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Approved Hospital Formulary

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Legacy Health

Approved Hospital Formulary

Pharmacy - Home (sharepoint.com) Contact Pharmacy

Restricted

Please review each of these drugs carefully.

abatacept	Restricted Medication
acetaminophen	IV Acetaminophen (Ofirmev) is Formulary Restricted
adalimumab	Restricted Medication
ado-trastuzumab emtansine	Restricted Medication
albendazole	Formulary Restricted Medication
alemtuzumab	Restricted Medication
alfentanil	Formulary Restricted Medication
alglucosidase alfa	Restricted Medication
alvimopan	Restricted Medication
aminolevulinic acid	Formulary Restricted Medication
amphotericin B	Formulary Restricted Medication
amphotericin B liposomal	Formulary Restricted Medication
anacaulase topical	Formulary Restricted Medication
aprepitant	Formulary Restricted Medication
arformoterol	Formulary Restricted Medication
artemether-lumefantrine	Formulary Restricted Medication
artesunate	Formulary Restricted Medication
Atezolizumab	Restricted Medication
atovaquone-proguanil	Formulary Restricted Medication
avacincaptad pegol	Formulary Restricted Medication
avelumab	Restricted Medication
aztreonam	Formulary Restricted Medication
baricitinib	Formulary Restricted Medication
belimumab	Restricted Medication
bevacizumab	Restricted Medication
bezlotoxumab	Restricted Medication
biotin	Formulary Restricted Medication
brentuximab vedotin	Restricted Medication
bupivacaine liposome	Formulary Restricted Medication
buprenorphine	ER Subcutaneous Injection; Formulary Restricted
cabazitaxel	Restricted Medication
cabotegravir	Formulary Restricted Medication
cabotegravir-rilpivirine	Formulary Restricted Medication
calaspargase pegol	Formulary Restricted Medication
canakinumab	Restricted Medication
cangrelor	Formulary Restricted Medication
cannabidiol	Formulary Restricted Medication
capsaicin topical	Capsaicin 8% (Qutenza) is Formulary Restricted
carfilzomib	Restricted Medication
ceftaroline	Non-Formulary Restricted Medication
cefTAZidime	Formulary Restricted Medication
ceftazidime-avibactam	Formulary Restricted Medication
ceftolozane-tazobactam	Formulary Restricted Medication
cemiplimab	Restricted Medication
cenobamate	Formulary Restricted Medication
certolizumab	Restricted Medication
cetuximab	Restricted Medication
cidofovir	Formulary Restricted Medication
cloZAPine	Formulary Restricted Medication
coenzyme Q10	Formulary Restricted Medication
creatine	Formulary Restricted Medication
cytarabine liposomal-daunorubicin liposomal	Restricted Medication
DACTINomycin	Restricted Medication
daratumumab	Restricted Medication
daratumumab-hyaluronidase	Restricted Medication
darbepoetin alfa	Restricted Medication
denosumab	Restricted Medication
dexmedetomidine	Formulary Restricted Medication (Igalmi)
dostarlimab	Formulary Restricted Medication
DOXOrubicin liposomal	Restricted Medication
dronedarone	New Starts Restricted
durvalumab	Restricted Medication
eculizumab	Restricted Medication
elosulfase alfa	Formulary Restricted Medication
empagliflozin	Formulary Restricted Medication
eribulin	Restricted Medication
ertapenem	Formulary Restricted Medication
esketamine	Formulary Restricted Medication
eslicarbazepine	Formulary Restricted Medication
etanercept	Restricted Medication
ethambutol	Formulary Restricted Medication
ethionamide	Formulary Restricted Medication
fam-trastuzumab deruxtecan	Restricted Medication
faricimab ophthalmic	Vabysmo: Formulary Restricted Medication
fat emulsion, intravenous	Smoflipid-Formulary Restricted
fibrinogen	Formulary Restricted Medication
flucytosine	Formulary Restricted Medication
fluoroestradiol F 18	Formulary Restricted Medication
foscarnet	Formulary Restricted Medication
fosfomycin	Formulary Restricted Medication
ganciclovir	Formulary Restricted Medication
ganciclovir ophthalmic	Formulary Restricted Medication
gemtuzumab ozogamicin	Restricted Medication
glucarpidase	Formulary Restricted Medication
golimumab	Restricted Medication
goserelin	Restricted Medication
hepatitis B adult vaccine	Heplisav is NF Restricted
hyaluronidase-rituximab	Restricted Medication
hyaluronidase/pertuzumab/trastuzumab	Restricted Medication
ibandronate	Restricted Medication
ibuprofen	IV Ibuprofen is Formulary Restricted
idursulfase	Formulary Restricted Medication
