

NEOSPORIN

NEOMYCIN/ BACITRACIN/ POLYMYXIN

ERYTHROMYCIN GENTAMICIN

Ciprofloxacin HCL

Chloramphenicol

Anti-Infectives Antibiotic- Eye

BACITRACIN BACITRACIN-POLYMYXIN B

Ophth Oint Ophth Oint

Ophth Oint

500units/g

, 1%, 0.5%

x x x

$ $ $

Drop Ophth Soln

3.5mg/mL

Ophth Oint Ophth Oint

0.5% (5mg/g) , 0.3%, (3mg/g)

x x x

x

Soln Ophth Oint

Soln

, 3.5mg-400units- 10,000units/g, 1.75mg- 10,000units/0.0

$$$ $/$$ $

$

Ophth Oint

25mg/mL 10,000units/

x

$

Ophth Oint

500units/g , 0.3%

x

$

Soln Ophth Soln

1mg/10,000units

x

$

Ophth Oint, Soln

0.1%- 0.3%, 0.3%

Ophth Soln Ophth Oint

0.1% 0.1%, 0.25%

Ophth Soln Ophth Soln,

0.5% S0.125%, 1%,

Ophth Drop

1%

Ophth Oint

3%

Ophth Oint,

10%, 15%, 30%

Soln

Ophth Oint,

0.1%-3.5mg-

Susp

10,000units/g

Ophth Susp,

0.2%-10%

Oint

Ophth Susp.

1%, 5,50,15ml

Ophth Susp

  • 0

    12% 0 125%

    • 0.5

      %-0.35%-

10,000units/mL

x

$$$

x

$$

x

$

x

$$

x

$

x

$$$

x

$

R

$$$$

x

$

x

$

Restricted to use in Ophthamology

Restricted to Opthalmology

x

$

x

$$$

11

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