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

Generic Name Pharmacological Category (up-to-date) Formulary Brief Notes / Similar NCF Medications Active? (if available) Miscellaneous Acetaminophen , Miscellaneous Yes Albuterol nebulized solution Beta2 Agonist Yes Anastrozole Antineoplastic Agent, Aromatase Inhibitor Yes Aspirin Antiplatelet Agent; Nonsteroidal Yes Anti-Inflammatory ; Salicylate Calcium supplement *Any formulation* Yes Clindamycin, topical ===REMOVED from NCF=== (See Benzoyl Removed January No Peroxide AND Clindamycin, topical combination) 2020 (Topical) - Topical *Any product* Corticosteriods (Topical) - High potency (Class I Yes Intermediate potency and II); Corticosteroid (Topical) - Low potency Corticosteroid (Topical) - Low Topical Corticosteroids *Any product* Corticosteriods (Topical) - High potency (Class I Yes potency and II); Corticosteroid (Topical) - Intermediate potency Corticosteroid, intranasal Intranasal Corticosteroid *Any product* Yes Dextroamphetamine / Central Pediatric use only Dextroamphetamine and amphetamine (long-acting) Yes Amphetamine (immediate release) Dextroamphetamine / Central Nervous System Stimulant Pediatric use only Dextroamphetamine and amphetamine (immediate Yes Amphetamine (long-acting) release) Donepezil Acetylcholinesterase Inhibitor (Central) 5mg and 10mg Yes strengths Ethambutol Antitubercular Agent Isoniazid; Pyrazinamide; Rifampin; Rifapentine Yes Fluoxetine , Selective Serotonin Reuptake Sertraline Yes Inhibitor

Printed on 09/29/2021 Page 1 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Similar NCF Medications Active? available) Miscellaneous Fluticasone / Salmeterol Removed Oct 2012 Fluticasone/salmeterol No (Advair®) Glucagon ; Hypoglycemia For outpatient use Yes (2nd generation), Histamine H1 Antagonist, Second Generation *Any product* Yes long-acting Isosorbide dinitrate ===REMOVED from NCF=== (see Removed Aug 2013 Isosorbide mononitrate No Isosorbide mononitrate) Isosorbide mononitrate Agent; Vasodilator Nitroglycerin 0.4 Milligrams; Sublingual; Yes Nitroglycerin patch , bulk-forming Bulk-forming Laxative *Any product* Yes Laxative, stimulant Stimulant Laxative *Any product* Yes Letrozole Antineoplastic Agent, Aromatase Inhibitor Yes Levothyroxine Thyroid Agent Yes Memantine N-Methyl-D-Aspartate (NMDA) Receptor Yes Antagonist Metformin Antidiabetic Agent; Biguanide Yes Methylphenidate (immediate Central Nervous System Stimulant Pediatric use only Methylphenidate (long-acting) Yes release) Methylphenidate (long-acting) Central Nervous System Stimulant Pediatric use only Methylphenidate (immediate release) Yes Mometasone (Asmanex®) Corticosteroid, Inhalant *Branded product* Yes

Printed on 09/29/2021 Page 2 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief Notes / Miscellaneous Similar NCF Medications Active? (up-to-date) (if available) Montelukast Leukotriene Receptor Antagonist Yes Nitroglycerin 0.4 milligrams, Antianginal Agent; Antidote, Isosorbide mononitrate; Nitroglycerin Yes sublingual Extravasation; Vasodilator patch Nitroglycerin patch Antianginal Agent; Antidote, Isosorbide mononitrate; Nitroglycerin Yes Extravasation; Vasodilator 0.4 milligrams; Sublingual Oral contraceptive pill, Contraceptive *Any product* Monophasic: 30-35mcg EE (medium); Yes monophasic: 20mcg EE (low) Oral contraceptive pill Oral contraceptive pill, Contraceptive *Any product* Monophasic: 20mcg EE (low) ; Oral Yes monophasic: 30-35mcg EE contraceptive pill (medium) Oral contraceptive pill, progestin Contraceptive *Any product* Etonogestrel; Implant; Intrauterine Yes only Device; Levonorgestrel Oral contraceptive pill, triphasic Contraceptive *Any product* Monophasics ; Oral Contraceptive Pill Yes Prednisone Corticosteroid, Systemic Yes Pyrazinamide Antitubercular Agent Ethambutol; Isoniazid; Rfapentine ; Yes Rifampin Rifampin Antitubercular Agent Ethambutol; Isoniazid; Pyrazinamide; Yes Rifapentine Salsalate Salicylate Yes Semaglutide, dulaglutide or ===REMOVED from NCF=== Dulaglutide removed from NCF; No liraglutide liraglutide and semaglutide remain on NCF Sertraline Antidepressant, Selective Citalopram; Escitalopram; Fluoxetine; Yes Serotonin Reuptake Inhibitor Paroxetine Sulfasalazine 5-Aminosalicylic Acid Derivative Hydroxychloroquine; Leflunomide; Yes Methotrexate

