|
aminolevulinic acid
|
- Restricted to its FDA approved indication
|
|
andexanet alfa
|
- Restricted to treatment of intracranial hemorrhage, neuraxial bleeding, and life-threatening extracranial bleeding that is not amendable to other medical and surgical interventions
- Restricted to bleeding from rivaroxaban or apixaban
- Restricted to bleeding from enoxaparin among patients who are allergic to protamine
|
|
ARIPiprazole
|
- Aripiprazole (Abilify Maintena®) is restricted to patients with schizophrenia.
|
|
bebtelovimab
|
- Restricted to use in accordance with EUA criteria. Included as an option consistent with the HM mAB tiered use criteria
|
|
belantamab mafodotin
|
- Restricted to its FDA approved indication
|
|
brexucabtagene autoleucel
|
- Restricted to patients with prior financial approval
|
|
bupivacaine/meloxicam
|
- Restricted to use for FDA approved indications with concurrent use of other extended-release local anesthetics
|
|
calcitonin
|
- Treatment of symptomatic hypercalcemia for patients who are unresponsive to IV therapy and are not appropriate candidates for pamidronate
|
|
cangrelor
|
- *Nonformulary* restricted to use in patients without oral or enteral access undergoing emergent intracoronary stent placement that have not been treated with a GPIIb/IIIa inhibitor
|
|
caplacizumab
|
- Inpatient use allowable for FDA-approved indication
|
|
cefiderocol
|
- Restricted to patients with gram negative infections with documented resistance to other agents
|
|
denosumab
|
- Restricted to patients with financial approval
|
|
eculizumab
|
- Restricted to patients who are registered with the manufacturer, Alexion Pharmaceuticals, Inc.
- Restricted to FDA-approved indications (PNH or aHUS) or for transplant patients who meet criteria according to the solid organ transplant clinical practice guideline
|
|
edaravone
|
- Restricted to patients with financial approval who have been registered with the drug manufacturer
|
|
esketamine
|
- Restricted to patients enrolled in the Spravato REMS program who have financial approval to continue SpravatoTM after hospital discharge
|
|
fam-trastuzumab deruxtecan-nxki
|
- Restricted to its FDA approved indication
|
|
fentaNYL
|
- Transdermal patch is restricted to continuation of home therapy or conversion of oral therapy in opioid tolerant patients, defined as at least 60 mg of oral morphine daily (or equianalgesic dose of another opioid) for at least one week
|
|
ferumoxytol
|
- Restricted to outpatient setting
|
|
fluPHENAZine
|
- Fluphenazine decanoate (Prolixin decanoate®) is restricted to patients with schizophrenia.
|
|
glucarpidase
|
- Restricts to patients with clinically toxic plasma methotrexate concentrations (>1 μM/L) and impaired renal function
- Requires a review of use by the HM Oncology Exception Review Panel physician
|
|
haloperidol
|
- Haloperidol decanoate (Haldol®) is restricted to patients with schizophrenia.
|
|
idecabtagene vicleucel
|
- Restricted to patients with prior financial approval
|
|
letermovir
|
- Restricted to inpatients in whom adequate transitions of care have been established regarding medication acquisition in the outpatient setting
|
|
lisocabtagene maraleucel
|
- Restricted to patients with prior financial approval
|
|
luspatercept-aamt
|
- Restricted to its FDA approved indication
|
|
maribavir
|
- Inpatient use should be restricted to patients in whom adequate transitions of care have been established regarding medication acquisition in the outpatient setting (i.e. prior authorization, etc)
|
|
meropenem-vaborbactam
|
- Restricted to patients with confirmed or suspected carbapenemase producing Enterobacteriaciae
|
|
paliperidone
|
- Paliperidone palmitate (Invega Sustenna®) is restricted to patients with schizophenia and schizoaffective disorder.
|
|
polyethylene glycol 3350 with electrolytes
|
- Plenvu is restricted to use as bowel cleansing agent in preparation for colonoscopy
|
|
ravulizumab
|
- Restricted to patients registered with the Ultomiris REMS program
|
|
risperiDONE
|
- Risperidone (Risperdal Consta®) is restricted to patients with schizophrenia and bipolar I disorder.
|
|
riTUXimab
|
- Rituxan Hycela® (rituximab and hyaluronidase human) is restricted to FDA-approved indications of follicular lymphoma, diffuse large B-cell lymphoma, and chronic lymphocytic leukemia
|
|
romosozumab-aqqg
|
- Restricted to patients who have not had an MI or stroke within the preceding year
|
|
selexipag
|
- IV selexipag is restricted to patients that have previously been receiving oral selexipag and are unable to tolerate medications by mouth
|
|
sotalol
|
- IV sotalol is restricted to use in patients with CrCl >60 mL/min being initiated on sotalol for atrial fibrillation, with no other concurrent medical conditions that may extend length of stay
|
|
tafasitamab-cxix
|
- Restricted to its FDA approved indication
|
|
tagraxofusp-erzs
|
- Restricted to use for its FDA-approved indication; Restricted to use in patients with financial approval for outpatient treatment cycles
|
|
tisagenlecleucel
|
- Financial approved required prior to administration
|
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