Microsoft word - formulary_03_2010

ILLINOIS DEPARTMENT OF PUBLIC HEALTH
AIDS DRUG ASSISTANCE PROGRAM (ADAP)
FORMULARY as of 6/1/2010
CATEGORY I
CATEGORY III
REVERSE TRANSCRIPTASE INHIBITORS (RTIs)
ANTIBIOTICS
didanosine (ddI, dideoxyinosine, Videx, Videx EC) CATEGORY IV (Other)
chlorhexidine gluconate (Peridex, PerioGard) testosterone enanthate, I.M only (no Kits)
zidovudine (AZT, azidothymidine, Retrovir) dicloxacillin sodium (Dycill, Dynapen, Pathocil) **Combivir (Epivir and Retrovir Combination) doxycycline hyclate (Doryx, Vibramycin, Vibra-Tabs) LIPID REGULATING
**Truvada (Emtriva and Viread combination) **Epzicom (Epivir and Ziagen Combination) ***Trizivir (Epivir, Retrovir and Ziagen Combination) ***Atripla (efavirenz/emtricitabine/tenofovir) ANTI-FUNGALS:
CATEGORY V - REQUIRING PRIOR APPROVAL
PROTEASE INHIBITORS (PIs)
enfurvirtide (Fuzeon); requires an additional
application; limited to a cap of 15 clients. valganciclovir hydrochloride (Valcyte) oral only;
Cap is limited to 35 clients concurrently. atovaquone (Mepron) – prescriptions will require prior
ANTI-VIRALS:
approval in all the following situations: ritonavir (Norvir) – reference prescribing gudelines
cidofovir plus probenecid (Vistide) intravenous 2) use as prophylaxis (rather than treatment); or 3) more than one prescription per year is written for a patient not approved for use of atovoquone as NON-NUCLEOSIDE (RTIs)
CRYPTOSPORIDIOSIS:
All pre-approval forms are located on the IDPH website MYCOBACTERIAL INFECTIONS:
**Indicates a fixed combination of two-drugs that are ENTRY INHIBITOR
considered two drugs in the 5+ drug limit; maraviroc (Selzentry) - Requires Trofile assay ***Trizivir and Atripla are a three-drug combination and isoniazid (isonicotinic acid hydrazide, INH) INTEGRASE INHIBITOR
isoniazid/pyrazinamide/rifampin (Rifater) See ADAP Prescribing Guidelines for quantity limits on CATEGORY II
Prescriptions for multi-source drugs should be written TREATMENT and PROPHYLAXIS of PCP
indicating “product substitution permitted” to ensure all
atovaquone (Mepron) – Pre-Approval (required)
efforts for fiscal stewardship on behalf of ADAP. In ANTI-DIARRHEA or WASTING SYNDROME
addition, this procedure will reduce the number of call- backs to prescribers by dispensing pharmacy. pentamidine isethionate (NebuPent, Pentam 300) All prescriptions for multi-source drugs (drugs
TOXOPLASMOSIS:
available in a brand-name and equal or greater than 1 sulfamethoxazole/trimethoprim (SMZ/TMP, Bactrim,) generic formulation) will be filled with the lowest cost clindamycin phosphate (Cleocin Phosphate) option available. Use of brand name drugs on the HEPATITIS-B TREATMENTS
clindamycin palmitate (Cleocin pediatric granules) ADAP formulary is for informational purposes only.

Source: http://www.hivcareconnect.com/ADAP%20Web%20page%20attachments/FORMULARY_03_2010.pdf