Printed on 09/29/2021 Page 3 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category (up-to-date) Formulary Brief (if Notes / Similar NCF Medications Active? Name available) Miscellaneous Tamoxifen Antineoplastic Agent, Estrogen Receptor Yes Antagonist; Selective Estrogen Receptor Modulator Digoxin , Miscellaneous; Digoxin Use (2016) Yes Cardiac Ondansetron ; Selective 5-HT3 Receptor Antiemetic Agents Yes Antagonist (2021) Ezetimibe Antilipemic Agent, 2-Azetidinone 2018 ACC/AHA Yes Cholesterol Guidelines (2019) Lisinopril Antihypertensive, ACEIs & ARBs in Yes Angiotensin-Converting Enzyme Inhibitor Heart Failure (2017) Losartan Antihypertensive, Angiotensin II ACEIs & ARBs in Yes Receptor Blocker Heart Failure (2017) Tretinoin, topical Topical Skin Product, Acne Acne (2013) *Any product* Yes Benzoyl Peroxide Topical Skin Product, Acne Acne Treatment (2020) Benzoyl Peroxide AND Clindamycin, topical combination Yes Benzoyl Peroxide AND Topical Skin Product, Acne; Topical Skin Acne Treatment (2020) Benzoyl Peroxide Yes Clindamycin, topical Product, Acne (Lincosamide ) combination Atomoxetine Norepinephrine Reuptake Inhibitor, ADHD (2020) Dextroamphetamine / Amphetamine (immediate release); Yes Selective Dextroamphetamine / Amphetamine (long-acting); Methylphenidate (immediate release); Methylphenidate (long-acting) Naltrexone, oral Antidote; Antagonist Alcohol Use Disorders Yes (2015) Clonazepam Benzodiazepine Alcohol Withdrawal Lorazepam Yes Syndrome (2015) Lorazepam Benzodiazepine Alcohol Withdrawal Clonazepam Yes Syndrome (2015) Imipramine ===REMOVED from NCF=== (see Antidepressant Use in Removed May Nortriptyline No Nortriptyline) Chronic Pain (2014) 2014

Printed on 09/29/2021 Page 4 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category Formulary Brief (if Notes / Similar NCF Medications Active? Name (up-to-date) available) Miscellaneous Amitriptyline Antidepressant, Tricyclic in Pain Nortriptyline Yes Mgmt (2014) Nortriptyline Antidepressant, Tricyclic Antidepressants in Pain Amitriptyline Yes Mgmt (2014) Topiramate , Miscellaneous Antiepileptic Medications Carbamazepine; Divalproex; Lamotrigine; Levetiracetam; Yes (2014) Phenytoin Carbamazepine Anticonvulsant, Miscellaneous Antiepileptics (2014) Divalproex; Lamotrigine; Levetiracetam; Phenytoin; Topiramate Yes Lamotrigine Anticonvulsant, Miscellaneous Antiepileptics (2014) Carbamazepine; Divalproex; Levetiracetam; Phenytoin; Yes Topiramate Levetiracetam Anticonvulsant, Miscellaneous Antiepileptics (2014) Carbamazepine; Divalproex; Lamotrigine; Phenytoin; Yes Topiramate Phenytoin Anticonvulsant, Hydantoin Antiepileptics (2014) Carbamazepine; Divalproex; Lamotrigine; Levetiracetam; Yes Topiramate Oxybutynin, Agent, Urinary Antimuscarinics (2019) Oxybutynin, Immediate-release Yes Extended-release Oxybutynin, Antispasmodic Agent, Urinary Antimuscarinics (2019) Oxybutynin, Extended-release Yes Immediate-release Clopidogrel Antiplatelet Agent Antiplatelets (2015) Aspirin Yes Ethosuximide Anticonvulsant, Succinimide Anti-Seizure (2021) Carbamazepine; Clonazepam; Divalproex; Gabapentin; Yes Lamotrigine; Levetiracetam; Phenytoin; Topiramate Oxcarbazepine Anticonvulsant, Miscellaneous Anti-Seizure Drugs (2021) Carbamazepine; Clonazepam; Divalproex; Gabapentin; Yes Lamotrigine; Levetiracetam; Phenytoin; Topiramate Hydroxyzine Histamine H1 Antagonist, First Anxiety Disorders (2021) Yes Generation Angiotensin receptor ===REMOVED from NCF=== Angiotensin II Receptor Removed April Losartan No blocker (see Losartan) Antagonists (2014) 2012

