Iowa <strong>ADAP</strong> FORMULARIES ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivudine/zidovudine (Trizivir), didanosine (ddI, Videx), lamivudine (Epivir, 3TC), lamivudine/zidovudine (Combivir), stavudine (d4T, Zerit), tenofovir (Viread), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir). PIs- amprenavir (Agenerase), indinavir (Crixivan), lopinavir/ritonavir (Kaletra), nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Fortovase). NnRTIs- delavirdine (Rescriptor), efavirenz (Sustiva), nevirapine (Viramune). Other- hydroxyurea (Hydrea). OI DRUGS PHS “A1 OI”s- acyclovir (Zovirax), azithromycin (Zithromax), clarithromycin (Biaxin), fluconazole (Diflucan), itraconazole (Sporonox), TMP/SMX (Bactrim, Septra). Other OIs- atovaquone (Mepron), clotrimazole (Mycelex), dapsone, ethambutol (Myambutol), ketoconazole (Nizoral), nystatin (Mycostatin), pentamidine (Pentam), rifabutin (Mycobutin). Hepatitis C- none. Kansas ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivudine/zidovudine (Trizivir), didanosine (ddI, Videx, Videx EC), lamivudine (Epivir, 3TC), lamivudine/zidovudine (Combivir), stavudine (d4T, Zerit), tenofovir (Viread), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir). PIs- amprenavir (Agenerase), indinavir (Crixivan), lopinavir/ritonavir (Kaletra), nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Fortovase, Invirase). NnRTIs- delavirdine (Rescriptor), efavirenz (Sustiva), nevirapine (Viramune). Other- hydroxyurea (Hydrea). OI DRUGS PHS “A1 OI”s- acyclovir (Zovirax), azithromycin (Zithromax),clarithromycin (Biaxin), famciclovir (Famvir), fluconazole (Diflucan), ganciclovir (Cytovene), itraconazole (Sporonox), TMP/SMX (Bactrim, Septra). Other OIs- atovaquone (Mepron), clindamycin (Cleocin), clotrimazole (Mycelex), dapsone, ethambutol (Myambutol), ketoconazole (Nizoral), Metronidazole (Flagyl), nystatin (Mycostatin), paromomycin (Humatin), pentamidine (Nebupent), rifabutin (Mycobutin). Hepatitis C- none. TREATMENTS FOR METABOLIC DISORDERS Wasting- dronabinol (Marinol), megestrol acetate (Megace), oxandrolone (Oxandrin). ALL OTHERS amitriptyline, cephalexin (Keflex), cephalexin hydrochloride (Keftab), clonazepam (Klonopin), trazodone (Desyrel). Kentucky ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivudine/zidovudine (Trizivir), didanosine (ddI, Videx, Videx EC), lamivudine (Epivir, 3TC), lamivudine/zidovudine (Combivir), stavudine (d4T, Zerit), tenofovir (Viread), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir). PIs- amprenavir (Agenerase), indinavir (Crixivan), lopinavir/ritonavir (Kaletra), nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Fortovase). NnRTIs- delavirdine (Rescriptor), efavirenz (Sustiva), nevirapine (Viramune). OI DRUGS PHS “A1 OI”s- acyclovir (Zovirax), azithromycin (Zithromax), clarithromycin (Biaxin), fluconazole (Diflucan), leucovorin (Wellcovorin), TMP/SMX (Bactrim, Septra). Other OIs- ciprofloxacin (Cipro), clindamycin (Cleocin), clotrimazole (Mycelex), dapsone, ethambutol (Myambutol), ketoconazole (Nizoral), nystatin (Mycostatin), primaquine, rifabutin (Mycobutin). Hepatitis C- none. TREATMENTS FOR METABOLIC DISORDERS Wasting- megestrol acetate (Megace). ALL OTHERS prenatal vitamins. Louisiana ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivudine/zidovudine (Trizivir), didanosine (ddI, Videx), lamivudine (Epivir, 3TC), lamivudine/zidovudine (Combivir), stavudine (d4T, Zerit), tenofovir (Viread), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir). PIs- amprenavir (Agenerase), indinavir (Crixivan), lopinavir/ritonavir (Kaletra), nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Fortovase, Invirase). NnRTIs- delavirdine (Rescriptor), efavirenz (Sustiva), nevirapine (Viramune).
