MEETING AGENDA COMMITTEE Location: Chair 1. CALL TO … · 2020-03-31 · 1. CALL TO ORDER: Welcome, Review meeting ground rules, Statement of Sunshine, Introductions, Moment of Silence,

Fort Lauderdale / Broward County EMA Broward County HIV Health Services Planning Council

An Advisory Board of the Broward County Board of County Commissioners 200 Oakwood Lane, Suite 100, Hollywood, FL, 33020 - Tel: 954-561-9681 / Fax: 954-561-9685

VISION: To ensure the delivery of high quality comprehensive HIV/AIDS services to low income and uninsured Broward County residents living with HIV, by providing a targeted, coordinated, cost-effective, sustainable, and client-centered system of care

MISSION: We direct and coordinate an effective response to the HIV epidemic in Broward County to ensure high quality, comprehensive care that positively impacts the health of individuals at all stages of illness. In so doing, we: Foster the substantive involvement of the HIV affected communities in assuring consumer satisfaction, identifying priority needs, and planning a responsive system of care

Support local control of planning and service delivery, and build partnerships among service providers, community organizations, and federal, state, and municipal governments Monitor and report progress within the HIV continuum of care to ensure fiscal responsibility and increase community support and commitment

MEETING AGENDA

COMMITTEE: ad-Hoc Local Pharmacy Advisory Committee (LPAC)

Date/Time: Thursday, April 9, 2015, 9:30am Location: Governmental Center Annex A-335

Chair: Dionne Proulx

1. CALL TO ORDER: Welcome, Review meeting ground rules, Statement of Sunshine, Introductions, Moment of

Silence, Public Comment

2. APPROVALS: 4/9/15 Agenda and 3/12/15 Meeting Minutes

3. UNFINISHED BUSINESS

4. MEETING ACTIVITIES/NEW BUSINESS

Goal/Work Plan Objective #: Action Items

Formulary Additions and Deletions (Handouts A, B-1 & B-2)

ACTION ITEM: Review and discuss suggested changes to the formulary.

5. GRANTEE REPORTS

6. PUBLIC COMMENT

7. AGENDA ITEMS/TASKS FOR NEXT MEETING: TBD

8. ANNOUNCEMENTS

9. ADJOURNMENT

PLEASE COMPLETE YOUR MEETING EVALUATIONS

THREE GUIDING PRINCIPLES OF THE BROWARD COUNTY

HIV HEALTH SERVICES PLANNING COUNCIL

• Linkage to Care • Retention in Care • Viral Load Suppression •

Fort Lauderdale / Broward County EMA

Broward County HIV Health Services Planning Council An Advisory Board of the Broward County Board of County Commissioners

200 Oakwood Lane, Suite 100, Hollywood, FL, 33020 - Tel: 954-561-9681 / Fax: 954-561-9685

Local Pharmacy Advisory Committee – Minutes – 3/12/15 1

MEETING MINUTES

COMMITTEE: Local Pharmacy Advisory Committee Meeting

Date/Time: Thursday, March 12, 2015, 9:30 a.m. Location: Gov't Center Annex A-335

Chair Dionne Proulx

Attendance

# Members Present Absent

Guests Grantee Staff

1 Proulx, D., Chair X Maharaj, A. Degraffenreidt, S.

2 Ehren, M. X Marangio, J. Morris, R.

3 Leverence, S. X Wynn, J.

4 Sherman, E. A HIVPC Staff

Sandler, C.

Quorum = 3 3 Johnson, B.

1. CALL TO ORDER:

The meeting was called to order at 9:30 a.m. Chairs, committee members, guests, grantee staff and

support staff self-introductions were made.

2. APPROVALS:

Motion #1 To approve today’s meeting agenda

Proposed by: Leverence, S Seconded by: Ehren, M.

Action: Passed Unanimously

Motion #2 To approve the meeting minutes of 2/12/14

Proposed by: Ehren, M. Seconded by: Leverence, S.

Action Passed Unanimously

3. UNFINISHED BUSINESS

None.

4. MEETING ACTIVITIES / NEW BUSINESS

a. Pharmacy Scorecard (Handout A)

HIVPC Staff gave an explanation of the modified scorecard which includes an overview of the

service category data points such as utilization, expenditures, and dispensed medications. The top

ten prescriptions are included on the scorecard by dispenses and expenditures. Staff noted that

many of the drugs overlap for both categories and that chronic long-term disease medications

such as Lisinopril (used to treat high blood pressure), make up the top ten prescriptions rather

Anti-Retroviral (ARV) medications. It was also mentioned that over 150 Part A clients were

enrolled in Marketplace insurance plans which may contribute to a decrease in expenditures over

the next year as a result of their medications being covered by private insurance.

b. Review Current Pharmacy Formulary (Handout B)

The current Part A formulary was presented to the committee. HIVPC Staff provided historical

procedures on reviewing the formulary data to determine whether or not to add or delete

medications on the list.

c. Review Pharmacy Utilization (Handout C)

The Committee reviewed the FY 2014-2015 pharmacy utilization. Members noted that although

all prescriptions had some utilization, the amounts were not large for many. Guests inquired about

the agencies who are responsible for dispensing the medications. The Florida Department of

Health in Broward County (FLDOH-BC), AIDS Healthcare Foundation (AHF), and Broward

Health were mentioned as responsible agencies for providing medications to clients. Members of

the committee discussed setting limits for prescriptions for medications with large quantities. A





guest explained that drugs for pain were limited due to fraud and abuse. Patients are referred to

specialists to prescribe this type of medication. She further discussed that they only dispense

from inside providers or from a referral from one of their specialists. A member from FLDOH-

BC mentioned that prescriptions are stamped to verify the patient has gone through the eligibility

process to receive these medications. However, he noted that this is not a considerable issue, as

the utilization is low.

d. Review Formulary for Additions and Deletions (Handout D)

Members of the committee reviewed the suggested changes to the formulary. These

recommendations are from the Medical Quality Improvement (QI) Network. HIVPC Staff

informed the members that two of the recommendations have not been added to the ADAP

formulary, and that Part A will not adopt these medications until ADAP adds it to its formulary.

A representative from the Grantee staff stated that the medications will automatically be added to

Part A once adapted by ADAP. A guest identified that Keppra, currently on Tier 3, was the best

anti-seizure medication. It is safest for patients who take protease inhibitors. Members further

discussed the utilization of the following drugs; Phenytoin, Carbamazepine (including the

extended release), Gabapentin, and Lamotrigine. A guest also pointed out that many patients at

her agency had an issue with accessing the medication and that it does not have a Patient

Assistance Program (PAP) available now that it has a generic. After much discussion on the

utilization of the abovementioned drugs, their accessibility, and their financial impact on

expenditures, the committee decided to wait to make a decision about moving Keppra to a

different Tier until more research was conducted. The committee reviewed the next

recommendation from the Medical QI Network. HIVPC Staff informed the committee that

Januvia is used in addition to Metformin and Glipizide to treat Type II diabetes. Members noted

that there is an available PAP for this medication which is simple to use. The following motion

was made:

Motion #3 To add Januvia to the Ryan White Part A Formulary under Tier 3.

Justification: There is not a diabetes medication on Tier 3, a PAP is available, and the number

of clients estimated to use the medication is low.

Proposed by: Leverence, S Seconded by: Ehren, M.

Action: Passed Unanimously

5. GRANTEE REPORTS A representative from the Grantee Staff introduced new QI Specialist, Richard Morris. She also

informed the committee on the CBS 4 media campaign that started on Monday, March 9th. This

campaign will be further advertised through the newspaper and other media outlets. There will be

multiple public service announcements (PSAs) around the campaigns “Beat HIV, Treat HIV” theme.

Patients can get more information regarding client services at: 954-357-9797.

6. PUBLIC COMMENT:

None.

7. AGENDA ITEMS / TASKS FOR NEXT MEETING: April 9, 2015, 9:30 a.m. Venue: TBD

Goal/Work Plan Objective #: Action Items

Review Formulary for Additions and

Deletions ACTION ITEM: Review and discuss suggested changes to the formulary.

8. ANNOUNCEMENTS None.

9. ADJOURNMENT

Without objection the meeting was adjourned at 11:22 a.m.





Local Pharmacy Advisory Committee Attendance CY 2015

Co

un

t

Meeting Month: March

Meeting Date: 12

1 Ehren, M. X

2 Leverence, S. X

3 Proulx, D., Chair X

4 Sherman, E. A

Quorum = 3 3

Brand Name Generic Name Drug Classification Tier

Achromycin Tetracycline Antiinfectives/Antiviral/Antibacterial 1Aldactone Spironolactone Cardiac & Anti-Hypertensive/Diuretic 1

Alomide Lodoxamide Ophthalmic/Misc/Other 1Alphagan Brimonide Ophthalmic/Glaucoma 1

Amino-Cerv Urea, misc Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1Amoxil Amoxicillin Antiinfectives/Antiviral/Antibacterial 1Antioxidant B-Plex with C Vitamins & Nutritional/Vitamins 1

Antivert Meclizine Misc/Other 1Anusol-HC Hydrocortisone Suppos Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1

Ativan Lorazepam CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1Atrovent Ipratropium Respiratory, Cough & Cold Allergy/Other 1Augmentin Amoxicill/Clav Antiinfectives/Antiviral/Antibacterial 1

Avapro Irbesartan Cardiac & Anti-Hypertensive/Angiotensin Receptor Blocker (ARB) 1Azopt Brinzolamide Ophthalmic/Glaucoma 1

Beconase AQ Beclomethasone Nasal 1

Benadryl Diphenhydramine Respiratory, Cough & Cold Allergy/Antihistamine 1

Bentyl Dicyclomine Gastrointest/Antispasmotic 1Benzagel Erythomycin / Benzoyl perox Topical, Dermatology, Rectal, Vaginal/Antibacterial 1Betoptic S Betaxolol Ophthalmic/Betablocker 1

Bicillin LA Penicillin Benzath Antiinfectives/Antiviral/Antibacterial 1

Bumex Bumetanide Cardiac & Anti-Hypertensive/Diuretic 1Bupropion Wellbutrin CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1Buspar Buspirone CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

Carafate Sucralfate Gastrointest/Misc/Other 1Cardec, Cardec DM, Cardec S

Bromphen/pseudephed / DM Respiratory, Cough & Cold Allergy/Antihist/Decongestant 1

Cardizem Diltiazem Cardiac & Anti-Hypertensive/Calcium Channel Blocker 1

Catapres Clonidine Cardiac & Anti-Hypertensive/Alpha Blockers 1Ceftin Cefuroxime Antiinfectives/Antiviral/Antibacterial 1Celecoxib Celebrex CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1

Celexa Citalopram CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1Celontin Methsuiximide CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Ryan White Part A Pharmacy Formulary - Updated 3/26/15Tier 1: In order to access Tier 1, clients must qualify for the Ryan White Part A Program based on eligiblity requirements.

