DAVID Y. IGE BRUCE S. ANDERSON, Ph.D. GOVERNOR OF HAWAII DIRECTOR OF HEALTH

STATE OF HAWAII DEPARTMENT OF HEALTH New additions to HARM REDUCTION SERVICES BRANCH formulary HIV DRUG ASSISTANCE PROGRAM (HDAP) 3627 Kilauea Avenue, Room 306 Honolulu, Hawaii 96816-2399

HIV DRUG ASSISTANCE PROGRAM (HDAP) FORMULARY – June 2019

HIV Antiretrovirals abacavir (Ziagen) emtricitabine (Emtriva) abacavir/lamivudine (Epzicom) emtricitabine/rilpivirine/tenofovir abacavir/lamivudine/zidovudine (Trizivir) alafenamide (Odefsey) atazanavir (Reyataz) emtricitabine/rilpivirine/tenofovir df atazanavir/cobicistat (Evotaz) (Complera) bictegravir/emtricitabine/tenofovir emtricitabine/tenofovir alafenamide alafenamine (Biktarvy) (Descovy) cobicistat (Tybost) emtricitabine/tenofovir df (Truvada) darunavir (Prezista) enfuvirtide (Fuzeon) darunavir/cobicistat (Prezcobix) etravirine (Intelence) darunavir/cobicistat/emtricitabine/tenofovir fosamprenavir (Lexiva) alafenamide (Symtuza) ibalizumab-uiyk (Trogarzo) 1 delavirdine (Rescriptor) indinavir (Crixivan) didanosine (Videx, Videx EC) lamivudine (Epivir) dolutegravir (Tivicay) lamivudine/tenofovir df (Cymduo) dolutegravir/abacavir/lamivudine (Triumeq) lamivudine/zidovudine (Combivir) dolutegravir/lamivudine (Dovato) lopinavir/ritonavir (Kaletra) dolutegravir/rilpivirine (Juluca) maraviroc (Selzentry) doravirine (Pifeltro) nelfinavir (Viracept) doravirine/lamivudine/tenofovir df (Delstrigo) nevirapine (Viramune, Viramune XR) efavirenz (Sustiva) raltegravir (Isentress, Isentress HD) efavirenz/emtricitabine/tenofovir df (Atripla) rilpivirine (Edurant) efavirenz/lamivudine/tenofovir df (Symfi, ritonavir (Norvir) Symfi-Lo) saquinavir hard gel (Invirase) elvitegravir/cobicistat/emtricitabine/ stavudine (Zerit) tenofovir alafenamide (Genvoya) tenofovir disoproxil fumarate (Viread) elvitegravir/cobicistat/emtricitabine/ tipranavir (Aptivus) tenofovir df (Stribild) zidovudine (Retrovir)

Pneumocystis carinii Pneumonia (PCP) atovaquone (Mepron ) primaquine dapsone trimethoprim/sulfamethoxazole (TMP/SMX) pentamidine-aerosolized (NebuPent)

Hawai‘i HIV Drug Assistance Program (HDAP) Formulary June 2019 1 HIV Related Anemia and Neutropenia epoetin alfa (Epogen, Procrit) leucovorin (Wellcovorin) filgrastim (Neupogen, G-CSF)

Viral Hepatitis daclatasvir (Daklinza) 2 peginterferon alfa-2a (Pegasys) elbasvir/grazoprevir (Zepatier) 2 peginterferon alfa-2b (PEG-Intron) entecavir (Baraclude)3 ribavirin (Copegus, Rebetol) glecaprevir/pibrentasvir (Mavyret) 2 sofosbuvir (Sovaldi) 2 hepatitis A/B vaccines (Twinrix, Havrix, Engerix-B) sofosbuvir/velpatasvir (Epclusa) 2 ledipasvir/sofosbuvir (Harvoni) 2 sofosbuvir/velpatasvir/voxilaprevir (Vosevi) 2 ombitasvir/paritaprevir/ritonavir (Technivie) 2 tenofovir alafenamide (Vemlidy) ombitasvir/paritaprevir/ritonavir; dasabuvir (Viekira Pak) 2 Opportunistic Infections acyclovir (Zovirax) isoniazid amphotericin B (Fungizone) itraconazole (Sporanox) amphotericin B liposomal (AmBisome) ketoconazole (Nizoral) azithromycin (Zithromax) megestrol acetate (Megace OS / ES) cephalexin (Keflex) norfloxacin (Noroxin) cidofovir (Vistide) paclitaxel (Taxol) ciprofloxacin (Cipro) posaconazole (Noxafil) clarithromycin (Biaxin) probenecid clindamycin (Cleocin) pyrazinamide clotrimazole (Lotrimin, Mycelex) pyrimethamine (Daraprim) daunorubicin liposomal (DaunoXome) rifabutin (Mycobutin) ethambutol (Myambutol) rifampin (Rifadin) famciclovir (Famvir) sulfadiazine fluconazole (Diflucan) valacyclovir (Valtrex) flucytosine (Ancobon) valganciclovir (Valcyte) foscarnet (Foscavir) vancomycin (Vancocin) ganciclovir (Cytovene) Other Anti-infectives dicloxacillin paromomycin (Humatin) doxycycline pneumococcal PSV (Pneumovax) erythromycin terbinafine (Lamisil) metronidazole (Flagyl) tetracycline oseltamivir (Tamiflu) zanamivir (Relenza)

