|
abatacept
|
- abatacept (Orencia) is restricted to use in the Outpatient setting by Rheumatology only
|
|
acetaminophen
|
- Acetaminophen IV (Ofirmev) - See comments for restrictions
|
|
acetylcysteine
|
- acetylcysteine (Acetadote/Mucomyst) nebulization - use by intensivists (Trauma, CCMS, LSU ICU) in patients who failed nebulized 3% NaCl
- acetylcysteine (Acetadote/Mucomyst) oral and IV - is restricted to treatment of APAP toxicity and non-acetaminophen induced acute liver injury. All other indications must be approved.
|
|
acyclovir topical
|
- Acyclovir ointment is restricted to large surface areas
|
|
adalimumab
|
- Restricted to outpatient use only
|
|
ado-trastuzumab emtansine
|
- ado-trastuzumab emtansine (Kadcyla) is restricted to use in the Outpatient setting
|
|
alemtuzumab
|
- alemtuzumab (Lemtrada) is restricted to use in the Outpatient setting and is a REMS medication
|
|
alglucosidase alfa
|
- Restricted to outpatient setting only
|
|
aminolevulinic acid
|
|
|
amivantamab
|
- Restricted to outpatient use only
|
|
aprepitant
|
- aprepitant (Emend) oral - is restricted to use by medical oncologists for the prevention of acute and delayed emesis for moderately or highly emetogenic chemotherapy
- aprepitant (Cinvanti) is restricted to use in the Outpatient setting by Hem/Onc only
|
|
ARIPiprazole
|
- ARIPiprazole (Abilify) is restricted to psychiatry or continuation of home meds
|
|
asenapine
|
- asenapine (Saphris) is restricted to psychiatry or continuation of home meds
|
|
asparaginase Erwinia chrysanthemi
|
- Restricted to outpatient setting only
|
|
atezolizumab
|
- atezolizumab (Tecentriq) is restricted to use in the Outpatient setting
|
|
avibactam-ceftazidime
|
- avibactam-ceftazidime (Avycaz) is restricted to Infections Disease physicians for the treatment of carbapenemase-resistant Enterobacteriaceae and the treatment of multi-drug resistant Pseudomonas resistant to ceftolozane/tazobactam
|
|
belimumab
|
- belimumab (Benlysta) is restricted to use in the Outpatient setting by Rheumatology only
|
|
benralizumab
|
- Restricted to outpatient setting only.
|
|
blinatumomab
|
- Acute Lymphoblastic Leukemia (B-cell precursor)
|
|
bosentan
|
- restricted to pediatric patients as continuation of home medications
|
|
brentuximab vedotin
|
- brentuximab vedotin (Adcetris) to restricted to use in the Outpatient setting by Hemo/Onc only
|
|
brivaracetam
|
|
|
bupivacaine liposome
|
- bupivaciane liposomal (Exparel) is restricted to adults undergoing anorectal surgeries, colectomies, knee/hip replacement, fractures, head and neck surgeries, and TAVR
|
|
C1 esterase inhibitor, human
|
- C1 esterase inhibitor, human (Berinert) is restricted to use in patients with confirmed or suspected hereditary angioedema only
|
|
calcitonin
|
- calcitonin IM (Miacalcin) is restricted to 2 doses in patients with symptomatic hypercalcemia and uncorrected calcium level of at least 13
|
|
cangrelor
|
|
|
cannabidiol
|
- continuation of home medication at Children's Hospital ONLY
|
|
caplacizumab
|
- Restricted to hematology/oncology and nephrology providers only
|
|
carfilzomib
|
- carfilzomib (Kyprolis) is restricted to use in the Outpatient setting by Hem/Onc only
|
|
cefiderocol
|
- ID providers (or Critical Care providers if a facility does not have an ID provider)
|
|
cefotaxime (non-formulary)
|
