AIDS Drug Assistance Monitoring Project: Appendix 5 STATE ADAP FORMULARIES

APPENDIX 5 :
STATE ADAP FORMULARIES

State	Antiretrovirals	OI Prophylaxis and Treatment
Alabama	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase)	acyclovir (Zovirax), fluconazole (Diflucan), ganciclovir (Cytovene), leucovorin, TMP/SMX (Bactrim/Septra)
Alaska	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)
Arizona	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept)	dapsone, pentamidine, TMP/SMX (Bactrim/Septra), trimethoprim
Arkansas	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir)	acyclovir (Zovirax), dapsone, famciclovir (Famvir), rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra), valacyclovir (Valtrex), "The consortia will provide many additional AIDS-related drugs not on the formulary for approximately 30 days allowing time to seek other sources of payment."
California	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase)	acyclovir (Zovirax), alpha-interferon, amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), bleomycin, clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), cyclophosphamide, dapsone, dexamethasone, doxorubicin, dronabinol (Marinol), erythropoietin (Epogen), ethambutol (Myambutol), filgrastim (Neupogen), fluconazole (Diflucan), flucytosine (Ancobon), foscarnet (Foscavir), ganciclovir (Cytovene), itraconazole (Sporanox), ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), methotrexate, nystatin, paromomycin (Humatin), pentamidine, prednisone, pyrimethamine (Fansidar), rifabutin (Mycobutin), sulfadiazine, TMP/SMX (Bactrim/Septra), trimethoprim, trimetrexate glucuronate (Neutrexin), vinblastine, vincristine
Colorado	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept)
Connecticut	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase)	acyclovir (Zovirax), amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), dapsone, dronabinol (Marinol), erythropoietin (Epogen), ethambutol (Myambutol), filgrastim (Neupogen), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), itraconazole (Sporanox), ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), metronidazole (Flagyl), nystatin, ofloxacin, paromomycin (Humatin), pentamidine, prednisone, primaquine, pyrimethamine (Fansidar), rifabutin (Mycobutin), sulfadiazine, terconazole, TMP/SMX (Bactrim/Septra), trimethoprim, pneumovax, Lomotil, hydroxyzine HCL (Atarax), prochlorperesine (Compazine), amoxicillin, amoxicillin/potassium clavulante (Augmentin), cefuroxime, cephalexin, dicloxacillin, vancomycin, acetaminophen w/codeine (Generic only), fentanyl transdermal system (Duragesic), amitriptyline (Elavil), lorazepam (Generic only), sertraline (Zoloft), hydrocortisone cream/lotion/ointment, lactic acid, triameinolone - acetonide cream/ointment, chlorhexidine gluconate (Peridex), loperamide hydrochloride (Imodium)
Delaware	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), clarithromycin (Biaxin), clotrimazole (Mycelex), dapsone, fluconazole (Diflucan), nystatin, paromomycin (Humatin), pentamidine, prednisone, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra), amitriptyline (Elavil), amoxicillin, carbamazepine (Tegretol), cephalexin, clemastine fumarate, clotrimazole/betamethasone cream, clotrimazole vaginal application (Monistat Dual), docusate calcium, doxycycline, erythromycin, loperamide (Imodium), metaproterenol inhaler, miconazole cream, penicillin, phenytoin (Dilantin), psyllium (Metamucil), Senekot-S Tab, calcium, magnesium and multivitamins with iron. The following agents will be provided for a four week period of illness only, not prophylaxis. Alternative funding must be applied for at the time of initiation of therapy. A negative response from a drug company or other entity must be presented before extension will be considered: erythropoietin (Epogen), filgrastim (Neupogen), ganciclovir (Oral only), The following will be obtained as a nutritional component of Home and Community-Based Care through the Division of Public Health:, dronabinol (Marinol), megestrol acetate (Megace), Multivitamins
