As of July 9, 2025 the following drugs are available through the Pharmacy Benefits Program (PBP).
To search for a specific drug, hit the "Ctrl" button and "f" and type the drug name.
HIV/AIDS DRUGS
ANTI-RETROVIRAL
BOOSTING AGENTS
• Cobicistat (Tybost)
• Ritonavir (Norvir)
CD4 DIRECTED ATTACHMENT HIV-1 INHIBITOR
• Fostemsavir (Rukobia)
CD4 DIRECTED POST-ATTACHMENT HIV-1 INHIBITOR
• Ibalizumab-uiyk (Trogarzo)#
FUSION INHIBITORS
• Maraviroc (Selzentry)
INTEGRASE INHIBITORS
• Dolutegravir (Tivicay) 50mg
• Elvitegravir (Vitekta)
• Raltegravir (Isentress)
• Cabotegravir (Vocabria)
LONG ACTING HIV-1 CAPSID INHIBITOR
• Lenacapavir (Sunlenca) injection #
NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
• Abacavir (Ziagen)
• Abacavir/Lamivudine (Epzicom)
• Abacavir/Lamivudine/Zidovudine (Trizivir)
• Emtricitabine (Emtriva)
• Emtricitabine/Tenofovir disoproxil fumarate (Truvada)
• Emtricitabine/Tenofovir alafenamide (Descovy)
• Lamivudine (Epivir)
• Lamivudine/ Tenofovir disoproxil fumarate (Cimduo/Temixys ) #
• Lamivudine/Zidovudine (Combivir)
• Tenofovir disoproxil fumarate (Viread)
• Zidovudine (Retrovir, AZT)
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
• Delavirdine (Rescriptor)
• Doravirine (Pifeltro)
• Efavirenz (Sustiva)
• Etravirine (Intelence)
• Nevirapine (Viramune, Viramune XR)
• Rilpivirine HCl (Edurant)
HIV-1 INTEGRASE STRAND TRANSFER INHIBITOR/ NRTI COMBINATION
• Bictegravir/Emtricitabine/Tenofovir alafenamide fumarate (Biktarvy)
• Dolutegravir/Abacavir/Lamivudine (Triumeq)
• Dolutegravir/Lamivudine (Dovato)
• Dolutegravir/Rilpivirine (Juluca)
• Elvitegravir/ Cobicistat/ Emtricitabine/ Tenofovir disoproxil fumarate (Stribild)
• Elvitegravir/Cobicistat/Emtricitabine/ Tenofovir alafenamide fumarate (TAF) (Genvoya)
NNRTI/NRTI COMBINATION
• Doravirine/Lamivudine/Tenofovir disoproxil fumarate (Delstrigo)
• Efavirenz/Emtricitabine/Tenofovir disoproxil fumarate (Atripla)
• Efavurenz 400 mg /Lamivudine/ Tenofovir disoproxil fumarate ++
• Efavurenz 600 mg/Lamivudine/ Tenofovir disoproxil fumarate ++
• Emtricitabine/Rilpivirine/Tenofovir alafenamide (Odefsey)
• Emtricitabine/Rilpivirine/Tenofovir disoproxil fumarate (Complera)
PROTEASE INHIBITORS (PI)
• Atazanavir (Reyataz)
• Darunavir (Prezista)
• Fosamprenavir (Lexiva)
• Indinavir (Crixivan)
• Lopinavir/Ritonavir (Kaletra)
• Nelfinavir (Viracept)
• Ritonavir (Norvir)
• Saquinavir (Invirase) tablets#
• Tipranavir (Aptivus)
CYP3A INHIBITOR/PROTEASE INHIBITOR
• Darunavir/Cobicistat (Prezcobix)
• Atazanavir/Cobicistat (Evotaz)
PROTEASE INHIBITOR/CYP3A INHIBITOR/NRTI
• Darunavir/Cobicistat/Emtricitabine/TAF (Symtuza)
INTEGRASE INHIBITOR/NNRTI COMBINATION LONG ACTING INJECTABLE
• Cabotegravir/Rilpivirine (Cabenuva)
ANALGESICS
• Acetaminophen with codeine (Tylenol w/Codeine) CIII **
• ASA/Butalbital/caffeine/codeine (Fiorinal w/codeine)
• Fentanyl Patch (Duragesic Patch) CII **
• Ibuprofen (600mg - 800mg Motrin)
• Morphine Sulfate (MS Contin) CII **
