Indiana state department of health

HIV MEDICAL SERVICES PROGRAM
Indiana ADAP Covered Pharmaceuticals
Generics are preferred. “▲” indicates generic only. “■” indicates a specified recipe and cost.
Additions and deletions made since the previous edition of this formulary are listed in RED and RED, respectively.
Refer to the DHHS Prescribing Guidelines at www.aidsinfo.nih.gov/guidelines for information regarding the treatment
of experienced and naive patients with highly active antiretroviral drugs.
For more information, contact the Medical Services Programs at 1-866-588-4948 (option 1).
Antiretrovirals: NRTI’s
Antiretrovirals: Integrase Inhibitors
Antibiotics
34. Amoxicillin+Clavulanate Acid (Augmentin) Antiretrovirals: Combination NRTI’s
Abacavir+Lamivudine+Zidovudine (Trizivir) Note: Not covered…
Zalcitabine (Hivid, ddC) discontinued 44. Isoniazid (Isonicotinic Acid Hydrazide, INH) Antiretrovirals: NNRTI’s
46. Penicillin G Benzathine (Bicillin L-A) Antiretrovirals: Cross-Class Combinations
17. Efavirenz+Emtricitabine+Tenofovir (Atripla) 19. Cobicistat+Elvitegravir+Emtricitabine+ Antifungals
55. Clotrimazole (Mycelex, Gyne-Lotrimin) Protease Inhibitors
troches, vaginal cream, or tablets 24. Lopinavir+Ritonavir (Kaletra, LPV/RTV) 59. Itraconazole (Sporanox) solution and capsules 60. Ketoconazole (Nizoral) cream and shampoo 61. Mary’s Magic Mouthwash ■
63. Nystatin (Mycostatin) liquid, cream, or tablets Note: Not covered…
Amprenavir (Agenerase) replaced by Lexiva Antivirals
Antiretrovirals: Entry Inhibitors
66. Acyclovir (Zovirax) oral or topical 70. Valganciclovir (Valcyte) ORAL ONLY
Testim) TOPICAL AND INJECTABLE ONLY
Cardiovascular Management
Gastrointestinal Care
75. Clopidogrel (not Plavix) ▲
119. Ondansetron (not Zofran) ▲
120. Pantoprazole (not Protonix) ▲
78. Hydrochlorothiazide (Microzide, HCTZ) Insomnia Management
84. Nitroglycerine (Nitro-Bid, Nitro-Dur, Nitrostat, 129. Zolpidem (not Ambien) NOT CR ▲
Neurologic/Psychiatric Management
130. Alprazolam (not Xanax) ▲
Chemical Dependency
90. Buprenorphine+Naloxone (not Suboxone) ▲
93. Naltrexone (ReVia, Depade, Vivitrol) 94. Nicotine Patches (Nicoderm CQ) MAX 14
PATCHES PER DISPENSE
Diabetes Management/Endocrinology
142. Levetiracetam (not Keppra) ▲
97. Diabetic Alcohol Swabs (any brand) MAX $2
PER 100 CT BOX
98. Diabetic Lancets SOFTCLIX ONLY
99. Diabetic Pen Needles BD ONLY
Nefazodone (not Serzone; ▲)
100. Diabetic Syringes BD ONLY
101. Diabetic Test Strips ABBOTT FREESTYLE LITE,
ABBOTT PRECISION XTRA, AND ROCHE ACCU-
CHEK AVIVA ONLY
150. Quetiapine (not Seroquel) NOT XR ▲
103. Glipizide (Glucotrol, Glucotrol XL) 154. Sumatriptan (not Imitrex) ▲
Tricyclic antidepressants (incl. TCAs such as 108. Insulin NPH/Insulin Regular (Humulin 70/30, 109. Levothyroxine (not Synthroid, Levothroid, or
156. Venlafaxine (Effexor) including XR Levoxyl) ▲
111. Metformin (Glucophage, Fortamet) including Pain Management
2.5/325mg, 5/325, 7.5/325, 10/325mg) MAX 8
TABS PER DAY
160. Acetaminophen+Hydrocodone (Vicodin, Norco; 2.5/325mg, 5/325mg, 7.5/325mg,
10/325mg) MAX 8 TABS PER DAY
161. Gabapentin (Neurontin)
162. Ibuprofen (Motrin)
163. Morphine Sulfate (MSIR, MS Contin)
164. Naproxen (Naprosyn)
165. Oxycodone (Roxicodone, Oxycontin, OxyIR)
166. Pregabalin (Lyrica)
167. Tramadol (Ultram)

Respiratory/Allergy Management
168. Albuterol (ProAir, Ventolin) HFA FORMULATION
ONLY
169. Beclomethasone (QVAR) 170. Budesonide+Formoterol (Symbicort) 171. Cetirizine (not Zyrtec) ▲

172. Fluticasone NS (not Flovent inhaler, not
Flonase) ▲
174. Loratadine (not Claritin) ▲
175. Tiotropium (Spiriva)
176. Triamcinolone NS (Nasacort AQ)

Miscellaneous
177. Alendronate (Fosamax)
178. Betamethasone (Diprolene) TOPICAL ONLY
179. Dronabinol (Marinol)
180. Finasteride (Proscar)
181. Imiquimod (Aldara)
182. Leucovorin

183. Polysaccharide Iron Complex (Ferrex 150, 184. Prednisone (Sterapred) 185. Pyridoxine (Vitamin B6)  186. Tamsulosin (not Flomax) ▲

Source: https://kristencenter-public.sharepoint.com/SiteAssets/blog/ADAP%20Formulary%201%20September%202013.pdf