- cefotaxime (Claforan) is restricted to pediatric patients; convert cefotaxime to ceftriaxone (Rocephin) in Adults
|
|
ceftaroline
|
- ceftaroline (Teflaro) is restricted to use by Infectious Diseases Physicians and Critical Care Specialties only
|
|
cefTAZidime
|
- ceftazidime is restricted to use by Infectious Diseases and Nephrology Physicians only
|
|
ceftolozane-tazobactam
|
- ceftolozane/tazobactam (Zerbaxa) is restricted to Infectious Disease physicians for treatment of multi-drug resistant Pseudomonas aeruginosa infections
|
|
certolizumab
|
- certolizumab (Cimzia) is restricted to use in the Outpatient setting
|
|
cetrorelix
|
|
|
cetuximab
|
- cetuximab (Erbitux) is restricted to use in the Outpatient setting
|
|
cloBAZam
|
- cloBAZam (Onfi) is restricted to adjunctive treatment of seizures associated with Lennox-Gastaut syndrome (LGS) in patients 2 years of age and older or continuation of home medication
|
|
clonazePAM
|
- *0.125 mg disintegrating tablet restricted to pediatrics only
|
|
clotrimazole topical
|
|
|
cloZAPine
|
|
|
dantrolene
|
- dantrolene (Ryanodex) 250 mg IV is restricted to malignant hyperthermia carts and for first dose treatment for malignant hyperthermia; subsequent doses should be administered using IV Dantrium
|
|
dapagliflozin
|
- Restricted to HF and CKD indication ONLY
|
|
daratumumab
|
- daratumumab (Darzalex) is restricted to use in the Outpatient setting
|
|
darbepoetin alfa
|
- Restricted to outpatient setting ONLY
|
|
degarelix
|
|
|
denosumab
|
- denosumab (Prolia) is restricted to use in the Outpatient setting
- denosumab (Xgeva) is restricted to use in the Outpatient setting for prevention of skeletal-related events in oncology patients with bone metastasis from solid tumors who are unable to take bisphosphonates due to renal insufficiency (CrCl <30ml/min)
|
|
diazePAM
|
- Rectal gel (Diastat) restricted to pediatrics
|
|
dostarlimab
|
- Restricted to outpatient use only
|
|
dronedarone
|
- dronedarone (Multaq) is restricted to continuation of home medication
|
|
dupilumab
|
- Restricted to outpatient setting only.
|
|
durvalumab
|
- durvalumab (Imfinzi) is restricted to use in the Outpatient setting
|
|
eculizumab
|
- Soliris is restricted to inpatient use for atypical hemolytic uremic syndrome.
|
|
elagolix
|
|
|
elotuzumab
|
- elotuzumab (Empliciti) is restricted to use in the Outpatient setting
|
|
empagliflozin
|
- Restricted to HF and CKD indication ONLY
|
|
enfortumab vedotin
|
- Enfortumab Vedotin (Padcev) is restricted to use in the Outpatient setting
|
|
epoetin alfa
|
- Procrit is restricted to outpatient only.
|
|
eptinezumab
|
- Restricted to outpatient use with prior authorization
|
|
eriBULin
|
- eriBULin (Halaven) is restricted to use in the Outpatient setting
|
|
esomeprazole
|
- esomeprazole (NexIUM) is restricted to pediatric patients
|
|
etanercept
|
- Restricted to outpatient use only
|
|
ethacrynic acid
|
- ethacrynic acid (Edecrin) is restricted to use in patients with heart failure who have hypersensitivity to sulfa-containing drugs
|
|
ferric carboxymaltose
|
- ferric carboxymaltose (Injectafer) is restricted to use in the Outpatient setting
|
|
ferric derisomaltose
|
- Restricted to outpatient use only
|
|
ferumoxytol
|
- Restricted to outpatient setting only
|
|
fidaxomicin
|
- fidaxomicin (Dificid) is restricted to use of recurrent CDI or vancomycin allergy. Restricted to ordering by ID or GI providers only.
