Mississippi AIDS Drug Assistance Program (ADAP) Formulary June 2024
PA = Prior Authorization Required CS = Controlled Substance
Generic Name Brand Name Therapeutic Classification Pharmacologic Classification
abacavir
Ziagen
Antiretroviral NRTI
abacavir / lamivudine
Epzicom
Antiretroviral
NRTI combo
abacavir / lamivudine /zidovudine
Trizivir
Antiretroviral NRTI combo
abacavir / dolutegravir / lamivudine
Triumeq
Antiretroviral INSTI/NRTI combo
atazanavir
Reyataz
Antiretroviral
PI
atazanavir/cobicistat
Evotaz
Antiretroviral
PI/PK Enhancer
bictegravir/emtricibatine/tenofovir alafenamide
Biktarvy
Antiretroviral
INSTI/NRTI combo
cabotegravir / rilpivirine
Cabenuva
Antiretroviral INSTI/NNRTI combo
cobicistat
Tybost
Antiretroviral PK Enhancer
darunavir
Prezista
Antiretroviral PI
darunavir / cobicistat
Prezcobix
Antiretroviral PI/PK Enhancer
darunavir/cobistat/emtricibatine/tenofovir
alafenamide
Symtuza
Antiretroviral PI/NRTI combo
dolutegravir
Tivicay
Antiretroviral INSTI
dolutegravir / lamivudine
Dovato
Antiretroviral INSTI/NRTI combo
dolutegravir / rilpivirine
Juluca
Antiretroviral INSTI/NNRTI combo
doravirine
Pifeltro
Antiretroviral NNRTI
doravirine/lamividine/tenofovir disoproxil fumarate
Delstrigo
Antiretroviral NNRTI/NRTI combo
efavirenz
Sustiva
Antiretroviral NNRTI
efavirenz/emtricibatine/tenofovir disoproxil fumarate
N/A (formerly Atripla)
Antiretroviral NNRTI/NRTI combo
efavirenz/lamivudine/tenofovir disoproxil fumarate
Symfi, SymfiLo
Antiretroviral NNRTI/NRTI combo
elvitegravir/cobistat/emtricitabine/tenofovir
alafenamide
Genvoya
Antiretroviral INSTI/NRTI combo
elvitegravir/cobistat/emtricitabine/tenofovir disoproxil
fumarate
Stribild
Antiretroviral INSTI/NRTI combo
emtricitabine
Emtriva
Antiretroviral NRTI
emtricitabine / tenofovir alafenamide
Descovy
Antiretroviral NRTI combo
emtricitabine / tenofovir disoproxil fumarate Truvada
Antiretroviral NRTI combo
enfuvirtide
Fuzeon
Antiretroviral Fusion inhibitor
etravirine
Intelence
Antiretroviral NNRTI
fosamprenavir
Lexiva
Antiretroviral PI
fostemsavir
Rukobia
Antiretroviral Gp-120 directed attachment inhibitor
Ibalizumab-uiyk injection
PA
Trogarzo
PA
Antiretroviral CD4 post-attachment HIV-1 inhibitor
***Quantity and Refill Limits may apply to some medications***
Mississippi AIDS Drug Assistance Program (ADAP) Formulary June 2024
PA = Prior Authorization Required CS = Controlled Substance
lamivudine
Epivir
Antiretroviral NRTI
lamivudine / zidovudine
Combivir
Antiretroviral NRTI combo
lenacapavir
PA
Sunlenca
PA
Antiretroviral
Capsid inhibitor
lopinavir / ritonavir
Kaletra
Antiretroviral PI/PK Enhancer
maraviroc
Selzentry
Antiretroviral CCR5 antagonist
nelfinavir
Viracept
Antiretroviral PI
nevirapine, nevirapine XR
Viramune, Viramune XR
Antiretroviral NNRTI
raltegravir, raltegravir HD
Isentress, Isentress HD
Antiretroviral INSTI
rilpivirine
Edurant
Antiretroviral NNRTI
rilpivirine / emtricitabine/ tenofovir disoproxil
fumarate
Complera
Antiretroviral NNRTI/NRTI combo
rilpivirine / emtricitabine / tenofovir alafenamide
Odefsey
Antiretroviral NNRTI/NRTI combo
ritonavir
Norvir
Antiretroviral PK Enhancer
saquinavir
Invirase
Antiretroviral PI
tenofovir alafenamide
Vemlidy
Antiretroviral NRTI
tenofovir disoproxil fumarate
Viread
Antiretroviral NRTI
tenofovir disoproxil fumarate / lamivudine Cimduo
Antiretroviral NRTI combo
