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Medications listed are available on OH EPIC Formulary, unless otherwise noted.
Not all formulary medications are available at each facility. Please refer to your local pharmacy for available inventory.
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hyaluronic acid-lidocaine hcl

hyaluronic acid-lidocaine hcl
Drug Name Form Strength Infusion Center Available Restricted Non-formulary Ambulatory Available Interchange REMS
Restylane DEVICE, SUPRAPERIOSTEAL, SUBCUTANEOUS 20-3 mg/mL        
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CLASS
940000
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OH Epic Formulary

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  • Indication: For cheek augmentation and correction of shape or volume differences in the midface region (contour deficiencies)
  • Service line: Plastic and Reconstructive Surgery
  • Formulary location: Ambulatory
  • Service location: Ambulatory clinic
  • Patient population: Adults > 21 years old
  • Prior authorization required: No
  • Restriction/criteria of use (all will apply unless specified): N/A
Last updated: Jun. 12, 2025
  • Ambulatory: Ambulatory Clinic, Plastic and Reconstructive Surgery

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