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General Information
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Table
General Information
| State/Territory | Open Formulary | Excluded Drugs (If Open Formulary) | ADAP support two separate formularies: full-pay medication program clients and ADAP-funded insurance program? | Additional Drugs and Services are availbable to clietns with clinical providers approval | Prior Authorizations | Drugs Requiring Prior Authorization |
|---|---|---|---|---|---|---|
| Alaska | No | No | No | No | ||
| Alabama | No | No | No | Yes | Cabenuva | |
| Arkansas | No | No | No | Yes | Hepatitis C Medications, Cabenuva, Sunlenca, Rukobia, Pifeltro, Fuzeon, Trogarzo, Delstrigo, Selzentry & Entecavir | |
| Arizona | No | Yes | Yes | Yes | Cabenuva, Egrifta SV & Serostim | |
| California | No | No | No | Yes | Fentanyl; Methadone; Dextroamphetamine;Methylphenidate; Crofelemer; Voriconazole; Gemifloxacin; imipenem/cilastatin; linezolid; moxifloxacin; paclitaxel; tenofovir alafenamide; doravirine; doravirine/lamivudine/tenofovir disoproxil fumarate; lenacapavir; enfuvirtide; fostemsavir; ibalizumab; Cycloserine; Ethionamide; para-aminosalicylate; grazoprevir/elbasvir; ledipasvir/sofosbuvir (Harvoni PA required); pegylated interferon; sofosbuvir; sofosbuvir/velpatasvir (Epclusa PA required); sofosbuvir/velpatasvir/voxilaprevir; valganciclovir; insulin delivery devices; tesamorelin; leuprolide; testosterone; Human Papillomavirus (HPV) 9-valent recombinant vaccine; oxandrolone; somatropin | |
| Colorado | No | No | No | No | ||
| Connecticut | No | No | No | Yes | Serostim & Xyosted | |
| District of Columbia | No | No | Yes | Yes | Hepatitis C Daraprim Dronabinol Epogen Subtex, Suboxone Serostim Statins some ARVs | |
| Delaware | No | No | No | Yes | Cabenuva and Selzentry | |
| Florida | No | No | No | Yes | Trogarzo | |
| Georgia | No | No | No | Yes | Trogarzo, Selzentry, Rukobia, Fuzeon | |
| Guam | No | No | No | No | ||
| Hawaii | No | No | 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 | Yes | Compound medications |
| Idaho | No | No | Yes | Yes | Adderall/Adderall XR, Focalin/Focalin XR, Concerta, Metadate CD/Metadate ER/Ritalin , Vyvanse, Dupixent, Austedo, Xenazine, Ingrezza | |
| 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 ( Mepron), enfuvirtide (Fuzeon), Finasteride, Hepatitis C medications, Hormone therapy medications, Trogarzo, Selzentry, Recombinant human growth hormone, Sildenafil, Sunlenca, Tadalafil |
| Indiana | No | Yes | No | No | ||
| Kansas | No | Yes | Yes | No | ||
| Kentucky | No | No | No | No | ||
| Louisiana | No | Yes | No | Yes | HCV medications require prior authorization. | |
| Massachusetts | Yes | Specific Exclusions: - Finasteride (Propecia)- Approved for prostate disorders only - Minoxidil (Rogaine) Class Exclusions: - Cosmetic Medications - Erectile Dysfunction Pharmaceuticals - Fertility Drugs - Herbal Medications | No | No | No | |
| Maryland | Yes | Infusion drugs (medical benefit); IVIG; Diagnostic products; Antiviral MAB; Cardiovascular diagnostics; Venosclerosing agents; Lung surfactants; PDE-5 inhibitors; Prostaglandin agonists; Opioids analgesics; Opioid containing drug products; Water; Tham solution; Tromethamine; IV dextrose-water solutions; Nucleic acid/nucleotide supplements; Diluent solutions; PKU formulations; Bioflavonoids; Agents for stomatological use; Saliva substitute agents; Fat absorption decreasing agents; Implantable contraceptives; Local anesthetics; Benzodiazepine-type injectable general anesthetics; Inhalant general anesthetics | No | Yes | Yes | HCV medications |
| Maine | No | No | No | Yes | Complera, Harvoni, Ledipasvir/sofosbuvir, Maraviroc, Mavyret, Selzentry, Sovaldi, Trogarzo | |
