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National Core Formulary

The IHS National Core Formulary represents the basic standard of care drugs which must be carried by all federal facilities to generally promote the parity, portability, quality, safety, convenience, and cost-effectiveness of the pharmacy benefit.

  • It establishes the "floor" for the pharmacy benefit.
  • Except in closed classes, facilities are expected to add other drugs to the local formulary as needed.
Last Updated: 11/10/2022
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The following is a list of Medications currently in the queue. 225 record(s) found.
The following is a list of Medications currently in the queue. 225 record(s) found.
MedicationPharmacological CategoryFormulary BriefNotesSimilar Medications
Finasteride 5 Alpha-Reductase Inhibitor Benign Prostatic Hypertrophy (Nov 2022)
Sulfasalazine 5-Aminosalicylic Acid Derivative Inflammatory Bowel Disease (2018) Hydroxychloroquine; Leflunomide; Methotrexate
Donepezil Acetylcholinesterase Inhibitor (Central) Alzheimer's disease (2019) 5mg and 10mg strengths
Epinephrine Injection Devices (both 0.15mg and 0.3mg) Alpha-/Beta- Agonist Epinephrine Injection Devices (2020 Any device, auto-injector or pre-filled syringe
Tamsulosin Alpha1 Blocker Benign Prostatic Hypertrophy (Nov 2022) Doxazosin; Prazosin
Prazosin Alpha1 Blocker; Antihypertensive Post Traumatic Stress Disorder (2021) Doxazosin; Tamsulosin
Doxazosin Alpha1 Blocker; Antihypertensive Benign Prostatic Hypertrophy (Nov 2022) Prazosin; Tamsulosin
Lactulose Ammonium Detoxicant; Laxative, Osmotic Hepatic Encephalopathy (2020) Polyethylene glycol
Acetaminophen Analgesic, Miscellaneous Short-Acting Opioids (2014)
Buprenorphine, long-acting (**REMS drug**) Analgesic, Opioid; Analgesic, Opioid Partial Agonist MAT for OUD (2021) Any formulation; Restricted to treatment of Opioid Use Disorder; **See REMS here** Exit Disclaimer: You Are Leaving www.ihs.gov  Buprenorphine, short-acting (**REMS drug**); Buprenorphine-Naloxone (**REMS drug**)
Buprenorphine-Naloxone (**REMS drug**) Analgesic, Opioid; Analgesic, Opioid Partial Agonist MAT for OUD (2021) **See REMS here** Exit Disclaimer: You Are Leaving www.ihs.gov  Naloxone
Buprenorphine, short-acting (**REMS drug**) Analgesic, Opioid; Analgesic, Opioid Partial Agonist MAT for OUD (2021) Any formulation; Restricted to treatment of Opioid Use Disorder; **See REMS here** Exit Disclaimer: You Are Leaving www.ihs.gov  Buprenorphine, long-acting (**REMS drug**); Buprenorphine-Naloxone (**REMS drug**)
Testosterone (**REMS Drug**) Androgen Male Hypogonadism (2022) Any formulation; Certain formulations (i.e., undecoanate) have REMS requirements Exit Disclaimer: You Are Leaving www.ihs.gov 
Sacubitril and Valsrtan Angiotensin II Receptor Blocker; Neprilysin Inhibitor Heart Failure with Reduced Ejection Fraction (HFrEF) (2022)
Nitroglycerin 0.4 milligrams, sublingual Antianginal Agent; Antidote, Extravasation; Vasodilator Anti-Anginal Treatment (2013) Isosorbide mononitrate; Nitroglycerin patch
Nitroglycerin patch Antianginal Agent; Antidote, Extravasation; Vasodilator Anti-Anginal Treatment (2013) Isosorbide mononitrate
Isosorbide mononitrate Antianginal Agent; Vasodilator Anti-Anginal Treatment (2013) Nitroglycerin patch
Digoxin Antiarrhythmic Agent, Miscellaneous; Cardiac Glycoside Heart Failure with Reduced Ejection Fraction (HFrEF) (2022)
Cephalexin Antibiotic, Cephalosporin (First Generation) Outpatient Abx Stewardship & URIs (2021) Pediatric and Adult oral formulations Cefdinir; Cefixime; Ceftriaxone Injection
Cefdinir Antibiotic, Cephalosporin (Third Generation) Outpatient Abx Stewardship & URIs (2021) Pediatric and Adult oral formulations Cefixime; Ceftriaxone Injection; Cephalexin
