Colorado SDAP Formulary 2018
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Colorado State Drug Assistance Program
Description of Medication Formularies | by brand name
Updated Sept. 18, 2018 (please discard / remove previous versions)
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THE STANDARD COLORADO ADAP FORMULARY (by brand name)
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HIV-SPECIFIC MEDICATIONS
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Brand NameGeneric NameBrief Description of CategoryPrior authorization?
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AptivusTipranivirPI - ANTIRETROVIRALNo prior authorization
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AtriplaEmtricitabine/Tenofovir/EfavirenzCOMB ANTIRETROVIRAL - NRTI, NNRTINo prior authorization
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Cimduo
Lamivudine/Tenofovir disoproxil fumarate
COMB ANTIRETROVIRAL NRTINo prior authorization
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CombivirZidovudine/LamivudineCOMB ANTIRETROVIRAL - NRTINo prior authorization
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Complera
Emtricitabine, rilpivirine, and tenofovir
COMB ANTIRETROVIRAL - NRTI, NNRTINo prior authorization
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CrixivanIndinavirPI - ANTIRETROVIRALNo prior authorization
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DescovyEmtricitabine/tenofovir alafenamideCOMB ANTIRETROVIRAL- NRTINo prior authorization
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EdurantRilpivirineNNRTI - ANTIRETROVIRALNo prior authorization
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EmtrivaEmtricitabine (FTC)NRTI - ANTIRETROVIRALNo prior authorization
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EpivirLamivudine (3TC)NRTI - ANTIRETROVIRALNo prior authorization
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EpzicomAbacavir/LamivudineCOMB ANTIRETROVIRAL - NRTINo prior authorization
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EvotazAtazanavir/ CobicistatCOMB ANTIRETROVIRAL (PI, CYP3A INHIBITOR)No prior authorization
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FuzeonEnfuvirtide (T-20)FI - ANTIRETROVIRALNo prior authorization
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Genvoya
Elvitegr/COBICIST/EMTRIC/TENOF ALAF
COMB ANTIRETROVIRAL (INSTI, NRTI, CYP3A INH)No prior authorization
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IntelenceEtravirineNNRTI - ANTIRETROVIRALNo prior authorization
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InviraseSaquinavir MesylatePI - ANTIRETROVIRALNo prior authorization
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IsentressRaltegravirINTEGRASE STRAND TRANSFER INHIBITOR (INSTI)No prior authorization
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Isentress XRRaltegravirINTEGRASE STRAND TRANSFER INHIBITOR (INSTI)No prior authorization
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JulucaDolutegravir/ rilpivirine2 MEDICATION COMB ARV (INSTI; NNRTI, PI)No prior authorization
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KaletraLopinavir/RitonavirCOMB ANTIRETROVIRAL (PI, CYP3A INHIBITOR)No prior authorization
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LevixaFosamprenavirPI - ANTIRETROVIRALNo prior authorization
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NorvirRitonavirPI - ANTIRETROVIRALNo prior authorization
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Odefsey
Emtricitabine, rilpivirine, and tenofovir alaf.
COMB ANTIRETROVIRAL - NRTI, NNRTINo prior authorization
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PrezcobixDarunavir /Cobicistat COMB ANTIRETROVIRAL (PI, CYP3A INHIBITOR)No prior authorization
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PrezistaDarunavirPI - ANTIRETROVIRALNo prior authorization
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RescriptorDelaviradineNNRTI - ANTIRETROVIRALNo prior authorization
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RetrovirZidovudine (AZT)NRTI - ANTIRETROVIRALNo prior authorization
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ReyatazAtazanavirPI - ANTIRETROVIRALNo prior authorization
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SelzentryMaravirocEI - ANTIRETROVIRALNo prior authorization
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StribildELVITEGR/Cobisist/Emtiric/TenofCOMB ANTIRETROVIRAL (INSTI, NRTI, CYP3A INH)No prior authorization
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SustivaEfavirenzNNRTI - ANTIRETROVIRALNo prior authorization
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Symfi LoEfavirenz/Lamivudine/Tenofovir Disoproxil FumarateNNRTI & NNRTI - ANTIRETROVIRALNo prior authorization
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Symtuza
Cobicistat, Duranuvir, Emtricitabine, Tenofovir Alafenamide
PI - CYP3A inhibitor, NRTI (2)No prior authorization
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TivicayDolutegravirINTEGRASE STRAND TRANSFER INHIBITOR (INSTI)No prior authorization
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TriumeqAbacavir/Dolutegravir/LamivudineCOMBINATION ANTIRETROVIRAL (INSTI, NRTI)No prior authorization
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TrizivirZidovudine/Lamivudine/AbacavirCOMB ANTIRETROVIRAL - NRTINo prior authorization
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TrogarzoIbalizumab
HIV INHIBITOR - BIOLOGIC - Monoclonal Antibodies
No prior authorization
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TruvadaEmtricitabine/TenofovirCOMB ANTIRETROVIRAL - NRTINo prior authorization
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TybostCobicistatCYP3A INHIBITORNo prior authorization
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VemlidyTenofovir alafenamideOff-label indication No prior authorization
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VidexDidanosine (ddI)NRTI - ANTIRETROVIRALNo prior authorization
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Videx ECDidanosine ECNRTI - ANTIRETROVIRALNo prior authorization
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ViraceptNelfinavirPI - ANTIRETROVIRALNo prior authorization
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ViramuneNevirapineNNRTI - ANTIRETROVIRALNo prior authorization
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Viramune XRNevirapineNNRTI - ANTIRETROVIRALNo prior authorization
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VireadTenofovirNRTI - ANTIRETROVIRALNo prior authorization
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VitektaElvitagravirINSTI - ANTIRETROVIRALNo prior authorization
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ZeritStavudine (d4T)NRTI - ANTIRETROVIRALNo prior authorization
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ZiagenAbacavirNRTI - ANTIRETROVIRALNo prior authorization
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OTHER COVERED MEDICATIONS
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Brand NameGeneric NameBrief Description of CategoryPrior authorization?
