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AMPICILLIN

PRINCIPEN

DICLOXACILLIN

DYNAPEN

PENICILLIN VK

VEETID

Gatifloxacin

Tequin

Levofloxacin

Levaquin

SULFASALAZINE

AZULFIDINE

SULFISOXAZOLE

GANTRISIN

TRIMETHOPRIM/

BACTRIM

SULFAMETHOXAZOLE

DOXYCYCLINE

VIBRAMYCIN

MINOCYCLINE

MINOCIN

TETRACYCLINE

SUMYCIN

CLINDAMYCIN

CLEOCIN

Fluoroquinolones

Sulfonamides

Tetracyclines

Atovaquone

Mepron

METRONIDAZOLE

FLAGYL

Therapeutic Class

Generic Name

Brand Name

Miscellaneous

ANTI-PROTOZOAL & TRICHOMONACIDES

AntiFungal

Fluconazole

Diflucan

Flucytosine GRISEOFULVIN

Ancobon

FULVICIN-PG, GRIS- PEG, GRISACTIN

Itraconazole

ULTRA, GRIFULVIN V Sporanox

NYSTATIN

Voriconazole

Vfend

ANTI-TUBERCULOSIS AGENTS Clofazimine

Lamprene

2

VERSION 05/2004

CHP

Relative Cost

x

$

x

$

x

$

PA

$$$

R

$$$

x

$$

x

$

x

$

x x

$ $

x

$

R

$

R

$$$$

x

$

Tab, Susp 500mg, 5 0 0 m g / 5 m L T a b , T a b D S , 4 0 0 m g / 8 0 m g ,

Tab, Cap, Gel 250mg, 500mg,

(Top, Vag)

375mg, 0.75%

Restricted to systemic use only.

(Topical use requires Prior

A

th

i

ti

)

Restricted to use in the treatment or prevention of Pneumocystis carinii pneumonia in patients who are tolerant to trimethoprim/

Cap, Susp, Drops

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

Cap, Susp

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

Tab, Soln

62 5mg/5mL 125mg, 250mg,

Tab

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

Susp

Tab, Cap

800mg/160mg,

2 0 0 4 0 / 5 5 0 m g , 1 0 0 m g

L

Cap, Susp

Tab, Cap, Susp

Cap

50mg, 75mg,

100mg,

0/ 100mg, 250mg,

500mg,

1/ 75mg, 150mg,

300mg

Oral Susp (Tab see notes)

750mg/ 5ml (250mg)

CHP Restrictions

Form

Strength

Tab

250mg, 500mg

Tab

500mg

Restricted to uncomplicated urinary tract infections or

i t i d i R e s t r i c t e d t o u s e i n t r e a t m e n t s i n

compliance w/ CDC guidelines for

STD Tablet (enteric coated);

Restricted to Rheumatology,

G

t

t

l

Tab

50mg, 100mg,

150mg, 200mg

R

$$$

Restricted to Dermatology, Podiatry, Endocrinology, Infectious Disease or diagnosis of onychomycosis, peripheral vascular disease, diabetes, HIV, recurrent cellulitis. Restricted also to Hematology for prophylaxis of serious fundal infections in patients with hematologic

Cap

Tab, Susp

250mg, 500mg

125mg, 165mg, 250mg, 330mg, 125mg/5mL

x DF

>$$$$$ $$$

li

i

ii

Tab, Cap (UltraMicrosize Only) Liq (Microsize Only)

100mg

R

>$$$$$

100,000units/g

x

$

50mg, 100mg

PA

>$$$$$

Cap

Vag Tab, Oint, Crm, Tab, Susp, Tab

Restricted to use in cancer patients, in patients with AIDS or AIDS- related conditions, in the treatment of vaginal candidiasis, and in the treatment of infections

Restricted to Infectious Disease Specialist or neutropenic patients with suspected aspergillosis

Cap

50mg, 100mg

x

$$

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