HANDOUT A

Brand Name Generic Name Drug Classification Tier Ciloxin Ciprofloxacin Ophthalmic/Antibiotic 1Cipro Ciprofloxacin Antiinfectives/Antiviral/Antibacterial 1Cipro HC Ciprofloxacin / HC Otic 1

Claritin Loratadine Respiratory, Cough & Cold Allergy/Antihistamine 1

Cleocin Clindamycin Antiinfectives/Antiviral/Antibacterial 1Cleocin Vag Clindamycin Topical, Dermatology, Rectal, Vaginal/Antibacterial 1Cogentin Benztropine CNS, Anxiety, Psych, Neuro, & Autonomic/Misc 1

Colace Docusate sodium Gastrointest/Laxative 1Colchicine Colchicine Misc/Other 1

Combivent, DuoNeb Albuterol / Ipratropium Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled 1

Condylox Podophilox Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1

Cordarone Amiiodarone Cardiac & Anti-Hypertensive/Antiarrythmic 1Coreg Carvedilol Cardiac & Anti-Hypertensive/AlphaBeta Blocker 1

Cortisporin Neomycin / HC Otic 1Cosopt Dorzolamide+Timolol Ophthalmic/Glaucoma 1Coumadin Warfarin Cardiac & Anti-Hypertensive/Anticoagulant 1

Danazol Danocrine Misc/Other 1

Dapsone Dapsone Opportunistic Infections (OIs) 1Darvocet N-100 Propox/Acet CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1Debrox Carbamide Peroxide Otic 1

Decadron Dexamethasone Antiinfectives/Antiinflammatory 1Deltasone Prednisone Antiinfectives/Antiinflammatory 1Dermasmoothe Fluocinolone Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1

Desyrel Trazodone CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

Dexacidin Dexameth/Neo/Poly Ophthalmic/Antibiotic 1

Diabeta, Glycron,

Glynase,Micronase

Glyburide Diabetes 1

Diamox Acetazolamide CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Dilantin Phenytoin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Diprosone Betamethasone Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1

Ditropan Oxybutinin Misc/Other 1Dyazide HCTZ/Triamterene Cardiac & Anti-Hypertensive/Diuretic 1

Dynapen Dicloxacillin Antiinfectives/Antiviral/Antibacterial 1Elavil Amitriptyline CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

HANDOUT A

Brand Name Generic Name Drug Classification Tier Elimite Permethrin Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1E-Mycin Erythromycin Ophthalmic/Antibiotic 1Enulose Lactulose Gastrointest/Laxative 1

Ery-tab Erythromycin base Antiinfectives/Antiviral/Antibacterial 1

Felbatol Felbamate CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Feosol Ferrous sulfate Blood/Blood Forming 1Feosol Ferrous sulfate/fumerate Vitamins & Nutritional/Vitamins 1

Fibercon Fiberlax Gastrointest/Laxative 1Fioricet Butalbi/Acetam/Caff CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1

Fioricet Butalbi/Acetam/Caff CNS, Anxiety, Psych, Neuro, & Autonomic/Antimigraine 1

Flagyl Metronidazole Antiinfectives/Other 1Flexeril Cyclobenzaprine CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1

Fluzone Influenza Vaccine Vaccines 1FML Fluorometholone Ophthalmic/Steroid 1

Folvite Folic Acid Vitamins & Nutritional/Vitamins 1Fortamet, Glucophage,

Glumetza, Riomet

Metformin Diabetes 1

Furoxone Furazolidone Antiinfectives/Antitubercular 1Gabapentin Neurontin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Generic Lipitor Atorvastatin Hyperlipidemia 1Glucotrol Glipizide Diabetes 1

GoLytely/Colyte GoLytely/Colyte Gastrointest/Misc/Other 1

Haldol Haloperidol CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1

Humalog Insulin Analog Diabetes 1

Humatin Paromomycin Antiinfectives/Other 1HydroDiuril HCTZ Cardiac & Anti-Hypertensive/Diuretic 1Hytone Hydrocortisone crm Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1

Hytrin Terazosin Cardiac & Anti-Hypertensive/Alpha Blockers 1

Imdur Isosorbide Mononitrate Cardiac & Anti-Hypertensive/Nitrates 1Imitrex (Oral Only) Sumatriptan CNS, Anxiety, Psych, Neuro, & Autonomic/Antimigraine 1Imodium Loperamide Paregoric Gastrointest/Antidiarrheal 1Inderal Propranolol Cardiac & Anti-Hypertensive/Beta Blockers 1

Isoniazid/INH Isoniazid/INH Antiinfectives/Antitubercular 1Isoptin, Calan Verapamil Cardiac & Anti-Hypertensive/Calcium Channel Blocker 1

HANDOUT A

Brand Name Generic Name Drug Classification Tier Keflex Cephalexin Antiinfectives/Antiviral/Antibacterial 1Kenalog Triamcinolone Topical, Dermatology, Rectal, Vaginal/Antifungal 1Kenalog Triamcinolone crm Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1

Klonopin Clonazepam CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Kwell Lindane Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1Lac-Hydrin Ammonium lact Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1Lamisil Terbinafine Antiinfectives/Antifungal 1

Lamisil Terbinafine Topical, Dermatology, Rectal, Vaginal/Antifungal 1

Lanoxin Digoxin Cardiac & Anti-Hypertensive/Cardiac Glycoside 1Lantus Insulin Glaritine Diabetes 1

Lasix Furosemide Cardiac & Anti-Hypertensive/Diuretic 1Levaquin Levofloxacin Antiinfectives/Antiviral/Antibacterial 1

Lidocaine , Xylocaine Oint, Jelly, Visc, Patch

Xylocaine/Lidocaine Topical, Dermatology, Rectal, Vaginal/Anaesthetic 1

Lioresal Baclofen CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1Lithonate Lithium Carb CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1Lo-Ovral 28 Ethinyl estradiol/ Norgestrel GYN/OB 1

Lopressor Metoprolol Cardiac & Anti-Hypertensive/Beta Blockers 1Lotrimin Clotrimazole Topical, Dermatology, Rectal, Vaginal/Antifungal 1

Lumigan Bimatoprost Ophthalmic/Glaucoma 1Macrodantin Nitrofurantoin Antiinfectives/Antiviral/Antibacterial 1MAGIC Mouthwash MAGIC Mouthwash Misc/Other 1

Mebaral Mephobarbital CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Medrol dosepak Methyprednisolone Antiinfectives/Antiinflammatory 1

Methadone Methadone CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1

Metrogel Metronidazole Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1Morphine MSContin, MSIR CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1Mycolog Nystatin / Triamcin Topical, Dermatology, Rectal, Vaginal/Antifungal 1

Mycostatin Nystatin Topical, Dermatology, Rectal, Vaginal/Antifungal 1

Mylanta DS Al, Mg, Simeth Gastrointest/Antacid 1Mylicon Simethicone Gastrointest/Antiflatulant 1Mysoline Primidone CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Naproxen Naprosyn CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1Nebupent Pentamidine Respiratory, Cough & Cold Allergy/Other 1

HANDOUT A

Brand Name Generic Name Drug Classification Tier Neosporin Neo/Poly/Bacit Ophthalmic/Antibiotic 1Neosporin Neo/Gramic/Poly Topical, Dermatology, Rectal, Vaginal/Antibacterial 1

Nitrostat,Nitro-Dur Nitroglycerin Cardiac & Anti-Hypertensive/Nitrates 1Normal Saline Sodium Chloride for Irrigation Misc/Other 1

Normodyne Labetalol Cardiac & Anti-Hypertensive/Beta Blockers 1

Norvasc Amlodipine Cardiac & Anti-Hypertensive/Calcium Channel Blocker 1Novolin Insulin NPH Diabetes 1

Novolin Insulin Regular Diabetes 1Ocean Nasal Sodium Chloride Nasal 1Omnicef Cefdinir Antiinfectives/Antiviral/Antibacterial 1

Ortho-Tricyclen 28 Ethinyl estrad/Norgest/placeb GYN/OB 1Paxil Paroxetine CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

PenVK Penicililn VK Antiinfectives/Antiviral/Antibacterial 1Percocet Oxycodone/Acet CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1Percodan Oxycodone/ASA CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1

Periactin Cyproheptadine Wasting 1Peri-Colace Docusate/Casanth Gastrointest/Laxative 1

