04 Formulary in pdf format - HIV/AIDS Information provided by ...

Maryland
Massachusetts
ADAP FORMULARIES
New drugs added since June 2002 indicated in bold.
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), atazanavir (Reyataz), indinavir (Crixivan), lopinavir/ritonavir (Kaletra), nelfinavir (Viracept), ritonavir
(Norvir), saquinavir (Fortovase, Invirase). NNRTIs- delavirdine (Rescriptor), efavirenz (Sustiva), nevirapine (Viramune). Otherhydroxyurea
(Hydrea). Entry Inhibitor- enfuvirtide (Fuzeon).
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, pyrimethamine (Daraprim, Fansidar), (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), erythromycin, ethambutol (Myambutol), epoetin alpha (Epogen, Procrit), filgrastim
(Neupogen), fomivirsen (Vitravene), ketoconazole (Nizoral), miconazole (Monistat), nystatin (Mycostatin), paromomycin (Humatin),
pentamidine (Pentam, Nebupent), pyrazinamide, rifabutin (Mycobutin), rifampim, valacyclovir (Valtrex), valganciclovir (Valcyte).
Hepatitis C- interferon alfa-2A (Roferon-A, Intron-A), peg-interferon alfa 2b (Peg-Intron), ribavirin (Rebetol).
TREATMENTS FOR METABOLIC DISORDERS
Hyperlipidemia- atorvastatin (Lipitor), fenofibrate (Tricor), gemfibrozil (generic only), glipizide, pravastatin (Pravachol). Wastingmegestrol
acetate (Megace), nandrolone, oxandrolone (Oxandrin), testosterone (injection and patches), thalidomide (Thalomid).
ALL OTHERS
amitriptyline (Elavil), amoxicillin, augmentin, buproprion (Wellbutrin, Zyban), cephalexin, citalopran HBr (Celexa), clotrimazole/
betamethasone (Lotrisone Cream), diphenoxylate-atropine (Lomotil), divalproex (Depakote, Depakene), doxycycline, fluoxetine
(Prozac), fluphenazine (Prolixin), gabapentin (Neurontin), haldoperidol (Haldol), hydroxizine (Atarax), imiquimod (Aldara), loperamide
(Imodium), metformin, metronidazole, nortriptyline (Aventlyl, Pamelor), octreotide (Sandostatin), olanzapine (Zyprexa),
oxymetholone (Anadrol-50), paroxetine (Paxil), prochlorperazine (Compazine), risperidone (Risperdal), sertraline (Zoloft), trazadone
(Desyrel/Desyrel Dividose), trimethoprim.
ANTIRETROVIRALS
NRTIs- abacavir (Ziagen), abacavir/lamivudine/zidovudine (Trizivir), didanosine (ddI, Videx, Videx EC), emtricitabine (Emtriva),
lamivudine (Epivir, 3TC),lamivudine/zidovudine (Combivir), stavudine (d4T, Zerit), tenofovir (Viread), zalcitabine (ddC, Hivid), zidovudine
(AZT, Retrovir). PIs- amprenavir (Agenerase), atazanavir (Reyataz), indinavir (Crixivan), lopinavir/ritonavir (Kaletra),
nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Fortovase, Invirase). NNRTIs- delavirdine (Rescriptor), efavirenz (Sustiva),
nevirapine (Viramune). Other- hydroxyurea (Hydrea). Entry Inhibitor- enfuvirtide (Fuzeon).
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,
pyrimethamine (Daraprim, Fansidar), 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.