FormWeb • Restricted Drugs

CHI Memorial

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CHI Memorial

Approved Hospital Formulary

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Restricted Drugs

Please review each of these drugs carefully.

abatacept	See Therapeutic Restrictions to Outpatient Locations
adalimumab	See Therapeutic Restrictions to Outpatient Locations
ado-trastuzumab	See Therapeutic Restrictions to Outpatient Locations
albiglutide	Non-formulary - patient may use own med
alendronate	See bisphosphonate restrictions
alvimopan	See Restrictions
aminolevulinic acid	See restrictions
amphotericin B	See restrictions.
amphotericin B lipid complex	See restrictions.
atezolizumab	Restricted to oupatient use only
avelumab	See Therapeutic Restrictions to Outpatient Locations
belimumab	See Therapeutic Restrictions to Outpatient Locations
benralizumab	See Therapeutic Restrictions to Outpatient Locations
bevacizumab	See Therapeutic Restrictions to Outpatient Locations
bevacizumab-awwb	See Therapeutic Restrictions to Outpatient Locations
bevacizumab-bvzr	See Therapeutic Restrictions to Outpatient Locations
bezlotoxumab	See restrictions
blinatumomab	See Therapeutic Restrictions to Outpatient Locations
brentuximab vedotin	See Therapeutic Restrictions to Outpatient Locations
brivaracetam	New starts restricted to neurology
bupivacaine liposomal	Non-formulary per P&T April 2016
C1 Inhibitor, Human	For Cinryze, see Therapeutic Restrictions to Outpatient Locations
caplacizumab-yhdp	Restricted Use Guidelines
carfilzomib	See Therapeutic Restrictions to Outpatient Locations
ceftaroline	See restrictions
ceftazidime	May be ordered by ID or approved by Antimicrobial Stewardship Team.
ceftazidime-avibactam	See Restriction Criteria
ceftolozane-tazobactam	See restrictions
cemiplimab-rwlc	See Therapeutic Restrictions to Outpatient Locations
certolizumab	Designated Non-formulary by P&T
cetuximab	See Therapeutic Restrictions to Outpatient Locations
ciprofloxacin	May be ordered by ID or for documented Pseudomonas ONLY.
cisatracurium	See Miscellaneous Restrictions
cobicistat	Restricted
collagenase topical	See Restriction Criteria
dalfopristin-quinupristin	See restrictions
DAPTOmycin	See restrictions
daratumumab	See Therapeutic Restrictions to Outpatient Locations
darbepoetin alfa	See Therapeutic Restrictions to Outpatient Locations
denosumab	See Policy (Only for Outpatients with CrCl < 35 ml/min)
digoxin immune FAB	Restricted Use Guidelines
dronedarone	Restricted Use Guidelines
droperidol	See restrictions
durvalumab	See Therapeutic Restrictions to Outpatient Locations
eculizumab	See Therapeutic Restrictions to Outpatient Locations
empagliflozin	See restrictions
epoetin alfa	See Therapeutic Restrictions to Outpatient Locations
eptinezumab	Restricted to outpatient use only
eriBULin	See Therapeutic Restrictions to Outpatient Locations
ertapenem	Restricted Use Guidelines
ethacrynic acid	See Restrictions
etidronate	See bisphosphonate restrictions]
exenatide	Not on formulary - patient may use own med
ferumoxytol	Only approved for outpatient use.
fexofenadine	See Therapeutic Restrictions to Outpatient Locations
fidaxomicin	See restrictions
fulvestrant	See Therapeutic Restrictions to Outpatient Locations
gemtuzumab	See Therapeutic Restrictions to Outpatient Locations
golimumab	See Therapeutic Restrictions to Outpatient Locations
goserelin	See Therapeutic Restrictions to Outpatient Locations
granisetron	Restricted Use Guidelines
ibandronate	See bisphosphonate restrictions
ibuprofen IV	See Analgesic Restrictions
inFLIXimab	See Restrictions
ipilimumab	Approved on a case by case basis for outpatient use only.
isavuconazonium	Restricted to ID
ixabepilone	See Therapeutic Restrictions to Outpatient Locations
leuprolide	See Therapeutic Restrictions to Outpatient Locations