Ceftriaxone, injection Antibiotic, Cephalosporin (Third Generation) STIs - PART 1 (2021) Cefdinir; Cefixime; Cephalexin
Cefixime Antibiotic, Cephalosporin (Third Generation) STIs - PART 1 (2021) For outpatient treatment of gonorrhea for Expedited Partner Therapy or when injection therapy is not possible Cefdinir; Ceftriaxone Injection; Cephalexin
Ciprofloxacin, oral Antibiotic, Fluoroquinolone Male Genitourinary Infections (Nov 2022)
Clindamycin Antibiotic, Lincosamide Outpatient Abx Stewardship & URIs (2021) Pediatric and Adult oral formulations
Azithromycin Antibiotic, Macrolide STIs - PART 1 (2021)
Nitrofurantoin Antibiotic, Miscellaneous Urinary Tract Infections (2021)
Trimethoprim-Sulfamethoxazole Antibiotic, Miscellaneous Skin & Soft Tissue Infections (2021)
Metronidazole, oral Antibiotic, Miscellaneous 2021 CDC Guidelines for Sexually Transmitted Infections (2021) Tinidazole
Tinidazole Antibiotic, Miscellaneous 2021 CDC Guidelines for Sexually Transmitted Infections (2021) Metronidazole
Polymyxin B/Trimethoprim, ophthalmic solution Antibiotic, Ophthalmic Ocular Treatments (2022) Artificial Tear substitute, ophthalmic (preservative free); Ciprofloxacin, ophthalmic solution; Corticosteroid (Ophthalmic) - Low Potency
Ciprofloxacin, ophthalmic solution Antibiotic, Ophthalmic Fluoroquinolone Ocular Treatments (2022) Artificial Tear substitute, ophthalmic (preservative free); Corticosteroid (Ophthalmic) - Low Potency; Polymyxin B/trimethoprim, Ophthalmic Solution
Penicllin V potassium Antibiotic, Penicillin Outpatient Abx Stewardship & URIs (2021) Pediatric and Adult oral formulations Amoxicillin; Amoxicillin and Clavulanate; Penicillin G benzathine
Amoxicillin Antibiotic, Penicillin Outpatient Abx Stewardship & URIs (2021) Pediatric and Adult oral formulations Amoxicillin and Clavulanate; Penicillin G benzathine; Penicllin V potassium
Amoxicillin and Clavulanate Antibiotic, Penicillin Outpatient Abx Stewardship & URIs (2021) Pediatric and Adult oral formulations Amoxicillin; Penicillin G benzathine; Penicllin V potassium
Penicillin G benzathine Antibiotic, Penicillin STIs - PART 1 (2021) Amoxicillin; Amoxicillin and Clavulanate; Penicllin V potassium
Rifaximin Antibiotic, Rifamycin Hepatic Encephalopathy (2020) After failure of, or intolerance to, lactulose monotherapy as indicated for hepatic encephalopathy Lactulose
Doxycycline Antibiotic, Tetracycline STIs - PART 1 (2021)
Mupirocin Antibiotic, Topical Skin & Soft Tissue Infections (2021)
Metronidazole, topical Antibiotic, Topical Rosacea (2022)
Dicyclomine Anticholinergic Agent Irritable Bowel Syndrome (2018)
Apixaban Anticoagulant; Direct Oral Anticoagulant (DOAC); Factor Xa Inhibitor Direct Oral Anticoagulants (2017) Warfarin
Warfarin Anticoagulant; Vitamin K Antagonist Direct Oral Anticoagulants (2017) Apixaban; Low-molecular weight heparin
Phenytoin Anticonvulsant, Hydantoin Antiseizure Drugs (2021) Carbamazepine; Divalproex; Lamotrigine; Levetiracetam; Topiramate
Topiramate Anticonvulsant, Miscellaneous Alcohol Use Disorder (2022) Carbamazepine; Divalproex; Lamotrigine; Levetiracetam; Phenytoin
Carbamazepine Anticonvulsant, Miscellaneous Bipolar Disorder (2022) Divalproex; Lamotrigine; Levetiracetam; Phenytoin; Topiramate
Levetiracetam Anticonvulsant, Miscellaneous Antiseizure Drugs (2021) Carbamazepine; Divalproex; Lamotrigine; Phenytoin; Topiramate
Lamotrigine Anticonvulsant, Miscellaneous Bipolar Disorder (2022) Carbamazepine; Divalproex; Levetiracetam; Phenytoin; Topiramate
Divalproex Anticonvulsant, Miscellaneous Bipolar Disorder (2022) Carbamazepine; Lamotrigine; Levetiracetam; Phenytoin; Topiramate