|
|
filgrastim
|
- filgrastim (Neupogen) is restricted to pediatric patients requiring doses less than 180mcg
|
|
flurbiprofen ophthalmic
|
- Restricted to ocular surgeries
|
|
fluticasone
|
- fluticasone (Flovent) inhalation is restricted to pediatric patients
|
|
fluticasone-salmeterol (non-formulary)
|
- fluticasone-salmeterol (Advair) HFA is restricted to kids <12 yrs and unable to use Breo (call MD for conversion)
|
|
fosaprepitant
|
- Emend IV restricted to use by medical oncologists for the prevention of acute and delayed emesis for moderately or highly emetogenic chemotherapy
|
|
fosfomycin
|
- fosfomycin (Monurol) is restricted to use in treating UTI's with VRE or ESBL-producing organisms
|
|
fulvestrant
|
|
|
ganirelix
|
|
|
gemtuzumab ozogamicin
|
- Restricted to outpatient use only
|
|
golimumab
|
- Restricted to outpatient setting only
|
|
goserelin
|
- Restricted to outpatient use only
|
|
guaifenesin-pseudoephedrine
|
- Restricted to outpatient setting only
|
|
guselkumab
|
- Restricted to outpatient use only
|
|
histrelin
|
- Restricted to outpatient use only
|
|
hyaluronidase-rituximab
|
- hyaluronidase-rituximab (Rituxan Hycela) is restricted to use in the Outpatient setting
|
|
hyaluronidase-trastuzumab
|
- Restricted to outpatient use only
|
|
hyaluronidase/pertuzumab/trastuzumab
|
- Restricted to outpatient setting ONLY
|
|
ibandronate
|
- ibandronate (Boniva) is restricted to use in the Outpatient setting
|
|
inFLIXimab
|
- inFLIXimab is restricted to the Outpatient setting except for Inpatient use by gastroenterologists in patients with Crohn's disease or ulcerative colitis who are nearing obstruction
|
|
ipilimumab
|
- ipilimumab (Yervoy) is restricted to use in the Outpatient setting
|
|
irinotecan liposomal
|
- irinotecan liposomal (Onivyde) is restricted to use in the Outpatient setting
|
|
iron dextran
|
- Restricted to outpatient use only.
|
|
isatuximab
|
- Restricted to outpatient setting only
|
|
ketamine
|
- ketamine oral - must be prescribed by a palliative care physician and patient must be DNR
- ketamine oral - is restricted to patient on 5W, RCU, SPCU and at least 18 years old
|
|
ketorolac-phenylephrine ophthalmic
|
- Restricted to ocular surgeries
|
|
leuprolide
|
- Restricted to outpatient use only
- EXCEPTION: Lupron Depot restricted and available through non-formulary process for patient's with prostate cancer with spinal metastasis that requires urgent treatment
|
|
levothyroxine
|
- levothyroxine IV (Synthroid) is restricted to patients with myxedema coma, LOPA patients, pediatrics, or if a patient is NPO for a prolonged period
|
|
liraglutide
|
- restricted to pediatric patients as continuation of home medications
|
|
loncastuximab tesirine
|
- Restricted to outpatient use only
|
|
lurasidone
|
- lurasidone (Latuda) is restricted to psychiatry or continuation of home meds
|
|
lurbinectedin
|
- Restricted to outpatient setting only
|
|
lutetium Lu 177 dotatate
|
- Ordering by hematology/oncology providers only
|
|
lutetium Lu 177 vipivotide tetraxetan
|
- Ordering by hematology/oncology providers only
|
|
margetuximab
|
- Restricted to outpatient use only
|
|
meningococcal group B vaccine
|
- meningococcal group B vaccine (Bexsero) is restricted for patients at least 10 years old with either of the following: initiation of eculizumab therapy or anatomical or functional asplenia
|
|
meperidine
|
- meperidine (Demerol) is restricted to the prevention and treatment of drug-induced or blood product-induced rigors (e.g., amphotericin B, platelets) and treatment of postoperative shivering
|
|
mepolizumab
|
- Restricted to outpatient setting only.
|
|
methylnaltrexone
|
- methylnaltrexone ( Relistor) is restricted to use in palliative care and oncology patients that are NPO
|
|
micafungin
|
|
|
mirvetuximab soravtansine
|
- Restricted to outpatient use only
|
|
mogamulizumab
|
- Restricted to outpatient setting only
|
|
nafarelin
|
- Restricted to outpatient use only
|
|
naloxegol
|
- naloxegol (Movantik) is restricted to use in patients with opioid induced constipation that have failed 2 or more laxatives
|
|
nivolumab
|
- nivolumab (Opdivo) is restricted to use in the Outpatient setting
|
|
nivolumab-relatlimab
|
- Restricted to outpatient use only
|
|
obinutuzumab
|
- obinutuzumab (Gazyva) is restricted to use in the Outpatient setting
|
|
octreotide
|
- octreotide (SandoSTATIN LAR Depot) is restricted to use in the Outpatient setting and for use with Lutathera in same day admissions ONLY
|
|
omalizumab
|
- Restricted to outpatient setting only.
