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 Cobicistat (Tybost) TRANSCRIPTASE INHIBITORS (NNRTI) Ritonavir (Norvir) Delavirdine (Rescriptor) Rilpivirine HCl (Edurant) CD4 DIRECTED POST-ATTACHMENT Efavirenz (Sustiva) HIV-1 INHIBITOR Etravirine (Intelence) Ibalizumab-uiyk (Trogarzo)# Nevirapine (Viramune, Viramune XR)
FUSION INHIBITORS Enfuvirtide (Fuzeon) HIV-1 INTEGRASE STRAND TRANSFER Maraviroc (Selzentry) INHIBITOR/ NRTI COMBINATION Elvitegravir/ Cobicistat/ Emtricitabine/ Tenofovir INTEGRASE INHIBITORS disoproxil fumarate (Stribild) Raltegravir (Isentress) Dolutegravir/Abacavir/Lamivudine (Triumeq) Dolutegravir (Tivicay) Elvitegravir/Cobicistat/Emtricitabine/ Tenofovir Elvitegravir (Vitekta) alafenamide (Genvoya) Bictegravir/Emtricitabine/Tenofovir alafenamide (Biktarvy) NUCLEOTIDE REVERSE Dolutegravir/Rilpivirine (Juluca) TRANSCRIPTASE INHIBITORS (NRTI) Abacavir (Ziagen) NNRTI/NRTI COMBINATION Abacavir/Lamivudine (Epzicom) Efavirenz/Emtricitabine/Tenofovir disoproxil Abacavir/Lamivudine/Zidovudine (Trizivir) fumarate (Atripla) Didanosine (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 Stavudine (Zerit) disoproxil fumarate (Symfi )++ Tenofovir disoproxil fumarate (Viread) Doravirine/Lamivudine/Tenofovir disoproxil Zidovudine (Retrovir, AZT) fumarate (Delstrigo) Doravirine (Pifeltro)
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AIDS Drug Assistance Program (ADAP) FORMULARY
HIV/AIDS DRUGS: ANTIBIOTICS ANTI-RETROVIRALS Amoxicillin Clavulanate (Augmentin) Azithromycin (Zithromax) PROTEASE INHIBITORS (PI) Ciprofloxacin (Cipro) [oral products only] Atazanavir (Reyataz) Clarithromycin (Biaxin, Biaxin XL) Darunavir (Prezista) Clindamycin HCL (Cleocin) Fosamprenavir (Lexiva) Doxycycline Hyclate (Vibramycin) Indinavir (Crixivan) Ethambutol (Myambutol) Lopinavir/Ritonavir (Kaletra) Isoniazid (INH) Nelfinavir (Viracept) Levofloxacin (Levaquin) Ritonavir (Norvir) Linezolid (Zyvox) Saquinavir (Invirase)# Metronidazole tablets (Flagyl) Tipranavir (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) Amitriptyline HCL (Elavil) Bupropion (Wellbutrin SR) ANALGESICS Duloxetine (Cymbalta) Acetaminophen with codeine (Tylenol Fluoxetine(Prozac) w/Codeine) CIII** Sertraline (Zoloft) Fentanyl Patch (Duragesic Patch) CII** Ibuprofen (600mg - 800mg Motrin) ANTI-DIARRHEAL Morphine Sulfate (MS Contin) CII** Diphenoxylate/Atropine (Lonox, Lomotil) CV** Tramadol (Ultram) CIV** Crofelemer (Mytesi) Oxycodone/Acetaminophen 5mg/325mg ASA/Butalbital/caffeine/codeine (Fiorinal w/codeine) ANTI-FUNGALS Clotrimazole (Mycelex, Lotrimin - Rx only) Fluconazole (Diflucan) Itraconazole (Sporanox) Ketoconazole (Nizoral – Rx only) Voriconazole (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) Spironolactone (Aldactone, Carospir) Lisinopril (Prinivil, Zestril, Qbrelis) ALPHA-1 BLOCKERS Doxazosin (Cardura, Cardura XL) ANGIOTENSIN II RECEPTOR BLOCKERS (ARB) Losartan (Cozaar) BETA-BLOCKERS Valsartan (Diovan) Labetalol Metoprolol tartrate Metoprolol succinate CALCIUM CHANNEL BLOCKERS Propranolol Amlodipine (Norvasc) Diltiazem 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) Carvedilol (Coreg) Valsartan/HCTZ (Diovan HCT) Carvedilol (Coreg CR) Amlodipine/Benazepril (Lotrel) LOOP DIURETICS Furosemide (Lasix)
DIRECT VASODILATORS Hydralazine (Apresoline)
SECONDARY COMBINATION PRODUCTS Triamterene/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) Glipizide (Glucotrol, Glucotrol XL) Metformin (Glucophage, Glucophage XL) ANTI-PSYCHOTICS Metformin and Pioglitazone (ActoPlus Met) Aripiprazole (Abilify) Metformin and Glipizide (Metaglip) Haloperidol (Haldol) Sitagliptin (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) Ezetimibe (Zetia) Oseltamivir (Tamiflu) Fenofibrate (Tricor) Ganciclovir (Zirgan) [ophthalmic] Pravastatin (Pravachol)
HEPATITIS B TREATMENT OPIOID ADDICTION TREATMENT Adefovir (Hepsera) Buprenorphine (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)# Lidocaine Patch (Lidoderm) Gabapentin (Neurontin)
TRANSGENDER HORMONES Estradiol valerate injection 10mg/ml Estradiol tablets Leuprolide acetate injection 3.75mg, 11.25mg Spironolactone tablet 50mg, 100 mg Finasteride 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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