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IHS National Pharmacy & Therapeutics Committee National Core Formulary; Last Updated: 09/23/2021 **Note: in GREY indicate removed items.**

Generic Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Active? Name available) Medications Apixaban ; Direct Oral Anticoagulant (DOAC); Direct Oral Warfarin Yes Factor Xa Inhibitor (2017) Bupropion , Nicotine Varenicline; Yes Dopamine/Norepinephrine-; Dependence (2015) Venlafaxine Smoking Cessation Aid Levonorgestrel (Plan B Contraceptive, Progestin Contraception *Branded product* Ulipristal Yes One-Step®) (2016) Umeclidinium/vilanterol Long-Acting Muscarinic Antagonist (LAMA) / LAMAs (2019) Tiotropium (Spiriva®) Yes Long-Acting Beta2 Agonist (LABA) Serotonin 5-HT1 agonist Antimigraine Agent; Serotonin 5-HT 1B/1D Triptans (2016) Any two (2) triptan medications are required, one Sumatriptan Yes (Triptan) Agonist must be sumatriptan Fluoxetine Antidepressant, Selective Serotonin Reuptake Sertraline Yes Inhibitor Emtricitabine/tenofovir Antiretroviral, Reverse Transcriptase Inhibitor, HIV Pre-Exposure For (1) Pre-Exposure HIV Prophylaxis, (2) Raltegravir Yes disoproxil fumarate Nucleoside (Anti-HIV); Antiretroviral, Reverse Prophylaxis (PrEP) Post-Exposure HIV Prophylaxis (with raltegravir) or Transcriptase Inhibitor, Nucleotide (Anti-HIV) (2018) (3) HIV Treatment (with raltegravir) in patients with contraindications for 1st line anti-HIV agents Omeprazole (enteric ===REMOVED from NCF=== (see Proton Pump Long-Term Use of Removed Feb 2014 Proton Pump Inhibitor No coated) Inhibitor) PPIs (2014) Ranitidine* Histamine GERD & PUD *(April 1, 2020) The Food and Administration Proton Pump Inhibitor Yes (2018) has recommended that all formulations of ranitidine be taken off the market due to contaminates of N-Nitrosodimethylamine (NDMA), a carcinogen, in ranitidine products. Methimazole Antithyroid Agent; Yes (2021) Doxazosin Alpha1 Blocker; Antihypertensive Benign Prostatic Prazosin; Tamsulosin Yes Hypertrophy (2016) Atorvastatin Antilipemic Agent, HMG-CoA Reductase Inhibitor Dyslipidemia Pravastatin; Yes Guideline Review Rosuvastatin; (2014) Simvastatin Lactulose Ammonium Detoxicant; , Osmotic Cirrhosis & Polyethylene glycol Yes Complications (2015) Oxybutynin, Antispasmodic Agent, Urinary Antimuscarinics Oxybutynin, Yes Extended-release (2019) Immediate-release

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Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? (up-to-date) available) Trospium ===REMOVED from NCF=== Antimuscarinics (2019) Removed Feb 2019 Oxybutynin, Extended-release; No (see Oxybutynin ER, IR) Oxybutynin, Immediate-release Oxybutynin, Immediate-release Antispasmodic Agent, Urinary Antimuscarinics (2019) Oxybutynin, Extended-release Yes Etonogestrel, implant Contraceptive; Progestin Contraception (2016) For use by a skilled and Oral contraceptive pill, progestin only Yes privileged provider Amitriptyline Antidepressant, Tricyclic in Pain Nortriptyline Yes Mgmt (2014) Imipramine ===REMOVED from NCF=== Antidepressant Use in Removed May 2014 Nortriptyline No (see Nortriptyline) Chronic Pain (2014) Isosorbide mononitrate Agent; Vasodilator Nitroglycerin 0.4 Milligrams; Yes Sublingual; Nitroglycerin patch Buprenorphine-naloxone (**REMS , Opioid; Analgesic, Opioid Use Disorder (2018) **See REMS here** Naloxone Yes drug**) Opioid Partial Agonist Naltrexone, oral ; Opioid Antagonist Alcohol Use Disorders Naloxone Yes (2015) Oral contraceptive pill, triphasic Contraceptive *Any product* Monophasics ; Oral Contraceptive Pill Yes Oral contraceptive pill, monophasic: Contraceptive *Any product* Monophasic: 30-35mcg EE (medium); Yes 20mcg EE (low) Oral contraceptive pill Oral contraceptive pill, monophasic: Contraceptive *Any product* Monophasic: 20mcg EE (low) ; Oral Yes 30-35mcg EE (medium) contraceptive pill Fluticasone/salmeterol Beta2 Agonist, Long-Acting; LABAs (2019) Mometasone (Asmanex®) Yes , Inhalant Atenolol Antihypertensive; Beta-Blocker, Beta Blockers (2014) Metoprolol; Yes Beta1 Selective Methylphenidate (immediate release) Central Pediatric use only Methylphenidate (long-acting) Yes

