Agenda · 2020-03-31 · 7. ADAP Update 8. Review Part A Drug Utilization Data A. Ryan White Part A...

Local Pharmacy Advisory Committee Meeting

Ryan White Part A Program Office

Stephen Abel, Chair

Agenda

Monday, April 9, 2012 at 3:30 p.m.

1. Call to Order

Please sign-in

2. Welcome and Introductions A. Review Meeting Ground Rules and Statement of Sunshine B. Review Public Comment (Please Sign-in at Front of Room) C. Committee Member Introductions D. Guest Introductions

3. Public Comment

4. Moment of Silence

5. Approve Today’s Agenda

6. Approve 10/10/11 Meeting Minutes

7. ADAP Update

8. Review Part A Drug Utilization Data A. Ryan White Part A Formulary (Handout A) B. Ryan White Part A Formulary Changes 2011-2012 (Handout B) C. Prescription Drug Utilization (Handout C) D. Recommendations for Additions to Formulary (Handout D)

9. NQC In+Care Campaign Retention Rates (Handout E)

10. Old Business/New Business

11. Agenda Items for Next Meeting

12. Next Meeting Date: To Be Determined

13. Adjournment

Please complete meeting evaluation forms.

IMPORTANT NOTICE. Please be aware this meeting and all information stated thereof is a matter of public

record under FL’s Government in the Sunshine Law (FL Statute, Chapter 119.01). Acknowledgement of HIV status

is not required, and if disclosed becomes a part of the public record.

http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0119/SEC01.HTM&Title=-%3e2008-%3eCh0119-%3eSection%2001#0119.01

Attendance # Members Present Absent

Guests 1 Dr. Stephen Abel, Chair X Bonnie Majcher 2 Clarissa Castro X Daniel Padron 3 Joey Wynn X Elizabeth Sherman 4 Michael Rajner X Jason King 5 Mike Ehren X Dr. Kenneth Poon 6 Seth Leverence X Mirta Soto Rosario Dr. Robert Heglar Grantee Staff Leonard Jones Shaundelyn Degraffenreidt HIVPC Support Staff Ariela Eshel Quorum = 4 5 Gladria De Sa

1. Call to Order (Government in the Sunshine)

The Chair called the meeting to order at 3:40 P.M.

2. Welcome and Introductions The Chair welcomed everyone and introductions were made. All Committee members stated potential conflicts. Attendees were notified of information regarding Government in the Sunshine Law and meeting reporting requirements, which includes the recording of minutes. In addition, they were advised that the acknowledgement of HIV status is not required but is subject to public record if it is disclosed.

3. Public Comment: None 4. Moment of Silence

A moment of silence was observed.

5. Approve 10/10/11 Meeting Agenda Motion #1 To “approve 10/10/11 Meeting Agenda” Proposed By Michael Rajner Seconded By Joey Wynn Action Passed Unanimously

6. Approve 7/11/11 Meeting Minutes

Motion #2 To “approve 7/11/11 Meeting Minutes.” Proposed By Michael Rajner Seconded By Seth Leverence Action Passed Unanimously

7. ADAP Update

The committee agreed to request from ADAP that ADAP updates be provided in writing within 10 business days in lieu of an ADAP representative being present to provide the report in person. An ADAP representative reported that based on current funding received from HRSA and funding projections, the ADAP is able to serve its existing clients and enroll and serve an additional 1,500 applicants from the ADAP waiting list. In addition, the bureau plans to clear the existing 332 clients from the AIDS Insurance Continuation Program (AICP) waiting list.

8. Review Part A Formulary A. Complete Review of Tier 1 Medication Categories (Handout A)

Representatives from the Medical QI Network presented and explained the Networks’ recommendations to the Local Pharmacy Advisory Committee (LPAC) for removal of drugs as stated below. The committee adopted the

Local Pharmacy Advisory Committee Monday, October 10, 2011 at 3:30 P.M.

Minutes

LPAC – October 10th, 2011 Minutes 2

recommendations with the exception for the removal of B-Plex with C (antioxidant) Vitamin B Complex, Antioxidant Formula.

B. Ryan White Part A Formulary (Handout B) The committee was presented with recommendations from Dr. Paula Eckardt and pharmacy staff at Memorial Hospital regarding the Oral Contraceptives category. Elizabeth Sherman, PharmD, a representative from Memorial Hospital, clarified the recommendations and justification as stated below.

REMOVED JUSTIFICATION

Ortho Novum 1/35

Therapeutic duplication; other medications from the same drug class are

available.

Ortho Novum 1/50

OrthoCept 28 Alesse 28

Ortho Novum 7/7/7 Tri Phasil 28

The committee decided to reduce the oral contraceptives category by accepting the recommendations via consensus. The formal motion with justification is stated below.

Motion #4 To “reduce the Oral Contraceptives Category on the Formulary to Lo Ovral 28

(Monophasic), Ortho-Tricyclen 28 (Triphasic) and Micronor 28 (Progestin only)” Proposed By Joey Wynn Seconded By Seth Leverence Action Passed Unanimously

It was agreed that LPAC will review the formulary on a quarterly basis to decide whether additions or removals of medications should be considered.

MEDICAL QI NETWORK RECOMMENDATIONS FOR REMOVAL JUSTIFICATION LPAC DECISION

Insulin Humulin 70/30 Duplicate Insulin Analog (Humalog) Simplify Formulary, Cost Saving Measure

Remove

Rosiglitazone (Avandia) Adverse effects, Contraindication Remove

Estrogen/Medroxyprogest (Prempro, Premphase) No utilization Remove

Gentamycin (Garamycin crm) Neosporin covers this Remove

Hexachlorophene (Phisohex) No utilization Remove

B-Plex with C (antioxidant) Vitamin B Complex, Antioxidant Formula

Reasonably priced OTC, Cost Saving Measure

Keep on formulary

Motion #3 To “accept recommendations by Medical QI Network with exception of removal of B-Plex” Proposed By Joey Wynn Seconded By Seth Leverence Action Passed Unanimously

LPAC – October 10th, 2011 Minutes 3

9. Dear Colleague Letter (Handout C) The draft ‘Dear Colleague’ letter, to make providers aware of the differential between Budesonide (Rhinocort) and Beclomethasone (Beconase AQ), was reviewed by the committee and accepted via consensus. The Grantee will ensure the letter is signed by all relevant parties.

10. Old/New Business

Members discussed the need for physicians and pharmacists to be a part of LPAC decision making. It was suggested that LPAC meeting on a quarterly basis at the later time of 3:30p.m.

Elizabeth Sherman, Memorial Hospital, and Mirta Soto-Rosario, AIDS Healthcare Foundation were voted in as new LPAC members.

Motion #5 To “add Elizabeth Sherman as a member to the Local Pharmacy Advisory

Committee” Proposed By Michael Rajner Seconded By Seth Leverence Action Passed Unanimously

Motion #6 To “add Mirta Soto-Rosario as a member to the Local Pharmacy Advisory

Committee” Proposed By Joey Wynn Seconded By Michael Rajner Action Passed Unanimously

A member shared kind words about Dr. Gary Morey, a former member, whose recent passing was a great loss to the community.

11. Agenda Items for Next Meeting: To be determined.

12. Next Meeting Date: To be determined. 13. Adjournment: Meeting was adjourned at 5:20P.M.

ANTIINFECTIVES Phenytoin (Dilantin) HCTZ (HydroDiuril) Laxative Antiviral Primidone (Mysoline) HCTZ/Triamterene (Dyazide) Docusate sodium (Colace)

Antibacterial Ferrous sulfate (Feosol) Topiramate (Topamax) Irbesartan (Avapro) Spironolactone (Aldactone) Docusate/Casanth (Peri-Colace)

Amoxicillin(Amoxil) Fiberlax (Fibercon)

Amoxicill/Clav (Augmentin) Analgesic Alpha Blockers Nitrates Lactulose (Enulose)

Cefdinir (Omnicef) Naproxen (Naprosyn) Clonidine (Catapres)

Ceftriaxone INJ (Rocephin) Antianxiety/Hypnotic Butalbi/Acetam/Caff (Fioricet) Terazosin (Hytrin) PPI Cefuroxime (Ceftin) Diazepam (Valium) Tramadol (Ultram) Isosorbide Mononitrate (Imdur) Lansoprazole (Prevacid)