Oxcarbazepine Anticonvulsant, Miscellaneous Bipolar Disorder (2022) Carbamazepine; Clonazepam; Divalproex; Gabapentin; Lamotrigine; Levetiracetam; Phenytoin; Topiramate
Phentermine and Topiramate ER (**REMS drug**) Anticonvulsant, Miscellaneous; Central Nervous System Stimulant Obesity Management (2022) **For REMS criteria, see Formulary Brief**
Gabapentin Anticonvulsant, Miscellaneous; GABA Analog Antiseizure Drugs (2021)
Ethosuximide Anticonvulsant, Succinimide Anti-Seizure Drugs (2021) Carbamazepine; Clonazepam; Divalproex; Gabapentin; Lamotrigine; Levetiracetam; Phenytoin; Topiramate
Bupropion Antidepressant, Dopamine/Norepinephrine-Reuptake Inhibitor; Smoking Cessation Aid Stimulant Use Disorder (2022) Varenicline; Venlafaxine
Fluoxetine Antidepressant, Selective Serotonin Reuptake Inhibitor Bipolar Disorder (2022) Sertraline
Sertraline Antidepressant, Selective Serotonin Reuptake Inhibitor Bipolar Disorder (2022) Citalopram; Escitalopram; Fluoxetine; Paroxetine
Citalopram Antidepressant, Selective Serotonin Reuptake Inhibitor Bipolar Disorder (2022) Escitalopram; Fluoxetine; Paroxetine; Sertraline
Escitalopram Antidepressant, Selective Serotonin Reuptake Inhibitor Bipolar Disorder (2022) Citalopram; Fluoxetine; Paroxetine; Sertraline
Paroxetine Antidepressant, Selective Serotonin Reuptake Inhibitor Bipolar Disorder (2022) Citalopram; Escitalopram; Fluoxetine; Sertraline
Duloxetine Antidepressant, Serotonin/Norepinephrine Reuptake Inhibitor/Antagonist Bipolar Disorder (2022) Bupropion; Venlafaxine
Venlafaxine Antidepressant, Serotonin/Norepinephrine Reuptake Inhibitor/Antagonist Bipolar Disorder (2022) Bupropion; Duloxetine
Nortriptyline Antidepressant, Tricyclic Bipolar Disorder (2022) Amitriptyline
Amitriptyline Antidepressant, Tricyclic Bipolar Disorder (2022) Nortriptyline
Alogliptin Antidiabetic Agent, Dipeptidyl Peptidase 4 (DPP-4) Inhibitor DPP-IV Inhibitors (2019)
Liraglutide -or- Semaglutide Antidiabetic Agent, Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist GLP-1 Receptor Agonists (2019) Select either of these subcutaneous agents, no preference given
Semaglutide -or- Liraglutide Antidiabetic Agent, Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist Long-term Pharmacotherapy for the Patient with Overweight or Obesity (2022) Select either of these subcutaneous agents, no preference given
Empagliflozin Antidiabetic Agent, Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor Heart Failure with Reduced Ejection Fraction (HFrEF) (2022)
Pioglitazone Antidiabetic Agent, Thiazolidinedione Thiazolidinediones (2017)
Metformin Antidiabetic Agent; Biguanide Diabetes Treatment Overview (2017)
Glipizide Antidiabetic Agent; Sulfonylurea Diabetes Treatment Overview (2017)
Loperamide Antidiarrheal Irritable Bowel Syndrome (2018)
Glucose, oral Antidote Glucagon Products Review (2021) Any formulation Glucagon
Glucagon Antidote; Hypoglycemia Glucagon Products Review (2021) For outpatient use
Naloxone Antidote; Opioid Antagonist Opioid Use Disorder (2018)
Naltrexone, oral Antidote; Opioid Antagonist Alcohol Use Disorder (2022) Naloxone
Naltrexone, extended-release for injection Antidote; Opioid Antagonist Opioid Use Disorder (2018)
Ondansetron Antiemetic; Selective 5-HT3 Receptor Antagonist Antiemetic Agents (2021)
Fluconazole, oral Antifungal Agent, Azole Derivative Male Genitourinary Infections (Nov 2022)
Clotrimazole, topical Antifungal Agent, Imidazole Derivative Male Genitourinary Infections (Nov 2022)
Allopurinol Antigout Agent; Xanthine Oxidase Inhibitor Gout (2016)
Glecaprevir/Pibrentasvir (Mavyret®) Antihepaciviral HCV Treatment (2018) Ledipasvir/sofosbuvir (Harvoni®); Sofosbuvir/velpatasvir (Epclusa®)
Ledipasvir/Sofosbuvir (Harvoni®) Antihepaciviral HCV Treatment (2018) Glecaprevir/Pibrentasvir (Mavyret®); Sofosbuvir/velpatasvir (Epclusa®)
