RYAN WHITE TITLE I DRUG FORMULARY

ORLANDO EMA

ANTI-RETROVIRALS
	Generic Name	Brand Name (for reference only)
Nucleoside Reverse Transcriptase Inhibitors	Abacavir	Ziagen
	Didanosine	Videx
	Hydroxyurea	Hydrea
	Lamivudine	Epivir
	Lamivudine/Zidovudine	Combivir
	Stavudine	Zerit
	Zalcitabine	Hivid
	Zidovudine	Retrovir
	Abacavir/Lamivudine/Zidovudine*	Trizivir*
Protease Inhibitors	Amprenavir	Agenerase
	Indinavir	Crixivan
	Nelfinavir	Viracept
	Ritonavir	Norvir
	Saquinavir	Fortovase
	Lopinavir/Ritonavir*	Kaletra*
Non-Nucleoside Reverse Transcriptase Inhibitors	Delavirdine	Rescriptor
	Efavirenz	Sustiva
	Nevirapine	Viramune
Nucleotide Reverse Transcriptase Inhibitors	Tenofovir Disoproxil Fumarate*	Viread*

TREATMENT OF INFECTIONS/CONDITIONS
	Generic Name	Brand Name (for reference only)
Anxiety	Alprazolam	Xanax
	Buspirone	Buspar
	Diazepam	Valium
Cancer	Methotrexate	Methotrexate
	Vincristine	Oncovin

Generic Name

Brand Name (for reference only)

	Foscarnet	Foscavir
CMV (Cytomegalovirus)	Ganciclovir	Cytovene
	Valganciclovir*	Valcyte*
Depression	Citalopram*	Celexa*
	Mirtazapine*	Remeron*
	Bupropion HCL	Wellbutrin
	Fluoxetine	Prozac
	Nefazodone	Serzone
	Paroxetine	Paxil
	Sertraline	Zoloft
	Venlafaxine HCL	Effexor
	Amitriptyline	Elavil
	Desipramine HCL	Nopramine
	Nortriptyline	Pamelor
	Trazadone HCL	Desyrel
Dermatitis	Ammonium Lactate	Lac-Hydrine 12% lotion*
	Imiquimod*	Aldara*
	Triamcinolone*	Kenalog*
Diabetes	Metformin	Glucophage
	Glipizide	Glucotrol
	Glyburide	Micronase
Diarrhea	Diphenoxylate HCL	Lomotil
	Loperamide	Imodium
	Opium Tincture
Fungal Infections	Clortimazole	Lotrimin
	Fluconazole	Diflucan
	Griseofulvin	Fulvicin
	Ketoconazole	Nizoral
	Miconazole	Micatin
	Nystatin	Mycostatin
	Terbenafine	Lamisil
	Terconazole	Terazol
Herpes	Acyclovir	Zovirax
	Famciclovir*	Famvir*
	Valacyclovir	Valtrex

	Generic Name	Brand Name (for reference only)
MAC (Mycobacterium Avium)	Azithromycin	Zithromax
	Capreomycin	Capastat
	Ciprofloxacin	Cipro
	Clarithromycin	Biaxin
	Clofazimine	Lamprene
	Ethambutol	Myambutol
	Rifabutin	Mycobutin
Migraines	Sumatriptan*	Imitrex*
PCP (Pneumocystis Carinni Pneumonia)	Atovaquone	Mepron
	Dapsone	Dapsone
	Pentamidine	Pentam
	Sulfamethoxazole and Trimethoprim	Bactrim, Septra
	Trimethoprim	Proloprim
	Trimetrexate (Sulfa Reactions only)	Neutrexin
Seizures	Gabapentin	Neurontin
	Lamotrigine	Lamictal
	Carbamazepine	Tegretol
	Phenytoin	Dilantin
	Valproic Acid	Depakote
Toxoplasmosis	Clindamycin	Cleocin
	Pyrimethamine	Daraprim
	Sulfadiazine	Microsulfon
Tuberculosis	Isoniazid	Nydriazid
Wasting	Cyproheptadine*	Periactin*
	Phenopropionate/Deconate	Nandrelone

