Medication (Generic) Medication Restriction Adults Peds (Brand) Acetaminophen IV Ofirmev Restricted for to pediatric patients
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1 Medication (Generic) Medication Restriction Adults Peds (Brand) Acetaminophen IV Ofirmev Restricted for to pediatric patients - with neutropenia who cannot take medications orally or rectally and closure of PDA in neonates with contraindications to indomethacin. Acetylcysteine IV Acetadote Restricted to toxicologists, GI, PICU attendings Albumin 24 hours restriction to specific indications-refer to albumin powerplan Alglucosidase alfa Lumizyme Restricted to outpatients Alvimopan Entereg Restricted to general surgeons, GI physicians, and surgical intensivists to accelerate the time to upper and lower gastrointestinal recovery following surgeries that include partial bowel resection with primary anastamosis in hospitalized patients at high risk for developing a postoperative ileus, including patients who: are unable to ambulate, have a previous history of a post-operative ileus, or are unable to advance their diet Amphothericin Ambisone Restricted to ID Anti-inhibitor Coagulant Complex (PCC) Asparaginase Erwinia chysanthemi Feiba Restricted to life/limb threatening hemorrhage to reverse warfarin associated coagulopathy Replaces the need to administer Fresh Frozen Plasma (FFP) INR greater than or equal to 1.5 OR high suspicion of elevated INR Erwinaze Restricted to pediatric oncology Aztreonam Azactam Restricted to indication- Severe beta-lactam allergy, Documented multi-drug resistant organism (MDRO) Belimumab Benlysta Restricted to outpatient use only
2 Bismuth sulfate/ metronidazole/ tetracycline Bupivacaine, liposomal Pylera Exparel Restricted to patients with PCN and macrolide allergies Restricted to the following procedures/surgeons for inpatient use only: Soft Skin Tissue (General surgery) TAP Blocks (Anesthesia) TKR THR Hysterectomies Breast Reconstruction Masectomy/Breast Dissection (Riker-pilot) Bupivacaine liposome is infiltrated into the surgical site by a physician in OR. A list of the approved physicians who have been inserviced by pharmacy is kept in the main and OR pharmacy Calcitonin Injection Miacalcin For treatment of hypercalcemia for a duration of 48 hours - Cefepime Maxipime Restricted to the following indications: indication-neutropenic fever Documented Pseudomonas aeruginosa or other multi-drug resistant organism (MDRO) Gram-negative meningitis Ceftazidime Fortaz Restricted to ID physicians Ciprofloxacin Cipro Restricted to the following indications: Empiric treatment of Gramnegative infections with severe beta-lactam allergy Treatment based on documented culture and sensitivity result Prostatitis Gastroenteritis Osteomyelitis Empiric Pseudomonas coverage Chlorothiazide Inj. Diuril Must meet the criteria as specified on the pharmacy intranet under specialty medications
3 Clarithromycin Biaxin Non formulary; used for H.pylori treatment only (prev-pak) Colistimethate Colistin Restricted to ID (inhaled and IV) - Daptomycin Cubicin Restricted to ID physicians Dexmedetomidine Precedex Restricted to Intensivists and CV surgeons for ventilator weaning. Peds: restricted to imaging sedation and ventilator weaning Dofetilide Tikosyn Restricted to physician who are REMS certified- refer to pharmacy website document for additional info Epoprostenol Flolan Restricted to the following: Peds ICU or patient enrolled in flolan program Adults; restricted to PAH specialist Ertapenem Invanz Restricted to ID physicians Erythropoietin Procrit/ Epogen For use ONLY in patients with anemia of critical illness, Jehovah's witness patients, anemia of chronic renal failure, chemotherapy induced anemia in non-myeloid malignancies, anemia related to myelodysplastic syndrome, or anemia induced by zidovudine or other nucleoside reverse transcriptase inhibitors used in the treatment of HIV or AIDS. Etomidate Amidate Physician certified in procedural sedation Fidaxomicin Dificid Restricted to ID and GI physicians Fomepizole Antizol Restricted to Toxicologists, Intensivists, ED, and PICU physicians Formoterol Foradil Restricted indication to adult patients with COPD in which a LABA as monotherapy is indicated Granisetron (IV or Kytril Limit use to patients with Oral) chemotherapy related nausea and vomiting refractory to ondansetron
