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Division of Public Health Services Office of the Assistant Director Public Health Preparedness Services Division of Public Health Services Office of the Assistant Director Public Health Preparedness Services 150 North 18th Avenue, #110 JANICE K. BREWER, GOVERNOR Phoenix, AZ 85007-3233 WILL HUMBLE, DIRECTOR (800) 334-1540 (602) 364-3263 FAX AIDS DRUG ASSISTANCE PROGRAM (ADAP) FORMULARY – PROVIDER VERSION January 16, 2014 (Alternate strengths and dose forms - with exclusion of injectable forms unless the medication is only available in such route - will be available upon provider’s preference) ANTIRETROVIRALS NUCLEOSIDE/NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS Abacavir (Ziagen) Didanosine EC (Videx, ddI) Emtricitabine (Emtriva) Lamivudine (Epivir, 3TC) Stavudine (Zerit, d4T) Tenofovir (Viread) Zidovudine (Retrovir, AZT) NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS Delavirdine (Rescriptor) Edurant (Rilpivirine) Efavirenz (Sustiva) Etravirine (Intelence) Nevirapine (Viramune) PROTEASE INHIBITORS Atazanavir (Reyataz) Darunavir (Prezista) Fosamprenavir Calcium (Lexiva) Indinavir (Crixivan) Lopinavir/Ritonavir (Kaletra) Nelfinavir (Viracept) Ritonavir (Norvir) Saquinavir (Invirase) Tipranavir (Aptivus) HIV ENTRY/FUSION INHIBITORS Enfuvirtide (Fuzeon) * Maraviroc (Selzentry) *** INTEGRASE INHIBITORS Raltegravir (Isentress) Dolutegravir (Tivicay) COMBINATION ANTIRETROVIRAL PRODUCTS Atripla (Efavirenz/Emtricitabine/Tenofovir) Combivir (Lamivudine/Zidovudine) Complera (Rilpivirine/Tenofovir/Emtricitabine) Epzicom (Lamivudine/Abacavir) Trizivir (Abacavir/Lamivudine/Zidovudine) Truvada (Tenofovir/Emtricitabine) Stribild (Elvitegravir, Cobicistat, Emtricitabine,Tenofovir) ALLERGY/COUGH/COLD Astelin (Azelastine HCL) Beconase AQ (Beclomethasone Dipropionate) Diphenhydramine Hydroxyzine Loratadine Pseudoephedrine Flunisolide Nasonex (mometasone) Guaifenesin with Codeine cough syrup ANALGESICS Acetaminophen/Codeine Acetaminophen/Hydrocodone Acetaminophen/Oxycodone Chloralphenazone/Isometheptene/Acetaminophen (For Migraine) Ibuprofen Methadone (For Pain, Not Addiction Rx) Morphine Sulfate Immediate Release Morphine Sulfate Sustained Release Naproxen Oxycodone Immediate Release Ultram (Tramadol HCL) ANTIBACTERIALS Amoxicillin Amoxicillin/Clavulanate Azithromycin (Zithromax) Cefpodoxime Cephalexin Ciprofloxacin Dicloxacillin Doxycycline Metronidazole Moxifloxacin Penicillin VK ANTI-ACID Omeprazole Ranitidine ANTICOAGULANTS Warfarin ANTIDIARRHEALS Diphenoxylate/Atropine Loperamide ANTIEMETICS Metoclopramide Prochlorperazine Promethazine Zofran (Ondansetron) ANTIFUNGALS Clotrimazole Oral Troches Fluconazole Itraconazole (Sporanox) Miconazole Vaginal Nystatin Suspension Voriconazole Pozaconazole ANTIMYCOBACTERIALS (MAC, TB) Azithromycin (Zithromax) Ciprofloxacin Clarithromycin (Biaxin) Ethambutol (Myambutol) Isoniazid (Inh) Pyridoxine (To Be Given With Inh) Pyrazinamide Rifabutin (Mycobutin) Rifampin CYTOMEGALOVIRUS PROPHYLAXIS AND TREATMENT Valganciclovir (Valcyte) * ELECTROLYTES/NUTRITION Ferrous Sulfate Folic Acid Multivitamin with 1 mg Folate/Pre-Natal Vitamins