• Oxycodone/Acetaminophen 5mg/325mg
• Tramadol (Ultram) CIV **
ANTICOAGULANTS
• Rivaroxaban (Xarelto) tablets
• Warfarin (Jantovan) tablets
ANTI-DEPRESSANTS
• Amitriptyline HCL (Elavil)
• Bupropion (Wellbutrin SR)
• Citalopram (Celexa)
• Duloxetine (Cymbalta)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac)
• Mirtazapine (Remeron)
• Paroxetine (Paxil)
• Sertraline (Zoloft)
• Trazodone
• Venlafaxine ER (Effexor ER)
ANTI-DIARRHEAL
• Crofelemer (Mytesi)
• Diphenoxylate/Atropine (Lonox, Lomotil) CV **
ANTI-EMETICS
• Meclizine (tab, chew tab)
• Metoclopramide [solution, tab]
• Ondansetron (Zofran) Injection
• Ondansetron Oral Solution
• Ondansetron [tab, ODT]
• Prochlorperazine [tab, injection]
• Prochlorperazine [suppository]
ANTI-FUNGALS
• Clotrimazole (Mycelex, Lotrimin - Rx only)
• Fluconazole (Diflucan)
• Itraconazole (Sporanox)
• Ketoconazole (Nizoral – Rx only)
• Voriconazole (Vfend)
Vulvovaginitis Candidiasis
• Ibrexfungerp (Brexafemme) 150mg tablet
• Butoconazole (Gynazole-1) vaginal 2% cream
• Terconazole 0.4% vaginal [cream, suppository}
• Terconazole 0.8% vaginal [cream, suppository]
ANTI-HISTAMINES (only oral products)
• Cetirizine (Zyrtec)
• Hydroxyzine HCl
• Hydroxyzine Pamoate
• Loratadine (Claritin)
• Promethazine DM
ANTI-HYPERTENSIVES
PRIMARY AGENTS
ACE INHIBITORS (ACEI)
• Benazepril (Lotensin)
• Lisinopril (Prinivil, Zestril, Qbrelis)
ANGIOTENSIN II RECEPTOR BLOCKERS (ARB)
• Losartan (Cozaar)
• Valsartan (Diovan)
CALCIUM CHANNEL BLOCKERS
• Amlodipine (Norvasc)
• Diltiazem XR
PRIMARY COMBINATION PRODUCTS
• Amlodipine/Benazepril (Lotrel)
• Lisinopril/HCTZ (Zestoretic)
• Losartan/HCTZ (Hyzaar)
• Valsartan/HCTZ (Diovan HCT)
SECONDARY AGENTS
ALDOSTERONE ANTAGONISTS
• Spironolactone (Aldactone, Carospir)
ALPHA-1 BLOCKERS
• Doxazosin (Cardura)
• Doxazosin (Cardura XL)
BETA-BLOCKERS
• Labetalol (Trandate)
• Metoprolol succinate (Toprol XL)
• Metoprolol tartrate (Lopressor)
• Propranolol
CENTRALLY ACTING AGENTS
• Clonidine patches (Catapres TTS)
• Clonidine tablet
COMBINED ALPHA AND BETA-BLOCKERS
• Carvedilol (Coreg)
• Carvedilol (Coreg CR)
LOOP DIURETICS
• Furosemide (Lasix)
DIRECT VASODILATORS
• Hydralazine (Apresoline)
SECONDARY COMBINATION PRODUCTS
• Hydralazine /Isosorbide (Bidil)
• Triamterene/HCTZ (Dyazide, Maxide)
ANTIMICROBIALS
• Amoxicillin Clavulanate (Augmentin)
• Azithromycin (Zithromax)
• Ciprofloxacin (Cipro)
• Clarithromycin (Biaxin, Biaxin XL)
• Clindamycin HCL (Cleocin)
• Doxycycline Hyclate (Vibramycin)
• Ethambutol (Myambutol)
• Isoniazid (INH)
• Levofloxacin (Levaquin)
• Linezolid (Zyvox)
• Metronidazole tablets (Flagyl)
• Metronidazole vaginal gel
• Pyrazinamide (Pyrazinamide)
• Pyrimethamine (Daraprim) #
• Rifabutin (Mycobutin)Rifampin (Rifadin)
• Rifapentine (Priftin)
• Sulfadiazine
Bacterial Vaginosis
• Clindamycin vaginal cream
• Secnidazole oral packets
Community Acquired Bacterial Pneumonia (Oral)
• Amoxicillin (Oral products)
