HIV DRUG ASSISTANCE PROGRAM (HDAP) - PDF Document

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  1. BRUCE S. ANDERSON, Ph.D. DIRECTOR OF HEALTH New additions to formulary DAVID Y. IGE GOVERNOR OF HAWAII STATE OF HAWAII DEPARTMENT OF HEALTH HARM REDUCTION SERVICES BRANCH HIVDRUG ASSISTANCE PROGRAM (HDAP) 3627 Kilauea Avenue, Room 306 Honolulu, Hawaii 96816-2399 HIV DRUG ASSISTANCE PROGRAM (HDAP) FORMULARY – January 2019 HIV Antiretrovirals abacavir (Ziagen) abacavir/lamivudine (Epzicom) abacavir/lamivudine/zidovudine (Trizivir) emtricitabine/rilpivirine/tenofovir df atazanavir (Reyataz) atazanavir/cobicistat (Evotaz) bictegravir/emtricitabine/tenofovir alafenamine (Biktarvy) cobicistat (Tybost) darunavir (Prezista) darunavir/cobicistat (Prezcobix) darunavir/cobicistat/emtricitabine/tenofovir alafenamide (Symtuza) delavirdine (Rescriptor) didanosine (Videx, Videx EC) dolutegravir (Tivicay) dolutegravir/abacavir/lamivudine (Triumeq) dolutegravir/rilpivirine (Juluca) doravirine (Pifeltro) doravirine/lamivudine/tenofovir df (Delstrigo) raltegravir (Isentress, Isentress HD) efavirenz (Sustiva) efavirenz/emtricitabine/tenofovir df (Atripla) elvitegravir (Vitekta) elvitegravir/cobicistat/emtricitabine/ tenofovir alafenamide (Genvoya) elvitegravir/cobicistat/emtricitabine/ tenofovir df (Stribild) emtricitabine (Emtriva) Pneumocystis carinii Pneumonia (PCP) atovaquone (Mepron suspension) dapsone pentamidine-aerosolized (NebuPent) HIV Related Anemia and Neutropenia epoetin alfa (Epogen, Procrit) filgrastim (Neupogen, G-CSF) emtricitabine/rilpivirine/tenofovir alafenamide (Odefsey) (Complera) emtricitabine/tenofovir alafenamide (Descovy) emtricitabine/tenofovir df (Truvada) enfuvirtide (Fuzeon) etravirine (Intelence) fosamprenavir (Lexiva) ibalizumab-uiyk (Trogarzo) 1 indinavir (Crixivan) lamivudine (Epivir) lamivudine/zidovudine (Combivir) lopinavir/ritonavir (Kaletra) maraviroc (Selzentry) nelfinavir (Viracept) nevirapine (Viramune, Viramune XR) rilpivirine (Edurant) ritonavir (Norvir) saquinavir hard gel (Invirase) stavudine (Zerit) tenofovir disoproxil fumarate (Viread) tipranavir (Aptivus) zidovudine (Retrovir) primaquine trimethoprim/sulfamethoxazole (TMP/SMX) leucovorin (Wellcovorin) Hawai‘i HIV Drug Assistance Program (HDAP) Formulary January 2019 1

  2. Viral Hepatitis daclatasvir (Daklinza)2 elbasvir/grazoprevir (Zepatier)2 entecavir (Baraclude)3 glecaprevir/pibrentasvir (Mavyret)2 hepatitis A/B vaccines (Twinrix, Havrix, Engerix-B) ledipasvir/sofosbuvir (Harvoni)2 ombitasvir/paritaprevir/ritonavir (Technivie) 2 ombitasvir/paritaprevir/ritonavir; dasabuvir (Viekira Pak)2 peginterferon alfa-2a (Pegasys) peginterferon alfa-2b (PEG-Intron) ribavirin (Copegus, Rebetol) sofosbuvir (Sovaldi)2 sofosbuvir/velpatasvir (Epclusa)2 sofosbuvir/velpatasvir/voxilaprevir (Vosevi)2 tenofovir alafenamide (Vemlidy) Opportunistic Infections isoniazid itraconazole (Sporanox) ketoconazole (Nizoral) megestrol acetate (Megace OS / ES) norfloxacin (Noroxin) paclitaxel (Taxol) posaconazole (Noxafil) probenecid pyrazinamide pyrimethamine (Daraprim) rifabutin (Mycobutin) rifampin (Rifadin) sulfadiazine valacyclovir (Valtrex) valganciclovir (Valcyte) vancomycin (Vancocin) Other Anti-infectives paromomycin (Humatin) pneumococcal PSV (Pneumovax) terbinafine (Lamisil) tetracycline zanamivir (Relenza) Antidepressants/Antipsychotics paroxetine (Paxil) quetiapine (Seroquel) bupropion (Wellbutrin, Wellbutrin SR) citalopram (Celexa) fluoxetine (Prozac) mirtazapine (Remeron) olanzapine (Zyprexa) acyclovir (Zovirax) amphotericin B (Fungizone) amphotericin B liposomal (AmBisome) azithromycin (Zithromax) cephalexin (Keflex) cidofovir (Vistide) ciprofloxacin (Cipro) clarithromycin (Biaxin) clindamycin (Cleocin) clotrimazole (Lotrimin, Mycelex) daunorubicin liposomal (DaunoXome) ethambutol (Myambutol) famciclovir (Famvir) fluconazole (Diflucan) flucytosine (Ancobon) foscarnet (Foscavir) ganciclovir (Cytovene) dicloxacillin doxycycline erythromycin metronidazole (Flagyl) oseltamivir (Tamiflu) amitriptyline (Elavil) aripiprazole (Abilify) risperidone (Risperdal) sertraline (Zoloft) venlafaxine (Effexor, Effexor XR) ziprasidone (Geodon) Hawai‘i HIV Drug Assistance Program (HDAP) Formulary January 2019 2