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Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? (up-to-date) available) Methylphenidate Central Nervous System Pediatric use only Methylphenidate (immediate release) Yes (long-acting) Stimulant Propylthiouracil Antithyroid Agent; Thioamide Hyperthyroidism (2021) Methimazole Yes Medroxyprogesterone Contraceptive, Progestin Contraception (2016) Medroxyprogesterone, oral; Oral Yes acetate, injection (Injection/Depot) contraceptive pill, progestin only Medroxyprogesterone, oral Contraceptive; Progestin Polycystic Ovarian Medroxyprogesterone acetate, injection; Yes Syndrome (2017) Oral contraceptive pill, progestin only Angiotensin receptor blocker ===REMOVED from NCF=== Angiotensin II Receptor Removed April 2012 Losartan No (see Losartan) Antagonists (2014) Clonazepam Benzodiazepine Alcohol Withdrawal Lorazepam Yes Syndrome (2015) Dedicated emergency Contraception (2016) Removed Sept 2013 Levonorgestrel (Plan B One-Step®); No contraceptive Ulipristal Ulipristal Contraceptive; Progestin Contraception (2016) Levonorgestrel (Plan B One-Step®) Yes Hydroxychloroquine Antimalarial Non-biologic DMARDs Leflunomide; Methotrexate; Sulfasalazine Yes (2016) Glecaprevir/pibrentasvir Antihepaciviral HCV Treatment (2018) Ledipasvir/sofosbuvir (Harvoni®); Yes (Mavyret®) Sofosbuvir/velpatasvir (Epclusa®) Polyethylene glycol Laxative, Osmotic Irritable Bowel *Any product* Lactulose Yes Syndrome (2018) Rifaximin , Rifamycin Hepatic Encephalopathy After failure of, or intolerance to, lactulose Lactulose Yes (2020) monotherapy as indicated for hepatic encephalopathy Nitroglycerin 0.4 milligrams, Antianginal Agent; Antidote, Isosorbide mononitrate; Nitroglycerin Yes sublingual Extravasation; Vasodilator patch Nitroglycerin patch Antianginal Agent; Antidote, Isosorbide mononitrate; Nitroglycerin 0.4 Yes Extravasation; Vasodilator milligrams; Sublingual

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Generic Medication Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? Name available) Isosorbide dinitrate ===REMOVED from NCF=== (see Isosorbide Removed Aug 2013 Isosorbide mononitrate No mononitrate) Ethambutol Antitubercular Agent Isoniazid; Pyrazinamide; Yes Rifampin; Rifapentine Intrauterine device, Contraceptive Contraception (2016) *Any product*; For use by a skilled Intrauterine device, levonorgestrel Yes copper and privileged provider Intrauterine device, Contraceptive, Progestin Contraception (2016) *Any product*; For use by a skilled Intrauterine device, copper Yes levonorgestrel and privileged provider Insulin detemir Insulin, Long-Acting Insulins (2015) *Branded product*; Pen Device Insulin glargine (Lantus®) Yes (Levemir®) Insulin glargine ===REMOVED from NCF=== (see Insulin NPTC Meeting Update Removed May 2019 Insulin detemir (Levemir®) No (Lantus®) detemir) (May 2019) Diclofenac Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) *Any formulation* Ibuprofen; Indomethacin; Yes Meloxicam; Naproxen Leflunomide Antirheumatic, Disease Modifying Non-biologic DMARDs Hydroxychloroquine; Yes (2016) Methotrexate; Sulfasalazine Methotrexate Antineoplastic Agent; Antirheumatic; Disease Non-biologic DMARDs Hydroxychloroquine; Yes Modifying; Immunosuppresant Agent (2016) Leflunomide; Sulfasalazine Sulfasalazine 5-Aminosalicylic Acid Derivative Hydroxychloroquine; Yes Leflunomide; Methotrexate Chlorthalidone Antihypertensive; Thiazide-Related Diuretic Agents (2014) Hydrochlorothiazide Yes Aripiprazole lauroxil , Atypical (Second Generation) - Long-Acting Injectable Injectable Haloperidol decanoate Yes Injectable (2020) Glucose, Oral Antidote Glucagon Delivery Devices Any formulation Glucagon Yes (2021) Glyburide ===REMOVED from NCF=== (see Glipizide) Sulfonylureas (2015) Removed May 2015 Glipizide No

