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Ca formulary master version 9. 2013.xlsx

AIDS DRUG ASSISTANCE PROGRAM (ADAP)
CALIFORNIA FORMULARY
FORMULARY ALPHA BY GENERIC
Effective 9/9/2013
P: 888-311-7632 www.ramsellcorp.com F: 800-848-4241 Version 9 2013
Generic Name
Brand Name
Restrictions
ADAP mandates the use of generic products whenever possible in accordance with applicable law or regulations.
Dispensing a brand name product when a generic is available requires prior authorization and a DAW 1 code.
Exceptions are noted by drug.

Brand only; generic covered for co-pay only ^ amikacin sulfate
Discmelt not covered; 2mg, 5mg, 10mg, 15mg, 20mg, 30mg tablets only ^ bleomycin
* bupropion
Not payable for smoking cessation, document diagnosis on original RX 1 gram injection only. Use of this medication is restricted for use in the treatment of multi- ^ capreomycin
drug resistant tuberculosis (MDR-TB). Documentation required 50mg and 70mg IV forms only; Use is restricted to treatment of invasive aspergillosis in ^* caspofungin
patients refractory to or intolerant of other therapies (ie: amphotericin B, lipid formulations of amphotericin B, and /or itraconazole) Oral generic forms only. Brand name Keflex discontinued 6/11/10 ^* ciprofloxacin
Oral and injectable forms for treatment of MAC only. Please provide treament regimen.
250mg capsules only. Use of this medication is restricted for use in the treatment of multi- ^ cycloserine
drug resistant tuberculosis (MDR-TB). Documentation required Brand only - 800mg tablet covered effective 11/19/12 ^ daunorubicin
* = Drug restricted to specific diagnosis, dose, form or circumstance● = Drug must be dispensed with a minimum 30 day supply^ = Drug requires a prior authorization AIDS DRUG ASSISTANCE PROGRAM (ADAP)
CALIFORNIA FORMULARY
FORMULARY ALPHA BY GENERIC
Effective 9/9/2013
P: 888-311-7632 www.ramsellcorp.com F: 800-848-4241 Version 9 2013
Generic Name
Brand Name
Restrictions
ADAP mandates the use of generic products whenever possible in accordance with applicable law or regulations.
Dispensing a brand name product when a generic is available requires prior authorization and a DAW 1 code.
Exceptions are noted by drug.

Restricted to treatment of severe debilitating depression; only 5mg and 10mg tablet form ^* dextroamphetamine
Brand only; generic covered for co-pay only ^ doxorubicin
Oral generic forms only; 50mg and 100mg strength only elvitegravir/cobicistat/emtricitabine/ten ●^ enfuvirtide
Brand only; please call or check website for special supplemental PA form ^ epoetin alpha
Procrit™ brand only; Epogen™ is NOT covered 250mg tablets only. Use of this medication is restricted for use in the treatment of multi- ^ ethionamide
drug resistant tuberculosis (MDR-TB). Documentation required ^* fentanyl
Restricted to hospice patients only with intolerance to oral analgesics ^ filgrastim
Oral form does not require a prior authorization; only the implant or injectable forms ^* ganciclovir
1.25mg/250mg, 2.5mg/500mg, 5mg/500mg tablets only * = Drug restricted to specific diagnosis, dose, form or circumstance● = Drug must be dispensed with a minimum 30 day supply^ = Drug requires a prior authorization AIDS DRUG ASSISTANCE PROGRAM (ADAP)
CALIFORNIA FORMULARY
FORMULARY ALPHA BY GENERIC
Effective 9/9/2013
P: 888-311-7632 www.ramsellcorp.com F: 800-848-4241 Version 9 2013
Generic Name
Brand Name
Restrictions
ADAP mandates the use of generic products whenever possible in accordance with applicable law or regulations.
Dispensing a brand name product when a generic is available requires prior authorization and a DAW 1 code.
Exceptions are noted by drug.