Sofosbuvir/Velpatasvir (Epclusa®) Antihepaciviral HCV Treatment (2018) Glecaprevir/Pibrentasvir (Mavyret®); Ledipasvir/Sofosbuvir (Harvoni®)
Torsemide -OR- Bumetanide Antihypertensive Heart Failure with Preserved Ejection Fraction (HFpEF) (2022) Bumetanide -OR- Torsemide; Furosemide
Bumetanide -OR- Torsemide Antihypertensive Heart Failure with Preserved Ejection Fraction (HFpEF) (2022) Furosemide; Torsemide -OR- Bumetanide
Furosemide Antihypertensive Heart Failure with Preserved Ejection Fraction (HFpEF) (2022)
Losartan Antihypertensive, Angiotensin II Receptor Blocker Hypertension (2022)
Lisinopril Antihypertensive, Angiotensin-Converting Enzyme Inhibitor Hypertension (2022)
Carvedilol, immediate-release Antihypertensive; Beta-Blocker with Alpha-Blocking Activity Heart Failure with Reduced Ejection Fraction (HFrEF) (2022) Atenolol; Propranolol
Atenolol Antihypertensive; Beta-Blocker, Beta1 Selective Hypertension (2022) Propranolol
Metoprolol succinate Antihypertensive; Beta-Blocker, Beta1 Selective Heart Failure with Reduced Ejection Fraction (HFrEF) (2022) Atenolol; Carvedilol, immediate-release; Propranolol
Metoprolol tartrate Antihypertensive; Beta-Blocker, Beta1 Selective Heart Failure with Reduced Ejection Fraction (HFrEF) (2022) Atenolol; Carvedilol, immediate-release; Metoprolol succinate
Propranolol Antihypertensive; Beta-Blocker, Non-Selective Migraine Prevention (2019) Atenolol
Amlodipine Antihypertensive; Calcium Channel Blocker, Dihydropyridine Hypertension (2022) Diltiazem
Diltiazem Antihypertensive; Calcium Channel Blocker, Nondihydropyridine Hypertension (2022) Amlodipine
Spironolactone Antihypertensive; Mineralocorticoid Receptor Antagonists; Potassium Sparing Diuretic Heart Failure with Reduced Ejection Fraction (HFrEF) (2022)
Hydrochlorothiazide Antihypertensive; Thiazide Diuretic Hypertension (2022) Chlorthalidone
Chlorthalidone Antihypertensive; Thiazide-Related Diuretic Hypertension (2022) Hydrochlorothiazide
Ezetimibe Antilipemic Agent, 2-Azetidinone Hyperlipidemia (2022)
Atorvastatin Antilipemic Agent, HMG-CoA Reductase Inhibitor Hyperlipidemia (2022) Pravastatin; Rosuvastatin; Simvastatin
Rosuvastatin Antilipemic Agent, HMG-CoA Reductase Inhibitor Hyperlipidemia (2022) Atorvastatin; Pravastatin; Simvastatin
Simvastatin Antilipemic Agent, HMG-CoA Reductase Inhibitor Hyperlipidemia (2022) Atorvastatin; Pravastatin; Rosuvastatin
Pravastatin Antilipemic Agent, HMG-CoA Reductase Inhibitor Hyperlipidemia (2022) Atorvastatin; Rosuvastatin; Simvastatin
Hydroxychloroquine Antimalarial Non-biologic DMARDs (2016) Leflunomide; Methotrexate; Sulfasalazine
Lithium Antimanic Agent Bipolar Disorder (2022)
Serotonin 5-HT1 agonist (Triptan) Antimigraine Agent; Serotonin 5-HT 1B/1D Receptor Agonist Acute Migraine (2021) Any two (2) triptan medications are required, one must be sumatriptan Sumatriptan
Sumatriptan Antimigraine Agent; Serotonin 5-HT 1B/1D Receptor Agonist Acute Migraine (2021) Any two (2) triptan medications are required, one must be sumatriptan
Letrozole Antineoplastic Agent, Aromatase Inhibitor NPTC Update Spring 2021
Anastrozole Antineoplastic Agent, Aromatase Inhibitor NPTC Update Spring 2021
Tamoxifen Antineoplastic Agent, Estrogen Receptor Antagonist; Selective Estrogen Receptor Modulator NPTC Update Spring 2021
Leuprolide Antineoplastic Agent, Gonadotropin-Releasing Hormone Agonist Treatment of Prostate Cancer (Nov 2022) **Any depot form**
Methotrexate Antineoplastic Agent; Antirheumatic; Disease Modifying; Immunosuppresant Agent Non-biologic DMARDs (2016) Hydroxychloroquine; Leflunomide; Sulfasalazine
Permethrin 5% cream Antiparasitic Agent, Topical; Pediculocide; Scabicidal Agent Sexually Transmitted Infections, Part III (2022) Permethrin 1%, any formulation