District of Columbia	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nevirapine (Viramune)	acyclovir (Zovirax), alpha-interferon, amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), cidofovir (Vistide), ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clotrimazole (Mycelex), dapsone, DOXIL, dronabinol (Marinol), ethambutol (Myambutol), fluconazole (Diflucan), ganciclovir (Cytovene), isoniazid (INH), ketoconazole (Nizoral), megestrol acetate (Megace), ofloxacin, pentamidine, pyrazinamide (PZA), pyrimethamine (Fansidar), rifabutin (Mycobutin), rifampin, sulfadiazine, TMP/SMX (Bactrim/Septra), ANALGESICS: acetomenaphine with codeine (Tylenol III and Tylenol IV), fentanyl patch (Duragesic), ibuprofen (800mg), morphine sulfate (MS Contin), ANTIBIOTICS: amoxicillin/clavulanate (Augmentin), ANTIDEPRESSANTS: fluoxetine HCL(Prozac), sertraline HCL (Zoloft), ANTIDIARRHEAL: dephenoxylate and atropine (Lomotil), TOPICAL STEROID: hydrocortisone cream 1%
Florida	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), azithromycin (Zithromax), clarithromycin (Biaxin), dapsone, ethambutol (Myambutol), fluconazole (Diflucan), rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra)
Georgia	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase)
Hawaii	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), cidofovir (Vistide), ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), dapsone, erythropoietin (Epogen, Procrit), ethambutol (Myambutol), filgrastim (Neupogen), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), itraconazole (Sporanox), ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), pentamidine, pyrimethamine (Fansidar), rifabutin (Mycobutin), rifampin, TMP/SMX (Bactrim/Septra), probenecid

Illinois	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), alpha-interferon, amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), cidofovir (Vistide), ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clotrimazole (Mycelex), dapsone, dronabinol (Marinol), ethambutol (Myambutol), famciclovir (Famvir), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporanox), ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), miconazole, nystatin, ofloxacin, paromomycin (Humatin), pentamidine, primaquine, pyrazinamide (PZA), pyrimethamine (Fansidar), rifabutin (Mycobutin), rifampin, Rifater, streptomycin, sulfadiazine, sulfamethoxazole, terconazole, TMP/SMX (Bactrim/Septra), trimethoprim, For use with cidofovir (Vistide):, probenecid, ANTIBIOTICS: amoxicillin, cefixime, cephalexin, chlorhexidine gluconate, dicloxacillin sodium, doxycycline, erythromycin, penicillin VK, tetracycline, MISCELLANEOUS HORMONES: danazol (Danocrine)
Indiana	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), clotrimazole (Mycelex), dapsone, fluconazole (Diflucan), nystatin, pentamidine, TMP/SMX (Bactrim/Septra), NOTE: Protease inhibitors and nevirapine (Viramune) are due to be added April 1, 1997., azithromycin and fluconazole will also be added at this time., clarithromycin, which was on the formulary, is being deleted April 1.
Iowa	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), clarithromycin (Biaxin), clotrimazole (Mycelex), dapsone, fluconazole (Diflucan), ketoconazole (Nizoral), nystatin, pentamidine, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra)
Kansas	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), saquinavir (Invirase), ritonavir (Norvir), nelfinavir (Viracept)	acyclovir (Zovirax), azithromycin (Zithromax), clarithromycin (Biaxin), clindamycin, dapsone, dronabinol (Marinol), famciclovir (Famvir), fluconazole (Diflucan), itraconazole (Sporonox), ketoconazole (Nizoral), clofazimine (Lamprene), megestrol acetate (Megace), ethambutol (Myambutol), atovaquone (Mepron), clotrimazole (Mycelex), pentamidine, rifabutin (Mycobutin), nystatin, paromomycin (Humatin), primaquine, TMP/SMX (Bactrim/Septra), ganciclovir (Cytovene)
Kentucky	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), ciprofloxacin (Cipro), clarithromycin (Biaxin), clotrimazole (Mycelex), dapsone, fluconazole (Diflucan), ketoconazole (Nizoral), megestrol acetate (Megace), nystatin, pentamidine, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra)
Louisiana	indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase)
Maine	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept)	acyclovir (Zovirax), dapsone, fluconazole (Diflucan), itraconazole (Sporanox), pentamidine, TMP/SMX (Bactrim/Septra). Additional drugs can be approved on a case-by-case basis.
