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State of Connecticut-Department of Social Services STATE OF CONNECTICUT-DEPARTMENT OF SOCIAL SERVICES 55 FARMINGTON AVENUE, HARTFORD, CONNECTICUT 06105 Connecticut AIDS Drug Assistance Program (CADAP) Formulary Effective: March 1, 2018 Antiretroviral: Multiclass Single Tablet Regimens Abacavir/ Lamivudine/ Dolutegravir Efavirenz/Emtricitabine/ Tenofovir Disoproxil Elvitegravir/Cobicistat/ Emtricitabine/Tenofovir ( Triumeq ) Fumarate (Atripla ) Disoproxil Fumarate (Stribild ) Bictegravir/ Emtricitabine/Tenofovir Elvitegravir, Cobicistat, Emtricitabine/Tenofovir Emtricitabine/Rilpivirine/ Tenofovir Disoproxil Alafenamide (Biktarvy) Alafenamide (Genvoya ) Fumarate (Complera ) Antiretroviral: Combination Medications Abacavir /Lamivudine (Epzicom) Atazanavir/Cobicistat (Evotaz) Lamivudine/Zidovudine (Combivir) Abacavir/Lamivudine/ Zidovudine Darunavir/Cobicistat (Prezcobix) Lopinavir/Ritonavir (Kaletra) (Trizivir) Emtricitabine/Tenofovir (Truvada) Antiretrovirals: Nucleoside Reverse Transcriptase Inhibitor (NRTIs) Medications Abacavir (Ziagen) Emtricitabine (Emtriva) Tenofovir DF (Viread) Didanosine (ddI, Videx, Videx EC) Lamivudine (3TC, Epivir, Epivir HBV ) Zidovudine (AZT, Retrovir ) Stavudine (Zerit) Antiretrovirals: Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTIs) Medications Delavirdine Mesylate (Rescriptor) Etravirine (Intelence) Rilpivirine (Edurant) Efavirenz (Sustiva) Nevirapine ( Viramune/Viramune XR ) Antiretrovirals: Protease Inhibitor (PIs) Medications Atazanavir Sulfate (Reyataz) Indinavir (Crixivan) Ritonavir (Norvir) Darunavir (Prezista) Lopinavir/Ritonavir (Kaletra) Saquinavir Mesylate (Invirase) Fosamprenavir (Lexiva) Nelfinavir (Viracept) Tipranavir (Aptivus) Antiretrovirals: Entry Inhibitor Medications Enfuvirtide, T-20 (Fuzeon) Maraviroc (Selzentry) Antiretrovirals: Integrase Inhibitor Medications Dolutegravir (Tivicay) Elvitegravir (Vitekta) Raltegravir (Isentress, Isentress HD) Dolutegravir/Rilpivirine (Juluca ) Antiretroviral Boosting Agent Cobicistat (Tybost) Antivirals: Herpes/CMV/Flu Medications Acyclovir (Zovirax) Foscarnet (Foscavir) Valacyclovir (Valtrex) Cidofovir (Vistide) Ganciclovir (Cytovene) Valganciclovir (Valcyte) Famciclovir (Famvir) Oseltamivir Phosphate (Tamiflu) Zanamivir (Relenza) Antivirals: Hepatitis B/ Hepatitis C Medications Entecavir (Baraclude) PEG-Interferon alfa-2b (PEG-INTRON ) Ribavirin (Copegus) PEG-Interferon alfa-2a (Pegasys) PEG-Interferon alfa-2b (PI - REDIPEN) Ribavirin (Rebetol) Analgesic /Anti-Inflammatory Medications Acetaminophen with codeine Gabapentin (Neurontin) Oxycodone with APAP/SLN (Roxicet/Percocet ) Celecoxib (Celebrex) Ibuprofen Oxycodone HCL – CR (OxyContin) Fentanyl Transdermal System (Duragesic) Ketoprofen (Orudis) Tramadol HCl (Ultram) Naproxen (Naprosyn) Antibiotics/ Anti-Infective Medications Amoxicillin Dapsone Paromomycin (Humatin) Amoxicillin/Clavulanate (Augmentin) Dicloxacillin Penicillin G Benzathine (Bicillin) Ampicillin Doxycycline Hyclate Penicillin V Potassium (Veetids) Atovaquone (Mepron) Ethambutol (Myambutol) Pentamidine (Pentam 300, NebuPent) Azithromycin (Zithromax) Gatifloxacin (Tequin) Primaquine Cefditoren Pivoxil (Spectracef) Gentamicin Pyrimethamine Ceftriaxone Leucovorin Rifabutin (Mycobutin) Cefuroxime Levofloxacin (Levaquin) Rifampin Cephalexin (Keflex) Metronidazole (Flagyl) Sulfadiazine Chlorhexidine gluconate (Peridex) Minocycline HCL (Dynacin) Trimethoprim (Proloprim) Ciprofloxacin (Cipro) Neomycin Sulfate (Cortisporin) Trimethoprim-sulfamethoxazole, TMP-SMZ Clarithromycin (Biaxin) Nitrofurantoin Monohydrate (Macrobid) Vancomycin Clindamycin (Cleocin) Ofloxacin (Floxin) Zanamivir (Relenza) Anti-Depressants/Psychotropic Medications/Sleep Medications Alprazolam (Xanax) Divalproex Sodium (Depakote) Paroxetine (Paxil) Amitriptyline HCL (Elavil) Duloxetine (Cymbalta) Quetiapine Fumarate (Seroquel) Aripiprazole (Abilify) Escitalopram Oxalate (Lexapro) Risperidone (Risperdal) Benztropine Mesylate (Cogentin) Fluoxetine