• California ADAP
  • FAQ
  • California Prior Authorization Forms
• Washington State AIDS Drug Assistance Program (EIP)
• Colorado SPAP – Bridging the Gap
• Texas HIV SPAP
• Secure Log In

California Prior Authorization Forms

Access to Trofile™ Assay through ADAP

The California Office of AIDS has authorized coverage of the HIV Tropism Assay for ADAP clients with no other insurance coverage. ADAP will only pay for the tropism assay by Monogram Biosciences (Trofile™). Prior authorization is required and clients must have evidence of ARV resistance, intolerance and/or lack of patient acceptability to reasonable alternatives resulting in inability to fully suppress HIV utilizing alternative regimens. Trofile assay results are forwarded directly to Ramsell Public Health Rx from Monogram Biosciences. If you are requesting the Trofile™ assay to be performed, please fill out section 2 only. Download PDF

back to top

Selzentry™ (Maraviroc) Prior Authorization

Maraviroc is approved for patients where there is evidence of ARV resistance, intolerance and/or lack of patient acceptability to reasonable alternative antiretroviral medications and already had a Tropism assay performed and the results confirm infection with CCR5 tropic HIV virus. Please fill out either section 3 OR section 4, whichever is applicable to your patient. Download PDF

back to top

Fuzeon

When completing Fuzeon access forms, please be sure to include all requested clinical information including CD4 lab measurements as well as two viral load measurements. IF your patient has never used Fuzeon, please submit TWO detectable viral load measurements within the last six-months in order to provide medical justification for starting Fuzeon. IF your patient has received Fuzeon previously through another insurance payer (e.g. Medi-Cal, Medicare Part D, private insurance), you must provide TWO detectable viral load measurements within a six-month period prior to the date the patient started Fuzeon treatment. Download PDF

back to top

Serostim

Please be sure to fill out Form A, section 1 of the application completely if your patient is a new-start applicant or is receiving Serostim thru another payer source. If you are requesting a refill of Serostim beyond the initial 3-month ADAP approval please fill out Form B. Download PDF

back to top

Peg-Intron

Peg-Intron is available for free through Schering-Plough’s Commitment to Care Free Peg-Intron program. Please fill out the Peg-Intron ADAP Access form and fax back to Ramsell Public Health Rx at 800-848-4241. Download PDF

back to top

Treament Exception Request Form

Please do not use this form to request medications that are not on the ADAP formulary. The TER forms will only be reviewed for the following purposes:

• To request formulary medications that exceed normal, FDA approved dosing guidelines
• To request formulary medications that have a medical justification outside of the scope of the restrictions and guidelines established by the California Office of AIDS Medical Advisory Committee.
• Download PDF

back to top