^ hepatitis A vaccine
^* hepatitis A/hepatitis B vaccine
^ hepatitis B vaccine
Oral form only; prescription strength only 500mg IM/IV vials only. Use of this medication is restricted for use in the treatment of ^* imipenem/cilastatin
extensively-drug resistant tuberculosis (XDR-TB). Documentation required ^ inteferon alfa-2b
^ interferon alfa-2a
^ interferon alfacon 1
^ interferon alfa-N3
^● itraconazole
Restricted to use for indications other than onychomycosis. Prior Authorization required ^ ketorolac tromethamine
Injectable form only; limited to a max of 120mg/day and 5 days therapy Brand only; generic covered for co-pay only. Epivir HB is NOT covered Restricted to use after trial of famotidine or ranitidine. Unrestricted in the treatment of ^* lansoprazole
erosive esophagitis and H. Pylori related Peptic Ulcer Disease. Documentation required 600mg tablets only; restricted to treatment of Community Acquired MRSA resistant to ^* linezolid
Vancomycin or the treatment of EXTENSIVELY drug resistant tuberculosis (XDR-TB). Documentation required. Please call or check website for special supplemental PA form ●^ maraviroc
500mg, 850mg, 1000mg tablets and 500mg ER and 750mg ER tablets only Not payable for detoxification treatment; must indicate diagnosis on PA; oral generic form ^* methadone
* = Drug restricted to specific diagnosis, dose, form or circumstance● = Drug must be dispensed with a minimum 30 day supply^ = Drug requires a prior authorization AIDS DRUG ASSISTANCE PROGRAM (ADAP)
CALIFORNIA FORMULARY
FORMULARY ALPHA BY GENERIC
Effective 9/9/2013
P: 888-311-7632 www.ramsellcorp.com F: 800-848-4241 Version 9 2013
Generic Name
Brand Name
Restrictions
ADAP mandates the use of generic products whenever possible in accordance with applicable law or regulations.
Dispensing a brand name product when a generic is available requires prior authorization and a DAW 1 code.
Exceptions are noted by drug.

Rheumatrex, Trexall Oral and injectable forms only Restricted to treatment of severe debilitating depression; restricted to 5mg, 10mg, 20mg ^* methylphenidate
SolTabs not covered; 15mg, 30mg, 45mg tablets form only 400mg tablets only. Use of this medication is restricted for use in the treatment of multi- ^* moxifloxacin
drug resistant tuberculosis (MDR-TB) Documentation of medications tried and failed required Long acting for wasting only. Commercially available products only. Compounded ^* nandrolone
Brand only; IR and XR formulations covered;generic covered for co-pay only Restricted to use after trial of famotidine or ranitidine AND lansoprazole. Unrestricted in ^* omeprazole
the treatment of erosive esophagitis and H. Pylori related Peptic Ulcer Disease. Documentation required ^* oxandrolone
Immediate release form only; Oral form only ^* paclitaxel
Enteric coated encapsulated microspheres/microtablets. (Axcan Products: Ultase MT 12,
Ultrase MT 20, Ultrase MT 18 and Ultrase MS4 have been romoved form the formulary effective 12/28/10) 4 gram packets only. Use of this medication is restricted for use in the treatment of multi- ^* para-aminosalicylate
drug resistant tuberculosis (MDR-TB). Documentation of medications tried and failed required Peg-Intron is available through Merck's free drug program only. Please call or check ^ pegylated interferon
Peg-Intron, Pegasys website for supplemental PA form Only the 1.2 MU per syringe (2ml) and 2.4MU per syringe (4ml) covered 100mg Extended Release Capsules only; generic form only 15mg, 30mg, 45mg tablets only. NDC 67544-0066-45 not covered start 5/22/12 ^* pneumococcal vaccine
Single dose dispensing, 1 time dispensing evey 6 years * = Drug restricted to specific diagnosis, dose, form or circumstance● = Drug must be dispensed with a minimum 30 day supply^ = Drug requires a prior authorization AIDS DRUG ASSISTANCE PROGRAM (ADAP)
CALIFORNIA FORMULARY
FORMULARY ALPHA BY GENERIC
Effective 9/9/2013
P: 888-311-7632 www.ramsellcorp.com F: 800-848-4241 Version 9 2013
Generic Name
Brand Name
Restrictions
ADAP mandates the use of generic products whenever possible in accordance with applicable law or regulations.
Dispensing a brand name product when a generic is available requires prior authorization and a DAW 1 code.
Exceptions are noted by drug.

