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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 (if Notes / Similar NCF Active? available) Miscellaneous Medications Acetaminophen , Miscellaneous Yes Albuterol nebulized solution Beta2 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-4) Inhibitor DPP-IV Inhibitors (2019) Yes Anastrozole Antineoplastic Agent, Aromatase Inhibitor Yes Aspirin Antiplatelet Agent; Nonsteroidal Anti-Inflammatory ; Salicylate Yes Azithromycin , Macrolide STIs - PART 1 (2021) Yes Electrolyte supplement *Any formulation* Yes Carbidopa-Levodopa (immediate Anti-Parkinson Agent; Decarboxylase Inhibitor- Precursor Parkinson's Disease Yes release) (2019) , topical ===REMOVED from NCF=== (See Benzoyl Peroxide AND Removed January No Clindamycin, topical combination) 2020 , intranasal Intranasal Corticosteroid *Any product* Yes Cyanocobalamin ( B12), Vitamin, Water Soluble Hematologic Supplements Yes oral (2016)

Printed on 09/25/2021 Page 1 of 18 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if available) Notes / Miscellaneous Similar NCF Active? Medications Dicyclomine Anticholinergic Agent Irritable Bowel Syndrome Yes (2018) , Miscellaneous; Cardiac Digoxin Use (2016) Yes Donepezil Acetylcholinesterase Inhibitor (Central) 5mg and 10mg strengths Yes Doxycycline Antibiotic, STIs - PART 1 (2021) Yes Dulaglutide ===REMOVED from NCF=== NPTC Meeting Update (2020) Removed Nov 2020 No Empagliflozin Antidiabetic Agent, -Glucose SGLT-2 Inhibitors (2019) Yes Cotransporter 2 (SGLT2) Inhibitor Epinephrine Injection Devices (both Alpha-/Beta- Agonist Epinephrine Injection Devices Any device, auto-injector or Yes 0.15mg and 0.3mg) (2020 pre-filled syringe Estradiol tablets Estrogen Derivative Menopausal Yes (2016) Ethinyl estradiol / Etonogestrel Contraceptive; Estrogen and Progestin Contraception (2016) Yes vaginal ring Combination Ethinyl estradiol / , 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 5 Alpha-Reductase Inhibitor Benign Prostatic Hypertrophy Yes (2016) Fluoride, oral Nutritional Supplement Supplements in Oral Health *Any oral formulation* Yes (2016)

Printed on 09/25/2021 Page 2 of 18 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief (if available) Notes / Miscellaneous Similar NCF Active? (up-to-date) Medications Folic Acid Vitamin, Water Soluble Supplements in Womens Any product containing >400 mcg / Yes Health (2016) daily dose Antihypertensive; Loop Failure Overview (2017) Yes Gabapentin , Miscellaneous; Gabapentin & Pregabalin in Yes GABA Analog Pain (2014) Gemfibrozil ===REMOVED from NCF=== Dyslipidemia Guidelines Removed Feb 2014 No Review (2014) Glipizide Antidiabetic Agent; Sulfonylurea Sulfonylureas (2015) Yes Glucagon ; For outpatient use Yes (2nd generation), long-acting H1 Antagonist, Second *Any product* Yes Generation Histamine H1 Antagonist, First Anxiety Disorders (2021) Yes Generation Insulin / Regular human (NovoLIN® R) Insulin, Short-Acting Insulins (2015) *Branded product* Yes Insulin aspart (NovoLog®) Insulin, Rapid-Acting Insulins (2015) *Branded product*; Pen Device Yes Insulin aspart / Insulin aspart protamine Insulin, Combination (70/30 Mix) Insulins (2015) *Branded product*; Pen Device Yes (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 Supplements *Any oral formulation* Yes (2016)

