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Aids Drug Assistance Program (Adap) Formulary – Provider Version

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Aids Drug Assistance Program (Adap) Formulary – Provider Version AIDS DRUG ASSISTANCE PROGRAM (ADAP) FORMULARY – PROVIDER VERSION April 22, 2021 (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) Doravirine (Pifeltro) Doravirine/Lamivudine (Delstrigo) Edurant (Rilpivirine) Efavirenz (Sustiva) Etravirine (Intelence) Nevirapine (Viramune) PROTEASE INHIBITORS Atazanavir (Reyataz) Atazanavir/Cobicistat (Evotaz) Cobicistat/Darunavir (Prezcobix) Darunavir (Prezista) Fosamprenavir Calcium (Lexiva) Indinavir (Crixivan) Lopinavir/Ritonavir (Kaletra) Nelfinavir (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) Tipranavir (Aptivus) HIV ENTRY/FUSION INHIBITORS Enfuvirtide (Fuzeon) Maraviroc (Selzentry)*** INTEGRASE INHIBITORS Dolutegravir (Tivicay) Raltegravir (Isentress) Raltegravir (Isentress HD) COMBINATION ANTIRETROVIRAL PRODUCTS Atripla (Efavirenz/Emtricitabine/Tenofovir) Biktarvy (bictegravir 50mg/emtricitabine 200mg/tenofovir alafenamide 25mg - BIC/FTC/TAF) Cimduo (lamivudine and tenofovir disoproxil fumerate) Combivir (Lamivudine/Zidovudine) Complera (Rilpivirine/Tenofovir/Emtricitabine) Descovy (emtricitabine 200mg, tenofovir alafenamide 25mg) Dovato (dolutegravir/lamivudine) Epzicom (Lamivudine/Abacavir) Genvoya (Cobicistat, Elvitegravir, 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 (ibalizumab-uiyk)****** ATTACHMENT INHIBITORS Rukobia (Fostemsavir) ALLERGY/COUGH/COLD Astelin (Azelastine HCL) Beconase AQ (Beclomethasone Dipropionate) Benzonatate Diphenhydramine Epi-Pen Flunisolide Guaifenesin with Codeine cough syrup Hydroxyzine Loratidine Nasonex (Mometasone) Pseudoephedrine ANALGESICS Acetaminophen/Codeine Acetaminophen/Hydrocodone Acetaminophen/Oxycodone Aspirin* Butalbital/APAP/Caffeine Celecoxib Chloralphenazone/Isometheptene/Acetaminophen (For Migraine) Diclofenac Gel Ibuprofen* Meloxicam Methadone (For Pain, Not Addiction Rx) Morphine Sulfate Immediate Release Morphine Sulfate Sustained Release Naproxen* Oxycodone Immediate Release Ultram (Tramadol 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 Ciprofloxacin Dicloxacillin Doxycycline Erythromycin Ophthalmic Ointment Levofloxacin Macrobid Metronidazole Moxifloxacin Neomycin/polymyxin/dexamethasone Neomycin/polymyxin/hydrocortisone Penicillin VK Tetracycline Tobradex (tobramycin/dexamethasone) Vancomycin Xifaxan Zyvox ANTICONVULSANT Oxcarbazepine ANTIDIARRHEALS Diphenoxylate/Atropine Loperamide ANTIEMETICS Metoclopramide 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 Promethazine Zofran (Ondansetron) ANTIFUNGALS Clotrimazole Oral Troches Fluconazole Itraconazole (Sporanox) Miconazole Vaginal Nystatin Suspension Posaconazole Voriconazole ANTIMYCOBACTERIALS (MAC, TB) Azithromycin (Zithromax) Ciprofloxacin Clarithromycin (Biaxin) Ethambutol (Myambutol) Isoniazid (INH) Primaquine Pyrazinamide Pyridoxine (To Be Given With Inh) Rifabutin (Mycobutin) Rifampin ANTIPARASITIC Alinia Ivermectin Tinidazole