8GENERIC BRAND FORMSKFHC DRUG FORMULARYAnti-infective – Anti-tubercular, continued • SEE PREVIOUS PAGE G Pyrazinamide500mg tabletRifabutin Mycobutin® 150mg capsuleRestriction: Restricted to prevention of MAC in pts. with advanced HIV. G Rifampin Rimactane® 150mg, 300mg capsuleAnti-infective – Anti-viralAnti-viral agents for HIV related cases, with the exception of Zidovudine and Didanosine, arecovered by fee for service Medi-Cal. Bill EDS, not KHS, for these patients. The carved outanti-viral agents are listed in the Appendix.Anti-virals for Hepatitis, both B and C are covered, but require prior authorization. Adherenceto treatment is essential. These are generally restricted to specialists, and monitoring is required.Acyclovir is the only Formulary medication for Genital Herpes Therapy: Sanford, et al, inGuide to Anti-microbial Therapy – 2007 suggests there is little difference between antiviral agentsfor genital herpes. KHS only allows Acyclovir at this time. An example of costs for these <strong>dru</strong>gs forrecurrent treatment is as follows:Medication & Days TherapyCost G Acyclovir 400mg TID x 5 days $6 G Valacyclovir 500mg BID x 3 days (non-<strong>formulary</strong>) $16 G Famvir® 125mg BID x 5 days (non-<strong>formulary</strong>) $16KHS requires failure of Acyclovir before the other agents would be allowed on prior authorization.Topical Antiviral Therapy requires prior authorization: Topical agents for antiviral therapy(Zovirax, Abreva®) require prior authorization because of their limited effect. Usually topicalproducts will only slightly decrease the duration of infection (3.4 vs. 4.1 days). Severe infectionsmay benefit more from systemic therapy. G Acyclovir Zovirax® 200mg/5ml susp, 200mg capsule, 200mg,400mg, 800mg tablet G Didanosine Videx® 25mg, 50mg, 100mg, 150mg chewable tablet,250mg, 400mg ec tablet,100mg, 167mg powderpacket, 2gm, 4gm for solution G Ganciclovir Cytovene® 250mg, 500mg capsuleRestriction: Prior authorization required. G Zidovudine Retrovir® 50mg/5ml syrup, 100mg capsule
KFHC DRUG FORMULARY 9GENERIC BRAND FORMSAnti-infective – Anti-viral Hepatitis B G Lamivudine Epivir (HBV)® 100mg tabletRestriction: Prior authorization required. G Entecavir Baraclude® 0.5mg, 1 mg tabletRestriction: Prior authorization required.Anti-ParkinsonismBromocriptine Parlodel® 2.5mg tablet, 5mg capsuleRestriction: Restricted to pts. w/amenorhhea, galactorrhea, or acromegaly. G Carbidopa & Levodopa Sinemet® 10mg-100mg, 25mg-100mg, 25mg-250mg tablet,25mg-100mg, 50mg-200mg cr tablet G Levodopa250mg, 500mg capsule G Pramipexxole Mirapex® 0.125mg, 0.25mg, 0.5mg, 0.75mg, 1mg,1.5mg tablet G Ropinirole Requip® 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg tabletAntidote G Leucovorin5mg, 25mg tabletSuccimer Chemet® 100mg capsuleAntigout G Allopurinol Zyloprim® 100mg, 300mg tablet G Colchicine & Probenecid ColBenemid® 0.5mg-500mg tablet G Probenecid Benemid® 500mg tabletSulfinpyrazone Anturane® 100mg tabletAntineoplasticAltretamine Hexalen® 50mg capsule G Anastrozole Arimidex® 1mg tablet G Bicalutamide Casodex® 50mg tabletChlorambucil Leukeran® 2mg tablet G Cyclophosphamide Cytoxan® 25mg, 50mg tabletEstramustine Emcyt® 140mg capsuleEtoposide Vepesid® 50mg capsuleContinued on next page
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