|
abatacept
|
- abatacept (Orencia) is restricted to use in the Outpatient setting by Rheumatology only
|
|
acetaminophen
|
- Acetaminophen IV (Ofirmev) - See comments for restrictions
|
|
acetylcysteine
|
- acetylcysteine (Acetadote/Mucomyst) nebulization - use by intensivists (Trauma, CCMS, LSU ICU) in patients who failed nebulized 3% NaCl
- acetylcysteine (Acetadote/Mucomyst) oral and IV - is restricted to treatment of APAP toxicity and non-acetaminophen induced acute liver injury. All other indications must be approved.
|
|
acyclovir topical
|
- Acyclovir ointment is restricted to large surface areas
|
|
adalimumab
|
- Restricted to outpatient use only
|
|
ado-trastuzumab emtansine
|
- ado-trastuzumab emtansine (Kadcyla) is restricted to use in the Outpatient setting
|
|
alemtuzumab
|
- alemtuzumab (Lemtrada) is restricted to use in the Outpatient setting and is a REMS medication
|
|
alglucosidase alfa
|
- Restricted to outpatient setting only
|
|
aminolevulinic acid
|
|
|
amivantamab
|
- Restricted to outpatient use only
|
|
aprepitant
|
- aprepitant (Emend) oral - is restricted to use by medical oncologists for the prevention of acute and delayed emesis for moderately or highly emetogenic chemotherapy
- aprepitant (Cinvanti) is restricted to use in the Outpatient setting by Hem/Onc only
|
|
ARIPiprazole
|
- ARIPiprazole (Abilify) is restricted to psychiatry or continuation of home meds
|
|
asenapine
|
- asenapine (Saphris) is restricted to psychiatry or continuation of home meds
|
|
asparaginase Erwinia chrysanthemi
|
- Restricted to outpatient setting only
|
|
atezolizumab
|
- atezolizumab (Tecentriq) is restricted to use in the Outpatient setting
|
|
avibactam-ceftazidime
|
- avibactam-ceftazidime (Avycaz) is restricted to Infections Disease physicians for the treatment of carbapenemase-resistant Enterobacteriaceae and the treatment of multi-drug resistant Pseudomonas resistant to ceftolozane/tazobactam
|
|
baclofen
|
- Baclofen suspension is formulary restricted to pediatrics
|
|
belimumab
|
- belimumab (Benlysta) is restricted to use in the Outpatient setting by Rheumatology only
|
|
benralizumab
|
- Restricted to outpatient setting only.
|
|
blinatumomab
|
- Blinatumomab (Blincyto) is formulary restricted to FDA approved indications of Acute Lymphoblastic Leukemia (B-cell precursor)
|
|
bosentan
|
- restricted to pediatric patients as continuation of home medications
|
|
brentuximab vedotin
|
- brentuximab vedotin (Adcetris) to restricted to use in the Outpatient setting by Hemo/Onc only
|
|
brivaracetam
|
|
|
budesonide-formoterol
|
|
|
bupivacaine liposome
|
- bupivaciane liposomal (Exparel) is restricted to adults undergoing anorectal surgeries, colectomies, knee/hip replacement, fractures, head and neck surgeries, and TAVR
|
|
calcitonin
|
- calcitonin IM (Miacalcin) is restricted to 2 doses in patients with symptomatic hypercalcemia and uncorrected calcium level of at least 13
|
|
calcitriol
|
- Calcitriol oral solutions and drops are restricted to pediatrics.
