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Colorado AIDS Drug Assistance Program Description of Medication Formularies

Effective Date: September 15, 2013


FORMULARY FOR THE HIV MEDICATION ASSISTANCE PROGRAM (RAMSELL GROUP 38002) AND FOR THE HEALTH INSURANCE ASSISTANCE PROGRAM (HIAP)- RAMSELL GROUP 38003 (EFFECTIVE SEPTEMBER 15, 2013) Brand Name Ziagen Epzicom Reyataz Prezista Rescriptor Videx Videx EC Tivicay Sustiva Stribild Emtriva Complera Truvada Atripla Fuzeon Intelence Levixa Crixivan Epivir Kaletra Selzentry Viracept Viramune Viramune XR Isentress Edurant Norvir Invirase Zerit Viread Aptivus Retrovir Combivir Trizivir Generic Name Abacavir Abacavir/Lamivudine Atazanavir Darunavir Delaviradine Didanosine (ddI) Didanosine EC Brief Description of Category NRTI - ANTIRETROVIRAL COMB ANTIRETROVIRAL - NRTI PI - ANTIRETROVIRAL PI - ANTIRETROVIRAL NNRTI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL INTEGRASE STRAND TRANSFER INHIBITOR (INSTI) NNRTI - ANTIRETROVIRAL COMBINATION ANTIRETROVIRAL NRTI - ANTIRETROVIRAL COMB ANTIRETROVIRAL - NRTI, NNRTI COMB ANTIRETROVIRAL - NRTI COMB ANTIRETROVIRAL - NRTI, NNRTI FI - ANTIRETROVIRAL NNRTI - ANTIRETROVIRAL PI - ANTIRETROVIRAL PI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL PI - ANTIRETROVIRAL CA - ANTIRETROVIRAL PI - ANTIRETROVIRAL NNRTI - ANTIRETROVIRAL NNRTI - ANTIRETROVIRAL II - ANTIRETROVIRAL NNRTI - ANTIRETROVIRAL PI - ANTIRETROVIRAL PI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL PI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL COMB ANTIRETROVIRAL - NRTI COMB ANTIRETROVIRAL - NRTI

Dolutegravir
Efavirenz ELVITEGR/COBICIST/EMTRIC/TENOF Emtricitabine (FTC) Emtricitabine, rilpivirine, and tenofovir Emtricitabine/Tenofovir Emtricitabine/Tenofovir/Efavirenz Enfuvirtide (T-20) Etravirine Fosamprenavir Indinavir Lamivudine (3TC) Lopinavir/Ritonavir Maraviroc Nelfinavir Nevirapine Nevirapine Raltegravir Rilpivirine Ritonavir Saquinavir Mesylate Stavudine (d4T) Tenofovir Tipranivir Zidovudine (AZT) Zidovudine/Lamivudine Zidovudine/Lamivudine/Abacavir

Zovirax Hepsera Amoxil Fungizone Abilify Tenormin Lipitor Mepron Alesse Zithromax Wellbutrin Peridex Vistide Celexa Biaxin Cleocin

Acyclovir Adefovir Amoxicillin Amphotericin Injection Aripiprazole Atenolol Atorvastatin Atovaquone Aviane and Generics Azithromycin Buproprion Chlorhexidine rinse Cidofovir Citalopram Clarithromycin Clindamycin

OPPORTINISTIC INFECTION MEDICATIONS BETA-ADRENERGIC BLOCKING AGENTS PENICILLINS OPPORTINISTIC INFECTION MEDICATIONS PSYCHOTROPIC MEDICATIONS BETA-ADRENERGIC BLOCKING AGENTS ANTIHYPERLIPIDEMIC ANTIPROTOZOAL DRUGS,MISCELLANEOUS CONTRACEPTIVES OPPORTINISTIC INFECTION MEDICATIONS ANTIDEPRESSANT ORAL RINSE FOR TREATMENT OF GINGIVITIS OPPORTINISTIC INFECTION MEDICATIONS PSYCHOTROPIC MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS

