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General Information
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Table
General Information
| State / Territory | Open Formulary | Excluded Drugs | Separate formularies for full-pay medication clients &. ADAP-funded insurance clients | Additional drugs available with clinical provider approval | Prior Authorizations | Drugs requiring prior authoriziation |
|---|---|---|---|---|---|---|
| Alabama | No | No | No | Yes | Sunlenca | |
| Alaska | No | No | No | No | ||
| Arizona | No | Yes | Yes | Yes | Egrifta, Serostim, Sunlenca & Cabenuva | |
| Arkansas | No | No | No | Yes | Cabenuva, Sunlenca, Rukobia, Pifeltro, Trogarzo, Delstrigo, Selzentry, Entecavir & Hepatitis C Medications | |
| California | No | No | No | Yes | Fentanyl, Methadone, Carbamazepine, Dextroamphetamine, Methylphenidate, tenofovir alafenamide, lenacapavir (Sunlenca), fostemsavir (Rukobia), ibalizumab (Trogarzo), insulin delivery devices, tesamorelin (Egrifta SV), human chorionic gonadotropin (HCG), oxandrolone, somatropin | |
| Colorado | No | No | Yes | No | ||
| Connecticut | No | No | No | Yes | Serostim, Xyosted | |
| Delaware | No | No | No | Yes | Cabenuva, Selzentry | |
| District of Columbia | No | No | Yes | Yes | Daklinza, Daliresp, Harvoni, lamiudine and tenofovir, Mavyret, Sovaldi, Viekira, Zepatier, Daraprim, Dronabino, Epogen, Procrit, Subutex and Suboxone, Serostim, Sunlenca | |
| Florida | No | No | No | Yes | Trogarzo and Sunlenca; semaglutide | |
| Georgia | No | No | No | Yes | Viread, Fuzeon, Rukobia, Selzentry, Trogarzo, Epclusa, Harvoni, Mavyret, Zepatier | |
| Hawaii | No | No | No | No | ||
| Idaho | No | No | Yes | Yes | Adderall / Adderall XR, Focalin / Focalin XR, Concerta / Metdate CD / Metadate ER / Ritalin, Vyvanse, Dupixent, Premarin, estradiol, progesterone capsules, Austedo, Xenazine, Ingrezza, depo-testosterone, testosterone | |
| Illinois | Yes | Botulinum toxin; Compounded medications for infusion; Gonadotropin; Hyaluronic acid derivatices, TNF-alpha blockers; Monoclonal antiboidies; Recombinant human growth hormone / Synthetic growth hormone; Antirheumatic antibetabolities; Cosmetic medications; Durable medical equipment; Erectile dysfunciton medications; Female sexual dysfunciton medications; Fertility drugs, Herbal medications; Injectable muscle relaxants; Nutrition supplements; Vaccines / immunizing biologicals; Weight loss medications; C-II, C-III, CIV, CV controlled substances | No | No | Yes | Atovaquone suspension, finasteride, ibalizumab (Trogarzo), maraviroc (Selzentry), Serostim, sildenafil, lenacapavir (Sunlenca), tadalafil |
| Indiana | No | Yes | No | No | ||
| Iowa | Yes | Abortifacients; Acne medications; Anti-rheumatic injectables; Blood Sera; Botulinum Toxin; Compound medications (prior authorization required*); Cosmetic medications; Durable medical equipment; Erectile dysfunction medications; Fertility medications; Hair removal/growth medications; Human Growth Hormone; Hyaluronic Acid derivatives; Immune Globulin intravenous; Infusions; Injectable muscle relaxants; Provider administered medications/injections; Medical cannabidiol; Schedule 2 controlled substances; Cough suppressants that contain controlled substances (hydrocodone, codeine, etc.) | No | Yes | No | |
| Kansas | No | No | No | No | ||
| Kentucky | No | No | No | No | ||
| Louisiana | No | Yes | No | Yes | Hepatitis C Direct Acting Antivirals | |
| Maine | No | No | No | Yes | Belbuca, Eliquis, Ozempic, Delstrigo, Posaconazole, Vosevi, Trogarzo, Mavyret, Harvoni Ledipasvir / Sofosbuvir, Sovaldi, Complera, Maraviroc, Selzentry | |
| Maryland | Yes | Infusion drugs that are primarily billed as medical benefit; Opioids/analgesics; Saliva substitute agents; Fat absorption decreasing agents; Implantable contraceptives; Local anesthetics; Injectable benzodiazepines; Barbiturates; Smoking deterrents; Belladonna alkaloids; Anti-obesity-anorexic agents; Emollients; Wound healing agents: OTC eye vasoconstrictors; Osmotic diuretics; Neuromuscular blocking agents; Homeopathic drugs; Herbal drugs; Solvents; Bulk chemicals; Numerous antineoplastic agents | No | Yes | Yes | HepC drugs and any medications over $4,100 |
| Massachusetts | Yes | Finasteride (for prostate disorders only); Cosmetic medications Erectile dysfunction pharmaceuticals; Fertility drugs; Herbal medications | No | No | No | |
| Michigan | No | No | Yes | Yes | Actos, Androderm, Androgel, cabotegravir / rilpivirine (Cabenuva), Daraprim, dulaglutide, Duragesic, epoetin alfa, Epogen, filgrastim, finasteride, Ibalizumab (Trogarzo), lenacapvir (Sunlenca), lidocaine patch, Lidoderm, liraglutide, methadone, methyltestosterone Neupogen, oxycodone ER oxcycontin, pioglitazone, pryimethamine, lenacapavir (Sunlenca), testosterone (injection, oral, topical), ibalizumab (Trogarzo), Trulicity, Victoza, Vocabria | |