Printed on 09/25/2021 Page 3 of 18 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Active? Name available) Medications , bulk-forming Bulk-forming Laxative *Any product* Yes Laxative, Stimulant Laxative *Any product* Yes Letrozole Antineoplastic Agent, Aromatase Inhibitor Yes Agent Yes Liraglutide or Antidiabetic Agent, Glucagon-Like Peptide-1 GLP-1 Select either of these subcutaneous agents, Yes semaglutide (GLP-1) Receptor Agonist (2019) 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 Syndrome Yes (2018) Lopinavir / ===REMOVED from NCF=== (see HIV PrEP (2018) Removed August 2013 No (Kaletra®) Emtricitabine/tenofovir) Losartan Antihypertensive, Angiotensin II Receptor Blocker ACEIs & ARBs in Heart Yes Failure (2017) Low-molecular weight Low-molecular Weight Heparin VTE Prophylaxis (2011) *Any product* Yes heparin Memantine N-Methyl-D-Aspartate (NMDA) Yes Antidiabetic Agent; Biguanide Yes Mometasone Corticosteroid, Inhalant *Branded product* Yes (Asmanex®)

Printed on 09/25/2021 Page 4 of 18 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category (up-to-date) Formulary Brief (if available) Notes / Similar NCF Active? Miscellaneous Medications 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**) extended release (Niaspan®) ===REMOVED from NCF=== Hyperlipidemia (2017) Removed Feb 2017 No ; Selective 5-HT3 Receptor Antiemetic Agents (2021) Yes Antagonist Ophthalmic 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 Penicillin G benzathine Antibiotic, Penicillin STIs - PART 1 (2021) Yes Phentermine Central Stimulant Obesity Treatment (2018) Yes Phosphodiesterase 5 (PDE5) Inhibitor Phosphodiesterase-5 Phosphodiesterase 5 Inhibitors *Any product* Yes (2018) Pioglitazone Antidiabetic Agent, Thiazolidinedione Thiazolidinediones (2017) Yes Pramipexole Anti-Parkinson Agent, Dopamine Agonist /Sleep Medications Yes (2021) Prednisone Corticosteroid, Systemic Yes

Printed on 09/25/2021 Page 5 of 18 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category (up-to-date) Formulary Brief (if available) Notes / Miscellaneous Similar NCF Active? Name Medications Prenatal Multivitamin Vitamin & 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) (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 Select either of these subcutaneous Yes (GLP-1) Receptor Agonist (2019) agents, no preference given Semaglutide, dulaglutide ===REMOVED from NCF=== Dulaglutide removed from NCF; liraglutide No or liraglutide and semaglutide remain on NCF Antihypertensive; Receptor Mineralocorticoid Receptor Yes Antagonists; Sparing Diuretic Antagonist in HF (2017) Antimigraine Agent; Serotonin 5-HT 1B/1D Triptans (2016) Any two (2) triptan medications are Yes Receptor Agonist required, one must be sumatriptan Tamoxifen Antineoplastic Agent, Estrogen Receptor Yes Antagonist; Selective Estrogen Tiotropium (Spiriva®) Long-Acting Anticholinergic Agent Inhaled Anticholinergics (2011) *Branded product* Yes ===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 Yes ACIP-recommended routine use in accordance with ACIP guidelines

Printed on 09/25/2021 Page 6 of 18 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) Vitamin D Vitamin D Analog Vitamin D (2010) *Any product* Yes Vitamin D Analog (Topical) Vitamin D Analog (2018) *Any product* Yes 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) Ipratropium, MDI ===REMOVED from NCF=== COPD Inhalers (2015) Removed Aug 2015 Albuterol, metered dose inhaler No (MDI); Tiotropium (Spiriva®) Saxagliptin ===REMOVED from NCF=== (see DPP-IV Inhibitors (2019) Removed Feb 2019 Alogliptin No Alogliptin) , in Pain Yes Mgmt (2014) Antihypertensive; Calcium , Calcium Channel Blockers Yes Nondihydropyridine (2014) (controlled or Calcium Channel Blockers Removed August 2014 Amlodipine No extended release) (2014) Warfarin ; Vitamin K Antagonist Direct Oral Apixaban; Low-molecular weight Yes (2017) heparin decanoate , Typical (First Generation) - Long-Acting Injectable Injectable lauroxil Yes Injectable (2020) Antipsychotic, Atypical Atypical Antipsychotic *Any product* ; Haloperidol Yes Agents (2015) decanoate Clopidogrel Antiplatelet Agent Antiplatelets (2015) Aspirin Yes Antihypertensive; Beta-Blocker, Beta Blockers (2014) ; Yes Non-Selective Antihypertensive; Beta-Blocker with Beta-blockers in Heart *Immediate-release only Atenolol; Metoprolol; Propranolol Yes Alpha-Blocking Activity Failure (2017)

