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AIDS Drug Assistance Program (ADAP) Formulary - October 3, 2013

NOTES: Formulary is subject to change based on available funds. ADAP does not cover all prescription strengths or forms of Formulary drugs.

Mandatory Generics - ADAP will cover only the generic form of A-rated drugs.

Drug Listings

Antiretroviral Therapy

(some antiretroviral combinations may be subject to utilization review )

  1. Nucleoside/Nucleotide Analogs abacavir (Ziagen), abacavir/lamivudine (Epzicom), didanosine (ddI, Videx, Videx EC), emtricitabine (Emtriva, FTC), lamivudine (3TC, Epivir), rilpivirine (Edurant), stavudine (d4T, Zerit), tenofovir (Viread), tenofovir/emtricitabine (Truvada), zidovudine (AZT, Retrovir), lamivudine/zidovudine (Combivir), abacavir/lamivudine/zidovudine (Trizivir)
  2. Protease Inhibitors amprenavir (Agenerase), atazanavir (Reyataz), darunavir (Prezista), fosamprenavir (Lexiva), indinavir (Crixivan), lopinavir/ritonavir (Kaletra), nelfinavir (Viracept), ritonavir (Norvir), saquinavir (Invirase, Fortovase), tipranavir (Aptivus) {Aptivus requires prior authorization, please call 1-800-832-5305}  
  3. Non-Nucleoside Reverse Transcriptase Inhibitors nevirapine (Viramune), delavirdine (Rescriptor), efavirenz (Sustiva), etravirine (Intelence)
  4. Fusion Inhibitors enfurvirtide (Fuzeon, T-20) {Fuzeon requires prior authorization, please call 1-800-832-5305}
  5. Multi-Class Antiretroviral Agent efavirenz/emtrictabine/tenofovir (Atripla), elvitegrav-cobicis-emtricitab-tenofov (Stribild), rilpivirine-tenofovir-emtricrabine (Complera)
  6. Integrase Inhibitors dolutefravir (Tivicay), raltagravir (Isentress)
  7. CCR5 Antagonist maraviroc (Selzentry) {maraviroc requires prior authorization, please call 1-800-832-5305}

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Opportunistic Infections

  1. Herpes Infections acyclovir, penciclovir, valacyclovir
  2. Mycobacterial Infections amikacin, capreomycin, ciprofloxacin, clarithromycin, cycloserine, ethambutol, ethionamide, gatifloxacin, isoniazid, kanamycin, moxifloxacin, ofloxacin, aminosalicyclic acid, pyrazinamide, rifabutin, rifampin w/wo combinations, rifapentine, streptomycin
  3. CMV disease formivirsen, foscarnet, ganciclovir, cidofovir, probenecid, valganciclovir
  4. Fungal infections amphotericin B, caspofungin, clotrimazole, econazole, fluconazole, flucytosine, griseofulvin, itraconazole, ketoconazole, miconazole, nystatin, terbinafine, terconazole, voriconazole
  5. Toxoplasmosis azithromycin, clindamycin, leucovorin, pyrimethamine, sulfadiazine, triple sulfa
  6. Cryptosporidiosis paromomycin
  7. Microsporidiosis albendazole
  8. Parasitic Infection ivermectin

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PCP Prophylaxis & Treatment

atovaquone, clindamycin, dapsone, hydroxyzine, leucovorin, pentamidine, primaquine, sulfadoxine/pyrimethamine, trimethoprim, sulfamethoxazole- trimethoprim
{atovaquone (Mepron) requires prior authorization, please call 1-800-832-5305}

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Antineoplastics

alitretinoin, bleomycin, cyclophosphamide, cytarabine, dexamethasone, doxorubicin, etoposide, hydroxurea, interferon alfa, doxorubicin, daunorubicin liposomal, lomustine, methotrexate, paclitaxel, prednisone, procarbazine, vinblastine, vincristine

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Other HIV/AIDS Related Conditions

  1. Wasting Syndrome cyproheptadine, dronabinol, testosterone, megestrol, thalidomide
  2. Prevention of bacterial infections in children ONLY (18 and under) intravenous immune globulin
  3. Condyloma alpha N3, imiquimod, podofilox
  4. Reiter's syndrome sulfasalazine
  5. Vaccines hepatitis A & B vaccines
  6. Prevention of dental cavities fluoride
  7. Hepatitis B adefovir, entecavir
  8. Hepatitis C apeginterferon, ribavirin
  9. Thrombosis enoxaparin, warfarin
  10. Vaccines HPV vaccine, meningococcal vaccine

