Ryan White Part B Formulary

Medications are listed below by generic and brand name.  They are grouped by indication or use.  The indication or use must be HIV-related.

Ryan White Part B Formulary (rev. 08/07/19)

 GENERIC NAME AVAILABLE BRAND NAME*

Must use generic when available

 CLASS OR TYPE OF DRUG**

Must be HIV related or for conditions that affect health outcomes related to HIV management
alprazolam Xanax anti-anxiety
diazepam Valium anti-anxiety
lorazepam Ativan anti-anxiety
triazolam Halcion anti-anxiety
amoxicillin Amoxil anti-bacterial
amoxicillin/clavulanic acid Augmentin anti-bacterial
cefuroxime Ceftin anti-bacterial
cephalexin Keflex anti-bacterial
ciprofloxacin Cipro anti-bacterial
dicloxacillin anti-bacterial
doxycycline Vibramycin anti-bacterial
moxifloxacin Avelox anti-bacterial
mupirocin Bactroban anti-bacterial
nitrofurantoin Macrobid anti-bacterial
penicillin anti-bacterial
warfarin Coumadin anti-coagulant
betamethasone/clotrimazole Lotrisone anti-infective
clotrimazole Lotrimin, Mycelex anti-infective
clotrimazole troches Mycelex Troches anti-infective
ketoconazole Nizoral anti-infective
metronidazole Flagyl anti-infective
nystatin Mycostatin Susp. anti-infective
valacyclovir Valtrex anti-viral
oseltamivir Tamiflu anti-viral
zanamivir Relenza anti-viral
amlodipine Norvasc cardiac
atenolol Tenormin cardiac
clonidine hydrochloride Catapres cardiac, opioid use disorder treatment
diltiazem Cardizem cardiac
doxazosin Cardura cardiac
enalapril Vasotec cardiac
fosinopril Monopril cardiac
irbesartan Avapro cardiac
labetolol Trandate cardiac
lisinopril Zestril cardiac
losartan Cozaar cardiac
metoprolol Lopressor cardiac
potassium cardiac
propranolol Inderal cardiac
verapamil Covera, Calan cardiac

* RWHAP B funds will pay for brand name formulations only if a generic formulation is not available. Brand names listed on the formulary are for reference only. ** Use of medications must be HIV-related, but is not restricted to the indication/use cited on the formulary. Alternatively, the medication must treat a co-morbid condition or disorder that affects HIV management or an individual’s health outcomes such as HIV viral load suppression. The information provided is only a resource and does not provide clinical advice or information.

GENERIC NAME AVAILABLE BRAND NAME*

Must use generic when available

 CLASS OR TYPE OF DRUG**

Must be HIV related or for conditions that affect health outcomes related to HIV management
fluocinonide Lidex dermatologic
imiquimod Aldara Cream dermatologic
bacitracin/neomycin/polymyxin B Neosporin dermatologic
triamcinolone: Eucerin (compond) dermatologic
diphenoxylate/atropine Lomotil, Lonox diarrhea
loperamide Imodium diarrhea
furosemide Lasix diuretic
hydrochlorothiazide diuretic
spironolactone Aldactone diuretic
levothyroxine Synthroid hormone
prednisone Deltasone hormone
testosterone Androderm, Androdgel, Oxandrin hormone
buprenorphine/naloxone Suboxone (sublingual film), Zubsolv (sublingual tablet), Bunavail (buccal film) opioid use disorder treatment
buprenorphine (monoproduct) Sublocade (injection), buprenorphine tablets opioid use disorder treatment♦
lofexidine Lucemyra opioid use disorder treatment
methadone Dolophine, Methadose opioid use disorder treatment‡
naltrexone Vivitrol (tablet and injection) opioid use disorder treatment, alcohol use disorder treatment
acetaminophen/codeine Tylenol 3 pain
butalbital/acetaminophen/caffeine Fioricet pain
celecoxib Celebrex pain
fentanyl Duragesic pain
gabapentin Neurontin pain (neuropathic)
hydrocodone Hycodan, Lortab, Vicodin pain
hydromorphone Dilaudid pain
methadone Dolophine pain
morphine sulphate MS Contin pain
naproxen sodium Naprosyn, Alleve pain
oxycodone Roxicodone, OxyContin pain
propoxyphene Darvon, Darvocet pain
tramadol Ultram pain
albuterol Ventolin, Accuneb, Duoneb, Proventil respiratory
beclomethasone QVAR respiratory
guaifenesin/codeine respiratory
salmeterol Serevent respiratory

* RWHAP B funds will pay for brand name formulations only if a generic formulation is not available. Brand names listed on the formulary are for reference only. ** Use of medications must be HIV-related, but is not restricted to the indication/use cited on the formulary. Alternatively, the medication must treat a co-morbid condition or disorder that affects HIV management or an individual’s health outcomes such as HIV viral load suppression. The information provided is only a resource and does not provide clinical advice or information. ♦The Drug Addiction and Treatment Act of 2000 limits office-based use of buprenorphine-containing products to prescribers who have met the qualifications to receive a waiver. These prescribers will have a special DEA number starting with the letter “X”. ‡ By law, methadone can only be dispensed through an opioid treatment program (OTP) certified by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA).

GENERIC NAME AVAILABLE BRAND NAME*

Must use generic when available

 CLASS OR TYPE OF DRUG**

Must be HIV related or for conditions that affect health outcomes related to HIV management
carbamazepine Tegretol seizures
clonazepam Klonopin seizures
divalproex sodium Depakote seizures
gabapentin Neurontin seizures
phenytoin Dilantin seizures
temazepam Restoril sleep
zolpidem Ambien sleep
dronabinol Marinol wasting
meningococcal conjugate vaccine

* RWHAP B funds will pay for brand name formulations only if a generic formulation is not available. Brand names listed on the formulary are for reference only. ** Use of medications must be HIV-related, but is not restricted to the indication/use cited on the formulary. Alternatively, the medication must treat a co-morbid condition or disorder that affects HIV management or an individual’s health outcomes such as HIV viral load suppression. The information provided is only a resource and does not provide clinical advice or information.

Last Updated: August 7, 2019.