Printed on 09/25/2021 Page 7 of 18 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) Metoprolol Antihypertensive; Beta-Blocker, Beta-blockers in Atenolol; Propranolol Yes Beta1 Selective (2017) Antilipemic Agent, HMG-CoA Dyslipidemia Atorvastatin; Pravastatin; Rosuvastatin Yes Reductase Inhibitor Guideline Review (2014) Dyslipidemia Removed April 2012 Atorvastatin; Pravastatin; Rosuvastatin; No Guidelines Review Simvastatin (2014) Rosuvastatin Antilipemic Agent, HMG-CoA Hyperlipidemia Atorvastatin; Pravastatin; Simvastatin Yes Reductase Inhibitor (2017) Pravastatin Antilipemic Agent, HMG-CoA Hyperlipidemia Atorvastatin; Rosuvastatin; Simvastatin Yes Reductase Inhibitor (2017) Benzoyl Peroxide AND Topical Skin Product, Acne; Acne Treatment Benzoyl Peroxide Yes Clindamycin, topical combination Topical Skin Product, Acne (2020) (Lincosamide Antibiotic) Benzoyl Peroxide Topical Skin Product, Acne Acne Treatment Benzoyl Peroxide AND Clindamycin, topical Yes (2020) combination Dolutegravir// Antiretroviral, Integrase Inhibitor HIV Treatment *Note: HLA B5701 testing Bictegravir/emtricitabine/tenofovir alafenamide; Yes (Anti-HIV) (2019) required prior to initiation Dolutegravir; Emtricitabine/tenofovir disoproxil fumarate; Raltegravir Buprenorphine, short-acting Analgesic, Opioid; Analgesic, MAT for OUD Any formulation; Restricted Buprenorphine, long-acting (**REMS drug**); Yes (**REMS drug**) Opioid Partial Agonist (2021) to treatment of Opioid Use Buprenorphine-naloxone (**REMS drug**) Disorder; **See REMS here** Buprenorphine, long-acting Analgesic, Opioid; Analgesic, MAT for OUD Any formulation; Restricted Buprenorphine, short-acting (**REMS drug**); Yes (**REMS drug**) Opioid Partial Agonist (2021) to treatment of Opioid Use Buprenorphine-naloxone (**REMS drug**) Disorder; **See REMS here** Varenicline Partial Agonist, Smoking Nicotine Yes Cessation Aid Dependence (2015) Venlafaxine Antidepressant, SNRIs (2012) Bupropion; Duloxetine Yes Serotonin/ /Antagonist Nicotine replacement therapy Smoking Cessation Aid Nicotine Combination NRT (nicotine Bupropion; Varenicline Yes (NRT), combination Dependence patches + any short-acting (2015) NRT product) Duloxetine Antidepressant, Diabetic Bupropion; Venlafaxine Yes Serotonin/Norepinephrine Neuropathy (2018) Reuptake Inhibitor/Antagonist