|
|
calcium acetate
|
- Restricted to patients taking prior to admission and post-thyroidectomy
|
|
cangrelor
|
|
|
cannabidiol
|
- continuation of home medication at Children's Hospital ONLY
|
|
caplacizumab
|
- Restricted to hematology/oncology and nephrology providers only
|
|
carbachol ophthalmic
|
- Restricted to ocular surgeries
|
|
carfilzomib
|
- carfilzomib (Kyprolis) is restricted to use in the Outpatient setting by Hem/Onc only
|
|
cefiderocol
|
- ID providers (or Critical Care providers if a facility does not have an ID provider)
|
|
cefotaxime (non-formulary)
|
- cefotaxime (Claforan) is restricted to pediatric patients; convert cefotaxime to ceftriaxone (Rocephin) in Adults
|
|
ceftaroline
|
- ceftaroline (Teflaro) is restricted to use by Infectious Diseases Physicians and Critical Care Specialties only
|
|
ceftolozane-tazobactam
|
- ceftolozane/tazobactam (Zerbaxa) is restricted to Infectious Disease physicians for treatment of multi-drug resistant Pseudomonas aeruginosa infections
|
|
certolizumab
|
- certolizumab (Cimzia) is restricted to use in the Outpatient setting
|
|
cetirizine (formulary, restricted to pediatrics)
|
|
|
cetrorelix
|
|
|
cetuximab
|
- cetuximab (Erbitux) is restricted to use in the Outpatient setting
|
|
ciprofloxacin-fluocinolone otic
|
- Restricted to Outpatient Use
|
|
cloBAZam
|
- cloBAZam (Onfi) is restricted to adjunctive treatment of seizures associated with Lennox-Gastaut syndrome (LGS) in patients 2 years of age and older or continuation of home medication
|
|
clonazePAM
|
- *0.125 mg disintegrating tablet restricted to pediatrics only
|
|
cloNIDine
|
- XR restricted to pediatrics
|
|
clotrimazole topical
|
|
|
cloZAPine
|
|
|
colistimethate
|
- Infectious Disease providers or Critical Care providers when ID providers are not available
|
|
collagenase topical
|
- Restricted to only inpatient burns and outpatient wound care
|
|
crisaborole topical
|
|
|
cycloSPORINE
|
- Cyclosporine (modified and non-modified) oral solution restricted to pediatrics
|
|
dalbavancin
|
|
|
dapagliflozin
|
- Restricted to Non- Diabetic Indications ONLY
|
|
daratumumab
|
- daratumumab (Darzalex) is restricted to use in the Outpatient setting
|
|
darbepoetin alfa
|
- Restricted to outpatient setting ONLY
|
|
degarelix
|
|
|
denosumab
|
- denosumab (Prolia) is restricted to use in the Outpatient setting
- denosumab (Xgeva) is restricted to use in the Outpatient setting for prevention of skeletal-related events in oncology patients with bone metastasis from solid tumors who are unable to take bisphosphonates due to renal insufficiency (CrCl <30ml/min)
|
|
diazePAM
|
- Rectal gel (Diastat) restricted to pediatrics
|
|
dimenhyDRINATE
|
- Dimenhydrinate injection formulary restricted to obstetrics.
|
|
diphtheria/tetanus/pertussis (DTaP) ped
|
- Daptacel is formulary restricted to pediatric patients.
|
|
dostarlimab
|
- Restricted to outpatient use only
|
|
dronabinol
|
- Oral Solution is Formulary Restricted to Pediatrics
|
|
dronedarone
|
- dronedarone (Multaq) is restricted to continuation of home medication
|
|
dupilumab
|
- Restricted to outpatient setting only.
|
|
durvalumab
|
- durvalumab (Imfinzi) is restricted to use in the Outpatient setting
|
|
eculizumab
|
- Soliris is formulary restricted to outpatient use (not preferred) and inpatient use for atypical hemolytic uremic syndrome only.
|
|
elagolix
|
|
|
elotuzumab
|
- elotuzumab (Empliciti) is restricted to use in the Outpatient setting
|
|
empagliflozin
|
- Restricted to Non-Diabetic indications ONLY
|
|
enfortumab vedotin
|
- Enfortumab Vedotin (Padcev) is restricted to use in the Outpatient setting
|
|
epoetin alfa
|
- Procrit is restricted to outpatient only.