Colorado AIDS Drug Assistance Program Description of Medication Formularies


Effective Date: September 15, 2013
Mycelex Dapsone Lomotil Depakote Nexium Myambutol Famvir Tricor Diflucan Foscavir Neurontin Cytovene Lopid Glucometer Glucose strips Micronase Hydrodiuril Various Sporanox Lancets Leucovorin Keppra Zestril Zestoretic Imodium A-D Cozaar Glucophage Glucovance Lopressor Flagyl Remeron OrthoNovum 1/35 Alinia Nystatin Zyprexa Veetids Nebupent Daraprim Seroquel Zantac Mycobutin Risperdal Crestor Zoloft Sulfadiazine Septra, Bactrim Various NuvaRing Valtrex Valcyte Chantix Effexor Vfend Geodon Clotrimazole Dapsone Diphenoxylate and Atropine Divalproex sodium Esomeprazole Ethambutol Famciclovir Fenofibrate Fluconazole Foscarnet Gabapentin Gancyclovir Gemfibrozil Glucometer Glucose Strips Glyburide Hydrochlorothiazide (HCTZ) Insulin Itraconazole Lancets Leucovorin Levetiracetam Lisinopril Lisinopril w/ HCTZ Loperamide Losartan Metformin Metformin w/ Glyburide Metoprolol Metronidazole Mirtazipine Necon 1/35 and Generics Nitazoxanide Nystatin Suspension Olanzapine Penicillin Pentamidine, aerosol Pyrimethamine Quetiapine Ranitidine Rifabutin Risperidone Rosuvastatin Sertraline Sulfadiazine Sulfamethoxazole/Trimethoprim Testosterone Vaginal Ring Valacyclovir Valganciclovir Varenicline Venlafaxine Voriconazole Ziprasidone ANTIFUNGAL AGENTS OPPORTINISTIC INFECTION MEDICATIONS ANTIDIARRHEALS ANTICONVULSANTS GASTROINTESTINAL MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS LIPOTROPICS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS ANTICONVULSANTS OPPORTINISTIC INFECTION MEDICATIONS LIPOTROPICS BLOOD SUGAR DIAGNOSTICS BLOOD SUGAR DIAGNOSTICS ANTIHYPERGLYCEMIC THIAZIDE AND RELATED DIURETICS INSULINS OPPORTINISTIC INFECTION MEDICATIONS LANCETS OPPORTINISTIC INFECTION MEDICATIONS ANTICONVULSANTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ANTIDIARRHEALS ANTIHYPERTENSIVES ANTIHYPERGLYCEMIC ANTIHYPERGLYCEMIC BETA-ADRENERGIC BLOCKING AGENTS ANTIPROTOZOAL DRUGS,MISCELLANEOUS PSYCHOTROPIC MEDICATIONS CONTRACEPTIVES ANTIPROTOZOAL DRUGS,MISCELLANEOUS ANTIFUNGAL ANTIBIOTICS PSYCHOTROPIC MEDICATIONS PENICILLINS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS PSYCHOTROPIC MEDICATIONS GASTROINTESTINAL MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS PSYCHOTROPIC MEDICATIONS ANTIHYPERLIPIDEMIC PSYCHOTROPIC MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS ANDROGENIC AGENTS CONTRACEPTIVES OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS SMOKING DETERRENT ANTIDEPRESSANT ANTIFUNGAL AGENTS PSYCHOTROPIC MEDICATIONS

AVAILABLE WITH PRIOR AUTHORIZATION: Aranesp Procrit,Epogen Neupogen Neulasta Pegasys Darbepoetin alfa Epoetin alfa/Erythropoietin Filgrastim Pegfilgrastim Peginterferon alfa-2a HEPATITIS C TREATMENT HEPATITIS C TREATMENT HEPATITIS C TREATMENT LEUKOCYTE (WBC) STIMULANTS OPPORTINISTIC INFECTION MEDICATIONS

Colorado AIDS Drug Assistance Program Description of Medication Formularies


Effective Date: September 15, 2013
Peg-Intron Copegus,Rebetol Alternative contraceptives Peginterferon alfa-2b Ribavirin Various OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS CONTRACEPTIVES

NOTE: This formulary applies to Ramsell Group 38002, the HIV Medication Assistance Program (HMAP) for people who do not have health insurance, and Ramsell Group 38003, the Health Insurance Assistance Program (HIAP). If you are on Bridging the Gap (Ramsell Group 38001) for those with Medicare, or the Preexisting Condition Insurance Plan (PCIP) call 303-692-2716 for formulary information.