Printed on 09/25/2021 Page 8 of 18 Printed on 09/25/2021 Page 9 of 18 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) Sevelamer carbonate Phosphate Binder Phosphate Binders For patients on dialysis who cannot use Calcium Yes (2018) calcium-based phosphate binders due to hypercalcemia Ethosuximide Anticonvulsant, Succinimide Anti-Seizure ; Clonazepam; Divalproex; Yes (2021) Gabapentin; ; Levetiracetam; ; Topiramate Anticonvulsant, Miscellaneous Anti-Seizure Drugs Carbamazepine; Clonazepam; Divalproex; Yes (2021) Gabapentin; Lamotrigine; Levetiracetam; Phenytoin; Topiramate Topiramate Anticonvulsant, Miscellaneous Antiepileptic Carbamazepine; Divalproex; Lamotrigine; Yes Medications (2014) Levetiracetam; Phenytoin Phenytoin Anticonvulsant, Antiepileptics Carbamazepine; Divalproex; Lamotrigine; Yes (2014) Levetiracetam; Topiramate Levetiracetam Anticonvulsant, Miscellaneous Antiepileptics Carbamazepine; Divalproex; Lamotrigine; Yes (2014) Phenytoin; Topiramate Lamotrigine Anticonvulsant, Miscellaneous Antiepileptics Carbamazepine; Divalproex; Levetiracetam; Yes (2014) Phenytoin; Topiramate Divalproex Anticonvulsant, Miscellaneous ER Lithium & Carbamazepine; Lamotrigine; Levetiracetam; Yes Divalproex (2012) Phenytoin; Topiramate Ceftriaxone Injection Antibiotic, Cephalosporin STIs - PART 1 Cefixime Yes (2021) Cefixime Antibiotic, Cephalosporin STIs - PART 1 For outpatient treatment of gonorrhea for Ceftriaxone Injection Yes (2021) Expedited Partner Therapy or when injection therapy is not possible Hydrochlorothiazide Antihypertensive; Thiazide (2014) Chlorthalidone Yes Diuretic Sertraline Antidepressant, Selective Citalopram; ; Fluoxetine; Yes Serotonin Reuptake Inhibitor Paroxetine Antidepressant, Selective SSRIs (2019) Citalopram; Escitalopram; Fluoxetine; Sertraline Yes Serotonin Reuptake Inhibitor Escitalopram Antidepressant, Selective SSRIs (2019) Citalopram; Fluoxetine; Paroxetine; Sertraline Yes Serotonin Reuptake Inhibitor

Printed on 09/25/2021 Page 10 of 18 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief Notes / Similar NCF Medications Active? (up-to-date) (if available) Miscellaneous Lorazepam Alcohol Clonazepam Yes Withdrawal Syndrome (2015) Corticosteroid (Topical) - Low Topical *Any product* Corticosteriods (Topical) - High potency (Class I and II); Yes potency Corticosteroid (Topical) - Intermediate potency 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) Moisturizers (both cream- Skin and Mucous Membrane 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 Corticosteroid (Topical) - Topical Corticosteroids *Any product* Corticosteriods (Topical) - High potency (Class I and II); Yes Intermediate potency Corticosteroid (Topical) - Low potency Corticosteriods (Topical) - Topical Corticosteroids Psoriasis (2018) Corticosteroid (Topical) - Intermediate potency; Corticosteroid Yes High potency (Class I and II) (Topical) - Low potency Atomoxetine Norepinephrine Reuptake ADHD (2020) / Amphetamine (immediate release); Yes Inhibitor, Selective Dextroamphetamine / Amphetamine (long-acting); Methylphenidate (immediate release); Methylphenidate (long-acting) Dextroamphetamine / Central Nervous System Stimulant Pediatric use only Dextroamphetamine and amphetamine (immediate release) Yes Amphetamine (long-acting) Dextroamphetamine / Central Nervous System Stimulant Pediatric use only Dextroamphetamine and amphetamine (long-acting) Yes Amphetamine (immediate release) Naproxen Nonsteroidal Anti-Inflammatory NSAIDs (2014) ; Ibuprofen; Indomethacin Yes Drug Sulindac NSAIDs in Removed May Diclofenac; Ibuprofen; Indomethacin; Meloxicam; Naproxen No Chronic Pain 2014 (2014) Meloxicam Nonsteroidal Anti-Inflammatory NSAIDs (2014) Diclofenac; Ibuprofen; Indomethacin; Naproxen Yes Drug Indomethacin Nonsteroidal Anti-Inflammatory NSAIDs (2014) Diclofenac; Ibuprofen; Meloxicam; Naproxen Yes Drug Ibuprofen Nonsteroidal Anti-Inflammatory NSAIDs (2014) Diclofenac; Indomethacin; Meloxicam; Naproxen Yes Drug

Printed on 09/25/2021 Page 11 of 18 National Core Formulary; Last Updated: 09/23/2021

