ILLINOIS DEPARTMENT OF PUBLIC HEALTH
AIDS Drug Assistance Program (ADAP)
FORMULARY as of 11/10/2014
158 DRUGS
CATEGORY I
Reverse Transcriptase Inhibitors (RTIs)
abacavir sulfate (Ziagen)
didanosine (DDI, Dideoxyinosine, Videx, Videx EC)
emtricitabine (Emtriva, FTC)
lamivudine (3TC, Epivir)
stavudine (D4T, Zerit)
tenofovir DF (Viread)
zidovudine (AZT, Azidothymidine, Retrovir)
Combination Drugs
***atripla (Efavirenz/Emtricitabine/Tenofovir)
**combivir (Epivir and Retrovir Combination)
CATEGORY III
Non-Nucleoside (RTIs)
delavirdine (Rescriptor)
efavirenz (Sustiva)
etravirine (Intelence)
nevirapine (Viramune)
rilpivirine (Edurant)
Entry Inhibitor
maraviroc (Selzentry) - Requires Trofile assay
Intergrase Inhibitor
dolutegravir (Tivicay)
raltegravir (Isentress)
vitekta (Elvitegravir)
Boosting Agents
***complera(Emtricitabine/Nilpivirine/Tenofovir)
Antibiotics
amoxicillin (Amoxil, Trimox, Wymox)
*azithromycin dihydrate (Zithromax)
cefixime (Suprax) suspension
Ceftriaxone 250 mg (Rocephin)
cephalexin monohydrate (Keflex)
chlorhexidine gluconate (Peridex, PerioGard)
*clarithromycin (Biaxin)
dicloxacillin sodium (Dycill, Dynapen, Pathocil)
doxycycline hyclate (Doryx, Vibramycin, Vibra-Tabs)
*levofloxacin (Levaquin)
metronidazole
penicillin G benzathine
**epzicom (Epivir and Ziagen Combination)
cobicistat (Tybust)
penicillin LA
****stribild(Elvitegravir/Cobicistat/Emtricitabine
Tenofovir Disoproxil Fumarate)
***triumeq (Dolutegravir/Lamivudine/Abacavir)
ritonavir (Norvir) – reference prescribing gudelines
penicillin VK
***trizivir (Epivir, Retrovir and Ziagen Combination
**truvada (Emtriva and Viread combination)
CATEGORY II
Treatment and Prophylaxis of PCP
amphotericin B (Fungizone) I.V. only
clotrimazole (Mycelex, Lotrimin)
fluconazole (Diflucan)
itraconazole (Sporanox)
miconazole (Monistat)
nystatin (Mycostatin)
Protease Inhibitors (PIs)
amprenavir (Agenerase), solution only
atazanavir (Reyataz)
darunavir (Prezista)
fosamprenavir calcium (Lexiva)
indinavir (Crixivan)
lopinavir/ritonavir (Kaletra)
nelfinavir mesylate (Viracept)
ritonavir (Norvir) – reference prescribing gudelines
saquinavir mesylate (Invirase)
tipranovir (Aptivus)
Anti-Fungals
atovaquone (Mepron) – Pre-Approval (required)
clindamycin HCl (Cleocin Hcl)
dapsone
pentamidine isethionate (NebuPent, Pentam 300)
primaquine phosphate
sulfamethoxazole/trimethoprim (SMZ/TMP, Bactrim)
trimethoprim (TMP, Proloprim, Trimpex)
Hepatitis B Treatments
adefovir Dipivoxil (Hepsera)
entecavir (Baraclude)
Anti-Virals
acyclovir (acycloguanosine, Zovirax)
cidofovir plus probenecid (Vistide) intravenous
famciclovir (Famvir)
valacyclovir hydrochloride (Valtrex)
Cryptosporidiosis
paromomycin sulfate (Humatin)
Mycobacterial Infections
*azithromycin dihydrate (Zithromax)
ciprofloxacin (Cipro)
*clarithromycin (Biaxin)
ethambutol (Myambutol)
isoniazid (Isonicotinic Acid Hydrazide, INH)
isoniazid/pyrazinamide/rifampin (Rifater)
*levofloxacin (Levaquin)
pyrazinamide
pyridoxine hydrochloride (B6)
rifabutin (Mycobutin)
rifampin (Rifadin, Rimactane)
Anti-Diarrhea or Wasting Syndrome
