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Therapeutic Class

Generic Name

Brand Name

Nalidixic Acid NITROFURANTOIN

Nitrofurantoin macrocrystals

Neg-Gram

FURADANTIN, MACRODANTIN Macrobid

TRIMETHOPRIM/ SULFAMETHOXAZOLE

BACTRIM

Anti- Spasmodics

BETHANECHOL CL

URECHOLINE

OXYBUTYNIN CHOLRIDE Tolterodine tartrate

DITROPAN Detrol

MORPHINE SULFATE

MSIR

OXYCODONE HCL

ROXICODONE

HYDROCODONE/ ACETAMINOPHEN

VICODIN

Opiate Agonists

CODEINE/ ACETAMINOPHEN

TYLENOL #2, TYLENOL #3, TYLENOL #4, TYLENOL w/ CODEINE

OXYCODONE/ ACETAMINOPHEN

PERCOCET

AZATHIOPRINE METHOTREXATE

IMURAN RHEUMATREX

Auranofin PENICILLAMINE

Ridaura CUPRIMINE

Fentanyl

Duragesic

HYDROMORPHONE

DILAUDID

14

MUSCULOSKELETAL AGENTS ACETAMINOPHEN ASPIRIN Analgesics

CARDURA

MINIPRESS Flomax

HYTRIN PYRIDIUM

TYLENOL

BPH

DOXAZOSIN MESYLATE

PRAZOSIN HCL Tamsulosin Hydrochloride

Analgesics

TERAZOSIN HCL PHENAZOPYRIDINE HCL

DICLOFENAC POTASSIUM

CATAFLAM, VOLTAREN, VOLTAREN-XR

Anti-Rheumatoid Drugs

Gold Compounds

Heavy Metal Antagonists

NON STEROIDAL ANTI-INFLAMMATORY AGENTS

Celecoxib

Celebrex

VERSION 05/2004

CHP

Relative Cost

x x

$$$ $

R x

$ $

x

$

90 R

$$ $$$$

CHP Restrictions

Macrocrystal

Restricted to Urology

Restricted to Oxybutin (Ditropan) intolerance. All patients on tolterodine will be converted to oxybutin for all new prescriptions. Exceptions will be patients with a history of oxybutin intolerance.

Tab, TabDS, 80-400mg, 160-

Susp

Tab

Tab, Syr Tab

800mg, 40-

200 /5 L 5mg, 10mg,

25mg 50mg

5mg, 5mg/5mL 1mg, 2mg

Tab

500mg, 1g

Cap, Susp

25mg, 50mg,

100mg,

Cap

/ 100mg

Form

Strength

Tab

1mg, 2mg, 4mg,

x

$$$

8mg

$

Cap

1mg, 2mg, 5mg

x

Cap

0.4mg

R

$$$

Tab, Cap

ALL

x

$$$

Tab

100mg, 200mg

x

$

Restricted to Urology for terazosin treatment failures

Tab Tab

50mg 2.5mg

x x

$$$ $$$

Cap Cap, Tab

3mg 125mg, 250mg

x x

$$$$ $$$

x x

$ $

QL

$$

QL

$

R

$$$$$

x

$$$

x x

$ >$$$$$

x

$$

Tab, Supp,

1mg, 2mg, 3mg,

Liq

4mg, 8mg,

ALL

ALL/

Tab, TabCR, 5mg, 10mg,

Cap, Oral Conc, Liq

20mg, 40mg, 80mg,

Tab, Cap

20mg/mL, 5/325mg,

5/500mg

Cap

15-325mg, 30- 325mg, 15- 300mg, 60- 300mg, 12- 120mg/5mL

Lozenges

ALL

ALL ALL

Tab, TabEC, ALL Chew, Buffered Tab 5/500mg

Restricted to max. 30 tabs/dispensing

Restricted to a max. dispensing qty. of 60 tabs or caps (15mg). Restricted to a max. dispensing qty.of 45 tabs or caps (30mg, 60mg)

Restricted to use in the treatment

of chronic and severe pain in

ti

t

Cap

100mg, 200mg

R

>$$$$$

Tab, TabER

25mg, 50mg,

R

$$

75mg, 100mg

Restricted to therapeutic failure or intolerance to all formulary generic NSAIDs plus a proton

Restricted to use for arthritis

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