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AbilifyAripiprazolePSYCHOTROPIC MEDICATIONSNo prior authorization
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AldactoneSpironolactoneHormonal Treatment No prior authorization
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AlesseAviane and GenericsCONTRACEPTIVESNo prior authorization
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AliniaNitazoxanideANTIPROTOZOAL DRUGS,MISCELLANEOUSNo prior authorization
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AmoxilAmoxicillinANTIBIOTICNo prior authorization
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AntabuseDisulfiramTREATMENT FOR CHRONIC ALCOHOLISMNo prior authorization
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AranespDarbepoetin alfaERYTHROPOIESIS STIMULATINGNo prior authorization
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Avelox, Moxeza, Vigamox
MoxifloxacinANTIBIOTICNo prior authorization
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AvodartDutasterideHormonal Treatment No prior authorization
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BaracludeEntecavirHEPATITIS B TREATMENTNo prior authorization
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BiaxinClarithromycinOPPORTINISTIC INFECTION MEDICATIONS No prior authorization
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CampralAcamprosate Calcium Tx for post-withdrawal alcohol dependenceNo prior authorization
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CelexaCitalopramANTIDEPRESSANTNo prior authorization
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ChantixVareniclineSMOKING DETERRENTNo prior authorization
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Cipro, ProquinCiprofloxacinANTIBIOTIC, ANTIBACTERIALNo prior authorization
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CleocinClindamycinOPPORTINISTIC INFECTION MEDICATIONS No prior authorization
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Copegus,RebetolRibavirinHEPATITIS C TREATMENTNo prior authorization
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CozaarLosartanANTIHYPERTENSIVESNo prior authorization
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CrestorRosuvastatinANTIHYPERLIPIDEMICNo prior authorization
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CymbaltaDuloxetineANTIDEPRESSANTNo prior authorization
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CytoveneGancyclovirOPPORTINISTIC INFECTION MEDICATIONS No prior authorization
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Daklinza**DaclatasvirHEPATITIS C TREATMENTNo prior authorization
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DapsoneDapsoneOPPORTINISTIC INFECTION MEDICATIONS No prior authorization
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DaraprimPyrimethamineOPPORTINISTIC INFECTION MEDICATIONS No prior authorization
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DelestrogenEstradiol VlareateHormonal Treatment No prior authorization
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Depa-EstradiolEstradiol CypionalteHormonal Treatment No prior authorization
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DepakoteDivalproex sodiumANTICONVULSANTSNo prior authorization
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DupixentDupilumabSevere atopic dermatitis injectionNo prior authorization
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DiflucanFluconazoleOPPORTINISTIC INFECTION MEDICATIONS No prior authorization
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EffexorVenlafaxineANTIDEPRESSANTNo prior authorization
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ElavilAmitriptylineANTIDEPRESSANTNo prior authorization
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Egrifta Tesamorelin for injectionsReduction of excess abdominal fatNo prior authorization
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Epclusa**
Aofosbuvir, Velpatasvir (with ribavirin)
HEPATITIS C TREATMENTNo prior authorization
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Ergocalciferol Ergocalciferol (Vitamin D capusule)VITAMIN DEFICIENCY ANTIHYPOPARATHYROID No prior authorization
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EstraceEstradiolHormonal Treatment No prior authorization
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EulexinFlutamineHormonal Treatment No prior authorization
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EvizioNaloxone autoinjection OPIOID OVERDOSE TREATMENTNo prior authorization
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FamvirFamciclovirOPPORTINISTIC INFECTION MEDICATIONS No prior authorization
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FarxigaDapagliflozinTREATMENT for TYPE 2 DIABETESNo prior authorization
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FlagylMetronidazoleANTIPROTOZOAL DRUGS,MISCELLANEOUSNo prior authorization
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FoscavirFoscarnetOPPORTINISTIC INFECTION MEDICATIONS No prior authorization
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FungizoneAmphotericin InjectionOPPORTINISTIC INFECTION MEDICATIONS No prior authorization
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GeodonZiprasidonePSYCHOTROPIC MEDICATIONSNo prior authorization
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