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VERSION 05/2004

ALUMINUM/ MAGNESIUM HYDROXIDE GEL/ SIMETHICONE

MAALOX EXTRA STRENGTH

Anti-Diarrheals

DIPHENOXYLATE HCL/ ATROPINE SULFATE

LOMOTIL

BISMUTH SUBSALICYLATE

PEPTO BISMOL

Antiemetics

Attapulgite DIMENHYDRINATE

Donnagel DRAMAMINE

MECLIZINE HCL PROCHLORPERAZINE

ANTIVERT COMPAZINE

PROMETHAZINE

PHENERGAN

ANTISPASMOTIC & GI MOBILITY AGENTS BELLADONNA ALKALOIDS PB

DONNATAL

DICYCLOMINE

BENTYL

Glycopyrrolate METOCLOPRAMIDE HCL

Robinul REGLAN

Digestants

Propantheline Bromide PANCRELIPASE

Probanthine Creon 5, Creon 10, Creon 20, PANCREASE, VIOKASE, IIOZYME

Therapeutic Class

Generic Name

Brand Name

Chew, Liq

262mg, 262/15mL,

Chew, Liq

524 /15 L 600mg,

Chew, Liq

600mg/15mL 50mg,

Chew, Tab

12 5mg/5mL 12.5mg, 25mg

Tab, CapSA, Syr, Supp

2.5mg, 5mg, 15mg, 10mg, 25mg, 30mg, 5mg/5mL

Tab, Supp

12.5mg, 25mg, 50mg

Tab, Cap, Elixir

16.2mg, 16.2mg/5mL

Tab, Cap,

10mg, 20mg,

Syr Tab

10mg/5mL 1mg, 2mg

Syr

5mg, 10mg,

Tab

5mg/5mL 7.5mg, 15mg

Cap, Tab, Pwd, CapEC

5000units- 16600units- 18750units

CHP

Relative Cost

x

$

x

$

x

$

x x

$ $

x x

$ $

x

$

x

$

x

$$

x

$

x

$

x

$$

x

$$$$

Form

Strength

Chew, Susp

200-200-25mg, 500-450- 40mg/5mL

Tab, Soln

2.5-0.025mg, 2.5- 0.025mg/ 5mL

CHP Restrictions

URSODIOL

ACTIGALL

RANITIDINE

ZANTAC

SULFASALAZINE

AZULFIDINE

BISACODYL

DULCOLAX

DOCUSATE SODIUM

COLACE

Gallstone Solubilizing Agents

H2 Antagonists

Inflammatory

Bowel Disease Laxatives &

Cathartics

SODIUM PHOSPHATE

FLEET ENEMA,

Lansoprazole Misoprostol

PHOSPHO SODA Prevacid

Cytotec

SIMETHICONE

MYLICON

SUCRALFATE

CARAFATE

Proton Pump

Inhibitors Misc. GI Drugs

x

$$$$

x

$$$

x

$$

x x

$ $

x

$

QL R

$$$$$ $$$

x

$

R

$$

Chew, Drops 40mg, 80mg,

Tab, Susp

40mg/0 6mL 1g, 1g/10mL

Excluding OTC

Quantity restricted to 1 (one)

capsule/day Use in patients of any age with

documented HX of GI bleed, gastric ulcer or patients >65 on

Restricted to use in the treatment of duodenal ulcer lasting up to 90 days from the dispensing date of the first prescription, except when the dosage is reduced to that which is recommended as

Tab

75mg, 150mg,

300mg,

Tab

1/ 500mg

Cap

300mg

Ta, Supp Cap, Syr

Liq, Oral Soln

Cap

5mg, 10mg

50mg, 100mg, 250mg, 20mg/5mL,

50mg/15mL, 6g-16g/100mL,

18g-48g/100mL 30mg

Tab

100mcg, 200mcg

Anti-Infectives GENITOURINARY TRACT AGENTS METHENAMINE HIPPURATE METHENAMINE MANDELATE

HIPREX, UREX MANDELAMINE

Tab

1g

TabEC, Susp 500mg,

  • 0

    5g/5mL

x

$

x

$

13

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