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Tab

2mg, 4mg

x 90 x

$ $ $$

ALL Tab, Elixir

ALL

0.25mg, 0.5mg, 0.75mg, 1mg, 1.5mg, 2mg,

Tab, Syrup

4mg, 6mg, 10mg, 20mg,

90

$

Chew, Tab

10mg/5ml 4mg, 5mg, 10mg

R

$$$$

Tab, Liq, Syr 1mg, 5mg, 5mg/5mL,15mg/

x

$

Tab

1mg, 2.5mg, 5mg, 10mg,

90

$

Inhaler

00 21mcg

R

$$$$

Tab

2.5mg, 5mg ALL

x x

$$ $

Cap (SR), Tab, Elixir,

l Cap

4mg

x

$

Restricted to pediatrics, Allergy/ Immunology and Pulmonology

Restricted to Pediatrics, Adult

Allergy/ Immunology, and

Pl

l

Payment limited to a minimum dispensing quantity of 480cc

Brand Name

VENTOLIN VARIOUS DECADRON

METAPROTERENOL

ALUPENT

Montelukast

Singulair

PREDNISOLONE

PRELONE

PREDNISONE

ORASONE

Therapeutic Class

Generic Name

Oral

ALBUTEROL AMINOPHYLLINE DEXAMETHASONE

Form

Antihistamines

Strength

Salmeterol Xinafoate

Serevent

VERSION 05/2004

Terbutaline THEOPHYLLINE

BROMPHENIRAMINE MALEATE

Brethine

THEODUR, THEOLAIR, SLOBID DIMETANE

CHP Restrictions

CHP

Relative Cost

CARBINOXAMINE MALEATE/ PSEUDOEPHEDRINE

RONDEC

Tab, Liq

4-60mg, 1- 15mg/mL

x

$

CARBINOXAMINE MALEATE/ PSEUDOEPHEDRINE/ DEXTROMETHROPHAN

RONDEC-DM

Drops

2mg-25mg- 4mg/mL

x

$

Tab, Syr

5mg, 10mg, 5mg/5mL

SP

$$$

Tab, Liq

4mg, 2mg/5mL

x

$

Cetirizine

Zyrtec

CHLORPHENIRAMINE MALEATE CHLORTRIMETON

Restricted to use after treatment

with generic, sedating

tihi

t

i

Clemastine

Tavist

Fexofenadine

Allegra

DIPHENHYDRAMINE

BENADRYL

LORATADINE

CLARITIN

PROMETHAZINE

PHENERGAN

Expectorants & Cough Preparations

ANTIHISTAMINE W/ ANTITUSSIVE (2 active ingredients)

Antihistamine containing Combinations

PROMETHAZINE-DM ANTIHISTAMINE W/ ANTITUSSIVE & NASAL DECONGESTANT (3 active ingredients)

Various

PHENERGAN DM Various

PHENYLEPHRINE-CHLORPHEN-DM PSEUDOEPHED-CHLORPHEN-DM PSEUDOEPHED-BROMPHEN-DM

Tab

1.34mg

x

$

Tab only

60mg

SP

$$$

Cap, Tab,

25mg, 50mg,

x

$

Tab Only Elixir Syr

10mg 12 5mg/5mL

SP

$$

Tab, Syr,

12.5mg, 25mg,

x

$

Supp

50mg,

6.25mg/5mL,

x

$

Restricted to use after treatment

with generic, sedating

tihi

t

i

Restricted to generic antihistamines therapy failures, Allergy/ Immunology or

Syrup

6.25-15mg/5mL

x x

$ $

Syrup

10-2-15mg/5mL

x

Liq

15-1-5mg/5mL

x

Elixir, Syr

15-1-5mg/5mL

x

$ $ $

16

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