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Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? available) Ledipasvir/sofosbuvir (Harvoni®) Antihepaciviral HCV Treatment Glecaprevir/pibrentasvir (Mavyret®); Yes (2018) Sofosbuvir/velpatasvir (Epclusa®) Sofosbuvir/velpatasvir (Epclusa®) Antihepaciviral HCV Treatment Glecaprevir/pibrentasvir (Mavyret®); Yes (2018) Ledipasvir/sofosbuvir (Harvoni®) Fluticasone / Salmeterol (Advair®) Removed Oct 2012 Fluticasone/salmeterol No Mometasone / Formoterol ===REMOVED from NCF=== (see LABAs (2019) Removed June 2019 Fluticasone/salmeterol No (Dulera®) Fluticasone/salmeterol) Oral contraceptive pill, progestin Contraceptive *Any product* Etonogestrel; Implant; Intrauterine Yes only Device; Levonorgestrel Isoniazid Antitubercular Agent Ethambutol; Pyrazinamide; Rifampin; Yes Rifapentine Pyrazinamide Antitubercular Agent Ethambutol; Isoniazid; Rfapentine ; Yes Rifampin Rifampin Antitubercular Agent Ethambutol; Isoniazid; Pyrazinamide; Yes Rifapentine Rifapentine Antitubercular Agent Rifapentine (2013) Ethambutol; Isoniazid; Pyrazinamide; Yes Rifampin Adalimumab -OR- Etanercept (can Antirheumatic, Disease Modifying; Tumor TNF Inhibitors ONLY In consultation Etanercept -OR- Adalimumab (can Yes choose either product) Necrosis Factor (TNF) Blocking Agent (2016) with a rheumatologist choose either product) Conjugated estrogen vaginal ===REMOVED from NCF=== (see NPTC Meeting Removed May 2018 Estrogen vaginal cream No cream, (Premarin) Estrogen vaginal cream) Update (May 2018) Estrogen vaginal cream Estrogen Derivative NPTC Meeting *Any product* Estradiol tablets Yes Update (May 2018) Citalopram Antidepressant, Selective Serotonin SSRIs (2019) Escitalopram; Fluoxetine; Paroxetine; Yes Reuptake Inhibitor Sertraline Dolutegravir Antiretroviral, Integrase Inhibitor (Anti-HIV) HIV Updates (2020) For HIV treatment in Emtricitabine/tenofovir disoproxil Yes pregnant patients fumarate; Raltegravir