Pharmacological Formulary Generic Medication Name Category (up-to-date) Brief (if Notes / Miscellaneous Similar NCF Medications Active? available) Amlodipine Antihypertensive; Calcium Calcium Diltiazem Yes Channel Blocker, Channel Dihydropyridine Blockers (2014) ===REMOVED from Calcium Removed August 2014 Diltiazem No NCF=== (see Diltiazem) Channel Blockers (2014) Carbamazepine Anticonvulsant, Antiepileptics Divalproex; Lamotrigine; Levetiracetam; Yes Miscellaneous (2014) Phenytoin; Topiramate Bictegravir/emtricitabine/tenofovir Antiretroviral, Integrase HIV Treatment Dolutegravir/abacavir/lamivudine; Yes alafenamide Inhibitor (Anti-HIV) (2019) Emtricitabine/tenofovir disoproxil fumarate; Raltegravir Alpha1 Blocker Benign Prostatic ; Yes Hypertrophy (2016) Prazosin in Removed Jan 2012 Doxazosin; Prazosin; Tamsulosin No PTSD (2012) Prazosin Alpha1 Blocker; PTSD Indication Doxazosin; Tamsulosin Yes Antihypertensive (2012) 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 Dolutegravir Antiretroviral, Integrase HIV Updates For HIV treatment in pregnant patients Emtricitabine/tenofovir disoproxil Yes Inhibitor (Anti-HIV) (2020) fumarate; Raltegravir Citalopram Antidepressant, Selective SSRIs (2019) Escitalopram; Fluoxetine; Paroxetine; Yes Serotonin Reuptake Sertraline Inhibitor Estrogen vaginal cream Estrogen Derivative NPTC Meeting *Any product* Estradiol tablets Yes Update (May 2018) Conjugated estrogen vaginal cream, ===REMOVED from NPTC Meeting Removed May 2018 Estrogen vaginal cream No (Premarin) NCF=== (see Estrogen Update (May vaginal cream) 2018) Adalimumab -OR- Etanercept (can Antirheumatic, Disease TNF Inhibitors ONLY In consultation with a rheumatologist Etanercept -OR- Adalimumab (can Yes choose either product) Modifying; Tumor Necrosis (2016) choose either product) Factor (TNF) Blocking Agent Antitubercular Agent Rifapentine Ethambutol; Isoniazid; Pyrazinamide; Yes (2013) Rifampin

Printed on 09/25/2021 Page 12 of 18 Printed on 09/25/2021 Page 13 of 18 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 Rifampin Antitubercular Agent Ethambutol; Isoniazid; Pyrazinamide; Yes Rifapentine Pyrazinamide Antitubercular Agent Ethambutol; Isoniazid; Rfapentine ; Rifampin Yes Isoniazid Antitubercular Agent Ethambutol; Pyrazinamide; Rifampin; Yes Rifapentine Oral contraceptive pill, Contraceptive *Any product* Etonogestrel; Implant; Intrauterine Device; Yes progestin only Levonorgestrel / Salmeterol Removed Oct Fluticasone/salmeterol No (Advair®) 2012 Mometasone / ===REMOVED from NCF=== (see LABAs (2019) Removed June Fluticasone/salmeterol No (Dulera®) Fluticasone/salmeterol) 2019 Sofosbuvir/velpatasvir Antihepaciviral HCV Treatment (2018) Glecaprevir/pibrentasvir (Mavyret®); Yes (Epclusa®) Ledipasvir/sofosbuvir (Harvoni®) Ledipasvir/sofosbuvir Antihepaciviral HCV Treatment (2018) Glecaprevir/pibrentasvir (Mavyret®); Yes (Harvoni®) Sofosbuvir/velpatasvir (Epclusa®) Glyburide ===REMOVED from NCF=== (see Glipizide) Sulfonylureas (2015) Removed May Glipizide No 2015 Glucose, Oral Antidote Glucagon Delivery Devices Any formulation Glucagon Yes (2021) Aripiprazole lauroxil Antipsychotic, Atypical (Second Generation) - Long-Acting Injectable Injectable Yes Injectable Antipsychotics (2020) Chlorthalidone Antihypertensive; Thiazide-Related Diuretic Diuretic Agents (2014) Hydrochlorothiazide Yes Sulfasalazine 5-Aminosalicylic Acid Derivative Hydroxychloroquine; Leflunomide; Yes Methotrexate Methotrexate Antineoplastic Agent; Antirheumatic; Disease Non-biologic DMARDs Hydroxychloroquine; Leflunomide; Yes Modifying; Immunosuppresant Agent (2016) Sulfasalazine