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Antibiotics

amoxicillin, amoxicillin-clavulanate, ampicillin, aztreonam, bacitracin, cefaclor, cefadroxil, cefazolin, cefixime, cefoxitin, cefpodoxime, cefprozil, ceftazidime, ceftriaxone, cefuroxime, cephalexin, cephradine, chloramphenicol, chlorhexidine, cloxacillin, dicloxacillin, doxycycline, erythromycin, fosfomycin, furazolidone, gentamicin, imipenem - cilastatin, levofloxacin, loracarbef, metronidazole, minocycline, mupirocin, nitrofurantoin, penicillin, sparfloxacin, spectinomycin, tetracycline, tobramycin, ticarcillin-clavulanate, vancomycin

  1. Other related drugs chlorhexidine gluconate, probenecid

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Analgesics

butalbital combination w/wo/ codeine, codeine w/wo/ ASA, APAP, diclofenac, diethylpropion, diflunisal, fenoprofen, fentanyl (patch only), flurbiprofen, hydrocodone w/ ASA, APAP, hydromorphone, ibuprofen, indomethacin, ketoprofen, ketorolac, levorphanol, lidocaine, methadone*, morphine, naproxen, oxycodone w/wo/ ASA, APAP, piroxicam, sulindac, tolmetin, tramadol

*Methadone is available only for pain relief; ADAP does not cover methadone maintenance

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Anti-Diarrheals/Malabsorption

atropine-diphenoxylate, loperamide, pancrelipase, opium

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Psychotropics

alprazolam, amitriptyline, aripiprazole, benztropine, bupropion, buspirone, butabarbital, chloral hydrate, chlordiazepoxide w/wo clidinium, chlorpromazine, citalopram, clomipramine, clonazepam, clorazepate, clozapine, desipramine, dextroamphetamine, diazepam, doxepin, duloxetine, escitalopram, fluoxetine, fluphenazine, flurazepam, fluvoxamine, halazepam, haloperidol, imipramine, lithium, lorazepam, loxapine, mesoridazine, methylphenidate, mirtazapine, molindone, nefazodone, nortriptyline, olanzapine, oxazepam, paroxetine, pemoline, pentobarbital, perphenazine, prochlorperazine, quetiapine, risperidone, secobarbital, sertraline, temazepam, thioridazine, thiothixene, trazodone, triazolam, trifluoperazine, trimipramine, venlafaxine, ziprasidone, zolpidem

Anticonvulsants carbamazepine, divalproex sodium, felbamate, gabapentin, lamotrigine, levetiracetam, magnesium sulfate, oxcarbazepine, phenytoin, pregabalin, primidone, tiagabine, topiramate, valproic acid

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Cardiac Medications**

acebutolol, amiloride, amlodipine, atenolol, benazepril, bendroflumethiazide, betaxolol, bisoprolol, bumetanide, candesartan, captopril, carteolol, carvedilol, chlorothiazide, chlorthalidone, clonidine, clopidogrel, digoxin, diltiazem, doxazosin, enalapril, felodipine, fosinopril, furosemide, guanabenz, guanadrel, guanfacine, hydralazine, hydrochlorothiazide, hydroflumethiazide, indapamide, irbesartan, isosorbide, isoxsuprine, isradipine, labetalol, lisinopril, losartan, methyclothiazide, methyldopa, metolazone, metoprolol, minoxidil, moexipril, moricizine, nadolol, nicardipine, nifedipine, nisoldipine, nitroglycerin, papaverine, penbutolol, pindolol, polythiazide, prazosin, procainamide, propranolol, quinapril, ramipril, sotalol, spironolactone, telmisartan, terazosin, tocainide, torsemide, trandolapril, triamterene, trichlormethiazide, valsartan, verapamil

** Cardiac medications listed individually are available in combination with other listed cardiac medications.

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Hyperlipidemia

atorvastatin, cholestyramine, colestipol, ezetimibe, fenofibrate, fluvastatin, gemfibrozil, niacin, omega 3 fatty acids (Rx only), pravastatin, rosuvastatin

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Gastrointenstinal Medications

amylase-lipase-protease, cimetidine, dolasetron, esomeprazole, granisetron, lansoprazole, metoclopramide, misoprostol, omeprazole, ondansetron, pantoprazole, rabeprazole, ranitidine, sucralfate, thiethylperazine, trimethobenzamide

