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Program HH Medication Program (ADAP) Formulary

The Program HH Formulary is a closed formulary. The formulary is reserved for HIV anti-retroviral therapy, medications used to treat side effects associated with anti-retroviral therapy, HIV opportunistic infections and some co-morbidities associated with HIV. If you feel a drug exists that is currently not on the Program HH Formulary that should be, please use the form below to submit a drug addition request. The form must be submitted by either a physician or pharmacist. Bolded fields must be filled out in order for your request to be considered. Once the form has been completed it should be faxed to 651-431-7414. All requests are reviewed by the Program HH Formulary Committee.

Formulary Drug Addition Request Form (PDF)

Program HH added the medication Egrifta to the Program HH Formulary on Sept. 1, 2011. Egrifta requires a prior authorization. To request prior authorization contact the MHCP Prescription Drug PA Agent by phone at 1-866-205-2818 or fax 1-866-648-4574.

Egrifta PA criteria

Program HH added the medications Incivek, Victrelis, Sovaldi and Olysio to the Program HH formulary for the treatment of Hepatitis C. These medications require prior authorization. The prior authorization criteria is for “on-label” usage. To request prior authorization contact the MHCP Prescription Drug PA Agent by phone at 1-866-205-2818 or fax 1-866-648-4574.

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
    Nitazoxanide (Alinia)
    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

    Boceprevir (Victrelis) Prior authorization required
    Ledipasvir/Sofosbuvir (Harvoni) Prior authorization required
    Peginterferon Alfa-2B (Pegintron)
    Pegylated interferon (Pegasys, PegIntron)
    Ribavirin 200mg 
    Sofosbuvir (Sovaldi) Prior authorization required
    Simeprevir (Olysio) Prior authorization required
    Telaprevir (Incivek) Prior authorization 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

    Dolutegravir (Tivicay)
    Dolutegravir/Abacavir/Lamivudine (Triumeq)
    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)
    Emtricitabine/ Rilpivirine/Tenofovir (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 authorization required

  • 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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