Magnesium Oxide Potassium Chloride Calcium carbonate Calcium carbonate /Vitamin D Calcium citrate Calcium citrate/Vitamin D GASTROINTESTINAL Dicyclomine Opium Tincture Pancrelipase (Ultrase Mt) HEPATITIS B TREATMENT Entecavir (Baraclude) HEPATITIS C TREATMENT Peginterferon Alfa 2B (Peg-Intron) ** Ribavirin ** HEPATITIS C TREATMENT ADVERSE SIDE EFFECTS, NEUTROPENIA, AND ANEMIA Epoetin Alfa (Procrit) Filgrastim (Neupogen) HERPES PROPHYLAXIS AND TREATMENT Acyclovir HORMONAL/METABOLIC AGENTS Estradiol Estrogen Conjugated (Premarin) Insulins Levothyroxine (Levoxyl or Synthroid) Medroxyprogesterone Megestrol (Megace) ES Niacin Sustained Release (Niaspan or Equivalent) Prednisone Testosterone Enanthate Testosterone Gel (Androgel) Testosterone (Androgel Pump) Testosterone Gel (Testim) Testosterone Cypionate HUMAN PAPILLOMAVIRUS Imiquimod Cream (Aldara) Podofilox Solution (Condylox) HYPERTENSION Amlodipine Atenolol Benazepril Diltiazem Sustained Release Doxazosin Enalapril Furosemide Hctz Hctz/Triamterene Lisinopril Losartan Metoprolol Spironolactone INFLUENZA ANTIVIRALS Oseltamivir Phosphate (Tamiflu) METABOLIC SYNDROME AGENTS Atorvastatin (Lipitor) Ezetimibe Gemfibrozil Glipizide Glyburide Metformin Pravastatin (Pravachol) Actos Fenofibrate (generic only) Rosuvastatin (Crestor) Sitagliptin (Januvia) MUSCLE RELAXANTS Cyclobenzaprine OTHER Alendronate (Fosamax) PERIPHERAL NEUROPATHY Carbamazepine Desipramine Gabapentin (Neurontin) Nortriptyline Pregabalin (Lyrica) PNEUMOCYSTIS/TOXOPLASMOSIS PROPHYLAXIS AND TREATMENT Atovaquone (Mepron) Clindamycin Dapsone Leucovorin Pentamidine Isethionate (Nebupent) Pyrimethamine (Daraprim) Sulfadiazine Sulfamethoxazole/Trimethoprim (SMZ/TMP) Trimethoprim PSYCHOTROPICS/NEUROLOGIC ANTIANXIETY/HYPNOTICS Diazepam Lorazepam Prazosin Propranolol Temazepam Zolpidem ANTICONVULSANTS Clonazepam Divalproex (Valproic Acid) Levetiracetam (Keppra) Phenytoin ANTIDEPRESSANTS Amitriptyline Bupropion Sr (Wellbutrin) Citalopram (Celexa) Desipramine Escitalopram (Lexapro) Fluoxetine Lamictal Mirtazapine Nortriptyline Paroxetine Sertraline (Zoloft) Trazodone Venlafaxine (Effexor) all formulations Duloxetine (Cymbalta) ANTIPSYCHOTICS Aripiprazole Olanzapine Risperidone Quetiapine (Seroquel) MOOD STABILIZERS Lithium Carbonate STIMULANTS Methylphenidate PULMONARY Albuterol Metered-Dose Inhaler (MDI) Flunisolide MDI Ipratropium HFA Beclomethasone (QVAR) TOPICALS Chlorhexidine Mouthwash Fluocinonide Cream/Ointment Hydrocortisone Cream/Ointment Ketoconazole Cream, Shampoo Mupirocin Ointment Selenium Sulfide Triamcinolone Cream/Ointment *Prior Authorization Procedure – see http://www.azdhs.gov/phs/hiv/adap/ ** For Peg-Intron and Ribavirin, Genentech and Merck-Schering currently has a patient assistance program for individuals with limited incomes. The physician may contact 1-888-941-3331 directly. *** For Maraviroc (Selzentry), VIIV Healthcare offers certificates that provide Tropism testing through Ryan White Part A and Ryan White Part B clinics. Providers may also request Tropism testing kits by calling either 602-339-4125 or 602-321-2554. UPDATED January 16, 2014 .
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