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Generic Medication Name Pharmacological Formulary Brief Notes / Miscellaneous Similar NCF Medications Active? Category (up-to-date) (if available) Raltegravir Antiretroviral, Integrase HIV Treatment For (1) HIV Post-Exposure Prophylaxis (with Emtricitabine/tenofovir disoproxil fumarate Yes Inhibitor (Anti-HIV) (2019) emtricitabine/ tenofovir DF) or (2) HIV Treatment (with emtricitabine/tenofovir DF) in patients with contraindications for 1st line anti-HIV agents Prazosin Alpha1 Blocker; PTSD Indication Doxazosin; Tamsulosin Yes Antihypertensive (2012) Terazosin Prazosin in Removed Jan 2012 Doxazosin; Prazosin; Tamsulosin No PTSD (2012) Tamsulosin Alpha1 Blocker Benign Prostatic Doxazosin; Prazosin Yes Hypertrophy (2016) Bictegravir/emtricitabine/tenofovir Antiretroviral, Integrase HIV Treatment Dolutegravir/abacavir/lamivudine; Yes alafenamide Inhibitor (Anti-HIV) (2019) Emtricitabine/tenofovir disoproxil fumarate; Raltegravir Carbamazepine , Antiepileptics Divalproex; Lamotrigine; Levetiracetam; Yes Miscellaneous (2014) Phenytoin; Topiramate Amlodipine Antihypertensive; Calcium Diltiazem Yes Calcium Channel Channel Blocker, Dihydropyridine Blockers (2014) Verapamil ===REMOVED from Calcium Removed August 2014 Diltiazem No NCF=== (see Diltiazem) Channel Blockers (2014) Ibuprofen Nonsteroidal NSAIDs (2014) Diclofenac; Indomethacin; Meloxicam; Yes Anti-Inflammatory Drug Naproxen Indomethacin Nonsteroidal NSAIDs (2014) Diclofenac; Ibuprofen; Meloxicam; Yes Anti-Inflammatory Drug Naproxen Meloxicam Nonsteroidal NSAIDs (2014) Diclofenac; Ibuprofen; Indomethacin; Yes Anti-Inflammatory Drug Naproxen Sulindac NSAIDs in Removed May 2014 Diclofenac; Ibuprofen; Indomethacin; No Chronic Pain Meloxicam; Naproxen (2014) Naproxen Nonsteroidal NSAIDs (2014) Diclofenac; Ibuprofen; Indomethacin Yes Anti-Inflammatory Drug Dextroamphetamine / Amphetamine Central Nervous Pediatric use only Dextroamphetamine and amphetamine Yes (immediate release) System Stimulant (long-acting)

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Pharmacological Category Formulary Generic Medication Name (up-to-date) Brief (if Notes / Miscellaneous Similar NCF Medications Active? available) Dextroamphetamine / Central Nervous System Pediatric use only Dextroamphetamine and amphetamine (immediate Yes Amphetamine (long-acting) Stimulant release) Atomoxetine Norepinephrine Reuptake ADHD (2020) Dextroamphetamine / Amphetamine (immediate Yes Inhibitor, Selective release); Dextroamphetamine / Amphetamine (long-acting); Methylphenidate (immediate release); Methylphenidate (long-acting) Corticosteriods (Topical) - Topical (2018) Corticosteroid (Topical) - Intermediate potency; Yes High potency (Class I and Corticosteroid (Topical) - Low potency II) Corticosteroid (Topical) - Topical Corticosteroids *Any product* Corticosteriods (Topical) - High potency (Class I and II); Yes Intermediate potency Corticosteroid (Topical) - Low potency Moisturizers (both cream- Skin and Mucous Membrane Atopic Corticosteriods (Topical) - High potency (Class I and II); Yes AND petroleum-based) Agent, Miscellaneous; Topical Dermatitis Corticosteroid (Topical) - Intermediate potency; Skin Product (2020) Corticosteroid (Topical) - Low potency; Tacrolimus Tacrolimus Calcineurin Inhibitor; Atopic Corticosteriods (Topical) - High potency (Class I and II); Yes Immunosuppressant Agent; Dermatitis Corticosteroid (Topical) - Intermediate potency; Topical Skin Product (2020) Corticosteroid (Topical) - Low potency; Moisturizers (both cream- AND petroleum-based) Corticosteroid (Topical) - Topical Corticosteroids *Any product* Corticosteriods (Topical) - High potency (Class I and II); Yes Low potency Corticosteroid (Topical) - Intermediate potency Lorazepam Benzodiazepine Alcohol Clonazepam Yes Withdrawal Syndrome (2015) Escitalopram Antidepressant, Selective SSRIs (2019) Citalopram; Fluoxetine; Paroxetine; Sertraline Yes Serotonin Reuptake Inhibitor Paroxetine Antidepressant, Selective SSRIs (2019) Citalopram; Escitalopram; Fluoxetine; Sertraline Yes Serotonin Reuptake Inhibitor Sertraline Antidepressant, Selective Citalopram; Escitalopram; Fluoxetine; Paroxetine Yes Serotonin Reuptake Inhibitor Hydrochlorothiazide Antihypertensive; Thiazide (2014) Chlorthalidone Yes Diuretic Cefixime Antibiotic, Cephalosporin STIs - PART 1 For outpatient treatment of Ceftriaxone Injection Yes (2021) gonorrhea for Expedited Partner Therapy or when injection therapy is not possible Ceftriaxone Injection Antibiotic, Cephalosporin STIs - PART 1 Cefixime Yes (2021)

