Ventura County Medical Center - Santa Paula Hospital Restricted formulary medication

Date restriction Generic Brand Route Form Dose Details on restriction applied Use only in post-op surg patients with strict NPO status up Acetaminophen Ofirmev IV soln 10 mg/mL to 24 hours maximum; Patients with strict NPO and rectal 9/12/2018 BBW route is not accessible. oral liq 120 mg-12 mg/5 mL BBW Acetaminophen-codeine Tylenol #3 Patient must be ≥ 12 years old 9/6/2017 oral tab 325 mg-30 mg, 300 mg-30 mg BBW Restricted: 1. Treatment of acute ischemic stroke (as per Cathflo VCMC protocol) 2. Massive pulmonary embolus with Alteplase inj powder 2 mg Activase hemodynamic compromise (pulmonary consult required) 3. Thrombolysis of clot-occluded catheters Amikacin Amikin IV soln 50 mg/mL, 250 mg/mL Required ID approval BBW Amphotericin B Amphotericin IV powder 50 mg Infectious Diseases Consult Required BBW Amphotericin B liposomal AmBisome IV powder 50 mg Infectious Diseases Consult Required

Infectious Diseases Consult Required 1. Treatment of invasive Aspergillus infection in patients Anidulafungin Eraxis Inj powder 50 mg, 100 mg 6/27/2018 refractory to or intolerant of other antifungal treatment. 2. Treatment of Candida resistant to fluconazole

Approval by intensivist in critical care areas. Use as 3rd or Angiotensin II Giapreza inj soln 5 mg/2 mL last line treatment only. Aprepitant Emend Outpatient oncology only Aripiprazole lauroxil long-acting Reserved for patients who are not compliant with daily Aristada IM susp 441 mg, 662 mg, 882 mg 11/4/2015 BBW injectable medication. Patients must have failed generically available atypical Asenapine Saphris sublingual tab 5 mg, 10 mg 12/19/2013 antipsychotic therapy Atezolizumab Tecentriq inj soln 1200 mg/20 mL Outpatient oncology only 9/7/2016 Aztreonam Azactam inj powder 1 g Requires ID approval Bendamustine Treanda Outpatient oncology only 6/24/2008 Bimatoprost opth Lumigan opthalmic soln 0.03% Restricted Bivalirudin Angiomax IV powder 250 mg Use in patient who are unable to use heparin 2/28/2008 Bortezomib Velcade IV powder 3.5 mg Restricted Bosentan Tracleer oral tab 62.5 mg Restricted inj soln 50 mg/5 mL 9/7/2016 Brivaracetam Briviact Requires Neurology approval oral tab 50 mg 9/7/2016 Cabazitaxel Jevtana IV soln 60 mg/1.5 mL Outpatient oncology only with pre-approval BBW Use in post-menopausal osteoporosis, Paget's disease, continuation of home medication only. Home nasal Miacalcin inj soln 200 units/mL 8/8/2018 formulation will NOT be subsituted with parenteral Calcitonin formulation. Use in FDA approved indication only - hypercalcemia, Miacalcin Nasal nasal spray 200 units/mL 8/8/2018 Paget's disease, postmenopausal osteoporosis. Pediatric patients only who would need 3rd generation Cefidinir Omnicef oral susp 125 mg/5 mL 1/9/2019 cephalosporin Cefotaxime Claforan inj powder 1 g, 2 g, 500 mg Limited to neonatal population 6/23/2015 Ceftaroline Teflaro IV powder 600 mg Requires ID consult 8/2/2016 Ventura County Medical Center - Santa Paula Hospital Restricted formulary medication

