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The Minnesota Department of Human Services provides services for more than one million Minnesotans in 87 counties and 11 tribes.

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ADAP (Program HH) Drug Formulary

Last updated- 12/01/2011

Minnesota’s formulary includes all primary HIV treatment drugs, Opportunistic Infection (OI) drugs and a number of side effect drugs. An advisory committee of HIV specialty physicians, pharmacists, case managers and consumers meet bi-annually to discuss issues and make recommendations.

Some drugs require prior authorization to be covered. Your doctor can request prior authorization by contacting the Minnesota Health Care Programs Prescription Drug Prior Authorization agent by phone at 866-205-2818 or fax 866-648-4574.

Sorting by classification

  • Antibiotics / antiprotozoal - Oral

    Penicillins/Cephalosporins

    Amoxicillin
    Amoxicillin/clavulanic acid (Augmentin)
    Cefpodoxime (Vantin)
    Cephadroxil (Duricef)
    Cephalexin (Keflex) capsules
    Dicloxacillin
    Nitrofurantoin (Furarex)
    Penicillin
    Sulfadiazine (Microsulfon)

    Macrolides

    Azithromycin (Zithromax)
    Clarithromycin (Biaxin)
    Erythromycin

    Tetracyclines

    Doxycycline
    Minocycline
    Tetracycline

    Quinolones

    Ciprofloxacin (Cipro)
    Levofloxacin (Levaquin)
    Moxifloxacin (Avelox)

    Other anti-infectives

    Clindamycin
    Isoniazid/Vitamin B6
    Metronidazole (Flagyl)
    Nebupent (Pentamidine)
    Paromomycin (Humatin)
    Trimethoprim/Sulfamethoxazole (Septra, Bactrim)

  • Antibiotics / antiseptics – Topical treatment

    Bacitracin
    Bacitracin/polymyxin
    Clindamycin 1% gel (Cleocin T)
    Chlorhexidine Gluconate (Peridex)
    Gentamycin, ophthalmic
    Mupirocin 2% ointment (generic only)
    Silver Sulfadiazine (Silvadene)

  • Anticonvulsants / Neuropathy

    Carbamazepine (Tegretol)
    Divalproex Sodium (Depakote/ER)
    Gabapentin (Neurontin)
    Lamotrigene (Lamictal)
    Levetiracetam (Keppra)
    Phenytoin (Dilantin)
    Primidone (Sterasoline)

  • Antidepressants

    Buproprion (Wellbutrin/SR/XL)
    Citalopram (Celexa)
    Desipramine (Norpramin)
    Duloxetine (Cymbalta)
    Escitalopram (Lexapro) [10mg Prior auth - tab split 20]
    Fluoxetine (Prozac)
    Fluvoxamine (Luvox)
    Isocarboxazid (Marplan)
    Lovastatin (Mevacor)
    Mirtazipine (Remeron)
    Paroxetine (Paxil)
    Sertraline (Zoloft)
    Trazodone (Desaryl)
    Venlafaxine (Effexor/XR)

  • Antidepressants - Tricyclic

    Amitriptyline
    Doxepin
    Imipramine
    Maprotiline HCL
    Nortriptyline
    Trimipramine Maleate

  • Antidiarrheal

    Diphenoxylate/Atropine (Lomotil)
    Loperamide (Imodium)

  • Antifungals - Oral

    Clotrimazole (Mycelex)
    Fluconazole (Diflucan)
    Flucytosine (Ancobon)
    Itraconazole (Sporanox)
    Nystatin (Nilstat)
    Voriconazole (Vfend)

  • Antifungals – Topical

    Buconazole
    Econazole
    Ketoconazole
    Miconazole
    Nystatin
    Terconazole

  • Anti-inflammatory - Other oral

    Hydrocortisone
    Prednisone

  • Antiparasitics

    Albendzaole
    Pyrimethamine (Daraprim)

  • Antipsychotic - For use with other antidepressant

    Aripiprazole (Abilify)
    Quetiapine (Seroquel)

  • Antivirals

    Acyclovir (Zovirax)
    Famciclovir (Famvir)
    Foscarnet (Foscavir)
    Penciclovir (Denavir – topical only)
    Relenza
    Tamiflu
    Valacylovir (Valtrex)
    Valganciclovir (Valcyte)