Prescription strength only; Oral form only Rebetol, Copegus; please note that not all generics are covered.
^ ribavirin/interferon alfa 2B
^● rosiglitazone maleate
Restricted to HIV/AIDS wasting syndrome; requires supplemental form and PA form with ^* somatropin
Brand only; generic covered for co-pay only Long acting for wasting or hypogonadism; transdermal, gel and injectable forms covered. ^* testosterone
Maximum of 200mg weekly. Must provide copy of the original RX with every start or
Brand Only. Generic covered for co-pay only. Drug is restricted to diagnosis of herpes simplex (HSV) or herpes zoster (HZV). HSV-max 10 days for acute treatment. Acute treatment and chronic suppressive therapy is approved only after failed trial of acyclovir. Drug is not payable for chronic suppressive treatment. Valtrex 1000mg NDCs: 00173-0565-04 & 00173-0565-10 have been taken off the ADAP * = Drug restricted to specific diagnosis, dose, form or circumstance● = Drug must be dispensed with a minimum 30 day supply^ = Drug requires a prior authorization AIDS DRUG ASSISTANCE PROGRAM (ADAP)
CALIFORNIA FORMULARY
FORMULARY ALPHA BY GENERIC
Effective 9/9/2013
P: 888-311-7632 www.ramsellcorp.com F: 800-848-4241 Version 9 2013
Generic Name
Brand Name
Restrictions
ADAP mandates the use of generic products whenever possible in accordance with applicable law or regulations.
Dispensing a brand name product when a generic is available requires prior authorization and a DAW 1 code.
Exceptions are noted by drug.

Restricted to a diagnosis of CMV. Payable for active treatment or suppressive treatment ^* valganciclovir
only; not payable for primary prophylaxis of CMV ^ vinblastine
^ vincristine
50mg and 200mg tablets and 200mg IV forms only; Use is restricted to treatment of ^* voriconazole
invasive aspergillosis in patients refractory to or intolerant of other therapies (ie: amphotericin B, lipid formulations of amphotericin B, and /or itraconazole) Generic covered for 300mg formulation only effective 10/30/12; all other formulations Brand required; generic covered for co-pay only other than 300mg formulation Brand only; generic covered for co-pay only Program Dispensing Policies1. Drugs marked with “•“ are to be dispensed with a minimum 28 day supply. Exceptions will require prior authorization.
2. Drugs marked with “*” Code 1 are restricted by a specific diagnosis, dose, form or circumstance of the client. Prior authorization may be required and granted only when Code 1 requirements are met.
3. Drugs marked with “^” require a prior authorization, Ramsell will request additional information (client and drug specific) before considering the authorization.
4. All drugs are to be dispensed with a maximum 30 – day supply. Exceptions will require a prior authorization.
5. Refills may be obtained after 80% of the previously dispensed days-supply has been used; however, there is an annual maximum of 13 fills per prescription.
6. All ADAP prescriptions must be reauthorized by the prescriber every 6 months. The claims adjudication system will accept 5 as the maximum number of refills.
7. Prior authorization is required for DEA class II and III drugs when quantity exceeds 120 and 240 respectively.
8. ADAP mandates the use of generic products whenever possible in accordance with applicable law or regulations. Dispensing a brand name product when a generic is available requires prior authorization and a DAW 1 code. Exceptions are noted by drug. Brand ARVs preferred9. All Antiretroviral combinations are screened against the most recent DHHS guidelines for the use antiretroviral therapy in adolesescents and adults (http://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf) for high dosage and non-recommended combinations. Regimens not conforming to these guidelines may be rejected at adjudication.
10. The following drug manufacturers are excluded from reimbursement thru the CA ADAP program:Able LABS, INC.
Pre-Package Specialists/PD-RX Pharmaceuticals Quality Care/Lake Erie Medical & Surgical Supply Rebel Distributors Corp (now Physician Partners) PLEASE NOTE: There may be some SPECIFIC DOSE FORMS of products on this formulary that may NOT BE COVERED OR REQUIRE PRIOR AUTHORIZATION. You can verify drug coverage by dialing the toll free Ramsell number listed below and select the Electronic Verification option. You will need your pharmacy NCPDP# and the drug’s 11 digit national drug code (NDC). (Ramsell Corporation 1-888-311-7632) * = Drug restricted to specific diagnosis, dose, form or circumstance● = Drug must be dispensed with a minimum 30 day supply^ = Drug requires a prior authorization

Source: http://www.ramselltech.info/PDF/CA_AlphaGeneric091713.pdf

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