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VERSION 05/2004

Therapeutic Class

Generic Name

ANTI-INFECTIVE AGENTS METRONIDAZOLE

Brand Name

FLAGYL

Form

Strength

Tab, Cap, Gel (Top, Vag)

250mg, 500mg, 375mg, 0.75%

CHP

Relative Cost

x

$

CHP Restrictions

Amebicides

Anthelmintics

PAROMOMYCIN SULFATE CHLOROQUINE PHOSPHATE MEBENDAZOLE PYRANTEL PAMOATE

Thiabendazole

ANTIBIOTICS- ORAL NEOMYCIN Aminoglycosides

Cephalosporins

CEFACLOR

HUMATIN

Cap

250mg

x

>$$$$$

ARALEN PHOSPHATE

Tab

250mg, 500mg

x

$

VERMOX

Chew

100mg

x

$

ANTIMINTH, PIN-RID

Cap, Liq

180mg,

x

$

Mintezol

Chew, Susp

500mg, 50mg/ml

x

$$

500mg/mL

MYCIFRADIN

CECLOR

Tab, Soln

500mg,

Cap, TabER, Susp

125mg/5mL 250mg,375mg,

500mg, 125mg/5mL, 187mg/5mL,

x

R

$

$$

Restricted to use for members 50 years old and over w/ lower respiratory tract infections.

Cefixime

Suprax

Tab, Liq

250mg/5mL 200mg, 400mg,

100mg/5ml

x

$$$

Medical progress notes>age, location of infection, verification of physician

Macrolides

CEPHALEXIN

Azithromycin

KEFLEX

Zithromax

Cap, Susp

250mg, 500mg, 100mg/mL, 125mg/5mL, 250mg

x

Tab

R

$

$$$

Restricted (except for

powder packs) to Inpatient use, Public Health Powder for oral suspension (200mg/5ml): Restricted to individuals less than 8 years

old with otitis media

Powder

packet (1 g): Restricted to Public Health, Infectious Disease, or approval of attending physician Tablet: Restricted to treatment of urogenital chlamydia or

Clarithromycin

Biaxin

Tab, Susp

250mg, 500mg, 125mg/5mL, 250mg/5mL

R

$$$

incubating syphilis and MAC Restricted to use in the prevention

and treatment of infections caused by Mycobacterium organisms, treatment of active duodenal ulcer associated w/ Heliobactor pylori, and in individuals 50 years old and over w/ lower respiratory tract

ERYTHROMYCIN/ SULFISOXAZOLE

PEDIAZOLE

Susp

200- 600mg/5mL

x

$$

ERYTHROMYCIN BASE

E-MYCIN, ERY-TAB

ERYTHROMYCIN ETHYLSUCCINATE

EES

AMOXICILLIN TRIHYDRATE

TRIMOX

AMOXICILLIN/ CLAVULANATE POTASSIUM

AUGMENTIN

Penicillins

x

$

x

$

x

$

R

$$$$

Tab, TabDR, CapDR

250mg, 333mg, 500mg

Tab, Chew, Susp, Drops, Granules Tab, Chew, Cap, Susp, Drops

400mg, 200mg, 200mg/5mL, 400mg/5mL, 125mg, 250mg, 500mg, 875mg, 125mg/5mL,

Tab, Chew, Susp

250mg/5mL, ALL

Restricted to ENT, Infectious Disease, Mammalian Bites, or in individuals less than 8 years old

1

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