Date restriction Generic Brand Route Form Dose Details on restriction applied CefTAZidime-avibactam Avycaz IV powder 2-0.5gm vials Requires ID consult 8/2/2016 Cetuximab Erbitux IV soln 2 mg/mL Restricted BBW Cinacalcet Sensipar oral tab 30 mg Restricted For treatment of refractory schizophrenic or schizoaffective Clozaril oral tab 25 mg, 100 mg BBW cloZAPine disorders following patient enrollment in the Clozapine FazaClo oral tab-ODT 25 mg, 100 mg Patient Management System. BBW Cocaine topical Cocaine topical top soln 4% OR use only with ENT approval 8/8/2018 BBW Codeine-promethazine Phenergan w Codeine oral syrup 10 mg-6.25 mg/5 mL 9/6/2017 Patient must be ≥12 years old IV powder 150 mg Colistimethate Colistin inhalation powder 150 mg Infectious Diseases Consult Required DAPTOmycin Cubicin IV powder 500 mg ID Approval required Daratumumab Darzalex IV soln 20 mg/mL Outpatient oncology only Dasatinib Sprycel oral tab 70 mg Restricted

Prolia: 60 mg/1 mL Denosumab Prolia, Xgeva SQ soln Outpatient oncology only 1/7/2015 Xgeva: 120 mg/1.7 mL

Desflurane Suprane inhalation liq 100% Restricted to patients with hepatic dysfunction restriction added 6/27/18 Diptheria/hepB/pertussis, Pediarix IM susp - Restricted acel/polio/tetanus DULoxetine Cymbalta oral cap-DR 20 mg, 30 mg Use in diabetic neuropathy failed other medications 1/25/2007 Durvalumab Imfinzi IV soln 50 mg/mL Outpatient oncology only 5/8/2019 Edaravone Radicava inj premix 30 mg/100 mL Outpatient oncology only 2/7/2018 Eletriptan Relpax oral tab 40 mg Restricted Entanercept Enbrel subQ soln 50mg/mL Treatment of refractory rheumatoid arthritis Epoprostenol Flolan IV powder 0.5 mg Restricted Eribulin Halaven inj soln 0.5 mg/mL Outpatient oncology only Ertapenem Invanz inj powder 1 g ID Approval required 2/22/2007 Only to be administered by trained physicians (Dr. Brecht- Etonogestrel Implant Implanon intradermal implant 68 mg 1/24/2008 Doscher, C.Howe) Fenoldopam Corlopam IV soln 10 mg/mL Restricted Ferric carboxymaltose Injectafer inj soln 50 mg/mL Outpatient oncology only 5/3/2017 Treatment of refractory life-threatening ventricular Flecainide Tambocor oral tab 50 mg arrhythmia only BBW aerosol with 44 mcg/inh, 110 mcg/inh, 220 Fluticasone Flovent inhalation Restricted adapter mcg/inh Fluticasone-salmeterol Advair Diskus inhalation powder 250 mcg-50 mcg/puff Continuation of home med only 4/8/2015 Fondaparinux Arixtra subQ soln 2.5 mg/0.5 mL, 7.5 mg/0.5 mL Patients with heparin induced thrombocytopenia only 12/4/2014 BBW Fosfomycin Monurol oral powder 3 gm/sachet Requires ID approval 2/4/2014 Galsulfase Naglazyme Peds Chemo/Infusion only 1/24/2008 Patient must not be on NPO status - concerns for Glipizide Glucotrol oral tab 5 mg, 10 mg 7/29/2014 hypoglycemia. Use in OB patients only, studies suggest that lower glyBURIDE Diabeta oral tab 5 mg concentrations cross placenta. Goserelin Zoladex subQ implant 3.6 mg, 10.8 mg Restricted Ventura County Medical Center - Santa Paula Hospital Restricted formulary medication

Date restriction Generic Brand Route Form Dose Details on restriction applied Hyoscamine Levsin SL sublingual tab 0.125 mg Outpatient oncology only Idursulfase Elaprase IV soln 2 mg/mL Restricted 12/9/2010 BBW 1 mg, 2 mg, 4 mg, 6 mg, 8 mg, 10 Patients must have failed generically available atypical Iloperidone Fanapt oral tab BBW mg, 12 mg antipsychotic therapy Imatinib Gleevec oral tab 100 mg Restricted