Cephalexin (Keflex) Hydroxyzine (Vistaril,Atarx) AlphaBeta Blocker Ciprofloxacin (Cipro) Lorazepam (Ativan) Narcotic Analgesic Carvedilol (Coreg) DIABETES Misc/OtherClindamycin (Cleocin) Temazepam (Restoril) Codeine/Acetam (Tylenol#3) Insulin Analog (Humalog) GoLytely (Colyte)

Doxycycline (Vibramycin) Hydrocodone / Acet Beta Blockers Insulin NPH (Novolin) Metoclopramide (Reglan)

Dicloxacillin (Dynapen) Antidepressant (Vicodin,VicodinES) Atenolol (Tenormin) Insulin Regular (Novolin) Sucralfate (Carafate)

Buspirone (Buspar) Methadone (Methadone) Labetalol (Normodyne) Insulin Glaritine(Lantus)

Erythromycin base (Ery-tab) Citalopram (Celexa) Morphine (MSContin, MSIR) Propranolol (Inderal) Actose (Pioglitazone) GYN/OBNitrofurantoin (Macrodantin) Doxepin (Sinequan) Oxycodone/ASA (Percodan) Metoprolol (Lopressor) Estrogen Conj (Premarin)

Penicillin Benzath (Bicillin LA) Paroxetine (Paxil) Oxycodone/Acet (Percocet) GASTROINTESTPenicililn VK (PenVK) Sertraline (Zoloft) Propox/Acet (Darvocet N-100) Antiarrythmic Antacid Primaquine (Primaquine) Trazodone (Desyrel) Amiiodarone (Cordarone) Al, Mg, Simeth (Mylanta DS)

Tetracycline (Achromycin) Lithium carb (Lithonate) Muscle RelaxantTrimethoprim (Proloprim) Baclofen (Lioresal) Anticoagulant Antidiarrheal

Antipsychotic Carisoprodol (Soma) Warfarin (Coumadin)

Antifungal Chlorpromazine (Thorazine) Cyclobenzaprine (Flexeril) Norethindrone (Micronor 28)

AmphoteracinB (Fungizone) Haloperidol (Haldol) AntiplateletTerbinafine (Lamisil) Perphenazine (Trilafon) Antiparkinson Aspirin* Clopidogrel (Plavix) Antiemetic NASAL

Carbidopa/levodop (Sinemet) Promethazine (Phenergan) Budesonide (Rhinocort)

Antitubercular Misc. Promethazine Suppos Beclomethasone (Beconase AQ)

Cycloserine (Seromycin) Benztropine (Cogentin) Antimigraine Calcium Channel Blocker Sodium Chloride (Ocean Nasl)

Furazolidone (Furoxone) Sumatriptan (Imitrex) (Oral Only) Amlodipine (Norvasc) AntiflatulantIsoniazid (INH) Anticonvulsant Butalbi/Acetam/Caff (Fioricet) Diltiazem (Cardizem) Simethicone (Mylicon) OTICIsoniazid/Rifampn (Rifamate) Acetazolamide(Diamox) Verapamil (Isoptin, Calan) Acetic Acid (Vosol)

Pyrazinamide (PZA) Carbamazepine (Tegretol) Nifedepine (Procardia,Adalat) Antispasmotic Acetic Acid / HC (Vosol HC)

Rifampin (Rifadin) Clonazepam (Klonopin) Dicyclomine (Bentyl) Neomycin / HC (Cortisporin)

Rifampin / Isoniazid(Rifamate) Ethosuximide (Zarontin) ACE Inhibitor Cardiac Glycoside Ciprofloxacin / HC (Cipro HC)

Felbamate (Felbatol)* Enalapril (Vasotec) Digoxin (Lanoxin) Digestive Enzyme Carbamide Peroxide (Debrox)

Other Mephobarbital(Mebaral) Lisinopril (Zestril, Prinivil) Pancrealipase (Ultrace MT)

Metronidazole (Flagyl) Methsuiximide (Celontin) DiureticParomomycin(Humatin) Phenobarbital Bumetanide (Bumex) H2Antagonist

Furosemide (Lasix) Ranitidine (Zantac)

CNS, ANXIETY, PSYCH, NEURO, & AUTONOMIC

CARDIAC & ANTI-HYPERTENSIVE

Angiotensin Receptor Blocker (ARB)

In order to access Tier One, clients must qualify for the Ryan White Part A eligibility requirements.

TIER ONERYAN WHITE PART A PHARMACY FORMULARY - Updated 03/21/12

Loperamide (Imodium)

Paregoric

Nitroglycerin (Nitrostat,Nitro-

Dur)

Ethinyl estradiol/ Norgestrel (Lo-

Ovral 28)

Ethinyl estrad/Norgest/placeb (Ortho-

Tricyclen 28)

Medroxyprogesterone (Provera,

Depo-Provera)

BLOOD/BLOOD FORMING

*Aspirin may only be dispensed with Clopidogrel

Ryan White Part A Formulary - Updated 3.21.12 1

HANDOUT A

In order to access Tier One, clients must qualify for the Ryan White Part A eligibility requirements.

TIER ONERYAN WHITE PART A PHARMACY FORMULARY - Updated 03/21/12

OPHTHALMIC Antitussive Corticosteroid Antibiotic Guaifenesin (Robitussin)

Ciprofloxacin (Ciloxin) Guaifen / DM (Robitussin DM) Oxybutinin (Ditropan)

Guaifen / Cod (Robitussin AC) Betamethasone (Diprosone) Prednisone (Deltasone)

Guaifen /Cod / Pseudoephed

Fluocinolone (Dermasmoothe) Probenecid

Erythromycin (E-Mycin) Hydrocortisone crm (Hytone)

Neo/Poly/Bacit (Neosporin)

Sulfacetamide (Sulamyd) BetaAgonist Oral Phenazopyridine (Pyridium)

Tobramycin (Tobrex) Albuterol (Ventolin) tab Triamcinolone crm (Kenalog) Celebrex (Celecoxib)

Td (Tetanus/Diptheria Injection)

Betablocker BetaAgonist Inhaled Topical: Misc/OtherBetaxolol (Betoptic S) Albuterol (Ventolin) Ammonium lact (Lac-Hydrin)

Timolol (Timoptic) Albuterol / Ipratropium

Lindane (Kwell)

Metronidazole (Metrogel) TMP-SMX ds

Glaucoma Salmeterol Discus (Serevent) Permethrin (Elimite) Dapsone

Brimonide (Alphagan) Podophilox (Condylox)

Bimatoprost (Lumigan) Corticosteroid Inhaled Selenium (Selsun)

Brinzolamide (Azopt) Triamcinolone (Azmacort) Urea, misc (Amino-Cerv)

Dorzolamide+Timolol (Cosopt)

Latanoprost (Xalatan) Xanthine VACCINESTheophylline (Theo-Dur) Influenza Vaccine (Fluzone)

Miotic Pneumovax (Pneumococcal)

Pilocarpine (Pilocar) OtherIpratropium (Atrovent) VITAMINS & NUTRITIONAL

Steroid Montileukast (Singulair) VitaminsFluorometholone (FML) Pentamidine (Nebupent)

Prednisolone (Pred Forte)

Folic Acid (Folvite)

Misc/Other Therapeutic (multivitamins)

Artificial tears (Tearisol) Anaesthetic B-Plex with C (antioxidant)

Lodoxamide (Alomide)

Naphazoline (Vasocon) WASTINGTrifluridine (Viroptic) Cyproheptadine (Periactin)

Antibacterial RESPIRATORY, COUGH &

Clindamycin (Cleocin Vag) OTHER / MISCELLANEOUSNeo/Gramic/Poly (Neosporin) Allopurinol (Zyloprim)

AntihistamineLoratadine (Claritin)

Diphenhydramine (Benadryl) Colchicine

Antifungal Danocrine (Danazol)

Antihist/Decongestant Clotrimazole (Lotrimin) Dexamethasone (Decadron)

Nystatin / Triamcin (Mycolog) Levothyroxine (Synthroid)

Triamcinolone (Kenalog) MAGIC Mouthwash

Pseudoephedrine (Sudafed) Terbinafine (Lamisil) Meclizine (Antivert)

Nystatin (Mycostatin)

Dexameth/Neo/Poly (Dexacidin)

TOPICAL, DERMATOLOGY, RECTAL, VAGINAL

Lidocaine (Xylocaine Oint,

Jelly, Visc, Patch)

Clobetasol (Temovate)

Diflorasone (Psorcon)

Hydrocortisone Suppos (Anusol-

HC)

Ferrous sulfate/fumerate

(Feosol)

Bromphen/pseudephed / DM

(Cardec, Cardec DM, Cardec S)