imiglucerase	Restricted Medication
inclisiran	Formulary Restricted Medication
inotuzumab ozogamicin	Restricted Medication
interferon beta-1a	Restricted Medication
ipilimumab	Restricted Medication
irinotecan liposomal	Restricted Medication
isoniazid	Formulary Restricted Medication
itraconazole	Formulary Restricted Medication
ivermectin	Formulary Restricted Medication
ixabepilone	Restricted Medication
lanreotide	Restricted Medication
loncastuximab tesirine	Formulary Restricted Medication
lumateperone	Formulary Restricted Medication
lurbinectedin	Restricted Medication
luspatercept	Restricted Medication
macitentan	Formulary Restricted Medication
melatonin	Formulary Restricted Medication
Mepolizumab	Restricted Medication
methoxsalen	Restricted Medication
methylnaltrexone	Formulary Restricted Medication
miFEPRIStone	Formulary Restricted Medication
mirvetuximab soravtansine	Ambulatory Formulary with Restrictions
molnupiravir	Formulary Restricted Medication
NAC (N-Acetyl-L-Cysteine)	Formulary Restricted Medication
naloxegol	Formulary Restricted Medication
natalizumab	Restricted Medication
naxitamab	Formulary Restricted Medication
necitumumab	Restricted Medication
nirmatrelvir-ritonavir	Formulary Restricted Medication
nirsevimab	Formulary Restricted Medication
nitazoxanide	Formulary Restricted Medication
Nivolumab	Restricted Medication
obinutuzumab	Restricted Medication
ocrelizumab	Restricted Medication
octreotide	Restricted Medication (Long Acting Intramuscular Injection)
omalizumab	Restricted Medication
PACLitaxel protein-bound	Restricted Medication
palifermin	Formulary Restricted Medication
palivizumab	Formulary Restricted Medication
panitumumab	Restricted Medication
pasireotide diaspartate	Formulary Restricted Medication
patiromer	Formulary Restricted Medication
pegfilgrastim	Restricted Medication
Pembrolizumab	Restricted Medication
pemivibart	Formulary Restricted Medication
pentamidine	(IV) Formulary Restricted Medication
pertuzumab	Restricted Medication
pimavanserin	Formulary Restricted Medication
plerixafor	Restricted Medication
polidocanol	Asclera - Formulary Restricted to IR
posaconazole	Formulary Restricted Medication
praziquantel	Formulary Restricted Medication
primaquine	Formulary Restricted Medication
pyrazinamide	Formulary Restricted Medication
pyrimethamine	Formulary Restricted Medication
Ramucirumab	Restricted Medication
ranibizumab ophthalmic	Susvimo: Formulary Restricted Medication
rasburicase	Formulary Restricted Medication
ravulizumab	Restricted Medication
remdesivir	Formulary Restricted Medication
ribavirin	Non-Formulary Restricted Medication
rifabutin	Formulary Restricted Medication
rifampin	Formulary Restricted Medication
rifapentine	Formulary Restricted Medication
riociguat	Formulary Restricted Medication
risankizumab	Restricted Medication
romiDEPsin	Restricted Medication
romiPLOStim	Restricted Medication
RSV mRNA vaccine	Formulary Restricted Medication
RSV vaccine preF3, recombinant	Formulary Restricted Medication
RSV vaccine, preF A-preF B, recombinant	Formulary Restricted Medication
sacituzumab govitecan	Restricted Medication
SARS-CoV-2 (COVID-19) mRNA	Formulary Restricted
selexipag	Formulary Restricted Medication
sugammadex	Formulary Restricted Medication
teclistamab	Formulary Restricted Medication
temsirolimus	Restricted Medication
tenecteplase	Formulary Restricted Medication
teplizumab	Formulary Restricted Medication
teprotumumab	Restricted Medication
teriparatide	Restricted Medication
testosterone	Some Formulations are Formulary Restricted
tocilizumab	Formulary Restricted Medication
tolvaptan	Formulary Restricted Medication
trabectedin	Restricted Medication
trastuzumab	Restricted Medication
triamcinolone hexacetonide	Rheumatology
triamcinolone ophthalmic	Formulary Restricted Medication-Xipere
triptorelin	Restricted Medication
ublituximab	Restricted Medication
ustekinumab	Restricted Medication
Vedolizumab	Restricted Medication
voriconazole	Formulary Restricted Medication
vutrisiran	Formulary Restricted Medication
ziv-aflibercept	Restricted Medication
zoledronic acid	Formulary Restricted Medication

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While others may view accessible pages, Legacy Health makes no warranty, express or implied,
as to the use of this information outside of Legacy Health.