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Insulin

acarbose, acetohexamide, chlorpropamide, glimepiride, glipizide, glyburide, insulin, metformin, miglitol, pioglitazone, repaglinide, rosiglitazone, tolazamide, tolbutamide

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Sinusitis Medications

acrivastine/pseudoephedrine, azatadine, brompheniramine w/wo combinations, budesonide, carbinoxamine, chlorpheniramine w/wo/ combinations, clemastine, dexbrompheniramine/pseudoephedrine, dexchlorpheniramine, diphenhydramine, mometasone, naphazoline w/wo combinations, phenir/ppa/phenylt./ pyrilamine, phenylephrine-promethazine, phenylprop-pyril-pheniramine, phenyltolox-APAP, phenyltolox/ pyril/pheniramine, promethazine, triprolidine

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Topical Steroids

alclometasone, amcinonide, amlexanox, betamethasone, clobetasol, clocortolone, desonide, desoximetasone, diflorasone, fluocinolone, fluorometholone, fluticasone, flurandrenolide, halcinonide, halobetasol, hydrocortisone w/wo/ combinations, neomycin w/wo/ combinations, prednicarbate, prednisolone, triamcinolone

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Bronchodilator/Respiratory Inhalants***

funisolide, salmeterol, albuterol, albuterol-ipratropium, terbutaline, beclomethasone, ipratropium, theophylline, bitolterol, metaproterenol, triamcinolone, budesonide, montelukast, zafirlukast, cromolyn, nedocromil, zileuton, dyphylline, oxtriphylline, fluticasone, pirbuterol, tiotropium, formoterol
*** Solutions for nebulizers are not covered.

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Urinary Incontinence

flavoxate, oxybutynin, tolterodine

Gynecological

estrogen, progestins, estrogens-progestins

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Ophthalmological

acetylcholine, apraclonidine, atropine, brimonidine, brinzolamide, carbachol, cyclopentolate, cyclopentolate-phenylephrine, dipivefrin, dorzolamide, dorzolamide-timolol, ecothiopate, homatropine, latanoprost, levobunolol, loteprednol, medrysone, metipranol, pilocarpine, prednisolone, rimexolone, timolol, tropicamide w/wo hydroxyamphetamine

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Partial Opioid Agonist

buprenorphine

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Nicotine Cessation (Rx only)

nicotine nasal spray, nicotine inhaler, varenicline

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Ancillary Devices

  • glucose monitor - limit one
  • glucose test control solution, glucose test strips
  • lancets/lancet devices, peak flow meter, spacers/aerochambers
  • syringes/needles ***

***reimbursable only with a prescription for an injectable drug covered by ADAP

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Drugs Requiring Prior Authorization - Request Form and Guidelines available (1-800-542-2437)

  1. Antiretroviral Therapy
    • enfurvirtide (Fuzeon, T-20). Call 1-800-832-5305 to initiate the prior authorization process.
    • tipranavir (Aptivus). Call 1-800-832-5305 to initiate the prior authorization process.
  2. PCP & Toxoplasmosis Indications
    • Atovaquone (Mepron) - for the treatment or prophylaxis of PCP or toxoplasmosis when first line treatments fail.
      Call 1-800-832-5305 to initiate the authorization process.
  3. Hematological Indications
    • Epoetin alfa - for AIDS related anemia, with: Hct<30% and/or Hgb<10g/dl; and serum erythropoietin levels<500mU/ml.
    • Filgrastim - for severe neutropenia due to: chemotherapy; or drug toxicity or HIV disease with ANC<500/mm3.
    • Sargramostim - for severe neutropenia due to: chemotherapy;or drug toxicity or HIV disease with ANC<500/mm3.
    • Immune globulin Rho (Win Rho SDF) - for HIV-associated thrombocytopenia; with platelets<20,000 mm3. Prior authorization is not required for children.
    • Oprelvekin (Neumega) - for chemotherapy induced thrombocytopenia; with platelet count <20,000/ul. and/or documented risk factors or clinical indications.

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Additional Information

HIV Uninsured Care Programs
Empire Station
P.O. Box 2052
Albany, NY 12220-0052

Instate Toll Free: 1-800-542-2437

Out of State: (518) 459-1641

TDD: (518) 459-0121