Restricted: Infectious Diseases Consult Required Use limited to therapy of nosocomial infections where pathogens are resistant to aminoglycosides, extended- spectrum penicillins, and cephalosporins are documented. Empirical use should be avoided. 1. Use of imipenem is limited to therapy of hospital (or nursing home) acquired poly-microbial infections (i.e. gram positive/negative, aerobic/anaerobic) where pathogens resistant to aminologycosides, extended-spectrum penicillins, and Imipenem-cilastatin Primaxin IV inj powder 250 mg-250 mg, 500 mg-500 mg cephalosporins are documented; empirical use should be avoided. 2. Plays an important role in the treatment of ESBL- producing strains. 3. Imipenem should NOT be used for community-acquired infections, monotherapy of serious enterococcal, MRSA, MRSE, Pseudomonas, or “Pseudomonad” infections, or as surgical prophylaxis. 4. Pneumonia with shock, MDRO (Multi Drug Resistant Organism) in the ICU setting. 5. Intra-abdominal infection with shock, MDRO/no MDRO risk.

1. Treatment of refractory Crohn’s Disease and 2. Treatment inFLIXimab Remicade IV powder 100 mg of refractory rheumatoid arthritis, both per VCMC Protocol. Insulin glulisine Apidra subQ soln 100 units/mL Restricted 1/24/2008 human recombinant 100 Insulin regular NovoLIN R inj soln Only for IV use, NOT SubQ. 7/29/2014 units/mL Ixabepilone Ixempra Outpatient oncology only 1/24/2008 IV soln 200 mg/20 mL Lacosamide Vimpat Continuation of home med oral tab 50 mg, 100 mg, 200 mg Lanthanum carbonate Fosrenol oral tab 500 mg Patient must be on dialysis 1/26/2012 Restricted to Myxedema coma, T4 protocol, critical care area with concern for poor oral absorption of med, non Levothyroxine Synthroid, Levothroidinj powder 200 mcg 6/27/2018 BBW critical care areas with concern for poor oral absorption of med after 7 days of holding oral therapy Lidocaine topical Lidocaine topical top film 5% Restricted Infectious Diseases Consult Required IV soln 2 mg/mL 1. Restricted to documented vancomycin resistant Linezolid Zyvox entercoccus. oral tab 600 mg 2. Unknown source of infection causing septic shock. 3. Pneumonia with septic shock with MDRO Ventura County Medical Center - Santa Paula Hospital Restricted formulary medication

