Formulary Management

Formulary Addition Request Specialty Pharmaceuticals
Request Form Medication List & Order Processing Guidelines

Specialty Pharmaceuticals Policy - Coming Soon

 Prisma Health Therapeutic Interchanges
Acyclovir (Zovirax)

Allergic Conjunctivitis Ophthalmic Solution

Amoxicillin-clavulanate products

Antibiotics, Oral (Miscellaneous - Adult)

Antihistamines - Intranasal

Antihistamine - Ophthalmic


Auryxia (ferric citrate)

Basaglar (insulin glargine)

Bupropion HBr (Aplenzin) - Bupropion HCl (Wellbutrin XL)

Calcium Supplements - Adult Oral

Carvedilol CR - Carvedilol

Codeine - Pediatrics (Post-Op)

Combigan Ophthalmic Solution

COPD Inhalers - ADULT

Corticosteroids, Inhaled (metered dose inhalers)

Cough Lozenges

Cystic Fibrosis Multivitamins

Diclofenac Potassium

Emend (fosaprepitant) injection

Factor VIIa, recombinant (NovoSeven RT)


Filgrastim - TBO-filgrastim

HMG-CoA Reductase Inhibitors ("Statins")

Hydromorphone ER (Exalgo)

Iron Products, Oral (Adult)

Iron Products, Oral (Pediatric)

Levocetirizine - Cetirizine

Long-Acting Beta Agonists/Corticosteroids, Inhaled (MDI)

Magnesium - Oral

Megestrol ES - Megestrol

Mesalamine-Containing Medications

Morphine Oral Extended Release Products


Namenda XR  

Nevirapine XR

Omega-3 Polyunsaturated Fatty Acids (Fish Oil)/Lovaza)

Oxycodone/APAP Oral Combination Product

Pancreaze (pancrelipase)

Phenytoin - Fosphenytoin

Phosphate Binders


Proton Pump Inhibitors (Adult)

Proton Pump Inhibitors (Pediatric)

Rosiglitazone Containing Products

Rubella Virus Vaccine

Skin Barrier - Topical Diaper Dermatitis


Steroids - Nasal 

Steroids - Topical (Low to Medium Potency)

Steroids - Topical (High to Very High Potency)

Tapentadol - Oxycodone

Toujeo (Insulin glargine 300U)

Treximet - sumatriptan + naproxen

Urinary Analgesic-Antispasmodic-Antiseptic Combinations

Zolpidem Containing Products


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