  • Appetite stimulants and/or Anti-nausea

    Dronabinol (Marinol)
    Levocarnitine oral
    Megestrol (Megace)
    Metoclopramide (Reglan)
    Ondansetron (Zofran) [Prior auth after 20 units/month]
    Prochlorperazine (Compazine)
    Somatropin (Serostim only)

  • Cell entry inhibitors

    Enfuvirtide/T-20 (Fuzeon)
    Maraviroc (Selzentry)

  • Colony stimulating factors

    Epogen/Procrit
    Neupogen

  • Growth hormone releasing factor (GRF)
  • Hepatitis B

    Adefovir Dipivoxil (Hepsera)
    Entecavir (Baraclude)
    Lamivudine (Epivir HBV)

  • Hepatitis C

    Incivek  (Prior auth required)
    Peginterferon Alfa-2B (Pegintron)
    Pegylated interferon (Pegasys, PegIntron)
    Ribavirin 200mg
    Victrelis  (Prior auth required)

  • Histamine-2 Receptor Antagonists (H2RA)

    Famotidine (Pepcid)
    Ranitidine (Zantac)

  • HIV-associated opportunistic infections

    Atovaquone (Mepron) for PCP
    Dapsone (avlosulfon) for PCP
    Ethambutol (Myambutol)
    Leucovorin
    Rifabutin (Mycobutin) for MAC
    Rifampin (Rifadin) for MAC
    Primaquine
    Pyrazinamide

  • HPV treatment – Topical treatment

    Imiquimod (Aldara)
    Podofilox (Condylox)

  • Integrase inhibitor

    Elvitgravir, Cobicistat, Emtricitabine, Tenofovir (Stribild)
    Raltegravir (Isentress)

  • Lipid lowering statins

    Atorvastatin (Lipitor)
    Fluvastatin (Lescol/XL)
    Pravastatin (Pravachol)
    Rosuvastatin (Crestor)
    Simvastatin (Zocor)

  • Lipid lowering agents - Other

    Cholestyramine
    Fenofibrate (Tricor)
    Gemfibrozil (Lopid )
    Niacin (Niaspan)

  • Non-nucleoside reverse transcriptase inhibitors

    Delavirdine (Rescriptor)
    Nevirapine (Viramune)
    Efavirenz (Sustiva)
    Etravirine (Intelence)
    Efavirenz/Emtricitabine/Tenofovir (Atripla)
    Rilpivirine (Edurant)

  • Nucleoside reverse transcriptase inhibitors

    Abacavir (Ziagen)
    Abacavir/Lamivudine (Epzicom) Emtricitabine/Tenofovir (Truvada)
    Abacavir/Lamivudine/Zidovudine (Trizivir)
    Complera
    Didanosine (Videx)
    Emtricitabine (Emtriva)
    Lamivudine (Epivir)
    Lamivudine/Zidovudine (Combivir)
    Stavudine (Zerit)
    Zidovudine (Retrovir)

  • Nucleotide analog

    Tenofovir (Viread)

  • Protease inhibitors

    Amprenavir (Agenerase)
    Atazanavir sulfate (Reyataz)
    Darunavir (Prezista)
    Fosamprenavir calcium (Lexiva)
    Indinavir (Crixivan)
    Lopinavir/Ritonavir (Kaletra)
    Nelfinavir (Viracept)
    Ritonavir (Norvir)
    Saquinavir (Invirase)
    Tipranavir (Aptivus)

  • Proton pump inhibitors (PPI)

    Lansoprazole (Prevacid)
    Omeprazole (Prilosec)
    Pantoprazole (Protonix) (Prior auth needed)

  • Sleep agents

    Zolpidem (Ambien)

  • Steroid treatment

    Androderm
    Androgel

  • Urinary incontinence

    Desmopressin acetate (DDAVP)
    Darafenacin (Enablex)
    Oxybutynin (Ditropan/XL)
    Trospium (Sanctura)

  • Vitamins

    Multivitamins (Certagen, OneDaily, Tab-a-Vite)
    (95050, 95500, 95540, 95600, 95680)
    Prenatal vitamins (Prenat Plus, Prenat Rx) (13411, 95339)

  • Miscellaneous

    Probenacid


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