Connecticut AIDS Drug Assistance Program (CADAP) Formulary, As of October 1, 2002

STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES 25 SIGOURNEY STREET * HARTFORD, CONNECTICUT 06106

Connecticut AIDS Drug Assistance Program (CADAP) Formulary Effective: November 1, 2007 Generic Name in Alphabetical / Numerical Order

1. Abacavir (Ziagen) 53. Diltiazem HCL (Cardizem) 2. Abacavir/Lamivudine/Zidovudine (Trizivir) 54. Diphenoxylate HCL (Lomotil, Lonox) 3. Acetaminophen with codeine 55. Divalproex Sodium (Depakote) 4. Acyclovir (Zovirax) 56. Doxycycline hyclate 5. Albuterol (Proventil) 57. Dronabinol (Marinol) 6. Alclometasone Dipropionate (Aclovate) 58. Efavirenz (Sustiva) 7. Alprazolam (Xanax) 59. Efavirenz/Emtricitabine/Tenofovir (Atripla) 8. Amitriptyline HCL (Elavil) 60. Emtricitabine (Emtriva) 9. Amlodipine (Norvasc) 61. Emtricitabine/Tenofovir (Truvada) 10. Amoxicillin 62. Enalapril Maleate (Vasotec) 11. Amoxicillin/Clavulanate pot. (Augmentin) 63. Enfuvirtide, T-20 (Fuzeon) 12. Amphotericin B (Fungizone B) 64. Engerix-B 13. Ampicillin 65. Erythropoetin (Epogen, Procrit) 14. Amprenavir (Agenerase) 66. Escitalopram Oxalate (Lexapro) 15. Atazanavir (Reyataz) 67. Esomeprazole (Nexium) 16. Atenolol (Tenormin) 68. Ethambutol (Myambutol) 17. Atorvastatin (Lipitor) 69. Famciclovir (Famvir) 18. Azelastine HCl (Astelin) 70. Famotidine (Pepcid) 19. Azithromycin (Zithromax) 71. Fenofibrate (Tricor) 20. Benztropine Mesylate (Cogentin) 72. Fentanyl transdermal system (Duragesic) 21. Betamethasone (Diprolene) 73. Filgrastim (G-CSF, Neupogen) 22. Budesonide (Rhinocort AQUA) 74. Fluconazole (Diflucan) 23. Bupropion HCL (Wellbutrin) 75. Fluocinonide (Lidex) 24. Buspirone (BuSpar) 76. Flunisolide (Aerobid) 25. Carbamazepine (Tegretol) 77. Fluoxetine HCL (Prozac) 26. Cefditoren Pivoxil (Spectracef) 78. Fluticasone Propionate (Cutivate) 27. Cefuroxime 79. Fluticasone Propionate (Flovent) 28. Celecoxib (Celebrex) 80. Fosamprenavir (Lexiva) 29. Cephalexin (Keflex) 81. Foscarnet (Foscavir) 30. Cetirizine (Zyrtec) 82. Furosemide 31. Chlorhexidine gluconate (Peridex) 83. Gabapentin (Neurontin) 32. Cholestyramine (Questran) 84. Ganciclovir (Cytovene) 33. Cidofovir (Vistide) 85. Gatifloxacin (Tequin) 34. Ciprofloxacin (Cipro) 86. Gemfibrozil (Lopid) 35. Citalopram (Celexa) 87. Gentamicin 36. Clarithromycin (Biaxin) 88. Glipizide 37. Clindamycin (Cleocin) 89. Glyburide 38. Clindamycin Gel (Cleocin T) 90. Granisetron HCl (Kytril) 39. Clobetasol Propionate (Temovate) 91. Guaifenesin/Codeine PH (Tussi-Organidin S-NR) 40. Clofibrate (Atromid-S) 92. Guaifenesin/DM HBr (Tussi-Organidin DM-S-NR) 41. Clonazepam (Klonopin) 93. Guaifenesin/pseudoephedrine (Entex PSE) 42. Clotrimazole (Mycelex, Lotrimin) 94. Havrix 43. Colesevelam HCl (Welchol) 95. Hydrochlorothiazide (HCTZ) 44. Comvax 96. Hydrocortisone Topical 45. Dapsone 97. Hydroxyurea 46. Darunavir (Prezista) 98. Hydroxyzine HCL (Atarax) 47. Delavirdine (Rescriptor) 99. Ibuprofen 48. Dexamethasone 100. Indinavir (Crixivan) 49. Diazepam 101. Insulin NPH 50. Dicloxacillin 102. Insulin Regular 51. Didanosine (ddI, Videx) 103. Ipratropium Bromide (Combivent) 52. Digoxin 104. Isosorbide Dinitrate CADAP Formulary Effective: November 1, 2007 Generic Name in Alphabetical / Numerical Order (continued)

