Kentucky Ma<strong>in</strong>e ADAP FORMULARIES New drugs added s<strong>in</strong>ce June 2002 <strong>in</strong>dicated <strong>in</strong> bold. ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivud<strong>in</strong>e/zidovud<strong>in</strong>e (Trizivir), didanos<strong>in</strong>e (ddI, Videx, Videx EC), lamivud<strong>in</strong>e (Epivir, 3TC), emtricitab<strong>in</strong>e (Emtriva), lamivud<strong>in</strong>e/zidovud<strong>in</strong>e (Combivir), stavud<strong>in</strong>e (d4T, Zerit), tenofovir (Viread), zalcitab<strong>in</strong>e (ddC, Hivid), zidovud<strong>in</strong>e (AZT, Retrovir). PIs- amprenavir (Agenerase), atazanavir (Reyataz), fosamprenavir (Lexiva), <strong>in</strong>d<strong>in</strong>avir (Crixivan), lop<strong>in</strong>avir/ritonavir (Kaletra), nelf<strong>in</strong>avir (Viracept), ritonavir (Norvir), saqu<strong>in</strong>avir (Fortovase Invirase). NNRTIs- delavird<strong>in</strong>e (Rescriptor), efavirenz (Sustiva), nevirap<strong>in</strong>e (Viramune). Other- hydroxyurea (Hydrea). OI DRUGS PHS “A1 OI”s- acyclovir (Zovirax), azithromyc<strong>in</strong> (Zithromax), clarithromyc<strong>in</strong> (Biax<strong>in</strong>), fluconazole (Diflucan), isoniazid (INH), itraconozole (Sporonox), leucovor<strong>in</strong> (Wellcovor<strong>in</strong>), sulfadiaz<strong>in</strong>e (Microsulfon), TMP/SMX (Bactrim, Septra). Other OIsciprofloxac<strong>in</strong> (Cipro), cl<strong>in</strong>damyc<strong>in</strong> (Cleoc<strong>in</strong>), clotrimazole (Mycelex), dapsone, ethambutol (Myambutol), ketoconazole (Nizoral), nystat<strong>in</strong> (Mycostat<strong>in</strong>), Primaqu<strong>in</strong>e, rifabut<strong>in</strong> (Mycobut<strong>in</strong>), rifamp<strong>in</strong>/rimactane (Rifid<strong>in</strong>), trimethoprim (Proloprim), valgancyclovir (Valcyte), loperamide (Imodium), pantoprazole (Protonix), promethaz<strong>in</strong>e HCI (Phenergan), Prenatal Vitam<strong>in</strong>s, Vacc<strong>in</strong>es for Hepatitis A&B. Hepatitis C- none. TREATMENTS FOR METABOLIC DISORDERS Wast<strong>in</strong>g- megestrol acetate (Megace). Removed 2003- pentamid<strong>in</strong>e (NebuPent). Louisiana ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivud<strong>in</strong>e/zidovud<strong>in</strong>e (Trizivir), didanos<strong>in</strong>e (ddI, Videx), emtricitab<strong>in</strong>e(Emtriva), lamivud<strong>in</strong>e (Epivir, 3TC), lamivud<strong>in</strong>e/zidovud<strong>in</strong>e (Combivir), stavud<strong>in</strong>e (d4T, Zerit), tenofovir (Viread), zalcitab<strong>in</strong>e (ddC, Hivid), zidovud<strong>in</strong>e (AZT, Retrovir). PIs- amprenavir (Agenerase), atazanavir (Reyataz), fosamprenavir (Lexiva), <strong>in</strong>d<strong>in</strong>avir (Crixivan), lop<strong>in</strong>avir/ritonavir (Kaletra), nelf<strong>in</strong>avir (Viracept), ritonavir (Norvir), saqu<strong>in</strong>avir (Fortovase, Invirase). NNRTIs- delavird<strong>in</strong>e (Rescriptor), efavirenz (Sustiva), nevirap<strong>in</strong>e (Viramune). ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivud<strong>in</strong>e/zidovud<strong>in</strong>e (Trizivir), didanos<strong>in</strong>e (ddI, Videx, Videx EC), emtricitab<strong>in</strong> (Emtriva), lamivud<strong>in</strong>e (Epivir, 3TC), lamivud<strong>in</strong>e/zidovud<strong>in</strong>e (Combivir), stavud<strong>in</strong>e (d4T, Zerit), tenofovir (Viread), zalcitab<strong>in</strong>e (ddC, Hivid), zidovud<strong>in</strong>e (AZT, Retrovir). PIs- amprenavir (Agenerase), atazanavir (Reyataz), fosamprenavir (Lexiva), <strong>in</strong>d<strong>in</strong>avir (Crixivan), lop<strong>in</strong>avir/ritonavir (Kaletra), nelf<strong>in</strong>avir (Viracept), ritonavir (Norvir), saqu<strong>in</strong>avir (Fortovase, Invirase). NNRTIs- delavird<strong>in</strong>e (Rescriptor), efavirenz (Sustiva), nevirap<strong>in</strong>e (Viramune). Other- hydroxyurea (Hydrea). Entry Inhibitor- enfuvirtide (Fuzeon). OI DRUGS PHS “A1 OI”s- acyclovir (Zovirax), azithromyc<strong>in</strong> (Zithromax), cidofovir (Vistide), clarithromyc<strong>in</strong> (Biax<strong>in</strong>), famciclovir (Famvir), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporonox), leucovor<strong>in</strong>, pyrimetham<strong>in</strong>e (Daraprim, Fansidar), sulfadiaz<strong>in</strong>e, TMP/SMX (Bactrim). Other OIs- ciprofloxac<strong>in</strong> (Cipro), dapsone, ethambutol (Myambutol), pentamid<strong>in</strong>e (Nebupent), pyraz<strong>in</strong>amide, rifampim. Hepatitis C- none.
