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Henry Ford Health

Approved Hospital Formulary

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Brand name products with an equivalent generic may not be available to order at Henry Ford Health. For questions, contact inpatient pharmacy.

Henry Ford Health

Approved Hospital Formulary

FormWeb QuickStart Questions or Suggestions? Pharmacy Intranet

Policy

Please review each of these drugs carefully.

acetaminophen	Tier 1: Acetaminophen Injection (Ofirmev)
albumin human	Tier 1: Albumin Dosing and Duration of Therapy Guidelines
alvimopan	Tier 1: Alvimopan (Entereg) Policy
ambrisentan	Tier 1: Inpatient endothelin receptor antagonist dispensing procedure
angiotensin II	Tier 1: Treatment of Refractory Vasoplegic Shock
antihemophilic factor	Tier 1: Inpatient use of antihemophilic factor recombinant, porcine sequence (Obizur) Injection
apixaban	Tier 1: Inpatient Anticoagulation Management Tier 1: Anticoagulation Reversal Guidelines Tier 1: Guidelines for Initial Anticoagulation in Venous Thromboembolism and Atrial Fibrillation Tier 1: Perioperative Medication Management
argatroban	Tier 1: Inpatient Anticoagulation Management Tier 1: Heparin Induced Thrombocytopenia (HIT) Guidelines
ARIPiprazole	Tier 1: Long Acting Injectable Antipsychotics
baricitinib	Tier 1: COVID-19 Clinical Management Guideline Tier 1: Pharmacist Initiated Renal Dose Adjustment for Adult Patients
bebtelovimab	Tier 1: Clinical Indications for use of COVID-19 Monoclonal Antibody Therapy
bortezomib	Tier 1: Bortezomib for inpatient use
bosentan	Tier 1: Inpatient endothelin receptor antagonist dispensing procedure
bupivacaine liposome	Tier 1: Bupivacaine Liposome (Exparel) Injection
bupivacaine-meloxicam	Tier 1: Appropriate use of bupivacaine and meloxicam solution (Zynrelef)
buprenorphine	Tier 1: Use of Transdermal Opioids in Acute Care Settings Tier 1: Low-dose inductions with buprenorphine for analgesia in hospitalized patients
calcitonin	Tier 1: Inpatient Use of Calcitonin Injection (Miacalcin)
cangrelor	Tier 1: Appropriate Use of Cangrelor (Kengreal)
clevidipine	Tier 1: Clevidipine
cloZAPine	Tier 1: Hospital-Based Prescribing, Dispensing, and Monitoring of Clozapine
Coagulation Factor Xa (recombinant), inactivated-zhzo	Tier 1: Anticoagulation Reversal Guidelines
cytarabine liposomal-daunorubicin liposomal	Tier 1: Appropriate Inpatient Administration of Daunorubicin and Cytarabine Liposomal (Vyxeos®) Policy
dabigatran	Tier 1: Inpatient Anticoagulation Management Tier 1: Anticoagulation Reversal Guidelines Tier 1: Guidelines for Initial Anticoagulation in Venous Thromboembolism and Atrial Fibrillation Tier 1: Perioperative Medication Management
dalbavancin	Tier 1: Utilization of Long-acting Lipoglycopeptides (LaLGP)
dantrolene	Tier 1: Dantrolene Injection
darbepoetin alfa	Tier 1: Darbepoetin/Epoetin Conversion Protocolâ€”Anemia of Chronic Kidney Disease
degarelix	Tier 1: Use of Degarelix at Henry Ford Health System
dofetilide	Tier 1: Dofetilide and Sotalol for Hospitalized Patients
droperidol	Tier 1: Droperidol Policy Tier 1: Prevention and Treatment of Postoperative Nausea and Vomiting in Adults
eculizumab	Tier 1: Eculizumab Use in the Inpatient Setting Tier 1: Guideline for Eculizumab Use in Kidney Transplant Patients
edoxaban	Tier 1: Inpatient Anticoagulation Management Tier 1: Anticoagulation Reversal Guidelines Tier 1: Guidelines for Initial Anticoagulation in Venous Thromboembolism and Atrial Fibrillation Tier 1: Perioperative Medication Management
