|
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
|
- formulary restricted as alternative to docosanol when application to large surface area is required
|
|
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
|
- Aminolevulinicacid (Gleolan) will be formulary restricted to surgeons who have completed appropriate training and have appropriate equipment on site.
|
|
amivantamab
|
- Restricted to outpatient use only
|
|
anti-thymocyte globulin (rabbit)
|
- Restricted for inpatient use in: allogeneic stem cell transplant for graft versus host disease prevention; or second line aplastic anemia or aplasia.
|
|
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
|
|
axatilimab
|
- Formulary restricted to treatment of chronic graft-versus-host disease (cGVHD) after failure of at least 2 prior lines of systemic therapy in adult and pediatric patients weighing ≥40 kg.
|
|
axicabtagene ciloleucel
|
- Restricted to CAR-T cell therapy
|
|
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
|
|
brexucabtagene autoleucel
|
- Restricted to CAR-T cell therapy
|
|
brivaracetam
|
- formulary restricted to failed levetiracetam therapy, continuation of home medication, or neurology
|
|
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
|
|
buprenorphine-naloxone
|
- Zubsolv is formulary restricted or psychiatry for microinduction dosing.
|
|
busulfan
|
- Restricted to stem cell transplant therapy (IV and oral).
|
|
cabotegravir-rilpivirine
|
- formulary restricted to outpatients
|
|
calcitonin
|
- calcitonin IM (Miacalcin) is restricted to 2 doses in patients with symptomatic hypercalcemia and corrected 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
|
|
canakinumab
|
- Formulary, restricted to outpatient use only
|
|
cangrelor
|
|
|
cannabidiol
|
- Restricted to Lennox Gastaut and Dravet Syndromes
|
|
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 providers.
|
|
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
|
- Clonazepam ODT – formulary restricted to patients weighing <50kg
|
|
clotrimazole topical
|
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|
|
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
|
|
darbepoetin alfa
|
- Restricted to outpatient setting ONLY
|
|
degarelix
|
|
|
denosumab
|
- denosumab (Prolia, Xgeva) is restricted to use in the Outpatient setting
|
|
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
|
|
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
|
|
|
glipiZIDE
|
- Glipizide is formulary restricted to behavioral health patients.
|
|
golimumab
|
- Restricted to outpatient setting only
|
|
goserelin
|
- Restricted to outpatient use only
|
|
granisetron
|
- Restricted to pediatrics who have failed ondansetron therapy
|
|
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
|
|
hyoscyamine/methenam/m-blue/sodium biphosphat
|
- Restricted to pediatrics and G6PD
|
|
ibandronate
|
- ibandronate (Boniva) is restricted to use in the Outpatient setting
|
|
ibuprofen
|
- IV Ibuprofen is restricted to pediatrics
|
|
imetelstat
|
- Restricted to outpatient use only.
|
|
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 and Onc/BMT
|
|
isradipine
|
- Isradipine formulary restricted for pediatrics
|
|
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
|
|
letermovir
|
- Restricted to inpatient use only for CMV prophylaxis in allogeneic stem cell transplant patients (CMV recipient positive and/or donor positive). IV formulation further restricted to patients who are NPO.
|
|
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
|
|
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
|
|
melphalan
|
- Restricted to inpatient. IV formulation 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.
|
|
methoxsalen
|
- Methoxsalen injection is restricted to sites that provide photopheresis therapy
|
|
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, Critical Care, and Oncology 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
|
|
palifermin
|
- Restricted to stem cell transplant patients receiving total body irradiation (TBI) as part of the conditioning regimen
|
|
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, stem cell transplant plans, and induction acute leukemia plans where appropriate.
|
|
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
|
|
pentosan polysulfate sodium
|
- Restricted to interstitial cystitis
|
|
pertuzumab
|
- pertuzumab (Perjeta) is restricted to use in the Outpatient setting
|
|
pioglitazone
|
- Restricted to behavioral health patients
|
|
plerixafor
|
- Restricted to stem cell mobilization.
|
|
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
|
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|
|
prazosin
|
|
|
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
|
|
rufinamide
|
|
|
sargramostim
|
- Restricted to use in patients with acute myeloid leukemia.
|
|
sAXagliptin
|
- Restricted to non-diabetic related indications.
|
|
siltuximab
|
- Formulary restricted to use in the outpatient setting. Restricted use in inpatient setting for the management of CRS and ICANS for patients who are intolerant to tocilizumab or if tocilizumab is not available (max of 1 dose in a 3 week period).
|
|
sirolimus protein-bound
|
- Restricted to outpatient use only.
|
|
sodium polystyrene sulfonate
|
- Restricted to NPO usage and pediatrics
|
|
sucralfate
|
- Suspension formulation is restricted to pediatrics
|
|
sucroferric oxyhydroxide
|
- Restricted to patients with gastroparesis/GI motility issues
|
|
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
|
|
tetracycline
|
- Restricted to treating H pylori only
|
|
tezepelumab
|
- Restricted to outpatient setting only.
|
|
thiotepa
|
- Restricted to inpatient use 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 formulary, restricted to use in the outpatient setting. Restricted use in the inpatient setting for treatment of patients with specific indications (see comments).
|
|
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
|
|
vigabatrin
|
- Restricted to hospitals registered with REMS program
|
|
zoledronic acid
|
- Reclast is restricted to use in the Outpatient setting
|
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