ALABAMA S ADAP FORMULARY OFFERS 117 MEDICATIONS - 2014 Alabama s ADAP formulary offers a minimum of one medication from each HIV antiretroviral class approved by the U.S. Food and Drug Administration (FDA). Alabama ADAP Eligibility Criteria 1. Medical Eligibility Criteria = HIV diagnosis documented by lab test confirmation 2. Financial Criteria = Total Gross Household Income at or below 250% of the Federal Poverty Level (FPL) 3. Alabama Resident = (A PO Box is accepted to confirm a physical Alabama residence with other documentation to confirm client is a permanent Alabama resident) 4. No public or private third party payer source to provide the same service provided with Ryan White funds. 5. Remain compliant with ADAP Client Eligibility Reassessment (CER) 2x/year A 30-day supply of each medication is shipped each month on a regular schedule from the ADAP Central Pharmacy to the ordering Clinic for the Client or designee to pick up. ADAP/MEDCAP Prescriptions will be active for 12 months but all ADAP prescriptions only must be updated for each client on active and waiting ADAP during Client Eligibility Reassessment (CER) twice a year. This does NOT apply to MEDCAP enrollees for 2014. MEDCAP prescriptions for medications NOT on the formulary are to be written on the blank page (last page) of the Prescription Form - 2014 Generic formulations will be dispensed when available unless the Clinician specifically requests the Brand formulation when ordering a medication. ASAP shipment requests must be approved by the ADAP Coordinator based on the clinic s next regular scheduled medication shipment that is more than 7 working days from the date of the ASAP request. Pre-approval must be obtained from the ADAP Coordinator for any medications to be shipped to an alternate site. Permission for the ADAP Central Pharmacy to ship medications outside of the Clinic will be limited to a pre-approved Physician s order for home delivery due to a Client s poor medical condition limiting travel to the clinic for medication pick up. Medication Pre-approval is a requirement for several medications on the ADAP formulary. For assistance to complete pre-approval processes, please contact the ADAP Coordinator or an Eligibility Specialist at 1-866-574-996). Failure to pick-up ADAP medications for three (3) consecutive months will result in the Client s ADAP enrollment status being changed to Inactive due to non-compliance with medication adherence. Failure to complete Client Eligibility Reassessment (CER) will result in the Client s enrollment status made Inactive due to failure to complete the CER enrollment requirement. Clients in Inactive or Denied enrollment status may reapply to be considered for enrollment in ADAP at any time through a Social worker/case manager or Clinician to complete the ADAP application process. When there is an ADAP waiting list, approved applications are placed at the back of the waiting list and placed on active ADAP on a first-come-first-serve basis with no medical criteria.
PRESCRIPTION FORM 2014 Prescriptions fills x 12 *All ADAP prescriptions must be updated and resubmitted with Client Eligibility Reassessment (CER) Check One [ ] ADAP [ ] MEDCAP OFFICE USE ADAP ID# PATIENT NAME (Print) Last First DOB / / ARV s (34) Agenerase amprenavir Aptivus tipranavir Atripla efavirenz, emtricitabine, tenofovir Combivir zidovudine, lamivudine Complera emtricitabine, rilpivirine, tenofovir, disoproxil fumarate Crixivan indinivir sulfate Edurant rilpivirine Emtriva emtricitabine Epivir lamivudine Epzicom abacavir sulfate, lamivudine Fuzeon** enfuvirtide **PA** Intelence etravirine Invirase saquinavir mesylate Isentress raltegravir Kaletra lopinavir, ritonavir Lexiva fosamprenavir Norvir ritonavir Prezista daraunavir Rescriptor delavirdine mesylate Retrovir zidovudine Reyataz atazanavir sulfate Selzentry** maraviroc **PA** elvitegravir, cobicistat, Stribild emtricitabine, tenofovir disoproxil fumarate Sustiva efavirenz Trizivir abacavir, zidovudine, lamivudine Truvada tenofovir DF, emtricitabine Videx didanosine (buffered versions) didanosine Videx EC (delayed release capsules) Viracept nelfinavir sulfate Viramune nevirapine Viread tenofovir disoproxil fumarate DF Zerit stavudine Ziagen abacavir Check when requesting an ASAP shipment ASAP Request Approved [ ] Denied [ ] Date Initial Prescriber Name (Print) License # Prescriber (Signature) Date Prescriber Phone # Clinic Name Shipping Address City State ZIP Date to Pharmacy / / ES