Peridex Oral Rinse Chlorhexidine 12% Solution Misc/Other 1

Phenergan Promethazine Gastrointest/Antiemetic 1

Phenobarbital Phenobarbital CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Pilocar Pilocarpine Ophthalmic/Miotic 1Plavix Aspirin Clopidogrel *Aspirin may

only be dispensed with Clopidogrel

Cardiac & Anti-Hypertensive/Antiplatelet 1

Pneumovax Pneumococcal Vaccine Vaccines 1

Pred Forte Prednisolone Ophthalmic/Steroid 1Premarin Estrogen Conj GYN/OB 1

Prevacid Lansoprazole Gastrointest/PPI 1

Prevnar 13 Pneumococcal Vaccine Vaccines 1

Primaquine Primaquine Antiinfectives/Antiviral/Antibacterial 1Probenecid Probenecid Misc/Other 1Procardia,Adalat Nifedepine Cardiac & Anti-Hypertensive/Calcium Channel Blocker 1

Proloprim Trimethoprim Antiinfectives/Antiviral/Antibacterial 1

Promethazine SupposPromethazine Suppos Gastrointest/Antiemetic 1

Provera, Depo-

Provera

Medroxyprogesterone GYN/OB 1

Psorcon Diflorasone Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1

HANDOUT A

Brand Name Generic Name Drug Classification Tier Pyrazinamide/PZA Pyrazinamide/PZA Antiinfectives/Antitubercular 1Pyridium Phenazopyridine Misc/Other 1Qvar Beclomethasone Respiratory, Cough & Cold Allergy/Corticosteroid Inhaled 1

Reglan Metoclopramide Gastrointest/Misc/Other 1

Remeron Mirtazapine CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1Restoril Temazepam CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1Rhinocort Budesonide Nasal 1

Rifadin Rifampin Antiinfectives/Antitubercular 1Rifamate Isoniazid/Rifampn Antiinfectives/Antitubercular 1

Rifamate Rifampin / Isoniazid Antiinfectives/Antitubercular 1

Risperdal Risperidone CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1Robitussin Guaifenesin Respiratory, Cough & Cold Allergy/Antitussive 1

Robitussin AC Guaifen / Cod Respiratory, Cough & Cold Allergy/Antitussive 1Robitussin DAC Guaifen /Cod / Pseudoephed Respiratory, Cough & Cold Allergy/Antitussive 1

Robitussin DM Guaifen / DM Respiratory, Cough & Cold Allergy/Antitussive 1Rocephin Ceftriaxone INJ Antiinfectives/Antiviral/Antibacterial 1Selsun Selenium Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1

Serevent Salmeterol Discus Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled 1

Seromycin Cycloserine Antiinfectives/Antitubercular 1Sinemet Carbidopa/levodop CNS, Anxiety, Psych, Neuro, & Autonomic/Antiparkinson 1Sinequan Doxepin CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

Singulair Montileukast Respiratory, Cough & Cold Allergy/Other 1Soma Carisoprodol CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1Sudafed Pseudoephedrine Respiratory, Cough & Cold Allergy/Antihist/Decongestant 1

Sulamyd Sulfacetamide Ophthalmic/Antibiotic 1

Synthroid Levothyroxine Misc/Other 1

TDAP Tetanus, Diptheria, and Pertussis Vaccines 1Tearisol Artificial tears Ophthalmic/Misc/Other 1

Tegretol Carbamazepine CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Temovate Clobetasol Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1Tenormin Atenolol Cardiac & Anti-Hypertensive/Beta Blockers 1

Tetanus/Diptheria Injection

Td Vaccines 1

Theo-Dur Theophylline Respiratory, Cough & Cold Allergy/Xanthine 1

HANDOUT A

Brand Name Generic Name Drug Classification Tier Therapeutic Multivitamins

Therapeutic Multivitamins Vitamins & Nutritional/Vitamins 1

Thorazine Chlorpromazine CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1

Timoptic Timolol Ophthalmic/Betablocker 1TMP-SMX ds TMP-SMX ds Opportunistic Infections (OIs) 1Tobrex Tobramycin Ophthalmic/Antibiotic 1Topamax Topiramate CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Tramadol Ultram CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1Trilafon Perphenazine CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1Tylenol#3 Codeine/Acetam CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1

Ultrace MT Pancrealipase Gastrointest/Digestive Enzyme 1Valium Diazepam CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1Vasocon Naphazoline Ophthalmic/Misc/Other 1Vasotec Enalapril Cardiac & Anti-Hypertensive/ACE Inhibitor 1Ventolin Albuterol tab Respiratory, Cough & Cold Allergy/BetaAgonist Oral 1Ventolin Albuterol Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled 1Vibramycin Doxycycline Antiinfectives/Antiviral/Antibacterial 1Vicodin,VicodinES Hydrocodone / Acet CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1

Viroptic Trifluridine Ophthalmic/Misc/Other 1Vistaril,Atarx Hydroxyzine CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1Vosol Acetic Acid Otic 1Vosol HC Acetic Acid / HC Otic 1

Xalatan Latanoprost Ophthalmic/Glaucoma 1

Zantac Ranitidine Gastrointest/H2Antagonist 1Zarontin Ethosuximide CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Zestril, Prinivil Lisinopril Cardiac & Anti-Hypertensive/ACE Inhibitor 1

Zoloft Sertraline CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1Zyloprim Allopurinol Misc/Other 1

HANDOUT A


Aptivus Tipranavir Antiretrovirals/Protease Inhibitors (PIs) 2

Atripla Tenofovir/Emtricitabine/Efavirenz

Antiretrovirals/Multiclass 2

Bactrim DS TMP/SMZ DS Other Conditions/Other Conditions 2

Biaxin Clarithromycin Other Conditions/Other Conditions 2

Clotrimazole Mycelex Troche Other Conditions/Other Conditions 2

Combivir Zidovudine/Lamivudine Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Complera Emtricitabine, Rilpivirine, Tenofovir Antiretrovirals/Multiclass 2

Crixivan Indinavir Antiretrovirals/Protease Inhibitors (PIs) 2

Daraprim Pyrimethamine Other Conditions/Other Conditions 2

Diflucan Fluconazole Other Conditions/Other Conditions 2

Edurant Rilpivirine Antiretrovirals/Nonnucleosides (NNRTIs) 2

Emtriva Emtricitabine Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Epivir Lamivudine Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Epzicom Abacavir/Lamivudine Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Fuzeon Enfuviritde Antiretrovirals/Entry/Fusion Inhibitor 2

Intelence Etravirine Antiretrovirals/Nonnucleosides (NNRTIs) 2

Invirase Saquinavir Antiretrovirals/Protease Inhibitors (PIs) 2

Isentress Raltegravir Antiretrovirals/Integrase Inhibitor 2

Kaletra Lopinavir/Ritonavir Antiretrovirals/Protease Inhibitors (PIs) 2

Leucovorin Folinic Acid Other Conditions/Other Conditions 2

Lexiva Fosamprenavir Antiretrovirals/Protease Inhibitors (PIs) 2

Mepron Atovaquone Other Conditions/Other Conditions 2

Monistat Miconazole Other Conditions/Other Conditions 2

Myambutol Ethambutol Other Conditions/Other Conditions 2

Mycobutin Rifabutin Other Conditions/Other Conditions 2

Nizoral Ketoconazole Other Conditions/Other Conditions 2

Tier 2: In order to access Tier Two, clients must be screened every six 6) months for the State AIDS Drugs Assistance Program ADAP) eligibility and must be ineligible and meet the Ryan Part A eligibility

requirements prior to the use of this formulary.

Ryan White Part A Pharmacy Formulary - Updated 3/26/15

HANDOUT A


Norvire Ritonavir Antiretrovirals/Protease Inhibitors (PIs) 2

Prezista Darunavir Antiretrovirals/Protease Inhibitors (PIs) 2

Rescriptor Delavirdine Antiretrovirals/Nonnucleosides (NNRTIs) 2

Retrovir Zidovudine Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Reyataz Atazanavir Antiretrovirals/Protease Inhibitors (PIs) 2

Selzentry Maraviroc Antiretrovirals/Entry/Fusion Inhibitor 2

Sporanox Itraconazole Other Conditions/Other Conditions 2

Stribild Elvitegravir, Cobicistat, Tenofovir,

Emtricitabine

Antiretrovirals/Multiclass 2

Sulfadiazine Sulfadiazine Other Conditions/Other Conditions 2

Sustiva Efavirenz Antiretrovirals/Nonnucleosides (NNRTIs) 2

Terazol Terconazole Other Conditions/Other Conditions 2

Tivicay Dolutegravir Antiretrovirals/Protease Inhibitors (PIs) 2

Trizivir Abacavir/Lamivudine/Zidovudine Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Truvada Tenofovir/Emtricitabine Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Valcyte Valganciclovir HCL Other Conditions/Other Conditions 2

Valtrex Valacyclovir Other Conditions/Other Conditions 2

Videx Didanosine Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Viracept Nelfinavir Antiretrovirals/Protease Inhibitors (PIs) 2

Viramune Nevirapine Antiretrovirals/Nonnucleosides (NNRTIs) 2

Viread Tenofovir Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Zerit Stavudine Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Ziagen Abacavir Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Zithromax Azithromycin Other Conditions/Other Conditions 2

Zovirax Acyclovir Other Conditions/Other Conditions 2

HANDOUT A

Brand Name Generic Name Drug Classification Tier Aldara Imiquimod Other Conditions/Opportunistic Infections (OIs) 3Bactroban Mupirocin Other Conditions/Opportunistic Infections (OIs) 3Crestor Rosuvastatin Other Conditions/Hyperlipidemia 3Cymbalta Duloxetine Other Conditions/Neuropathy 3Depakote Divalproex Other Conditions/Other Side Effects/Conditions 3

Geodon Ziprasidone Other Conditions/Other Side Effects/Conditions 3Januvia Sitagliptin Diabetes 3Keppra Levetiracetam Other Conditions/Anticonvulsant 3Lamictal Lamotrigine Other Conditions/Neuropathy 3Leucovorin Folinic Acid Other Conditions/Supplement 3Lopid Gemfibrozil Other Conditions/Hyperlipidemia 3Lyrica Pregabalin Other Conditions/Neuropathy 3Marinol Bronabinol Other Conditions/Wasting 3

Megace Megestrol Other Conditions/Wasting 3Pamelor Nortriptyline Other Conditions/Neuropathy 3

Pravachol Pravastatin Other Conditions/Hyperlipidemia 3Tricor Fenofibrate Other Conditions/Hyperlipidemia 3Zostavax Zozter Vaccine Live Vaccines 3

Tier 3: In order to access Tier Three clients must meet the Ryan Part A eligibility requirements and have a Patient Assistance Program (PAP) application completed for each medication. Client

may be eligible to receive a 10-day supply, with an option for extention, while waiting for

approval.