diphenoxylate/atropine (Lomotil)
loperamide (Imodium)
Toxoplasmosis
*azithromycin dihydrate (Zithromax)
clindamycin palmitate (Cleocin Pediatric Granules)
Leucovorin Calcium (Folinic Acid)
clindamycin phosphate (Cleocin Phosphate)
pyrimethamine (Daraprim)
sulfadiazine
sulfamethoxazole (Gantanol, Urobak)
CATEGORY IV
Anti-Convulsants
keppra (Levetiracetam)
valproic acid (Divalproex)
Anti-Depressants
Other
Angiotensin-Converting Enzyme Inhibitors
Antidiabetic: Thiazolidinediones
pioglitazone (Actos)
Anti-Psychotics
olanzapine (Zyprexa)
risperidone (Risperdal)
quetiapine (Seroquel, XR)
valproic acid
Beta-Adrenergic Blocking Agents
amitriptyline
*bupropion (Wellbutrin SR, Wellbutrin XL)
citalopram (Celexa)
atenolol/chlorthalidone (Tenoretic)
atenolol (Tenormin)
doxepin
duloxetine (Cymbalta)
escitalopram (Lexapro)
carvedilol (Coreg)
metoprolol (Lopressor, Toprol XL)
propranolol (Inderal LA)
fluoxetine (Prozac)
mirtazapine (Remeron)
timolol (Blocadren)
paroxetine (Paxil, Paxil CR)
sertraline (Zoloft)
amlodipine (Norvasc)
diltiazem (Cardizem, Taztia XT)
venlafaxine (Effexor, Effexor XR)
felodipine (Plendil)
nifedipine XL, ER (Procardia, Adalat)
Antidiabetic: Bigunanides
metformin (Glucophage Glucophage XL)
Antidiabetic: Combinations
glyburide/metformin (Glucovance)
rosiglitazone/metformin (Avandamet)
Antidiabetic: Insulins
gabapentin (Neurontin)
imiquimod cream (Aldara)
testosterone cypionate (no Kits)
testosterone enanthate, I.M only (no Kits)
benazepril (Lotensin)
enalapril (Vasotec)
enalapril/hctz (Vaseretic)
lisinopril (Prinivil, Zestril)
quinapril (Accupril)
ramipril (Altace)
Humalog (all formulations)
Humalog Mix
Humulin (all formulations)
insulin glargine (Lantus)
Novolin (all formulations)
Novolog (all formulations)
Novolog Mix Flexpen
Antidiabetic: Sulfonylureas
glipizide (Glucotrol, XL)
Calcium-Channel Blocking Agents
verapamil (Covera HS)
verapamil (Verelan, Isoptin SR, Calan, Calan SR)
Cardiac
losartan (Cozaar)
losartan/hctz (Hzaar)
valsartan (Diovan)
valsartan/hctz (Diovan HCT)
Central Agonists
clonidine (Catapres)
minoxidil
Diuretics
furosemide (LASIX)
hctz/triamterene (DYAZIDE, MAXIDE)
hydrochlorothiazide
lisinopril/hctz (Prinzide, Zestoretic)
glyburide (Diabeta)
CATEGORY IV cont.
Nitrates and Nitrites
Lipid Lowering Agents
atorvastatin (Liptor)
fenofibrate (Tricor)
pravastatin (Pravachol)
nitroglycerin sublingual tab, spray, cap
Smoking Cessation
*bupropion (Wellbutrin SR, Wellbutrin XL)
CATEGORY V
REQUIRING PRIOR APPROVAL
"Category V" drugs are pre-approval drugs only, all pre-approval forms are located on the IDPH website (www.idph.state.il.us/health/aids/adap.htm
enfurvirtide (Fuzeon); requires pre-approval and limited to a cap of 15 clients concurrently.
valaganciclovir hydrochloride (Valcyte) ; Oral only and is limited to a cap of 35 clients concurrently.
atovaquone (Mepron) - requires prior approval in all of the following situations:
1) use for more than 21 days
2) use as prophylaxis (rather than treatment); or
3) more than one prescription per year is written for a patient not approved for use of atovoquone as prophylaxis.
