|
acetaminophen
|
- IV acetaminophen is restricted to OR, PACU, and ICU areas
|
|
agalsidase beta
|
- Restricted to outpatient setting with prior financial approval
|
|
andexanet alfa
|
- Restricted to emergency department, intensive care unit, and operating room
|
|
anifrolumab-fnia
|
- Restricted to outpatient setting with financial approval
|
|
axicabtagene ciloleucel
|
- Restricted to certified Yescarta REMS treatment centers (HMH only)
- Restricted to outpatient setting with financial approval
|
|
belantamab mafodotin
|
- Restricted to outpatient setting with financial approval
|
|
Benralizumab
|
- Restricted to outpatient setting with financial approval
|
|
brexucabtagene autoleucel
|
- Restricted to certified Tecartus REMS treatment centers
|
|
cemiplimab
|
- Restricted to outpatient setting with financial approval
|
|
crizanlizumab-tmca
|
- Restricted to outpatient setting with financial approval
|
|
dalbavancin
|
- Restricted to outpatient setting
|
|
Daratumumab
|
- Restricted to outpatient setting with financial approval
|
|
darbepoetin alfa
|
- Restricted to outpatient use with financial approval or inpatient use for oncologic indications
|
|
degarelix
|
- Restricted to outpatient setting with financial approval
|
|
denosumab
|
- Restricted to outpatient setting
|
|
durvalumab
|
- Restricted to outpatient setting with financial approval
|
|
eculizumab
|
- Restricted to outpatient setting with financial approval or inpatient use for emergent care of newly diagnosed disease or continuation of maintenance therapy that is medically necessary
|
|
edaravone
|
- Restricted to outpatient setting
|
|
emapalumab
|
- Restricted to outpatient setting with financial approval or inpatient use for the FDA approved indication for emergent care of newly diagnosed disease or continuation of maintenance therapy that is medically necessary
|
|
enfortumab vedotin-ejfv
|
- Restricted to outpatient setting with prior financial approval
|
|
esketamine
|
- Restricted to hospitals enrolled the Spravato REMS program and patient care areas that can provide monitoring by psychiatry trained nurses for at least 2 hours following each dose
|
|
fam-trastuzumab deruxtecan-nxki
|
- Restricted to outpatient setting with financial approval
|
|
ferric carboxymaltose
|
- Restricted to outpatient setting
|
|
goserelin
|
- Restricted to outpatient setting with financial approval
|
|
hetastarch
|
- Restricted to use within OR/procedural areas
|
|
hexaminolevulinate
|
- Restricted to FDA approved indication for use in the operating room
|
|
idecabtagene vicleucel
|
- Restricted to Abecma REMS treatment centers (HMH only)
|
|
inotuzumab ozogamicin
|
- Restricted to outpatient use with financial approval or inpatient use for FDA approved indications
|
|
leuprolide
|
- Restricted to outpatient setting with financial approval; Allow inpatient use for 3.75 mg dose for fertility preservation in women undergoing emergent chemotherapy
|
|
lisocabtagene maraleucel
|
- Restricted to Breyanzi REMS treatment centers (HMH only)
|
|
lurbinectedin
|
- Restricted to outpatient setting with financial approval
|
|
luspatercept-aamt
|
- Restricted to outpatient setting with financial approval
|
|
Moxetumomab Pasudotox
|
- Restricted to outpatient setting with financial approval or for the first cycle of an FDA approved indication in the inpatient setting
|
|
obinutuzumab
|
- Restricted to outpatient setting with financial approval
|
|
ocrelizumab
|
- Restricted to outpatient setting with financial approval
|
|
olaratumab
|
- Restricted to outpatient setting with financial approval
|
|
palonosetron
|
- Restricted to outpatient setting
|
|
patisiran
|
- Restricted to outpatient setting with financial approval
|
|
pegloticase
|
- Restricted to outpatient setting with financial approval
|
|
pertuzumab/trastuzumab/hyaluronidase-zzxf
|
- Restricted to outpatient setting with financial approval
|
|
polatuzumab vedotin-piiq
|
- Restricted to outpatient setting with financial approval
|
|
Porfimer
|
- Restricted to outpatient setting with financial approval
|
|
ravulizumab
|
- Restricted to outpatient setting with financial approval
|
|
romosozumab-aqqg
|
- Restricted to outpatient setting with financial approval
|
|
sacituzumab govitecan-hziy
|
- Restricted to outpatient setting with prior financial approval
|
|
Sebelipase alfa
|
- Restricted to outpatient setting with financial approval
|
|
Sipuleucel-T
|
- Restricted to outpatient setting with financial approval
|
|
sotalol
|
- IV sotalol is restricted to use in the cath lab at entities prepared to operationalize patient flow and medication safety as determined by entity cath lab director and pharmacy director
|
|
sugammadex
|
- Restricted to the operating room
|
|
tafasitamab-cxix
|
- Restricted to outpatient setting with financial approval
|
|
tagraxofusp-erzs
|
- Restricted to outpatient administration after first treatment cycle
|
|
talimogene laherparepvec
|
- Restricted to outpatient setting with financial approval
|
|
tebentafusp
|
- Restricted to inpatient oncology unit (for the first three infusions - patient to be admitted in an observation status) / outpatient infusion for subsequent infusions
|
|
teprotumumab
|
- Restricted to outpatient setting with financial approval
|
|
tisagenlecleucel
|
- Restricted to certified Kymriah REMS treatment centers (HMH only)
|
|
tocilizumab
|
- Restricted to outpatient use for FDA labeling with financial approval or inpatient use for cytokine release syndrome or COVID
|
|
trastuzumab
|
- Restricted to outpatient setting with financial approval
|
|
trastuzumab and hyaluronidase-oysk
|
- Restricted to outpatient setting with financial approval
|
|
vedolizumab
|
- Restricted to outpatient setting
|
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