ADAP-Formulary.Pdf

DELAWARE HEALTH AND SOCIAL SERVICES ______Division of Public Health ______

Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011

Antiretrovirals Abacavir (Ziagen) Abacavir/lamivudine (Epzicom) Amprenavir (Agenerase) Atazanavir (Reyataz) Complera (emtricitabine, rilpivirine and tenofovir) Darunavir (Prezista) Delavirdine (Rescriptor) Didanosine (ddI, Videx, Videx EC[all strengths]) Edurant (rilpivirine) Efavirenz (Sustiva-all strengths) Efavirenz/Emtricitabine/Tenofovir (Atripla) Emtricitabine (Emtriva) Enfuvirtide (Fuzeon) Etravirine (Intelence) Fosamprenavir (Lexiva) Indinavir (Crixivan) Lamivudine (3TC, Epivir all strengths) Lopinavir/Ritonavir (Kaletra) Maraviroc (Selzentry)– Pre-approval a must (call 302-744-1050) Nelfinavir (Viracept – all strengths) Nevirapine (Viramune) Raltegravir (Isentress) Ritonavir (Norvir) Saquinavir (Invirase [all strengths] or Fortovase) Stavudine (d4T, Zerit, Zerit XR) Tenofovir (Viread) Tenofovir disoproxil/emtricitabine (Truvada) Tipranavir (Aptivus) Zidovudine (AZT, Retrovir) Zidovudine/Lamivudine (Combivir) Zidovudine/Lamivudine/Abacavir (Trizivir)

Clients on prescriptions other than antiretrovirals or treatments for opportunistic infections require documentation on file at their physicians’ office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY HIV/AIDS. DELAWARE HEALTH AND SOCIAL SERVICES ______Division of Public Health ______

Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011

Antivirals/Antifungals/Antimicrobials Antivirals Antimicrobials Acyclovir (Zovirax) Cefixime (Suprax) Copegus (Ribavirin) Cefuroxime (Ceftin) Entecavir (Baraclude) Cephalexin (Keflex, Biocef, Keftab) Famciclovir (Famvir) Cidofovir (Vistide) Foscarnet (Foscavir) Ciprofloxacin (Cipro) Ganciclovir Capsules (Cytovene) Clarithromycin (Biaxin) Interferon Alfa-2b+ Ribavirin (Intron A+ Clindamycin (Cleocin) Rebetrol, Rebetron, Peg-Intron)i Dapsone (Avo-Sulfon) Imiquimod (Aldara) Dicloxacillin (Dycill, Dynapen, Pathocill) Pegasys (Peginterferon alfa-2a) i Doxycycline (Vibramycin, Doxy, Doxychel, Leucovorin (Wellcovorin) Monodox, etc) Valacyclovir (Valtrex) Ethambutol (Myambutol) Valganciclovir (Valcyte) Gatifloxacin (Tequin) Vitravene (Fomivirsen) Isoniazid (INH) Levofloxacin (Levaquin) Moxifloxacin (Avelox) Antifungals Ofloxacin (Floxin) Clotrimazole Troches (Mycelex) Paromomycin (Humatin) Clotrimazole Vaginal (Gyne-Lotrimin) Penicillin (Pen Vee K, Veetids, Beepen-VK, Spectazole (Econazole nitrate 1% cream) V-Cillin K, etc) Fluconazole (Diflucan) Pentamidine (Nebupent) Itraconazole (Sporanox) Primaquine (Primaquine Phosphate) Ketoconazole Tablets and Cream (Nizoral) Pyrazinamide (Pyrazinamide) Mycostatin (Nystatin) Pyrimethamine (Daraprim) Terconazole Rifamycins-Rifabutin (Mycobutin) and Vfend (Voriconazole) Rifampin Sulfadiazine (Microsulfon) Sulfamethoxazole/Trimethoprim (Bactrim, Antimicrobials Septra, various brands) Amoxicillin (Amoxil, Polymox, Trimox) Antibiotics (all types, all manufactures)* Amoxicillin & Clavulanate Potassium (Augmentin) Ampicillin (Omnipen, Principen) Atovaquone (Mepron) Azithromycin (Zithromax) Clients on prescriptions other than antiretrovirals or treatments for opportunistic infections require documentation on file at their physicians’ office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY HIV/AIDS. DELAWARE HEALTH AND SOCIAL SERVICES ______Division of Public Health ______

Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011

Gastrointestinal Agents/Nutritional Supplements/Appetite Stimulants/Antidiarrheals Gastrointestinal Agents Nutritional Supplements/Appetite stimulants Carafate (Sucralfate) Cyproheptadine (Periactin) Esomeprazole (Nexium) Pyridoxine (Vitamin B-6) Famotidine (Pepcid) Hemorrhoidal Creams & Suppository (All brands) Lansoprazole (Prevacid) Antidiarrheals Nizatidine (Axid) Diphenoxylate+ Atropine (Lomotil) Omeprazole (Prilosec) Loperamide (Imodium) Pancrease Enzymes (All commercially available formulations, generics) Antiemetic Pantoprazole (Protonix) Promethazine (Phenergan, various generics) Rabeprazole (Aciphex) Prochlorperazine (Compazine) Ranitidine (Zantac)