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Generic Medication Pharmacological Category Formulary Brief Notes / Miscellaneous Similar NCF Medications Active? Name (up-to-date) (if available) Divalproex Anticonvulsant, Miscellaneous ER Lithium & Carbamazepine; Lamotrigine; Levetiracetam; Yes Divalproex (2012) Phenytoin; Topiramate Lamotrigine Anticonvulsant, Miscellaneous Antiepileptics Carbamazepine; Divalproex; Levetiracetam; Yes (2014) Phenytoin; Topiramate Levetiracetam Anticonvulsant, Miscellaneous Antiepileptics Carbamazepine; Divalproex; Lamotrigine; Yes (2014) Phenytoin; Topiramate Phenytoin Anticonvulsant, Hydantoin Antiepileptics Carbamazepine; Divalproex; Lamotrigine; Yes (2014) Levetiracetam; Topiramate Topiramate Anticonvulsant, Miscellaneous Antiepileptic Carbamazepine; Divalproex; Lamotrigine; Yes Medications Levetiracetam; Phenytoin (2014) Ethosuximide Anticonvulsant, Succinimide Anti-Seizure Carbamazepine; Clonazepam; Divalproex; Yes (2021) Gabapentin; Lamotrigine; Levetiracetam; Phenytoin; Topiramate Oxcarbazepine Anticonvulsant, Miscellaneous Anti-Seizure Carbamazepine; Clonazepam; Divalproex; Yes Drugs (2021) Gabapentin; Lamotrigine; Levetiracetam; Phenytoin; Topiramate Sevelamer carbonate Phosphate Binder Phosphate For patients on dialysis who cannot Calcium Yes Binders (2018) use calcium-based phosphate binders due to hypercalcemia Duloxetine Antidepressant, Diabetic Bupropion; Venlafaxine Yes Serotonin/Norepinephrine Reuptake Neuropathy Inhibitor/Antagonist (2018) Nicotine replacement Smoking Cessation Aid Nicotine Combination NRT (nicotine patches + Bupropion; Varenicline Yes therapy (NRT), Dependence any short-acting NRT product) combination (2015) Venlafaxine Antidepressant, SNRIs (2012) Bupropion; Duloxetine Yes Serotonin/Norepinephrine Reuptake Inhibitor/Antagonist Varenicline Partial Nicotine Agonist, Smoking Nicotine Bupropion Yes Cessation Aid Dependence (2015) Buprenorphine, Analgesic, Opioid; Analgesic, Opioid MAT for OUD Any formulation; Restricted to Buprenorphine, short-acting (**REMS drug**); Yes long-acting (**REMS Partial Agonist (2021) treatment of Opioid Use Disorder; Buprenorphine-naloxone (**REMS drug**) drug**) **See REMS here** Buprenorphine, Analgesic, Opioid; Analgesic, Opioid MAT for OUD Any formulation; Restricted to Buprenorphine, long-acting (**REMS drug**); Yes short-acting (**REMS Partial Agonist (2021) treatment of Opioid Use Disorder; Buprenorphine-naloxone (**REMS drug**) drug**) **See REMS here**