|
|
eptinezumab
|
- Restricted to outpatient use with prior authorization
|
|
ergocalciferol
|
- Ergocalciferol oral solutions and drops are restricted to pediatrics
|
|
eriBULin
|
- eriBULin (Halaven) is restricted to use in the Outpatient setting
|
|
esomeprazole
|
- esomeprazole (NexIUM) is restricted to pediatric patients
|
|
etanercept
|
- Restricted to outpatient use only
|
|
ethacrynic acid
|
- ethacrynic acid (Edecrin) is restricted to use in patients with heart failure who have hypersensitivity to sulfa-containing drugs
|
|
fat emulsion, intravenous
|
- See Comments for individual product restrictions
|
|
ferric carboxymaltose
|
- ferric carboxymaltose (Injectafer) is restricted to use in the Outpatient setting
|
|
ferric derisomaltose
|
- Restricted to outpatient use only
|
|
ferumoxytol
|
- Restricted to outpatient setting only
|
|
fidaxomicin
|
- fidaxomicin (Dificid) is restricted to use of Infectious Disease or GI providers
|
|
filgrastim
|
- filgrastim (Neupogen) is restricted to pediatric patients requiring doses less than 180mcg
|
|
flurbiprofen ophthalmic
|
- Restricted to ocular surgeries
|
|
fluticasone
|
- fluticasone (Flovent) inhalation is restricted to pediatric patients
|
|
fluticasone-salmeterol
|
- fluticasone-salmeterol (Advair) HFA is restricted to kids <12 yrs and unable to use Breo (call MD for conversion)
|
|
fondaparinux
|
- Formulary Restricted to HIT
|
|
fosaprepitant
|
- Emend IV restricted to use by medical oncologists for the prevention of acute and delayed emesis for moderately or highly emetogenic chemotherapy
|
|
fosfomycin
|
- fosfomycin is restricted to use in outpatients and in treating UTI's with VRE or ESBL-producing organisms in inpatients
|
|
fulvestrant
|
|
|
ganirelix
|
|
|
gemtuzumab ozogamicin
|
- Restricted to outpatient use only
|
|
glipiZIDE
|
- Glipizide is formulary restricted to behavioral health patients.
|
|
golimumab
|
- Restricted to outpatient setting only
|
|
goserelin
|
- Restricted to outpatient use only
|
|
guaifenesin-pseudoephedrine
|
- Restricted to outpatient setting only
|
|
guanFACINE
|
- XR restricted to pediatrics
|
|
guselkumab
|
- Restricted to outpatient use only
|
|
hetastarch
|
- Restricted to Labor and Delivery
|
|
histrelin
|
- Restricted to outpatient use only
|
|
human papillomavirus vaccine
|
- restricted to outpatient and clinics
|
|
hyaluronidase-rituximab
|
- hyaluronidase-rituximab (Rituxan Hycela) is restricted to use in the Outpatient setting
|
|
hyaluronidase-trastuzumab
|
- Restricted to outpatient use only
|
|
hyaluronidase/pertuzumab/trastuzumab
|
- Restricted to outpatient setting ONLY
|
|
ibandronate
|
- ibandronate (Boniva) is restricted to use in the Outpatient setting
|
|
ibuprofen
|
- IV Ibuprofen is restricted to pediatrics
|
|
inclisiran
|
- Restricted to outpatient use only
|
|
inFLIXimab
|
- inFLIXimab is restricted to the Outpatient setting except for Inpatient use by gastroenterologists in patients with Crohn's disease or ulcerative colitis who are nearing obstruction
|
|
ipilimumab
|
- ipilimumab (Yervoy) is restricted to use in the Outpatient setting
|
|
irinotecan liposomal
|
- irinotecan liposomal (Onivyde) is restricted to use in the Outpatient setting
|
|
iron dextran
|
- Restricted to outpatient use only.
