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Expectorants

GUAIFENESIN

ROBITUSSIN ROBITUSSIN AC SSKI

Liq

100mg/5mL

x x x

$ $ $

GUIAFENESIN/ CODEINE POTASSIUM IODIDE SATURATED SOLN

Liq, Syr Oral Drop

100mg-10mg/5m 1g/mL

PROMETHAZINE w/ CODEINE

PHENERGAN w/ CODEINE

Syrup

6.25mg-10mg/5m

x

$

PROMETHAZINE w/ CODEINE/ PHENYLEPHRINE

PHENERGAN VC w/ CODEINE

Liq

6.25mg-5mg- 10mg/5mL

x

$

PROMETHAZINE w/ DEXTROMETHORPHAN

PHENERGAN-DM

Syrup

6.25-15mg/5mL

x

$

PROMETHAZINE/ PHENYLEPHRINE

PHENERGAN VC

Liq

6.25mg-5mg/5m

x

$

BROMPHENIRAMINE & PSEUDOEPHEDRINE

BROMFED

CapCR, Elixir, Syr

12-120mg, 6- 60mg, 1- 15mg/5mL, 4- 5/2mg

x

$

BROMODIPHENHYDRAMINE /CODEINE

BROMANYL

Liq

x

$

TRIPROLIDINE HCL/ PSEUDOEPHEDRINE

ALLERFRIM

Tab, Syr

1.5-30mg/5mL

x

$

DEXTROMETHORPHAN ANTITUSSIVE w/ EXPECTORANT (2 active ingredients)

BENYLIN DM GUIATUSS DM

Liq Liq

10mg/5ml

x x

$ $

DEXTROMETHORPHAN- GUAIFENESIN

Liq, Syr, TabSR

10-100mg/5mL

x

$

ANTITUSSIVE w/ NASAL DECONGESTANT & EXPECTORANT (3 active ingredients)

GUIATUSSIN DAC

Liq

x

$

17

Therapeutic Class

Antitussives

Strength

CHP

Relative Cost

15-1-4mg/mL

x

$

30-2-10mg/5mL

x

$

x

$

Gel, Soln Crm ,Gel,

1.5%, 2% 0.025%, 0.05%,

Top Liq Cm

0 1% 0 01% 1%

Top Oint

500units/g

Gel, Top Soln 1% , Lot, Swab

Gel, Soln

1.5%, 2%

PSEUDOEPHED- CARBINOXAMINE-DM

CARDEC-DM

Liq

PSEUDOEPHEDRINE- CHLORPHEN W/ CODEINE

Liq

ANTIHISTAMINE w/ NASAL DECONGESTANT (2 active ingredients)

Various

ERYTHROMYCIN

ERYDERM

TRETINOIN

RETIN-A, Retin-A Micro

SILVER SULFADIAZINE

SILVADENE

BACITRACIN

BACIQUENT

CLINDAMYCIN

CLEOCIN

ERYTHROMYCIN

ERYDERM

Nasal Decongestant

PSEUDOEPHEDRINE

SUDAFED

Restricted to failures on formulary agent(s)

Generic Name

x xAL

$$ $$$

Covered through age 21; Micro-Gel Non Formulary

x x PA

$ $ $

Restricted to failures on formulary agent(s)

x

$$

Acne SKIN AND MUCOUS MEMBRANE AGENTS BENZOYL PEROXIDE CLINDAMYCIN

BENZAC CLEOCIN

Tab, Liq, Syr 30mg, 60mg, 15mg/5mL, 0/

Gel

5%, 10%

Gel, Top Soln 1%

, Lot, Swa

b

Brand Name

Form

VERSION 05/2004

CHP Restrictions

Anti-Infectives

Antibiotic Topical Agents

x

$

PA

$

x

$

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