X hits on this document

677 views

0 shares

0 downloads

0 comments

21 / 190

(ROTOCAPS)

Cap, Inh

200mcg,

Soln, Syr

0.083%, 0.5%,

VERSION 05/2004

Fluticasone/salmeterol

ROBAXIN

Tab

500mg, 750mg

PROVENTIL, VENTOLIN

Inhaler

90mcg/dose

PROVENTIL, VENTOLIN

Tab, TabER,

2mg, 4mg, 8mg,

Beclomethasone Budesonide Budesonide

QVAR Pulmicort Turbuhaler

Pulmicort Respules

CROMOLYN SODIUM

INTAL

Flunisolide Fluticasone Propionate

Aerobid, Aerobid-M Flovent

IPRATROPIUM BROMIDE

ATROVENT

Nedocromil Sodium SODIUM CHLORIDE FOR INHALATION

Tilade BRONCHO SALINE

Terbutaline

Brethaire

Triamcinolone Acetonide

Azmacort

x

$$$

R

$$$$$

R

$$$$$

x

$$$$

x

$$$$

R

$$$$

x

$$$

x

$$

x

$

x

$

x

$

Advair Diskus

Soln

20mg/mL

Oral Inhaler

250mcg

15

METHOCARBAMOL RESPIRATORY AGENTS ALBUTEROL

x

$$

x

$$

x

$$

Therapeutic Class

Generic Name

IBUPROFEN

INDOMETHACIN

Leflunomide

NAPROXEN

NAPROXEN SODIUM

PIROXICAM SALSALATE SULINDAC Rofecoxib

CARISOPRODOL CHLORZOXAZONE CYCLOBENZAPRINE HCL DANTROLENE SODIUM

Restricted to moderate to sever asthma

Anti-Asthmatic Inhalers/Solutions

ALBUTEROL

Oral Inhaler 100mcg

Restricted to pediatric patients

Restricted to pediatric patients

Restricted to patients w/ moderate to severe asthma

Excludes UNIT DOSE vials

MOTRIN

Tab, Susp

300mg, 400mg, 600mg, 800mg,

x

INDOCIN

Cap, CapCR

100 / 25mg, 50mg,

x

Arava

Tab

75mg 10mg, 20mg,

R

NAPROSYN, NAPRELAN

Tab, TabEC

100mg 250mg, 375mg,

x

500mg,

ANAPROX

Tab

1/ 275mg, 550mg

x

FELDENE DISALCID CLINORIL Vioxx

Cap

10mg, 20mg

R R R R

Tab, Cao

500mg, 750mg

Tab Tab

150mg, 200mg

12.5mg, 25mg, 50mg

SOMA

Tab

PARAFON FORTE DSC

Tab

FLEXERIL

Tab

DANTRIUM

Cap

Aero Inh

44mcg, 110mcg, 220mcg

Inh Soln,

18mcg, 0.02%

Neb Soln Oral Inhaler

1.75mg

Inh. Soln

0.9%, 3%, 10%, 0.45%

Aerosol w/ or w/o adapt

0.2mg

Miscellaneous

Skeletal Muscle Relaxants

PENTAZOCINE/ NALOXONE BACLOFEN

Relative Cost

$

CHP Restrictions

$$$$

Brand Name

Form

Strength

CHP

TALWIN NX

Tab

50mg/0.5mg

x

LIORESAL

Tab

10mg, 20mg

R

Oral Inhaler

40mcg, 80mcg

Pwd

200mcg

Soln

0.25mg/2mL,

Inh, Neb

0 5mg/2mL 800mcg/spray,

$

>$$$$$

$

Restricted to Rheumatology

$

R

Oral Inhaler

100mch/50mcg, 250mcg/50mcg, 500mcg/50mcg.

350mg

500mg

10mg

25mg, 50mg, 100mg

x x x R

$$ $ $ $$$

i

l

di j

Restricted to use in spasticity resulting from serious upper neuron disorders (that is, cerebral palsy and spastic hemiplegial), generalized demyelinating disease (that is, multiple scelrosis), and

$ $ $ >$$$$$

Restricted to use for arthritis

Restricted to use for arthritis

Restricted to use for arthritis

Restricted to therapeutic failure or intolerance to all formulary generic NSAIDs plus a proton pump inhibitor, Plus failure on trial

$$$$ $$

Restricted to use in spasticity resulting from multiple sclerosis or

Document info
Document views677
Page views677
Page last viewedThu Jan 19 18:04:17 UTC 2017
Pages190
Paragraphs4697
Words16946

Comments