Printed on 09/29/2021 Page 5 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category Formulary Brief (if Notes / Similar NCF Medications Active? Name (up-to-date) available) Miscellaneous (both cream- Skin and Atopic Dermatitis Corticosteriods (Topical) - High potency (Class I and II); Yes AND petroleum-based) Agent, Miscellaneous; Topical (2020) Corticosteroid (Topical) - Intermediate potency; Corticosteroid Skin Product (Topical) - Low potency; Tacrolimus Tacrolimus Calcineurin Inhibitor; Atopic Dermatitis Corticosteriods (Topical) - High potency (Class I and II); Yes Immunosuppressant Agent; (2020) Corticosteroid (Topical) - Intermediate potency; Corticosteroid Topical Skin Product (Topical) - Low potency; Moisturizers (both cream- AND petroleum-based) Atypical Antipsychotic, Atypical Atypical *Any product* Aripiprazole lauroxil; Haloperidol decanoate Yes Antipsychotic Agents (2015) Atenolol Antihypertensive; Beta-Blocker, Beta Blockers Metoprolol; Propranolol Yes Beta1 Selective (2014) Propranolol Antihypertensive; Beta-Blocker, Beta Blockers Atenolol; Metoprolol Yes Non-Selective (2014) Carvedilol Antihypertensive; Beta-Blocker Beta-blockers in *Immediate-release Atenolol; Metoprolol; Propranolol Yes with Alpha-Blocking Activity Heart Failure (2017) only Metoprolol Antihypertensive; Beta-Blocker, Beta-blockers in Atenolol; Propranolol Yes Beta1 Selective Heart Failure (2017) Doxazosin Alpha1 Blocker; Antihypertensive Benign Prostatic Prazosin; Tamsulosin Yes Hypertrophy (2016) Finasteride 5 Alpha-Reductase Inhibitor Benign Prostatic Yes Hypertrophy (2016) Tamsulosin Alpha1 Blocker Benign Prostatic Doxazosin; Prazosin Yes Hypertrophy (2016) Amlodipine Antihypertensive; Calcium Calcium Channel Diltiazem Yes Channel Blocker, Dihydropyridine Blockers (2014) Diltiazem Antihypertensive; Calcium Calcium Channel Amlodipine Yes Channel Blocker, Blockers (2014) Nondihydropyridine Nifedipine (controlled or Calcium Channel Removed August Amlodipine No extended release) Blockers (2014) 2014 Verapamil ===REMOVED from NCF=== Calcium Channel Removed August Diltiazem No (see Diltiazem) Blockers (2014) 2014

