2020 PROVIDENCE FORMULARY A Updates November, 2019 Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/22/2019 t:slim x2 insulin pump cartridge REMOVE FROM Non-Formulary FORMULARY 11/22/2019 autosoft xc infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 11/22/2019 varisoft infusion infusion set for insulin pump REMOVE FROM Non-Formulary set FORMULARY 11/22/2019 tiadylt er diltiazem hcl ADD TO FORMULARY Non-Preferred Generics 11/22/2019 NPLATE romiplostim ADD TO FORMULARY Injectables 11/27/2019 clocortolone clocortolone pivalate ADD TO FORMULARY Non-Preferred pivalate Brands 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 1 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/27/2019 GABACAINE gabapentin/lidocaine REMOVE FROM Non-Formulary FORMULARY BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 2 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates December, 2019 Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/06/2019 EYLEA aflibercept REMOVE FROM Non-Formulary FORMULARY 12/06/2019 PRILO PATCH lidocaine/prilocaine REMOVE FROM Non-Formulary FORMULARY 12/06/2019 xenon xe-133 xenon 133 in carbon dioxide REMOVE FROM Non-Formulary FORMULARY 12/06/2019 xenon xe-133 xenon 133 in carbon dioxide REMOVE FROM Non-Formulary FORMULARY 12/06/2019 xenon xe-133 xenon 133 in carbon dioxide REMOVE FROM Non-Formulary FORMULARY 12/06/2019 xenon xe-133 xenon 133 in carbon dioxide REMOVE FROM Non-Formulary FORMULARY 12/14/2019 INSULIN insulin aspart ADD TO FORMULARY Non-Preferred ASPART Generics 12/14/2019 INSULIN insulin aspart ADD TO FORMULARY Non-Preferred ASPART Generics PENFILL 12/14/2019 INSULIN insulin aspart protamine ADD TO FORMULARY Non-Preferred ASPART PROT- human/insulin aspart Generics INSULN ASP 12/14/2019 INSULIN insulin aspart protamine ADD TO FORMULARY Non-Preferred ASPART PROT- human/insulin aspart Generics INSULN ASP 12/14/2019 INSULIN insulin aspart ADD TO FORMULARY Non-Preferred ASPART Generics FLEXPEN 12/14/2019 everolimus everolimus ADD TO FORMULARY Non-Preferred Specialty BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 3 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/14/2019 everolimus everolimus ADD TO FORMULARY Non-Preferred Specialty 12/14/2019 everolimus everolimus ADD TO FORMULARY Non-Preferred Specialty 12/14/2019 EGRIFTA SV tesamorelin acetate ADD TO FORMULARY Non-Preferred Specialty 12/20/2019 anthralin anthralin REMOVE FROM Non-Formulary FORMULARY 12/20/2019 anthralin anthralin REMOVE FROM Non-Formulary FORMULARY 12/20/2019 anthralin anthralin REMOVE FROM Non-Formulary FORMULARY 12/20/2019 anthralin anthralin REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 metaproterenol metaproterenol sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 12/20/2019 ERYTHROCIN erythromycin stearate REMOVE FROM Non-Formulary STEARATE FORMULARY BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 4 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 ketamine hcl ketamine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 sodium nitroprusside sodium REMOVE FROM Non-Formulary nitroprusside FORMULARY 12/20/2019 phenylephrine hcl phenylephrine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 vitamin b-6 pyridoxine hcl (vitamin b6) REMOVE FROM Non-Formulary FORMULARY 12/20/2019 phentermine hcl phentermine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 betamethasone betamethasone acetate, REMOVE FROM Non-Formulary acetate micro micronized FORMULARY 12/20/2019 betamethasone betamethasone acetate, REMOVE FROM Non-Formulary acetate micro micronized FORMULARY 12/20/2019 ketamine hcl ketamine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 loperamide loperamide hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 8hr arthritis pain acetaminophen REMOVE FROM Non-Formulary FORMULARY 12/20/2019 sleep aid doxylamine succinate REMOVE FROM