105. Isosorbide mononitrate (Imdur) 163. Pioglitazone HCL (Actos) 106. Itraconazole (Sporanox) 164. Pneumococcal vaccine (individual doses) 107. Ketoconazole (Nizoral) 165. Pravastatin (Pravachol) 108. Ketoconazole 2% (Nizoral Shampoo) 166. Prednisone 109. Ketoprofen (Orudis) 167. Primaquine 110. Labetalol HCL (Normodyne) 168. Prochlorperazine (Compazine) 111. Lactic Acid 169. Pyrimethamine 112. Lactulose (Kristalose) 170. Quetiapine Fumarate (Seroquel) 113. Lamivudine (3TC, Epivir) 171. Rabeprazole Sodium (Aciphex) 114. Lamivudine/Abacavir (Epzicom) 172. Raltegravir (Isentress) 115. Lamivudine/Zidovudine (Combivir) 173. Ranitidine HCL (Zantac) 116. Lansoprazole (Prevacid) 174. Recombivax HB 117. Leucovorin 175. Ribavirin (Copegus) 118. Levocarnitine/Oral (Carnitor) 176. Ribavirin (Rebetol) 119. Levofloxacin (Levaquin) 177. Rifabutin (Mycobutin) 120. Levothyroxine Sodium (Synthroid) 178. Risperidone (Risperdal) 121. Lisinopril (Prinivil, Zestril) 179. Ritonavir (Norvir) 122. Lithium 180. Rosiglitazone Maleate (Avandia) 123. Loperamide HCL (Imodium) 181. Rosuvastatin Calcium (Crestor) 124. Lopinavir/Ritonavir (Kaletra) 182. Salmeterol (Advair Diskus) 125. Lorazepam 183. Salmeterol Xinafoate (Serevent) 126. Maraviroc (Selzentry) 184. Saquinavir (Fortovase) 127. Megestrol acetate (Megace) 185. Saquinavir mesylate (Invirase) 128. Mepron 186. Somatropin (Serostim) * 129. Metformin HCL (Glucophage) 187. Sertraline (Zoloft) 130. Metoprolol Succinate (Toprol-XL) 188. Spironolactone 131. Metronidazole (Flagyl) 189. Stavudine (d4T, Zerit) 132. Metronidazole Cream (MetroCream) 190. Strovite Forte 133. Minocycline HCL (Dynacin) 191. Strovite Plus 134. Minoxidil 192. Sulfadiazine 135. Mirtazapine (Remeron) 193. Terbinafine (Lamisil) 136. Mometasone furoate monohydrate (Nasonex) 194. Temazepam (Restoril) 137. Mupirocin Oint. (Bactroban Oint.) 195. Tenofovir DF (Viread) 138. Nandrolone decanoate (Deca-Durabolin) 196. Terconazole (Terazol 3&7) 139. Naproxen (Naprosyn) 197. Testosterone (Androderm) 140. Nelfinavir (Viracept) 198. Testosterone (Androgel) 141. Neomycin Sulfate (Cortisporin) 199. Testosterone-cypionate (Depo-testosterone) 142. Nevirapine (Viramune) 200. Testosterone Gel (Testim 1%) 143. Nitrofurantoin Monohydrate (Macrobid) 201. Tipranavir (Aptivus) 144. Nitroglycerin 202. Trazodone 145. Nortriptyline HCL 203. Triamcinolone Acetonide (Nasacort AQ) 146. Nystatin 204. Triamcinolone-acetonide Topical 147. Ofloxacin (Floxin) 205. Trimethoprim (Proloprim) 148. Olanzapine (Zyprexa) 206. Trimethoprim-sulfamethoxazole, TMP-SMZ 149. Ondansetron HCl (Zofran) 207. Twinrix 150. Oxandrolone (Oxandrin) 208. Valacyclovir (Valtrex) 151. Oxycodone HCL controlled release (Oxycontin) 209. Valganciclovir (Valcyte) 152. Oxymetholone (Anadrol-50) 210. Vancomycin 153. Pantoprazole Sodium (Protonix) 211. Vaqta 154. Paromomycin (Humatin) 212. Venlafaxine (Effexor) 155. Paroxetine (Paxil) 213. Verapamil (Covera HS) 156. PEG-Interferon alfa-2a (Pegasys) 214. Voriconazole (Vfend) 157. PEG-Interferon alfa-2b (PEG-INTRON) 215. Zalcitabine (ddC, Hivid) 158. PEG-Interferon alfa-2b (PEG-INTRON REDIPEN) 216. Zidovudine (AZT, Retrovir) 159. Penicillin G Benzathine (Bicillin) 217. Zolpidem Tartrate (Ambien / Ambien CR) 160. Penicillin V Potassium (Veetids) 161. Pentamidine (Pentam 300, NebuPent) * denotes Prior Authorization required effective September 15, 2006 162. Pinecrolimus (Elidel)