|
|
isatuximab
|
- Restricted to outpatient setting only
|
|
isavuconazonium
|
- Restricted to Infectious Disease providers only
|
|
Japanese enceph vacc SA14-14-2, inactivated
|
- restricted to outpatient and clinics
|
|
ketamine
|
- ketamine oral - must be prescribed by a palliative care physician and patient must be DNR
- ketamine oral - is restricted to patient on 5W, RCU, SPCU and at least 18 years old
|
|
ketorolac-phenylephrine ophthalmic
|
- Restricted to ocular surgeries
|
|
lanreotide
|
- Restricted to outpatient use only
|
|
leuprolide
|
- Restricted to outpatient use only
- EXCEPTION: Lupron Depot restricted and available through non-formulary process for patient's with prostate cancer with spinal metastasis that requires urgent treatment
|
|
levothyroxine
|
- levothyroxine IV (Synthroid) is restricted to patients with myxedema coma, LOPA patients, pediatrics, or if a patient is NPO for a prolonged period
|
|
linaclotide
|
- restricted to continuation of home therapy and to GI practitioners
|
|
liraglutide
|
- restricted to pediatric patients as continuation of home medications
|
|
loncastuximab tesirine
|
- Restricted to outpatient use only
|
|
lurasidone
|
- lurasidone (Latuda) is restricted to psychiatry or continuation of home meds
|
|
lurbinectedin
|
- Restricted to outpatient setting only
|
|
lutetium Lu 177 dotatate
|
- Ordering by hematology/oncology providers only
|
|
lutetium Lu 177 vipivotide tetraxetan
|
- Ordering by hematology/oncology providers only
|
|
margetuximab
|
- Restricted to outpatient use only
|
|
meningococcal conjugate vaccine
|
- Menveo restricted to patients <2 years and patients who have already started the series
|
|
meningococcal group B vaccine
|
- Bexsero is restricted- formulary non-preferred for outpatient
|
|
meperidine
|
- meperidine (Demerol) is restricted to the prevention and treatment of drug-induced or blood product-induced rigors (e.g., amphotericin B, platelets) and treatment of postoperative shivering
|
|
mepolizumab
|
- Restricted to outpatient setting only.
|
|
metFORMIN
|
- Metformin is formulary restricted to behavioral health and pediatric patients.
|
|
methylnaltrexone
|
- methylnaltrexone ( Relistor) is restricted to use in palliative care patients, oncology patients, or failure of NLT 2 other laxatives
|
|
metoclopramide
|
- Solution formulation is restricted to Pediatrics
|
|
micafungin
|
- Restricted to Infectious Disease and Critical Care Physicians
|
|
mirvetuximab soravtansine
|
- Restricted to outpatient use only
|
|
mogamulizumab
|
- Restricted to outpatient setting only
|
|
moxifloxacin
|
- For use in non-tuberculosis mycobacterium infections
|
|
moxifloxacin ophthalmic
|
- restricted to retinopathy of prematurity and surgery settings.
|
|
mycophenolate mofetil
|
- Oral Solution is Formulary Restricted to Pediatrics
|
|
nafarelin
|
- Restricted to outpatient use only
|
|
naloxegol
|
- naloxegol (Movantik) is restricted to use in patients with opioid induced constipation that have failed 2 or more laxatives
|
|
naloxone
|
- Nasal spray is restricted to outpatient use
|
|
naltrexone
|
- Injection restricted to outpatient use
|
|
nivolumab
|
- nivolumab (Opdivo) is restricted to use in the Outpatient setting
|
|
nivolumab-relatlimab
|
- Restricted to outpatient use only
|
|
obinutuzumab
|
- obinutuzumab (Gazyva) is restricted to use in the Outpatient setting
|
|
octreotide
|
- Octreotide acetate LAR will be formulary-restricted to outpatient and in conjunction with Lutathera administration in same day admissions ONLY
|
|
omalizumab
|
- Restricted to outpatient setting only.