Pre Approval for Gender Transition and Maintenance only (See "Prescribing Guidelines" for link on guidelines and protocols)
Estradiol, Oral
Estradiol, Transdermal
Estradiol, Injectable
Finasteride
Progestin
Spironolactone
* Duplicate drug appears in more than one sub category
**Indicates a fixed combination of two-drugs that are considered two drugs in the 5+ drug limit.
*** Indicates a fixed three-drug combination and are considered three drugs in the 5+ drug limit.
****Stribild is a three-drug combination and is considered three drugs in the 5+ drug limit.
See ADAP Prescribing Guidelines for quantity limits on some drugs.
Prescriptions for multi-source drugs should be written indicating "product subsitution permitted" to ensure all efforts for fiscal stewardship on behalf of ADAP. In addition, this
procedure will reduce the number of call-backs to prescribers by dispensing pharmacy.
All prescriptions for multi-source drugs (drugs available in a brand-name and equal or greater than 1 generic formulation) will be filled with the lowest cost option available. Use of
brand name drugs on the ADAP formulary is for informational purposes only.
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
AIDS Drug Assistance Program (ADAP)
FORMULARY as of 11/10/2014
158 DRUGS
Drug Name
abacavir sulfate (Ziagen)
acyclovir (acycloguanosine, Zovirax)
adefovir Dipivoxil (Hepsera)
amitriptyline
amlodipine (Norvasc)
amoxicillin (Amoxil, Trimox, Wymox)
amphotericin B (Fungizone) I.V. only
amprenavir (Agenerase), solution only
atazanavir (Reyataz)
atenolol/chlorthalidone (Tenoretic)
atenolol (Tenormin)
atorvastatin (Lipitor)
atovaquone (Mepron) – Pre-Approval (required)
***atripla (efavirenz/emtricitabine/tenofovir)
*azithromycin dihydrate (Zithromax)
bupropion (Wellbutrin SR Wellbutrin XL)
benazepril (Lotensin)
carvedilol (Coreg)
cefixime (Suprax) suspension
Ceftriaxone 250 mg (Rocephin)
cephalexin monohydrate (Keflex)
chlorhexidine gluconate (Peridex, PerioGard)
cidofovir plus probenecid (Vistide) intravenous
ciprofloxacin (Cipro)
citalopram (Celexa)
*clarithromycin (Biaxin)
clindamycin HCl (Cleocin Hcl)
clindamycin palmitate (Cleocin pediatric granules)
leucovorin calcium (folinic acid)
clindamycin phosphate (Cleocin Phosphate)
clonidine (Catapres)
clotrimazole (Mycelex, Lotrimin)
cobicistat (Tybust)
**combivir (Epivir and Retrovir Combination)
Drug Name
Drug Name
enfurvirtide (Fuzeon)
entecavir (Baraclude)
**epzicom (Epivir and Ziagen Combination)
escitalopram (Lexapro)
Estradiol, Oral
Estradiol, Transdermal
Estradiol, Injectable
ethambutol (Myambutol)
etravirine (Intelence)
famciclovir (Famvir)
felodipine (Plendil)
gabapentin (Neurontin)
glipizide (Glucotrol, XL)
glyburide (Diabeta)
glyburide/metformin (Glucovance)
hctz/triamterene (DyazideYazide, Maxide)
Humalog (all formulations)
Humalog Mix
Humulin (all formulations)
hydrochlorothiazide
imiquimod cream (Aldara)
indinavir (Crixivan)
insulin glargine (Lantus)
itraconazole (Sporanox)
isoniazid (isonicotinic acid hydrazide, INH)
isoniazid/pyrazinamide/rifampin (Rifater)
keppra (Levetiracetam)
lamivudine (3TC, Epivir)
levofloxacin (Levaquin)
lisinopril/hctz (Prinzide, Zestoretic)
lisinopril (Prinivil, Zestril)
loperamide (Imodium)
lopinavir/ritonavir (Kaletra)
losartan (Cozaar)
losartan/hctz (Hzaar)
maraviroc (Selzentry) - Requires Trofile assay
metformin (Glucophage Glucophage XL)
metoprolol (Lopressor, Toprol XL)
fenofibrate (Tricor)
Finasteride
fluconazole (Diflucan)
fluoxetine (Prozac)
fosamprenavir calcium (Lexiva)
furosemide (Lasix)
metronidazole
miconazole (Monistat)
minoxidil
mirtazapine (Remeron)
nelfinavir mesylate (Viracept)
nevirapine (Viramune)