Page 2 of 2 STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES 25 SIGOURNEY STREET * HARTFORD, CONNECTICUT 06106

Connecticut AIDS Drug Assistance Program (CADAP) Formulary – Effective: November 1, 2007 Anti-Virals: Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs) - 13 Abacavir (Ziagen) Emtricitabine (Emtriva) Stavudine (d4T, Zerit) Abacavir/Lamivudine/Zidovudine (Trizivir) Emtricitabine/Tenofovir (Truvada) Tenofovir DF (Viread) Didanosine (ddI, Videx, Videx EC) Lamivudine (3TC, Epivir) Zalcitabine (ddC, Hivid) Efavirenz/Emtricitabine/Tenofovir (Atripla) Lamivudine/Zidovudine (Combivir) Zidovudine (AZT, Retrovir) Lamivudine/Abacavir (Epzicom) Anti-Virals: Integrase Inhibitors - 1 Raltegravir (Isentress) Anti-Virals: Protease Inhibitors (PIs) - 11 Amprenavir (Agenerase) Indinavir (Crixivan) Ritonavir (Norvir) Atazanavir Sulfate (Reyataz) Lopinavir/Ritonavir (Kaletra) Saquinavir (Fortovase) Darunavir (Prezista) Nelfinavir (Viracept) Saquinavir mesylate (Invirase) Fosamprenavir (Lexiva) Tipranavir (Aptivus) Anti-Virals: Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) - 3 Delavirdine (Rescriptor) Efavirenz (Sustiva) Nevirapine (Viramune) Anti-Virals: Entry Inhibitors - 2 Enfuvirtide, T-20 (Fuzeon) - injectable Maraviroc (Selzentry) - oral Anti-Virals: Herpes Treatments/CMV Disease - 7 Acyclovir (Zovirax) Famciclovir (Famvir) Valacyclovir (Valtrex) Cidofovir (Vistide) Foscarnet (Foscavir) Valganciclovir (Valcyte) Ganciclovir (Cytovene) Anti-Virals: Hepatitis C Treatments - 5 PEG-Interferon alfa-2a (Pegasys) PEG-Interferon alfa-2b (PI - REDIPEN) Ribavirin (Copegus) PEG-Interferon alfa-2b (PEG-INTRON) Ribavirin (Rebetol) Antibiotics - 24 Amoxicillin Clarithromycin (Biaxin) Neomycin Sulfate (Cortisporin) Amoxicillin/Clavulanate pot. (Augmentin) Clindamycin (Cleocin) Nitrofurantoin Monohydrate ((Macrobid) Ampicillin Dicloxacillin Ofloxacin (Floxin) Azithromycin (Zithromax) Doxycycline Hyclate Paromomycin (Humatin) Cefditoren Pivoxil (Spectracef) Gatifloxacin (Tequin) Penicillin G Benzathine (Bicillin) Cefuroxime Gentamicin Penicillin V Potassium (Veetids) Cephalexin (Keflex) Levofloxacin (Levaquin) Rifabutin (Mycobutin) Ciprofloxacin (Cipro) Minocycline HCL (Dynacin) Vancomycin Anti-fungal Agents – 9 Amphotericin B (Fungizone B) Itraconazole (Sporanox) Terbinafine (Lamisil) Clotrimazole (Mycelex, Lotrimin) Ketoconazole (Nizoral) Terconazole (Terazol 3 & 7) Fluconazole (Diflucan) Nystatin Voriconazole (Vfend) Other Anti-infective Agents - 10 Dapsone Pentamidine (Pentam 300, NebuPent) Trimethoprim-sulfamethoxazole, TMP-SMZ Ethambutol (Myambutol) Primaquine Trimethoprim (Proloprim) Mepron Pyrimethamine Metronidazole (Flagyl) Sulfadiazine Anti-Hyperlipidemic Agents - 8 Atorvastatin (Lipitor) Colesevelam HCl (Welchol) Pravastatin (Pravachol) Cholestyramine (Questran) Fenofibrate (Tricor) Rosuvastatin Calcium (Crestor) Clofibrate (Atromid-S) Gemfibrozil (Lopid) Analgesic Agents - 3 Acetaminophen with codeine Fentanyl Transdermal System (Duragesic) Oxycodone HCL - CR (Oxycontin)