Maryland	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), alpha-interferon, amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), clarithromycin (Biaxin), clotrimazole (Mycelex), dapsone, ethambutol (Myambutol), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), pentamidine, pyrazinamide (PZA), pyrimethamine (Fansidar), rifabutin (Mycobutin), rifampin, TMP/SMX (Bactrim/Septra)
Massachusetts	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), alpha-interferon, clarithromycin (Biaxin), clindamycin, clotrimazole (Mycelex), dapsone, fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), ketoconazole (Nizoral), leucovorin, nystatin, pentamidine, pyrimethamine (Fansidar), rifabutin (Mycobutin), sulfadiazine, terconazole, TMP/SMX (Bactrim/Septra), butaconazole (Femstat)
Michigan	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), amphotericin B, azithromycin (Zithromax), clarithromycin (Biaxin), clotrimazole (Mycelex), dapsone, fluconazole (Diflucan), ketoconazole (Nizoral), pentamidine, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra)
Minnesota	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), dapsone, dronabinol (Marinol), ethambutol (Myambutol), fluconazole (Diflucan), ganciclovir (Cytovene), itraconazole (Sporanox), ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), nystatin, paromomycin (Humatin), pentamidine, prednisone, pyrimethamine (Fansidar), rifabutin (Mycobutin), rifampin, TMP/SMX (Bactrim/Septra), valacyclovir (Valtrex), chlor-hexidine (Peridex), cimetidine (Tagamet), hydrocortisone, diphenoxylate (Lomotil), loperamide HCI (Immodium), ranitidine (Zantac)
Mississippi	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), saquinavir (Invirase)	acyclovir (Zovirax), azithromycin (Zithromax), dapsone, fluconazole (Diflucan), ganciclovir (Cytovene), pentamidine, TMP/SMX (Bactrim/Septra), sertraline (Zoloft). Note: fluconazole (Diflucan) is only covered for one month, conditional upon application to Pfizer patient assistance program.
Missouri	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), dapsone, ethambutol (Myambutol), famciclovir (Famvir), fluconazole (Diflucan), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporanox), ketoconazole (Nizoral), leucovorin, metronidazole (Flagyl), miconazole, nystatin, ofloxacin, pentamidine, prednisone, pyrimethamine (Fansidar), rifabutin (Mycobutin), rifampin, sulfadiazine, TMP/SMX (Bactrim/Septra), valacyclovir (Valtrex), ANALGESICS: codeine, Darvocet, Ibuprofen, morphine (immediate release), Percocet, Tylenol III w/codeine, ANTIBIOTICS: amoxicillin, amoxicillin/potassium (Augmentin), cefuroxime, cephalexin, doxycycline, erythromycin, penicillin, ANTICONVULSANTS: carbamazepine (Tegretol), phenytoin (Dilantin), ANTIDIARRHEALS: diphenoxylate (Lomotil), loperamide (Imodium), ANTIFUNGAL: griseofulvin, ANTIHISTAMINES: diphenhydramine (Benadryl), hydroxyzine, PSYCHOTROPICS: doxepin, NEUROPATHIC PAIN/PERIPHERAL NEUROPATHY: amitriptyline (Elavil), nortriptyline (Pamelor), TOPICAL CORTICOSTEROIDS: betamethasone, clobetasol, desoximetasone, fluocinolone, fluocinonide, hydrocortisone, triamcinolone
Montana	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept)	pentamidine
Nebraska	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), atovaquone (Mepron), ciprofloxacin (Cipro), clarithromycin (Biaxin), clofazimine (Lamprene), clotrimazole (Mycelex), dapsone, ethambutol (Myambutol), fluconazole (Diflucan), isoniazid (INH), ketoconazole (Nizoral), nystatin, pentamidine, pyrazinamide (PZA), rifabutin (Mycobutin), rifampin, TMP/SMX (Bactrim/Septra), Antidepressants (individual drugs not specified on formulary).
