AIDS Drugs Assistance Program (ADAP) FORMULARY

The following drugs are available through the District of Columbia AIDS Drug Assistance Program.

ANTI-RETROVIRALS:

BOOSTING AGENTS NON-NUCLEOSIDE REVERSE (Tybost) TRANSCRIPTASE INHIBITORS (NNRTI) (Norvir) (Rescriptor) HCl (Edurant) CD4 DIRECTED POST-ATTACHMENT (Sustiva) HIV-1 INHIBITOR (Intelence) -uiyk (Trogarzo)# (Viramune, Viramune XR)

FUSION INHIBITORS (Fuzeon) HIV-1 INTEGRASE STRAND TRANSFER (Selzentry) INHIBITOR/ NRTI COMBINATION / Cobicistat/ / Tenofovir INTEGRASE INHIBITORS disoproxil fumarate (Stribild) (Isentress) // (Triumeq) Dolutegravir (Tivicay) Elvitegravir/Cobicistat/Emtricitabine/ Tenofovir Elvitegravir (Vitekta) alafenamide (Genvoya) /Emtricitabine/ (Biktarvy) NUCLEOTIDE REVERSE Dolutegravir/Rilpivirine (Juluca) TRANSCRIPTASE INHIBITORS (NRTI) Abacavir (Ziagen) NNRTI/NRTI COMBINATION Abacavir/Lamivudine (Epzicom) Efavirenz/Emtricitabine/ Abacavir/Lamivudine/ (Trizivir) fumarate (Atripla) (Videx) Emtricitabine/Rilpivirine/Tenofovir disoproxil Emtricitabine (Emtriva) fumarate (Complera) Emtricitabine/Tenofovir disoproxil fumarate Emtricitabine/Rilpivirine/Tenofovir alafenamide (Truvada) (Odefsey) Emtricitabine/Tenofovir alafenamide (Descovy) Efavurenz 400 mg /Lamivudine/ Tenofovir Lamivudine (Epivir) disoproxil fumarate (Symfi Lo)++ Lamivudine/Zidovudine (Combivir) Efavurenz 600 mg/Lamivudine/ Tenofovir (Zerit) disoproxil fumarate (Symfi )++ Tenofovir disoproxil fumarate (Viread) /Lamivudine/Tenofovir disoproxil Zidovudine (Retrovir, AZT) fumarate (Delstrigo) Doravirine (Pifeltro)

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AIDS Drug Assistance Program (ADAP) FORMULARY

HIV/AIDS DRUGS: ANTI-RETROVIRALS Amoxicillin Clavulanate (Augmentin) Azithromycin (Zithromax) PROTEASE INHIBITORS (PI) (Cipro) [oral products only] (Reyataz) Clarithromycin (Biaxin, Biaxin XL) (Prezista) HCL (Cleocin) (Lexiva) Doxycycline Hyclate (Vibramycin) (Crixivan) Ethambutol (Myambutol) /Ritonavir (Kaletra) Isoniazid (INH) (Viracept) Levofloxacin (Levaquin) Ritonavir (Norvir) Linezolid (Zyvox) (Invirase)# Metronidazole tablets (Flagyl) (Aptivus) Metronidazole vaginal gel Pyrazinamide (Pyrazinamide) CYP3A INHIBITOR/PROTEASE INHIBITOR Pyrimethamine (Daraprim)# Darunavir/Cobicistat (Prezcobix) Rifabutin (Mycobutin) Atazanavir/Cobicistat (Evotaz) Rifampin (Rifadin) Sulfadiazine PROTEASE INHIBITOR/CYP3A INHIBITOR/NRTI Darunavir/Cobicistat/Emtricitabine/TAF ANTI-DEPRESSANTS (Symtuza) HCL (Elavil) Bupropion (Wellbutrin SR) ANALGESICS Duloxetine (Cymbalta) Acetaminophen with (Tylenol Fluoxetine(Prozac) w/Codeine) CIII** Sertraline (Zoloft) Patch (Duragesic Patch) CII** Ibuprofen (600mg - 800mg Motrin) ANTI-DIARRHEAL Sulfate (MS Contin) CII** /Atropine (Lonox, Lomotil) CV** Tramadol (Ultram) CIV** Crofelemer (Mytesi) Oxycodone/Acetaminophen 5mg/325mg ASA/Butalbital/caffeine/codeine (Fiorinal w/codeine) ANTI-FUNGALS (Mycelex, Lotrimin - Rx only) Fluconazole (Diflucan) (Sporanox) (Nizoral – Rx only) (Vfend)

899 North Capitol Street, NE Fourth Floor, Washington, DC 20002 Tel. (202) 671-4900 Fax (202) 673-4365

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AIDS Drug Assistance Program (ADAP) FORMULARY

ANTI-HYPERTENSIVES

PRIMARY AGENTS: SECONDARY AGENTS:

ACE INHIBITORS (ACEI) ALDOSTERONE ANTAGONISTS Benazepril (Lotensin) (Aldactone, Carospir) Lisinopril (Prinivil, Zestril, Qbrelis) ALPHA-1 BLOCKERS Doxazosin (Cardura, Cardura XL) ANGIOTENSIN II RECEPTOR BLOCKERS (ARB) (Cozaar) BETA-BLOCKERS Valsartan (Diovan) Labetalol Metoprolol tartrate Metoprolol succinate CALCIUM CHANNEL BLOCKERS (Norvasc) XR CENTRALLY ACTING AGENTS Clonidine tablet PRIMARY COMBINATION PRODUCTS Clonidine patches (Catapres TTS) Benazepril/HCTZ Lisinopril/HCTZ COMBINED ALPHA AND BETA-BLOCKERS Losartan/HCTZ (Hyzaar) (Coreg) Valsartan/HCTZ (Diovan HCT) Carvedilol (Coreg CR) Amlodipine/Benazepril (Lotrel) LOOP DIURETICS Furosemide (Lasix)

DIRECT VASODILATORS Hydralazine (Apresoline)

SECONDARY COMBINATION PRODUCTS /HCTZ (Dyazide, Maxide) Hydralazine /HCTZ (Bidil)

899 North Capitol Street, NE Fourth Floor, Washington, DC 20002 Tel. (202) 671-4900 Fax (202) 673-4365

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AIDS Drug Assistance Program (ADAP) FORMULARY

ANTI-PARKINSON’S AGENT HYPOGLYCEMICS Benztropine (Cogentin) (Glucotrol, Glucotrol XL) Metformin (Glucophage, Glucophage XL) ANTI-PSYCHOTICS Metformin and Pioglitazone (ActoPlus Met) Aripiprazole (Abilify) Metformin and Glipizide (Metaglip) Haloperidol (Haldol) (Januvia) Olanazapine (Zyprexa) Sitagliptin/Metformin (Janumet) Quetiapine (Seroquel) Risperidone (Risperdal) KAPOSI’S SARCOMA TREATMENTS Ziprasidone (Geodon) Interferon Alpha-2b (Intron A) Doxorubicin (Doxil) ANTI-VIRALS Generic Doxorubicin (Lipodox) Acyclovir (Zovirax) [oral and topical] Cidofovir (Vistide) LIPID LOWERING AGENT Valacyclovir (Valtrex) Atorvastatin (Lipitor) Valganciclovir (Valcyte) (Zetia) Oseltamivir (Tamiflu) Fenofibrate (Tricor) Ganciclovir (Zirgan) [ophthalmic] Pravastatin (Pravachol)

HEPATITIS B TREATMENT ADDICTION TREATMENT Adefovir (Hepsera) (Subutex) CIII**# Entecavir (Baraclude) Buprenorphine/Naloxone (Suboxone) CIII**# Peginterferon alfa-2a (Pegasys) Peginterferon alfa-2b (Peg-Intron) OPIOID ANTAGONIST Tenofovir alafenamide (Vemlidy) Naloxone (Evzio) 2mg Auto-injector Naloxone (Narcan) 4mg Nasal spray HEPATITIS C Daclatasvir (Daklinza) # OSTEOPOROSIS Elbasvir and grazoprevir (Zepatier) # Alendronate plus Vitamin D Glecaprevir /pibretasvir (Mavyret) # Calcitonin-salmon Nasal spray Ledipasvir and Sofosbuvir (Harvoni) # Raloxifene (Evista) Ombitasvir/Paritaprevir/Ritonavir/ Dasabuvir (Viekira Pak, Viekira XR) # Peginterferon alfa-2a (Pegasys) Peginterferon alfa-2b (Peg-Intron) Ribavirin (Rebetol, Copegus) Sofosbuvir (Sovaldi) # Tenofovir alafenamide (Vemlidy)

899 North Capitol Street, NE Fourth Floor, Washington, DC 20002 Tel. (202) 671-4900 Fax (202) 673-4365

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AIDS Drug Assistance Program (ADAP) FORMULARY

PCP PROPHYLAXIS Aerosolized Pentamidine (Nebupent) WEIGHT LOSS/WASTING Atovaquone Suspension (Mepron) Dronabinol (Marinol/Syndros) CIII** # Dapsone Megestrol (Megace, Megace ES) Sulfamethoxazole-Trimethoprim (Bactrim) Oxandrolone (Oxandrin) CIII ** Somatropin (Serostim) # TOPICAL STEROIDS Hydrocortisone 2.5% [cream, lotion, ointment] Hydrocortisone valerate 0.2% [cream] MISCELLANEOUS Berocca Plus vitamins (Rx Only) TOPICAL ANESTHETICS Epoetin Alfa (Procrit, Epogen)# Patch (Lidoderm) (Neurontin)

TRANSGENDER HORMONES Estradiol valerate injection 10mg/ml Estradiol tablets Leuprolide acetate injection 3.75mg, 11.25mg Spironolactone tablet 50mg, 100 mg tablet 5 mg Testosterone cypionate injection, CIII** Testosterone, topical 1%, (Androgel) CIII** (generic only) Testosterone pump, topical 1.62%, (Androgel) CIII** Conjugated estrogen tablet 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, 1.25 mg

** DENOTES CONTROLLED SUBSTANCES # DENOTES PRIOR AUTHORIZATION ++ DENOTES DOSAGE STRENGTH CAUTION

CONTROLLED SUBSTANCES ARE AVAILABLE AT ANY CONTRACTED NETWORK PHARMACY

Delivery Available – inquire with individual pharmacy

UPDATED February 22, 2019 CONFIDENTIAL FAX (202) 673-4365

899 North Capitol Street, NE Fourth Floor, Washington, DC 20002 Tel. (202) 671-4900 Fax (202) 673-4365

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