Permethrin 1% Antiparasitic Agent, Topical; Pediculocide; Scabicidal Agent Sexually Transmitted Infections, Part III (2022) *Any formulation* Permethrin 5% cream
Pramipexole Anti-Parkinson Agent, Dopamine Agonist Insomnia/Sleep Medications (2021)
Carbidopa-Levodopa, immediate-release Anti-Parkinson Agent; Decarboxylase Inhibitor-Dopamine Precursor Parkinson's Disease (2019)
Clopidogrel Antiplatelet Agent Antiplatelets (2015) Aspirin
Aspirin Antiplatelet Agent; Nonsteroidal Anti-Inflammatory Drug; Salicylate Pregnancy & Prenatal Care (2021)
Atypical antipsychotic Antipsychotic, Atypical Bipolar Disorders (2022) *Any product* Aripiprazole lauroxil; Haloperidol decanoate
Aripiprazole lauroxil Antipsychotic, Atypical (Second Generation) - Injectable Long-Acting Injectable Antipsychotics (2020) Injectable Haloperidol decanoate
Haloperidol decanoate Antipsychotic, Typical (First Generation) - Injectable Long-Acting Injectable Antipsychotics (2020) Injectable Aripiprazole lauroxil
Dolutegravir Antiretroviral, Integrase Inhibitor (Anti-HIV) HIV Updates (2020) For HIV treatment in pregnant patients Emtricitabine/tenofovir disoproxil fumarate; Raltegravir
Bictegravir/Emtricitabine/Tenofovir alafenamide Antiretroviral, Integrase Inhibitor (Anti-HIV) HIV Treatment (2019) Dolutegravir/abacavir/lamivudine; Emtricitabine/tenofovir disoproxil fumarate; Raltegravir
Dolutegravir/Abacavir/Lamivudine Antiretroviral, Integrase Inhibitor (Anti-HIV) HIV Treatment (2019) *Note: HLA B5701 testing required prior to initiation Bictegravir/Emtricitabine/Tenofovir alafenamide; Dolutegravir; Emtricitabine/tenofovir disoproxil fumarate; Raltegravir
Raltegravir Antiretroviral, Integrase Inhibitor (Anti-HIV) HIV Treatment (2019) For (1) HIV Post-Exposure Prophylaxis (with emtricitabine/ tenofovir DF) or (2) HIV Treatment (with emtricitabine/tenofovir DF) in patients with contraindications for 1st line anti-HIV agents Emtricitabine/tenofovir disoproxil fumarate
Emtricitabine/Tenofovir disoproxil fumarate Antiretroviral, Reverse Transcriptase Inhibitor, Nucleoside (Anti-HIV); Antiretroviral, Reverse Transcriptase Inhibitor, Nucleotide (Anti-HIV) HIV Pre-Exposure Prophylaxis (PrEP) (2018) For (1) Pre-Exposure HIV Prophylaxis, (2) Post-Exposure HIV Prophylaxis (with raltegravir) or (3) HIV Treatment (with raltegravir) in patients with contraindications for 1st line anti-HIV agents Raltegravir
Leflunomide Antirheumatic, Disease Modifying Non-biologic DMARDs (2016) Hydroxychloroquine; Methotrexate; Sulfasalazine
Etanercept -OR- Adalimumab (can choose either product) Antirheumatic, Disease Modifying; Tumor Necrosis Factor (TNF) Blocking Agent TNF Inhibitors (2016) ONLY In consultation with a rheumatologist Adalimumab -OR- Etanercept (can choose either product)
Adalimumab -OR- Etanercept (can choose either product) Antirheumatic, Disease Modifying; Tumor Necrosis Factor (TNF) Blocking Agent TNF Inhibitors (2016) ONLY In consultation with a rheumatologist Etanercept -OR- Adalimumab (can choose either product)
Oxybutynin, immediate-release Antispasmodic Agent, Urinary Antimuscarinics (2019) Oxybutynin, extended-release
Oxybutynin, extended-release Antispasmodic Agent, Urinary Antimuscarinics (2019) Oxybutynin, Immediate-release
Methimazole Antithyroid Agent; Thioamide Hyperthyroidism (2021) Propylthiouracil
Propylthiouracil Antithyroid Agent; Thioamide Hyperthyroidism (2021) Methimazole
Rifampin Antitubercular Agent Treatment of Tuberculosis (2021) Ethambutol; Isoniazid; Pyrazinamide; Rifapentine
Rifapentine Antitubercular Agent Treatment of Tuberculosis (2021) Ethambutol; Isoniazid; Pyrazinamide; Rifampin
