Special Pharmaceutical Benefits Program HIV/AIDS Baseline Drug Formulary

Please Note: DO NOT SUBMIT CLAIMS FOR DRUGS THAT ARE NOT LISTED BELOW:

Active SPBP cardholders with identification numbers beginning with the prefix SP1 are eligible for any of the following drugs:

acyclovir/valacyclovir alpha interferon amikacin amphotericin b Aptivus Atripla (efavirenz, emtricitabine, enofovir)* zithromycin Bactrim/Septra/tmp smx Biaxin bleomycin capreomycin ciprofloxacin clindamycin clofazimine clotrimazole Combivir Crixivan cycloserine dapsone dexamethasone doxorubicin Emtriva Epivir Epzicom ethambutol ethionamide

etoposide famciclovir fluconazole flucytosine Foscavir Fuzeon ganciclovir Hivid Intelence (etavirine)* Invirase/Fortovase isoniazid Isentress (raltegravir)* itraconazole Kaletra kanamycin sulfate ketoconazole leucovorin Lexiva Marinol Megace Mepron Neutrexin Norvir nystatin ofloxacin paromomycin sulfate pentamidine prednisone Prezista (darunavir)*

primaquine phosphate pyrazinamide pyrimethamine rescriptor Reyataz Retrovir rifabutin rifampin Selzentry (maraviroc)* sulfadiazine sulfadoxine&pyrimethamine Sustiva terconazole triple sulfa Trizivir Truvada Valcyte (valganciclovir) Videx vinblastine sulfate vincristine sulfate Viracept Viramune Viread (tenofovir disoproxil fumarate) Vistide (cidofovir injection) Zerit Ziagen

*Intelence and Selzentry added to the HIV/AIDS Baseline Formulary Effective:
February 1, 2008

HIV/AIDS drugs are provided through Ryan White Care Act Part B (formerly known as Title II) funds and State funds.

For general information, the SPBP operates a toll free telephone line: 1-800-922-9384.
The SPBPs email address is: SPBP@state.pa.us, or you may access the DPW website at http://www.dpw.state.pa.us/ search or click on key words AIDS/HIV and follow the links to the Special Pharmaceutical Benefits Program. NOTE: This program is called ADAP in other states.

If a client has third party insurance that covers drugs, including Medicare Part D, it must be billed prior to billing SPBP. Call SPBP Provider Services for billing questions at: 1-800-835-4080.

SPBP DRUG COVERAGE IS DISCONTINUED IF THE CLIENT BECOMES ELIGIBLE FOR DRUG COVERAGE THROUGH THE MEDICAL ASSISTANCE ACCESS CARD AND/OR A MEDICAL ASSISTANCE MANAGED CARE ORGANIZATION, BECOMES INCARCERATED OR MOVES OUT OF STATE.
CLIENTS MAY NOT HAVE DRUGS PROVIDED THROUGH BOTH MEDICAL ASSISTANCE AND THE SPBP.

Note: You must inform SPBP staff in writing of any change to your address, income, family composition or insurance coverage.