Date restriction Generic Brand Route Form Dose Details on restriction applied 20 mg, 40 mg, 60 mg, 80 mg, 120 Patients must have failed generically available atypical Lurasidone Latuda oral tab 12/19/2013 BBW mg antipsychotic therapy 1. Prevention or treatment of drug induced or blood product-induced rigors or post-anesthesia shivering. 2. Pre- and post-analgesia where fast onset and short duration Meperidine Demerol HCl inj soln 25 mg/mL improve patient care. 3. Acute episodes of moderate to BBW severe pain in patients with adverse reactions, allergies, or unsuccessful pain management with first line opiods in equi- analgesic doses Restricted to outpatient use under direction of Mepolizumab Nucala inj powder 100 mg 9/7/2016 pulmonologist Meropenem Merrem IV powder 1 g, 500 mg Requires ID Approval Glucophage oral tab 500 mg, 850 mg Restricted: Scr, contrast, comorbidities 7/29/2014 BBW metFORMIN Glucophage XR oral tab-XR 500 mg Restricted: Scr, contrast, comorbidities 7/29/2014 BBW Mitotane Lysodern oral tab 500 mg Outpatient oncology only 11/19/2009 BBW Palliative Care patients only prescribed by palliative care Morphine oral soln 20 mg/mL BBW physician Moxifloxacin Vigamox top soln 0.5% Restricted to eye surgery cases only 6/12/2019 Naltrexone (IM) Vivitrol inj susp 380 mg Behavioral Health use only 6/23/2015 Oncology Infusion Center/Anacapa Neuroscience Center Natalizumab Tysabri inj soln 300 mg/ 15 mL 3/4/2015 BBW use ONLY 1. Restricted to use in patients with Class IV heart failure of moderate to severe intensity. 2. Heart failure resistant to Nesiritide Natrecor IV powder 1.5 mg loop diuretics and nitroglycerin, with clinical signs of volume overload. 3. Attending physician order required NIFEdipine Procardia oral cap 10 mg Restricted NIFEdipine Procardia XL oral tab-XR 30 mg, 60 mg Restricted Nimotop oral cap 30 mg Use limited to treatment of patients with subarachnoid BBW niMODipine Nymalize oral solution 60 mg/20 mL hemorrhage Nivolumab Opdivo IV soln 40 mg/4 mL, 100 mg/10 mL Outpatient oncology only 4/21/2016 PACLitaxel protein-bound Abraxane IV powder 100 mg Restricted BBW 5000 units-17000 units-27,000 units 10000 units-34000 units-55000 Pancrelipase Zenpep oral cap-DR Cystic fibrosis patients only 12/19/2013 units 15000 units-51000 units-82000 units Pantoprazole Protonix IV IV powder 40 mg Restricted Pembrolizumab Keytruda Inj soln 25 mg/mL Outpatient oncology only 9/6/2017 Restricted to pediatric patients. May use in adult patients Potassium chloride potassium chloride oral liq 20 mEq/15 mL who are at risk of developing metabolic alkalosis or bicarb 1/9/2019 level > 28 or at the discretion of attending physician. Pregabalin Lyrica oral cap 75 mg Restricted Ventura County Medical Center - Santa Paula Hospital Restricted formulary medication

Date restriction Generic Brand Route Form Dose Details on restriction applied Phenergan with Promethazine-codeine oral syrup 10 mg-6.25 mg/5 mL Patient must be ≥12 years old Codeine Prothrombin complex concentrate 500 units (400-620 units Factor Kcentra™ inj powder Ordering restricted to attending level providers 10/24/2013 (human) IX) BBW Ramucirumab Cyramza Inj soln 10 mg/mL Outpatient oncology only 5/8/2019 Restricted to hematology/oncology patients. Must have cancer or being newly diagnosed with cancer AND have Laboratory tumor lysis syndrome (LTLS) or Clincial TLS - LTLS Rasburicase Elitek inj powder 1.5 mg, 7.5 mg 11/14/2018 BBW with one of the following consitions of renal failure, cardiac arrhythmia, or seizure. For full dosing guideline refer to policy and procedure on rasburicase in Policystat PH.117. romiDEPsin Istodax inj powder 10 mg Outpatient oncology only. On demand only. Patients, Prescribers & Medical center must be registered romiPLOStim Nplate inj powder 250 mcg, 500 mcg 8/28/2008 with the REMS program Sargramostim Leukine inj soln 500 mcg/mL Restricted Sodium citrate N/A catheter lock soln 4% For hemodialysis catheter lock use only 10/24/2013 Tapentadol Nucynta oral tab 50 mg Prescriber must be a physician on the Palliative Care Team 5/24/2012 BBW Ticlopidine Ticlid oral tab 250 mg Restricted Tigecycline Tygacil IV powder 50 mg Infectious Diseases Consult Required Tiotropium bromide monohydrate Spiriva HandiHaler inhalation powder Continuation of home med 6/29/2014 Tocilizumab Actemra IV soln 20 mg/mL Outpatient oncology only 1/27/2011 BBW traMADol Ultram oral tab 50 mg Patient must be ≥ 18 years old 9/6/2017 BBW Vedolizumab Entyvio inj soln 300 mg/5 mL Outpatient oncology only 5/8/2019 IV powder 200 mg Voriconazole VFENDoral powder 40 mg/mL Infectious Diseases Consult Required oral tab 200 mg Restricted: stage IV Colon CA unresponsive to FULFIRI & Ziv-aflibercept Zaltrap IV soln 25 mg/mL 11/15/2012 Oxaliplatin based regimen