Pyrazinamide Antitubercular Agent Treatment of Tuberculosis (2021) Ethambutol; Isoniazid; Rifampin
Ethambutol Antitubercular Agent Treatment of Tuberculosis (2021) Isoniazid; Pyrazinamide; Rifampin; Rifapentine
Isoniazid Antitubercular Agent Treatment of Tuberculosis (2021) Ethambutol; Pyrazinamide; Rifampin; Rifapentine
Valacyclovir Antiviral Agent, Oral 2021 CDC Guidelines for Sexually Transmitted Infections (2021)
Oseltamivir Antiviral Agent; Neuraminidase Inhibitor Treatment of Influenza (2019)
Clonazepam Benzodiazepine Antiseizure Drugs (2021) Lorazepam
Lorazepam Benzodiazepine Alcohol Withdrawal Syndrome (2015) Clonazepam
Albuterol, metered dose inhaler (MDI) Beta2 Agonist Asthma & COPD Guidelines Review (2019) *Any product*
Albuterol nebulized solution Beta2 Agonist Asthma & COPD Guidelines Review (2019)
Fluticasone/Salmeterol Beta2 Agonist, Long-Acting; Corticosteroid, Inhalant LABAs (2019) Mometasone (Asmanex®)
Alendronate Bisphosphonate Derivative Osteoporosis (2016)
Laxative, bulk-forming Bulk-forming Laxative Added July 2011 (Constipation) *Any product*
Tacrolimus, topical Calcineurin Inhibitor; Immunosuppressant Agent; Topical Skin Product Atopic Dermatitis (2020) Corticosteriods (Topical) - High Potency (Class I and II); Corticosteroid (Topical) - Intermediate Potency; Corticosteroid (Topical) - Low Potency; Moisturizers (both cream- AND petroleum-based)
Dextroamphetamine / Amphetamine (immediate release) Central Nervous System Stimulant ADHD (Jan 2020) Pediatric use only
Dextroamphetamine / Amphetamine (long-acting) Central Nervous System Stimulant ADHD (Jan 2020) Pediatric use only
Methylphenidate (immediate release) Central Nervous System Stimulant ADHD (Jan 2020) Pediatric use only Methylphenidate (long-acting)
Methylphenidate (long-acting) Central Nervous System Stimulant ADHD (Jan 2020) Pediatric use only Methylphenidate (immediate release)
Oral contraceptive pill, extended cycle Contraceptive Contraception (2016) *Any product*
Oral contraceptive pill, monophasic: 20mcg EE (low) Contraceptive Contraception (2016) *Any product*
Oral contraceptive pill, monophasic: 30-35mcg EE (medium) Contraceptive Contraception (2016) *Any product*
Oral contraceptive pill, progestin only Contraceptive Contraception (2016) *Any product*
Oral contraceptive pill, triphasic Contraceptive Contraception (2016) *Any product*
Intrauterine device, copper Contraceptive Long Acting Reversible Contraception (2021) *Any product*; For use by a skilled and privileged provider Intrauterine device, levonorgestrel
Intrauterine device, levonorgestrel Contraceptive, Progestin Long Acting Reversible Contraception (2021) *Any product*; For use by a skilled and privileged provider Intrauterine device, copper
Levonorgestrel (Plan B One-Step®) Contraceptive, Progestin Contraception (2016) *Branded product* Ulipristal
Medroxyprogesterone acetate, injection Contraceptive, Progestin (Injection/Depot) Contraception (2016) Medroxyprogesterone, oral; Oral contraceptive pill, progestin only
Ethinyl estradiol / Etonogestrel vaginal ring Contraceptive; Estrogen and Progestin Combination Contraception (2016)
Ethinyl estradiol / Norelgestromin, transdermal Contraceptive; Estrogen and Progestin Combination Contraception (2016)
Etonogestrel, implant Contraceptive; Progestin Long Acting Reversible Contraception (2021) For use by a skilled and privileged provider Oral contraceptive pill, progestin only
Medroxyprogesterone, oral Contraceptive; Progestin Polycystic Ovarian Syndrome (2017) Medroxyprogesterone acetate, injection; Oral contraceptive pill, progestin only
Ulipristal Contraceptive; Progestin Receptor Modulator Contraception (2016) Levonorgestrel (Plan B One-Step®)
Mometasone (Asmanex®) Corticosteroid, Inhalant Asthma & COPD Guidelines Review (2019) *Branded product*