Erythomycin / Benzoyl perox

(Benzagel)

Chlorhexidine 12% Solution

(Peridex Oral Rinse)

Methyprednisolone (Medrol

dosepak)

Sodium Chloride for Irrigation

(Normal Saline)

OPPORTUNISTIC INFECTIONS (OIs)


HANDOUT A

ANTIRETROVIALS OTHER CONDITIONS

Nucleosides/Nucleotide (NRTIs) Opportunistic Infections (OIs)

Atripla (Tenofovir/Emtricitabine/Efavirenz) Bactrim DC (TMP/SMZ DS)

Combivir (Zidovudine/Lamivudine) Biaxin (Clarithromycin)

Emtriva (Emtricitabine) Clotrimazole (Mycelex Troche)

Epivir (Lamivudine) Daraprim (Pyrimethamine)

Epzicom (Abacavir/Lamivudine) Diflucan (Fluconazole)

Retrovir (Zidovudine) Ketoconazole (Nizoral)

Trizivir (Abacavir/Lamivudine/Zidovudine) Leucovorin (Folinic Acid)

Truvada (Tenofovir/Emtricitabine) Mepron (Atovaquone)

Videx (Didanosine) Monistat (Miconazole)

Viread (Tenofovir) Myambutol (Ethambutol)

Zerit (Stavudine) Mycobutin (Rifabutin)

Ziagen (Abacavir) Sporanox (Itraconazole)

Sulfadiazine

Nonnucleosides (NNRTIs) Terazol (Terconazole)

Intelence (Etravirine) Valacyclovir (Valtrex)

Rescriptor (Delavirdine) Valganciclovir HCL (Valcyte)

Sustive (Efavirenz) Zithromax (Azithromycin)

Viramune (Nevirapine) Zovirax (Acyclovir)

Protease Inhibitors (PIs)

Aptivus (Tipranavir)

Crixivan (Indinavir)

Invirase (Saquinavir)

Kaletra (Lopinavir/Ritonavir)

Lexiva (Fosamprenavir)

Norvire (Ritonavir)

Prezista (Darunavir)

Reyataz (Atazanavir)

Viracept (Nelfinavir)

Entry/Fusion Inhibitor

Fuzeon (Enfuviritde)

Maraviroc (Selzentry)

Integrase Inhibitor

Isentress (Raltegravir)

RYAN WHITE PART A PHARMACY FORMULARY - Updated 03/21/12

TIER TWOIn order to access Tier Two, clients must be screened every six (6) months for the State AIDS Drugs

Assistance Program (ADAP) eligibility and must be ineligible and meet the Ryan Part A eligibility

requirements prior to the use of this formulary.


HANDOUT A

ANTIRETROVIALS Other Side Effects/Conditions

Nucleosides/Nucleotide (NRTIs) Depakote (Divalproex)

Hivid (Zalcitabine) Geodon (Ziprasidone)

Risperdal (Risperidone)

Protease Inhibitor

Agenerase (Amprenavir) Supplement

Folinic Acid (Leucovorin)

OTHER CONDITIONS

Anticonvulsant Wasting

Levetiracetam (Keppra) Marinol (Bronabinol)

Megace (Megestrol)

Antiemetics

Hydrea (Hydroxyurea)

Flu Medication

Relenza (Zanamivir)

Hyperglycemia

Diabeta (Glyburide)

Glucophage (Metformin)

Glucotrol (Glipizide)

Hyperlipidemia

Crestor (Rosuvastatin)

Lipitor (Atorvastatin)

Lopid (Gemfibrozil)

Pravachol (Pravastatin)

Tricor (Fenofibrate)

Neuropathy

Cymbalta (Duloxetine)

Elavil (Amitriptyline)

Lamictal (Lamotrigine)

Lyrica (Pregabalin)

Neurontin (Gabapentin)

Pamelor (Nortriptyline)

Opportunistic Infections (OIs)

Imiquimod (Aldara)

Mupirocin (Bactroban)

RYAN WHITE PART A PHARMACY FORMULARY - Updated 03/21/12

In order to access Tier Three clients must meet the Ryan Part A eligibility requirements and have a

Patient Assistance Program (PAP) application completed for each medication.

TIER THREE


HANDOUT A

LPAC April 9, 2012 Page 1

RYAN WHITE PART A FORMULARY CHANGES 2011-2012

1.10.11

To “Add TMP-SMX ds and Dapsone (for sulfa allergic individuals) to the Part A Formulary Tier 1 to provide for PCP prophylaxis/maintenance therapy for individuals pending ADAP enrollment.” Justification: For time sensitive OI interventions for medications that have no PAP To “remove Seroquel from the Part A Formulary Tier 1.” Justification: Simple PAP application for clients. Only 94 clients utilized last quarter, therefore possible to complete PAPs. Potential cost savings of $11,758.36 per quarter.

2.14.11 To “Remove Fluphenazine (Prolixin), Acetaminophen (Tylenol), Aspirin, Ibuprofen (Motrin), and Fentanyl (Duragesic) from Ryan White Part A Formulary Tier 1.”

Justification: Fluphenazine (Prolixin): No longer standard of care Acetaminophen (Tylenol), Asprin, Ibuprofen (Motrin): Over the counter medications, low cost for generic formulation. The dispensing fee is greater than cost of the medication. Fentanyl (Duragesic): PAP available and accessible

To “Add ‘Oral Only’ to Sumatriptan (Imitrex).” Justification: To clarify the formulary

3.24.11 - HIVPC To “Remove the expiration date of the Ryan White Part A Formulary Tier 3.” Justification: To provide temporary access to medications for clients in an emergency situation To “remove the following from Ryan White Part A Formulary Tier 3”:

Aripiprazole (Abilify) Lexapro (Escitalopram Oxalate) Prozac (Fluoxetine) Remeron (Mirtazapine) Wellbutrin (Bupropion) Zoloft (Sertraline) Compazine (Prochlorperazine) Epogen (Erythropoietin) Relenza (Zanamivir) Lomotil (Diphenoxylate) Omeprazole (Prilosec) Baraclude (Entecavir) Engerix-B (Hepatitis B) Havrix (Hepatitis A) Hepsera (Adefovir) Peg-Intron (Peginterferon Alfa) (2B) Levofloxacin (Levaquin) Twinrix (Hepatitis A/B)

Justification: PAP available and accessible To “Add Pneumovax (Pneumococcal) to Part A Tier 1 Formulary” Justification: Required for standard of care to be consistent with PHS Guidelines

4.11.11 To “Remove Vancomycin INJ (Vancocin), Streptomycin INJ, Tuberculin test (PPD, Aplisol), and Voriconazole (V-Fend) from Ryan White Part A Formulary Tier 1.” Justification: Vancomycin INJ (Vancocin): No utilization (PAP available), Streptomycin INJ: No utilization, Tuberculin test (PPD, Aplisol): No utilization; available from other sources, Voriconazole (V-Fend): No utilization (PAP available)

LPAC April 9, 2012 Page 2

6.13.11 To “Remove Heparin sod INJ (Heparin) from Ryan White Part A Formulary Tier 1.” Justification: No utilization FY 2010; alternative products exist. Lovenox is an alternative that has a PAP (at 250% FPL or below). Heparin sod INJ (Heparin) is a blood thinner in the Cardiac & Anti-Hypertensive category.

7.11.11 To “Remove Aripiprazole (Abilify) from Ryan White Part A Formulary Tier 1.” Justification: Previously removed from ADAP Formulary, PAP available To “Remove Quinine from Ryan White Part A Formulary Tier 1.” Justification: Under utilization, PAP available To “Remove Cyclopentolate (Cyclogyl) from Ryan White Part A Formulary Tier 1.”