Nevada	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir)	acyclovir (Zovirax), azithromycin (Zithromax), dapsone, fluconazole (Diflucan), TMP/SMX (Bactrim/Septra)
New Hampshire	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), dapsone, ethambutol (Myambutol), fluconazole (Diflucan), ganciclovir (Cytovene), isoniazid (INH), ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), metronidazole (Flagyl), nystatin, pentamidine, primaquine, pyrazinamide (PZA), pyrimethamine (Fansidar), rifabutin (Mycobutin), rifampin, sulfadoxine, TMP/SMX (Bactrim/Septra), trimethoprim
New Jersey	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), saquinavir (Invirase)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), cycloserine, dapsone, ethambutol (Myambutol), ethionamide, fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporanox), IVIG, ketoconazole (Nizoral), leucovorin, ofloxacin, paromomycin (Humatin), pentamidine, prednisone, pyrazinamide (PZA), rifabutin (Mycobutin), rifampin, streptomycin, TMP/SMX (Bactrim/Septra), Pneumovax (pneumococcal vaccine).
New Mexico	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), alpha-interferon, amikacin, amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), dapsone, erythropoietin (Epogen, Procrit), ethambutol (Myambutol), famciclovir (Famvir), filgrastim (Neupogen), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), itraconazole (Sporanox), ketoconazole (Nizoral), megestrol acetate (Megace), nystatin, pentamidine, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra), trimethoprim, ANTIDEPRESSANTS: sertraline (Zoloft), ANTISEBORRHEA: Tegrin Shampoo
New York	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), albendazole (Albenza), alpha-interferon, amikacin, amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), bleomycin, capreomycin, cidofovir (Vistide), ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clotrimazole (Mycelex), cyclophosphamide, cycloserine, cyproheptadine HCI (Periactin), cytarabine, dapsone, DaunoXome, dexamethasone, DOXIL, doxorubicin, dronabinol (Marinol), erythropoietin (Procrit), ethambutol (Myambutol), ethionamide, etoposide, famciclovir (Famvir), filgrastim (Neupogen), fluconazole (Diflucan), flucytosine (Ancobon), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporanox), IVIG, kanamycin, ketoconazole (Nizoral), leucovorin, lomustine, megestrol acetate (Megace), methotrexate, metronidazole (Flagyl), miconazole, nystatin, ofloxacin, para aminosalicyclic acid (PAS), paromomycin (Humatin), pentamidine, prednisone, primaquine, procarbazine, pyrazinamide (PZA), pyrimethamine (Fansidar), rifabutin (Mycobutin), rifampin, Rifater, streptomycin, sulfadiazine, sulfadoxine, sulfamethoxazole, terconazole, TMP/SMX (Bactrim/Septra), trimethoprim, triple sulfa, vinblastine, vincristine, ANTIFUNGAL: griseofulvin, ANALGESICS: butalbuital, comb.w/wo codeine, codeine w/wo ASA, APAP, diclofenac, diflunisal, fenoprofen, fentanyl (patch only), flurbiprofen, hydrocodone w/ASA, APAP, hydromorphone, ibuprofen, indomethacin, ketoprofen, ketorolac tromethamine, levorphanol tartrate, methadone hydrochloride, morphine sulfate, naproxen, oxycodone