***complera(emtricitabine/rilpivirine/tenofovir)
dapsone
darunavir (Prezista)
delavirdine (Rescriptor)
dicloxacillin sodium (Dycill, Dynapen, Pathocil)
didanosine (ddI, dideoxyinosine, Videx, Videx EC)
diltiazem (Cardizem, Taztia XT)
diphenoxylate/atropine (Lomotil)
dolutegravir (Tivicay)
doxycycline hyclate (Doryx, Vibramycin, Vibra-Tabs)
doxepin
duloxetine (Cymbalta)
efavirenz (Sustiva)
emtricitabine (Emtriva, FTC)
enalapril (Vasotec)
enalapril/hctz (Vaseretic)
Drug Name
nifedipine XL, ER (Procardia, Adalat)
nitroglycerin sublingual tab, spray, cap
Novolin (all formulations)
Novolog (all formulations)
Novolog Mix Flexpen
nystatin (Mycostatin)
olanzapine (Zyprexa)
paromomycin sulfate (Humatin)
paroxetine (Paxil, Paxil CR)
penicillin G benzathine
penicillin LA
penicillin VK
pentamidine isethionate (NebuPent, Pentam 300)
pioglitazone (Actos)
pravastatin (Pravachol)
Drug Name
pyrimethamine (Daraprim)
quetiapine (Seroquel, XR)
quinapril (Accupril)
raltegravir (Isentress)
ramipril (Altace)
rifabutin (Mycobutin)
rifampin (Rifadin, Rimactane)
rilpivirine (Edurant)
risperidone (Risperdal)
ritonavir (Norvir) – reference prescribing gudelines
rosiglitazone/metformin (Avandamet)
saquinavir mesylate (Invirase)
sertraline (Zoloft)
Spironolactone
stavudine (d4T, Zerit)
****stribild(elvitegravir/cobicistat/emtricitabine tenofovir
disoproxil fumarate)
Drug Name
tenofovir DF (Viread)
testosterone cypionate (no Kits)
testosterone enanthate, I.M only (no Kits)
timolol (Blocadren)
tipranovir (Aptivus)
trimethoprim (TMP, Proloprim, Trimpex)
***trizivir (Epivir, Retrovir and Ziagen Combination
**truvada (Emtriva and Viread combination)
valacyclovir hydrochloride (Valtrex)
valganciclovir hydrochloride (Valcyte)
valproic acid
valproic acid (Divalproex)
valsartan (Diovan)
valsartan/hctz (Diovan HCT)
venlafaxine (Effexor, Effexor XR)
Progestin
primaquine phosphate
sulfadiazine
verapamil (Covera HS)
verapamil (Verelan, Isoptin SR, Calan, Calan SR)
propranolol (Inderal LA)
sulfamethoxazole (Gantanol, Urobak)
vitekta (Elvitegravir)
pyrazinamide
pyridoxine hydrochloride (B6)
sulfamethoxazole/trimethoprim (SMZ/TMP, Bactrim)
zidovudine (AZT, azidothymidine, Retrovir)
Prior Approval Drugs
"Category V" drugs are pre-approval drugs only, all pre-approval forms are located on the IDPH website (www.idph.state.il.us/health/aids/adap.htm
enfurvirtide (Fuzeon); requires pre-approval and limited to a cap of 15 clients concurrently.
valaganciclovir hydrochloride (Valcyte); Oral only and is limited to a cap of 35 clients concurrently.
atovaquone (Mepron) - requires prior approval in all of the following situations:
1) use for more than 21 days
2) use as prophylaxis (rather than treatment); or
3) more than one prescription per year is written for a patient not approved for use of atovoquone as prophylaxis.
Pre Approval for Gender Transition and Maintenance only (See "Prescribing Guidelines" for link on guidelines and protocols)
Estradiol, Oral
Estradiol, Transdermal
Estradiol, Injectable
Finasteride
Progestin
Spironolactone
* Duplicate drug appears in more than one sub category
** Indicates a fixed combination of two-drugs that are considered two drugs in the 5+ drug limit.
*** Indicates a fixed three-drug combination and are considered three drugs in the 5+ drug limit.
**** Stribild is a three-drug combination and is considered four drugs in the 5+ drug limit.
See ADAP Prescribing Guidelines for quantity limits on some drugs.
Prescriptions for multi-source drugs should be written indicating "product subsitution permitted" to ensure all efforts for fiscal stewardship on behalf of ADAP. In addition, this
procedure will reduce the number of call-backs to prescribers by dispensing pharmacy.