Justification: Non-utilization 10.10.11

To “Remove Alesse 28 from Ryan White Part A Formulary Tier 1.” Justification: Therapeutic duplication; other medications from the same drug class are available. To “Remove Estrogen/Medroxyprogest (Prempro, Premphase) from Ryan White Part A Formulary Tier 1.” Justification: No utilization To “Remove Gentamycin (Garamycin crm) from Ryan White Part A Formulary Tier 1.” Justification: Neosporin covers this To “Remove Hexachlorophene (Phisohex) from Ryan White Part A Formulary Tier 1.” Justification: No utilization To “Remove Insulin Humulin 70/30 from Ryan White Part A Formulary Tier 1.” Justification: Duplicate Insulin Analog (Humalog) Simplify Formulary, Cost Saving Measure To “Remove Ortho Novum 1/35 from Ryan White Part A Formulary Tier 1.” Justification: Therapeutic duplication; other medications from the same drug class are available. To “Remove Ortho Novum 1/50 from Ryan White Part A Formulary Tier 1.” Justification: Therapeutic duplication; other medications from the same drug class are available. To “Remove Ortho Novum 7/7/7 from Ryan White Part A Formulary Tier 1.” Justification: Therapeutic duplication; other medications from the same drug class are available. To “Remove OrthoCept 28 from Ryan White Part A Formulary Tier 1.” Justification: Therapeutic duplication; other medications from the same drug class are available. To “Remove Rosiglitazone (Avandia) from Ryan White Part A Formulary Tier 1.” Justification: Adverse effects, Contraindication To “Remove Tri Phasil 28 from Ryan White Part A Formulary Tier 1.” Justification: Therapeutic duplication; other medications from the same drug class are available. To “Keep Lo Ovral 28 (Monophasic), Ortho-Tricyclen 28 (Triphasic) and Micronor 28 (Progestin only) on Ryan White Part A Formulary Tier 1.” Justification: Reduce the Oral Contraceptives Category on the Formulary

Tier 1 Ophthalmic $ Amount Dispensing Fee # ClientsAntibiotic Ciprofloxacin (Ciloxin) $119.79 $90.00 11Dexameth/Neo/Poly (Dexacidin) $0.00 $0.00 0

Erythromycin (E-Mycin) $55.42 $45.00 4Neo/Poly/Bacit (Neosporin) $117.35 $82.50 6Sulfacetamide (Sulamyd) $0.00 $0.00 0Tobramycin (Tobrex) $41.54 $37.50 5

Antibiotic Total $334.10 $255.00 26Betablocker Betaxolol (Betoptic S) $31.42 $15.00 2Timolol (Timoptic) $133.55 $112.50 8

Betablocker Total $164.97 $127.50 10Cycloplegic MydriaticCyclopentolate (Cyclogyl) (Removed 7.11.11)

$38.50 $7.50 1

Cycloplegic Mydriatic Total $38.50 $7.50 1

GlaucomaBrimonide (Alphagan) $219.42 $67.50 3Bimatoprost (Lumigan) $369.35 $90.00 9Brinzolamide (Azopt) $189.78 $82.50 2Dorzolamide+Timolol (Cosopt) $645.48 $135.00 7

Latanoprost (Xalatan) $551.85 $180.00 11Glaucoma Total $1,975.88 $555.00 32

MioticPilocarpine (Pilocar) $0.00 $0.00 0

Miotic Total $0.00 $0.00 0Steroid Fluorometholone (FML) $10.53 $7.50 1Prednisolone (Pred Forte) $114.08 $82.50 9

Steroid Total $124.61 $90.00 10Misc./OtherArtificial tears (Tearisol) $8.67 $7.50 1Lodoxamide (Alomide) $391.04 $97.50 4Naphazoline (Vasocon) $0.00 $0.00 0Trifluridine (Viroptic) $0.00 $0.00 0

Misc./Other Total $399.71 $105.00 5Ophthalmic Total $3,037.77 $1,140.00 84

Drug Utilization 3.1.11-1.31.12 HANDOUT C

LPAC April 9, 2012 1

Tier 1 Respiratory, Cough & Cold, Allergy $ Amount Dispensing Fee # ClientsAntihistamineLoratadine (Claritin) $4,153.11 $3,682.50 169Diphenhydramine (Benadryl) $229.46 $202.50 14

Antihistamine Total $4,382.57 $3,885.00 183Antihist/DecongestantBromphen/pseudephed / DM (Cardec, Cardec DM, Cardec S) $0.00 $0.00 0

Pseudoephedrine (Sudafed) $0.00 $0.00 0Antihist/Decongestant Total $0.00 $0.00 0

AntitussiveGuaifenesin (Robitussin) $140.19 $127.50 12Guaifen / DM (Robitussin DM) $0.00 $0.00 0Guaifen / Cod (Robitussin AC) $0.00 $0.00 0Guaifen /Cod / Pseudoephed (Robitussin DAC) $0.00 $0.00 0

Antitussive Total $140.19 $127.50 12BetaAgonist OralAlbuterol (Ventolin) tab $393.41 $217.50 12

BetaAgonist Oral Total $393.41 $217.50 12

Albuterol (Ventolin) $52.55 $37.50 5Albuterol / Ipratropium (Combivent, DuoNeb) $1,303.50 $7.50 1Salmeterol Discus (Serevent) $1,372.13 $236.50 11

BetaAgonist Inhaled Total $2,728.18 $281.50 17Corticosteroid InhaledTriamcinolone (Azmacort) $3,431.62 $2,481.50 156

Corticosteroid Inhaled Total $3,431.62 $2,481.50 156

XanthineTheophylline (Theo-Dur) $0.00 $0.00 0

Xanthine Total $0.00 $0.00 0OtherIpratropium (Atrovent) $322.94 $52.50 2Montileukast (Singulair) $8,246.01 $1,170.00 61Pentamidine (Nebupent) $0.00 $0.00 0

Other Total $8,568.95 $1,222.50 63Respiratory, Cough & Cold, Allergy Total $19,644.92 $8,215.50 443

BetaAgonist Inhaled



Tier 1 Otic $ Amount Dispensing Fee # Clients

Acetic Acid (Vosol) $0.00 $0.00 0Acetic Acid / HC (Vosol HC) $21.52 $7.50 1Neomycin / HC (Cortisporin) $82.95 $67.50 8Ciprofloxacin / HC (Cipro HC) $561.05 $469.00 57Carbamide Peroxide (Debrox) $0.00 $0.00 0Otic Total $665.52 $544.00 66



Tier 1 Nasal $ Amount Dispensing Fee # Clients

Budesonide (Rhinocort) $11,154.69 $1,125.00 65Beclomethasone (Beconase AQ) $826.61 $697.50 50Sodium Chloride (Ocean Nasl) "Deep Sea Nasal Spray" $8.07 $7.50 1Nasal Total $11,989.37 $1,830.00 116



Tier 1 Other/Miscellaneous $ Amount Dispensing Fee

# Clients

Allopurinol (Zyloprim) $632.51 $585.00 23Chlorhexidine 12% Solution (Peridex Oral Rinse) $617.07 $482.00 52Colchicine $26.60 $22.50 3Danocrine (Danazol) $0.00 $0.00 0Dexamethasone (Decadron) $8.11 $7.50 1Levothyroxine (Synthroid) $65.56 $52.50 4MAGIC Mouthwash $401.23 $105.00 7Meclizine (Antivert) $126.03 $67.50 8Methyprednisolone (Medrol dosepak) $138.61 $127.50 16Oxybutinin (Ditropan) $224.10 $180.00 9Prednisone (Deltasone) $761.16 $684.50 59Probenecid $0.00 $0.00 0Sodium Chloride for Irrigation (Normal Saline) $0.00 $0.00 0Phenazopyridine (Pyridium) $34.02 $30.00 4Celebrex (Celecoxib) $4,958.08 $652.50 35Td (Tetanus/Diptheria Injection) $0.00 $0.00 0 Other/Miscellaneous Total $7,993.08 $2,996.50 221



Tier 1 Cardiac and Anti-Hypertensive $ Amount Dispensing Fee # Clients

Enalapril (Vasotec) $4,618.00 $4,327.50 154Lisinopril (Zestril, Prinivil) $14,541.42 $13,626.50 458

ACE Inhibitor Total $19,159.42 $17,954.00 612

Irbesartan (Avapro) $11,367.08 $2,692.50 90Angiotensin Receptor Blocker (ARB) Total $11,367.08 $2,692.50 90

Clonidine (Catapres) $2,038.42 $1,755.50 71Terazosin (Hytrin) $1,041.93 $930.00 43

Alpha Blockers Total $3,080.35 $2,685.50 114

Carvedilol (Coreg) $1,005.40 $853.50 25AlphaBeta Blocker Total $1,005.40 $853.50 25

Atenolol (Tenormin) $3,281.69 $3,174.55 102Labetalol (Normodyne) $480.04 $225.00 8Propranolol (Inderal) $236.23 $219.50 9Metoprolol (Lopressor)

Metoprolol Succinate ER $272.59 $142.50 7Lopressor $84.84 $77.00 4

Metoprolol Tartrate $1,572.18 $1,344.50 53Beta Blockers Total $5,927.57 $5,183.05 183

