New Hampshire AIDS Drug Assisstance Program Formulary

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New Hampshire 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) fosamprenavir (Lexiva) 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) Other hydroxyurea (Hydrea)

HIV Drug Resistance Tests: Genotypic tests are covered under Title II.

Opportunistic Infection (OI) Treatment & Prophylaxis
Public Health Service Recommanded OI drugs acyclovir (Zovirax) azithromycin (Zithromax) cidofovir (Vistide) clarithromycin (Biaxin) famciclovir (Famvir)	fluconazole (Diflucan) foscarnet (Foscavir) ganciclovir (Cytovene) isoniazid itraconazole (Sporanox) leucovorin (Wellcovorin)	pyrazinamide pyrimethamine (Daraprim) rifampin sulfadiazine TMP/SMX (Bactrim, Septra)

All Others
New Hampshire ADAP has an open formulary, all FDA approved drugs are covered, with the following exclusions: Class Exclusions: Cosmetics (e.g. Botox, Mylobloc) Erectile Dysfunction Medications (e.g. Viagra, Edex, Muse) Fertility Drugs Hair Growth Stimulants (e.g. Propecia, Rogaine) Herbal Medications Immunizing Biologicals Less than Effective Drugs Nutritional Supplements Over the Counter Medications Sex Reassignment Drugs Vitamins and Minerals (e.g. iron) Specific drug exclusions: Active medication containing more than one ingredient antirheumatic injectables (e.g. Enbrel) botulinum toxin compounded mediations for infusion (e.g. Botox, Mylobloc) contraceptives (e.g. Ortho-Novum) enfuvirtide (Fuzeon) finasteride (e.g. Propecia) gonadatropins hyaluronic acid derivatives (e.g. Hyalgan, Synvisc) immune globulin intravenous IGIV (e.g. Sandoflobulin, Venoglobulin) injectable muscle relaxants (e.g. Lioresal) medroxyprogesterone (e.g. Depo Provera) mifepristone (e.g. Mifeprex) monoclonal antibodies (e.g. Remicade, Synagis) propoxyphene (e.g. Darvon) recombinant human growth hormone HGH (e.g. Geref, Humatrop)
Medical Criteria
Dosage and administration shall follow FDA approved guidelines as indicated in the Physician's Desk Reference (PDR), i.e. no off-label use allowed. Generic interchange is required when available unless otherwise prescribed. All drugs are covered in any dose form. For administering pentamidine, also covered: Respirguard II nebulizer system and one 12 ml syringe w/20 gauge needle One 10 ml container sterile water and one unit dose Alu-Pent w/hand-held nebulizer

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Last modified: 12/15/2006
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