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Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? (up-to-date) available) Dolutegravir/abacavir/lamivudine Antiretroviral, Integrase HIV Treatment (2019) *Note: HLA B5701 testing Bictegravir/emtricitabine/tenofovir alafenamide; Yes Inhibitor (Anti-HIV) required prior to initiation Dolutegravir; Emtricitabine/tenofovir disoproxil fumarate; Raltegravir Benzoyl Peroxide Topical Skin Product, Acne Acne Treatment Benzoyl Peroxide AND Clindamycin, topical Yes (2020) combination Benzoyl Peroxide AND Clindamycin, Topical Skin Product, Acne; Acne Treatment Benzoyl Peroxide Yes topical combination Topical Skin Product, Acne (2020) (Lincosamide Antibiotic) Pravastatin Antilipemic Agent, HMG-CoA Hyperlipidemia Atorvastatin; Rosuvastatin; Simvastatin Yes Reductase Inhibitor (2017) Rosuvastatin Antilipemic Agent, HMG-CoA Hyperlipidemia Atorvastatin; Pravastatin; Simvastatin Yes Reductase Inhibitor (2017) Lovastatin Dyslipidemia Removed April 2012 Atorvastatin; Pravastatin; Rosuvastatin; Simvastatin No Guidelines Review (2014) Simvastatin Antilipemic Agent, HMG-CoA Dyslipidemia Atorvastatin; Pravastatin; Rosuvastatin Yes Reductase Inhibitor Guideline Review (2014) Metoprolol Antihypertensive; Beta-blockers in Atenolol; Propranolol Yes Beta-Blocker, Beta1 Selective Heart Failure (2017) Carvedilol Antihypertensive; Beta-Blocker Beta-blockers in *Immediate-release only Atenolol; Metoprolol; Propranolol Yes with Alpha-Blocking Activity Heart Failure (2017) Propranolol Antihypertensive; Beta Blockers (2014) Atenolol; Metoprolol Yes Beta-Blocker, Non-Selective Clopidogrel Antiplatelet Agent Antiplatelets (2015) Aspirin Yes Atypical antipsychotic Antipsychotic, Atypical Atypical *Any product* Aripiprazole lauroxil; Haloperidol decanoate Yes Antipsychotic Agents (2015) Haloperidol decanoate Antipsychotic, Typical (First Long-Acting Injectable Aripiprazole lauroxil Yes Generation) - Injectable Injectable Antipsychotics (2020) Warfarin Anticoagulant; K Direct Oral Apixaban; Low-molecular weight heparin Yes Antagonist Anticoagulants (2017)

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Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? available) Diltiazem Antihypertensive; , Calcium Channel Amlodipine Yes Nondihydropyridine Blockers (2014) Nifedipine (controlled or extended Calcium Channel Removed August 2014 Amlodipine No release) Blockers (2014) Nortriptyline Antidepressant, Tricyclic Antidepressants in Pain Amitriptyline Yes Mgmt (2014) Saxagliptin ===REMOVED from NCF=== (see Alogliptin) DPP-IV Inhibitors (2019) Removed Feb 2019 Alogliptin No Ipratropium, MDI ===REMOVED from NCF=== COPD Inhalers (2015) Removed Aug 2015 Albuterol, metered dose inhaler No (MDI); Tiotropium (Spiriva®) Etanercept -OR- Adalimumab Antirheumatic, Disease Modifying; Tumor TNF Inhibitors (2016) ONLY In consultation with Adalimumab -OR- Etanercept Yes (can choose either product) Necrosis Factor (TNF) Blocking Agent a rheumatologist (can choose either product) Acetaminophen Analgesic, Miscellaneous Yes Albuterol nebulized solution Beta2 Agonist Yes Albuterol, metered dose inhaler Beta2 Agonist NPTC Meeting Update *Any product* Yes (MDI) (Nov 2017) Alendronate Derivative Osteoporosis (2016) Yes Allopurinol Antigout Agent; Xanthine Oxidase Inhibitor Gout (2016) Yes Alogliptin Antidiabetic Agent, Dipeptidyl Peptidase 4 DPP-IV Inhibitors (2019) Yes (DPP-4) Inhibitor Anastrozole Antineoplastic Agent, Aromatase Inhibitor Yes Aspirin Antiplatelet Agent; Nonsteroidal Yes Anti-Inflammatory Drug; Salicylate

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Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Active? available) Medications Azithromycin Antibiotic, Macrolide STIs - PART 1 (2021) Yes Calcium Electrolyte supplement *Any formulation* Yes Carbidopa-Levodopa (immediate Anti-Parkinson Agent; Decarboxylase Parkinson's Disease Yes release) Inhibitor-Dopamine Precursor (2019) Clindamycin, topical ===REMOVED from NCF=== (See Benzoyl Peroxide Removed January 2020 No AND Clindamycin, topical combination) Corticosteroid, intranasal Intranasal Corticosteroid *Any product* Yes Cyanocobalamin (Vitamin B12), oral Vitamin, Water Soluble Hematologic Yes Supplements (2016) Dicyclomine Anticholinergic Agent Irritable Bowel Yes Syndrome (2018) Digoxin , Miscellaneous; Cardiac Digoxin Use (2016) Yes Donepezil Acetylcholinesterase Inhibitor (Central) 5mg and 10mg strengths Yes Doxycycline Antibiotic, Tetracycline STIs - PART 1 (2021) Yes Dulaglutide ===REMOVED from NCF=== NPTC Meeting Update Removed Nov 2020 No (2020) Empagliflozin Antidiabetic Agent, Sodium-Glucose Cotransporter 2 SGLT-2 Inhibitors (2019) Yes (SGLT2) Inhibitor Epinephrine Injection Devices (both Alpha-/Beta- Agonist Epinephrine Injection Any device, auto-injector or Yes 0.15mg and 0.3mg) Devices (2020 pre-filled syringe Estradiol tablets Estrogen Derivative Menopausal Hormone Yes Therapy (2016)