tipranavir
Aptivus
Antiretroviral PI
zidovudine
Retrovir
Antiretroviral PI
INSTI = Integrase Strand Transfer Inhibitor, NNRTI = Non-Nucleoside Reverse Transcriptase Inhibitor, NRTI = Nucleoside/Nucleotide Reverse Transcriptase Inhibitor, PK= Pharmokinetic, PI = Protease Inhibitor
acetaminophen (Tylenol)
Analgesic Non-salicylate analgesic 325mg, 500mg tablet
ibuprofen (Motrin)
Analgesic Non-steroidal anti-inflammatory drug 200mg tablet
meloxicam (Mobic)
Analgesic Non-steroidal anti-inflammatory drug 7.5mg, 15mg tablet
metformin (Glucovance)
Antidiabetic Biguanide 500mg,1000mg, ER 500mg tablet
sitagliptin (Januvia)
Antidiabetic
Dipeptidyl Peptidase-4 Inhibitor
(DPP-4 inhibitor)
25mg, 50mg, 100mg tablet
exenatide (Byetta BCise)
Antidiabetic Glucagon-like peptide-1 agonist 2mg injection
liraglutide (Victoza)
Antidiabetic Glucagon-like peptide-1 agonist injection
Glucagon 1mg Kit
Antidiabetic Glycogenolytic (anti-hypoglycemic) injection
insulin NPH and insulin regular
Antidiabetic Insulin-70/30 injection
insulin isophane (NPH) (Novolin N)
Antidiabetic Insulin-intermediate acting injection
insulin glargine (Lantus)
Antidiabetic Insulin-long acting injection
insulin aspart (Novolog)
Antidiabetic Insulin-rapid acting injection
***Quantity and Refill Limits may apply to some medications***
Mississippi AIDS Drug Assistance Program (ADAP) Formulary June 2024
PA = Prior Authorization Required CS = Controlled Substance
insulin regular(Novolin)
Antidiabetic Insulin-short acting
injection
dapagliflozin (Faxiga)
Antidiabetic
Sodium-glucose co-transporter 2
(SGLT2) inhibitor
5mg , 10mg tablet
empagliflozin (Jardiance)
Antidiabetic
Sodium-glucose co-transporter 2
(SGLT2) inhibitor
10mg, 25mg tablet
glipizide extended release
Antidiabetic Sulfonylurea
5mg , 10mg er tablet
brimonidine (Alphagan)
Antiglaucoma Alpha-2 agonist .1%, .15% eye drops
brinzolamide (Azopt)
Antiglaucoma Carbonic anhydrase inhibitor eye drops
latanoprost (Xalatan)
Antiglaucoma Prostaglandin 2.5% eye drops
pilocarpine
Antiglaucoma Miotic 1%,2% , 4% eye drops
timolol (Timopitc)
Antiglaucoma Beta blocker .25%, .5% eye drops
atovaquone (Mepron)
Anti-infective Amebicide 750 mg/ 5ml oral liquid
metronidazole (Flagyl)
Anti-infective Amebicide, trichomonaside 500 mg tablet .75% vaginal gel
terbinafine (Lamisil)
Anti-infective Antifungal
250 mg tablet
pentamidine (NebuPent)
Anti-infective Antifungal 300mg aerosol/vial
valacyclovir (Valtrex)
Anti-infective Antiherpetic antiviral 1 gram tablet
valganciclovir (Valcyte)
Anti-infective Antiherpetic antiviral (CMV) 450 mg tablet
pyrimethamine (Daraprim)
Anti-infective Antimalarial 25 mg tablet
chlorhexidine gluconate (0.12%) (Peridex)
Anti-infective Antimicrobial oral liquid
ethambutol (Myambutol)
Anti-infective Antimycobacterial 400 mg tablet
isoniazid
Anti-infective Antimycobacterial 300 mg tablet
pyrazinamide
Anti-infective Antimycobacterial 500 mg tablet
rifabutin (Mycobutin)
Anti-infective Antimycobacterial 150 mg capsule
rifampin
Anti-infective Antimycobacterial 150 mg, 300 mg capsule
rifapentine (Priftin)
Anti-infective Antimycobacterial 150 mg tablet
acyclovir (Zovirax)
Anti-infective Antiviral 400 mg tablet
clotrimazole
Anti-infective Azole antifungal 10 mg oral troche, 1% cream
fluconazole (Diflucan)
Anti-infective Azole antifungal 150 tablet