Printed on 09/29/2021 Page 6 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? available) Ammonium Detoxicant; Laxative, Osmotic & Yes Complications (2015) Ipratropium, MDI ===REMOVED from NCF=== COPD Inhalers Removed Aug 2015 Albuterol, metered dose inhaler (MDI); No (2015) Tiotropium (Spiriva®) Dedicated emergency Contraception (2016) Removed Sept 2013 Levonorgestrel (Plan B One-Step®); No contraceptive Ulipristal Ethinyl estradiol / Etonogestrel Contraceptive; Estrogen and Progestin Contraception (2016) Yes vaginal ring Combination Ethinyl estradiol / Contraceptive; Estrogen and Progestin Contraception (2016) Yes Norelgestromin, transdermal Combination Etonogestrel, implant Contraceptive; Progestin Contraception (2016) For use by a skilled and Oral contraceptive pill, progestin only Yes privileged provider Intrauterine device, copper Contraceptive Contraception (2016) *Any product*; For use by a Intrauterine device, levonorgestrel Yes skilled and privileged provider Intrauterine device, Contraceptive, Progestin Contraception (2016) *Any product*; For use by a Intrauterine device, copper Yes levonorgestrel skilled and privileged provider Levonorgestrel (Plan B Contraceptive, Progestin Contraception (2016) *Branded product* Ulipristal Yes One-Step®) Medroxyprogesterone acetate, Contraceptive, Progestin (Injection/Depot) Contraception (2016) Medroxyprogesterone, oral; Oral Yes injection contraceptive pill, progestin only Oral contraceptive pill, Contraceptive Contraception (2016) *Any product* Yes extended cycle Ulipristal Contraceptive; Progestin Receptor Contraception (2016) Levonorgestrel (Plan B One-Step®) Yes Modulator Duloxetine Antidepressant, Serotonin/Norepinephrine Diabetic Neuropathy Bupropion; Venlafaxine Yes Reuptake Inhibitor/Antagonist (2018) Chlorthalidone Antihypertensive; Thiazide-Related Diuretic Agents Hydrochlorothiazide Yes (2014)

Printed on 09/29/2021 Page 7 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? Name (up-to-date) available) Hydrochlorothiazide Antihypertensive; Thiazide (2014) Chlorthalidone Yes Diuretic Apixaban ; Direct Oral Direct Oral Warfarin Yes Anticoagulant (DOAC); Factor Xa Inhibitor (2017) Warfarin Anticoagulant; K Direct Oral Apixaban; Low-molecular Yes Antagonist Anticoagulants weight heparin (2017) Alogliptin Antidiabetic Agent, DPP-IV Inhibitors Yes Dipeptidyl Peptidase 4 (2019) (DPP-4) Inhibitor Saxagliptin ===REMOVED from DPP-IV Inhibitors Removed Feb 2019 Alogliptin No NCF=== (see Alogliptin) (2019) Epinephrine Injection Alpha-/Beta- Agonist Epinephrine Any device, auto-injector or pre-filled syringe Yes Devices (both 0.15mg and Injection Devices 0.3mg) (2020 Divalproex Anticonvulsant, ER Lithium & Carbamazepine; Yes Miscellaneous Divalproex (2012) Lamotrigine; Levetiracetam; Phenytoin; Topiramate Lithium Antimanic Agent ER Lithium & Yes Divalproex (2012) Gabapentin Anticonvulsant, Gabapentin & Yes Miscellaneous; GABA Pregabalin in Pain Analog (2014) Proton Pump Inhibitor Proton Pump Inhibitor GERD & PUD *Any product* Yes (2018) Ranitidine* Histamine GERD & PUD *(April 1, 2020) The Food and Drug Administration has Proton Pump Inhibitor Yes (2018) recommended that all formulations of ranitidine be taken off the market due to contaminates of N-Nitrosodimethylamine (NDMA), a carcinogen, in ranitidine products. Liraglutide or semaglutide Antidiabetic Agent, GLP-1 Receptor Select either of these subcutaneous agents, no preference given Yes Glucagon-Like Peptide-1 Agonists (2019) (GLP-1) Receptor Agonist Semaglutide or liraglutide Antidiabetic Agent, GLP-1 Receptor Select either of these subcutaneous agents, no preference given Yes Glucagon-Like Peptide-1 Agonists (2019) (GLP-1) Receptor Agonist Glucose, Oral Antidote Glucagon Delivery Any formulation Glucagon Yes Devices (2021)

