MICHIGAN DRUG ASSISTANCE PROGRAM 1 Last Updated: 7/1/15 All Previous Versions Obsolete HIV / AIDS Related Treatments HIV Treatment and Prevention Website: http://www.aidsinfo.nih.gov/ Antiretrovirals Nucleoside/Nucleotide Reverse Non-Nucleoside Reverse CCR-5 Inhibitor Selzentry (Maraviroc) - MIDAP will no longer utilize the previous form of medical Transcriptase Inhibitors Transcriptase Inhibitors necessity for authorizing tropism assay coverage Abacavir (ZIAGEN) Delavirdine (RESCRIPTOR) Process for obtaining tropism assay: Abacavir/lamivudine (EPZICOM) Efavirenz (SUSTIVA) - Any MIDAP patient that requires a tropism test Abacavir/lamivudine/zidovudine Nevirapine (VIRAMUNE, VIRAMUNE XR) * will need to complete the ViiV Healthcare Tropsim (TRIZIVIR) Etravirine (INTELENCE) Access Program certificate form. These may be obtained by your local ViiV representative. Didanosine (VIDEX EC*, VIDEX Rilpivirine (EDURANT) - Please note that the Trofile assay requires the HIV- soln) Protease Inhibitors & Combinations 1 RNA PCR to be >1000 copies/mL. Emtricitabine (EMTRIVA) Atazanavir (REYATAZ) - The Trofile DNA assay should only be used when Emtricitabine/Tenefovir (TRUVADA) Darunavir (PREZISTA) the HIV-1 RNA PCR is less than the lower limit of Lamivudine (EPIVIR)* Fosamprenavir (LEXIVA) detection (ie. undetectable). Lamivudine/zidovudine Process for obtaining Selzentry (maraviroc) Indinavir (CRIXIVAN) (COMBIVIR)* coverage: Lopinavir/ritonavir (KALETRA) Stavudine (ZERIT)* - MIDAP will approve the use of Selzentry for Nelfinavir (VIRACEPT)* Tenofovir (VIREAD) members who have tropism results of R5 virus Ritonavir (NORVIR) ONLY. Dual / mixed virus will not be approved. Zidovudine (RETROVIR)* Saquinavir (INVIRASE) - To obtain coverage of this drug, please fax the lab HIV Integrase Inhibitor Tipranavir (APTIVUS) result to the MIDAP Office at 1-517-335-7723 Raltegravir (ISENTRESS) Darunavir/Cobicistat (PREZCOBIX) - Please allow 2 days for processing. Dolutegravir (TIVICAY) Atazanavir/Cobicistat (EVOTAZ) Fusion Inhibitors NNRTI/NRTI Combination Enfuvirtide (FUZEON) Efavirenz/emtricitabine/tenofovir (ATRIPLA) Elvitegravir/Cobicistat/Emtricitabine/ Pharmacokinetic Enhancers Emtricitabine/rilpivirine/tenofovir (COMPLERA) Tenofovir (STRIBILD) Cobicistat (TYBOST) Abacavir/dolutegravir/lamivudine (TRIUMEQ) Opportunistic Infections PCP infections Toxoplasmosis Fungal infections Co-trimoxazole, TMP/SMX Co-trimoxazole, TMP/SMX Amphotericin B* (BACTRIM/SEPTRA SS, DS)* (BACTRIM/SEPTRA SS, DS)* Clotrimazole (MYCELEX)* Dapsone Dapsone Ketoconazole (NIZORAL)* (excluding shampoo) Pentamidine (PENTAM)* Pyrimethamine (DARAPRIM) Terbinafine (LAMISIL)* Atovaquone (MEPRON) PA Leucovorin* Fluconazole (DIFLUCAN)* Primaquine* Azithromycin (ZITHROMAX)* Voriconazole (VFEND)* Trimethoprim* Clindamycin (CLEOCIN)* Itraconazole (SPORANOX)* Clindamycin (CLEOCIN)* Leucovorin* Nystatin* Mycobacterial infections Sulfadiazine Others Azithromycin (ZITHROMAX)* Atovaquone (MEPRON) PA Hepatitis B Vaccine Clarithromycin (BIAXIN)* Herpes infections Hepatitis A Vaccine Ethambutol (MYAMBUTOL)* Acyclovir (ZOVIRAX)* ST1 Pneumococcal Vaccine Rifabutin (MYCOBUTIN) Famciclovir (FAMVIR)* ST2 Influenza Vaccine Ciprofloxacin (CIPRO)* Valacyclovir (VALTREX)* ST2 Ribavirin (REBETOL, RIBASPHERE, Levofloxicin (LEVAQUIN)* CMV infections COPEGUS)* Cryptosporidiosis Cidofovir (VISTIDE) Interferon alfa-2b (INTRON-A) Paromomycin* Foscarnet* Peginterferon alfa-2a (PEGASYS) Atovaquone (MEPRON) PA Ganciclovir* Peginterferon alfa-2b (PEG-INTRON KIT) Azithromycin (ZITHROMAX)* Valganciclovir (VALCYTE)* 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category. MICHIGAN DRUG ASSISTANCE PROGRAM 2 Last Updated: 7/1/15 All Previous Versions Obsolete Analgesics Antiretroviral Agents and Boosters Cidofovir (VISTIDE) Nonsteroidal Anti-inflammatory Agents Abacavir (ZIAGEN) Famciclovir (FAMVIR)* ST2 Celecoxib (CELEBREX) Abacavir/dolutegravir/lamivudine Foscarnet * Diclofenac (VOLTAREN)* (TRIUMEQ) Ganciclovir * Abacavir/lamivudine (EPZICOM) Oseltamivir (TAMIFLU) Diclofenac/misoprostol (ARTHROTEC) Abacavir/lamivudine/zidovudine Ribavirin (REBETOL, RIBASPHERE, Nabumetone* (TRIZIVIR) COPEGUS)* Ibuprofen 800mg (MOTRIN 800mg)* Atazanavir (REYATAZ) Rimantadine (FLUMADINE)* Atazanavir/Cobicistat (EVOTAZ) Valacyclovir (VALTREX)* ST2 Opiate Agonists Cobicistat (TYBOST) Valganciclovir (VALCYTE) acetaminophen /caffeine/butabital Darunavir (PREZISTA) Zanamivir (RELENZA) (FIORICET)* Darunavir/Cobicistat (PREZCOBIX acetaminophen/caffeine/butabital/codeine Delavirdine (RESCRIPTOR) Cephalosporins (FIORICET/CODEINE)* Cephalexin (KEFLEX)* Asa/caffeine/butabital (FIORINAL)* Didanosine (VIDEX EC*, VIDEX soln) Dolutegravir (TIVICAY) Asa/caffeine/butabital/codeine Efavirenz (SUSTIVA) Quinolones (FIORINAL/CODEINE)* Ciprofloxacin (CIPRO)* Efavirenz /emtricitabine/tenofovir Codeine* Levofloxicin (LEVAQUIN)* (ATRIPLA) Codeine/Acetaminophen (TYLENOL #3, Elvitegravir/Cobicistat/Emtricitabine/ Ofloxacin * #4)* Tenofovir (STRIBILD) Fentanyl (DURAGESIC)* PA Emtricitabine (EMTRIVA) Macrolides Hydrocodone/Acetaminophen (VICODIN, Emtricitabine/tenofovir (TRUVADA) Azithromycin (ZITHROMAX)* VICODIN ES, LORTAB)* Emtricitabine/rilpivirine/tenofovir Clarithromycin (BIAXIN*, BIAXIN XL) Hydromorphone (DILAUDID)* (COMPLERA) Erythromycin* Meperidine (DEMEROL)* Enfuvirtide (FUZEON) Penicillins Methadone* Etravirine (INTELENCE) Amoxicillin (TRIMOX, AMOXIL)* Morphine (ROXANOL, MS-CONTIN)* Fosamprenavir (LEXIVA) Amoxicllin/clavulanic acid Morphine (ORAMORPH SR) Indinavir (CRIXIVAN) (AUGMENTIN*, AUGMENTIN ES- Oxycodone (OXY-IR)* Lamivudine (EPIVIR)* 600, AUGMENTIN XR) Oxycodone/Acetaminophen (PERCOCET)* Lamivudine/zidovudine (COMBIVIR)* Penicillin* Tramadol (ULTRAM)* Maraviroc (SELZENTRY) Penicillin inj (BICILLIN LA) Tramadol/Acetaminophen (ULTRACET)* Nelfinavir (VIRACEPT) Tetracyclines Oxycodone (OXYCONTIN) PA Nevirapine (VIRAMUNE)* Doxycycline* Raltegravir (ISENTRESS) Rilpiviring (EDURANT) Anti-Infectives Vaginal Antimicrobials Ritonavir (NORVIR) Antifungal Antibiotics Metronidazole (METROGEL)* vag Amphotericin B (AMPHOCIN)* Saquinavir ( INVIRASE) Stavudine (ZERIT)* Ophthalmic