All perscriptions for multi-source drugs (drugs available in a brand-name and equal or greater than 1 generic formulation) will be filled with the lowest cost option available. Use
of brand name drugs on the ADAP formulary is for informational purposes only.
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
AIDS DRUG ASSISTANCE PROGRAM (ADAP)
PRESCRIBING GUIDELINES
Drugs provided by the AIDS Drug Assistance Program (ADAP) MUST not exceed a $2,000 per month benefits cap and MUST be
prescribed in accordance with these guidelines. Revisions to prescribing guidelines may be made upon recommendations of the
Department’s ADAP Medical Issues Advisory Board.
CATEGORY I

Category I anti-retroviral therapies should be prescribed in accordance with the latest Public Health Service (PHS)
guidelines. The Website is: http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf

All newly FDA approved anti-retroviral therapies will be considered for addition to the formulary, however:
a.
b.
No more than five (5) drugs* from Category I (and Fuzeon) prescribed concurrently (Up to two protease
inhibitors or a protease inhibitor and an NNRTI may be provided concurrently), except with prior approval from
ADAP. There are no exceptions to this prescribing guideline, except ritonavir (Norvir), at a reduced dosage may
be prescribed for pharmacokinetic (PK) boosting, cobicistat (Tybust), and
Any change in Category I therapies will require a discontinue order of the old prescription to be sent or faxed to
CVS Caremark Pharmacy before the new order can be filled.
* Combivir, Truvada, and Epzicom are fixed dose combinations and are considered two (2) drugs when ordered.
* Trizivir, Atripla, Stribild, Complera and Triumeq are fixed-dosage combinations of 3 drugs and are considered
three (3) drugs when ordered.
* Kaletra contains Norvir at a reduced dosage and is considered one plus PK boosted drug when ordered.




HIV co-receptor (CCR5 and/or CXCR4) tropism assay must be run and submitted to ADAP prior to prescribing Selzentry.
CATEGORY II
atovaquone (Mepron) prescriptions will require prior approval in all the following situations: 1) use for more than 21 days,
2) use as prophylaxis (rather than treatment); or 3) more than one prescription per year is written for a patient not approved
for use of atovoquone as prophylaxis. Pre-approval form will be available on the IDPH website (www.idph.state.il.us).
ritonavir (Norvir) - tablets will be dispensed unless other formations are required by prescriber due to tolerance issues. ADAP
may require prior approval for other formulations.
CATEGORY V
enfurvirtide (Fuzeon); requires a separate application. Eligibility is based on medical criteria, with a cap limit of 15 clients.
Prior approval by the Department will be faxed, via electronic file to the pharmacy as authorization. Fuzeon is considered
one of the five (5) drugs along with those in Category 1.

valganciclovir (Valcyte) oral only: limited to a cap of 35 clients concurrently.

atovaquone (Mepron) – see notes under Category II.

Neither enfurvirtide (Fuzeon) nor valganciclovir (Valcyte) are considered within the $2,000 benefits cap.




OTHER GENERAL GUIDELINES
All prescriptions for multi-source drugs (drugs available in a brand-name and equal or greater than 1 generic formulation)
will be filled with the lowest cost option available. Use of brand name drugs on the ADAP formulary is for informational
purposes only.
For coverage under ADAP, prescriptions for multi-source drugs should be written indicating “product substitution
permitted” to ensure all efforts for fiscal stewardship are able to be implemented by ADAP through its dispensing pharmacy.
In addition, this procedure will reduce the number of call-backs to prescribers by dispensing pharmacy.
All prescriptions must be written for no more than 3 refills. Then the client will be required to re-visit their HIV Care
Provider before a new prescription can be written.
All pre-approval form can be located on the IDPH website (www.idph.state.il.us) for all prescriptions requiring preapproval.
Revised: 11/10/2014
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
AIDS DRUG ASSISTANCE PROGRAM (ADAP)
PRESCRIBING GUIDELINES
Guidance References for Primary Care Protocol for Hormone Treatment for Gender Transition and Maintenance: 1) The Center for Excellence for Transgender Health ‐ Primary Care Protocol ‐ Hormone Administration: http://transhealth.ucsf.edu/trans?page=protocol‐hormones 2) The World Professional Association for Transgender Health ‐ Standards of Care: http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf Revised: 11/10/2014