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Home , Delavirdine, Docusate, Efavirenz, Fostemsavir, Imiquimod, Isometheptene

AIDS DRUG ASSISTANCE PROGRAM (ADAP) FORMULARY – PROVIDER VERSION

April 22, 2021

(Alternate strengths and dose forms - with exclusion of injectable forms unless the is only available in such route - will be available upon provider’s preference)

ANTIRETROVIRALS NUCLEOSIDE/NUCLEOTIDE INHIBITORS (Ziagen) EC (Videx, ddI) (Emtriva) (Epivir, 3TC) (Zerit, d4T) Tenofovir (Viread) (Retrovir, AZT)

NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (Rescriptor) (Pifeltro) Doravirine/Lamivudine (Delstrigo) Edurant () (Sustiva) (Intelence) (Viramune)

PROTEASE INHIBITORS (Reyataz) Atazanavir/ (Evotaz) Cobicistat/ (Prezcobix) Darunavir (Prezista) (Lexiva) (Crixivan) / (Kaletra) (Viracept) Ritonavir (Norvir) Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

Saquinavir (Invirase) (Aptivus)

HIV ENTRY/FUSION INHIBITORS (Fuzeon) (Selzentry)***

INTEGRASE INHIBITORS (Tivicay) (Isentress) Raltegravir (Isentress HD)

COMBINATION ANTIRETROVIRAL PRODUCTS Atripla (Efavirenz/Emtricitabine/Tenofovir) Biktarvy ( 50mg/emtricitabine 200mg/ 25mg - BIC/FTC/TAF) Cimduo (lamivudine and fumerate) Combivir (Lamivudine/Zidovudine) Complera (Rilpivirine/Tenofovir/Emtricitabine) Descovy (emtricitabine 200mg, tenofovir alafenamide 25mg) Dovato (dolutegravir/lamivudine) Epzicom (Lamivudine/Abacavir) Genvoya (Cobicistat, , Emtricitabine and Tenofovir Alafenamide) Juluca (dolutegravir/rilpivirine) Odesfey (Emtricitabine 200 mg, Rilpivirine 25mg, Tenofovir Alafenamide 25 mg) Stribild (Elvitegravir, Cobicistat, Emtricitabine, Tenofovir) Symfi (Efavirenz/Lamivudine - Tenofovir Disoproxil Fumerate) Symfi Lo (Efavirenz/Lamivudine - Tenofovir Disoproxil Fumerate) Symtuza (darunavir, cobicistat, emtricitabine and tenofovir alafenamide) Triumeq (Abacavir/Dolutegravir/Lamivudine) Trizivir (Abacavir/Lamivudine/Zidovudine) Truvada (Tenofovir/Emtricitabine)

PHARMACOKINETIC BOOSTER Cobicistat (Tybost)

Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

CD4 DIRECTED POST-ATTACHMENT HIV-1 INHIBITOR Trogarzo (-uiyk)******

ATTACHMENT INHIBITORS Rukobia ()

ALLERGY/COUGH/COLD Astelin (Azelastine HCL) Beconase AQ (Beclomethasone Dipropionate) Benzonatate Epi-Pen Flunisolide Guaifenesin with Codeine cough syrup Loratidine Nasonex (Mometasone)

ANALGESICS Acetaminophen/Codeine Acetaminophen/Hydrocodone Acetaminophen/Oxycodone * /APAP/ Celecoxib Chloralphenazone/Isometheptene/Acetaminophen (For ) Diclofenac Gel * Meloxicam (For Pain, Not Addiction Rx) Sulfate Immediate Release Morphine Sulfate Sustained Release Naproxen* Oxycodone Immediate Release Ultram ( HCL)

Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

ANTIBACTERIALS Amoxicillin Amoxicillin/Clavulanate Aithromycin (Zithromax) Bleph 10 Cefdinir Cefadroxil Cefpodoxime Cephalexin Doxycycline Ophthalmic Ointment Macrobid Moxifloxacin /polymyxin/ Neomycin/polymyxin/hydrocortisone VK Tobradex (tobramycin/dexamethasone) Vancomycin Xifaxan Zyvox

ANTICONVULSANT Oxcarbazepine

ANTIDIARRHEALS Diphenoxylate/ Loperamide

ANTIEMETICS

Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

Prochlorperazine Zofran ()

ANTIFUNGALS Oral Troches Fluconazole (Sporanox) Miconazole Vaginal Nystatin

ANTIMYCOBACTERIALS (MAC, TB) Azithromycin (Zithromax) Ciprofloxacin Clarithromycin (Biaxin) Ethambutol (Myambutol) Isoniazid (INH) Primaquine Pyrazinamide (To Be Given With Inh) (Mycobutin) Rifampin

ANTIPARASITIC Alinia Tinidazole

BLOOD PRESSURE Benazepril Bumetanide Chlorthalidone Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

Clonidine Diltiazem Sustained Release Enalapril Hctz Hctz/Triamterene Hydralazine Lisinopril Losartan Metoprolol

CARDIAC Isosorbide Ranexa

CYTOMEGALOVIRUS PROPHYLAXIS AND TREATMENT (Valcyte)

ELECTROLYTES/NUTRITION Calcium acetate Calcium carbonate Calcium carbonate/ D Calcium citrate Calcium citrate/ Ferrous Sulfate Folic L-Methylfolate (7.5 and/or 15mg capsules only) with 1 mg /Pre-Natal Chloride