Printed on 09/25/2021 Page 14 of 18 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) Leflunomide Antirheumatic, Disease Non-biologic Hydroxychloroquine; Methotrexate; Yes Modifying DMARDs (2016) Sulfasalazine Diclofenac Nonsteroidal Anti-Inflammatory NSAIDs (2014) *Any formulation* Ibuprofen; Indomethacin; Meloxicam; Yes Drug Naproxen Insulin glargine (Lantus®) ===REMOVED from NCF=== NPTC Meeting Removed May 2019 Insulin detemir (Levemir®) No (see Insulin detemir) Update (May 2019) Insulin detemir (Levemir®) Insulin, Long-Acting Insulins (2015) *Branded product*; Pen Device Insulin glargine (Lantus®) Yes Intrauterine device, Contraceptive, Progestin Contraception (2016) *Any product*; For use by a skilled and Intrauterine device, copper Yes levonorgestrel privileged provider Intrauterine device, copper Contraceptive Contraception (2016) *Any product*; For use by a skilled and Intrauterine device, levonorgestrel Yes privileged provider Ethambutol Antitubercular Agent Isoniazid; Pyrazinamide; Rifampin; Yes Rifapentine Isosorbide dinitrate ===REMOVED from NCF=== Removed Aug 2013 Isosorbide mononitrate No (see Isosorbide mononitrate) Nitroglycerin patch Agent; Antidote, Isosorbide mononitrate; Nitroglycerin Yes Extravasation; Vasodilator 0.4 milligrams; Sublingual Nitroglycerin 0.4 milligrams, Antianginal Agent; Antidote, Isosorbide mononitrate; Nitroglycerin Yes sublingual Extravasation; Vasodilator patch Polyethylene glycol Laxative, Osmotic Irritable Bowel *Any product* Lactulose Yes Syndrome (2018) Antibiotic, Rifamycin Hepatic After failure of, or intolerance to, lactulose Lactulose Yes Encephalopathy monotherapy as indicated for hepatic (2020) encephalopathy Glecaprevir/pibrentasvir Antihepaciviral HCV Treatment (2018) Ledipasvir/sofosbuvir (Harvoni®); Yes (Mavyret®) Sofosbuvir/velpatasvir (Epclusa®) Hydroxychloroquine Antimalarial Non-biologic Leflunomide; Methotrexate; Yes DMARDs (2016) Sulfasalazine

Printed on 09/25/2021 Page 15 of 18 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Name Pharmacological Category Formulary Brief (if Notes / Similar NCF Medications Active? (up-to-date) available) Miscellaneous Ulipristal Contraceptive; Progestin Contraception (2016) Levonorgestrel (Plan B One-Step®) Yes Receptor Modulator Dedicated emergency contraceptive Contraception (2016) Removed Sept Levonorgestrel (Plan B One-Step®); Ulipristal No 2013 Clonazepam Benzodiazepine Alcohol Withdrawal Lorazepam Yes Syndrome (2015) Angiotensin receptor blocker ===REMOVED from NCF=== Angiotensin II Receptor Removed April Losartan No (see Losartan) Antagonists (2014) 2012 Medroxyprogesterone, oral Contraceptive; Progestin Polycystic Ovarian Medroxyprogesterone acetate, injection; Oral Yes Syndrome (2017) contraceptive pill, progestin only Medroxyprogesterone acetate, injection Contraceptive, Progestin Contraception (2016) Medroxyprogesterone, oral; Oral contraceptive Yes (Injection/Depot) pill, progestin only ; (2021) Methimazole Yes Methylphenidate (long-acting) Central Nervous System Pediatric use only Methylphenidate (immediate release) Yes Stimulant Methylphenidate (immediate release) Central Nervous System Pediatric use only Methylphenidate (long-acting) Yes Stimulant Atenolol Antihypertensive; Beta-Blocker, Beta Blockers (2014) Metoprolol; Propranolol Yes Beta1 Selective Fluticasone/salmeterol Beta2 Agonist, Long-Acting; LABAs (2019) Mometasone (Asmanex®) Yes Corticosteroid, Inhalant Oral contraceptive pill, monophasic: Contraceptive *Any product* Monophasic: 20mcg EE (low) ; Oral Yes 30-35mcg EE (medium) contraceptive pill Oral contraceptive pill, monophasic: Contraceptive *Any product* Monophasic: 30-35mcg EE (medium); Oral Yes 20mcg EE (low) contraceptive pill Oral contraceptive pill, triphasic Contraceptive *Any product* Monophasics ; Oral Contraceptive Pill Yes