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Generic Medication Name Pharmacological Category Formulary Brief (if available) Notes / Miscellaneous Similar NCF Active? (up-to-date) Medications Ethinyl estradiol / Etonogestrel Contraceptive; Estrogen and Progestin Contraception (2016) Yes vaginal ring Combination Ethinyl estradiol / Norelgestromin, Contraceptive; Estrogen and Progestin Contraception (2016) Yes transdermal Combination Ezetimibe Antilipemic Agent, 2-Azetidinone 2018 ACC/AHA Cholesterol Yes Guidelines (2019) Fibric Acid Derivative ===REMOVED from NCF=== Hyperlipidemia (2017) Removed Feb 2017 No Finasteride 5 Alpha-Reductase Inhibitor Benign Prostatic Hypertrophy Yes (2016) Fluoride, oral Nutritional Supplement Supplements in Oral Health (2016) *Any oral formulation* Yes Folic Acid Vitamin, Water Soluble Supplements in Womens Health Any product containing >400 mcg / Yes (2016) daily dose Furosemide Antihypertensive; Loop Diuretic Heart Failure Overview (2017) Yes Gabapentin Anticonvulsant, Miscellaneous; GABA Gabapentin & Pregabalin in Pain Yes Analog (2014) Gemfibrozil ===REMOVED from NCF=== Dyslipidemia Guidelines Review Removed Feb 2014 No (2014) Glipizide Antidiabetic Agent; Sulfonylurea Sulfonylureas (2015) Yes Glucagon Antidote; Hypoglycemia For outpatient use Yes (2nd generation), Histamine H1 Antagonist, Second *Any product* Yes long-acting Generation Hydroxyzine Histamine H1 Antagonist, First Anxiety Disorders (2021) Yes Generation

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Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Active? available) Medications Insulin / Regular human (NovoLIN® Insulin, Short-Acting Insulins (2015) *Branded product* Yes R) Insulin aspart (NovoLog®) Insulin, Rapid-Acting Insulins (2015) *Branded product*; Pen Device Yes Insulin aspart / Insulin aspart Insulin, Combination (70/30 Mix) Insulins (2015) *Branded product*; Pen Device Yes protamine (NovoLog® Mix 70/30) Insulin NPH (NovoLIN® N) Insulin, Intermediate-Acting Insulins (2015) *Branded product* Yes Insulin NPH / Regular human insulin Insulin, Combination (70/30 Mix) Insulins (2015) *Branded product* Yes (NovoLIN® 70/30) Iron, oral Iron Salt Hematologic *Any oral formulation* Yes Supplements (2016) Laxative, bulk-forming Bulk-forming Laxative *Any product* Yes Laxative, stimulant Stimulant Laxative *Any product* Yes Letrozole Antineoplastic Agent, Aromatase Inhibitor Yes Agent Yes Liraglutide or semaglutide Antidiabetic Agent, Glucagon-Like Peptide-1 GLP-1 Receptor Select either of these subcutaneous Yes (GLP-1) Receptor Agonist Agonists (2019) agents, no preference given Lisinopril Antihypertensive, Angiotensin-Converting ACEIs & ARBs in Heart Yes Inhibitor Failure (2017) Lithium Antimanic Agent ER Lithium & Divalproex Yes (2012) Loperamide Antidiarrheal Irritable Bowel Yes Syndrome (2018)