HANDOUT A

Drug Classification Generic Name Brand Name Tier

Antiinfectives/Antiinflammatory Dexamethasone Decadron 1Antiinfectives/Antiinflammatory Methyprednisolone Medrol dosepak 1Antiinfectives/Antiinflammatory Prednisone Deltasone 1Antiinfectives/Antiviral/Antibacterial Amoxicillin Amoxil 1Antiinfectives/Antiviral/Antibacterial Amoxicill/Clav Augmentin 1Antiinfectives/Antiviral/Antibacterial Cefdinir Omnicef 1Antiinfectives/Antiviral/Antibacterial Ceftriaxone INJ Rocephin 1

Antiinfectives/Antiviral/Antibacterial Cefuroxime Ceftin 1Antiinfectives/Antiviral/Antibacterial Cephalexin Keflex 1Antiinfectives/Antiviral/Antibacterial Ciprofloxacin Cipro 1Antiinfectives/Antiviral/Antibacterial Clindamycin Cleocin 1Antiinfectives/Antiviral/Antibacterial Doxycycline Vibramycin 1Antiinfectives/Antiviral/Antibacterial Dicloxacillin Dynapen 1Antiinfectives/Antiviral/Antibacterial Erythromycin base Ery-tab 1Antiinfectives/Antiviral/Antibacterial Nitrofurantoin Macrodantin 1

Antiinfectives/Antiviral/Antibacterial Penicillin Benzath Bicillin LA 1Antiinfectives/Antiviral/Antibacterial Penicililn VK PenVK 1Antiinfectives/Antiviral/Antibacterial Primaquine Primaquine 1Antiinfectives/Antiviral/Antibacterial Tetracycline Achromycin 1

Antiinfectives/Antiviral/Antibacterial Trimethoprim Proloprim 1

Antiinfectives/Antiviral/Antibacterial Levofloxacin Levaquin 1Antiinfectives/Antifungal Terbinafine Lamisil 1Antiinfectives/Antitubercular Cycloserine Seromycin 1

Antiinfectives/Antitubercular Furazolidone Furoxone 1Antiinfectives/Antitubercular Isoniazid/INH Isoniazid/INH 1

Antiinfectives/Antitubercular Isoniazid/Rifampn Rifamate 1

Antiinfectives/Antitubercular Pyrazinamide/PZA Pyrazinamide/PZA 1Antiinfectives/Antitubercular Rifampin Rifadin 1Antiinfectives/Antitubercular Rifampin / Isoniazid Rifamate 1Antiinfectives/Other Metronidazole Flagyl 1

Antiinfectives/Other Paromomycin Humatin 1Blood/Blood Forming Ferrous sulfate Feosol 1


HANDOUT A

Drug Classification Generic Name Brand Name Tier CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic Diazepam Valium 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic Hydroxyzine Vistaril,Atarx 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic Lorazepam Ativan 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic Temazepam Restoril 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Buspirone Buspar 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Citalopram Celexa 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Doxepin Sinequan 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Amitriptyline Elavil 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Mirtazapine Remeron 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Paroxetine Paxil 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Sertraline Zoloft 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Trazodone Desyrel 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Lithium Carb Lithonate 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Wellbutrin Bupropion 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic Chlorpromazine Thorazine 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic Haloperidol Haldol 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic Perphenazine Trilafon 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic Risperidone Risperdal 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Misc Benztropine Cogentin 1CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Acetazolamide Diamox 1CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Carbamazepine Tegretol 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Clonazepam Klonopin 1CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Ethosuximide Zarontin 1CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Felbamate Felbatol 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Mephobarbital Mebaral 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Methsuiximide Celontin 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Neurontin Gabapentin 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Phenobarbital Phenobarbital 1CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Phenytoin Dilantin 1CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Primidone Mysoline 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Topiramate Topamax 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic Naprosyn Naproxen 1CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic Butalbi/Acetam/Caff Fioricet 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic Ultram Tramadol 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic Celebrex Celecoxib 1

HANDOUT A

Drug Classification Generic Name Brand Name Tier CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Codeine/Acetam Tylenol#3 1CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Hydrocodone / Acet Vicodin,VicodinES 1CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Methadone Methadone 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic MSContin, MSIR Morphine 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Oxycodone/ASA Percodan 1CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Oxycodone/Acet Percocet 1CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Propox/Acet Darvocet N-100 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant Baclofen Lioresal 1CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant Carisoprodol Soma 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant Cyclobenzaprine Flexeril 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Antiparkinson Carbidopa/levodop Sinemet 1CNS, Anxiety, Psych, Neuro, & Autonomic/Antimigraine Sumatriptan Imitrex (Oral Only) 1

CNS, Anxiety, Psych, Neuro, & Autonomic/Antimigraine Butalbi/Acetam/Caff Fioricet 1Cardiac & Anti-Hypertensive/ACE Inhibitor Enalapril Vasotec 1

Cardiac & Anti-Hypertensive/ACE Inhibitor Lisinopril Zestril, Prinivil 1Cardiac & Anti-Hypertensive/Angiotensin Receptor Blocker (ARB) Irbesartan Avapro 1Cardiac & Anti-Hypertensive/Alpha Blockers Clonidine Catapres 1

Cardiac & Anti-Hypertensive/Alpha Blockers Terazosin Hytrin 1

Cardiac & Anti-Hypertensive/AlphaBeta Blocker Carvedilol Coreg 1Cardiac & Anti-Hypertensive/Beta Blockers Atenolol Tenormin 1Cardiac & Anti-Hypertensive/Beta Blockers Labetalol Normodyne 1

Cardiac & Anti-Hypertensive/Beta Blockers Propranolol Inderal 1Cardiac & Anti-Hypertensive/Beta Blockers Metoprolol Lopressor 1Cardiac & Anti-Hypertensive/Antiarrythmic Amiiodarone Cordarone 1

Cardiac & Anti-Hypertensive/Anticoagulant Warfarin Coumadin 1

Cardiac & Anti-Hypertensive/Antiplatelet Aspirin Clopidogrel *Aspirin may

only be dispensed with Clopidogrel

Plavix 1

Cardiac & Anti-Hypertensive/Calcium Channel Blocker Amlodipine Norvasc 1Cardiac & Anti-Hypertensive/Calcium Channel Blocker Diltiazem Cardizem 1

Cardiac & Anti-Hypertensive/Calcium Channel Blocker Verapamil Isoptin, Calan 1

Cardiac & Anti-Hypertensive/Calcium Channel Blocker Nifedepine Procardia,Adalat 1Cardiac & Anti-Hypertensive/Cardiac Glycoside Digoxin Lanoxin 1Cardiac & Anti-Hypertensive/Diuretic Bumetanide Bumex 1

Cardiac & Anti-Hypertensive/Diuretic Furosemide Lasix 1Cardiac & Anti-Hypertensive/Diuretic HCTZ HydroDiuril 1

HANDOUT A

Drug Classification Generic Name Brand Name Tier Cardiac & Anti-Hypertensive/Diuretic HCTZ/Triamterene Dyazide 1Cardiac & Anti-Hypertensive/Diuretic Spironolactone Aldactone 1Cardiac & Anti-Hypertensive/Nitrates Nitroglycerin Nitrostat,Nitro-Dur 1

Cardiac & Anti-Hypertensive/Nitrates Isosorbide Mononitrate Imdur 1

Diabetes Insulin Analog Humalog 1Diabetes Insulin NPH Novolin 1Diabetes Insulin Regular Novolin 1

Diabetes Insulin Glaritine Lantus 1Diabetes Glipizide Glucotrol 1

Diabetes Glyburide Diabeta, Glycron,

Glynase,Micronase

1

Diabetes Metformin Fortamet,

Glucophage, Glumetza, Riomet

1

Gastrointest/Antacid Al, Mg, Simeth Mylanta DS 1

Gastrointest/Antidiarrheal Loperamide Paregoric Imodium 1Gastrointest/Antiemetic Promethazine Phenergan 1

Gastrointest/Antiemetic Promethazine Suppos Promethazine Suppos 1

Gastrointest/Antiflatulant Simethicone Mylicon 1

Gastrointest/Antispasmotic Dicyclomine Bentyl 1Gastrointest/Digestive Enzyme Pancrealipase Ultrace MT 1Gastrointest/H2Antagonist Ranitidine Zantac 1

Gastrointest/Laxative Docusate sodium Colace 1

Gastrointest/Laxative Docusate/Casanth Peri-Colace 1Gastrointest/Laxative Fiberlax Fibercon 1Gastrointest/Laxative Lactulose Enulose 1

Gastrointest/PPI Lansoprazole Prevacid 1Gastrointest/Misc/Other GoLytely/Colyte GoLytely/Colyte 1Gastrointest/Misc/Other Metoclopramide Reglan 1

