FormWeb • Care Area restrictions

Houston Methodist

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Houston Methodist

Approved Hospital Formulary

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Care Area restrictions

Please review each of these drugs carefully.

acetaminophen	IV acetaminophen is restricted to OR, PACU, and ICU areas
agalsidase beta	Restricted to outpatient setting with prior financial approval
anifrolumab-fnia	Restricted to outpatient setting with financial approval
axicabtagene ciloleucel	Restricted to certified Yescarta REMS treatment centers (HMH only) Restricted to outpatient setting with financial approval
belantamab mafodotin	Restricted to outpatient setting with financial approval
Benralizumab	Restricted to outpatient setting with financial approval
brexucabtagene autoleucel	Restricted to certified Tecartus REMS treatment centers
cemiplimab	Restricted to outpatient setting with financial approval
crizanlizumab-tmca	Restricted to outpatient setting with financial approval
dalbavancin	Restricted to outpatient setting
Daratumumab	Restricted to outpatient setting with financial approval
darbepoetin alfa	Restricted to outpatient use with financial approval or inpatient use for oncologic indications
degarelix	Restricted to outpatient setting with financial approval
denosumab	Restricted to outpatient setting
durvalumab	Restricted to outpatient setting with financial approval
eculizumab	Restricted to outpatient setting with financial approval or inpatient use for emergent care of newly diagnosed disease or continuation of maintenance therapy that is medically necessary
edaravone	Restricted to outpatient setting
emapalumab	Restricted to outpatient setting with financial approval or inpatient use for the FDA approved indication for emergent care of newly diagnosed disease or continuation of maintenance therapy that is medically necessary
enfortumab vedotin-ejfv	Restricted to outpatient setting with prior financial approval
esketamine	Restricted to hospitals enrolled the Spravato REMS program and patient care areas that can provide monitoring by psychiatry trained nurses for at least 2 hours following each dose
fam-trastuzumab deruxtecan	Restricted to outpatient setting with financial approval
ferric carboxymaltose	Restricted to outpatient setting
goserelin	Restricted to outpatient setting with financial approval
hetastarch	Restricted to use within OR/procedural areas
hexaminolevulinate	Restricted to FDA approved indication for use in the operating room
idecabtagene vicleucel	Restricted to Abecma REMS treatment centers (HMH only)
inotuzumab ozogamicin	Restricted to outpatient use with financial approval or inpatient use for FDA approved indications
leuprolide	Restricted to outpatient setting with financial approval; Allow inpatient use for 3.75 mg dose for fertility preservation in women undergoing emergent chemotherapy
lisocabtagene maraleucel	Restricted to Breyanzi REMS treatment centers (HMH only)
lurbinectedin	Restricted to outpatient setting with financial approval
luspatercept-aamt	Restricted to outpatient setting with financial approval
Moxetumomab Pasudotox	Restricted to outpatient setting with financial approval or for the first cycle of an FDA approved indication in the inpatient setting
obinutuzumab	Restricted to outpatient setting with financial approval
ocrelizumab	Restricted to outpatient setting with financial approval
olaratumab	Restricted to outpatient setting with financial approval
palonosetron	Restricted to outpatient setting
patisiran	Restricted to outpatient setting with financial approval
pegloticase	Restricted to outpatient setting with financial approval
pertuzumab/trastuzumab/hyaluronidase-zzxf	Restricted to outpatient setting with financial approval
polatuzumab vedotin	Restricted to outpatient setting with financial approval
Porfimer	Restricted to outpatient setting with financial approval
ravulizumab	Restricted to outpatient setting with financial approval
romosozumab-aqqg	Restricted to outpatient setting with financial approval
sacituzumab govitecan	Restricted to outpatient setting with prior financial approval
Sebelipase alfa	Restricted to outpatient setting with financial approval
Sipuleucel-T	Restricted to outpatient setting with financial approval
sotalol	IV sotalol is restricted to use in the cath lab at entities prepared to operationalize patient flow and medication safety as determined by entity cath lab director and pharmacy director
sugammadex	Restricted to the operating room
tafasitamab-cxix	Restricted to outpatient setting with financial approval
tagraxofusp-erzs	Restricted to outpatient administration after first treatment cycle
talimogene laherparepvec	Restricted to outpatient setting with financial approval
tebentafusp	Restricted to inpatient oncology unit (for the first three infusions - patient to be admitted in an observation status) / outpatient infusion for subsequent infusions
teprotumumab	Restricted to outpatient setting with financial approval
tisagenlecleucel	Restricted to certified Kymriah REMS treatment centers (HMH only)
tocilizumab	Restricted to outpatient use for FDA labeling with financial approval or inpatient use for cytokine release syndrome or COVID
trastuzumab	Restricted to outpatient setting with financial approval
trastuzumab and hyaluronidase-oysk	Restricted to outpatient setting with financial approval
vedolizumab	Restricted to outpatient setting

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