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Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if available) Notes / Similar NCF Active? Miscellaneous Medications Lopinavir / Ritonavir (Kaletra®) ===REMOVED from NCF=== (see HIV PrEP (2018) Removed August No Emtricitabine/tenofovir) 2013 Losartan Antihypertensive, Angiotensin II Receptor ACEIs & ARBs in Heart Yes Blocker Failure (2017) Low-molecular weight heparin Low-molecular Weight Heparin VTE Prophylaxis (2011) *Any product* Yes Memantine N-Methyl-D-Aspartate (NMDA) Receptor Yes Antagonist Metformin Antidiabetic Agent; Biguanide Yes Mometasone (Asmanex®) Corticosteroid, Inhalant *Branded product* Yes Montelukast Leukotriene Receptor Antagonist Yes Naloxone Antidote; Opioid Antagonist Treatment of Opioid Overdose Yes (2014) Naltrexone, extended-release for injection Antidote; Opioid Antagonist Opioid Use Disorder (2018) **See REMS here** Yes (**REMS drug**) Niacin extended release (Niaspan®) ===REMOVED from NCF=== Hyperlipidemia (2017) Removed Feb 2017 No Ondansetron ; Selective 5-HT3 Receptor Antiemetic Agents (2021) Yes Antagonist Ophthalmic Prostaglandin Analog Ophthalmic Prostaglandin Analog Ophth Prostaglandin Analogs *Any product* Yes (2018) Oral contraceptive pill, extended cycle Contraceptive Contraception (2016) *Any product* Yes Oseltamivir Antiviral Agent; Neuraminidase Inhibitor Treatment of Influenza (2019) Yes

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Generic Medication Pharmacological Category (up-to-date) Formulary Brief (if available) Notes / Miscellaneous Similar NCF Active? Name Medications Penicillin G benzathine Antibiotic, Penicillin STIs - PART 1 (2021) Yes Phentermine Central Nervous System Stimulant Obesity Treatment (2018) Yes Phosphodiesterase 5 Phosphodiesterase-5 Phosphodiesterase 5 Inhibitors *Any product* Yes (PDE5) Inhibitor (2018) Pioglitazone Antidiabetic Agent, Thiazolidinedione Thiazolidinediones (2017) Yes Pramipexole Anti-Parkinson Agent, Dopamine Agonist Insomnia/Sleep Medications Yes (2021) Prednisone Corticosteroid, Systemic Yes Prenatal Multivitamin Vitamin Pregnancy & Prenatal Care Must contain >400 mcg of folic acid/dose Yes (2021) Proton Pump Inhibitor Proton Pump Inhibitor GERD & PUD (2018) *Any product* Yes Pyridoxine (Vitamin B6) Vitamin, Water Soluble Supplements in Obstetrics Yes (2016) Salmeterol (Serevent®) ===REMOVED from NCF=== Inhaled Anticholinergics (2011) Removed Sept 2011 No Salsalate Salicylate Yes Semaglutide or liraglutide Antidiabetic Agent, Glucagon-Like Peptide-1 GLP-1 Receptor Agonists (2019) Select either of these subcutaneous Yes (GLP-1) Receptor Agonist agents, no preference given Semaglutide, dulaglutide ===REMOVED from NCF=== Dulaglutide removed from NCF; No or liraglutide liraglutide and semaglutide remain on NCF Spironolactone Antihypertensive; Receptor Mineralocorticoid Receptor Yes Antagonists; Potassium Sparing Diuretic Antagonist in HF (2017)

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Generic Medication Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Active? Name available) Medications Sumatriptan Antimigraine Agent; Serotonin 5-HT 1B/1D Receptor Triptans (2016) Any two (2) triptan medications are required, Yes Agonist one must be sumatriptan Tamoxifen Antineoplastic Agent, Estrogen Receptor Antagonist; Yes Selective Estrogen Receptor Modulator Tiotropium (Spiriva®) Long-Acting Anticholinergic Agent Inhaled *Branded product* Yes Anticholinergics (2011) Trazodone ===REMOVED from NCF=== Insomnia (2015) Removed Oct 2015 No Tretinoin, topical Topical Skin Product, Acne Acne (2013) *Any product* Yes , All Vaccines (2011) All ACIP recommended vaccines for routine Yes ACIP-recommended use in accordance with ACIP guidelines Vitamin D Vitamin D Analog Vitamin D (2010) *Any product* Yes Vitamin D Analog Vitamin D Analog Psoriasis (2018) *Any product* Yes (Topical)

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