Printed on 09/29/2021 Page 8 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief Notes / Miscellaneous Similar NCF Medications Active? (up-to-date) (if available) Allopurinol Antigout Agent; Xanthine Gout (2016) Yes Oxidase Inhibitor Glecaprevir/pibrentasvir Antihepaciviral HCV Treatment Ledipasvir/sofosbuvir (Harvoni®); Yes (Mavyret®) (2018) Sofosbuvir/velpatasvir (Epclusa®) 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®) Furosemide Antihypertensive; Loop Diuretic Heart Failure Yes Overview (2017) Rifaximin Antibiotic, Rifamycin Hepatic After failure of, or intolerance to, Lactulose Yes Encephalopathy lactulose monotherapy as indicated (2020) for Dolutegravir Antiretroviral, Integrase Inhibitor HIV Updates For HIV treatment in pregnant patients Emtricitabine/tenofovir disoproxil Yes (Anti-HIV) (2020) fumarate; Raltegravir Emtricitabine/tenofovir disoproxil Antiretroviral, Reverse HIV Pre-Exposure For (1) Pre-Exposure HIV Raltegravir Yes fumarate Transcriptase Inhibitor, Prophylaxis Prophylaxis, (2) Post-Exposure HIV Nucleoside (Anti-HIV); (PrEP) (2018) Prophylaxis (with raltegravir) or (3) Antiretroviral, Reverse HIV Treatment (with raltegravir) in Transcriptase Inhibitor, patients with contraindications for 1st Nucleotide (Anti-HIV) line anti-HIV agents Lopinavir / Ritonavir (Kaletra®) ===REMOVED from NCF=== HIV PrEP (2018) Removed August 2013 No (see Emtricitabine/tenofovir) Bictegravir/emtricitabine/tenofovir Antiretroviral, Integrase Inhibitor HIV Treatment Dolutegravir/abacavir/lamivudine; Yes alafenamide (Anti-HIV) (2019) Emtricitabine/tenofovir disoproxil fumarate; Raltegravir Dolutegravir/abacavir/lamivudine Antiretroviral, Integrase Inhibitor HIV Treatment *Note: HLA B5701 testing required Bictegravir/emtricitabine/tenofovir Yes (Anti-HIV) (2019) prior to initiation alafenamide; Dolutegravir; Emtricitabine/tenofovir disoproxil fumarate; Raltegravir Raltegravir Antiretroviral, Integrase Inhibitor HIV Treatment For (1) HIV Post-Exposure Emtricitabine/tenofovir disoproxil fumarate Yes (Anti-HIV) (2019) Prophylaxis (with emtricitabine/ tenofovir DF) or (2) HIV Treatment (with emtricitabine/tenofovir DF) in patients with contraindications for 1st line anti-HIV agents Fibric Acid Derivative ===REMOVED from NCF=== Hyperlipidemia Removed Feb 2017 No (2017) Niacin extended release ===REMOVED from NCF=== Hyperlipidemia Removed Feb 2017 No (Niaspan®) (2017)

Printed on 09/29/2021 Page 9 of 17 Printed on 09/29/2021 Page 10 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? (up-to-date) available) Pravastatin Antilipemic Agent, HMG-CoA Hyperlipidemia (2017) Atorvastatin; Rosuvastatin; Simvastatin Yes Reductase Inhibitor Rosuvastatin Antilipemic Agent, HMG-CoA Hyperlipidemia (2017) Atorvastatin; Pravastatin; Simvastatin Yes Reductase Inhibitor Methimazole ; Thioamide Hyperthyroidism (2021) Propylthiouracil Yes Propylthiouracil Antithyroid Agent; Thioamide Hyperthyroidism (2021) Methimazole Yes Oseltamivir Antiviral Agent; Neuraminidase Treatment of Influenza Yes Inhibitor (2019) Salmeterol (Serevent®) ===REMOVED from NCF=== Inhaled Anticholinergics Removed Sept 2011 No (2011) Trospium ===REMOVED from NCF=== (see Antimuscarinics (2019) Removed Feb 2019 Oxybutynin, Extended-release; No Oxybutynin ER, IR) Oxybutynin, Immediate-release Trazodone ===REMOVED from NCF=== Insomnia (2015) Removed Oct 2015 No Pramipexole Anti-Parkinson Agent, Dopamine Insomnia/Sleep Yes Agonist Medications (2021) Insulin / Regular human (NovoLIN® R) Insulin, Short-Acting Insulins (2015) *Branded product* Yes Insulin aspart (NovoLog®) Insulin, Rapid-Acting Insulins (2015) *Branded product*; Yes Pen Device Insulin aspart / Insulin aspart protamine Insulin, Combination (70/30 Mix) Insulins (2015) *Branded product*; Yes (NovoLog® Mix 70/30) Pen Device Insulin detemir (Levemir®) Insulin, Long-Acting Insulins (2015) *Branded product*; Insulin glargine (Lantus®) Yes Pen Device Insulin NPH (NovoLIN® N) Insulin, Intermediate-Acting Insulins (2015) *Branded product* Yes