OTHER
	Generic Name	Brand Name (for reference only)
Antibiotics	Amoxicillin Trihydrate	Amoxil
	Amoxocillin Clavulanate	Augmentin
	Cefuoxime Axetil	Ceftin
	Cephalexin	Keflex
	Dicloxacillin	Dynapen
	Doxycycline	Vibramycin
	Gatifloxacin*	Tequin*
	Levofloxacin	Levaquin
	Metronidazole	Flagyl
	Minocycline HCL	Minocin
	Neomycin Sulfate	Neomycin Sulfate
	Paromomycin	Humatin
	Tetracycline	Achromycin
(ophthalmic)	Ofloxacin*	Floxin (otic)*
(topical)	Muciprocin*	Bactroban*
Analgesics APAP = Acetaminophen ASA = Acetylsalicylic Acid (Aspirin)	Codeine Phosphate / APAP	Tylenol Codeine
	Codeine Phosphate / ASA	Empirin
	Codeine Phosphate
	Codeine Sulfate
	Fenoprofen Calcium	Nalfon
	Fentanyl	Duragesic
	Hydrocodone	Hydrocodone
	Hydrocodone / APAP	Vicodin
	Hydrocodone / Ibuprofen	Vicoprofen
	Ibuprofen*	Motrin*
	Indomethacin	Indocin
	Ketoprofen	Orudis
	Levorphenol Tartrate	Levo Dromoran
	Morphine Sulfate
	Naproxen	Naprosyn
	Oxycodone*	Oxycontin*
	Oxycodone / APAP	Percocet
	Oxycodone / ASA	Percodan
	Propoxyphene / APAP*	Darvocet*
	Rofecoxib*	Vioxx*
	Sulindac	Clinoril
	Tramadol*	Ultram*
(topical)	Lidocaine / Prilocaine*	Emla Cream*

	Generic Name	Brand Name (for reference only)
Anti-Arthritic	Nabumetone*	Relafen*
Cardiac / Hypertension Drugs	Amlodipine*	Norvasc*
	Clonidine*	Catapres*
	Lanoxin*	Digoxin*
	Enalapril*	Vasotec*
	Furosemide*	Lasix*
	Hydrochlorothiazide*	Hydrodiuril*
	Lisinopril*	Zestril*
	Losartan*	Cozaar*
	Propanolol*	Inderal*
	Spironolactone*	Aldactone*
	Triamterene / Hydrochlorothiazide (HCTZ)*	Dyazide*
	Verapamil*	Isoptin*
Anti-Emetics	Metoclopramide	Reglan
	Prochlorperazine	Compazine
Anti-Coagulants	Warfarin*	Coumadin*
Antihelmintic	Albendazole	Albenza
Antihistamines	Cetirizine*	Zyrtec*
	Hydroxyzine*	Atarax*
	Promethazine	Phenergen
Anti-Psychotics	Lithium*	Lithium*
	Olanzapine*	Zyprexa*
	Risperidone*	Risperdal*
	Haloperidol	Haldol
Anti-Glaucoma (ophthalmic Beta Blocker)	Betaxolol*	Betoptic*
Bronchodilators (Asthma)	Albuterol*	Proventil*, Ventolin*
	Ipatroprium*	Atrovent*
	Montelukast Sodium*	Singulair*
	Salmeterol*	Serevent*

	Generic Name	Brand Name (for reference only)
Corticosteroids	Betamethasone	Celestone
	Dexamethasone	Decadron
	Fluticasone*	Flonase*, Flovent*
	Methylprednisolone*	Medrol*
	Prednisone	Deltasone
Cough Medicines	Guaifenesin*	Robitussin*
Cholesterol Reducing Drugs	Atorvastatin	Lipitor
	Cerivastatin	Baycol
	Gemfibrozil	Lopid
	Pravastatin	Pravachol
Dental Medications	Chlorhexidine Gluconate*	Peridex*
Gastro-Intestinal Drugs	Omeprazole*	Prilosec*
	Ranitidine	Zantac
Hematopoietic Agents	Filgrastim	Neupogen
Laxatives	Biscodyl*	Dulcolax*
	Docusate Sodium	Colace
	Polyethylene Glycol*	Miralax*
	Senna / Docusate Sodium*	Senekot S*
	Sodium Biphosphate and Sodium Phosphate*	Fleet's Enema*
Muscle Relaxants	Cyclobenzaprine*	Flexaril*
Sleeping Aids / Sedatives	Zolpidem*	Ambien*
Vaccines	Engerex	Hepatitis B
	Fluogen	Influenza
	Hepititis A Vaccine	Havrix Adult
	Pneumococcal Vaccine Polyvalent	Pneumovax

