antiretrovirals

DELAWARE HEALTH
AND SOCIAL SERVICES
_______________________________________________________________
Division of Public Health
_______________________________________________________________
Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011 Antiretrovirals
Abacavir (Ziagen)
Abacavir/lamivudine (Epzicom)
Amprenavir (Agenerase)
Atazanavir (Reyataz)
Complera (emtricitabine, rilpivirine and tenofovir)
Darunavir (Prezista)
Delavirdine (Rescriptor)
Didanosine (ddI, Videx, Videx EC[all strengths])
Edurant (rilpivirine)
Efavirenz (Sustiva-all strengths)
Efavirenz/Emtricitabine/Tenofovir (Atripla)
Emtricitabine (Emtriva)
Enfuvirtide (Fuzeon)
Etravirine (Intelence)
Fosamprenavir (Lexiva)
Indinavir (Crixivan)
Lamivudine (3TC, Epivir all strengths)
Lopinavir/Ritonavir (Kaletra)
Maraviroc (Selzentry)– Pre-approval a must (call 302-744-1050)
Nelfinavir (Viracept – all strengths)
Nevirapine (Viramune)
Raltegravir (Isentress)
Ritonavir (Norvir)
Saquinavir (Invirase [all strengths] or Fortovase)
Stavudine (d4T, Zerit, Zerit XR)
Tenofovir (Viread)
Tenofovir disoproxil/emtricitabine (Truvada)
Tipranavir (Aptivus)
Zidovudine (AZT, Retrovir)
Zidovudine/Lamivudine (Combivir)
Zidovudine/Lamivudine/Abacavir (Trizivir)
Clients on prescriptions other than antiretrovirals or treatments for
opportunistic infections require documentation on file at their physicians’
office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY
HIV/AIDS.
DELAWARE HEALTH
AND SOCIAL SERVICES
_______________________________________________________________
Division of Public Health
_______________________________________________________________
Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011 Antivirals/Antifungals/Antimicrobials
Antivirals
Antimicrobials
Interferon Alfa-2b+ Ribavirin (Intron A+ Rebetrol, Rebetron, Peg-Intron)i
Dicloxacillin (Dycill, Dynapen, Pathocill) Pegasys (Peginterferon alfa-2a) i
Doxycycline (Vibramycin, Doxy, Doxychel, Isoniazid (INH)Levofloxacin (Levaquin)Moxifloxacin (Avelox) Antifungals
Penicillin (Pen Vee K, Veetids, Beepen-VK, RifampinSulfadiazine (Microsulfon)Sulfamethoxazole/Trimethoprim (Bactrim, Antimicrobials
Antibiotics (all types, all manufactures)* Amoxicillin & Clavulanate Potassium (Augmentin)Ampicillin (Omnipen, Principen)Atovaquone (Mepron)Azithromycin (Zithromax) Clients on prescriptions other than antiretrovirals or treatments for
opportunistic infections require documentation on file at their physicians’
office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY
HIV/AIDS.
DELAWARE HEALTH
AND SOCIAL SERVICES
_______________________________________________________________
Division of Public Health
_______________________________________________________________
Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011 Gastrointestinal Agents/Nutritional Supplements/Appetite Stimulants/Antidiarrheals
Gastrointestinal Agents
Nutritional Supplements/Appetite
stimulants
Famotidine (Pepcid)Hemorrhoidal Creams & Suppository (All brands)Lansoprazole (Prevacid) Antidiarrheals
Pancrease Enzymes (All commerciallyavailable formulations, generics) Antiemetic
Promethazine (Phenergan, various generics) Inhalers/Bronchodilators/Oral Steroids/Asthma Prophylaxis
Clients on prescriptions other than antiretrovirals or treatments for
opportunistic infections require documentation on file at their physicians’
office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY
HIV/AIDS.
DELAWARE HEALTH
AND SOCIAL SERVICES
_______________________________________________________________
Division of Public Health
_______________________________________________________________
Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011 Antidepressants/Antipsychotics/Agents for Sleep
Lithium Carbonat e (Lithobid, all others) Oral Hypoglycemics/Insulinii
Glyburide (DiaBeta, Micronase, generic) * Insulins (all types, all manufacturers) * Metformin (Glucophage, Glucopahage XR,Fortamet)* iiOther FDA Approved supplies for
management of Diabetes Mellitus (limited
to syringes, alcohol swabs, blood glucose
monitors, lancets, and test strips)
Clients on prescriptions other than antiretrovirals or treatments for
opportunistic infections require documentation on file at their physicians’
office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY
HIV/AIDS.
DELAWARE HEALTH
AND SOCIAL SERVICES
_______________________________________________________________
Division of Public Health
_______________________________________________________________
Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011 Pain Medications
Nonnarcotic analgesics
Narcotic analgesics
Diclofenac (Cataflam, Voltaren, generics) Morphine Sulfate (Avinza, MSIR, Oramorph Nabumetone (Relafen)Naproxen (Aleve, Anaprox, Naprosyn,Naprelan)Oxaprozin (Daypro)Piroxicam (Feldene, generics)Sulindac (Clinoril)Tolmentin (Tolectin)Tramadol (Ultram) Vaccines
Topical Medications
Clients on prescriptions other than antiretrovirals or treatments for
opportunistic infections require documentation on file at their physicians’
office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY
HIV/AIDS.
DELAWARE HEALTH
AND SOCIAL SERVICES
_______________________________________________________________
Division of Public Health
_______________________________________________________________
Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011 Lipid Lowering Agents
Niacin (Niaspan, Nicotinic Acid, Slo-Niacin, Antihypertensives/Cardiac Medications-combination products of those listed below also
Nifedipine (Adalat, Adalat CC, Procardia, Telmisartan/Hydrochlorothiazide (Micardis Lisinopril (Prinivil, Zestril, all generics) Clients on prescriptions other than antiretrovirals or treatments for
opportunistic infections require documentation on file at their physicians’
office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY
HIV/AIDS.
DELAWARE HEALTH
AND SOCIAL SERVICES
_______________________________________________________________
Division of Public Health
_______________________________________________________________
Delaware AIDS Drug Assistance Program (ADAP) Formulary as of September 27, 2011 Prescription Antihistamines (including combination products)
Agents for Osteopenia/Osteoporosis
Miscellaneous
Triamcino lone 1% Dental Paste(Aristocort) Anticonvulsants
The following ADAP medications may not require a prescription
Dexchlorpheniramine (Polaramine, various) Famotidine (Pepcid)Ferrous Sulfate (Feosol, Mol-Iron, Slow Fe) Clients on prescriptions other than antiretrovirals or treatments for
opportunistic infections require documentation on file at their physicians’
office stating that THE DISORDER IS RELATED TO OR EXACERBATED BY
HIV/AIDS.

Source: http://delawarehiv.org/uploads/PDF/ADAP-Formulary.pdf