Corticosteroid (Ophthalmic) - Low Potency Corticosteroid, Ophthalmic Ocular Treatments (2022) *Any product - see Form Brief for suggested products Artificial Tear substitute, Ophthalmic (Preservative Free); Ciprofloxacin, Ophthalmic Solution; Polymyxin B/trimethoprim, Ophthalmic Solution; Prednisolone, Ophthalmic Suspension
Prednisolone acetate, ophthalmic suspension Corticosteroid, Ophthalmic Ocular Treatments (2022) Artificial Tear substitute, ophthalmic (preservative free); Ciprofloxacin, ophthalmic solution; Corticosteroid (Ophthalmic) - Low Potency; Polymyxin B/Trimethoprim, ophthalmic solution
Prednisone Corticosteroid, Systemic Atopic Dermatitis (2020)
Calcium Electrolyte Supplement Osteoporosis (2016) *Any formulation*
Estradiol tablets Estrogen Derivative Gender-Affirming Medications (2022) Estradiol for Injection; Estradiol, transdermal
Estrogen vaginal cream Estrogen Derivative NPTC Meeting Update (May 2018) *Any product* Estradiol tablets
Estradiol, transdermal Estrogen Derivative Gender Affirming Therapies (2022) *Any patch* Estradiol for Injection; Estradiol tablets
Estradiol for Injection Estrogen Derivative Gender Affirming Therapies (2022) Either valerate or cypionate product Estradiol tablets; Estradiol, transdermal
Hydroxyzine Histamine H1 Antagonist, First Generation Anxiety Disorders (2021)
H1 Antagonist (2nd generation), long-acting Histamine H1 Antagonist, Second Generation Allergic Rhinitis (2018) *Any product*
Famotidine Histamine H2 Antagonist Fall 2022 NPTC Meeting Update
Insulin aspart / Insulin aspart protamine (NovoLog® Mix 70/30) Insulin, Combination (70/30 Mix) Diabetes Treatment Overview (2017) *Branded product*; Pen Device
Insulin NPH / Regular human insulin (NovoLIN® 70/30) Insulin, Combination (70/30 Mix) Diabetes Treatment Overview (2017) *Branded product*
Insulin NPH (NovoLIN® N) Insulin, Intermediate-Acting Diabetes Treatment Overview (2017) *Branded product*
Insulin detemir (Levemir®) Insulin, Long-Acting Long-acting Insulins & Biosimilars (2021) *Branded product*; Pen Device
Insulin glargine, any Insulin, Long-Acting Long-Acting Insulins & Biosimilars (2021) An interchangeable biosimilar product is a biosimilar that meets additional requirements outlined by the law that allows for the FDA to approve biosimilar and interchangeable biosimilar medications. Insulin detemir (Levemir®)
Insulin aspart (NovoLog®) Insulin, Rapid-Acting Diabetes Treatment Overview (2017) *Branded product*; Pen Device
Insulin Regular human (NovoLIN® R) Insulin, Short-Acting Diabetes Treatment Overview (2017) *Branded product*
Corticosteroid, intranasal Intranasal Corticosteroid Allergic Rhinitis (2018) *Any product*
Iron, oral Iron Salt Pregnancy & Prenatal Care (2021) *Any oral formulation*
Polyethylene glycol Laxative, Osmotic Irritable Bowel Syndrome (2018) *Any product* Lactulose
Montelukast Leukotriene Receptor Antagonist Asthma & COPD Guidelines Review (2019)
Tiotropium (Spiriva®) Long-Acting Anticholinergic Agent Long Acting Muscarinic Antagonists (2019) *Branded product*
Umeclidinium/Vilanterol Long-Acting Muscarinic Antagonist (LAMA) / Long-Acting Beta2 Agonist (LABA) LAMAs (2019) Tiotropium (Spiriva®)
Low-molecular weight heparin Low-molecular Weight Heparin VTE Prophylaxis (2011) *Any product*
Memantine N-Methyl-D-Aspartate (NMDA) Receptor Antagonist Alzheimer's disease (2019)
Meloxicam Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Ibuprofen; Indomethacin; Naproxen
Naproxen Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Ibuprofen; Indomethacin
Ibuprofen Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Indomethacin; Meloxicam; Naproxen
Indomethacin Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) Diclofenac; Ibuprofen; Meloxicam; Naproxen