HCL (Prozac) Sertraline (Zoloft) Bupropion HCL (Wellbutrin) Hydroxyzine HCL (Atarax) Temazepam (Restoril) Buspirone (BuSpar) Lithium Trazodone Citalopram (Celexa) Lorazepam (Ativan) Venlafaxine (Effexor) Clonazepam (Klonopin) Mirtazapine (Remeron) Zolpidem Tartrate (Ambien/ Diazepam (Valium) Nortriptyline HCL Ambien CR ) Olanzapine (Zyprexa) Anti-Fungal Medications Amphotericin B (Fungizone B ) Itraconazole (Sporanox) Terbinafine (Lamisil) – Topical/Tablet Clotrimazole (Mycelex, Lotrimin ) Ketoconazole (Nizoral) Terconazole (Terazol 3 & 7) Fluconazole (Diflucan) Nystatin Voriconazole (Vfend) Anti-Seizure Medications Carbamazepine (Tegretol) Lamotrigine (Lamictal XR) Cardiovascular Medications Amlodipine (Norvasc) Ezetimibe (Zetia) Metoprolol Succinate (Toprol-XL) Atenolol (Tenormin) Fenofibrate (Tricor) Minoxidil Atorvastatin (Lipitor) Fenofibric Acid (Trilipix) Nitroglycerin Cholestyramine (Questran) Furosemide (Lasix) Omega-3 Acid Ethyl Esthers (Lovaza) Clofibrate (Atromid-S) Gemfibrozil (Lopid) Pravastatin (Pravachol) Clopidigrel (Plavix) Hydrochlorothiazide (HCTZ) Rosuvastatin Calcium (Crestor) Colesevelam HCl (Welchol) Isosorbide Dinitrate Spironolactone Digoxin Isosorbide Mononitrate (Imdur) Valsartan (Diovan) Diltiazem HCL (Cardizem) Labetalol HCL (Normodyne) Valsartan and HCTZ (Diovan HCTZ) Enalapril Maleate (Vasotec) Lisinopril (Prinivil, Zestril) Verapamil (Covera HS) Decongestant & Expectorant Agents Desloratadine (Clarinex) Guaifenesin/Codeine PH (Tussi-Organidin S-NR) Guaifenesin/DM HBr(Tussi-Organidin DM-S-NR ) Guaifenesin/pseudoephedrine (Entex PSE) Dermatologic Medications Alclometasone Dipropionate (Aclovate) Fluticasone Propionate (Cutivate) Metronidazole Cream (MetroCream) Betamethasone (Diprolene) Hydrocortisone Topical Mupirocin Ointment (Bactroban Ointment) Clindamycin Gel (Cleocin T) Imiquimod (Aldara) Pimecrolimus (Elidel) Clobetasol Propionate (Temovate) Ketoconazole 2% (Nizoral Shampoo) Triamcinolone-Acetonide (Topical) Fluocinonide (Lidex) Lactic Acid Endocrine/Metabolic Medications Alendronate Sodium Insulin Regular Prednisone Alendronate Sodium/Cholecalciferol Levothyroxine Sodium (Synthroid) Rosiglitazone Maleate (Avandia) Dexamethasone Megestrol Acetate (Megace) Somatropin (Serostim)* Dronabinol (Marinol) Metformin HCL (Glucophage) Testosterone (Androderm) Exenatide (Byetta) Nandrolone decanoate (Deca-Durabolin) Testosterone (Androgel) Glipizide Oxandrolone (Oxandrin) Testosterone (Testim 1%) gel Glyburide Oxymetholone (Anadrol-50) Testosterone-cypionate (Depo-Testosterone) Insulin NPH Pioglitazone HCL (Actos) Gastrointestinal Medications Diphenoxylate HCL (Lomotil, Lonox) Lactulose (Kristalose) Pantoprazole Sodium (Protonix) Esomeprazole (Nexium) Lansoprazole (Prevacid) Prochlorperazine (Compazine) Famotidine (Pepcid) Loperamide HCL (Imodium) Rabeprazole Sodium (Aciphex) Granisetron (Kytril) Ondansetron (Zofran) Ranitidine HCL (Zantac) Hematological Medications Erythropoietin (Epogen, Procrit) Filgrastim (G-CSF, Neupogen) Hydroxyurea Opiate Antidote Naloxone (Narcan) Nasal Spray Respiratory Medications Albuterol (Proventil) Flunisolide (Aerobid) Mometasone Furoate monohydrate (Nasonex) Azelastine HCl (Astelin) Fluticasone Propionate (Flovent) Salmeterol Xinafoate (Serevent) Budesonide (Rhinocort AQUA) Fluticasone/Salmeterol (Advair Diskus) Triamcinolone Acetonide (Nasacort AQ) Flunisolide (Aerobid) Ipratropium Bromide/Albuterol Sulfate (Combivent) Vaccines Comvax Meningococcal (Menactra, Menveo, Menomune) Twinrix Engerix-B Pneumococcal Vaccine (individual doses) Varicella- Zoster (Shingrix) Havrix Recombivax HB Vaqta Vitamins & Minerals Calcium Supplements (Calcium, Calcium + Ferrous Sulfate Strovite; Forte/Plus D/Advance/One Vitamin D, Calcium + Vitamin D + Levocarnitine/Oral (Carnitor) Vitamin D Supplements (all strengths) Magnesium) BOLD denotes new to formulary as of March 1st (BOLD ITALICS ) denotes Brand Name * ITALICS denotes Prior Authorization required effective September 15, 2006 .
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