Antidepressants/Antipsychotics amitriptyline (Elavil) olanzapine (Zyprexa) aripiprazole (Abilify) paroxetine (Paxil) bupropion (Wellbutrin, Wellbutrin SR) quetiapine (Seroquel) citalopram (Celexa) risperidone (Risperdal) fluoxetine (Prozac) sertraline (Zoloft) mirtazapine (Remeron) venlafaxine (Effexor, Effexor XR) nortriptyline (Pamelor) ziprasidone (Geodon)

Hawai‘i HIV Drug Assistance Program (HDAP) Formulary June 2019 2

Antidiarrheals crofelemer (Mytesi) loperamide (Imodium) diphenoxylate/atropine (Lomotil) Antihyperlipidemics atorvastatin (Lipitor) pitavastatin (Livalo) fenofibrate (Tricor) pravastatin (Pravachol) gemfibrozil (Lopid) rosuvastatin (Crestor) niacin extended-release tablets (Niaspan)

Cardiovascular agents amlodipine (Norvasc) metoprolol succinate (Toprol XL) clopidogrel (Plavix) metoprolol tartrate (Lopressor) furosemide (Lasix) metoprolol tartrate/hydrochlorothiazide hydrochlorothiazide (Lopressor HCT) isosorbide mononitrate (Ismo) olmesartan (Benicar) lisinopril (Zestril) olmesartan/hydrochlorothiazide (Benicar HCT) lisinopril/hydrochlorothiazide (Zestoretic) spironolactone (Aldactone) losartan (Cozaar) warfarin (Coumadin)

Dermatologic agents alitretinoin gel (Panretin Gel) hydrocortisone 1% 5-fluorouracil (Efudex) imiquimod (Aldara) hexachlorophene (PhisoHex) 3% sinecatechins ointment 15% (Veregen)

Diabetes glyburide pioglitazone (Actos) metformin (Glucophage) rosiglitazone (Avandia)

Gender Transitioning; Transgender Patients dutasteride (Avodart) medroxyprogesterone acetate, oral estradiol- oral, sublingual, transdermal (Provera) estradiol valerate for IM progesterone, micronized estradiol cypionate for IM injection spironolactone (Aldactone) finasteride- 1 MG, 5 MG (Propecia, Proscar)4 testosterone cypionate for IM injection testosterone gel (Androgel)

Substance Use Disorder: Medication Assisted Treatment and Opioid Overdose acamprosate (Campral) naloxone- injection, auto-injector, intranasal buprenorphine (Subutex)5 (Narcan) buprenorphine/naloxone (Suboxone) 5 naltrexone- injection, oral clonidine (Catapres) (Vivitrol, ReVia, Depade) disulfiram (Antabuse)

Hawai‘i HIV Drug Assistance Program (HDAP) Formulary June 2019 3

Other albuterol (Proventil, Ventolin) naproxen alendronate (Fosamax) omeprazole (Prilosec) cyanocobalamin (B12) injection ondansetron (Zofran) denosumab (Prolia) pancrelipase (Ultrase MT20) divalproex sodium (Depakote) pantoprazole (Protonix) dutasteride (Avodart) pregabalin (Lyrica) (EpiPen) prednisone fluticasone (Flonase, Flovent) prochlorperazine (Compazine) finasteride (Proscar)4 risedronate (Actonel) gabapentin (Gralise, Neurontin) somatropin (rDNA origin) for injection hydroxyurea (Hydrea) (Serostim) 6 lamotrigine (Lamictal) tamsulosin (Flomax) levabuterol (Xopenex) terazosin (Hytrin) levetiracetam (Keppra) testosterone cypionate for IM injection levothyroxine (Synthroid) testosterone gel (Androgel) medroxyprogesterone acetate for injection varenicline (Chantix) (Depo-Provera)

1 Ibalizumab-uiyk (Trogarzo) is not available through HDAP’s contract , CarePlus. Access and infusion service must be arranged on a case-by-case basis. Contact the HDAP office for assistance in making the necessary arrangements.

2 Treatment slots for HCV direct-acting antivirals may be limited. Prescriber or pharmacy must call HDAP for slot.

3 Concomitant ART is required for HDAP coverage of entecavir.

4 HDAP does not cover finasteride for treatment of male hair loss.

5 SAMHSA waiver and DEA registration are required to prescribe buprenorphine.

6 HDAP coverage of somatropin is limited to treatment of wasting or cachexia to increase lean body mass and body weight, and improve physical endurance. Concomitant ART is required. No coverage for any off-label use.

For more information, please call (808) 733-9362 or (808) 733-9361.

Hawai‘i HIV Drug Assistance Program (HDAP) Formulary June 2019 4