Printed on 09/29/2021 Page 11 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? available) Insulin NPH / Regular Insulin, Combination (70/30 Mix) Insulins (2015) *Branded product* Yes human insulin (NovoLIN® 70/30) Dicyclomine Anticholinergic Agent Irritable Bowel Yes Syndrome (2018) Loperamide Antidiarrheal Irritable Bowel Yes Syndrome (2018) Polyethylene glycol Laxative, Osmotic Irritable Bowel *Any product* Lactulose Yes Syndrome (2018) Fluticasone/salmeterol Beta2 Agonist, Long-Acting; Corticosteroid, LABAs (2019) Mometasone (Asmanex®) Yes Inhalant Mometasone / Formoterol ===REMOVED from NCF=== (see LABAs (2019) Removed June 2019 Fluticasone/salmeterol No (Dulera®) Fluticasone/salmeterol) Umeclidinium/vilanterol Long-Acting Muscarinic Antagonist (LAMA) / LAMAs (2019) Tiotropium (Spiriva®) Yes Long-Acting Beta2 Agonist (LABA) Aripiprazole lauroxil Antipsychotic, Atypical (Second Generation) - Long-Acting Injectable Injectable Haloperidol decanoate Yes Injectable (2020) Haloperidol decanoate Antipsychotic, Typical (First Generation) - Long-Acting Injectable Injectable Aripiprazole lauroxil Yes Injectable Antipsychotics (2020) Buprenorphine, long-acting Analgesic, Opioid; Analgesic, Opioid Partial MAT for OUD (2021) Any formulation; Restricted Buprenorphine, short-acting (**REMS Yes (**REMS drug**) Agonist to treatment of Opioid Use drug**); Buprenorphine-naloxone Disorder; **See REMS here** (**REMS drug**) Buprenorphine, short-acting Analgesic, Opioid; Analgesic, Opioid Partial MAT for OUD (2021) Any formulation; Restricted Buprenorphine, long-acting (**REMS Yes (**REMS drug**) Agonist to treatment of Opioid Use drug**); Buprenorphine-naloxone Disorder; **See REMS here** (**REMS drug**) Estradiol tablets Estrogen Derivative Menopausal Hormone Yes Therapy (2016) Spironolactone Antihypertensive; Receptor Mineralocorticoid Yes Antagonists; Potassium Sparing Diuretic Receptor Antagonist in HF (2017) Bupropion Antidepressant, Nicotine Dependence Varenicline; Venlafaxine Yes Dopamine/Norepinephrine-Reuptake Inhibitor; (2015) Smoking Cessation Aid

Printed on 09/29/2021 Page 12 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? available) Nicotine replacement therapy Smoking Cessation Aid Nicotine Combination NRT (nicotine patches Bupropion; Varenicline Yes (NRT), combination Dependence (2015) + any short-acting NRT product) Varenicline Partial Nicotine Agonist, Smoking Nicotine Bupropion Yes Cessation Aid Dependence (2015) Hydroxychloroquine Antimalarial Non-biologic Leflunomide; Methotrexate; Yes DMARDs (2016) Sulfasalazine Leflunomide Antirheumatic, Disease Modifying Non-biologic Hydroxychloroquine; Methotrexate; Yes DMARDs (2016) Sulfasalazine Methotrexate Antineoplastic Agent; Antirheumatic; Non-biologic Hydroxychloroquine; Leflunomide; Yes Disease Modifying; Immunosuppresant DMARDs (2016) Sulfasalazine Agent Diclofenac Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) *Any formulation* Ibuprofen; Indomethacin; Yes Meloxicam; Naproxen Ibuprofen Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Indomethacin; Yes Meloxicam; Naproxen Indomethacin Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Ibuprofen; Meloxicam; Yes Naproxen Meloxicam Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Ibuprofen; Yes Indomethacin; Naproxen Naproxen Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Ibuprofen; Indomethacin Yes Sulindac NSAIDs in Chronic Removed May 2014 Diclofenac; Ibuprofen; No Pain (2014) Indomethacin; Meloxicam; Naproxen Cyanocobalamin (Vitamin Vitamin, Water Soluble Hematologic Yes B12), oral Supplements (2016) Isoniazid Antitubercular Agent Ethambutol; Pyrazinamide; Yes Rifampin; Rifapentine Iron, oral Iron Salt Hematologic *Any oral formulation* Yes Supplements (2016)

