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VERSION 05/2004

Therapeutic Class

Generic Name

CYCLOSERINE ETHAMBUTOL ETHIONAMIDE ISONIAZID

PYRAZINAMIDE RIFABUTIN

RIFAMPIN

RIFAMPIN/ ISONIAZID RIFAMPIN/ ISONIAZID/ PYRAZINAMIDE

SEROMYCIN

Cap

250mg

x

$$$$$

MYAMBUTOL

Tab

100mg,400mg

x

$$$$

TRECATOR-SC

Tab

150mg

x

$$$$$

LANIAZID

Tab, Syr

50mg, 100mg,

90

$

300mg,

PYRAZINAMIDE

Tab

0/ 500mg

x

$$$

MYCOBUTIN

Cap

150mg

R

$$$$

Brand Name

Form

Strength

150mg, 300mg

x

$$$

300-150mg

x

$$$$$

125-50-300mg

x

$$$$$

CHP Restrictions

RIMACTANE

Cap

RIFAMATE

Cap

RIFATER

Tab

CHP

Relative Cost

Restricted to use in the prevention of disseminated Mycobacterium avium complex (MAC) disease in patients with advanced HIV

Efavirenz

Sustiva

Ganciclovir Sodium

Cytovene

Indinavir

Crixivan

Lamivudine (3TC)

Epivir

Nelfinavir Mesylate

Viracept

Nevirapine

Viramune

Ritonavir

Norvir

Saquinavir

Invirase

Stavudine

Zerit

Zalcitabine (ddC)

Hivid

AMANTADINE

SYMMETREL

Atanavir

Reytaz

Didanosine (ddl)

Videx

CHLOROQUINE PHOSPHATE

ARALEN PHOSPHATE

HYDROXYCHLOROQUINE

PLAQUENIL

PRIMAQUINE

Pyrimethamine

Daraprim

QUININE

QUINAMM

ANTIVIRALS

(HIV/AIDS)

ACYCLOVIR

ZOVIRAX

ANTI- MALARIAL AGENTS

Anastrozole

Arimidex

AZATHIOPRINE

IMURAN

Busulfan

Myleran

CHLORAMBUCIL

LEUKERAN

Altretamine ANTI-NEOPLASTIC AGENTS

Hexalen

Cap, Tab, Susp

200mg, 400mg, 800mg,

Cap, Syr

200mg/5mL 100mg,

Caps

50mg/5mL 100mg, 150mg &

Chew, Soln

200mg 25mg, 50mg,

Tab

100mg, 150mg, 167mg, 250mg, 50mg, 100mg,

Oral Cap

200mg 600mg 250mg, 500mg

R

xC

R

R

R

Cap

Tab, Soln

Tab, Oral

Pwd Tab

Cap, Soln

Cap

Cap

Tab

150mg,

xC

10mg/mL 250mg, 625mg,

xC

200mg 50mg/g

xC

200mg, 400mg

100mg,

600mg/7 5mL 200mg

15mg, 20mg,

30mg 40mg 0.375mg,

  • 0

    75mg

x R

xC

xC xC

R

$

Restricted to use in herpes genitalis (Herpes simplex 2) immunocompromised patients,

$

Restricted to HIV, Infectious

$$$$

Disease Services Restricted to HIV, Infectious

$$$

Disease Services Restricted to HIV, Infectious

Disease Services

$$$$$

Restricted to HIV, Infectious

$$$$$ $$$$$ $$$$

Disease Services Restricted to HIV, Infectious

Disease Services Restricted to HIV, Infectious

Disease Services Restricted to HIV, Infectious

>$$$$$

Disease Services Restricted to HIV, Infectious

$$$$ >$$$$$

Disease Services Restricted to HIV, Infectious

Disease Services Restricted to HIV, Infectious

>$$$$$ $$$$

Disease Services Restricted to HIV, Infectious

Disease Services Restricted to HIV, Infectious

$$$

Disease Services Restricted to HIV, Infectious

Disease Services

Tab

250mg, 500mg

x

Tab

200mg

x

Tab

26.3mg

x

Tab

25mg

x

Tab, Cap

180mg, 200mg,

x

260mg, 300mg,

Cap

50mg

x

$ $$ $ $ $

x

>$$$$$

x

$$$

x

$$

x

$

Restricted to Hematology/

Oncology or approval of attending Restricted to Hematology/

Oncology Restricted to Hematology/

Oncology Restricted to Hematology/

Oncology

Tab

1mg

Tab

50mg

Tab

2mg

Tab

2mg

3

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