• Cefpodoxime
• Moxifloxacin
Mycobacterium Tuberculosis
1st line
• Rifapentine (Priftin)
2nd line
• Bedaquiline (Sirturo)
• Pretomanid
• Cycloserine (Seromycin)
• Ethionamide (Trecalor)
• Para-aminosalicylic acid (Pacer)
• Streptomycin solution
ANTI-PARKINSON’S AGENT
• Benztropine (Cogentin)
ANTI-PSYCHOTICS
• Aripiprazole (Abilify)
• Haloperidol (Haldol)
• Olanazapine (Zyprexa)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)
ANTI-VIRALS
• Acyclovir (Zovirax) [oral and topical]
• Cidofovir (Vistide)
• Ganciclovir (Zirgan) [ophthalmic]
• Nirmeltravir/ritonavir (Paxlovid) [Covid-19]
• Oseltamivir (Tamiflu)
• Valacyclovir (Valtrex)
• Valganciclovir (Valcyte)
ANXIOLYTICS
• Buspirone (Buspar) tablets
• Diazepam (Valium) [tablets, oral solution] (Quantity Limit) #
• Lorazepam (Ativan) [tablets, ER capsule, oral solution] (Quantity Limit) #
CHRONIC OBSRUCTIVE PULMONARY DISEASE (COPD)
• Albuterol Inhaler (ProAir)
• Beclomethasone (Qvar) Redihaler
• Fluticasone Inhaler (Flovent)
• Roflumilast (Daliresp) tablet#
• Salmeterol (Severent)
• Tiotropium (Spiriva) Handihaler
• Tiotropium (Respimat)
COPD COMBINATIONS
• Albuterol/Ipratropium (Combivent Respimat)
• Budesonide/Formoterol (Symbicort)
• Tiotropium/Olodaterol (Stiolto Respimat)
NEBULIZERS
• Albuterol nebulizer Solution
• Albuterol/Ipratropium (DuoNeb) nebulizer Solution
HEPATITIS B TREATMENT
• Adefovir (Hepsera)
• Entecavir (Baraclude)
• Lamivudine (Epivir HBV)
• Peginterferon alfa-2a (Pegasys)
• Peginterferon alfa-2b (Peg-Intron)
• Tenofovir alafenamide (Vemlidy)
HEPATITIS C
• Daclatasvir (Daklinza) #
• Elbasvir and grazoprevir (Zepatier) #
• Glecaprevir /pibretasvir (Mavyret) #
• Ledipasvir and Sofosbuvir (Harvoni) #
• Ombitasvir/Paritaprevir/Ritonavir/
• Dasabuvir (Viekira Pak, Viekira XR) #
• Peginterferon alfa-2a (Pegasys)
• Peginterferon alfa-2b (Peg-Intron)
• Ribavirin (Rebetol, Copegus)
• Sofosbuvir (Sovaldi) #
• Tenofovir alafenamide (Vemlidy)
HISTAMINE TYPE-2 RECEPTOR ANTAGONIST (H2RA)
• Famotidine 40 mg (Pepcid) tab, oral suspension
• Lansoprazole/Amoxicillin/Clarithromycin (Prev Pac)
• Omeprazole 40 mg DR cap (Prilosec)
• Pantoprazole 20mg, 40 mg DR tab, 40mg oral susp. quantity limits apply
HYPOGLYCEMICS
• Canagliflozin (Invokana)
• Dapagliflozin (Farxiga)
• Empagliflozin (Jardiance)
• Glipizide (Glucotrol, Glucotrol XL)
• Metformin (Glucophage, Glucophage XL)
• Metformin and Pioglitazone (ActoPlus Met)
• Metformin and Glipizide (Metaglip)
• Nateglinide (Starlix)
• Semaglutide (Ozempic, Rybelsus)
• Sitagliptin (Januvia)
• Sitagliptin/Metformin (Janumet)
KAPOSI’S SARCOMA TREATMENTS
• Doxorubicin (Doxil)
• Generic Doxorubicin (Lipodox)
• Interferon Alpha-2b (Intron A)
LIPID LOWERING AGENTS #
• Atorvastatin (Lipitor)
• Atorvastatin/Amlodipine (Caduet)
• Bempedoic Acid (Nexletol)
• Ezetimibe (Zetia)
• Fenofibrate (Tricor)
• Pravastatin (Pravachol)
• Rosuvastatin (Crestor)
MAIN PROTEASE INHIBITOR
• Nirmatrelvir/ritonavir (Paxlovid) Inj.
