[The Access Project]

To Local HIV
Care Consortiums		 To VT ADAP
Contact Page		 To ALL Other ADAPs
Main Page		 To Access Project
Home Page

Vermont ADAP Formulary
Which drugs are covered?

All drugs are listed by catagory and alphabetically, starting with their generic names followed by the brand names in parenthesis. Click on a high-lighted item in green to see a detailed description of the drug. To search for a specific drug, hold down both the control key (command key on the Mac) and the F key, then type in the drug name.
For a list of specific medical criterias, see the bottom of this page.
Antiretroviral
Nucleoside/tide Reverse
Transcriptase Inhibitor (NRTI)
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)		 Protease Inhibitor (PI)
amprenavir (Agenerase)
atazanavir (Reyataz)
fosamprenavir (Lexiva)
indinavir (Crixivan)
lopinavir/ritonavir (Kaletra)
nelfinavir (Viracept)
ritonavir (Norvir)
saquinavir (Fortavase)
saquinavir (Invirase) 		Non-nucleoside Reverse Transcriptase Inhibitor (NnRTI)
delavirdine (Rescriptor)
efavirenz (Sustiva)
nevirapine (Viramune)
Other
hydroxyurea (Hydrea)

Entry Inhibitor
enfuvirtide (Fuzeon)*

HIV Drug Resistance Tests: Both genotypic and phenotypic tests are covered. Limited to 6-9 tests per year, with prior approval based upon justification by physician.
Opportunistic Infection (OI) Treatment & Prophylaxis
Public Health Service
Recommanded OI drugs
acyclovir (Zovirax)
azithromycin (Zithromax)
cidofovir (Vistide)
clarithromycin (Biaxin)
famciclovir (Famvir)
fluconazole (Diflucan)
foscarnet (Foscavir)
itraconazole (Sporanox)
leucovorin (Wellcovorin)
pyrimethamine (Daraprim)
sulfadiazine
TMP/SMX (Bactrim/Septra)
 Other OI drugs
amphotericin B (Fungizone)
atovaquone (Mepron)
ciprofloxacin (Cipro)
clindamycin(Cleocin)
clotrimazole (Lotrimin, Mycelex)
dapsone
doxorubicin liposomal (DOXIL)
ethambutol (Myambutol)
 filgrastim GCSF (Neupogen)
ketoconazole (Nizoral)
nystatin (Mycostatin)
pentamidine (NebuPent, Pentam)
primaquine
rifabutin (Mycobutin)
trimethoprim
valganciclovir (Valcyte)

isoniazid (INH) and rifampin are covered through the TB Program.
Hyperlipidemia
artovastatin (Lipitor)
fluvastatin (Lescol)
 gemfibrozil (Lopid)
lovastatin (Mevacor)
 pravastatin (Pravachol)
simvastatin (Zocor)

Wasting
megestrol acetate (Megace)


Other
amitriptyline (Elavil)
Buproprion (Wellbutrin / SR)
citalopram (Celexa)
fentanyl (Duragesic)
fluoxetine (Prozac)
gabapentin (Neurontin)
 ibuprofen (Motrin)
loperamide (Imodium)
morphine sulfate (MS Contin)
nefazadone (Serzone)
paroxetine (Paxil)
 polycarbophil (Fibercon)
psyllium (Metamucil)
sertraline (Zoloft)
trazodone (Desyrel)
venlaxafine (Effexor)

Vaccines
Hepatitis A Hepatitis B pneumococcal vaccines as outpatient treatment (Pnemovax,Pnu-imune)

Medical Criteria
The following drugs will not be processed without prior authorization.
Providers should call Sheila Jones at (802) 863-7253. For administering Pentamidine, also covered: Respirguard II nebulizer system and one 12 ml syringe with 20 gauge needle. One 10 ml container of sterile water and one unit dos Alu-pent with hand-held nebulizer.

*Additional Eligibility Requirements for Fuzeon: (Limited to 4 slots)
  • The patient must be treatment-experienced. Fuzeon is FDA-approved for treatment-experienced patients only.
  • There must be evidence of virologic failure despite ongoing antiretroviral therapy.
      "Virologic failure" is defined by either of the following criteria:
    • Incomplete virologic response: not achieving a viral load of <400 copies/mL by 24 weeks or <50 copies/mL by 48 weeks in a treatment-naive patient initiating therapy.
    • Virologic rebound: repeatedly detectable viremia after a period of undetectable virus.
    • Both of these criteria assume a high level of compliance with the antiviral regimen.
  • Patient must have had a recent HIV resistance test conducted, and have her/his ARV history expertly reviewed, so as to determine an optimal base regimen of at least two active and tolerated ARVs.
  • The optimal use of Fuzeon is with at least two other active antiretrovirals.
  • The prescribing physician and her/his practice must have the capacity and expertise to educate the patient regarding preparation and administration of Fuzeon therapy, and be committed to monitoring adherence. The patient must be capable of adhering to the treatment regimen, either by self-administration or with assistance.
  • The request must be reviewed and approved by the AMAP Coordinator and the physicians who sit on the AMAP Advisory Committee.
  • VT AMAP must be the payer of last resort.
    • Has the patient applied to the Roche/Trimeris Patient Assistance Program?
    • Can the patient access the medication through Medicaid? The patient must supply a copy of the PATH letter of determination.
    • Can the patient access the medication through private insurance?
    VT AMAP can assist with co-payments with all of the above options. If patient demonstrates that there is no other source of assistance available, VT AMAP will assume cost of therapy.
Recent Updates • Home • Hepatitis B and C • About The Network • The Access Project • Simple Fact Sheets

Last modified: 12/15/2006
copyright © 2007 The Network
Contact The Network