Printed on 09/29/2021 Page 13 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? (up-to-date) available) Pyridoxine (Vitamin B6) Vitamin, Water Soluble Supplements in Yes Obstetrics (2016) Fluoride, oral Nutritional Supplement Supplements in Oral *Any oral formulation* Yes Health (2016) Folic Acid Vitamin, Water Soluble Supplements in Any product containing >400 mcg / Yes Womens Health (2016) daily dose Phentermine Central Nervous System Obesity Treatment Yes Stimulant (2018) Ophthalmic Prostaglandin Analog Ophthalmic Prostaglandin Analog Ophth Prostaglandin *Any product* Yes Analogs (2018) Naloxone Antidote; Treatment of Opioid Yes Overdose (2014) Buprenorphine-naloxone Analgesic, Opioid; Analgesic, Opioid Use Disorder **See REMS here** Naloxone Yes (**REMS drug**) Opioid Partial Agonist (2018) Naltrexone, extended-release for Antidote; Opioid Antagonist Opioid Use Disorder **See REMS here** Yes injection (**REMS drug**) (2018) Alendronate Derivative Osteoporosis (2016) Yes Carbidopa-Levodopa (immediate Anti-Parkinson Agent; Parkinson's Disease Yes release) Decarboxylase (2019) Inhibitor-Dopamine Precursor Sevelamer carbonate Phosphate Binder Phosphate Binders For patients on who cannot Calcium Yes (2018) use calcium-based phosphate binders due to hypercalcemia Phosphodiesterase 5 (PDE5) Phosphodiesterase-5 Enzyme Phosphodiesterase 5 *Any product* Yes Inhibitor Inhibitor Inhibitors (2018) Medroxyprogesterone, oral Contraceptive; Progestin Polycystic Ovarian Medroxyprogesterone acetate, Yes Syndrome (2017) injection; Oral contraceptive pill, progestin only Omeprazole (enteric coated) ===REMOVED from NCF=== Long-Term Use of PPIs Removed Feb 2014 Proton Pump Inhibitor No (see Proton Pump Inhibitor) (2014)

Printed on 09/29/2021 Page 14 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? Name (up-to-date) available) Terazosin Prazosin in PTSD Removed Jan 2012 Doxazosin; Prazosin; Tamsulosin No (2012) Prazosin Alpha1 Blocker; Antihypertensive PTSD Indication Doxazosin; Tamsulosin Yes (2012) Prenatal Multivitamin Vitamin Pregnancy & Must contain >400 mcg of folic acid/dose Yes Prenatal Care (2021) Corticosteriods (Topical) - Topical Corticosteroids (2018) Corticosteroid (Topical) - Yes High potency (Class I and Intermediate potency; II) Corticosteroid (Topical) - Low potency Vitamin D Analog (Topical) Vitamin D Analog Psoriasis (2018) *Any product* Yes Rifapentine Antitubercular Agent Rifapentine (2013) Ethambutol; Isoniazid; Yes Pyrazinamide; Rifampin Azithromycin Antibiotic, Macrolide STIs - PART 1 (2021) Yes Cefixime Antibiotic, Cephalosporin STIs - PART 1 (2021) For outpatient treatment of gonorrhea for Ceftriaxone Injection Yes Expedited Partner Therapy or when injection therapy is not possible Ceftriaxone Injection Antibiotic, Cephalosporin STIs - PART 1 (2021) Cefixime Yes Doxycycline Antibiotic, Tetracycline STIs - PART 1 (2021) Yes Penicillin G benzathine Antibiotic, Penicillin STIs - PART 1 (2021) Yes Empagliflozin Antidiabetic Agent, Sodium-Glucose SGLT-2 Inhibitors Yes Cotransporter 2 (SGLT2) Inhibitor (2019) Venlafaxine Antidepressant, SNRIs (2012) Bupropion; Duloxetine Yes Serotonin/Norepinephrine Reuptake Inhibitor/Antagonist Tiotropium (Spiriva®) Long-Acting Anticholinergic Agent Inhaled *Branded product* Yes Anticholinergics (2011)