Antimicrobials Clotrimazole (MYCELEX)* Ciprofloxacin (CILOXAN)* Tenofovir (VIREAD)* Fluconazole (DIFLUCAN)* Erythromycin* Tipranavir (APTIVUS) Itraconazole (SPORANOX)* Ofloxacin (OCUFLOX)* Zidovudine (RETROVIR)* Ketoconazole (NIZORAL)*(excluding Otic Antimicrobials Antituberculosis Agents shampoo) Ciprofloxacin/dexamethasone Ethambutol (MYAMBUTOL)* Terbinafine (LAMISIL)* (CIPRODEX) Isoniazid* Voriconazole (VFEND)* Ciprofloxacin/hc (CIPRO HC) Pyridoxine* (adjunct to Isoniazid only) Pyrazinamide* Antiprotozoals, Miscellaneous Topical Antimicrobials Atovaquone (MEPRON) PA Rifabutin (MYCOBUTIN)* Rifampin (RIFADIN)* Acyclovir (ZOVIRAX) Paromomycin * Clindamycin (CLEOCIN-T)* Pentamidine (PENTAM)* Other Antivirals Clotrimazole/betamethasone Acyclovir (ZOVIRAX)* ST1 (LOTRISONE)* Entecavir (BARACLUDE) Erythromycin* 1) BRAND NAMEs indicated by CAPITAL, generic names indicated by lower case, * indicates the generic equivalent is available. 2) MANDATORY GENERIC PROGRAM - MIDAP excludes coverage of brand-name drugs with FDA approved generic equivalents. 3) PA = Prior Authorization required. 4) QL= Quantity Limit. 5) Step Therapy: ST1 = the prerequisite drug for ST2 drug(s) in same category; ST2 drugs require a trial of ST1 drug in same category. MICHIGAN DRUG ASSISTANCE PROGRAM 3 Last Updated: 7/1/15 All Previous Versions Obsolete Metronidazole (METROCREAM*, Diltiazem (CARDIZEM, TAZTIA XT) * Antipsychotics METROGEL) Felodipine (PLENDIL) * Haloperidol ( oral)* Nystatin* Nifedipine XL, ER (PROCARDIA, Chlorpromazine (oral)* Silvadene (SSD)* ADALAT) * Olanzapine (ZYPREXA)* Terbinafine (LAMISIL AT)* Verapamil (COVERA HS) Risperidone (RISPERDAL) Verapamil (VERELAN, ISOPTIN SR, Quetiapine (SEROQUEL) # Other Antimicrobials CALAN, CALAN SR)* # low doses only covered for tapering, Co-trimoxazole, TMP/SMX (BACTRIM not for use as a sedative/hypnotic / SEPTRA SS, DS)* Central Agonists Clindamycin (CLEOCIN)* Clonidine (CATAPRES)* Anxiolytics, Sedatives and Hypnotics Dapsone Minoxidil* Buspirone (BUSPAR)* Metronidazole (FLAGYL)* Zolpidem (AMBIEN*, AMBIEN CR) Lipid Lowering Agents Primaquine Pyrimethamine (DARAPRIM) Atorvastatin (LIPITOR)* Benzodiazepines Sulfadiazine Cholestyramine (QUESTRAN)* Alprazolam (XANAX)* Trimethoprim* Fenofibrate* (LOFIBRA) Clonazepam (KLONOPIN)* Gemfibrozil (LOPID)* Diazepam (VALIUM)* Interferons Niacin (NIASPAN) Lorazepam (ATIVAN)* Interferon alfa-2b (INTRON-A) Pravastatin (PRAVACHOL)* Temazepam (RESTORIL)* Peginterferon alfa-2a (PEGASYS) Peginterferon alfa-2b (PEG-INTRON Nitrates and Nitrites Selective Serotonin Agonists KIT ) Nitroglycerin sublingual tab, spray, cap* Sumatriptan (IMITREX)* Skeletal Muscle Relaxants Cardiovasculars Diuretics Baclofen* Furosemide (LASIX)* Angiotensin II Receptor Antagonists Cyclobenzaprine (FLEXERIL)* Hydrochlorothiazide * Losartan (COZAAR)* ST1 Tizanidine (ZANAFLEX)* Losartan/hctz (HYZAAR)* ST1 Hctz/triamterene (DYAZIDE, Smoking Cessation Valsartan (DIOVAN) ST2 MAXZIDE) * Bupropion (ZYBAN) Valsartan/hctz Nicotine patch ( NICODERM CQ)* (DIOVAN HCT) ST2 CNS Nicotine lozenge Anticonvulsants