Gastrointest/Misc/Other Sucralfate Carafate 1GYN/OB Estrogen Conj Premarin 1

GYN/OB Medroxyprogesterone Provera, Depo-Provera

1

GYN/OB Ethinyl estrad/Norgest/placeb Ortho-Tricyclen 28 1GYN/OB Ethinyl estradiol/ Norgestrel Lo-Ovral 28 1

HANDOUT A

Drug Classification Generic Name Brand Name Tier Hyperlipidemia Atorvastatin Generic Lipitor 1Nasal Budesonide Rhinocort 1Nasal Beclomethasone Beconase AQ 1

Nasal Sodium Chloride Ocean Nasal 1Ophthalmic/Antibiotic Ciprofloxacin Ciloxin 1Ophthalmic/Antibiotic Dexameth/Neo/Poly Dexacidin 1Ophthalmic/Antibiotic Erythromycin E-Mycin 1Ophthalmic/Antibiotic Neo/Poly/Bacit Neosporin 1Ophthalmic/Antibiotic Sulfacetamide Sulamyd 1Ophthalmic/Antibiotic Tobramycin Tobrex 1

Ophthalmic/Betablocker Betaxolol Betoptic S 1Ophthalmic/Betablocker Timolol Timoptic 1Ophthalmic/Glaucoma Brimonide Alphagan 1Ophthalmic/Glaucoma Bimatoprost Lumigan 1Ophthalmic/Glaucoma Brinzolamide Azopt 1Ophthalmic/Glaucoma Dorzolamide+Timolol Cosopt 1Ophthalmic/Glaucoma Latanoprost Xalatan 1Ophthalmic/Miotic Pilocarpine Pilocar 1

Ophthalmic/Steroid Fluorometholone FML 1Ophthalmic/Steroid Prednisolone Pred Forte 1Ophthalmic/Misc/Other Artificial tears Tearisol 1

Ophthalmic/Misc/Other Lodoxamide Alomide 1Ophthalmic/Misc/Other Naphazoline Vasocon 1Ophthalmic/Misc/Other Trifluridine Viroptic 1

Opportunistic Infections (OIs) TMP-SMX ds TMP-SMX ds 1

Opportunistic Infections (OIs) Dapsone Dapsone 1

Misc/Other Allopurinol Zyloprim 1

Misc/Other Chlorhexidine 12% Solution Peridex Oral Rinse 1Misc/Other Colchicine Colchicine 1Misc/Other Danocrine Danazol 1

Misc/Other Levothyroxine Synthroid 1

Misc/Other MAGIC Mouthwash MAGIC Mouthwash 1Misc/Other Meclizine Antivert 1

Misc/Other Oxybutinin Ditropan 1

Misc/Other Probenecid Probenecid 1

HANDOUT A

Drug Classification Generic Name Brand Name Tier Misc/Other Sodium Chloride for Irrigation Normal Saline 1

Misc/Other Phenazopyridine Pyridium 1

Otic Acetic Acid Vosol 1Otic Acetic Acid / HC Vosol HC 1Otic Neomycin / HC Cortisporin 1

Otic Ciprofloxacin / HC Cipro HC 1Otic Carbamide Peroxide Debrox 1

Respiratory, Cough & Cold Allergy/Antihistamine Loratadine Claritin 1Respiratory, Cough & Cold Allergy/Antihistamine Diphenhydramine Benadryl 1Respiratory, Cough & Cold Allergy/Antihist/Decongestant Bromphen/pseudephed / DM Cardec, Cardec DM,

Cardec S

1

Respiratory, Cough & Cold Allergy/Antihist/Decongestant Pseudoephedrine Sudafed 1

Respiratory, Cough & Cold Allergy/Antitussive Guaifenesin Robitussin 1Respiratory, Cough & Cold Allergy/Antitussive Guaifen / DM Robitussin DM 1Respiratory, Cough & Cold Allergy/Antitussive Guaifen / Cod Robitussin AC 1

Respiratory, Cough & Cold Allergy/Antitussive Guaifen /Cod / Pseudoephed Robitussin DAC 1Respiratory, Cough & Cold Allergy/BetaAgonist Oral Albuterol tab Ventolin 1

Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled Albuterol Ventolin 1

Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled Albuterol / Ipratropium Combivent, DuoNeb 1

Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled Salmeterol Discus Serevent 1Respiratory, Cough & Cold Allergy/Corticosteroid Inhaled Beclomethasone Qvar 1

Respiratory, Cough & Cold Allergy/Xanthine Theophylline Theo-Dur 1

Respiratory, Cough & Cold Allergy/Other Ipratropium Atrovent 1Respiratory, Cough & Cold Allergy/Other Montileukast Singulair 1

Respiratory, Cough & Cold Allergy/Other Pentamidine Nebupent 1

Topical, Dermatology, Rectal, Vaginal/Anaesthetic Xylocaine/Lidocaine Lidocaine , Xylocaine Oint, Jelly, Visc, Patch

1

Topical, Dermatology, Rectal, Vaginal/Antibacterial Clindamycin Cleocin Vag 1

Topical, Dermatology, Rectal, Vaginal/Antibacterial Neo/Gramic/Poly Neosporin 1

Topical, Dermatology, Rectal, Vaginal/Antibacterial Erythomycin / Benzoyl perox Benzagel 1Topical, Dermatology, Rectal, Vaginal/Antifungal Clotrimazole Lotrimin 1

Topical, Dermatology, Rectal, Vaginal/Antifungal Nystatin / Triamcin Mycolog 1Topical, Dermatology, Rectal, Vaginal/Antifungal Triamcinolone Kenalog 1

HANDOUT A

Drug Classification Generic Name Brand Name Tier Topical, Dermatology, Rectal, Vaginal/Antifungal Terbinafine Lamisil 1Topical, Dermatology, Rectal, Vaginal/Antifungal Nystatin Mycostatin 1Topical, Dermatology, Rectal, Vaginal/Corticosteroid Clobetasol Temovate 1

Topical, Dermatology, Rectal, Vaginal/Corticosteroid Diflorasone Psorcon 1

Topical, Dermatology, Rectal, Vaginal/Corticosteroid Betamethasone Diprosone 1Topical, Dermatology, Rectal, Vaginal/Corticosteroid Fluocinolone Dermasmoothe 1Topical, Dermatology, Rectal, Vaginal/Corticosteroid Hydrocortisone crm Hytone 1

Topical, Dermatology, Rectal, Vaginal/Corticosteroid Hydrocortisone Suppos Anusol-HC 1Topical, Dermatology, Rectal, Vaginal/Corticosteroid Triamcinolone crm Kenalog 1

Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Ammonium lact Lac-Hydrin 1

Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Lindane Kwell 1Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Metronidazole Metrogel 1

Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Permethrin Elimite 1Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Podophilox Condylox 1

Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Selenium Selsun 1Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other Urea, misc Amino-Cerv 1Vaccines Influenza Vaccine Fluzone 1

Vaccines Pneumococcal Vaccine Pneumovax 1

Vaccines Pneumococcal Vaccine Prevnar 13 1Vaccines Tetanus, Diptheria, and Pertussis TDAP 1Vaccines Td Tetanus/Diptheria

Injection

1

Vitamins & Nutritional/Vitamins Ferrous sulfate/fumerate Feosol 1Vitamins & Nutritional/Vitamins Folic Acid Folvite 1

Vitamins & Nutritional/Vitamins Therapeutic Multivitamins Therapeutic

Multivitamins

1

Vitamins & Nutritional/Vitamins B-Plex with C Antioxidant 1

Wasting Cyproheptadine Periactin 1

HANDOUT A


Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Zidovudine/Lamivudine Combivir 2

Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Emtricitabine Emtriva 2

Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Lamivudine Epivir 2

Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Abacavir/Lamivudine Epzicom 2

Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Zidovudine Retrovir 2

Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Abacavir/Lamivudine/Zidovudine Trizivir 2

Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Tenofovir/Emtricitabine Truvada 2

Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Didanosine Videx 2

Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Tenofovir Viread 2

Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Stavudine Zerit 2

Antiretrovirals/Nucleosides/Nucleotide (NRTIs) Abacavir Ziagen 2

Antiretrovirals/Nonnucleosides (NNRTIs) Etravirine Intelence 2

Antiretrovirals/Nonnucleosides (NNRTIs) Delavirdine Rescriptor 2

Antiretrovirals/Nonnucleosides (NNRTIs) Efavirenz Sustiva 2

Antiretrovirals/Nonnucleosides (NNRTIs) Nevirapine Viramune 2

Antiretrovirals/Nonnucleosides (NNRTIs) Rilpivirine Edurant 2

Antiretrovirals/Protease Inhibitors (PIs) Dolutegravir Tivicay 2

Antiretrovirals/Protease Inhibitors (PIs) Tipranavir Aptivus 2

Antiretrovirals/Protease Inhibitors (PIs) Indinavir Crixivan 2

Antiretrovirals/Protease Inhibitors (PIs) Saquinavir Invirase 2

Antiretrovirals/Protease Inhibitors (PIs) Lopinavir/Ritonavir Kaletra 2

Antiretrovirals/Protease Inhibitors (PIs) Fosamprenavir Lexiva 2

Antiretrovirals/Protease Inhibitors (PIs) Ritonavir Norvire 2

Antiretrovirals/Protease Inhibitors (PIs) Darunavir Prezista 2

Antiretrovirals/Protease Inhibitors (PIs) Atazanavir Reyataz 2

Antiretrovirals/Protease Inhibitors (PIs) Nelfinavir Viracept 2

Antiretrovirals/Entry/Fusion Inhibitor Enfuviritde Fuzeon 2

Antiretrovirals/Entry/Fusion Inhibitor Maraviroc Selzentry 2

Antiretrovirals/Integrase Inhibitor Raltegravir Isentress 2


Tier 2: In order to access Tier Two, clients must be screened every six 6) months for the State AIDS Drugs Assistance Program ADAP) eligibility and must be ineligible and meet the Ryan Part A eligibility

requirements prior to the use of this formulary.

