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Mississippi General Formulary

Anti-HIV Drugs

Non-nucleosides (Non-Nukes or NNRTIs)

• delavirdine (Rescriptor)
• efavirenz (Sustiva)
• efavirenz (Sustiva) and Truvada (Viread and Emtriva)
• nevirapine (Viramune)
• etravirine (Expanded Access Program): TMC-125

• atazanavir (Reyataz)
• darunavir (Prezista)
• fosamprenavir (Lexiva)
• indinavir (Crixivan)
• lopinavir/ritonavir (Kaletra)
• nelfinavir (Viracept)
• ritonavir (Norvir)
• saquinavir mesylate (Invirase) - (older Fortovase rarely used)
• tipranavir (Aptivus)
• amprenavir (Agenerase) - not pictured. Replaced by Lexiva

Entry Inhibitors

• enfuvirtide (Fuzeon)*

Nucleoside/tides (NRTIs or nukes)

• abacavir (Ziagen)
• lamivudine/abacavir (Epzicom)
• abacavir/lamivudine/zidovudine (Trizivir)
• didanosine (ddI, Videx, Videx EC)
• emtricitabine (Emtriva)
• emtricitabine/tenofovir (Truvada)
• lamivudine (lamivudine, Epivir)
• lamivudine/zidovudine (Combivir)
• stavudine (d4T, Zerit)
• tenofovir (Viread)
• zidovudine (AZT, Retrovir)
• zalcitabine (DDC, HIVID) - discontinued*

• maraviroc (Expanded Access Program): Celsentri

• raltegravir (Expanded Access Program): MK-0518

Specific Medical Criteria:
See right of page for other General Formulary Drugs)

• amitriptyline (Elavil): Diagnosis of peripheral neuropathy
• ethambutol(Myambutol): Must conform to existing policy - contact ADAP Coordinator
• fluconazole (Diflucan): Diagnosis of Severe Fungal Infections with treatment of recurrent Vaginal candidias only after 3 episodes; Pediatric Suspension also available
• ganciclovir (Cytovene): capsules only for maintenance therapy for persons with defined CMV retinitis.
• itraconazole (Sporanox): Diagnosis of histoplasmosis
• gabapentin (Neurontin): Diagnosis of peripheral neuropathy
• oxandrolone (Oxandrin): Special criteria: >/= 10% loss of bodyweight from baseline, compliant with antiretroviral therapy for >/= 3 months, treatment limited up to 12 weeks of therapy
• sertraline (Zoloft): Diagnosis of depression
• sulfadiazine: Diagnosis of toxoplasmosis
  

*Additional Eligibility Requirements for Fuzeon:
• Documented 3 regimen failure
• Genotypic showing multiple resistance
• CD4 < 350

Pediatric Medical Criteria:
Pediatric preparations restricted to pediatric patients only.
Pediatric solutions available for:

• lamivudine (3TC, Epivir),
• zidovudine (AZT, Retrovir),
• pentamidine & TMP/SMX (Bactrim) suspension,
• fluconazole(Diflucan) suspension.

Mississippi Resources

Mississippi General Formulary

Public Health Service Recommanded OI drugs

• acyclovir (Zovirax)
• azithromycin (Zithromax)
• clarithromycin (Biaxin)
• fluconazole (Diflucan)
• ganciclovir (Cytovene)
• itraconazole (Sporanox)
• leucovorin
• pyrimethamine (Daraprim)
• sulfadiazine
• TMP/SMX(Bactrim)

Other OI drugs

• clindamycin (Cleocin)
• clotrimazole (Mycelex)
• dapsone
• ethambutol (Myambutol)
• pentamidine
• valacyclovir (Valtrex)
• valganciclovir (Valcyte)

Other Covered Drugs

• oxandrolone (Oxandrin) for Wasting Syndrome
• atorvastatin (Lipitor) for Hyperlipidemia
• Niacin for Hyperlipidemia
• amitriptyline (Elavil)
• citalopram (Celexa)
• gabapentin (Neurontin)
• sertraline (Zoloft)
• isoniazid(INH) and rifampin are covered through the TB Program

Hepatitis Treatments

• peginterferon alfa-2a (Pegasys) + ribavirin (Copegus)
• interferon alfa-2b (Intron A) with ribavirin (Rebetron)
• peginterferon alfa-2b (PEG-Intron) and ribavirin (Rebetol)
• ribavirin (Rebetol, Copegus, generic)

HIV Resistance Tests

• Mississippi does not cover any HIV resistance tests.

Last modified: 08/08/2007
© 2007 The Network