itraconazole (Sporanox)
Anti-infective Azole antifungal 200 mg capsule, 10mg/ml liquid
voriconazole (Vfend)
Anti-infective Azole antifungal 50 mg, 200mg tablet,
amoxicillin (Amoxil)
Anti-infective Beta-lactam antibiotic 500 mg capsule, 875mg tablet
elbasvir/grazoprevir (Zepatier)
Anti-infective Hepatitis C antiviral tablet
glecaprevir/pibrentasvir (Mavyret)
Anti-infective Hepatitis C antiviral tablet
ledipasvir/sofosbuvir (Harvoni)
Anti-infective Hepatitis C antiviral tablet
sofosbuvir/velpatasvir (Epclusa)
Anti-infective Hepatitis C antiviral tablet
***Quantity and Refill Limits may apply to some medications***
Mississippi AIDS Drug Assistance Program (ADAP) Formulary June 2024
PA = Prior Authorization Required CS = Controlled Substance
clindamycin (Cleocin)
Anti-infective Lincosamide antibiotic
150 mg capsule
azithromycin (Zithromax)
Anti-infective Macrolide antibiotic 250 mg, 600 mg tablet
clarithromycin (Biaxin)
Anti-infective Macrolide antibiotic
500mg tablet
sulfadiazine
Anti-infective Sulfonamide antibiotic 500mg tablet
sulfamethoxazole/trimethoprim (Bactrim, Bactrim DS)
Anti-infective Sulfonamide antibiotic SS, DS tablet, oral liquid
dapsone
Anti-infective Sulfone antibiotic 100mg tablet
doxycycline hyclate
Anti-infective Tetracycline antibiotic 100mg tablet
apixaban (Eliquis)
Blood formation and coagulation Anticoagulant
2.5mg, 5mg tablet
rivaroxaban (Xarelto)
Blood formation and coagulation Anticoagulant
2.5mg,10mg,15mg, 20mg tablet
lisinopril
Cardiovascular
Angiotensin converting enzyme (ACE
inhibitor)
10mg, 20mg tablet
lisinopril/hydrochlorothiazide
(Zestoretic)
Cardiovascular ACE inhibitor/ thiazide diuretic 10/12.5mg, 20/12.5mg, 20/25mg tablet
azilsartan (Edarbi)
Cardiovascular Angiotensin II receptor blocker (ARB) 40mg, 80mg tablet
losartan (Cozaar)
Cardiovascular
Angiotensin II receptor blocker (ARB) 50mg, 100mg tablet
olmesartan (Benicar)
Cardiovascular Angiotensin II receptor blocker (ARB) 5mg, 20mg,40mg tablet
azilsartan/chlorthalidone (Edarbyclor)
Cardiovascular ARB/ thiazide diuretic 40/12.5mg, 40/25mg tablet
losartan/hydrochlorothiazide (Hyzaar)
Cardiovascular ARB/ thiazide diuretic
50/12.5 mg,100/12.5mg, 100/25mg
tablet
carvedilol (Coreg)
Cardiovascular Beta-blocker 12.5mg, 25 mg tablet
metoprolol succinate (Toprol XL)
Cardiovascular
Beta-blocker 25mg, 50mg,100mg tablet
amlodipine (Norvasc)
Cardiovascular Calcium channel blocker 5mg, 10mg tablet
nifedipine ER (Procardia XL)
Cardiovascular
Calcium channel blocker 30mg, 60mg, 90mg tablet
clonidine (Catapres)
Cardiovascular Centrally acting alpha 2 agonist
.1mg, .2mg, .3mg tablet
potassium chloride (Klor Con)
Cardiovascular Electrolyte replacement 10MEQ, 20MEQ tabs
furosemide (Lasix)
Cardiovascular Loop diuretic 20mg, 40mg tablet
clopidogrel (Plavix)
Cardiovascular Platelet inhibitor 75mg tablet
spironolactone (Aldactone)
Cardiovascular Potassium sparing diuretic 25mg, 50mg tablet
hydralazine
Cardiovascular Vasodilating agents 10mg, 25mg,50, 100 mg tablet
hydrochlorothiazide
Cardiovascular Thiazide diuretic 12.5 mg capsule; 25mg tablet
ezetimibe (Zetia)
Cardiovascular, antihyperlipidemic Cholesterol absorption inhibitor 10mgtablet
fenofibrate (Tricor)
Cardiovascular, antihyperlipidemic Fibric acid derivative 48mg, 145mg tablet
atorvastatin (Lipitor)