HANDOUT A


Antiretrovirals/Multiclass Tenofovir/Emtricitabine/Efavirenz

Atripla 2

Antiretrovirals/Multiclass Emtricitabine, Rilpivirine, Tenofovir Complera 2

Antiretrovirals/Multiclass Elvitegravir, Cobicistat, Tenofovir, Emtricitabine

Stribild 2

Other Conditions/Other Conditions TMP/SMZ DS Bactrim DS 2

Other Conditions/Other Conditions Clarithromycin Biaxin 2

Other Conditions/Other Conditions Mycelex Troche Clotrimazole 2

Other Conditions/Other Conditions Pyrimethamine Daraprim 2

Other Conditions/Other Conditions Fluconazole Diflucan 2

Other Conditions/Other Conditions Ketoconazole Nizoral 2

Other Conditions/Other Conditions Folinic Acid Leucovorin 2

Other Conditions/Other Conditions Atovaquone Mepron 2

Other Conditions/Other Conditions Miconazole Monistat 2

Other Conditions/Other Conditions Ethambutol Myambutol 2

Other Conditions/Other Conditions Rifabutin Mycobutin 2

Other Conditions/Other Conditions Itraconazole Sporanox 2

Other Conditions/Other Conditions Sulfadiazine Sulfadiazine 2

Other Conditions/Other Conditions Terconazole Terazol 2

Other Conditions/Other Conditions Valacyclovir Valtrex 2

Other Conditions/Other Conditions Valganciclovir HCL Valcyte 2

Other Conditions/Other Conditions Azithromycin Zithromax 2

Other Conditions/Other Conditions Acyclovir Zovirax 2

HANDOUT A

Drug Classification Generic Name BrandName Tier Diabetes Sitagliptin Januvia 3Other Conditions/Anticonvulsant Levetiracetam Keppra 3Other Conditions/Hyperlipidemia Rosuvastatin Crestor 3Other Conditions/Hyperlipidemia Gemfibrozil Lopid 3Other Conditions/Hyperlipidemia Pravastatin Pravachol 3

Other Conditions/Hyperlipidemia Fenofibrate Tricor 3Other Conditions/Neuropathy Duloxetine Cymbalta 3Other Conditions/Neuropathy Lamotrigine Lamictal 3Other Conditions/Neuropathy Pregabalin Lyrica 3Other Conditions/Neuropathy Nortriptyline Pamelor 3Other Conditions/Opportunistic Infections (OIs) Imiquimod Aldara 3Other Conditions/Opportunistic Infections (OIs) Bactroban Mupirocin 3Other Conditions/Other Side Effects/Conditions Divalproex Depakote 3

Other Conditions/Other Side Effects/Conditions Ziprasidone Geodon 3Other Conditions/Supplement Leucovorin Folinic Acid 3Other Conditions/Wasting Bronabinol Marinol 3

Other Conditions/Wasting Megestrol Megace 3

Vaccines Zoster Vaccine Live Zostavax 3

Tier 3: In order to access Tier Three clients must meet the Ryan Part A eligibility requirements and have a Patient Assistance Program (PAP) application completed for each medication. Client may be

eligible to receive a 10-day supply, with an option for extention, while waiting for approval.


HANDOUT A

Generic Name Brand Name Drug Classification Tier

Acetazolamide Diamox CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Acetic Acid Vosol Otic 1

Acetic Acid / HC Vosol HC Otic 1Al, Mg, Simeth Mylanta DS Gastrointest/Antacid 1

Albuterol Ventolin Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled 1Albuterol tab Ventolin Respiratory, Cough & Cold Allergy/BetaAgonist Oral 1Albuterol / Ipratropium Combivent, DuoNeb Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled 1

Allopurinol Zyloprim Misc/Other 1Amiiodarone Cordarone Cardiac & Anti-Hypertensive/Antiarrythmic 1

Amitriptyline Elavil CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1Amlodipine Norvasc Cardiac & Anti-Hypertensive/Calcium Channel Blocker 1Ammonium lact Lac-Hydrin Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1

Amoxicill/Clav Augmentin Antiinfectives/Antiviral/Antibacterial 1Amoxicillin Amoxil Antiinfectives/Antiviral/Antibacterial 1

Artificial tears Tearisol Ophthalmic/Misc/Other 1

Aspirin Clopidogrel *Aspirin may only

be dispensed with Clopidogrel

Plavix Cardiac & Anti-Hypertensive/Antiplatelet 1

Atenolol Tenormin Cardiac & Anti-Hypertensive/Beta Blockers 1

Atorvastatin Generic Lipitor Hyperlipidemia 1Baclofen Lioresal CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1Beclomethasone Beconase AQ Nasal 1Beclomethasone Qvar Respiratory, Cough & Cold Allergy/Corticosteroid Inhaled 1

Benztropine Cogentin CNS, Anxiety, Psych, Neuro, & Autonomic/Misc 1

Betamethasone Diprosone Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1

Betaxolol Betoptic S Ophthalmic/Betablocker 1

Bimatoprost Lumigan Ophthalmic/Glaucoma 1B-Plex with C Antioxidant Vitamins & Nutritional/Vitamins 1Brimonide Alphagan Ophthalmic/Glaucoma 1Brinzolamide Azopt Ophthalmic/Glaucoma 1Bromphen/pseudephed / DM Cardec, Cardec DM,

Cardec S

Respiratory, Cough & Cold Allergy/Antihist/Decongestant 1


HANDOUT A

Generic Name Brand Name Drug Classification Tier Budesonide Rhinocort Nasal 1Bumetanide Bumex Cardiac & Anti-Hypertensive/Diuretic 1Buspirone Buspar CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

Butalbi/Acetam/Caff Fioricet CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1Butalbi/Acetam/Caff Fioricet CNS, Anxiety, Psych, Neuro, & Autonomic/Antimigraine 1Carbamazepine Tegretol CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Carbamide Peroxide Debrox Otic 1Carbidopa/levodop Sinemet CNS, Anxiety, Psych, Neuro, & Autonomic/Antiparkinson 1Carisoprodol Soma CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1Carvedilol Coreg Cardiac & Anti-Hypertensive/AlphaBeta Blocker 1

Cefdinir Omnicef Antiinfectives/Antiviral/Antibacterial 1Ceftriaxone INJ Rocephin Antiinfectives/Antiviral/Antibacterial 1Cefuroxime Ceftin Antiinfectives/Antiviral/Antibacterial 1Celebrex Celecoxib CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1Cephalexin Keflex Antiinfectives/Antiviral/Antibacterial 1Chlorhexidine 12% Solution Peridex Oral Rinse Misc/Other 1Chlorpromazine Thorazine CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1Ciprofloxacin Cipro Antiinfectives/Antiviral/Antibacterial 1

Ciprofloxacin Ciloxin Ophthalmic/Antibiotic 1Ciprofloxacin / HC Cipro HC Otic 1Citalopram Celexa CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

Clindamycin Cleocin Antiinfectives/Antiviral/Antibacterial 1Clindamycin Cleocin Vag Topical, Dermatology, Rectal, Vaginal/Antibacterial 1Clobetasol Temovate Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1

Clonazepam Klonopin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Clonidine Catapres Cardiac & Anti-Hypertensive/Alpha Blockers 1

Clotrimazole Lotrimin Topical, Dermatology, Rectal, Vaginal/Antifungal 1

Codeine/Acetam Tylenol#3 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1Colchicine Colchicine Misc/Other 1Cyclobenzaprine Flexeril CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1

Cycloserine Seromycin Antiinfectives/Antitubercular 1

Cyproheptadine Periactin Wasting 1Danocrine Danazol Misc/Other 1

Dapsone Dapsone Opportunistic Infections (OIs) 1

Dexameth/Neo/Poly Dexacidin Ophthalmic/Antibiotic 1

HANDOUT A

Generic Name Brand Name Drug Classification Tier Dexamethasone Decadron Antiinfectives/Antiinflammatory 1Diazepam Valium CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1Dicloxacillin Dynapen Antiinfectives/Antiviral/Antibacterial 1

Dicyclomine Bentyl Gastrointest/Antispasmotic 1

Diflorasone Psorcon Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1Digoxin Lanoxin Cardiac & Anti-Hypertensive/Cardiac Glycoside 1Diltiazem Cardizem Cardiac & Anti-Hypertensive/Calcium Channel Blocker 1

Diphenhydramine Benadryl Respiratory, Cough & Cold Allergy/Antihistamine 1Docusate sodium Colace Gastrointest/Laxative 1

Docusate/Casanth Peri-Colace Gastrointest/Laxative 1

Dorzolamide+Timolol Cosopt Ophthalmic/Glaucoma 1Doxepin Sinequan CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

Doxycycline Vibramycin Antiinfectives/Antiviral/Antibacterial 1Enalapril Vasotec Cardiac & Anti-Hypertensive/ACE Inhibitor 1

Erythomycin / Benzoyl perox Benzagel Topical, Dermatology, Rectal, Vaginal/Antibacterial 1Erythromycin E-Mycin Ophthalmic/Antibiotic 1Erythromycin base Ery-tab Antiinfectives/Antiviral/Antibacterial 1

Estrogen Conj Premarin GYN/OB 1

Ethinyl estrad/Norgest/placeb Ortho-Tricyclen 28 GYN/OB 1Ethinyl estradiol/ Norgestrel Lo-Ovral 28 GYN/OB 1Ethosuximide Zarontin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Felbamate Felbatol CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Ferrous sulfate Feosol Blood/Blood Forming 1Ferrous sulfate/fumerate Feosol Vitamins & Nutritional/Vitamins 1