w/wo ASA, APAP, piroxicam, sulfindac, tolmetin, ANTIBIOTICS: amoxicillin, amoxicillin K + clavulanate, ampicillin, aztreonam, bacitracin, cefaclor, cefadroxil, cefazolin, cefixime, cefoxitin, cefpodoxime, cefprozil, ceftazidime, ceftriaxone, cefuroxime, cephalexin, cephradine, chloramphenicol, cloxacillin, dicloxacillin, doxycycline, erythromycin , erythromycin-ethylsuccinate erythromycin-ethylsuccinate and sulfisoxazole acetyl, furazolidone, gentamicin, imipenem-cilastatin, loracarbef, minocycline, nitrofurantoin, penicillin G, penicillin V potassium, spectinomycin, tetracycline, ticarcillin K+clavulanate, tobramycin, vancomycin, ANTICONVULSANTS: carbamazepine (Tegretol), divalproex sodium, magnesium sulfate, phenytoin (Dilantin), primidone, valproic acid, PSYCHOTROPIC: alprazolam, amitriptyline, bupropion, buspirone, butabarbital, chloral hydrate, chlordiazepoxide w/wo clidinium, chlorpromazine, clomipramine, clonazepam, clorazepate, clozapine, desipramine, dextroamphetamine-sulfate, diazepam, doxepin HCL, fluoxetine, fluphenazine, flurazepam, fluvoxamine, halazepam, haloperidol, imipramine, lithium carbonate, lithium citrate, lorazepam, loxapine, mesoridazine, methylphenidate, molindone, nefazodone, nortriptyline, oxazepam, paroxetine, pemoline, pentobarbital, perphenazine, prazepam, prochlorperazine, risperidone, secobarbital, sertraline, temazepam, thioridazine, thiothixene, trazodone, triazolam, trifluoperazine, trimipramine, venlafaxine, zolpidem, ANTIDIARRHEALS: loperamide (Imodium), Lomotil, ocreotide acetate, paregoric, tincture of opium, OTHER: chlorhexidine gluconate, probenecid, podofilox, fluoride, VACCINES: hepatitis A & B

North Carolina	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), clarithromycin (Biaxin), clindamycin, dapsone, fluconazole (Diflucan), ganciclovir (Cytovene), itraconazole (Sporanox), ketoconazole (Nizoral), nystatin, paromomycin (Humatin), pentamidine, pyrimethamine (Fansidar), rifabutin (Mycobutin), sulfadiazine, TMP/SMX (Bactrim/Septra)
North Dakota	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept)	acyclovir (Zovirax), alpha-interferon, amikacin, amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), bleomycin, ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), dapsone, doxorubicin, erythropoietin (Epogen, Procrit), ethambutol (Myambutol), filgrastim (Neupogen), fluconazole (Diflucan), flucytosine (Ancobon), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporanox), IVIG, ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), metronidazole (Flagyl), nystatin, paromomycin (Humatin), pentamidine, prednisone, primaquine, pyrazinamide (PZA), pyrimethamine (Fansidar), rifabutin (Mycobutin), Rifamate, rifampin, streptomycin, sulfadiazine, TMP/SMX (Bactrim/Septra), trimetrexate glucuronate (Neutrexin), vinblastine, vincristine, ANALGESIC: fentanyl (patch), ANTICONVULSANTS: carbamazepine (Tegretol), phenytoin (Dilantin), valproic acid, ANTIVIRAL: trifluridine (Viroptic), PSYCHOTROPIC: sertraline (Zoloft), The formulary list also states:, "Drugs not included on this list but requested for HIV-related conditions will be considered on an individual basis."