Cardiovascular, antihyperlipidemic HMG-CoA reductase inhibitor 10mg, 20mg, 40mg tablet
pravastatin (Pravachol)
Cardiovascular, antihyperlipidemic HMG-CoA reductase inhibitor 20mg, 40mg, 80mg tablet
rosuvastatin (Crestor)
Cardiovascular, antihyperlipidemic HMG-CoA reductase inhibitor 10mg, 20mg,40mg tablet
***Quantity and Refill Limits may apply to some medications***
Mississippi AIDS Drug Assistance Program (ADAP) Formulary June 2024
PA = Prior Authorization Required CS = Controlled Substance
omega-3-acid ethyl esters (Lovaza)
Cardiovascular, antihyperlipidemic Lipotropic
1 Gram capsule
niacin extended release
Cardiovascular, antihyperlipidemic Vitamin, lipotropic 500mg, 1000mg tablet
benztropine (Cogentin)
Central nervous system Anticholinergic 1mg tablet
gabapentin (Neurontin)
Central nervous system Anticonvulsant, mood stabilizer
100mg, 300mg,400mg cap; 600mg,
800mg tab
lamotrigine (Lamictal)
Central nervous system Anticonvulsant, mood stabilizer
25mg, 100mg, 150mg tablet, 100mg
ER tablet
levetiracetam (Keppra)
Central nervous system Anticonvulsant, mood stabilizer 500mg tablet, 500mg XR tablet
bupropion (Wellbutrin, SR, XL)
Central nervous system Antidepressant-miscellaneous,
aminoketone
tablet
ondansetron (Zofran)***
Central nervous system Anti-nausea 4mg, 8mg tablet, 4mg, 8mg ODT
quetiapine (Seroquel)
Central nervous system Antipsychotic, antimanic 50mg, 200mg, 300mg tablet
olanzapine (Zyprexa)
Central nervous system Antipsychotic, antimanic 5mg,7.5mg, 10mg tablet
buspirone (Buspar)
Central nervous system Anxiolytic 10mg, 15mg tablet
hydroxyzine pamoate (Vistaril)***
Central nervous system Anxiolytic 25 mg capsule
memantine (Namenda)
Central nervous system N-methyl-D-aspartae (NMDA) inhibitor 5mg, 10mg tablet
donepezil (Aricept)
Central Nervous System Cholinesterase inhibitor 5mg, 10mg, 23mg tablet
mirtazapine (Remeron)
Central nervous system Tetracyclic antidepressant 15mg,30mg tablet
citalopram (Celexa)
Central nervous system antidepressant Selective serotonin reuptake inhibitor 20mg, 40mg tablet
escitalopram (Lexapro)
Central nervous system antidepressant Selective serotonin reuptake inhibitor 5mg, 10mg, 20mg tablet
fluoxetine (Prozac)
Central nervous system antidepressant Selective serotonin reuptake inhibitor 10mg, 20mg capsule
sertraline (Zoloft)
Central nervous system antidepressant Selective serotonin reuptake inhibitor
50mg, 100mg tablet
trazodone (Desyrel)
Central nervous system antidepressant Serotonin reuptake inhibitor 50mg, 100mg, 150mg tablet
duloxetine (Cymbalta)
Central nervous system antidepressant Serotonin-norepinephrine reuptake inhibitor 20mg, 30mg, 60mg capsule
venlafaxine (Effexor ER)
Central nervous system antidepressant Serotonin-norepinephrine reuptake
inhibitor
75mg, 150mg capsule
***Quantity and Refill Limits may apply to some medications***
Mississippi AIDS Drug Assistance Program (ADAP) Formulary June 2024
PA = Prior Authorization Required CS = Controlled Substance
amitriptyline (Elavil)
Central nervous system antidepressant Tricyclic antidepressant (TCA)
10mg, 25mg, 50mg tablet
ketoconazole (Nizoral)
Dermatologic Azole antifungal 2% topical cream
permethrin (Elimite)
Dermatologic Anti-infective, scabicide 5% topical cream
podofilox (Condylox)
Dermatologic Antiviral 0.5% topical gel
betamethasone/clotrimazole (Lotrisone)***
Dermatologic Corticosteroid, antifungal topical cream