Amiodarone (Cordarone) $0.00 $0.00 0Antiarrythmic Total $0.00 $0.00 0

Warfarin (Coumadin)Coumadin $636.39 $606.00 17

Warafin Sodium $117.27 $105.00 6Anticoagulant Total $753.66 $711.00 23

Aspirin Clopidogrel (Plavix) $7,849.22 $911.50 30Antiplatelet Total $7,849.22 $911.50 30

Amlodipine (Norvasc)Norvasc $7,352.89 $7,050.00 254

Amlodipine Besylate $2,000.68 $1,897.50 88Diltiazem (Cardizem) $2,432.64 $1,104.50 41Verapamil (Isoptin, Calan) $100.34 $75.00 4Nifedipine (Procardia,Adalat)

Procardia $321.86 $165.00 8Nifedipine $917.67 $356.50 22

Calcium Channel Blocker Total $13,126.08 $10,648.50 417

Digoxin (Lanoxin)

Angiotensin Receptor Blocker (ARB)

Alpha Blockers

AlphaBeta Blocker

Beta Blockers

Antiarrythmic

Anticoagulant

ACE Inhibitor

Antiplatelet

Calcium Channel Blocker

Cardiac Glycoside



Cardiac and Anti-Hypertensive $ Amount Dispensing Fee # Clients

Digoxin $130.71 $112.50 3Lanoxin $139.37 $82.50 2

Cardiac Glycoside Total $270.08 $195.00 5

Bumetanide (Bumex) $53.32 $41.50 1Furosemide (Lasix) $529.49 $504.50 23HCTZ (HydroDiuril) $9,239.33 $8,895.00 329HCTZ/Triamterene (Dyazide) $820.50 $767.00 37Spironolactone (Aldactone) $322.88 $270.00 11

Diuretic Total $10,965.52 $10,478.00 401

Nitroglycerin (Nitrostat,Nitro-Dur)Nitroglycerin $7.76 $7.50 1

Nitrostat $37.65 $30.00 3Isosorbide Mononitrate (Imdur) $154.19 $97.50 2

Nitrates Total $199.60 $135.00 6Cardiac and Anti-Hypertensive Total $73,703.98 $52,447.55 1,906

Nitrates

Diuretic



Tier 1 Diabetes $ Amount Dispensing Fee # Clients

Insulin Analog (Humalog) $409.28 $180.00 13Insulin 70/30 (Novolin) (Removed 10.10.11)

$3,584.22 $1,795.00 64

Humulin 70/30 (Removed 10.10.11)

$337.48 $30.00 4

Insulin NPH (Novolin) $347.36 $165.00 7Insulin Regular (Novolin) $251.78 $150.00 13Insulin Glaritine (Lantus) $5,234.90 $1,207.50 52Rosiglitazone (Avandia) (Removed 10.10.11)

$431.46 $37.50 2

Actos (Pioglitazone) $734.05 $592.50 19Diabetes Total $11,330.53 $4,157.50 174

Insulin Syringe U100 0.5 ml $3,073.86 $1,335.00 61Truetrack Test Strips $878.66 $295.00 12Blood Gkucose Trutrack $11,127.45 $2,692.50 119

Total $15,079.97 $4,322.50 192Diabetes Total $26,410.50 $8,480.00 366

Not on the Formulary



Tier 1 CNS, Anxiety, Psych, Neuro, & Autonomic

$ Amount Dispensing Fee # Clients

Diazepam (Valium) $315.78 $292.50 18Hydroxyzine (Vistaril, Atarx)

Vistaril $50.82 $39.50 3HydrOXYzine Hydrochloride $1,270.97 $881.50 56

HydrOXYzine Pamoate $1,329.64 $975.00 48Lorazepam (Ativan) $951.91 $892.50 34Temazepam (Restoril)

Temazepam $1,026.73 $840.00 29Restoril $2,508.64 $2,415.00 118

Antianxiety/Hypnotic Total $7,454.49 $6,336.00 306

Buspirone (Buspar) $449.89 $352.50 16Citalopram (Celexa)

Citalopram $5,338.51 $4,425.50 191Celexa $7.51 $7.50 1

Doxepin (Sinequan) $870.85 $636.00 27Paroxetine (Paxil) $1,527.90 $1,207.50 51Sertraline (Zoloft) $0.00 $0.00 0Trazodone (Desyrel) $5,172.99 $4,465.00 188Lithium carb (Lithonate) $241.34 $187.50 8

Antidepressant Total $13,608.99 $11,281.50 482

Chlorpromazine (Thorazine) $370.02 $276.00 16Haloperidol (Haldol) $701.29 $300.00 10Fluphenazine (Prolixin) $0.00 $0.00 0Perphenazine (Trilafon) $991.47 $293.00 16Risperdone (Risperdal) $0.00 $0.00 0

Antipsychotic Total $2,062.78 $869.00 42

Benztropine (Cogentin) $312.88 $262.50 12Miscellaneous Total $312.88 $262.50 12

Acetazolamide (Diamox) $15.88 $7.50 1Carbamazepine (Tegretol) $148.79 $129.50 5Clonazepam (Klonopin) $399.83 $367.50 19Ethosuximide (Zarontin) $0.00 $0.00 0Felbamate (Felbatol)* $0.00 $0.00 0Mephobarbital(Mebaral) $0.00 $0.00 0Methsuiximide (Celontin) $0.00 $0.00 0Phenobarbital $0.00 $0.00 0Phenytoin (Dilantin)

Antianxiety/Hypnotic

Antidepressant

Antipsychotic

Miscellaneous

Anticonvulsant



CNS, Anxiety, Psych, Neuro, & Autonomic $ Amount Dispensing Fee # Clients

Phenytoin Sodium, Extended Release $27.05 $7.50 1Phenytoin, Extended Release $915.02 $349.00 15

Primidone (Mysoline) $0.00 $0.00 0Topiramate (Topamax)

Topiramate $59.20 $52.50 5Topamax $182.32 $15.00 1

Levetiracetam (Keppra) (Moved to Tier 3 4.11.11) $10.08 $7.50 1Anticonvulsant Total $1,758.17 $936.00 48

Acetaminophen (Tylenol) (Removed 2.14.11) $63.08 $60.00 7Aspirin (Removed 2.14.11) $1,260.93 $1,230.00 113

Aspir-Low $343.81 $337.50 36Aspirin EC Lo-Dose $7.75 $7.50 1

Aspirin Enteric Coated $184.28 $180.00 15Ibuprofen(Motrin) (Removed 2.14.11) $1,136.97 $990.00 87Naproxen (Naprosyn)

Naproxen $1,450.95 $892.50 63Naproxen Enteric Coated $28.29 $22.50 3

Naprosyn $50.37 $45.00 5Butalbi/Acetam/Caff (Fioricet) - See BelowTramadol (Ultram) $1,314.91 $1,119.50 62

Analgesic Total $5,841.34 $4,884.50 392

Codeine/Acetam (Tylenol#3) $671.46 $525.00 57Hydrocodone / Acet (Vicodin,VicodinES) $1,283.26 $1,125.00 92Methadone (Methadone) $42.38 $30.00 1Morphine (MSContin, MSIR) $0.00 $0.00 0Oxycodone/ASA (Percodan) $713.17 $127.50 3Oxycodone/Acet (Percocet) $836.60 $555.00 40Propox/Acet (Darvocet N-100) $0.00 $0.00 0

Narcotic Analgesic Total $3,546.87 $2,362.50 193

Baclofen (Lioresal) $85.55 $82.50 3Carisoprodol (Soma) $109.64 $82.50 5Cyclobenzaprine (Flexeril) $1,036.24 $947.00 74

Muscle Relaxant Total $1,231.43 $1,112.00 82

Carbidopa/levodop (Sinemet) $64.74 $45.00 1Antiparkinson Total $64.74 $45.00 1

Sumatriptan (Imitrex) (Oral Only)Sumatriptan Succinate $562.45 $405.00 23

Imitrex $256.18 $15.00 1

Muscle Relaxant

Antiparkinson

Antimigraine

Analgesic

Narcotic Analgesic



CNS, Anxiety, Psych, Neuro, & Autonomic $ Amount Dispensing Fee # ClientsButalbi/Acetam/Caff (Fioricet) $454.61 $360.00 25

Antimigraine Total $1,273.24 $780.00 49CNS, Anxiety, Psych, Neuro, & Autonomic Total