PRESCRIPTION FORM 2014 Check One [ ] ADAP [ ] MEDCAP OFFICE USE ADAP ID# PATIENT NAME (Print) Last First DOB / / OI MEDICATIONS (29) Ancobon flucytosine Bactrim DS sulfamethoxazole/trimethoprim DS Biaxin clarithromycin Cleocin clindamycin Dapsone - Daraprim pyrimethamine Deltasone prednisone Diflucan fluconazole Famvir famciclovir Foscavir foscarnet Fungizone amphotericin B INH isoniazid Megace megestrol Mepron atovaquone Myambutol ethambutol Mycobutin rifabutin NebuPent pentamidine Probenecid - Procrit** epoetin alfa **PA** Pyrazinamide - (PZA) Sporonox itraconazole Sulfadiazine Oral Valcyte valganciclovir Valtrex valacyclovir VFEND voriconazole Vistide cidofovir Wellcovorin leucovorin Zithromax azithromycin Zovirax acyclovir - Check when requesting an ASAP shipment ASAP shipment Approved [ ] Denied [ ] Date Initial All ADAP prescriptions must be updated and resubmitted with Client Eligibility Reassessment (CER) every 6 months. Prescription refills x12 Prescriber Name (Print) License # Prescriber (Signature) Date Prescriber Phone # Clinic Name Shipping Address City State Zip Code Date to Pharmacy / / ES Initials
PRESCRIPTION 2014 Check One [ ] ADAP [ ] MEDCAP OFFICE USE ADAP ID# PATIENT NAME (Print) Last First DOB / / Medications listed under Other Medications may be removed from the formulary at any time to ensure that Alabama s ADAP continues to maintain adequate funding to provide Anti-HIV medications for enrollees; or in the event there is a need to re-instate the ADAP waiting list Other Medications (13) Baraclude entecavir Gardasil-IM - Havrix-IM hepatitis A virus Hepsera adedefovir Intron-A interferon alfa-2b Pegasys peg-interferon alfa-2a Peg-Intron peg-interferon alfa-2b Pneumovax pneumococcal 23-IM Rebetol ribavirin Rebetron ribavirin/interferon alfa-2b Recombivax hepatitis B virus HB-IM Roferon-A interferon alfa-2a Twinrix-IM hepatitis A and B virus PRE-APPROVAL REQUIREMENTS Fuzeon**PA** requires pre-approval prior to a prescription being processed by the ADAP Central Pharmacy. Call the ADAP Eligibility Office at 1-866-574-9964 or go to www.adph.org to access instructions and forms. Procrit**PA** requires pre-approval prior to a prescription being processed by the ADAP Central Pharmacy. Call the ADAP Eligibility Office at 1-866-574-9964 or go to www.adph.org to access pre-approval instructions and forms. Selzentry**PA** Tropism Assay testing required prior to a prescription being processed by the ADAP Pharmacy. Call the ADAP Eligibility Office at 1-866-574-9964 or go to www.adph.org to access Tropism Assay pre-approval instructions and forms. Check when requesting an ASAP shipment ASAP shipment Approved [ ] Denied [ ] Date Initials All ADAP prescriptions must be updated and resubmitted at Client Eligibility Reassessment (CER) every 6 months. Prescription refills x12 Prescriber Name (Print) License # Prescriber (Signature) Date Prescriber Phone # Clinic Name Shipping Address City State Zip Code Date to Pharmacy / / ES Initials
ADAP / MEDCAP PRESCRIPTION FORM 2014 ADAP Enrollees ADAP Formulary Medications Only Check One ADAP [ ] MEDCAP [ ] OFFICE USE ID# PATIENT NAME (Print) Last First DOB / / Order Medications NOT on the formulary on this prescription form for MEDCAP Enrollees Check when requesting an ASAP shipment ASAP shipment Approved [ ] Denied [ ] Date Initial There is no twice a year Client Eligibility Reassessment (CER) requirement for MEDCAP Prescription refills x12 for MEDCAP Complete this information Only when ordering a medication above. Prescriber Name (Print) License # Prescriber (Signature) Date Prescriber Phone # Clinic Name Shipping Address City State Zip Code Date to Pharmacy / / ES Initials