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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.
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)
Ryan White Part A Formulary - Updated 3.21.12 2
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.
Ryan White Part A Formulary - Updated 3.21.12 3
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
Ryan White Part A Formulary - Updated 3.21.12 4
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 2
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 3
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 4
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 5
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 6
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 7
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 8
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 9
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 10
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 11
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 12
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 13
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 14
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 15
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 16
Tier 1 Wasting $ Amount Dispensing Fee # ClientsCyproheptadine (Periactin) $1,683.27 $1,127.00 66 Wasting Total $1,683.27 $1,127.00 66
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 17
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 18
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 19
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 20
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 21
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 22
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 23
Tier 2 Other Conditions $ Amount Dispensing Fee
# Clients
OPPORTUNISTIC INFECTIONS (OIs)
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 24
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
OPPORTUNISTIC INFECTIONS (OIs)
OTHER SIDE EFFECTS/CONDITIONS
ANTICONVULSANT
PROTEASE INHIBITOR
NUCLEOS(T)IDES (NRTIs)
ANTIEMETICS
FLU MEDICATION
HYPERGLYCEMIA
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 25
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
Drug Utilization 3.1.11-1.31.12 HANDOUT C
LPAC April 9, 2012 26
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