| Minnesota | Yes | Controlled, class-seconded medications | No | No | Yes | As per state Medicaid FFS |
| Mississippi | No | No | No | Yes | Sunlenca | |
| Missouri | No | No | No | No | ||
| Montana | No | No | No | Yes | Mavyret | |
| Nebraska | Yes | Cosmetic medications; Weight loss medications | No | Yes | No | |
| Nevada | No | No | No | Yes | Daklinza Egrifta, Egrifta SV, Epclusa, Harvoni, Mavyret, Olysio, Sovaldi, Technivie, Trogarzo, Viekira Pak, Viekira XR, Vosevi, Zepatier | |
| New Hampshire | Yes | Compound drugs; Botulinum toxin compounds and cosmetic products; Erectile dysfunction drugs; Fertility drugs; Hair growth dtimulants; Herbal medications; Hyaluronic acid ferivatives; Immune hlobulin, intravenous; Injectable muscle relaxants; Mifepristone; Over-the-counter drugs (exceptions apply); recombinant human growth hormone; Gene therapy | No | No | Yes | Clinical criteria medication list: https://nhadap.primetherapeutics.com/downloads/providers/nhadap_clinical_criteria_list.pdf |
| New Jersey | Yes | Vitamins; cough and cold product; drugs used for cosmetic reasons. | No | No | Yes | Cabanuva, Aptivus, Fuzeon, Selzentry, Daraprim, Serostim, Egrifta, Maniol, Megace, Mepron, Oxandrin. |
| New Mexico | Yes | Hepatitis C Direct-Acting Antivirals (DAAs) | No | No | No | |
| New York | No | No | No | Yes | Sargramostin, atovaqone, enfuvirtide (Fuzeon), Epivir HBV, tipranavir (Ativus), maraviroc (Selzentry), IVIG, Daklinza, Viekira, Zepatier, Mavret, Symtuza, ibalizumab (Trogarzo) | |
| North Carolina | No | Yes | No | No | ||
| North Dakota | Yes | Abortifacients; Acne medications; All controlled substances; Antipsychotics; Antirheumatic injectables; Blood; Botulinum toxin; Chemotherapeutic agents; Compounded medications; Cosmetic medications; Cough suppressants; Durable medical equipment; Erectile dysfunction treatments; Fertility medications; Gabapentinoids; Hair removal / growth medications; Herbal medications; Human growth hormone; Hyaluronic acid derivatives; Immunoglobulin intravenous; Infusions; Muscle relaxants | Yes | Yes | No | |
| Ohio | Yes | Abortifacients; Alzheimer's medications; Acne medications; Botulinum Toxin; Chemotherapeutic agents [except imiquimod cream 5% [Aldara]); Controlled substances (Class Schedules II, III, IV, and V, except pregabalin, topical testosterone)); Cosmetic medications / hair Removal / growth Medications; Egrifta SV; Fertility medications; Finasteride; Herbal medications; Human growth hormone; Hyaluronic acid derivatives; Injectable muscle relaxants; Sexual dysfunction medications; GLP-1 agaonists. | No | No | No | |
| Oklahoma | No | No | No | Yes | Cabenuva, Pifeltro, Delstrigo, Hepatitis C Direct Acting Antivirals | |
| Oregon | Yes | Anorexia, weight loss, weight gain; Fertility medications; Erectile dysfunction medications; Hair growth or cosmetic medications ; Prescription vitamins and minerals; Non-prescription drugs (OTCs); Nutritional/Dietary Supplements (including herbal supplements); Durable Medical Equipment | Yes | Yes | Yes | Lenacapavir (Sunlenca), Hepatitis C Direct Acting Antivirals, Serostim, Egrifta, Tadalafil, Sildenafil |
| Pennsylvania | No | No | No | No | ||
| Puerto Rico | No | No | No | Yes | Cabenuva, Rukobia, Sunlenca, Trogarzo, Egrifta, Epclusa, Harvoni, Mavyret, Sovaldi, Vosevi and Zepatier. | |
| Rhode Island | No | No | No | No | ||
| South Carolina | No | No | No | Yes | Trogarzo Egrifta | |
| South Dakota | No | No | No | No | ||
| Tennessee | No | Yes | Yes | No | ||
| Texas | No | Yes | No | No | ||
| Utah | No | Yes | Yes | Yes | Jynneos, MMR, Varcella | |
| Vermont | No | No | No | No | ||
| Virginia | No | Yes | No | No | ||
| Washington | Yes | Drugs for weight loss, anorexia, or weight gain; Fertility drugs; Drugs for hair growth or cosmetic purposes; Drugs for cold or cough symptoms; Drugs for erectile dysfunction; Most prescription vitamins and minerals; Non-prescription drugs; Non-FDA-approved products; Bulk chemicals | Yes | Yes | Yes | Egrifta after 24 weeks Sunlenca |
| West Virginia | No | No | No | No | ||
| Wisconsin | No | No | No | No | ||
| Wyoming | Yes | Hemophilia medications; Botulinum toxin; Gonadotropin; Finasteride (except for prostate disorders); Hyaluronic acid derivatives; Immune globulin, intravenous (IVIG); Injectable muscle relaxants; Mifepristone; Minoxidil; Antirheumatic injectables; Monoclonal antibodies; Nutritional supplements; Propoxyphene; Recombinant human growth hormone; Synthetic growth hormone; Durable medical equipment; Cosmetic medications; Erectile dysfunction pharmaceuticals; Female sexual dysfunction pharmaceuticals; Fertility drugs Herbal medications | No | Yes | Yes | Vitamins and pain relievers (i.e. ibuprofen, Opioids, Hepatitis C Direct Acting Antivirals |
| TOTAL | 14 | 11 | 14 | 29 |