Maryland Massachusetts ADAP FORMULARIES New drugs added s<strong>in</strong>ce June 2002 <strong>in</strong>dicated <strong>in</strong> bold. ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivud<strong>in</strong>e/zidovud<strong>in</strong>e (Trizivir), didanos<strong>in</strong>e (ddI, Videx), lamivud<strong>in</strong>e (Epivir, 3TC), lamivud<strong>in</strong>e/zidovud<strong>in</strong>e (Combivir), stavud<strong>in</strong>e (d4T, Zerit), tenofovir (Viread), zalcitab<strong>in</strong>e (ddC, Hivid), zidovud<strong>in</strong>e (AZT, Retrovir). PIs- amprenavir (Agenerase), atazanavir (Reyataz), <strong>in</strong>d<strong>in</strong>avir (Crixivan), lop<strong>in</strong>avir/ritonavir (Kaletra), nelf<strong>in</strong>avir (Viracept), ritonavir (Norvir), saqu<strong>in</strong>avir (Fortovase, Invirase). NNRTIs- delavird<strong>in</strong>e (Rescriptor), efavirenz (Sustiva), nevirap<strong>in</strong>e (Viramune). Otherhydroxyurea (Hydrea). Entry Inhibitor- enfuvirtide (Fuzeon). OI DRUGS PHS “A1 OI”s- acyclovir (Zovirax), azithromyc<strong>in</strong> (Zithromax), cidofovir (Vistide), clarithromyc<strong>in</strong> (Biax<strong>in</strong>), famciclovir (Famvir), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (Nydrazid, Rifamate), itraconazole (Sporonox), leucovor<strong>in</strong>, pyrimetham<strong>in</strong>e (Daraprim, Fansidar), (Rifad<strong>in</strong>, Rimactane), sulfadiaz<strong>in</strong>e, TMP/SMX (Bactrim). Other OIs- amphoteric<strong>in</strong> B (Fungisone), atovaquone (Mepron), ciprofloxac<strong>in</strong> (Cipro,Ciloxan), cl<strong>in</strong>damyc<strong>in</strong> (Cleoc<strong>in</strong>), clotrimazole (Lotrim<strong>in</strong>, Mycelex), dapsone, daunorubic<strong>in</strong> citrate liposomal (DaunoXome), erythromyc<strong>in</strong>, ethambutol (Myambutol), epoet<strong>in</strong> alpha (Epogen, Procrit), filgrastim (Neupogen), fomivirsen (Vitravene), ketoconazole (Nizoral), miconazole (Monistat), nystat<strong>in</strong> (Mycostat<strong>in</strong>), paromomyc<strong>in</strong> (Humat<strong>in</strong>), pentamid<strong>in</strong>e (Pentam, Nebupent), pyraz<strong>in</strong>amide, rifabut<strong>in</strong> (Mycobut<strong>in</strong>), rifampim, valacyclovir (Valtrex), valganciclovir (Valcyte). Hepatitis C- <strong>in</strong>terferon alfa-2A (Roferon-A, Intron-A), peg-<strong>in</strong>terferon alfa 2b (Peg-Intron), ribavir<strong>in</strong> (Rebetol). TREATMENTS FOR METABOLIC DISORDERS Hyperlipidemia- atorvastat<strong>in</strong> (Lipitor), fenofibrate (Tricor), gemfibrozil (generic only), glipizide, pravastat<strong>in</strong> (Pravachol). Wast<strong>in</strong>gmegestrol acetate (Megace), nandrolone, oxandrolone (Oxandr<strong>in</strong>), testosterone (<strong>in</strong>jection and patches), thalidomide (Thalomid). ALL OTHERS amitriptyl<strong>in</strong>e (Elavil), amoxicill<strong>in</strong>, augment<strong>in</strong>, buproprion (Wellbutr<strong>in</strong>, Zyban), cephalex<strong>in</strong>, citalopran HBr (Celexa), clotrimazole/ betamethasone (Lotrisone Cream), diphenoxylate-atrop<strong>in</strong>e (Lomotil), divalproex (Depakote, Depakene), doxycycl<strong>in</strong>e, fluoxet<strong>in</strong>e (Prozac), fluphenaz<strong>in</strong>e (Prolix<strong>in</strong>), gabapent<strong>in</strong> (Neuront<strong>in</strong>), haldoperidol (Haldol), hydroxiz<strong>in</strong>e (Atarax), imiquimod (Aldara), loperamide (Imodium), metform<strong>in</strong>, metronidazole, nortriptyl<strong>in</strong>e (Aventlyl, Pamelor), octreotide (Sandostat<strong>in</strong>), olanzap<strong>in</strong>e (Zyprexa), oxymetholone (Anadrol-50), paroxet<strong>in</strong>e (Paxil), prochlorperaz<strong>in</strong>e (Compaz<strong>in</strong>e), risperidone (Risperdal), sertral<strong>in</strong>e (Zoloft), trazadone (Desyrel/Desyrel Dividose), trimethoprim. ANTIRETROVIRALS NRTIs- abacavir (Ziagen), abacavir/lamivud<strong>in</strong>e/zidovud<strong>in</strong>e (Trizivir), didanos<strong>in</strong>e (ddI, Videx, Videx EC), emtricitab<strong>in</strong>e (Emtriva), lamivud<strong>in</strong>e (Epivir, 3TC),lamivud<strong>in</strong>e/zidovud<strong>in</strong>e (Combivir), stavud<strong>in</strong>e (d4T, Zerit), tenofovir (Viread), zalcitab<strong>in</strong>e (ddC, Hivid), zidovud<strong>in</strong>e (AZT, Retrovir). PIs- amprenavir (Agenerase), atazanavir (Reyataz), <strong>in</strong>d<strong>in</strong>avir (Crixivan), lop<strong>in</strong>avir/ritonavir (Kaletra), nelf<strong>in</strong>avir (Viracept), ritonavir (Norvir), saqu<strong>in</strong>avir (Fortovase, Invirase). NNRTIs- delavird<strong>in</strong>e (Rescriptor), efavirenz (Sustiva), nevirap<strong>in</strong>e (Viramune). Other- hydroxyurea (Hydrea). Entry Inhibitor- enfuvirtide (Fuzeon). OI DRUGS PHS “A1 OI”s- acyclovir (Zovirax), azithromyc<strong>in</strong> (Zithromax), cidofovir (Vistide), clarithromyc<strong>in</strong> (Biax<strong>in</strong>), famciclovir (Famvir), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporonox), leucovor<strong>in</strong>, pyrimetham<strong>in</strong>e (Daraprim, Fansidar), sulfadiaz<strong>in</strong>e, TMP/SMX (Bactrim). Hepatitis C- all FDA approved drugs. ALL OTHERS Open <strong>Formulary</strong> - All FDA approved drugs are covered except the follow<strong>in</strong>g: Specific open formulary exclusions: antirheumatic <strong>in</strong>jectables (e.g. Enbrel), botul<strong>in</strong>um tox<strong>in</strong> (e.g. botox, mylobloc) compounded medications for <strong>in</strong>fusion, active medication conta<strong>in</strong><strong>in</strong>g more than one <strong>in</strong>gredient, gonadotrop<strong>in</strong>, f<strong>in</strong>asteride (Propecia), hyaluronic acid derivatives (e.g. Hyalgan, Synvisc), immune globul<strong>in</strong> <strong>in</strong>travenous IGIV (e.g. sandoglobul<strong>in</strong>, Venoglobul<strong>in</strong>), <strong>in</strong>jectable muscle relaxants (e.g. Lioresal), mifepristone, m<strong>in</strong>oxidil (Roga<strong>in</strong>e), monoclonal antibodies (e.g. Remicade, Synagis), propoxyphene, recomb<strong>in</strong>ant human growth hormone HGH (e.g. Geref, Humatrop), Viagra. Class Exculsions:fertility drugs, fluorides, herbal medicaitons, immuniz<strong>in</strong>g biologicals, iron, less than effective drugs, nutritional supplements, over the counter mediations exceptions:(Acetam<strong>in</strong>ophen, Imodium and Metamucil), sex-reassignment drugs, smok<strong>in</strong>g cessaton drugs, vitam<strong>in</strong>s and m<strong>in</strong>erals.
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