	Generic Name	Brand Name (for reference only)
Vitamins / Supplements	B Complex Vitamin*
	B-12 Injection*
	Calcitonin*
	Calcium*
	Folic Acid*
	Iron*
	Potassium*

DRUGS APPROVED FOR CONDITIONAL DISPENSING ONLY
	Generic Name	Brand Name (for reference only)
Anti-Fungal	Itraconazole	Sporanox
In order for a patient to obtain this medication, either Histoplasmosis or Aspergillosis must have been identified and documented in the client’s chart by his or her physician. In addition, a Letter of Medical Necessity must be completed by the perscriber.
Anti-Wasting	Digestive Enzymes*	Ultrase*
	Dronabinol	Marinol
	Megestrol Acetate	Megace
An Appetite Stimulant Letter of Medical Necessity is required and the need for these medications must be reassessed monthly.
Anti-Wasting	Oxandrolone	Oxandrine
	Oxymetholone*	Anadrol*
One of the following conditions must have been identified and documented in the client’s chart by his or her physician: The patient is experiencing involuntary weight loss of 3% in one month, 5% in 6 months or 10% in 12 months If the patient’s baseline weight is not available, then the patient will qualify for assistance if his or her Body Mass Index (BMI) is less than 80% of a normal reading.
Anti-Wasting	Testosterone Injection	Depo-Testosterone
The patient’s testosterone level must be below a normal reading. Prescribing physicians must include the patient’s most recent testosterone level on the prescription for this medication.
	Generic Name	Brand Name (for reference only)
Anti-Toxoplasmosis	Leucovorin Calcium	Wellcovorin
This medication may only be reimbursed for the treatment of Toxoplasmosis and must be written as such on the prescription.
Hematopoietic Agent	Epoetin Alfpha	Procrit
Initial Therapy – patient must meet all three requirements and documentation must exist: No gastrointestinal bleeding Hemotocrit < 33% and Hemoglobin < 11 Lab Data within 3 months of PA Continuation of Therapy – patient must meet all three requirements and documentation must exist: No gastrointestinal bleeding Hemotocrit < 39% and Hemoglobin of 11-13 Lab Data within 3 months of PA
Diabetes Medications / Supplies	Insulin*
	Blood Glucose Strips*
	Lancets*
	Syringes*
Reimbursement will occur only when dispensed for the treatment of insulin dependent diabetes mellitus. This must be indicated as such on the prescription. Lancets and Blood Glucose strips will be dispensed in packages of at least 180 every three months.
Hormones	Conjugated Estrogen*	Premarin*
	Estrogen Products*
	Progesterone Products*
Reimbursement will occur for menopausal women only who have been denied Patient Assistance. Documentation of denial must be provided.
Vitamins / Supplements	Prenatal Vitamins*
Reimbursement will occur for pregnant women only.

	Generic Name	Brand Name (for reference only)
IV-Drugs	Alpha Inerferon	Roferon
	Amphotericine	Abelcet/Ambisome
	Blemycin Sulfate	Blenoxane
	Cidofovir/Probenecid	Vistide
	Doxorubicin	Adriamycin
	Fomivirsen	Vitravene
	Gamma Globulin/IVIG	Gamimune
	Lipsomal Daunorubicin	DuanoXome
	Paclitaxel (for KS only)	Taxol
	Vinblastin Sulfate	Velban
Dispensing of these medications will occur on a case-by-case basis. Patient must have been denied Patient Assistance and documentation of denial must be provided.