Inhalers/Bronchodilators/Oral Steroids/Asthma Prophylaxis Albuterol Inhaler (Ventolin)* Ipratropium (Atrovent) * Albuterol/Ipratropium (Combivent) * Isoproterenol (Isuprel) * Beclomethasone (Qvar,) * Metaproterenol Inhaler (Alupent)* Budesonide (Pulmicort) * Montelukast (Singulair)* Dexamethasone (all forms, all strengths) Prednisone (Deltasone) Flunisolide (Aerobid) * Salmeterol (Serevent)* Fluticasone (Flovent) * Terbutaline (Brethine, Brethaire, etc) * Fluticasone/Salmeterol (Advair Diskus) Triamcinolone (Azmacort, generic) *

Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011

Antidepressants/Antipsychotics/Agents for Sleep Alprazolam (Xanax) * Lithium Carbonat e (Lithobid, all others) Amitriptyline (Elavil) * Lexapro (Escitalopram)* Amoxapine (Asendin) * Lorazepam (Ativan) * Aripiprazole (Abilify) Maprotiline (Ludiomil) * Benztropine (Cogentin) Mirtazapine (Remeron) * Bupropion (Zyban, Wellbutrin) * Nefazodone (Serzone) * Buspirone (Buspar) Nortriptyline (Aventyl, Pamelor) * Chlordiazepoxide (Librium) * Olanzapine (Zyprexa) * Chlorpromazine (Thorazine) Oxazepam (Serax) * Citalopram (Celexa) * Paroxetine (Paxil, Paxil CR) * Clomipramine (Anafranil) * Protriptyline (Vivactil) * Clorazepate (Tranxene) * Quetiapine (Seroquel) Desipramine (Norpramin) * Risperidone (Risperdal) Diazepam (Valium) * Saphris (Asenapine) Duloxetine (Cymbalta) Sertraline (Zoloft) * Estazolam (Prosom) * Sinequan(Doxepin) Fluoxetine (Prozac) * Temazepam (Restoril) * Flurazepam (Dalmane) * Trazodone (Desyrel) Fluvoxamine (Luvox) * Trifluoperazine (Stelazine) Haloperidol (Haldol) Trimipramine (Surmontil) * Imipramine (Tofranil,generic) * Venlafaxine (Effexor, Effexor SR) * Invega (Paliperidone) Zolpidem (Ambien)*

Oral Hypoglycemics/Insulinii Acarbose (Precose)* Pioglitazone (Actos) * Glimepiride (Amaryl) * Repaglinide (Prandin) Glipizide (Glucotrol, Glucotrol XL, Rosiglitazone (Avandia) * generic)* Sitagliptin (Januvia) Glyburide (DiaBeta, Micronase, generic) * Insulins (all types, all manufacturers) * Metformin (Glucophage, Glucopahage XR, Fortamet)* iiOther FDA Approved supplies for Metformin/Rosiglitazone (Avandamet) management of Diabetes Mellitus (limited Metformin/Sitagliptin (Janumet) to syringes, alcohol swabs, blood glucose Metformin/Repaglinide (PrandiMet) monitors, lancets, and test strips) Clients on prescriptions other than antiretrovirals or treatments for opportunistic infections require documentation on file at their physicians’ office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY HIV/AIDS. DELAWARE HEALTH AND SOCIAL SERVICES ______Division of Public Health ______

Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011

Pain Medications Nonnarcotic analgesics Narcotic analgesics Diclofenac (Cataflam, Voltaren, generics) Acetaminophen/oxycodone (Percocet, Etodolac (Lodine, generics) Roxicet, Endocet) Fenoprofen (Nalfon, generics) Codeine containing pain relievers Fentanyl Transdermal System (Duragesic) Hydrocodone and derivatives Florinef Acetate (Fludrocortisone) Hydrocodone/IBU (Reprexain) Flurbiprofen (Ansaid, generics) Hydromorphone and derivatives Ibuprofen (Motrin) Meperidine (Demerol, generics) Ketoprofen (Orudis, various generics) Morphine Sulfate (Avinza, MSIR, Oramorph Ketorolac (Toradol) SR, MS Contin) Meclofenamate (generics) Oxycodone (Endocodone, Oxycontin, Meloxicam (Mobic) Roxicodone, OxyIR, OxyFAST, M-oxy) Methylprednisolone (Medrol) Propoxyphene (Darvon, Darvon N) Nabumetone (Relafen) Naproxen (Aleve, Anaprox, Naprosyn, Naprelan) Oxaprozin (Daypro) Piroxicam (Feldene, generics) Sulindac (Clinoril) Tolmentin (Tolectin) Tramadol (Ultram)