$37,090.19 $28,824.00 1,606



Tier 1 Anti-Infectives $ Amount Dispensing Fee # Clients

Amoxicillin (Amoxil) $690.87 $579.50 72Amoxicill/Clav (Augmentin) $741.86 $472.50 57Cefdinir (Omnicef) $21.77 $15.00 2Ceftriaxone INJ (Rocephin) $8.21 $7.50 1Cefuroxime (Ceftin) $39.66 $22.50 3Cephalexin (Keflex) $348.87 $285.00 32Ciprofloxacin (Cipro)

Cipro HC $98.28 $22.50 3Ciprofloxacin Hydrochloride $561.05 $469.00 57

Clindamycin (Cleocin)Clindamycin Hydrochloride $192.62 $157.50 21

Cleocin HCl $17.57 $15.00 2Doxycycline (Vibramycin)

Doxycycline Hyclate $726.13 $677.00 63Doxycycline Monohydrate $10.04 $7.50 1

Dicloxacillin (Dynapen) $9.97 $7.50 1Erythromycin base (Ery-tab) $7.50 $7.50 1Nitrofurantoin (Macrodantin)

Macrodantin $68.68 $22.50 3Nitrofurantoin Macrocrystals $53.88 $30.00 4

Nitrofurantoin Monohydrate/Macrocrystals $34.95 $7.50 1Penicillin Benzath (Bicillin LA) $141.71 $90.00 8Penicililn VK (PenVK) $155.19 $114.50 14Primaquine (Primaquine) $0.00 $0.00 0Tetracycline (Achromycin) $114.27 $105.00 7Trimethoprim (Proloprim) $0.00 $0.00 0

Antibacterial Total $4,043.08 $3,115.00 353

Amphoteracin B (Fungizone) $0.00 $0.00 0Terbinafine (Lamisil) $954.66 $692.00 48

Antifungal Total $954.66 $692.00 48

Cycloserine (Seromycin) $0.00 $0.00 0Furazolidone (Furoxone) $0.00 $0.00 0Isoniazid (INH) $194.09 $165.00 8Rifampin/Isoniazid (Rifamate) $0.00 $0.00 0Rifampin (Rifadin) $56.81 $15.00 2Pyrazinamide (PZA) $0.00 $0.00 0

Antitubercular Total $250.90 $180.00 10

Metronidazole (Flagyl) Metronidazole $568.33 $450.00 46

Antifungal

Antitubercular

Antibacterial

Other



Anti-Infectives $ Amount Dispensing Fee # ClientsFlagyl $38.40 $15.00 2Paromomycin (Humatin) $0.00 $0.00 0

Other Total $606.73 $465.00 48Anti-Infectives Total $5,855.37 $4,452.00 459



Tier 1 Gastrointest $ Amount Dispensing Fee

# Clients

Al, Mg, Simeth (Mylanta DS) $285.94 $247.50 15Antacid Total $285.94 $247.50 15

Loperamide (Imodium) $992.06 $746.50 47Paregoric $0.00 $0.00 0

Antidiarrheal Total $992.06 $746.50 47

Promethazine (Phenergan) $0.00 $0.00 0Promethazine Suppos $0.00 $0.00 0

Antiemetic Total $0.00 $0.00 0

Simethicone (Mylicon) $0.00 $0.00 0Antiflatulant Total $0.00 $0.00 0

Dicyclomine (Bentyl) $85.28 $60.00 3Antispasmotic Total $85.28 $60.00 3

Pancrealipase (Ultrace MT) $192.04 $15.00 1Digestive Enzyme Total $192.04 $15.00 1

Ranitidine (Zantac) $3,219.89 $2,827.50 121H2Antagonist Total $3,219.89 $2,827.50 121

Docusate sodium (Colace) $414.47 $330.00 20Docusate/Casanth (Peri-Colace)

Doc-Q-Lace $2.21 $2.00 1DOC-Q-LACE 100 MG CAPSULE $143.05 $135.00 10

Fiberlax (Fibercon) $0.00 $0.00 0Lactulose (Enulose) $185.52 $127.50 11

Laxative Total $745.25 $594.50 42

Lansoprazole (Prevacid)Lansoprazole $13,253.37 $4,177.50 156

Prevacid $7,706.41 $2,370.00 167Prevacid SoluTab $487.10 $37.50 3

PPI Total $21,446.88 $6,585.00 326

GoLytely (Colyte) $16.70 $7.50 1Metoclopramide (Reglan) $131.11 $120.00 6Sucralfate (Carafate) $61.15 $37.50 2

Misc/Other Total $208.96 $165.00 9Gastrointest Total $27,176.30 $11,241.00 564

Antacid

PPI

Misc/Other

Antidiarrheal

Antiemetic

Antiflatulant

Antispasmotic

Digestive Enzyme

Laxative

H2Antagonist



Tier 1 Vaccine $ Amount Dispensing Fee # Clients

Influenza Vaccine (Fluzone) $0.00 $0.00 0Pneumovax (Pneumococcal)

Pneumovax 23 $63.62 $7.50 1Pneumovax 23 (obsolete) $27.69 $7.50 1

Vaccine Total $91.31 $15.00 2



Tier 1 Vitamins $ Amount Dispensing Fee # ClientsFerrous sulfate/fumerate (Feosol) $1,947.03 $1,819.00 110Folic Acid (Folvite) $774.16 $682.50 74Therapeutic (multivitamins)

Multivitamin $669.26 $608.00 98Therapeutic Vitamins $32.98 $30.00 1

B-Plex with C (antioxidant) $363.64 $325.50 50Antioxidant Formula $10,864.01 $9,127.50 339

Antioxidant Ultra Formula $11.17 $7.50 1Vitamins Total $14,662.25 $12,600.00 673



Tier 1 Wasting $ Amount Dispensing Fee # ClientsCyproheptadine (Periactin) $1,683.27 $1,127.00 66 Wasting Total $1,683.27 $1,127.00 66



Tier 1 Topical, Dermatology, Rectal, Vaginal $ Amount Dispensing Fee

# Clients

Lidocaine (Xylocaine Oint, Jelly, Visc, Patch) $71.09 $37.50 4Anaesthetic Total $71.09 $37.50 4

Clindamycin (Cleocin Vag)Cleocin T $7.79 $7.50 1

Clindamycin, Vaginal $39.02 $22.50 3Neo/Gramic/Poly (Neosporin) $0.00 $0.00 0Erythomycin / Benzoyl perox (Benzagel) $118.76 $67.50 3

Benzoyl Peroxide Wash $59.48 $37.50 4Benzoyl Peroxide-Erythromycin $43.59 $22.50 2

Erythromycin, Topical $16.54 $15.00 2Antibacterial Total $285.18 $172.50 15

Clotrimazole (Lotrimin) $70.95 $30.00 4Nystatin (Mycostatin)

Nystatin $111.60 75 $9.00Nystatin Topical $199.66 150 $12.00

Nystatin-Triamcinolone $965.92 822 $65.00Triamcinolone (Kenalog) $3,431.62 2,482 $156.00Terbinafine (Lamisil)

Terbinafine Hydrochloride, Topical $16.06 $7.50 1Lamisil AT Jock Itch $38.48 $15.00 2

Antifungal Total $4,834.29 $3,580.50 249

Clobetasol (Temovate) Clobetasol Propionate $327.59 $225.00 20

Clobetasol Propionate Emollient $214.43 $127.50 7Temovate $9.46 $7.50 1

Diflorasone (Psorcon) $101.64 $15.00 1Betamethasone (Diprosone)

Betamethasone Dipropionate, Augmented $46.30 $22.50 3Betamethasone Valerate $20.16 $15.00 2

Betamethasone Dipropionate $10.12 $7.50 1Fluocinolone (Dermasmoothe)

Derma-Smoothe/FS $1,536.03 $292.50 11Fluocinolone Acetonide $15.31 $7.50 1

Hydrocortisone crm (Hytone) $107.25 $37.50 5Hydrocortisone Suppos (Anusol-HC)

Hydrocortisone, Rectal $155.40 $105.00 7Hydrocortisone, Topical $3,431.48 $287.00 $22.00

Hydrocortisone/Neomycin/Polymyxin B $158.76 $22.50 2Triamcinolone crm (Kenalog) $3,431.62 $2,481.50 156

Cortosteroid Total $9,565.55 $3,653.50 239

Ammonium lact (Lac-Hydrin)Ammonium Lactate $261.52 $180.00 15

Anaesthetic

Corticosteroid

Antifungal

Antibacterial

Topical: Misc/Other



Topical, Dermatology, Rectal, Vaginal $ Amount Dispensing Fee

# Clients

Lac-Hydrin $323.40 $127.50 11Hexachlorophene (Phisohex) $0.00 $0.00 0Lindane (Kwell) $0.00 $0.00 0Metronidazole (Metrogel) $394.87 $257.00 27