Decongestant & Expectorant Agents - 3 Guaifenesin/Codeine PH (Guaitussin-AC) Guaifenesin/pseudoephedrine (Entex PSE) Guaifenesin/DM HBr (Tussi-Organidin DM-S-NR) Anti-inflammatory Agents (NSAID) - 4 Celecoxib (Celebrex) Ibuprofen Naproxen (Naprosyn) Ketoprofen (Orudis) Dermatological Agents - 13 Alclometasone Dipropionate (Aclovate) Fluticasone Propionate (Cutivate) Mupirocin Oint. (Bactroban Oint.) Betamethasone (Diprolene) Hydrocortisone Topical Pimecrolimus (Elidel) Clindamycin Gel (Cleocin T) Ketoconazole 2% (Nizoral Shampoo) Triamcinolone-Acetonide Topical Clobetasol Propionate (Temovate) Lactic Acid Fluocinonide (Lidex) Metronidazole Cream (MetroCream) Antihypertensive/Cardiac Agents - 16 Amlodipine (Norvasc) Hydrochlorothiazide (HydroDIURIL) Minoxidil Atenolol (Tenormin) Isosorbide Dinitrate Nitroglycerin Digoxin Isosorbide Mononitrate (Imdur) Spironolactone Diltiazem HCL (Cardizem) Labetalol HCL (Normodyne) Verapamil (Covera HS) Enalapril Maleate (Vasotec) Lisinopril (Prinivil, Zestril) Furosemide Metoprolol Succinate (Toprol-XL) Anti-Depressants / Psychotropic Agents - 25 Alprazolam (Xanax) Divalproex Sodium (Depakote) Paroxetine (Paxil) Amitriptyline HCL (Elavil) Escitalopram Oxalate (Lexapro) Prochlorperazine (Compazine) Benztropine Mesylate (Cogentin) Fluoxetine HCL (Prozac) Questiapine Fumarate (Seroquel) Bupropion HCL (Wellbutrin) Hydroxyzine HCL (Atarax) Risperidone (Risperdal) Buspirone (BuSpar) Lithium Sertraline (Zoloft) Carbamazepine (Tegretol) Lorazepam Trazodone Citalopram (Celexa) Mirtazapine (Remeron) Venlafaxine (Effexor) Clonazepam (Klonopin) Nortriptyline HCL Diazepam Olanzapine (Zyprexa) Gastrointestinal Agents: Proton Pump Inhibitors (PPIs) - 6 Esomeprazole (Nexium) Lansoprazole (Prevacid) Rabeprazole Sodium (Aciphex) Famotidine (Pepcid) Pantoprazole Sodium (Protonix) Ranitidine HCL (Zantac) Vaccines - 7 Comvax Pneumococcal Vaccine (individual doses) Vaqta Engerix-B Recombivax HB Havrix Twinrix Endocrine/Metabolic Agents (Steroids) - 9 Nandrolone decanoate (Deca-Durabolin) Prednisone Testosterone (Androderm) Oxandrolone (Oxandrin) Somatropin (Serostim) Testosterone-cypionate (Depo-Testosterone) Oxymetholone (Anadrol-50) Testosterone (Androgel) Testosterone Gel (Testim 1%) Bronchial Dilators/Respiratory Agents - 9 Albuterol (Proventil) Flunisolide (Aerobid) Salmeterol (Advair Diskus) Azelastine HCl (Astelin) Fluticasone Propionate (Flovent) Salmeterol Xinafoate (Serevent) Budesonide (Rhinocort AQUA) Ipratropium Bromide (Combivent) Triamcinolone Acetonide (Nasacort AQ) Diabetes Agents - 7 Glipizide Insulin Regular Rosiglitazone Maleate (Avandia) Glyburide Metformin HCL (Glucophage) Insulin NPH Pioglitazone HCL (Actos) Miscellaneous - 22 Cetirizine HCL (Zyrtec) Gabapentin (Neurontin) Loperamide HCL (Imodium) Chlorhexidine gluconate (Peridex) Granisetron (Kytril) Megestrol acetate (Megace) Dexamethasone Hydroxyurea Mometasone furoate monohydrate (Nasonex) Diphenoxylate HCL (Lomotil, Lonox) Lactulose (Kristalose) Ondansetron (Zofran) Dronabinol (Marinol) Leucovorin Strovite Forte / Plus / Advance Erythropoetin (Epogen, Procrit) Levocarnitine/Oral (Carnitor) Temazepam (Restoril) Filgrastim (G-CSF, Neupogen) Levothyroxine Sodium (Synthroid) Zolpidem Tartrate (Ambien / Ambien CR)

BOLD denotes new to formulary as of November 1, 2007 (3 drugs) TOTAL Drugs on CADAP Formulary = 217 BOLD ITALICS denotes Prior Authorization required effective September 15, 2006 Revised December 2007