Diclofenac Nonsteroidal Anti-Inflammatory Drug NSAIDs (2014) *Any formulation* Ibuprofen; Indomethacin; Meloxicam; Naproxen
Atomoxetine Norepinephrine Reuptake Inhibitor, Selective ADHD (Jan 2020) Dextroamphetamine / Amphetamine (immediate release); Dextroamphetamine / Amphetamine (long-acting); Methylphenidate (immediate release); Methylphenidate (long-acting)
Fluoride, oral Nutritional Supplement Supplements in Oral Health (2016) *Any oral formulation*
Artificial Tear substitute, ophthalmic (preservative free) Ophthalmic Agent, Miscellaneous Ocular Treatments (2022) *Any Preservative-Free product* Ciprofloxacin, Ophthalmic Solution; Corticosteroid (Ophthalmic) - Low Potency; Polymyxin B/trimethoprim, Ophthalmic Solution
Ophthalmic Prostaglandin Analog Ophthalmic Prostaglandin Analog Ophth Prostaglandin Analogs (2018) *Any product*
Varenicline Partial Nicotine Agonist, Smoking Cessation Aid Nicotine Dependence (2020) Bupropion
Sevelamer carbonate Phosphate Binder Phosphate Binders (2018) For patients on dialysis who cannot use calcium-based phosphate binders due to hypercalcemia Calcium
Sildenafil Phosphodiesterase-5 Enzyme Inhibitor Erectile Dysfunction (Nov 2022) Tadalafil
Tadalafil Phosphodiesterase-5 Enzyme Inhibitor Erectile Dysfunction (Nov 2022) Sildenafil
Proton Pump Inhibitor Proton Pump Inhibitor GERD & PUD (2018) *Any product*
Salsalate Salicylate Added June 2008 (NSAIDs)
Moisturizers (both cream- AND petroleum-based) Skin and Mucous Membrane Agent, Miscellaneous; Topical Skin Product Atopic Dermatitis (2020) Corticosteriods (Topical) - High potency (Class I and II); Corticosteroid (Topical) - Intermediate potency; Corticosteroid (Topical) - Low potency; Tacrolimus
Nicotine replacement therapy (NRT), combination Smoking Cessation Aid Nicotine Dependence (2020) Combination NRT (nicotine patches + any short-acting NRT product) Bupropion; Varenicline
Laxative, stimulant Stimulant Laxative Added July 2011 (Constipation) *Any product*
Levothyroxine Thyroid Agent Originally added 2004
Corticosteroid (Topical) - Intermediate Potency Topical Corticosteroids Atopic Dermatitis (2020) *Any product* Corticosteroid (Topical) - Low Potency
Corticosteroid (Topical) - Low Potency Topical Corticosteroids Atopic Dermatitis (2020) *Any product* Corticosteroid (Topical) - Intermediate Potency
Corticosteroids (Topical) - High Potency (Class I and II) Topical Corticosteroids Alopecia Areata (2022) Corticosteroid (Topical) - Intermediate Potency; Corticosteroid (Topical) - Low Potency
Tretinoin, topical Topical Skin Product, Acne Treatment of Acne vulgaris (2020) *Any product*
Benzoyl Peroxide Topical Skin Product, Acne Acne Treatment (2020) Benzoyl Peroxide AND Clindamycin, topical combination
Benzoyl Peroxide AND Clindamycin, topical combination Topical Skin Product, Acne; Topical Skin Product, Acne (Lincosamide Antibiotic) Acne Treatment (2020) Benzoyl Peroxide
Sunscreen, Sun Protection Factor (SPF) 30 or greater Ultraviolet light protectant, topical Rosacea Treatment (2022)
Vaccines, All ACIP-recommended Vaccines Vaccine (2011) All ACIP recommended vaccines for routine use in accordance with ACIP guidelines
Prenatal Multivitamin Vitamin Pregnancy & Prenatal Care (2021) Must contain >400 mcg of folic acid/dose
Vitamin D Vitamin D Analog Pregnancy & Prenatal Care (2021) *Any product*
Vitamin D Analog, topical Vitamin D Analog Psoriasis (2018) *Any product*
Pyridoxine (Vitamin B6) Vitamin, Water Soluble Pregnancy & Prenatal Care (2021)
Cyanocobalamin (Vitamin B12), oral Vitamin, Water Soluble Hematologic Supplements (2016)
Folic Acid Vitamin, Water Soluble Pregnancy & Prenatal Care (2021) Any product containing >400 mcg / daily dose