Ohio	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), azithromycin (Zithromax), clarithromycin (Biaxin), clotrimazole (Mycelex), dapsone, fluconazole (Diflucan), ketoconazole (Nizoral), nystatin, pentamidine, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra)
Oklahoma	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase)	acyclovir (Zovirax), azithromycin (Zithromax), clarithromycin (Biaxin), dapsone, fluconazole (Diflucan), itraconazole (Sporanox), pentamidine, rifabutin (Mycobutin)
Oregon	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir)	acyclovir (Zovirax), fluconazole (Diflucan)
Pennsylvania	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase)	acyclovir (Zovirax), alpha-interferon, amikacin, amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), bleomycin, capreomycin, ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), cycloserine, dapsone, dexamethasone, doxorubicin, dronabinol (Marinol), ethambutol (Myambutol), ethionamide, etoposide, fluconazole (Diflucan), flucytosine (Ancobon), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporanox), kanamycin, ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), nystatin, ofloxacin, paromomycin (Humatin), pentamidine, prednisone, primaquine, pyrazinamide (PZA), pyrimethamine (Fansidar), rifabutin (Mycobutin), rifampin, Rifater, sulfadiazine, sulfadoxine, terconazole, TMP/SMX (Bactrim/Septra), trimetrexate glucuronate (Neutrexin), triple sulfa, valacyclovir (Valtrex), vinblastine, vincristine, clozaril
Puerto Rico		"ADAP actual formulary provides for any medically indicated drug as requested by the RICs HIV specialist doctor according to the approved treatment guidelines. No pre-authorization, compliance requirements or restrictions on off-label use are established or recommended by the Pharmaceutic and Therapeutic Committee."


Rhode Island	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), alpha-interferon, atovaquone (Mepron), azithromycin (Zithromax), clarithromycin (Biaxin), dapsone, ethambutol (Myambutol), fluconazole (Diflucan), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporanox), pentamidine, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra)
South Carolina	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase)	acyclovir (Zovirax), azithromycin (Zithromax), clarithromycin (Biaxin), clotrimazole (Mycelex), dapsone, famciclovir (Famvir), fluconazole (Diflucan), ketoconazole (Nizoral), nystatin, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra), valacyclovir (Valtrex)
South Dakota	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), nevirapine (Viramune)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), ciprofloxacin (Cipro), clarithromycin (Biaxin), clofazimine (Lamprene), clotrimazole (Mycelex), dapsone, fluconazole (Diflucan), itraconazole (Sporanox), megestrol acetate (Megace), pentamidine, pyrimethamine (Fansidar), rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra), valacyclovir (Valtrex), ANALGESICS: amitriptyline (Elavil), fentanyl (patch), morphine, MS Contin, propoxyphene (Darvocet), Tylenol #3 w/codeine, ANTICONVULSANTS: carbamazapine (Tegretol), divalproex sodium (Depakote), felbatol (Felbamate), phenytoin (Dilantin), ANTIEMETICS: prochlorperazine (Compazine),
Tennessee	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), clarithromycin (Biaxin), dapsone, fluconazole (Diflucan), itraconazole (Sporanox), megestrol acetate (Megace), pentamidine, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra), Pediatric formulations of AZT, 3TC and ddI are available.
Texas	Priority 1:, didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept)	Priority 1:, acyclovir (Zovirax), dapsone, IVIG, TMP/SMX (Bactrim/Septra), trimethoprim, Priority 2:, azithromycin (Zithromax), clarithromycin (Biaxin), fluconazole (Diflucan), ganciclovir (Cytovene), itraconazole (Sporanox), megestrol acetate (Megace), pentamidine, If the demand for the Priority 1 medications increases beyond the budget capacity to continue to furnish all the medications on the formulary, the program will begin to eliminate the medications in Priority 3 and then Priority 2, as necessary. The program will not abruptly cease purchasing Priority 2 and 3 medications. The process will be gradual to allow individuals currently taking Priority 2 and 3 medications an opportunity to look for other programs to provide these medications. Providing medications according to their priority will serve as the budgetary control to purchase all medications on the formulary., Priority 3 medications (alpha-interferon, amphotericin B, atovaquone, ethambutol and rifabutin) are currently not available.