Metronidazole $568.33 $450.00 46Metronidazole Topical $142.71 $60.00 4Metronidazole Vaginal $1,111.10 $22.50 3

Permethrin (Elimite) $210.76 $131.50 13Podophilox (Condylox) $0.00 $0.00 0Selenium (Selsun) $61.68 $45.00 4Urea, misc (Amino-Cerv) $0.00 $0.00 0

Topical: Misc/Other Total 3,074.37 1,273.50 123Topical, Dermatology, Rectal, Vaginal Total $17,830.48 $8,717.50 630



Tier 1 Opportunistic Infections $ Amount Dispensing Fee

# Clients

TMP-SMX ds $0.00 $0.00 0Dapsone $0.00 $0.00 0 Opportunistic Infections Total $0.00 $0.00 0



Tier 1 GYN/OB $ Amount Dispensing Fee # Clients

Estrogen Conj (Premarin) $1,368.34 $345.00 10Estrogen/ Medroxyprogest (Prempro, Premphase) $0.00 $0.00 0Medroxyprogesterone (Provera, Depo-Provera)

Depo-Provera Contraceptive $149.89 $97.50 10Provera $15.98 $15.00 1

Ethinyl estrad/Norgest/placeb (Ortho-Tricyclen 28) $115.42 $75.00 3Ethinyl estradiol/ Norgestrel (Lo-Ovral 28) $15.18 $7.50 1Norethindrone (Micronor 28) $0.00 $0.00 0GYN/OB Total $1,664.81 $540.00 25



Tier 1 Blood/Blood Forming $ Amount Dispensing Fee # Clients

Ferrous sulfate (Feosol) $1,947.03 $1,819.00 110 Blood/Blood Forming Total $1,947.03 $1,819.00 110



Tier 2 ARV's $ Amount Dispensing Fee # Clients

Atripla (Tenofovir/Emtricitabine/Efavirenz) $0.00 $0.00 0

Combivir (Zidovudine/Lamivudine) $0.00 $0.00 0Emtriva (Emtricitabine) $0.00 $0.00 0Epivir (Lamivudine) $0.00 $0.00 0Epzicom (Abacavir/Lamivudine) $0.00 $0.00 0Retrovir (Zidovudine) $0.00 $0.00 0Trizivir (Abacavir/Lamivudine/Zidovudine) $0.00 $0.00 0

Truvada (Tenofovir/Emtricitabine) $0.00 $0.00 0Videx (Didanosine) $0.00 $0.00 0Viread (Tenofovir) $0.00 $0.00 0Zerit (Stavudine) $0.00 $0.00 0Ziagen (Abacavir) $0.00 $0.00 0

NUCLEOS(T)IDES (NRTIs) Total $0.00 $0.00 0

Intelence (Etravirine) $0.00 $0.00 0Rescriptor (Delavirdine) $0.00 $0.00 0Sustive (Efavirenz) $0.00 $0.00 0Viramune (Nevirapine) $0.00 $0.00 0

NONNUCLEOSIDES (NNRTIs) Total $0.00 $0.00 0

Aptivus (Tipranavir) $0.00 $0.00 0Crixivan (Indinavir) $0.00 $0.00 0Invirase (Saquinavir) $0.00 $0.00 0Kaletra (Lopinavir/Ritonavir) $0.00 $0.00 0Lexiva (Fosamprenavir) $0.00 $0.00 0Norvire (Ritonavir) $0.00 $0.00 0Prezista (Darunavir) $0.00 $0.00 0Reyataz (Atazanavir) $0.00 $0.00 0Viracept (Nelfinavir) $0.00 $0.00 0

PROTEASE INHIBITORS (PIs) Total $0.00 $0.00 0

Fuzeon (Enfuviritde) $0.00 $0.00 0Maraviroc (Selzentry) $0.00 $0.00 0

ENTRY/FUSION INHIBITOR Total $0.00 $0.00 0

Isentress (Raltegravir) $0.00 $0.00 0INTEGRASE INHIBITOR Total $0.00 $0.00 0

ARV's Total $0.00 $0.00 0

NONNUCLEOSIDES (NNRTIs)

PROTEASE INHIBITORS (PIs)

NUCLEOS(T)IDES (NRTIs)

ENTRY/FUSION INHIBITOR

INTEGRASE INHIBITOR



Tier 2 Other Conditions $ Amount Dispensing Fee

# Clients


Bactrim DC (TMP/SMZ DS) $0.00 $0.00 0Biaxin (Clarithromycin) $0.00 $0.00 0Clotrimazole (Mycelex Troche) $0.00 $0.00 0Daraprim (Pyrimethamine) $0.00 $0.00 0DDS (Dapsone) $0.00 $0.00 0Diflucan (Fluconazole)

Diflucan $8.35 $7.50 1Fluconazole $62.24 $60.00 7

Ketoconazole (Nizoral) $0.00 $0.00 0Leucovorin (Folinic Acid) $0.00 $0.00 0Mepron (Atovaquone) $0.00 $0.00 0Monistat (Miconazole) $0.00 $0.00 0Myambutol (Ethambutol) $0.00 $0.00 0Mycobutin (Rifabutin) $0.00 $0.00 0Sporanox (Itraconazole) $0.00 $0.00 0Sulfadiazine $0.00 $0.00 0Terazol (Terconazole) $0.00 $0.00 0Valacyclovir (Valtrex) $0.00 $0.00 0Valganciclovir HCL (Valcyte) $0.00 $0.00 0Zithromax (Azithromycin) $0.00 $0.00 0Zovirax (Acyclovir) $0.00 $0.00 0Other Conditions Total $70.59 $67.50 8



Tier 3 $ Amount Dispensing Fee # Clients

ARV's

Hivid (Zalcitabine) $0.00 $0.00 0NUCLEOS(T)IDES (NRTIs) Total $0.00 $0.00 0

Agenerase (Amprenavir) $0.00 $0.00 0PROTEASE INHIBITOR Total $0.00 $0.00 0

OTHER CONDITIONS

Levetiracetam (Keppra) $10.08 $7.50 1ANTICONVULSANT Total $10.08 $7.50 1

Hydrea (Hydroxyurea) $0.00 $0.00 0ANTIEMETICS Total $0.00 $0.00 0

Relenza (Zanamivir) $0.00 $0.00 0FLU MEDICATION Total $0.00 $0.00 0

Diabeta (Glyburide) $0.00 $0.00 0Glucophage (Metformin) $0.00 $0.00 0Glucotrol (Glipizide) $0.00 $0.00 0

HYPERGLYCEMIA Total $0.00 $0.00 0

Crestor (Rosuvastatin) $0.00 $0.00 0Lipitor (Atorvastatin) $0.00 $0.00 0Lopid (Gemfibrozil) $0.00 $0.00 0Pravachol (Pravastatin) $0.00 $0.00 0Tricor (Fenofibrate) $0.00 $0.00 0

HYPERLIPIDEMIA Total $0.00 $0.00 0

Cymbalta (Duloxetine) $0.00 $0.00 0Elavil (Amitriptyline) $0.00 $0.00 0Lamictal (Lamotrigine) $0.00 $0.00 0Lyrica (Pregabalin) $0.00 $0.00 0Neurontin (Gabapentin) $0.00 $0.00 0Pamelor (Nortriptyline) $0.00 $0.00 0

NEUROPATHY Total $0.00 $0.00 0

Imiquimod (Aldara) $0.00 $0.00 0Mupirocin (Bactroban) $0.00 $0.00 0

OPPORTUNISTIC INFECTIONS (OIs) Total$0.00 $0.00 0

HYPERLIPIDEMIA

NEUROPATHY


OTHER SIDE EFFECTS/CONDITIONS

ANTICONVULSANT

PROTEASE INHIBITOR

NUCLEOS(T)IDES (NRTIs)

ANTIEMETICS

FLU MEDICATION

HYPERGLYCEMIA



Tier 3 $ Amount Dispensing Fee # Clients

Depakote (Divalproex) $0.00 $0.00 0Geodon (Ziprasidone) $0.00 $0.00 0Risperdal (Risperidone) $0.00 $0.00 0

