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Portsmouthoh.org

Client Name: _________________________ O
__ FORMULARY
SSN: _________________________
Please check the appropriate box next to any of the following medications you are prescribing for the above- referenced patient. This list is the current OHDAP Formulary through March 2008.
Anti Acids
Mental Health
Delavirdine, DLV (Rescriptor®)
Nizatidine (Axid®)
Amitriptyline (Elavil®)
Efavirenz, EFV (Sustiva®)
Omeprazole (Prilosec®)
Aripiprazole (Abilify®)
Etravirine (Intelence®)
Ranitidine (Zantac®)
Buproprion (Wellbutrin®)
Nevirapine (Viramune®)
Anti Diarrheals
Citalopram HBr (Celexa®)
Atropine diphenoxylate (Lomotil®)
Desipramine (Norpramin®)
Abacavir (Ziagen®)
Loperamide (Immodium®)
Divalproex sodium (Depakote®)
Didanosine, ddI (Videx EC®)
Anti Fungals
Duloxetine HCl (Cymbalta®)
Emtricitabine, FTC (Emtriva®)
Clotrimazole (Mycelex® Troche)
Fluoxetine (Prozac®)
Lamivudine, 3TC (Epivir®)
Lamotragine (Lamictal
dipropionate (Lotrazone®)
Stavudine, d4T (Zerit®)
Fluconazole (Diflucan®)
Mirtazapine (Remeron®)
Zidovudine, AZT (Retrovir®)
Nystatin (Nilstat®)
Nefazodone (Serzone®)
AZT + 3TC (Combivir®)
Itraconazole (Sporanox®)
Paroxetine (Paxil®)
AZT + 3TC + Abacavir (Trizivir®)
Ketoconazole (Nizoral®)
Pregabalin (Lyrica®)
Abacavir + Lamivudine (Epzicom®)
Anti Nausea
Quetiapine fumerate (Seroquel®)
Prochloroperazine (Compazine®)
Risperidone (Risperdal®)
Promethazine (Phenergan®)
Sertraline (Zoloft®)
Nucleotide Analogues
Diabetes Treatment
Trazodone (Desyrel®, Trialodine®)
Tenafovir (Viread®)
Acarbose (Precose®)
Venlafaxine (Effexor®)
Emtricitabine + Tenofovir (Truvada®)
Glipizide (Glucotrol®)
Ziprasidone Hcl (Geodon®)
Insulin and supplies (need rx for syringes) PCP Prophylaxis & Tx
Protease Inhibitors
Metformin (Glucophage®)
Atovaquone (Mepron®)
Piaglitizone (Actos®)
Dapsone (Dapsone®)
Amprenavir (Agenerase®)
Rosiglitazone maleate (Avandia®)
Pentamidine (Pentam®)
Atazanavir (Reyataz®)
Herpes Treatment
TMP/SMZ (Bactrim®/Septra®)
Darunavir (Prezista®)
Acyclovir (Zovirax®)
Fosamprenavir (Lexiva®)
Famciclovir (Famvir®)
Toxo Prophylaxis & Tx
Indinivavir sulfate (Crixivan®)
Valacyclovir (Valtrex®)
Nelfinavir (Viracept®)
Cardiac-Related Treatment
Pyrimethamine (Daraprim®)
Ritonavir (Norvir®)
Atorvastatin (Lipitor®)
Ritonavir + Lopinavir (Kaletra®)
Clopodogrel bisulfate (Plavix®)
TB Treatment
Saquinavir (Invirase®)
Ezetimibe (Zetia®)
Ethambutol (Myambutol®)
Tipranavir (Aptivus®)
Fenofibrate (Tricor®)
Isoniazid (INH)
Gemfibrozil (Lopid®)
Other Formulary Medications
Cross-Class Combos
Pravastatin (Pravachol®)
Rosuvastatin calcium (Crestor®)
Medroxyprogesterone (Depo-Provera®) No
prefilled syringes
(Atripla®)
MAI Prophylaxis & Tx
Azithromycin (Zithromax®)
Penicillin G benzathine (Bicillin LA®)
Integrase Inhibitors
Clarithromycin (Biaxin®)
Valganciclovir (Valcyte®)
Rifabutin (Mycobutin®)
Varenicline (Chantix®) 6 months/lifetime
CCR5 Antagonists
Vaccines
Imiquimod (Aldara® Cream)
Maraviroc (Selzentry®)**
Hep A vaccine (Havrix®)
Podofilox (Condylox®)
Fusion Inhibitors
(Engerix®/Recombivax®)
Enfuvirtide (Fuzeon®)**
Hep A/Hep B vaccine (Twinrix®)
Wasting Syndrome
**For instructions on obtaining authorization for Fuzeon or Selzentry, please contact the OHDAP
nurse at 1-800-777-4775

Source: http://portsmouthoh.org/sites/default/files/documents/OHDAP_Formulary.pdf

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