Fiberlax Fibercon Gastrointest/Laxative 1

Fluocinolone Dermasmoothe Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1

Fluorometholone FML Ophthalmic/Steroid 1Folic Acid Folvite Vitamins & Nutritional/Vitamins 1

Furazolidone Furoxone Antiinfectives/Antitubercular 1Furosemide Lasix Cardiac & Anti-Hypertensive/Diuretic 1Glipizide Glucotrol Diabetes 1

Glyburide Diabeta, Glycron, Glynase,Micronase

Diabetes 1

GoLytely/Colyte GoLytely/Colyte Gastrointest/Misc/Other 1Guaifen / Cod Robitussin AC Respiratory, Cough & Cold Allergy/Antitussive 1

HANDOUT A

Generic Name Brand Name Drug Classification Tier Guaifen / DM Robitussin DM Respiratory, Cough & Cold Allergy/Antitussive 1Guaifen /Cod / Pseudoephed Robitussin DAC Respiratory, Cough & Cold Allergy/Antitussive 1Guaifenesin Robitussin Respiratory, Cough & Cold Allergy/Antitussive 1

Haloperidol Haldol CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1HCTZ HydroDiuril Cardiac & Anti-Hypertensive/Diuretic 1HCTZ/Triamterene Dyazide Cardiac & Anti-Hypertensive/Diuretic 1Hydrocodone / Acet Vicodin,VicodinES CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1Hydrocortisone crm Hytone Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1Hydrocortisone Suppos Anusol-HC Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1Hydroxyzine Vistaril,Atarx CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1

Influenza Vaccine Fluzone Vaccines 1

Insulin Analog Humalog Diabetes 1Insulin Glaritine Lantus Diabetes 1Insulin NPH Novolin Diabetes 1Insulin Regular Novolin Diabetes 1Ipratropium Atrovent Respiratory, Cough & Cold Allergy/Other 1Irbesartan Avapro Cardiac & Anti-Hypertensive/Angiotensin Receptor Blocker (ARB) 1Isoniazid/INH Isoniazid/INH Antiinfectives/Antitubercular 1

Isoniazid/Rifampn Rifamate Antiinfectives/Antitubercular 1Isosorbide Mononitrate Imdur Cardiac & Anti-Hypertensive/Nitrates 1Labetalol Normodyne Cardiac & Anti-Hypertensive/Beta Blockers 1

Lactulose Enulose Gastrointest/Laxative 1

Lansoprazole Prevacid Gastrointest/PPI 1Latanoprost Xalatan Ophthalmic/Glaucoma 1Levofloxacin Levaquin Antiinfectives/Antiviral/Antibacterial 1

Levothyroxine Synthroid Misc/Other 1Lindane Kwell Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1

Lisinopril Zestril, Prinivil Cardiac & Anti-Hypertensive/ACE Inhibitor 1

Lithium Carb Lithonate CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1Lodoxamide Alomide Ophthalmic/Misc/Other 1Loperamide Paregoric Imodium Gastrointest/Antidiarrheal 1

Loratadine Claritin Respiratory, Cough & Cold Allergy/Antihistamine 1Lorazepam Ativan CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1

MAGIC Mouthwash MAGIC Mouthwash Misc/Other 1Meclizine Antivert Misc/Other 1

HANDOUT A

Generic Name Brand Name Drug Classification Tier Medroxyprogesterone Provera, Depo-

Provera

GYN/OB 1

Mephobarbital Mebaral CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Metformin Fortamet,

Glucophage, Glumetza, Riomet

Diabetes 1

Methadone Methadone CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1Methsuiximide Celontin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Methyprednisolone Medrol dosepak Antiinfectives/Antiinflammatory 1Metoclopramide Reglan Gastrointest/Misc/Other 1

Metoprolol Lopressor Cardiac & Anti-Hypertensive/Beta Blockers 1Metronidazole Flagyl Antiinfectives/Other 1Metronidazole Metrogel Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1Mirtazapine Remeron CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1Montileukast Singulair Respiratory, Cough & Cold Allergy/Other 1MSContin, MSIR Morphine CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1Naphazoline Vasocon Ophthalmic/Misc/Other 1Naprosyn Naproxen CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1

Neo/Gramic/Poly Neosporin Topical, Dermatology, Rectal, Vaginal/Antibacterial 1Neo/Poly/Bacit Neosporin Ophthalmic/Antibiotic 1Neomycin / HC Cortisporin Otic 1

Neurontin Gabapentin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Nifedepine Procardia,Adalat Cardiac & Anti-Hypertensive/Calcium Channel Blocker 1Nitrofurantoin Macrodantin Antiinfectives/Antiviral/Antibacterial 1

Nitroglycerin Nitrostat,Nitro-Dur Cardiac & Anti-Hypertensive/Nitrates 1

Nystatin Mycostatin Topical, Dermatology, Rectal, Vaginal/Antifungal 1

Nystatin / Triamcin Mycolog Topical, Dermatology, Rectal, Vaginal/Antifungal 1

Oxybutinin Ditropan Misc/Other 1Oxycodone/Acet Percocet CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1Oxycodone/ASA Percodan CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1

Pancrealipase Ultrace MT Gastrointest/Digestive Enzyme 1

Paromomycin Humatin Antiinfectives/Other 1Paroxetine Paxil CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

Penicililn VK PenVK Antiinfectives/Antiviral/Antibacterial 1

HANDOUT A


Penicillin Benzath Bicillin LA Antiinfectives/Antiviral/Antibacterial 1Pentamidine Nebupent Respiratory, Cough & Cold Allergy/Other 1

Permethrin Elimite Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1Perphenazine Trilafon CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1Phenazopyridine Pyridium Misc/Other 1

Phenobarbital Phenobarbital CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1Phenytoin Dilantin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Pilocarpine Pilocar Ophthalmic/Miotic 1Pneumococcal Vaccine Pneumovax Vaccines 1Pneumococcal Vaccine Prevnar 13 Vaccines 1

Podophilox Condylox Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1Prednisolone Pred Forte Ophthalmic/Steroid 1

Prednisone Deltasone Antiinfectives/Antiinflammatory 1Primaquine Primaquine Antiinfectives/Antiviral/Antibacterial 1Primidone Mysoline CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Probenecid Probenecid Misc/Other 1Promethazine Phenergan Gastrointest/Antiemetic 1

Promethazine Suppos Promethazine Suppos Gastrointest/Antiemetic 1

Propox/Acet Darvocet N-100 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1

Propranolol Inderal Cardiac & Anti-Hypertensive/Beta Blockers 1Pseudoephedrine Sudafed Respiratory, Cough & Cold Allergy/Antihist/Decongestant 1Pyrazinamide/PZA Pyrazinamide/PZA Antiinfectives/Antitubercular 1

Ranitidine Zantac Gastrointest/H2Antagonist 1

Rifampin Rifadin Antiinfectives/Antitubercular 1Rifampin / Isoniazid Rifamate Antiinfectives/Antitubercular 1

Risperidone Risperdal CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1

Salmeterol Discus Serevent Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled 1Selenium Selsun Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1Sertraline Zoloft CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

Simethicone Mylicon Gastrointest/Antiflatulant 1Sodium Chloride Ocean Nasal Nasal 1

Sodium Chloride for Irrigation Normal Saline Misc/Other 1Spironolactone Aldactone Cardiac & Anti-Hypertensive/Diuretic 1

Sucralfate Carafate Gastrointest/Misc/Other 1

HANDOUT A

Generic Name Brand Name Drug Classification Tier Sulfacetamide Sulamyd Ophthalmic/Antibiotic 1Sumatriptan Imitrex (Oral Only) CNS, Anxiety, Psych, Neuro, & Autonomic/Antimigraine 1Td Tetanus/Diptheria

Injection

Vaccines 1

Temazepam Restoril CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1Terazosin Hytrin Cardiac & Anti-Hypertensive/Alpha Blockers 1Terbinafine Lamisil Antiinfectives/Antifungal 1

Terbinafine Lamisil Topical, Dermatology, Rectal, Vaginal/Antifungal 1Tetanus, Diptheria, and Pertussis TDAP Vaccines 1

Tetracycline Achromycin Antiinfectives/Antiviral/Antibacterial 1

Theophylline Theo-Dur Respiratory, Cough & Cold Allergy/Xanthine 1Therapeutic Multivitamins Therapeutic

Multivitamins

Vitamins & Nutritional/Vitamins 1

Timolol Timoptic Ophthalmic/Betablocker 1

TMP-SMX ds TMP-SMX ds Opportunistic Infections (OIs) 1Tobramycin Tobrex Ophthalmic/Antibiotic 1Topiramate Topamax CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1

Trazodone Desyrel CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1

Triamcinolone Kenalog Topical, Dermatology, Rectal, Vaginal/Antifungal 1Triamcinolone crm Kenalog Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1Trifluridine Viroptic Ophthalmic/Misc/Other 1

Trimethoprim Proloprim Antiinfectives/Antiviral/Antibacterial 1Ultram Tramadol CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1Urea, misc Amino-Cerv Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1

Verapamil Isoptin, Calan Cardiac & Anti-Hypertensive/Calcium Channel Blocker 1

Warfarin Coumadin Cardiac & Anti-Hypertensive/Anticoagulant 1

Wellbutrin Bupropion CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1Xylocaine/Lidocaine Lidocaine , Xylocaine

Oint, Jelly, Visc, Patch

Topical, Dermatology, Rectal, Vaginal/Anaesthetic 1

HANDOUT A


Abacavir Ziagen Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Abacavir/Lamivudine Epzicom Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Abacavir/Lamivudine/Zidovudine Trizivir Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Acyclovir Zovirax Other Conditions/Other Conditions 2