Printed on 09/25/2021 Page 16 of 18 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) Buprenorphine-naloxone Analgesic, Opioid; Analgesic, Opioid Opioid Use Disorder (2018) **See REMS here** Naloxone Yes (**REMS drug**) Partial Agonist Naltrexone, oral Antidote; Opioid Antagonist Alcohol Use Disorders (2015) Naloxone Yes Isosorbide mononitrate Antianginal Agent; Vasodilator Nitroglycerin 0.4 Milligrams; Sublingual; Yes Nitroglycerin patch Amitriptyline Antidepressant, Tricyclic Antidepressants in Pain Nortriptyline Yes Mgmt (2014) ===REMOVED from NCF=== (see Antidepressant Use in Removed May 2014 Nortriptyline No Nortriptyline) Chronic Pain (2014) Etonogestrel, implant Contraceptive; Progestin Contraception (2016) For use by a skilled and Oral contraceptive pill, progestin only Yes privileged provider Oxybutynin, Immediate-release Antispasmodic Agent, Urinary Antimuscarinics (2019) Oxybutynin, Extended-release Yes Trospium ===REMOVED from NCF=== (see Antimuscarinics (2019) Removed Feb 2019 Oxybutynin, Extended-release; No Oxybutynin ER, IR) Oxybutynin, Immediate-release Oxybutynin, Extended-release Antispasmodic Agent, Urinary Antimuscarinics (2019) Oxybutynin, Immediate-release Yes Lactulose Ammonium Detoxicant; Laxative, Cirrhosis & Complications Polyethylene glycol Yes Osmotic (2015) Atorvastatin Antilipemic Agent, HMG-CoA Dyslipidemia Guideline Pravastatin; Rosuvastatin; Simvastatin Yes Reductase Inhibitor Review (2014) Doxazosin Alpha1 Blocker; Antihypertensive Benign Prostatic Prazosin; Tamsulosin Yes Hypertrophy (2016) Methimazole Antithyroid Agent; Thioamide Hyperthyroidism (2021) Propylthiouracil Yes (enteric coated) ===REMOVED from NCF=== (see Long-Term Use of PPIs Removed Feb 2014 Proton Pump Inhibitor No Proton Pump Inhibitor) (2014)

Printed on 09/25/2021 Page 17 of 18 National Core Formulary; Last Updated: 09/23/2021

Generic Medication Pharmacological Category (up-to-date) Formulary Brief (if Notes / Miscellaneous Similar NCF Active? Name available) Medications * Histamine GERD & PUD *(April 1, 2020) The Food and Drug Administration has Proton Pump Yes (2018) recommended that all formulations of ranitidine be Inhibitor taken off the market due to contaminates of N-Nitrosodimethylamine (NDMA), a , in ranitidine products. 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 (3) Transcriptase Inhibitor, Nucleotide (Anti-HIV) (2018) HIV Treatment (with raltegravir) in patients with contraindications for 1st line anti-HIV agents Fluoxetine Antidepressant, Selective Serotonin Reuptake Sertraline Yes Inhibitor Serotonin 5-HT1 agonist Antimigraine Agent; Serotonin 5-HT 1B/1D Receptor Triptans (2016) Any two (2) triptan medications are required, one must Sumatriptan Yes (Triptan) Agonist be sumatriptan Umeclidinium/ Long-Acting (LAMA) / LAMAs (2019) Tiotropium Yes Long-Acting Beta2 Agonist (LABA) (Spiriva®) Levonorgestrel (Plan B Contraceptive, Progestin Contraception *Branded product* Ulipristal Yes One-Step®) (2016) Bupropion Antidepressant, Nicotine Varenicline; Yes Dopamine/Norepinephrine-Reuptake Inhibitor; Dependence (2015) Venlafaxine Smoking Cessation Aid Apixaban Anticoagulant; Direct Oral Anticoagulant (DOAC); Direct Oral Warfarin Yes Factor Xa Inhibitor Anticoagulants (2017)

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