| Michigan | No | No | Yes | Yes | Actos; Androderm; Androgel; Atovaquone; Cabenuva; Cabotegravir/rilpivirine; Daraprim; Delatestryl; Duragesic; Epoetin alfa; Filgrastim; Finasteride; Ibalizumab; Lidocaine Patch 5%; Liraglutide; Methadone; Methyltestosterone; Neupogen; Oxycodone/Oxycodone ER; Oxycontin; Pioglitazone; Procrit; Pyrimethamine; Testim; Testosterone; Testosterone injection; Testosterone oral; Testosterone topical; Testred; Trogarzo; Vocabria | |
| Minnesota | No | No | No | Yes | We are required to follow the same prior authorizations as our state Medicaid Fee For Service. https://mn.gov/dhs/partners-and-providers/policies-procedures/minnesota-health-care-programs/provider/types/rx/pa-criteria/ | |
| Missouri | No | No | No | No | ||
| Mississippi | No | No | No | No | ||
| Montana | No | No | No | Yes | Fuzeon | |
| 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 | |
| Nebraska | Yes | Weight loss medications | No | Yes | Yes | Schedule II medications require prior authorization |
| New Hampshire | Yes | Compound Drugs; Botulinum Toxin Compounds; and Cosmetics Products; Erectile Dysfunction Drugs; Fertility Drugs; Hair Growth Stimulants; Herbal Medications; Hyaluronic Acid Derivatives; Immune Globulin; Intravenous Injectable Muscle Relaxants; Mifepristone; Over the Counter Drugs *; Recombinant Human Growth Hormone | No | No | Yes | View criteria |
| New Jersey | Yes | Over the counter products, weight loss, and ED products (defined as lifestyle). | No | No | Yes | Cabenuva, Aptivus, Fuzeon,Selzentry, Daraprim, Serostim, Egrifta, Marinol, Megace, Mepron, Oxandrin. |
| New Mexico | Yes | None | No | No | No | |
| Nevada | No | No | No | Yes | Egrifta, Egrifta SV any Hepatitis C Treatment Drugs, Trogarzo | |
| New York | No | No | No | No | ||
| Ohio | Yes | Abortifacients; Alzheimers Medication; Acne Medications; Botulinum Toxin; Chemotherapeutic Agents [EXCEPT imiquimod cream 5% (Aldara); Controlled Substances: Class Schedules II, III, IV, and V [EXCEPT pregabalin (Lyrica), topical testosterone]; Cosmetic Medications/ Hair Removal/Growth Medications; Durable Medical Equipment; Egrifta SV; Fertility Medication;Finasteride; Hepatitis C Treatments; Herbal Medications; Human Growth Hormone; Hyaluronic Acid Derivatives; Injectable Muscle Relaxants; Protease Inhibitors; Nucleoside Reverse Transcriptase Inhibitors; Non-Nucleoside Reverse Transcriptase Inhibitors; Sexual Dysfunction Medications | No | No | Yes | Trogarzo, Rukobia (fostemsavir) prior auth required for Rukobia only if the client does not have insurance. |
| Oklahoma | No | No | No | No | ||
| 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 | No | Yes | Hep C when insurance denies. |
| 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 | Yes | No | Yes | Cabenuva Trogarzo | |
| South Dakota | No | No | No | No | ||
| Tennessee | No | Yes | Yes | No | ||
| Texas | No | Yes | No | No | ||
| Utah | No | Yes | Yes | No | ||
| Virginia | No | Yes | No | No | ||
| Vermont | No | No | No | No | ||
| Washington | Yes | Medicare Exclusion Drugs | Yes | Yes | Yes | Only Egrifta which is restricted to diagnosis code. |
| Wisconsin | No | No | No | No | ||
| Wyoming | Yes | Hemophilia medications; Botulinum toxin; Gonadotropin; Finasteride (except for prostate disorders); Hyaluronic acid derivatives; Immune globulin intravenous (IGIV); Sandoglobulin, Venoglobulin; Injectable muscle relaxants; Antirheumatic injectables; Monoclonal antibodies; Nutritional supplements; Recombinant human growth hormone (HGH); Synthetic growth hormone; Egrifta; Durable medical equipment; Cosmetic medications; Erectile dysfunction pharmaceuticals; Female sexual dysfunction pharmaceuticals; Fertility drugs; Herbal medications | No | Yes | Yes | Hepatitis C treatment medications (i.e. Harvoni, Viekira XR, Sovaldi, Ribavirin, Zepatier, Technivie, Daklinza, Epclusa) must be prior authorized. |