FORMULARY FOR THE BRIDGING THE GAP COLORADO PROGRAM (RAMSELL GROUP 38001) Brand Name Ziagen Epzicom Reyataz Prezista Rescriptor Videx Videx EC Tivicay Sustiva Stribild Emtriva Complera Truvada Atripla Fuzeon Intelence Levixa Crixivan Epivir Kaletra Selzentry Viracept Viramune Viramune XR Isentress Edurant Norvir Invirase Zerit Viread Aptivus Retrovir Combivir Trizivir Generic Name Abacavir Abacavir/Lamivudine Atazanavir Darunavir Delaviradine Didanosine (ddI) Didanosine EC Brief Description of Category NRTI - ANTIRETROVIRAL COMB ANTIRETROVIRAL - NRTI PI - ANTIRETROVIRAL PI - ANTIRETROVIRAL NNRTI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL INTEGRASE STRAND TRANSFER INHIBITOR (INSTI) NNRTI - ANTIRETROVIRAL COMBINATION ANTIRETROVIRAL NRTI - ANTIRETROVIRAL COMB ANTIRETROVIRAL - NRTI, NNRTI COMB ANTIRETROVIRAL - NRTI COMB ANTIRETROVIRAL - NRTI, NNRTI FI - ANTIRETROVIRAL NNRTI - ANTIRETROVIRAL PI - ANTIRETROVIRAL PI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL PI - ANTIRETROVIRAL CA - ANTIRETROVIRAL PI - ANTIRETROVIRAL NNRTI - ANTIRETROVIRAL NNRTI - ANTIRETROVIRAL II - ANTIRETROVIRAL NNRTI - ANTIRETROVIRAL PI - ANTIRETROVIRAL PI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL PI - ANTIRETROVIRAL NRTI - ANTIRETROVIRAL COMB ANTIRETROVIRAL - NRTI COMB ANTIRETROVIRAL - NRTI

Dolutegravir
Efavirenz ELVITEGR/COBICIST/EMTRIC/TENOF Emtricitabine (FTC) Emtricitabine, rilpivirine, and tenofovir Emtricitabine/Tenofovir Emtricitabine/Tenofovir/Efavirenz Enfuvirtide (T-20) Etravirine Fosamprenavir Indinavir Lamivudine (3TC) Lopinavir/Ritonavir Maraviroc Nelfinavir Nevirapine Nevirapine Raltegravir Rilpivirine Ritonavir Saquinavir Mesylate Stavudine (d4T) Tenofovir Tipranivir Zidovudine (AZT) Zidovudine/Lamivudine Zidovudine/Lamivudine/Abacavir

Zovirax Hepsera Amoxil Fungizone Abilify Tenormin Lipitor

Acyclovir Adefovir Amoxicillin Amphotericin Injection Aripiprazole Atenolol Atorvastatin

OPPORTINISTIC INFECTION MEDICATIONS BETA-ADRENERGIC BLOCKING AGENTS PENICILLINS OPPORTINISTIC INFECTION MEDICATIONS PSYCHOTROPIC MEDICATIONS BETA-ADRENERGIC BLOCKING AGENTS ANTIHYPERLIPIDEMIC