Non-Formulary FORMULARY 12/20/2019 KADIAN morphine sulfate REMOVE FROM Non-Formulary FORMULARY 12/20/2019 venlafaxine hcl er venlafaxine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 venlafaxine hcl er venlafaxine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 venlafaxine hcl er venlafaxine hcl REMOVE FROM Non-Formulary FORMULARY BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 5 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 venlafaxine hcl er venlafaxine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 povidone k-30 povidone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 povidone k-30 povidone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 testosterone testosterone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 adapalene- adapalene/benzoyl peroxide REMOVE FROM Non-Formulary benzoyl peroxide FORMULARY 12/20/2019 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 12/20/2019 versabase gel base no.239 REMOVE FROM Non-Formulary anhydrous hrt FORMULARY 12/20/2019 ABC COMPLETE multivit-calc-min/ferrous REMOVE FROM Non-Formulary SENIOR fumarate/folic acid/vit FORMULARY WOMEN'S k1/lutein 12/20/2019 REFRESH carboxymethylcellulose REMOVE FROM Non-Formulary RELIEVA PF sodium/glycerin/pf FORMULARY 12/20/2019 NOVOLIN N insulin nph human isophane REMOVE FROM Non-Formulary FLEXPEN FORMULARY 12/20/2019 NOVOLIN N insulin nph human isophane REMOVE FROM Non-Formulary FLEXPEN FORMULARY 12/20/2019 NOVOLIN R insulin regular, human REMOVE FROM Non-Formulary FLEXPEN FORMULARY 12/20/2019 NOVOLIN R insulin regular, human REMOVE FROM Non-Formulary FLEXPEN FORMULARY BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 6 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 senna sennosides REMOVE FROM Non-Formulary FORMULARY 12/20/2019 gerber good start lactobacillus reuteri REMOVE FROM Non-Formulary grow kids FORMULARY 12/20/2019 westab one cyanocobalamin/folic REMOVE FROM Non-Formulary acid/pyridoxine FORMULARY 12/20/2019 CLOZARIL clozapine REMOVE FROM Non-Formulary FORMULARY 12/20/2019 CLOZARIL clozapine REMOVE FROM Non-Formulary FORMULARY 12/20/2019 HEALON GV hyaluronate sodium ADD TO FORMULARY Injectables PRO 12/20/2019 MICROVIX LP lidocaine/prilocaine/benzalk REMOVE FROM Non-Formulary onium chloride/dressing FORMULARY 12/20/2019 LANOXIN digoxin REMOVE FROM Non-Formulary PEDIATRIC FORMULARY 12/20/2019 LANOXIN digoxin REMOVE FROM Non-Formulary FORMULARY 12/20/2019 norethindrone-eth norethindrone acetate- ADD TO FORMULARY Preventative estradiol-fe ethinyl estradiol/ferrous fumarate 12/20/2019 isosorbide isosorbide dinitrate REMOVE FROM Non-Formulary dinitrate FORMULARY 12/20/2019 sulconazole sulconazole nitrate ADD TO FORMULARY Non-Preferred nitrate Generics 12/20/2019 sulconazole sulconazole nitrate ADD TO FORMULARY Non-Preferred nitrate Generics 12/20/2019 dapsone dapsone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 dapsone dapsone REMOVE FROM Non-Formulary FORMULARY BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 7 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 etonogestrel- etonogestrel/ethinyl estradiol REMOVE FROM Non-Formulary ethinyl estradiol FORMULARY 12/20/2019 eluryng etonogestrel/ethinyl estradiol REMOVE FROM Non-Formulary FORMULARY 12/27/2019 ciprofloxacin-d5w ciprofloxacin REMOVE FROM Non-Formulary lactate/dextrose 5 % in FORMULARY water 12/27/2019 cupric chloride cupric chloride REMOVE FROM Non-Formulary FORMULARY 12/27/2019 cupric chloride cupric chloride REMOVE FROM Non-Formulary FORMULARY 12/27/2019 amoxicillin- amoxicillin/potassium ADD TO FORMULARY Preferred clavulanate clavulanate Generics potass 12/27/2019 l-glutathione glutathione REMOVE FROM Non-Formulary FORMULARY 12/27/2019 l-glutathione glutathione REMOVE FROM Non-Formulary FORMULARY 12/27/2019 l-glutathione glutathione REMOVE FROM Non-Formulary FORMULARY 12/27/2019 l-glutathione