OMEGA-3 FATTY ACIDS
• Omega-3 Fatty Acids/Fish Oil (Lovaza)
OPIOID ADDICTION TREATMENT
• Buprenorphine (Subutex) CIII **#
• Buprenorphine/Naloxone (Suboxone) CIII **#
OPIOID ANTAGONIST
• Naloxone (Evzio) 2mg Auto-injector
• Naloxone (Narcan) 4mg Nasal spray
OSTEOPOROSIS
• Alendronate 70mg plus Vitamin D
• Calcitonin-salmon Nasal spray
• Raloxifene (Evista)
PCP PROPHYLAXIS
• Aerosolized Pentamidine (Nebupent)
• Atovaquone Suspension (Mepron)
• Dapsone tablets
• Sulfamethoxazole-Trimethoprim (Bactrim)
SMOKING CESSATION
• Par-Varenicline
• Apo-Varenicline
THYROID DISORDER
• Levothyroxine (Synthroid) tablets
• Methimazole tablets
• Propylthiouracil/PTU tablets
TOPICAL STEROIDS
• Hydrocortisone 2.5% [cream, lotion, ointment]
• Hydrocortisone valerate 0.2% cream
TOPICAL ANESTHETICS
• Lidocaine Patch (Lidoderm)
URINARY TRACT INFECTION
• Nitrofurantoin (Macrobid)
• Fosfomycin
• Cefdinir (Omnicef)
WEIGHT LOSS/WASTING
• Dronabinol (Marinol/Syndros) CIII ** #
• Megestrol (Megace, Megace ES)
• Oxandrolone (Oxandrin) CIII **
• Somatropin (Serostim) #
MISCELLANEOUS
• Berocca Plus vitamins (Rx Only)
• Epoetin Alfa (Procrit, Epogen) #
• Pyridoxine 50mg
• Gabapentin (Neurontin)
• V-C Forte vitamin (Rx only)
Pre Exposure Prophylaxis Drug Assistance Program (PrEPDAP)
NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
• Emtricitabine/Tenofovir disoproxil fumarate (Truvada)
• Emtricitabine/Tenofovir alafenamide (Descovy)
Post Exposure Prophylaxis (PEP)
ANTIMICROBIALS
• Doxycycline Hyclate (Vibramycin)
INTEGRASE INHIBITORS
• Dolutegravir (Tivicay)
• Raltegravir (Isentress) 400 mg tablets only
NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
• Emtricitabine/Tenofovir disoproxil fumarate (Truvada)
• Emtricitabine/Tenofovir alafenamide (Descovy)
HIV-1 INTEGRASE STRAND TRANSFER INHIBITOR/ NRTI COMBINATION
• Bictegravir/Emtricitabine/Tenofovir alafenamide fumarate (Biktarvy)
• Elvitegravir/Cobicistat/Emtricitabine/ Tenofovir alafenamide fumarate (TAF) (Genvoya)
NNRTI/NRTI COMBINATION
• Emtricitabine/Rilpivirine/Tenofovir alafenamide (Odefsey)
• Emtricitabine/Rilpivirine/Tenofovir disoproxil fumarate (Complera)
** DENOTES CONTROLLED SUBSTANCES
# DENOTES PRIOR AUTHORIZATION
++ DENOTES DOSAGE STRENGTH CAUTION
CONTROLLED SUBSTANCES ARE AVAILABLE AT ANY CONTRACTED NETWORK PHARMACY
Delivery Available – inquire with individual pharmacy
UPDATED July 9, 2025
CONFIDENTIAL FAX (202) 673-4365