Utah	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)
Vermont	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), cidofovir (Vistide), clarithromycin (Biaxin), clotrimazole (Mycelex), dapsone, DOXIL, filgrastim (Neupogen), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), itraconazole (Sporanox), ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), nystatin, pentamidine, primaquine, pyrimethamine (Fansidar), rifabutin (Mycobutin), sulfadoxine, sulfamethoxazole, TMP/SMX (Bactrim/Septra), ANTIDIARRHEAL: ocreotide acetate (Sandostatin)
Virginia	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), nelfinavir (Viracept)	acyclovir (Zovirax), azithromycin (Zithromax), dapsone, fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), pentamidine, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra), People unable to tolerate the protease inhibitor indinavir (Crixivan) or who develop resistance may receive another FDA approved protease inhibitor. This will be considered on an individual basis.
Washington	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nevirapine (Viramune)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), dapsone, dronabinol (Marinol), ethambutol (Myambutol), famciclovir (Famvir), fluconazole (Diflucan), itraconazole (Sporanox), ketoconazole (Nizoral), leucovorin, megestrol acetate (Megace), metronidazole (Flagyl), miconazole, nystatin, paromomycin (Humatin), pentamidine, primaquine, pyrimethamine (Fansidar), rifabutin (Mycobutin), rifampin, sulfadiazine, sulfadoxine, terconazole, TMP/SMX (Bactrim/Septra), trimethoprim, amoxicillin, amoxicillin/potassium (Augmentin), ampicillin, cefixime, cephalexin, cimetidine, diphenoxylate/atropine (Lomotil), erythromycin, estrogen , medroxyprogesterone, famotidine, loperamide (Imodium), metoclopramide (Reglan), miconazole, nizatidine , phenazopyridine, podofilox, prochlorperazine (Compazine), promethazine (Phenergan), ranitidine (Zantac), tetracycline
West Virginia	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	clotrimazole (Mycelex), dapsone, ketoconazole (Nizoral), nystatin, pentamidine, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra)
Wisconsin	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept), nevirapine (Viramune)	acyclovir (Zovirax), atovaquone (Mepron), azithromycin (Zithromax), clarithromycin (Biaxin), dapsone, fluconazole (Diflucan), pentamidine, rifabutin (Mycobutin), TMP/SMX (Bactrim/Septra)
Wyoming	didanosine (ddI, Videx), lamivudine (3TC, Epivir), stavudine (d4T, Zerit), zalcitabine (ddC, HIVID), zidovudine (AZT, Retrovir), indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase), nelfinavir (Viracept)	acyclovir (Zovirax), alpha-interferon, amikacin, amphotericin B, atovaquone (Mepron), azithromycin (Zithromax), bleomycin, ciprofloxacin (Cipro), clarithromycin (Biaxin), clindamycin, clofazimine (Lamprene), clotrimazole (Mycelex), dapsone, doxorubicin, erythropoietin (Epogen, Procrit), ethambutol (Myambutol), filgrastim (Neupogen), fluconazole (Diflucan), foscarnet (Foscavir), ganciclovir (Cytovene), isoniazid (INH), itraconazole (Sporanox), leucovorin, megestrol acetate (Megace), metronidazole (Flagyl), nystatin, paromomycin (Humatin), pentamidine, prednisone, primaquine, pyrazinamide (PZA), pyrimethamine (Fansidar), rifabutin (Mycobutin), Rifamate, rifampin, streptomycin, sulfadiazine, TMP/SMX (Bactrim/Septra), triple sulfa, vinblastine, vincristine, ANALGESIC: ibuprofen, MS Contin, ANTICONVULSANT: carbamezapine (Tegretol), phenytoin (Dilantin), valproic acid (Depakote), ANTIDEPRESSANT: fluoxetine (Prozac), sertraline (Zoloft), ANTIVIRAL: trifluridine (Viroptic)

Appendix 4

Appendix 6

Last modified: 7/19/97
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