Program HH Medication Program (ADAP) Formulary
The Program HH Formulary is a closed formulary. The formulary is reserved for HIV anti-retroviral therapy, medications used to treat side effects associated with anti-retroviral therapy, HIV opportunistic infections and some co-morbidities associated with HIV. If you feel a drug exists that is currently not on the Program HH Formulary that should be, please use the form below to submit a drug addition request. The form must be submitted by either a physician or pharmacist. Bolded fields must be filled out in order for your request to be considered. Once the form has been completed it should be faxed to 651-431-7414. All requests are reviewed by the Program HH Formulary Committee.
Formulary Drug Addition Request Form (PDF)
Program HH added the medication Egrifta to the Program HH Formulary on Sept. 1, 2011. Egrifta requires a prior authorization. To request prior authorization contact the MHCP Prescription Drug PA Agent by phone at 1-866-205-2818 or fax 1-866-648-4574.
Egrifta PA criteria
Formulary Drug Addition Request Form (PDF)
Program HH added the medication Egrifta to the Program HH Formulary on Sept. 1, 2011. Egrifta requires a prior authorization. To request prior authorization contact the MHCP Prescription Drug PA Agent by phone at 1-866-205-2818 or fax 1-866-648-4574.
Egrifta PA criteria