Colorado AIDS Drug Assistance Program Description of Medication Formularies


Effective Date: September 15, 2013
Mepron Alesse Zithromax Wellbutrin Peridex Vistide Celexa Biaxin Cleocin Mycelex Dapsone Lomotil Depakote Nexium Myambutol Famvir Tricor Diflucan Foscavir Neurontin Cytovene Lopid Glucometer Glucose strips Micronase Hydrodiuril Various Sporanox Lancets Leucovorin Keppra Zestril Zestoretic Imodium A-D Cozaar Glucophage Glucovance Lopressor Flagyl Remeron OrthoNovum 1/35 Alinia Nystatin Zyprexa Veetids Nebupent Daraprim Seroquel Zantac Mycobutin Risperdal Crestor Zoloft Sulfadiazine Septra, Bactrim Various NuvaRing Valtrex Valcyte Chantix Effexor Atovaquone Aviane and Generics Azithromycin Buproprion Chlorhexidine rinse Cidofovir Citalopram Clarithromycin Clindamycin Clotrimazole Dapsone Diphenoxylate and Atropine Divalproex sodium Esomeprazole Ethambutol Famciclovir Fenofibrate Fluconazole Foscarnet Gabapentin Gancyclovir Gemfibrozil Glucometer Glucose Strips Glyburide Hydrochlorothiazide (HCTZ) Insulin Itraconazole Lancets Leucovorin Levetiracetam Lisinopril Lisinopril w/ HCTZ Loperamide Losartan Metformin Metformin w/ Glyburide Metoprolol Metronidazole Mirtazipine Necon 1/35 and Generics Nitazoxanide Nystatin Suspension Olanzapine Penicillin Pentamidine, aerosol Pyrimethamine Quetiapine Ranitidine Rifabutin Risperidone Rosuvastatin Sertraline Sulfadiazine Sulfamethoxazole/Trimethoprim Testosterone Vaginal Ring Valacyclovir Valganciclovir Varenicline Venlafaxine ANTIPROTOZOAL DRUGS,MISCELLANEOUS CONTRACEPTIVES OPPORTINISTIC INFECTION MEDICATIONS ANTIDEPRESSANT ORAL RINSE FOR TREATMENT OF GINGIVITIS OPPORTINISTIC INFECTION MEDICATIONS PSYCHOTROPIC MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS ANTIFUNGAL AGENTS OPPORTINISTIC INFECTION MEDICATIONS ANTIDIARRHEALS ANTICONVULSANTS GASTROINTESTINAL MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS LIPOTROPICS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS ANTICONVULSANTS OPPORTINISTIC INFECTION MEDICATIONS LIPOTROPICS BLOOD SUGAR DIAGNOSTICS BLOOD SUGAR DIAGNOSTICS ANTIHYPERGLYCEMIC THIAZIDE AND RELATED DIURETICS INSULINS OPPORTINISTIC INFECTION MEDICATIONS LANCETS OPPORTINISTIC INFECTION MEDICATIONS ANTICONVULSANTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ANTIDIARRHEALS ANTIHYPERTENSIVES ANTIHYPERGLYCEMIC ANTIHYPERGLYCEMIC BETA-ADRENERGIC BLOCKING AGENTS ANTIPROTOZOAL DRUGS,MISCELLANEOUS PSYCHOTROPIC MEDICATIONS CONTRACEPTIVES ANTIPROTOZOAL DRUGS,MISCELLANEOUS ANTIFUNGAL ANTIBIOTICS PSYCHOTROPIC MEDICATIONS PENICILLINS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS PSYCHOTROPIC MEDICATIONS GASTROINTESTINAL MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS PSYCHOTROPIC MEDICATIONS ANTIHYPERLIPIDEMIC PSYCHOTROPIC MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS ANDROGENIC AGENTS CONTRACEPTIVES OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS SMOKING DETERRENT ANTIDEPRESSANT

Colorado AIDS Drug Assistance Program Description of Medication Formularies


Effective Date: September 15, 2013
Vfend Geodon Voriconazole Ziprasidone ANTIFUNGAL AGENTS PSYCHOTROPIC MEDICATIONS

AVAILABLE WITH PRIOR AUTHORIZATION: Aranesp Procrit,Epogen Neupogen Neulasta Pegasys Peg-Intron Copegus,Rebetol Alternative contraceptives Darbepoetin alfa Epoetin alfa/Erythropoietin Filgrastim Pegfilgrastim Peginterferon alfa-2a Peginterferon alfa-2b Ribavirin Various HEPATITIS C TREATMENT HEPATITIS C TREATMENT HEPATITIS C TREATMENT LEUKOCYTE (WBC) STIMULANTS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS OPPORTINISTIC INFECTION MEDICATIONS CONTRACEPTIVES

NOTE: For Bridging the Gap Colorado, ADAP provides assistance for ALL medications on the enrollee's Medicare prescription drug plan (with the exception of erectile dysfunction drugs) up until the catastrophic coverage level. Once the enrollee has reached the catastrophic coverage level, ADAP assistance is limited to the formulary listed above.