4 Histrelin Supprelin LA Restricted to pediatric endocrinologists Ibuprofen lysine Neoprofen Use restricted to neonates in ICU for treatment of PDA in patients with contraindications to Indomethacin Indomethacin (IV Indocin Restricted to neonates in ICU for the only) treatment of PDA Infliximab Remicade Restricted to outpatient use only. For any inpatient orders, manager approval is required. Insulin Regular (IV Humulin R Used for treatment of hyperkalemia or only) for continuous drips IVIG Gammagard Restricted to specific indications-refer specialty drugs document on pharmacy website Levalbuterol (Nebs) openex Restricted to ADULT patients who are on it from home for a duration of 24 hours unless physician specifies do not substitute Restricted to Pediatric patients with cardiac defect or arrhythmia who have been receiving levalbuterol as a home medication or pediatric patients with life-threatening tachycardia not resolved by reduced doses of albuterol. Lexiscan Regadenoson Use restricted to Stress Lab only Linezolid Zyvox Restricted to ID physicians - Meropenem Merrem Restricted to indication: Inadequate response to at least one of the following broad-spectrum antibiotics: Zosyn/Unasyn Ciprofloxacin Ceftriaxone/Cefepime Aztreonam Aminoglycosides Treatment of documented (or highly suspected) multi-drug resistant organisms such as Acinetobacter or organisms that produce extendedspectrum beta-lactamases (ESBLs, Therapy for neutropenic fever, Treatment for necrotizing pancreatitis Restricted to ID
5 Methylnaltrexone Relistor Restricted to GI and Palliative Care Micafungin Mycamine Restricted to ID physicians Moxifloxacin Avelox Restricted to indication-cap with severe beta-lactam allergy, Documented penicillin-resistant Streptococcus pneumonia, CAP treatment failure of beta-lactam and/or macrolide Pegfligrastim Neulasta Restricted to outpatient use only. Prochloperazine Compazine Restricted for migraine treatment Propofol Diprivan Mechanical Sedation ONLY, restricted to OR, ER, anesthesia, ICU, 5West, and pre-procedure Ribavirin (Aerolized) ID restricted - Sandostatin LAR Depot Octreotide Restricted to outpatient use only Sildenafil IV Revatio For pediatric patients with PAH only. Sodium Chloride 3% Hypertonic Saline Nephrologist, Intensivist, neurosurgeons, and Endocrinologist. Central line preferred Tadalafil Adcirca Restricted for the treatment of WHO group 1 PAH Terbutaline sulfate (not oral) Brethine In ICU only, continuous nebulization by RN/RRT (Registered Respiratory Therapist) Tigecycline Tygacil Restricted to ID physicians Tolvaptan Samsca Restricted to nephrologist and cardiologist for use in the treatment of hypervolemic or euvolemic hyponatremia Treprostinil Remodulin Restricted to PAH specialist x Vancomycin Vancocin Restricted to indication: Documented methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative Staphylococcus or ampicillin-resistant Enterococcus, Gram-positive infections in patients with severe
6 beta-lactam allergy, Empiric treatment of (please check one of the following): Pneumonia [health care associated pneumonia (HCAP) or ICU patients with community acquired pneumonia (CAP) and severe beta-lactam allergy] Endocarditis Meningitis Line infection Skin/soft tissue (nosocomial infection or community-acquired MRSA) Cardiac/Ventricular Assist Device (VAD) surgical prophylaxis with severe beta-lactam allergy Vedolizumab Entyvio Restricted to outpatient infusion and gastroenterologists for the approved FDA indications only Voriconazole Vfend Restricted to ID physicians Zoledronic Acid Zometa/ Reclast Reclast is restricted to outpatient use only. Zometa can be used inpatient for hypercalcemia, but not for multiple myeloma or metastatic bone lesions
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