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Microsoft word - adap_formulary_09_01_2013.docx
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
AIDS DRUG ASSISTANCE PROGRAM (ADAP)
FORMULARY as of 09/17/2013
REVERSE TRANSCRIPTASE INHIBITORS (RTIs)
clindamycin phosphate (Cleocin Phosphate)
clindamycin palmitate (Cleocin pediatric granules) leucovorin calcium
didanosine (ddI, dideoxyinosine, Videx, Videx EC)
zidovudine (AZT, azidothymidine, Retrovir)
**Combivir (Epivir and Retrovir Combination)
**Truvada (Emtriva and Viread combination)
**Epzicom (Epivir and Ziagen Combination)
chlorhexidine gluconate (Peridex, PerioGard)
testosterone enanthate, I.M only (no Kits)
***Trizivir (Epivir, Retrovir and Ziagen Combination)
testosterone cypionate (no Kits
dicloxacillin sodium (Dycill, Dynapen, Pathocil)
doxycycline hyclate (Doryx, Vibramycin, Vibra-Tabs)
PROTEASE INHIBITORS (PIs)
CATEGORY V - REQUIRING PRIOR APPROVAL
(Fuzeon); requires an additional application; limited to a
(Valcyte) oral only;
Cap is limited to 35 clients concurrently.
(Mepron) – prescriptions will require prior approval in all
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 prophylaxis.
All pre-approval forms are located on the IDPH website
**Indicates a fixed combination of two-drugs that are considered two
maraviroc (Selzentry) - Requires Trofile assay
***Trizivir and Atripla are a three-drug combination and are considered
isoniazid (isonicotinic acid hydrazide, INH)
****Stribild is a three-drug combination and is considered four drugs.
See ADAP Prescribing Guidelines for quantity limits on some drugs.
Prescriptions for multi-source drugs should be written indicating
TREATMENT and PROPHYLAXIS of PCP
“product substitution permitted
” to ensure all efforts for fiscal
atovaquone (Mepron) – Pre-Approval (required)
stewardship on behalf of ADAP. In addition, this procedure will reduce
the number of call-backs to prescribers by dispensing pharmacy.
ANTI-DIARRHEA or WASTING SYNDROME
pentamidine isethionate (NebuPent, Pentam 300)
for multi-source drugs (drugs available in a brand-
name and equal or greater than 1 generic formulation) will be filled with
the lowest cost option available. Use of brand name drugs on the ADAP
sulfamethoxazole/trimethoprim (SMZ/TMP, Bactrim,)
formulary is for informational purposes only.
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
AIDS DRUG ASSISTANCE PROGRAM (ADAP)
Drugs provided by the AIDS Drug Assistance Program (ADAP) MUST
not exceed a $2,000 per month benefits cap and MUST
prescribed in accordance with these guidelines. Revisions to prescribing guidelines may be made upon recommendations of the
Department’s ADAP Medical Issues Advisory Board.
Category I anti-retroviral therapies should be prescribed in accordance with the latest Public Health Service (PHS)
guidelines. The Website is: http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf
All newly FDA approved anti-retroviral therapies will be considered for addition to the formulary, however:
No more than five (5) drugs* from Category I (and Fuzeon)
prescribed concurrently (Up to two protease
inhibitors or a protease inhibitor and an NNRTI may be provided concurrently), except with prior approval from
ADAP. There are no exceptions to this prescribing guideline
, except ritonavir (Norvir), at a reduced dosage may
be prescribed for pharmacokinetic (PK) boosting, and
Any change in Category I therapies will require a discontinue order of the old prescription to be sent or faxed to CVS Caremark Pharmacy before the new order can be filled.
* Combivir, Truvada, and Epzicom are fixed dose combinations and are considered two (2) drugs when ordered. * Trizivir and Atripla are fixed-dosage combinations of 3 drugs and are considered three (3) drugs when ordered. * Kaletra contains Norvir at a reduced dosage and is considered one plus PK boosted drug when ordered.
HIV co-receptor (CCR5 and/or CXCR4) tropism assay must be run prior to prescribing Selzentry.
atovaquone (Mepron) prescriptions will require prior approval in all the following situations: 1)
use for more than 21 days,
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 prophylaxis. Pre-approval form will be available on the IDPH website (www.idph.state.il.us).
ritonavir (Norvir) - tablets will be dispensed unless other formations are required by prescriber due to tolerance issues. ADAP
may require prior approval for other formulations.
enfurvirtide (Fuzeon); requires a separate application. Re-approval in 2011 is also required for all current prescriptions.
Eligibility is based on medical criteria, with a cap limit of 15 clients. Prior approval by the Department will be faxed, via electronic file to the pharmacy as authorization. Fuzeon is considered one of the five (5) drugs along with those in Category 1.
valganciclovir (Valcyte) oral only: limited to a cap of 35 clients concurrently.
atovaquone (Mepron) – see notes under Category II.
Neither enfurvirtide (Fuzeon) nor valganciclovir (Valcyte) are considered within the $2,000 benefits cap.
OTHER GENERAL GUIDELINES
for multi-source drugs (drugs available in a brand-name and equal or greater than 1 generic formulation)
will be filled with the lowest cost option available. Use of brand name drugs on the ADAP formulary is for informational purposes only.
For coverage under ADAP, prescriptions for multi-source drugs should be written indicating “product substitution
” to ensure all efforts for fiscal stewardship are able to be implemented by ADAP through its dispensing pharmacy.
In addition, this procedure will reduce the number of call-backs to prescribers by dispensing pharmacy.
must be written for no more than 3 refills
. Then the client will be required to re-visit their HIV Care
Provider before a new prescription can be written.
form can be located on the IDPH website (www.idph.state.il.us) for all prescriptions requiring pre-
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