Vaccines Hepatitis A Vaccine (Havrix, Vaqta) Influenza Hepatitis B Vaccine (Energix-B, Pnuemovax 23 Recombivax HB, Comvax) TdAP Hepatitis A & Hepatitis B Combined Td (Twinrix)

Topical Medications Fluocinonide (Fluonex, Lidex, Lidex-E, Ketoconazole Cream (Nizoral) Lonide, Lyderm, and Vanos) Miconazole Cream (Monistat) Hydrocortisone (Cortef, Hydrocortone, Nystatin with or without Triamcinolone Cortisol) Creams (all brands) Clients on prescriptions other than antiretrovirals or treatments for opportunistic infections require documentation on file at their physicians’ office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY HIV/AIDS. DELAWARE HEALTH AND SOCIAL SERVICES ______Division of Public Health ______

Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011

Lipid Lowering Agents Atorvastatin (Lipitor) Mevacor (Lovastatin) Cholestyramine (Questran) Niacin (Niaspan, Nicotinic Acid, Slo-Niacin, Colesevelam (Welchol) Niacin) Ezetimibe (Zetia) Omega-3-acid ethyl esters (Lovaza) Ezetimibe/Simvastatin (Vytorin) Pravastatin (Pravachol) Fenofibrate (Tricor) Rosuvastatin (Crestor) Fenofibrate Micronized (Antara) Simvastatin (Zocor) Gemfibrozil (Lopid)

Antihypertensives/Cardiac Medications-combination products of those listed below also covered Apresonline (Hydralazine) Metolazone (Mykrox, Zaroxolyn, all Amlodipine (Norvasc) generics) Amlodipine/atorvastatin (Caduet) Metoprolol (Lopressor, Toprol XL, all Aspirin (all formulations, all generics) formulations, all generics) Atenolol (Tenormin, all generics) Minoxidil (Loniten) Clonidine (Catapres, all formulations, Nifedipine (Adalat, Adalat CC, Procardia, all generics) Procardia XL, all generics) Clopidogrel (Plavix) Olmesartan (Benicar) Coreg (Carvedilol) Propranolol (Inderal, all generics) Digoxin (all manufacturers) Quinapril (Accupril) Diltiazem (Cardizem, Cardizem CD, Ramipril (Altace) Cardizem SR, Cardia XT, Tiazac) Spironolactone (Aldactone, all generics) Enalapril (Vasotec, all generics) Telmisartan/Hydrochlorothiazide (Micardis Felodipine (Plendil) Hct) Fosinopril (Monopril) Triamterene (Dyrenium, generics, all Furosemide (Lasix, generics) combinations) Hydrochlorothiazide (all generics) Valsartan (Diovan) Isradipine (Dynacirc CR) Verapamil (Calan, Calan SR, Covera, Labetalol (Trandate, Normodyne) Isoptin, Verelan, generics) Lisinopril (Prinivil, Zestril, all generics) Warfarin (Coumadin) Losartan (Cozaar)

Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011

Prescription Antihistamines (including combination products) Brompheniramine (Dimetapp, various) Fexofenadine (Allegra) Cetirizine (Zyrtec) Hydroxyzine (Vistaril, all generics) Desloratadine (Clarinex) Loratadine (Claritin) Diphenhydramine (Benadryl) Phenergan (Promethazine)

Agents for Osteopenia/Osteoporosis Alendronate (Fosamax) Risedronate (Actonel) Ibandronate (Boniva)

Miscellaneous Epoetin Alfa (Epo, Procrit, various) Probenecid (for Cidofovir therapy) Filgrastim (Neupogen) Testosterone Replacement Products (all Levothyroxine (Synthroid, Levothyroid, types) Levoxyl, generics) Triamcino lone 1% Dental Paste(Aristocort)

Anticonvulsants Carbamazepine (Tegretol) Levetiracetam (Keppra) Ethosuximide (Zarontin) Pentobarbital (Nembutal) Gabapentin (Neurontin) Phenytoin (Dilantin) Clonazepam (Klonopin) Tiagabine (Gabitril) Lamotrigine (Lamictal) Valproate (Depakene, Depakote)

The following ADAP medications may not require a prescription Brompheniramine (Dimetapp, various) Ibuprofen (Motrin) Clemastine (Tavist) Loperamide (Imodium) Clotrimazole Vaginal (Gyne-Lotrimin) Loratadine (Claritin) Dexchlorpheniramine (Polaramine, various) Naproxen (Aleve, Anaprox, Naprosyn, Diphenhydramine (Benadryl) Naprelan) Docusate-Sennoside (Senokot –S) Nizatidine (Axid) Famotidine (Pepcid) Ferrous Sulfate (Feosol, Mol-Iron, Slow Fe)