Atazanavir Reyataz Antiretrovirals/Protease Inhibitors (PIs) 2

Atovaquone Mepron Other Conditions/Other Conditions 2

Azithromycin Zithromax Other Conditions/Other Conditions 2

Clarithromycin Biaxin Other Conditions/Other Conditions 2

Darunavir Prezista Antiretrovirals/Protease Inhibitors (PIs) 2

Delavirdine Rescriptor Antiretrovirals/Nonnucleosides (NNRTIs) 2

Didanosine Videx Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Dolutegravir Tivicay Antiretrovirals/Protease Inhibitors (PIs) 2

Efavirenz Sustiva Antiretrovirals/Nonnucleosides (NNRTIs) 2

Elvitegravir, Cobicistat, Tenofovir,

Emtricitabine

Stribild Antiretrovirals/Multiclass 2

Emtricitabine Emtriva Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Emtricitabine, Rilpivirine, Tenofovir Complera Antiretrovirals/Multiclass 2

Enfuviritde Fuzeon Antiretrovirals/Entry/Fusion Inhibitor 2

Ethambutol Myambutol Other Conditions/Other Conditions 2

Etravirine Intelence Antiretrovirals/Nonnucleosides (NNRTIs) 2

Fluconazole Diflucan Other Conditions/Other Conditions 2

Folinic Acid Leucovorin Other Conditions/Other Conditions 2

Fosamprenavir Lexiva Antiretrovirals/Protease Inhibitors (PIs) 2

Indinavir Crixivan Antiretrovirals/Protease Inhibitors (PIs) 2

Itraconazole Sporanox Other Conditions/Other Conditions 2

Ketoconazole Nizoral Other Conditions/Other Conditions 2

Lamivudine Epivir Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2


Tier 2: In order to access Tier Two, clients must be screened every six 6) months for the State AIDS Drugs Assistance Program ADAP) eligibility and must be ineligible and meet the Ryan Part A eligibility requirements

prior to the use of this formulary.

HANDOUT A


Lopinavir/Ritonavir Kaletra Antiretrovirals/Protease Inhibitors (PIs) 2

Maraviroc Selzentry Antiretrovirals/Entry/Fusion Inhibitor 2

Miconazole Monistat Other Conditions/Other Conditions 2

Mycelex Troche Clotrimazole Other Conditions/Other Conditions 2

Nelfinavir Viracept Antiretrovirals/Protease Inhibitors (PIs) 2

Nevirapine Viramune Antiretrovirals/Nonnucleosides (NNRTIs) 2

Pyrimethamine Daraprim Other Conditions/Other Conditions 2

Raltegravir Isentress Antiretrovirals/Integrase Inhibitor 2

Rifabutin Mycobutin Other Conditions/Other Conditions 2

Rilpivirine Edurant Antiretrovirals/Nonnucleosides (NNRTIs) 2

Ritonavir Norvire Antiretrovirals/Protease Inhibitors (PIs) 2

Saquinavir Invirase Antiretrovirals/Protease Inhibitors (PIs) 2

Stavudine Zerit Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Sulfadiazine Sulfadiazine Other Conditions/Other Conditions 2

Tenofovir Viread Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Tenofovir/

Emtricitabine/Efavirenz

Atripla Antiretrovirals/Multiclass 2

Tenofovir/Emtricitabine Truvada Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Terconazole Terazol Other Conditions/Other Conditions 2

Tipranavir Aptivus Antiretrovirals/Protease Inhibitors (PIs) 2

TMP/SMZ DS Bactrim DS Other Conditions/Other Conditions 2

Valacyclovir Valtrex Other Conditions/Other Conditions 2

Valganciclovir HCL Valcyte Other Conditions/Other Conditions 2

Zidovudine Retrovir Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

Zidovudine/Lamivudine Combivir Antiretrovirals/Nucleosides/Nucleotide (NRTIs) 2

HANDOUT A

Generic Name Brand Name Drug Classification Tier Bronabinol Marinol Other Conditions/Wasting 3Divalproex Depakote Other Conditions/Other Side Effects/Conditions 3Duloxetine Cymbalta Other Conditions/Neuropathy 3Fenofibrate Tricor Other Conditions/Hyperlipidemia 3Gemfibrozil Lopid Other Conditions/Hyperlipidemia 3

Imiquimod Aldara Other Conditions/Opportunistic Infections (OIs) 3Lamotrigine Lamictal Other Conditions/Neuropathy 3Leucovorin Folinic Acid Other Conditions/Supplement 3Levetiracetam Keppra Other Conditions/Anticonvulsant 3Megestrol Megace Other Conditions/Wasting 3Mupirocin Bactroban Other Conditions/Opportunistic Infections (OIs) 3Nortriptyline Pamelor Other Conditions/Neuropathy 3Pravastatin Pravachol Other Conditions/Hyperlipidemia 3

Pregabalin Lyrica Other Conditions/Neuropathy 3Rosuvastatin Crestor Other Conditions/Hyperlipidemia 3

Sitagliptin Januvia Diabetes 3Ziprasidone Geodon Other Conditions/Other Side Effects/Conditions 3Zoster Virus Live Zostavax Vaccines 3

Tier 3: In order to access Tier Three clients must meet the Ryan Part A eligibility requirements and have a Patient Assistance Program (PAP) application completed for each medication. Client may be eligible to receive a 10-day supply, with an option for extention,

while waiting for approval.


HANDOUT A

REQUEST FOR PART A FORMULARY ADDITIONS

Drug Description Cost Per Dose (quantity) Projected

Annual Cost PAP

Recommended Tier

Keppra (Levetiracetam)

by UCB

Keppra (levetiracetam) is an anti-epileptic drug, also called an anticonvulsant. Levetiracetam is used to treat partial onset seizures in adults and children who are at least 1 month old. Levetiracetam is also used to treat tonic-clonic seizures in adults and children who are at least 6 years old, and myoclonic seizures in adults and children who are at least 12 years old.

500mg - $33.21* (500)

750mg - $50.31* (500) *Generic prices

$11,025.72 (500mg) -

$16,702.92 (750mg)*

*Based on generic prices, since dose amounts may differ, the actual cost may fall between totals

No – has recently gone generic

Tier 1 (currently on Tier 3, but

there is no longer a PAP)

Tricor (Fenofibrate)

Fenofibrate is used to reduce the amounts of fatty substances such as cholesterol and triglycerides in the blood and to increase the amount of HDL (high-density lipoprotein) in the blood, and treat hypertriglyceridemia, or mixed dyslipidemia. Fenofibrate is in a class of medications called antilipemic agents. It works by speeding the natural processes that remove cholesterol from the body.

Fenofibrate comes as a capsule, a delayed-release (long-acting) capsule, and a tablet to take by mouth. It is usually taken once a day. Some fenofibrate products should be taken with a meal. Other brands (Tricor) may be taken with or without food.

Tricor

48mg - $5.97 (90)

145mg - $11.82 (90) Fenofibrate

48mg - $9.85 (90)

145mg - $32.94 (90)

Tricor $119.40 (48mg) - $236.40 (145mg)

Fenofibrate

$664.20 (48mg) -

$1,006.20 (145mg)

No Currently on

Tier 3

Ibuprofen

Used to treat pain or as an anti-inflammatory. Prescribed as needed for acute or chronic pain.

600mg - $1.90 (100)

800mg - $2.79 (100)

No Tier 1

bjohnson

Typewritten Text

HANDOUT B-1

Drug Classification Generic Name Brand Name Tier FY 2014 Utilization

# clients # dispenses CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Acetazolamide Diamox 1 2 6 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Carbamazepine Tegretol 1 6*~ 8*~ CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Clonazepam Klonopin 1 35 163 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Neurontin Gabapentin 1 196 609 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Phenytoin Dilantin 1 11~ 56~ CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Primidone Mysoline 1 1 10 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Topiramate Topamax 1 56 275 Other Conditions/Anticonvulsant Levetiracetam Keppra 3 1 1 Other Conditions/Neuropathy Lamotrigine Lamictal 3 1 1

*includes regular and extended release doses

~ does not interact well with protease inhibitors

Motion: To move Keppra (Levetiracetam) from Tier 3 to Tier 1.

Justification: Keppra (Levetiracetam) is an anti-seizure medication that is the safest choice for patients who take protease inhibitors (found in some ARVs); not all clients are on protease inhibitors. Phenytoin, Carbamazepine (including extended release and regular formulations), Lamotrigine, and Neurontin are all on Tier 1, and are also used as anti-seizure medication. There is a generic version of Keppra available, and therefore no PAP exists. DHHS has also recommended the use of Levetiracetam over other anticonvulsant medications.

Estimation of Cost: Estimate that all clients currently using Phenytoin and Caramazepine would start using Levetiracetam (17 clients) would switch to Keppra, and 33% of clients using Neurontin/Gabapentin would begin using Levetiracetam (65 clients). Clients currently using Levetiracetam would continue using it.

$33.21 (per 500mg dose) * 4 doses (90 day supply) = $132.84 per year $50.31 (per 750mg dose) * 4 doses (90 day supply) = $201.24 per year

$132.84 (per 500mg dose) * approx. 83 clients = $11,025.72 $201.24 (per 750mg dose) * approx. 83 clients = $16,702.92

The cost of the current prescriptions utilized by clients who would likely switch to Levetiracetam is approximately $4,727.13.

Carbamezapine $168.04 on Levetiracetam $797.04-$1,207.44 Neurontin/Gabapentin $3,392.53 on Levetiracetam $8,634.60-$13,080.60 Phenytoin $1,150.48 on Levetiracetam $1,461.24-$2,213.64 Lamotrigine $16.08 on Levetiracetam $132.84-$201.24

csandler

Typewritten Text

HANDOUT B-2

Documents

MEETING AGENDA COMMITTEE Location: Chair 1. CALL TO … · 2020-03-31 · 1. CALL TO ORDER: Welcome, Review meeting ground rules, Statement of Sunshine, Introductions, Moment of Silence,