Pharmacy Formulary Tier 1 (PDF)
Clients must qualify for the Ryan White Part A eligibility requirements.

Pharmacy Formulary Tier 2 (PDF)
Clients must be screened every six (6) months for the State AIDS Drugs Assistance Program (ADAP) eligibility and must be ineligible and meet the Ryan Part A eligibility requirements prior to the use of this formulary.

Pharmacy Formulary Tier 3 (PDF)
Clients must meet the Ryan Part A eligibility requirements and have a Patient Assistance Program (PAP) application completed for each medication.

Forms

• Formulary Change Request Form (PDF)
• Medication Exception Request Form(PDF)

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