Raltegravir Potassium (RAL) 100 mg Chewable Tab (Isentress Chew)

Raltegravir Potassium (RAL) 100 mg Chewable Tab (Isentress Chew)

Non-Formulary Use Criteria: 1. Regimen has been established in consultation with Regional HIV Consultant Pharmacist, expert consultation service or Regional Medical Director. 2. Patient must be highly treatment-experienced. 3. HAART selection must be directed by appropriate resistance testing. 4. The ability exists to construct a HAART regimen to include: 3 active and proper antretroviral drugs or, at least 1 active drug plus an appropriate antiretroviral drug combination with some residual activity. 5. All supporting documents must be attached to include, at a minimum, copies of all available viral loads and CD4 counts, copies of all available resistance tests, description of all known previous HAART regimens, assessment of patient’s adherence to HAART, and the complete HAART regimen being requested. 6. Maraviroc requests must include results of the CCR5 co-receptor tropism assay. 7. None of the antiretroviral drugs of the new/proposed HAART regimen should be started until the non-formulary requests are approved. (same as other HIV medications) MLP Requires Cosign

Dr. M Blatstein

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