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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

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