  3. Antidiarrheals crofelemer (Mytesi) diphenoxylate/atropine (Lomotil) loperamide (Imodium) Antihyperlipidemics atorvastatin (Lipitor) fenofibrate (Tricor) gemfibrozil (Lopid) niacin extended-release tablets (Niaspan) pitavastatin (Livalo) pravastatin (Pravachol) rosuvastatin (Crestor) Cardiovascular agents amlodipine (Norvasc) clopidogrel (Plavix) furosemide (Lasix) hydrochlorothiazide isosorbide mononitrate (Ismo) lisinopril (Zestril) lisinopril/hydrochlorothiazide (Zestoretic) losartan (Cozaar) metoprolol succinate (Toprol XL) metoprolol tartrate (Lopressor) metoprolol tartrate/hydrochlorothiazide (Lopressor HCT) olmesartan (Benicar) olmesartan/hydrochlorothiazide (Benicar HCT) spironolactone (Aldactone) warfarin (Coumadin) Dermatologic agents hydrocortisone 1% cream imiquimod (Aldara) sinecatechins ointment 15% (Veregen) Diabetes pioglitazone (Actos) rosiglitazone (Avandia) Gender Transitioning; Transgender Patients dutasteride (Avodart) estradiol- oral, sublingual, transdermal estradiol valerate for IM injection estradiol cypionate for IM injection finasteride- 1 MG, 5 MG (Propecia, Proscar)4 alitretinoin gel (Panretin Gel) 5-fluorouracil (Efudex) hexachlorophene (PhisoHex) 3% glyburide metformin (Glucophage) medroxyprogesterone acetate, oral (Provera) progesterone, micronized spironolactone (Aldactone) testosterone cypionate for IM injection testosterone gel (Androgel) Substance Use Disorder: Medication Assisted Treatment and Opioid Overdose acamprosate (Campral) buprenorphine (Subutex)5 buprenorphine/naloxone (Suboxone) 5 clonidine (Catapres) disulfiram (Antabuse) naloxone- injection, auto-injector, intranasal (Narcan) naltrexone- injection, oral (Vivitrol, ReVia, Depade) Hawai‘i HIV Drug Assistance Program (HDAP) Formulary January 2019 3

  4. Other albuterol (Proventil, Ventolin) alendronate (Fosamax) cyanocobalamin (B12) injection divalproex sodium (Depakote) dutasteride (Avodart) epinephrine autoinjector (EpiPen) finasteride (Proscar)4 gabapentin (Gralise, Neurontin) hydroxyurea (Hydrea) levabuterol (Xopenex) levetiracetam (Keppra) levothyroxine (Synthroid) medroxyprogesterone acetate for injection (Depo-Provera) naproxen 1Ibalizumab-uiyk (Trogarzo) is not available through HDAP’s contract pharmacy, 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. omeprazole (Prilosec) ondansetron (Zofran) pancrelipase (Ultrase MT20) pantoprazole (Protonix) pregabalin (Lyrica) prednisone prochlorperazine (Compazine) risedronate (Actonel) somatropin (rDNA origin) for injection (Serostim) 6 tamsulosin (Flomax) terazosin (Hytrin) testosterone cypionate for IM injection testosterone gel (Androgel) varenicline (Chantix) 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 January 2019 4