epoetin alfa	Tier 1: Darbepoetin/Epoetin Conversion Protocol-Anemia of Chronic Kidney Disease
epoprostenol	Tier 1: Intravenous Prostacyclin Policy
esketamine	Tier 1: Esketamine (Spravato) administration at Henry Ford Health System
etanercept	Tier 1: Inpatient Etanercept Policy
fentaNYL	Tier 1: Inpatient HFHS Transdermal Fentanyl Patch
hemin	Tier 1: Hemin for Injection (PanhematinÂ®) Inventory and Preparation
heparin	Tier 1: Inpatient Anticoagulation Management Tier 1: Anticoagulation Reversal Guidelines Tier 1: Heparin Induced Thrombocytopenia (HIT) Guidelines
inFLIXimab	Tier 1: Inpatient Infliximab Infusion Policy
insulin detemir	Tier 1: Inpatient Use of Insulin Detemir
insulin regular	Tier 1: Concentrated U500 Human Insulin Policy
levoFLOXacin	Tier 1: Pharmacist Initiated Renal Dose Adjustment for Adult Patients
macitentan	Tier 1: Inpatient endothelin receptor antagonist dispensing procedure
methadone	Tier 1: Methadone use in the inpatient or emergency department settings
miFEPRIStone	Tier 1: Mifepristone Policy
nirsevimab	Tier 1: Inpatient Use of Nirsevimab (Beyfortus)
ondansetron	Tier 1: Antiemetic Management of Chemotherapy-Induced Nausea and Vomiting Tier 1: Prevention and Treatment of Postoperative Nausea and Vomiting in Adults
oritavancin	Tier 1: Utilization of Long-acting Lipoglycopeptides (LaLGP)
paliperidone	Tier 1: Long Acting Injectable Antipsychotics
palonosetron	Tier 1: Antiemetic Management of Chemotherapy-Induced Nausea and Vomiting
phentolamine	Tier 1: Guideline for the Management of Infiltration and Extravasation Injuries Secondary to Cytotoxic and Non-Cytotoxic Agents
prothrombin complex	Tier 1: Four Factor Prothrombin Complex Concentrate (Kcentra)
rasburicase	Tier 1: Rasburicase Policy
rifAXIMin	Tier 1: Inpatient Use of Rifaximin
riociguat	Tier 1: Inpatient oral soluble guanylate cyclase (sGC) stimulator dispensing procedure
risperiDONE	Tier 1: Long Acting Injectable Antipsychotics
riTUXimab	Tier 1: Inpatient rituximab infusion policy
rivaroxaban	Tier 1: Inpatient Anticoagulation Management Tier 1: Anticoagulation Reversal Guidelines Tier 1: Guidelines for Initial Anticoagulation in Venous Thromboembolism and Atrial Fibrillation Tier 1: Perioperative Medication Management
romiPLOStim	Tier 1: Criteria for Use of Romiplostim in the Inpatient Setting
romosozumab	Tier 1: Romosozumab Injection (Evenity)
selexipag	Tier 1: Inpatient use of selexipag
sotalol	Tier 1: Dofetilide and Sotalol for Hospitalized Patients
sugammadex	Tier 1: Appropriate Use of Sugammadex
talquetamab	Tier 1: Tecvayli (teclistamab-cqyv) and Talvey (talquetamab-tgvs) REMS Program
teclistamab	Tier 1: Tecvayli (teclistamab-cqyv) and Talvey (talquetamab-tgvs) REMS Program
terlipressin	Tier 1: Terlipressin (Terlivaz)
tixagevimab-cilgavimab	Tier 1: Clinical Indications for use of COVID-19 Monoclonal Antibody Therapy
tocilizumab	Tier 1: COVID-19 Clinical Management Guideline Tier 2: Identification and Management of Adverse Reactions to CAR-T
tolvaptan	Tier 1: Inpatient Tolvaptan (Samsca) Criteria for Use
treprostinil	Tier 1: Intravenous Prostacyclin Policy Tier 1: Subcutaneous Treprostinil (Remodulin) Policy Tier 1: Oral Treprostinil Diolamine (Orenitram) Policy
uridine	Tier 1: Uridine Triacetate Policy
warfarin	Tier 1: Inpatient Anticoagulation Management Tier 1: Guidelines for Initial Anticoagulation in Venous Thromboembolism and Atrial Fibrillation Tier 1: Anticoagulation Reversal Guidelines Tier 1: Anticoagulation Management of Patients on Durable Mechanical Circulatory Support at Henry Ford Health System

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