|
|
omeprazole
|
- omeprazole (PriLOSEC) is restricted to Pediatric patients
|
|
oxandrolone
|
- Restricted to Burn Patient Population
|
|
paliperidone
|
- paliperidone (Invega) is restricted to psychiatry or continuation of home meds
|
|
palonosetron
|
- Restricted to use in outpatient oncology setting and inpatients on cisplatin therapy
|
|
panitumumab
|
- panitumumab (Vectibix) is restricted to use in the Outpatient setting
|
|
pegfilgrastim
|
- pegfilgrastim (Neulasta & Neulasta On-Body Injector) is restricted to use in the Outpatient setting
|
|
pegloticase
|
- pegloticase (Krystexxa) is restricted to use in the Outpatient setting
|
|
pembrolizumab
|
- pembrolizumab (Keytruda) is restricted to use in the Outpatient setting
|
|
pertuzumab
|
- pertuzumab (Perjeta) is restricted to use in the Outpatient setting
|
|
pioglitazone
|
- Restricted to behavioral health patients
|
|
polidocanol
|
- Formulary Restricted to Outpatient
|
|
polymyxin B sulfate
|
- Infectious Disease providers or Critical Care providers when ID providers are not available
|
|
poractant alfa
|
|
|
posaconazole
|
- posaconazole (Noxafil) is restricted Infectious Disease or Oncology
|
|
potassium chloride
|
- Potassium chloride oral solution is formulary restricted to pediatrics
|
|
prasugrel
|
|
|
QUEtiapine
|
- QUEtiapine ER (Seroquel XR) is formulary, but is restricted to continuation of home medications
|
|
ramucirumab
|
- ramucirumab (Cyramza) is restricted to use in the Outpatient setting by Hem/Onc only
|
|
raNITIdine (non-formulary)
|
- raNITIdine (Zantac) is restricted to pediatric patients
|
|
Ravulizumab
|
- Ultomiris is formulary restricted to outpatient use only (preferred).
|
|
relugolix
|
|
|
reslizumab
|
- Restricted to outpatient setting only
|
|
rimegepant
|
|
|
risankizumab
|
- Restricted to use in the Outpatient setting
|
|
rizatriptan
|
- rizatroptan (Maxalt) is restricted to patients intolerant to sumatriptan
|
|
romiDEPsin
|
- Restricted to outpatient use only
|
|
romiPLOStim
|
- romiPLOStim (Nplate) is restricted to use in the Outpatient setting by Hem/Onc only
|
|
romosozumab
|
- Restricted to outpatient setting only
|
|
sAXagliptin
|
- Restricted to non-diabetic related indications.
|
|
sirolimus protein-bound
|
- Restricted to outpatient use only.
|
|
sodium polystyrene sulfonate
|
- Restricted to NPO usage and pediatrics
|
|
sucralfate
|
- Suspension formulation is restricted to pediatrics
|
|
sugammadex
|
- sugammadex (Bridion) is restricted to use in the main operating room and main PACU
|
|
tacrolimus topical
|
- Formulary Restricted to pts who have failed topical steroids or cannot use topical steroids
|
|
tafasitamab
|
|
|
tagraxofusp
|
- Restricted to outpatient use only
|
|
tezepelumab
|
- Restricted to outpatient setting only.
|
|
thyrotropin alfa
|
- Non-formulary for outpatient infusion
|
|
tigecycline
|
- tigecycline (Tygacil) is restricted to infectious disease and critical care specialties
|
|
tildrakizumab
|
- Restricted to outpatient use only
|
|
tisotumab vedotin
|
- Restricted to outpatient use only
|
|
tocilizumab
|
- tocilizumab (Actemra) is restricted to use in the Outpatient setting
|
|
tolvaptan
|
- tolvaptan (Samsca) is restricted to treatment of euvolemic and hypervolemic hyponatremia
|
|
trabectedin
|
- Trabectedin (Yondelis) is restricted to use in the Outpatient setting
|
|
tremelimumab
|
- Restricted to outpatient use only
|
|
trilaciclib
|
- Restricted to outpatient setting only
|
|
triptorelin
|
- Restricted to outpatient use only
|
|
typhoid vaccine, inactivated
|
- restricted to outpatient and clinics
|
|
ustekinumab
|
- Restricted to outpatient use only
|
|
valrubicin
|
- valrubicin (Valstar) is restricted to use in the Outpatient setting
|
|
vedolizumab
|
- vedolizumab (Entyvio) is restricted to use in the Outpatient setting to patients with Ulcerative colitis & Crohn's Disease
|
|
zoledronic acid
|
- Reclast is restricted to use in the Outpatient setting
|
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