Maine <strong>ADAP</strong> FORMULARIES ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivudine/zidovudine (Trizivir), didanosine (ddI, Videx, Videx EC), lamivudine (Epivir, 3TC), lamivudine/zidovudine (Combivir), stavudine (d4T, Zerit), tenofovir (Viread), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir). PIs- amprenavir (Agenerase), indinavir (Crixivan), lopinavir/ritonavir (Kaletra), nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Fortovase). NnRTIs- delavirdine (Rescriptor), efavirenz (Sustiva), nevirapine (Viramune). Other- hydroxyurea (Hydrea). OI DRUGS PHS “A1 OI”s- acyclovir (Zovirax), azithromycin (Zithromax), cidofovir (Vistide), clarithromycin (Biaxin), famciclovir (Famvir), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporonox), leucovorin, pyrazinamide, pyrimethamine (Daraprim, Fansidar), rifampim, sulfadiazine, TMP/SMX (Bactrim). Other OIs- ciprofloxacin (Cipro), dapsone, ethambutol (Myambutol), pentamidine (Nebupent). Hepatitis C- none. Maryland ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivudine/zidovudine (Trizivir), didanosine (ddI, Videx), lamivudine (Epivir, 3TC), lamivudine/zidovudine (Combivir), stavudine (d4T, Zerit), tenofovir (Viread), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir). PIs- amprenavir (Agenerase), indinavir (Crixivan), lopinavir/ritonavir (Kaletra), nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Fortovase, Invirase). NnRTIs- delavirdine (Rescriptor), efavirenz (Sustiva), nevirapine (Viramune). Other- hydroxyurea (Hydrea). OI DRUGS PHS “A1 OI”s- acyclovir (Zovirax), azithromycin (Zithromax), cidofovir (Vistide), clarithromycin (Biaxin), famciclovir (Famvir), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (Nydrazid, Rifamate), itraconazole (Sporonox), leucovorin, pyrazinamide, pyrimethamine (Daraprim, Fansidar), rifampim (Rifadin, Rimactane), sulfadiazine, TMP/SMX (Bactrim). Other OIs- amphotericin B (Fungisone), atovaquone (Mepron), ciprofloxacin (Cipro,Ciloxan), clindamycin (Cleocin), clotrimazole (Lotrimin, Mycelex), dapsone, daunorubicin citrate liposomal (DaunoXome), ethambutol (Myambutol), epoetin alpha (Epogen, Procrit), filgrastim (Neupogen), fomivirsen (Vitravene), ketoconazole (Nizoral), miconazole (Monistat), nystatin (Mycostatin), paromomycin (Humatin), pentamidine (Pentam, Nebupent), rifabutin (Mycobutin), valacyclovir (Valtrex). Hepatitis C- interferon alpha-2A (Roferon-A, Intron-A). TREATMENTS FOR METABOLIC DISORDERS Hyperlipidemia- atorvastatin (Lipitor), pravastatin (Pravachol). Wasting- megestrol acetate (Megace), nandrolone, oxandrolone (Oxandrin), testosterone (injection and patches), thalidomide (Thalomid). ALL OTHERS amitriptyline (Elavil), buproprion (Wellbutrin, Zyban), citalopran HBr (Celexa), clotrimazole/betamethasone (Lotrisone Cream), diphenoxylate-atropine (Lomotil), divalproex (Depakote, Depakene), fluoxetine (Prozac), fluphenazine (Prolixin), gabapentin (Neurontin), haldoperidol (Haldol), hydroxizine (Atarax), imiquimod (Aldara), loperamide (Imodium), nortriptyline (Aventlyl, Pamelor), octreotide (Sandostatin), olanzapine (Zyprexa), oxymetholone (Anadrol-50), paroxetine (Paxil), prochlorperazine (Compazine), risperidone (Risperdal), sertraline (Zoloft), trazadone (Desyrel/Desyrel Dividose). Massachusetts ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivudine/zidovudine (Trizivir), didanosine (ddI, Videx, Videx EC), lamivudine (Epivir, 3TC), lamivudine/zidovudine (Combivir), stavudine (d4T, Zerit), tenofovir (Viread), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir). PIs- amprenavir (Agenerase), indinavir (Crixivan), lopinavir/ritonavir (Kaletra), nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Fortovase, Invirase). NnRTIs- delavirdine (Rescriptor), efavirenz (Sustiva), nevirapine (Viramune). Other- hydroxyurea (Hydrea). OI DRUGS PHS “A1 OI”s- acyclovir (Zovirax), azithromycin (Zithromax), cidofovir (Vistide), clarithromycin (Biaxin), famciclovir (Famvir), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporonox), leucovorin, pyrazinamide, pyrimethamine (Daraprim, Fansidar), rifampim, sulfadiazine, TMP/SMX (Bactrim). Hepatitis C- all FDA approved drugs. ALL OTHERS Open Formulary - All FDA approved drugs are covered except the following: Specific open formulary exclusions: antirheumatic injectables (e.g. Enbrel), botulinum toxin (e.g. botox, mylobloc) compounded medications for infusion, active medication containing more than one ingredient, gonadotropin, finasteride (Propecia), hyaluronic acid derivatives (e.g. Hyalgan, Synvisc), immune globulin intravenous IGIV (e.g. sandoglobulin, Venoglobulin), injectable muscle relaxants (e.g. Lioresal), mifepristone, minoxidil (Rogaine), monoclonal antibodies (e.g. Remicade, Synagis), propoxyphene, recombinant human growth hormone HGH (e.g. Geref, Humatrop), Viagra. Class Exculsions:fertility drugs, fluorides, herbal medicaitons, immunizing biologicals, iron, less than effective drugs, nutritional supplements, over the counter mediations exceptions:(Acetaminophen, Imodium and Metamucil), sex-reassignment drugs, smoking cessaton drugs, vitamins and minerals.
Change language