GASTROINTESTINAL * Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

Bismuth Subsalicylate Dicyclomine * Famotidine Go-Lytely Miralax Nu-Lytely Opium Tincture Pancrelipase Capsules (any manufacture) Pantoprazole Pylera Sodium Bicarbonate

HEMATOLOGIC Brilinta Clopidogrel Enoxaparin Eliquis Pradaxa Warfarin Xarelto

HEPATITIS B TREATMENT (Baraclude) Tenofovir Alafenamide (Vemlidy)

HEPATITIS C TREATMENT Epclusa***** Harvoni***** Mavyret***** Sovaldi***** Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

Ribavirin** Zepatier*****

HEPATITIS C TREATMENT ADVERSE , NEUTROPENIA, AND ANEMIA Epoetin Alfa (Procrit) Filgrastim (Neupogen)

HERPES PROPHYLAXIS AND TREATMENT Acyclovir

HORMONAL/METABOLIC AGENTS Anastrozole Androderm Bicalutamide Contraceptives (Oral-only) Endometrin tablets Injectable Injectable Conjugated (Premarin) Evista Insulins (Levoxyl or Synthroid) Liothyronine Medroxyprogesterone Megestrol (Megace) ES Sustained Release (Niaspan or Equivalent) Prednisone Prometrium (Androgel Pump) Testosterone Gel (Androgel) Testosterone Gel (Testim)

Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

HUMAN PAPILLOMAVIRUS Imiquimod Cream (Aldara) Podofilox Solution (Condylox)

INFLUENZA ANTIVIRALS Oseltamivir Phosphate (Tamiflu)

METABOLIC SYNDROME AGENTS Actos (Lipitor) Glipizide Glyburide Jardiance Metformin Omega-3 Acid Ethyl (Pravachol) (Crestor) Saxenda Sitagliptin (Januvia) Trulicity Victoza

MUSCLE RELAXANTS

OPHTHALMIC Durezol Lantanoprost 1% Ophthalmic Solution Timolol Opth. Solution

OTHER 1.1% Sodium Fluoride Toothpaste Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

1.1% Sodium Fluoride Gel Wipes* Alendronate (Fosamax) Allopurinol Free Style Libre Blood Glucose Monitoring System/Supplies* Nipro Diagnostic Brand Blood Glucose Monitoring System/Supplies* (Nasal Spray Only – No Injectable) Nitrostat Needles**** Prolia Syringes****

PERIPHERAL NEUROPATHY Gabapentin (Neurontin) Pregabalin (Lyrica)

PNEUMOCYSTIS/TOXOPLASMOSIS PROPHYLAXIS AND TREATMENT Atovaquone (Mepron) Dapsone Leucovorin Pentamidine Isethionate (Nebupent) Pyrimethamine (Daraprim) Sulfadiazine Sulfamethoxazole/Trimethoprim (SMZ/TMP) Trimethoprim

PSYCHOTROPICS/NEUROLOGIC ADDICTION Naltrexone (Tablets only)

ANTIANXIETY/HYPNOTICS Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

Diazepam (All strengths) Silenor

ANTICONVULSANTS Divalproex (Valproic Acid) Lamictal Levetiracetam (Keppra)

ANTIDEPRESSANTS Sr (Wellbutrin) (Celexa) Desipramine (Cymbalta) (Lexapro) Nortriptyline (Zoloft) Strattera (Effexor) Viibryd

ANTIPSYCHOTICS Geodon Haldol Latuda Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

Loxapine (Seroquel) Saphris

MOOD STABILIZERS Lithium Carbonate

OTHER Tablets Vyvanse

PULMONARY Advair Inhaler Albuterol Metered-Dose Inhaler (MDI) Beclomethasone (QVAR) Flunisolide MDI Ipratropium HFA Montelukast Spiriva Symbicort

SMOKING CESSATION Chantix

TOPICALS 5% Efudex Cream (may prescribe with/without separate Rx for the DoseRite Rectal Applicator) 5% Lidocaine Ointment Chlorhexidine Mouthwash Fluocinonide Cream/Ointment Hydrocortisone Cream/Ointment Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

Ketoconazole Cream, Shampoo Ointment Cream Selenium Sulfide Silvadene Cream Triamcinolone Cream/Ointment

UROLOGY Finasteride ER Oxybutynin IR ER Tolterodine IR

======*A current prescription written by a medical provider must be presented for the medication(s) prior to these products being dispensed by the pharmacy.

**For , Genentech 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.

****A current prescription written by a medical provider must be presented for all syringes and/or needles prior to these products being dispensed by the pharmacy. In addition, the patient must have a prescription order for a formulary approved injectable medication. ADAP is strictly prohibited from participating in “needle exchange” programs.

*****Please review and submit all data elements contained within the HCV patient registry to ADAP as indicated. The Arizona ADAP HCV patient registry can be obtained by contacting ADAP directly at 602-364- 3610/toll free at 800-334-1540 or on the ADHS public website at http://www.azdhs.gov/phs/hiv/adap/index.htm.

Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans

******Please contact OptumRx 340B pharmacy (855-428-3552) at time of prescription order to arrange for specialized medication delivery.

Updated: April 22, 2021

Douglas A. Ducey | Governor Cara M. Christ, MD, MS | Director

150 North 18th Avenue, Suite 130, Phoenix, AZ 85007-3247 P | 602-364-3610 F | 602-364-3263 W | azhealth.gov Health and Wellness for all Arizonans