|
|
omeprazole
|
- omeprazole (PriLOSEC) is restricted to Pediatric patients
|
|
paliperidone
|
- paliperidone (Invega) is restricted to psychiatry or continuation of home meds
|
|
palonosetron
|
- Restricted to use in outpatient oncology setting and inpatients on cisplatin therapy
|
|
panitumumab
|
- panitumumab (Vectibix) is restricted to use in the Outpatient setting
|
|
pegfilgrastim
|
- pegfilgrastim (Neulasta & Neulasta On-Body Injector) is restricted to use in the Outpatient setting
|
|
pegloticase
|
- pegloticase (Krystexxa) is restricted to use in the Outpatient setting
|
|
pembrolizumab
|
- pembrolizumab (Keytruda) is restricted to use in the Outpatient setting
|
|
pertuzumab
|
- pertuzumab (Perjeta) is restricted to use in the Outpatient setting
|
|
poractant alfa
|
|
|
posaconazole
|
- posaconazole (Noxafil) is restricted to adult patients and must be ordered by ID or oncology physicians
|
|
prasugrel
|
|
|
prothrombin complex
|
|
|
QUEtiapine
|
- QUEtiapine ER (Seroquel XR) is formulary, but is restricted to continuation of home medications
|
|
ramucirumab
|
- ramucirumab (Cyramza) is restricted to use in the Outpatient setting by Hem/Onc only
|
|
raNITIdine (non-formulary)
|
- raNITIdine (Zantac) is restricted to pediatric patients
|
|
Ravulizumab
|
- Restricted to outpatient use only
|
|
relugolix
|
|
|
reslizumab
|
- Restricted to outpatient setting only
|
|
rimegepant
|
|
|
risankizumab
|
- Restricted to use in the Outpatient setting
|
|
rizatriptan
|
- rizatroptan (Maxalt) is restricted to patients intolerant to sumatriptan
|
|
romiPLOStim
|
- romiPLOStim (Nplate) is restricted to use in the Outpatient setting by Hem/Onc only
|
|
romosozumab
|
- Restricted to outpatient setting only
|
|
sevelamer
|
- Renvela is restricted to adult patients unable to tolerate Velphoro and pediatric patients
- The Renvela brand of sevelamer is non-formulary and not stocked
|
|
sodium tetradecyl sulfate
|
- sodium tetradecyl sulfate (Sotradecol) is restricted to treatment of severe bleeding secondary to esophageal varices that has failed other treatment modalities. Reserved mainly for pediatric patients at OLOL but can also be used for adult patients
|
|
sugammadex
|
- sugammadex (Bridion) is restricted to use in the main operating room and main PACU
|
|
tafasitamab
|
|
|
tagraxofusp
|
- Restricted to outpatient use only
|
|
tezepelumab
|
- Restricted to outpatient setting only.
|
|
thyrotropin alfa
|
- Non-formulary for outpatient infusion
|
|
tigecycline
|
- tigecycline (Tygacil) is restricted for use in patients with anaphylactic allergy or resistance to all other appropriate available antibiotic options
|
|
tildrakizumab
|
- Restricted to outpatient use only
|
|
tisotumab vedotin
|
- Restricted to outpatient use only
|
|
tocilizumab
|
- tocilizumab (Actemra) is restricted to use in the Outpatient setting
|
|
tolvaptan
|
- tolvaptan (Samsca) is restricted to treatment of euvolemic and hypervolemic hyponatremia
|
|
trabectedin
|
- Trabectedin (Yondelis) is restricted to use in the Outpatient setting
|
|
tremelimumab
|
- Restricted to outpatient use only
|
|
trilaciclib
|
- Restricted to outpatient setting only
|
|
triptorelin
|
- Restricted to outpatient use only
|
|
ustekinumab
|
- Restricted to outpatient use only
|
|
valrubicin
|
- valrubicin (Valstar) is restricted to use in the Outpatient setting
|
|
vedolizumab
|
- vedolizumab (Entyvio) is restricted to use in the Outpatient setting to patients with Ulcerative colitis & Crohn's Disease
|
|
zoledronic acid
|
- Reclast is restricted to use in the Outpatient setting
|
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