Printed on 09/29/2021 Page 15 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Medications Active? available) Citalopram Antidepressant, Selective Serotonin SSRIs (2019) Escitalopram; Fluoxetine; Yes Reuptake Inhibitor Paroxetine; Sertraline Escitalopram Antidepressant, Selective Serotonin SSRIs (2019) Citalopram; Fluoxetine; Yes Reuptake Inhibitor Paroxetine; Sertraline Paroxetine Antidepressant, Selective Serotonin SSRIs (2019) Citalopram; Escitalopram; Yes Reuptake Inhibitor Fluoxetine; Sertraline Atorvastatin Antilipemic Agent, HMG-CoA Reductase Dyslipidemia Guideline Pravastatin; Rosuvastatin; Yes Inhibitor Review (2014) Simvastatin Simvastatin Antilipemic Agent, HMG-CoA Reductase Dyslipidemia Guideline Atorvastatin; Pravastatin; Yes Inhibitor Review (2014) Rosuvastatin Gemfibrozil ===REMOVED from NCF=== Dyslipidemia Guidelines Removed Feb 2014 No Review (2014) Lovastatin Dyslipidemia Guidelines Removed April 2012 Atorvastatin; Pravastatin; No Review (2014) Rosuvastatin; Simvastatin Glipizide Antidiabetic Agent; Sulfonylurea Sulfonylureas (2015) Yes Glyburide ===REMOVED from NCF=== (see Sulfonylureas (2015) Removed May 2015 Glipizide No Glipizide) Pioglitazone Antidiabetic Agent, Thiazolidinedione Thiazolidinediones (2017) Yes Adalimumab -OR- Etanercept Antirheumatic, Disease Modifying; Tumor TNF Inhibitors (2016) ONLY In consultation with a Etanercept -OR- Adalimumab Yes (can choose either product) Necrosis Factor (TNF) Blocking Agent rheumatologist (can choose either product) Etanercept -OR- Adalimumab Antirheumatic, Disease Modifying; Tumor TNF Inhibitors (2016) ONLY In consultation with a Adalimumab -OR- Etanercept Yes (can choose either product) Necrosis Factor (TNF) Blocking Agent rheumatologist (can choose either product) Serotonin 5-HT1 agonist Antimigraine Agent; Serotonin 5-HT Triptans (2016) Any two (2) triptan medications are Sumatriptan Yes (Triptan) 1B/1D Receptor Agonist required, one must be sumatriptan Sumatriptan Antimigraine Agent; Serotonin 5-HT Triptans (2016) Any two (2) triptan medications are Yes 1B/1D Receptor Agonist required, one must be sumatriptan

Printed on 09/29/2021 Page 16 of 17 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Miscellaneous Similar NCF Active? (up-to-date) available) Medications , All ACIP-recommended Vaccines (2011) All ACIP recommended vaccines for routine use in Yes accordance with ACIP guidelines Vitamin D Vitamin D Analog Vitamin D (2010) *Any product* Yes Low-molecular weight heparin Low-molecular Weight Heparin VTE Prophylaxis (2011) *Any product* Yes Conjugated estrogen vaginal ===REMOVED from NCF=== (see NPTC Meeting Update Removed May 2018 Estrogen vaginal No cream, (Premarin) Estrogen vaginal cream) (May 2018) cream Estrogen vaginal cream Estrogen Derivative NPTC Meeting Update *Any product* Estradiol tablets Yes (May 2018) Insulin glargine (Lantus®) ===REMOVED from NCF=== (see NPTC Meeting Update Removed May 2019 Insulin detemir No Insulin detemir) (May 2019) (Levemir®) Albuterol, metered dose inhaler Beta2 Agonist NPTC Meeting Update *Any product* Yes (MDI) (Nov 2017) Dulaglutide ===REMOVED from NCF=== NPTC Meeting Update Removed Nov 2020 No (2020)

Printed on 09/29/2021 Page 17 of 17