triamcinolone ***
Dermatologic Corticosteroid 0.1% topical cream
imiquimod (Aldara)
Dermatologic Immune response modifier
5% topical cream
prednisone
Endocrine Corticosteroid
1, 2.5, 5, 10, 20 ,50mg tablets, liquid
oxandrolone (Oxandrin)
Endocrine Anabolic steroid 2.5mg, 10mg tablets
levothyroxine
Endocrine Thyroid supplement tablet
tesmorelin (Egrifta SV)
Endocrine Growth hormone releasing factor analogue injection
loperamide
Gastrointestinal Antidiarrheal 2mg capsule
promethazine (Phenergan)***
Gastrointestinal Antihistamine, antiemetic 12.5mg , 25 mg tab & suppository
polyethylene gycol 3350 (Miralax)
Gastrointestinal Laxative, osmotic oral powder
famotidine (Pepcid)
Gastrointestinal, acid reducing Histamine 2 receptor blocker
20 mg, 40 mg tablets
omeprazole (Prilosec)
Gastrointestinal, acid reducing Proton pump inhibitor 20mg, 40 mg capsules
finasteride (Proscar)
Genitourinary 5-Alpha Reductase Inhibitor 10mg tablet
tamsulosin (Flomax)
Genitourinary Alpha-blocker 0.4mg capsule
oxybutynin (Ditropan XL)
Genitourinary
Bladder antispasmodic 5mg, 10mg tablet
erythromycin
Opthalmic
Macrolide antibiotic eye ointment
gentamicin
Opthalmic Aminoglycoside antibiotic eye drop
prednisolone (Pred Mild, Pred Forte)
Opthalmic
Corticosteroid 0.12%, 1% eye drops
tobramycin/dexamethasone (Tobradex)
Opthalmic Aminoglycoside + Corticosteroid eye drop, eye ointment
trimethoprim sulf/polymyxin (Polytrim)
Opthalmic Anti-infective, scabicide eye drop
alendronate (Fosamax)
Osteoporosis Bisphosphonate 70mg tablet
tiotropium (Spiriva)
Respiratory Anti-cholinergic, oral inhaled 18mcg handihaler
albuterol HFA (Proair HFA)
Respiratory Beta-2 Agonist 90mcg inhaler
budesonide (Pulmicort)
Respiratory Corticosteroid 90mcg, 180mcg flexinhaler
budesonide/formoterol (Symbicort)
Respiratory
Corticosteroid + Long acting Beta-
2 Agonist, oral inhaled
80-4.5, 160-4.5 inhaler
cetirizine (Zyrtec)
Respiratory Antihistamine 10mg tablet
cyproheptadine (Periactin)
Respiratory Antihistamine 4mg tablet
montelukast (Singulair)
Respiratory Leukotriene receptor antagonist 10mg tablet
***Quantity and Refill Limits may apply to some medications***
Mississippi AIDS Drug Assistance Program (ADAP) Formulary June 2024
PA = Prior Authorization Required CS = Controlled Substance
buprenorphine/naloxone
CS
(Suboxone)***
Substance abuse Opiate agonist/antagonist
2mg, 8mg SLtablet, 2mg, 4mg
,8mg,12mg film
buprenorphine
CS
(Subutex)***
Substance abuse Opiate agonist/antagonist 2mg, 8mg SL tablet
naloxone (Narcan)***
Substance abuse Opiate antagonist
4mg nasal spray
Omron blood pressure monitor
Testing supply blood pressure Ancillary Supply monitor
Contour Next meter
Testing supply diabetes Ancillary Supply
meter
Contour Next test strips
Testing supply diabetes Ancillary Supply
50 count , 100 count test strips
alcohol pads
Testing supply diabetes Ancillary Supply
pads
lancets
Testing supply diabetes Ancillary Supply lancets
syringes
Testing supply diabetes Ancillary Supply syringes
pen needles
Testing supply diabetes Ancillary Supply pen needles
ergocalciferol (vitamin D2)
Vitamin Vitamin 1.25mg (50,000 units) capsule
folic acid
Vitamin Vitamin 1mg tablet
leucovorin
Vitamin Vitamin 5mg tablet
vitamin B complex
Vitamin Vitamin tablet
***Quantity and Refill Limits may apply to some medications***