levalbuterol	On formulary with restrictions
levothyroxine	See restricted use criteria for IV levothyroxine
linaclotide	Restricted to continuation of home meds only
linezolid	See restrictions
liraglutide	Not on formulary - patient may use own med
lubiprostone	Restricted to continuation of home meds only
lurasidone	Use is restricted to continuation of home therapy
lurbinectedin	See restrictions
meperidine	See analgesic restrictions
meropenem	See restrictions
methylnaltrexone	See Restrictions
micafungin	May only be ordered by ID or Intensivists.
moxifloxacin	May be ordered by ID
naloxegol	See restrictions
natalizumab	See Therapeutic Restrictions to Outpatient Locations
necitumumab	See Therapeutic Restrictions to Outpatient Locations
nitazoxanide	See Restrictions
nitrofurantoin	Nitrofurantoin macrocrystals (Macrodantin) restricted to patients requiring medication administration via feeding tube.
nivolumab	See Therapeutic Restrictions to Outpatient Locations
obinutuzumab	See Therapeutic Restrictions to Outpatient Locations
ocrelizumab	See Therapeutic Restrictions to Outpatient Locations
octreotide	For Sandostatin LAR, see Therapeutic Restrictions to Outpatient Locations
ofatumumab	See Therapeutic Restrictions to Outpatient Locations
omalizumab	See Therapeutic Restrictions to Outpatient Locations
oritavancin	See anti-infective restrictions
PACLitaxel protein-bound	See Therapeutic Restrictions to Outpatient Locations
paliperidone XR	Not on formulary - patient may use own med. Call MD and recommend Risperidone for new starts.
palonosetron	See Restrictions
panitumumab	See Therapeutic Restrictions to Outpatient Locations
pegfilgrastim	Restricted to outpatient use
pembrolizumab	See Therapeutic Restrictions to Outpatient Locations
pentamidine	See restriction criteria for IV formulation
peramivir	See Anti-infective Restrictions
pertuzumab	See Therapeutic Restrictions to Outpatient Locations
pneumococcal 23-valent vaccine	See restrictions
polidocanol	See restriction criteria
posaconazole	See Restriction Criteria
pramlintide	Not on formulary. Patient may use home supply.
prasugrel	Restricted Use Guidelines
qual	Restricted Use
ramucirumab	See Therapeutic Restrictions to Outpatient Locations
remifentanil	See restrictions
risedronate	See bisphosphonate restrictions
riTUXimab	See Therapeutic Restrictions to Outpatient Locations
rituximab-abbs	See Therapeutic Restrictions to Outpatient Locations
rituximab-pvvr	See Therapeutic Restrictions to Outpatient Locations
roflumilast	See Restrictions
sacubitril-valsartan	See restrictions
selegiline	Restricted Use Guidelines
simvastatin	Use of 80-mg dose of simvastatin should be restricted to patients who have been taking that dose chronically (eg, for 12 months or more) without evidence of muscle toxicity.
sugammadex	See restrictions
temsirolimus	See Therapeutic Restrictions to Outpatient Locations
tigecycline	See restrictions
Tocilizumab	See Therapeutic Restrictions to Outpatient Locations
tolvaptan	Restricted Use Guidelines
trastuzumab	See Therapeutic Restrictions to Outpatient Locations
trastuzumab-anns	See Therapeutic Restrictions to Outpatient Locations
varicella-zoster vaccine live	Restricted to outpatient
vedolizumab	Outpatient use only
venetoclax	See restriction criteria
voriconazole	See restrictions
zaleplon	May use only for Neuro pts since shorter acting (MD must fill out Non-Formulary Request Form!)
zoledronic acid	See Therapeutic Restrictions to Outpatient Locations

Pharmacy Phone Numbers
Memorial Pharmacy (Glenwood) 423-495-8380
Memorial Hixson Pharmacy 423-495-7137
Stat 423-495-7470
Outpatient 423-495-8981
Chemo 423-495-7475
Surgery 423-495-8779

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as to the use of this information outside of Memorial Health Care System.