BLOOD PRESSURE Amlodipine Atenolol Benazepril Bumetanide Carvedilol 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 Doxazosin Enalapril Furosemide Hctz Hctz/Triamterene Hydralazine Lisinopril Losartan Metoprolol Midodrine Propranolol Spironolactone CARDIAC Isosorbide Ranexa CYTOMEGALOVIRUS PROPHYLAXIS AND TREATMENT Valganciclovir (Valcyte) ELECTROLYTES/NUTRITION Calcium acetate Calcium carbonate Calcium carbonate/Vitamin D Calcium citrate Calcium citrate/Vitamin D Ferrous Sulfate Folic Acid L-Methylfolate (7.5 and/or 15mg capsules only) Magnesium Oxide Multivitamin with 1 mg Folate/Pre-Natal Vitamins Potassium Chloride GASTROINTESTINAL Bisacodyl* 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 Cimetidine Dicyclomine Docusate* Famotidine Go-Lytely Lactulose Lansoprazole Miralax Nu-Lytely Omeprazole Opium Tincture Pancrelipase Capsules (any manufacture) Pantoprazole Pylera Ranitidine Sodium Bicarbonate HEMATOLOGIC Brilinta Clopidogrel Enoxaparin Eliquis Pradaxa Warfarin Xarelto HEPATITIS B TREATMENT Entecavir (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 SIDE EFFECTS, NEUTROPENIA, AND ANEMIA Epoetin Alfa (Procrit) Filgrastim (Neupogen) HERPES PROPHYLAXIS AND TREATMENT Acyclovir HORMONAL/METABOLIC AGENTS Anastrozole Androderm Bicalutamide Contraceptives (Oral-only) Endometrin Estradiol tablets Estradiol Cypionate Injectable Estradiol Valerate Injectable Estrogen Conjugated (Premarin) Evista Insulins Levothyroxine (Levoxyl or Synthroid) Liothyronine Medroxyprogesterone Megestrol (Megace) ES Methylprednisolone Niacin Sustained Release (Niaspan or Equivalent) Prednisone Prometrium Testosterone (Androgel Pump) Testosterone Cypionate Testosterone Enanthate 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 Atorvastatin (Lipitor) Ezetimibe Fenofibrate Gemfibrozil Glipizide Glyburide Jardiance Metformin Omega-3 Acid Ethyl Esters Pitavastatin Pravastatin (Pravachol) Rosuvastatin (Crestor) Saxenda Sitagliptin (Januvia) Trulicity Victoza MUSCLE RELAXANTS Cyclobenzaprine OPHTHALMIC Durezol Lantanoprost Prednisolone 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 Alcohol Wipes* Alendronate (Fosamax) Allopurinol Free Style Libre Blood Glucose Monitoring System/Supplies* Meclizine Nipro Diagnostic Brand Blood Glucose Monitoring System/Supplies* Naloxone (Nasal Spray Only – No Injectable) Nitrostat Needles**** Prolia Syringes**** 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 ADDICTION Naltrexone (Tablets only) ANTIANXIETY/HYPNOTICS Buspirone 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 Doxepin (All strengths) Lorazepam Silenor Temazepam Zolpidem ANTICONVULSANTS Clonazepam Divalproex (Valproic Acid) Lamictal Levetiracetam (Keppra) Phenytoin ANTIDEPRESSANTS Amitriptyline Bupropion Sr (Wellbutrin) Citalopram (Celexa) Desipramine Duloxetine (Cymbalta) Escitalopram (Lexapro) Fluoxetine Mirtazapine Nortriptyline Paroxetine Sertraline (Zoloft) Strattera Trazodone Venlafaxine (Effexor) Viibryd ANTIPSYCHOTICS Aripiprazole Chlorpromazine Geodon Haldol Latuda Douglas A. Ducey
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