Minnesota AIDS Drug Assisstance Program Formulary

Minnesota ADAP Formulary
Which drugs are covered?

All drugs are listed by catagory and alphabetically, starting with their generic names followed by the brand names in parenthesis. Click on a high-lighted item in green to see a detailed description of the drug. To search for a specific drug, hold down both the control key (command key on the Mac) and the F key, then type in the drug name. For a list of specific medical criterias, see the bottom of this page.

Antiretroviral
Nucleoside/tide Reverse Transcriptase Inhibitor (NRTI) abacavir (Ziagen) abacavir/lamivudine/zidovudine (Trizivir) didanosine (ddI, Videx, Videx EC) emtricitabine (Emtriva) lamivudine (Epivir, 3TC) lamivudine/zidovudine (Combivir) stavudine (d4T, Zerit) tenofovir (Viread) zalcitabine (ddC, HIVID) zidovudine (AZT, Retrovir)	Protease Inhibitor (PI) amprenavir (Agenerase) atazanavir (Reyataz) indinavir (Crixivan) lopinavir/ritonavir (Kaletra) nelfinavir (Viracept) ritonavir (Norvir) saquinavir (Fortavase) saquinavir (Invirase)	Non-nucleoside Reverse Transcriptase Inhibitor (NnRTI) delavirdine (Rescriptor) efavirenz (Sustiva) nevirapine (Viramune) Entry Inhibitor enfuvirtide (Fuzeon)* Other hydroxyurea (Hydrea)

HIV Drug Resistance Tests: None.

Opportunistic Infection (OI) Treatment & Prophylaxis
Public Health Service Recommanded OI drugs acyclovir (Zovirax) azithromycin (Zithromax) cidofovir (Vistide) clarithromycin (Biaxin) fluconazole (Diflucan) ganciclovir (Cytovene) itraconazole (Sporanox) leucovorin (Wellcovorin) pyrazinamide pyrimethamine (Daraprim) rifampin (Rifadin, Rifamate) sulfadiazine TMP/SMX(Bactrim, Septra)	Other OI drugs albendazole (Albenza) amoxicillin amoxicillin/culvulanate (Augmentin) amphotericin B (Fungizone) atovaquone (Mepron) cephalexin (Keflex) ciprofloxacin (Cipro) clindamycin (Cleocin) clotrimazole (Lotrimin, Mycelex) dapsone dicloxacillin doxycycline (Vibramycin) econazole (Spectazole) erythromycin (EES) erythromycin/ethanol ethambutol (Myambutol)	gentamicin ketoconazole (Nizoral) levofloxacin (Levaquin) metronidazole (Flagyl, Metrogel) miconazole (Micatin, Moniatat, Zeasorb-AF) nystatin (Mycostatin) ofloxacin (Ocuflox) paramomycin (Humatin) penicillin V Potassium (Vestids) pentamidine (NebuPent, Pentam) primaquine rifabutin (Mycobutin) silver sulfadiazine (Thermazene SSD) terconazole (Terazol 7) Tobramycin Sulfate valacyclovir (Valtrex) valgancyclovir (Valcyte)

Hyperlipidemia
atrovostatin (Lipitor) cholestyramine (Questran) fenofibrate (Tricor)	fulvastatin (Lescol) gemfibrozil (Lopid) niacin (Niaspan)	pravastatin (Pravachol) simvastatin (Zocor)

Wasting
dronabinol (Marinol)	megestrol acetate (Megace)

Other
amitriptyline (Elavil) amoxapine (Ascendin) bacitracin bacitracin/polymyxinB bacitracin Zinc bupropion (Wellbutrin) carbamazepine (Tegretol) cefadroxil (Duricef) cefazolin (Ancef) chlor-hexidine (Peridex) cimetidine (Tagamet) citalopram (Celexa) clomipramine (Anafranil) colfazamine (Lamprene) desipramine (Norpramin, Petrofane) diphenoxylate HCI w/ Atropine (Lomotil, Lonox)	divalproex (Depakote) doxepin (Sinequan) fluoxetine (Prozac) fluvoxamine (Luvox) gabapentin (Neurontin) Hydrocortisone (various formulations) imipramine (Tofranil) lamotrigine (Lamictal) loperimide (Imodium) magnesium sulfate maprotiline (Ludiomil) minocycline (Minocin) mirtazapine (Remeron) nefazodone (Serzone) neomycin nitrofurantoin (Macrodantin) nortriptyline (Aventyl, Pamelor)	paroxetine (Paxil) phenelzine (Nardil) phenytoin (Dilantin) prendisone primidone (Mysoline) probenecid prochlorperazine (Pyrazinamide) protriptyline (Vivactil) rantitidine (Zantac) sertraline (Zoloft) tetracycline tranylcypromine (Pamate) trazodone (Desyrel, Trialodine) trimipramine (Surmontil) tobramycin vancomycin valporic acid (Depkene) venlafxine (Effexor) vitamines (generics)

Medical Criteria
Amphotericin B is only covered as an oral suspension. Ganciclovir is only covered in capsule form, not IV. To help with drug prescribing, your doctor can talk to the ADAP Physician Advisory Group about the latest HIV research. Call the ADAP office at (612) 297-3344 or (800) 657-3761 for a referral.

*Additional Eligibility Requirements for Fuzeon: (Limited to 5 free slots and 15 slots with co-pay) Physician must fill out a prior authorization form. Client currently enrolled in ADAP & eligible to receive services. Client NOT eligible for payment of Fuzeon through Medicaid or other third-party payer. Client has failed most recent HAART regimen. Client has a CD4 count of less than 350. Client has a viral load of greater than 1,000. Based on resistance testing, a medically appropriate 3-drug regimen cannot be constructed without including Fuzeon. Must be sensitive to more than one antiretroviral. Suiiitable arrangements for administration of Fuzeon and client education/training in use of Fuzeon have been made. Patttient is judged as likely to be reasonably adherent to the other drugs in the regimen.

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Minnesota ADAP FormularyWhich drugs are covered?

Minnesota ADAP Formulary
Which drugs are covered?