OTHER SIDE EFFECTS/CONDITIONS Total$0.00 $0.00 0

Folinic Acid (Leucovorin) $0.00 $0.00 0Supplement Total $0.00 $0.00 0

Marinol (Bronabinol) $0.00 $0.00 0Megace (Megestrol) $0.00 $0.00 0

WASTING Total $0.00 $0.00 0Tier 3 Total $10.08 $7.50 1

Supplement

WASTING



LPAC, 4.9.12 Page 1

Recommended Additions to the Ryan White Part A Formulary

Add Megace (Dr. Eckardt) Justification: Periactin fails to work sometimes

Megace is currently on Tier 3 of the Ryan White Formulary PAP available - Strativa Pharmaceuticals

Add Statins and Diabetes Medications (Dr. Eckardt)

Diabetes medications on current Ryan White Formulary: Insulin Analog (Humalog) Insulin NPH (Novolin) Insulin Regular (Novolin) Insulin Glaritine(Lantus) Actose (Pioglitazone) Insulin 70/30 (Novolin) – Removed October 2011

o Justification: Duplicate Insulin Analog (Humalog) Simplify Formulary, Cost Saving Measure

Rosiglitazone (Avandia) - Removed October 2011 o Justification: Adverse effects, Contraindication

Statins currently on Tier 3 of the Ryan White Formulary: Crestor (Rosuvastatin); Astrazeneca Pharmaceuticals and Xubex Pharmaceutical Lipitor (Atorvastatin); Pfizer Lopid (Gemfibrozil); RX Outreach and Xubex Pharmaceutical Pravachol (Pravastatin); RX Outreach and Xubex Pharmaceutical Tricor (Fenofibrate); Abbott

Consider the barriers to obtaining Ensure through Abbott PAP (Dr. Heglar)

Abbott recently tightened its income criteria for the Ensure PAP to 100% FPL There is a cap on medical nutritionals – no new applications accepted at this time "due to increased demands for

assistance" but providers are instructed to call to see if there is availability Some Medicaid/Medicare plans do not cover Ensure

Megace Strativa Pharmaceuticals Patient must not have any prescription coverage for through any Private, State or Federal Program - including Medicaid, Medicare & Medicare Part D; Medicare Part D patients must submit documentation of the medication not being covered. Patients with private insurance must attach a pharmacy printout or documentation of the medication not being covered. 200% FPL; Shipped to provider; Megace ES Oral Suspension: 30-day supply

Crestor Astrazeneca Pharmaceuticals AZ & Me Prescription Savings Program For People Without Insurance

Patients must meet qualifying income eligibility criteria; Patients must not receive prescription drug coverage through private insurance or government program or such as Medicare (Part A or B), Medicare Prescription Drug Program (Part D), Medicaid, VA or military benefits, State Assistance Program for medicines. Patient must be a US resident, green card holder or work visa holder; Patients who appear to be eligible for the PAP and also appear to be eligible for federal or state programs, the AstraZeneca PAP will provide one-on-one education and counseling to assist that patient through the application process for those programs; Income limit; Single - $35,000, Couple-$48,000; Shipped to provider or patient; 90 day supply

Astrazeneca Pharmaceuticals AZ & Me Prescription Savings Program For People With Medicare Part D

Patient must meet qualifying income criteria; Patient must be enrolled in Medicare Part D; Patient must have spent 3% of the annual household income on out-of-pocket prescription medicines within calendar year; Income limit; Single - $35,000, Couple-$48,000; Shipped to provider or patient; 90 day supply

HANDOUT D

LPAC, 4.9.12 Page 2

Xubex Pharmaceutical Free Medication Program

This program is not based on need. Anyone can receive a free 30-day supply of medication with prescription; Shipped to patient; 90 day supply

Lipitor PFIZER, INC. Connection to Care

Patients must not have any prescription drug coverage; Patients must meet program income guidelines; Hardship Exceptions: Individuals who have prescription coverage for prescription medicines may still be eligible for assistance through Connection to Care if they are experiencing significant financial or medical hardship; 200% FPL; Shipped to provider; 90 day supply

PFIZER, INC. Lipitor $4 Co-Pay Card

This Card is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare or other federal or state healthcare programs, private insurance plans or other health or pharmacy benefit programs which reimburse you for the entire cost of your prescription drugs; Patient's out-of-pocket expense must be greater than $4 per prescription. If your out-of-pocket expenses for a 1-month supply (30 tablets) are $54 or less, you will pay $4 for a 1-month supply. If your out-of-pocket expenses for a 1-month supply (30 tablets) exceed $54, you qualify for up to $50 in savings for a 1-month supply. In either case, you can only qualify for up to $600 of savings per calendar year. After maximum of $600, you will pay usual monthly out-of-pocket costs; Patient takes the Co-Pay card to a participating pharmacy to receive discount

PFIZER, INC. Pfizer Pfriends

Pfizer Pfriends is a program that helps eligible patients without prescription coverage get savings on Pfizer medicines, regardless of their age, or income, through participating pharmacies. Enrolling in the program is free. You may be eligible if you have no prescription coverage, and reside in the US, Puerto Rico or the US Virgin Islands; The Pfizer Pfriends savings program is not health insurance. For a complete list of participating pharmacies please go to www.PfizerHelpfulAnswers.com or call the toll-free number 866-706-2400. There are no membership fees to participate in the Pfizer Pfriends program. Estimated savings range up to 15-36% and depend on such factors as the particular drug purchased, amount purchased, and the pharmacy where purchased; Pharmacy Card

Lopid RX Outreach An individual of any age can participate in the program, as long as the program's financial guidelines are met; 300% FPL; Shipped to provider or patient; 90 day supply

XUBEX PHARMACEUTICAL Xubex Pharmaceutical Services

This program is for generic medications only; Shipped to provider or patient; Amount shipped is based on amount requested on application

Pravachol Rx Outreach An individual of any age can participate in the program, as long as the program's financial guidelines are met; 300% FPL; Shipped to either Provider or Patient-medications sent to wherever the patient requests it; 90 day supply

XUBEX PHARMACEUTICAL Xubex Pharmaceutical Services

This program is for generic medications only; Shipped to provider or patient; Amount shipped is based on amount requested on application

Tricor ABBOTT Abbott Patient Assistance Foundation

The Abbott Patient Assistance Program is designed to help financially disadvantaged individuals receive a limited supply of Abbott pharmaceutical products at no cost; To be eligible for this program, patients must not have prescription drug coverage for the requested medication through an employer, other third party payer, Medicaid or any other state or federally-funded program, and must be financially disadvantaged based upon current Federal Poverty Guidelines adjusted for household size; Patients with prescription drug coverage, including enrollment in a Medicare Part D Prescription Drug Plan, who have difficulty accessing their Abbott medications may be eligible for assistance by obtaining a Pharmaceutical Assistance Program exception based on health-related expenditures and household income; Shipped to provider; 90 day supply

HANDOUT D

NQC In+Care Retention Rates Third Period

In+Care Campaign Retention Measures

Gap Measure Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS who did not have a medical visit with a provider with prescribing privileges in the last 6 months of the measurement year. Medical Visit Frequency Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS who had at least one medical visit with a provider with prescribing privileges in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. Patients Newly Enrolled in Medical Care Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS who were newly enrolled with a medical provider with prescribing privileges who had a medical visit in each of the 4-month periods in the measurement year. Viral Load Suppression Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with a viral load less than 200 copies/mL at last viral load test during the measurement year.

Data Submission Dates

Submission Due Date Measurement Year* 24 Month Measurement Period**

12/01/2011 10/01/2010 - 09/30/2011 10/01/2009 - 09/30/2011

02/01/2012 12/01/2010 - 11/30/2011 12/01/2009 - 11/30/2011

04/02/2012 02/01/2011 - 01/31/2012 02/01/2010 - 01/31/2012

06/01/2012 04/01/2011 - 03/31/2012 04/01/2010 - 03/31/2012 08/01/2012 06/01/2011 - 05/31/2012 06/01/2010 - 05/31/2012

10/01/2012 08/01/2011 - 07/31/2012 08/01/2010 - 07/31/2012

12/03/2012 10/01/2011 - 09/30/2012 10/01/2010 - 09/30/2012

*applies to the following measures: Gap Measure, Patients Newly Enrolled in Medical Care, and Viral Load Suppression ** applies to the Medical Visit Frequency measure

HANDOUT E

NQC In+Care Retention Rates Third Period

Broward County Rates

HANDOUT E

Agenda · 2020-03-31 · 7. ADAP Update 8. Review Part A Drug Utilization Data A. Ryan White Part A...

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