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Formulary 10-03.xls

Mount Auburn Hospital Formulary Updated 10/8/03
Generic Name
Trade Name and Form
Formulary Notes
ALEMTUZUMAB
CAMPATH 30 MG/3 ML INJ
Oncologist ONLY
ALTEPLASE
TPA 50 MG INJ
Restricted
ALTEPLASE
TPA 100 MG INJ
Restricted
AMIFOSTINE
ETHYOL 500 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
AMIKACIN
AMIKIN 500 MG INJ
ID Approval Required
ACID
AMPHOTERICIN B
ABELCET 100 MG INJ
ID Approval Required
AMPHOTERICIN B
AMBISOME INJ
ID Approval Required
Mount Auburn Hospital Formulary Updated 10/8/03
ATOVAQUONE
MEPRON SUSP 750 MG/5 ML
ID Approval Required
Mount Auburn Hospital Formulary Updated 10/8/03
BICALUTAMIDE
CASODEX 50 MG TABLET
Oncologist ONLY
BLEOMYCIN
BLENOXANE 15 UN INJ
Oncologist ONLY
BUSULFAN
MYLERAN 2 MG TABLET
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
CARBOPLATIN
PARAPLATIN 50 MG INJ
Oncologist ONLY
ID Approval Required
CASPOFUNGIN CANCIDAS
INJECTION
Before Use
CEFTAZIDIME
FORTAZ 2 GM INJ
ID Approval Required
CEFTAZIDIME
FORTAZ 1 GM INJ
ID Approval Required
CEFTRIAXONE
ROCEPHIN 250 MG INJ
ID Approval Required
CEFTRIAXONE
ROCEPHIN 2 GM INJ
ID Approval Required
CEFTRIAXONE
ROCEPHIN 1 GM INJ
ID Approval Required
CHLORAMBUCIL
LEUKERAN 2 MG TABLET
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
CIPROFLOXACIN
CIPRO 400 MG IV BAG
ID Approval Required
CIPROFLOXACIN
CIPRO 200 MG IV BAG
ID Approval Required
CISPLATIN
PLATINOL 50 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
CYCLOPHOSPHAMIDE
CYTOXAN 50 MG TABLET
Oncologist ONLY
CYCLOPHOSPHAMIDE
CYTOXAN 25 MG TABLET
Oncologist ONLY
CYCLOPHOSPHAMIDE
CYTOXAN 1000 MG INJ
Oncologist ONLY
CYTARABINE
ARA-C 500 MG INJ
Oncologist ONLY
CYTARABINE
ARA-C 2000 MG INJ
Oncologist ONLY
CYTARABINE
ARA-C 100 MG INJ
Oncologist ONLY
DACARBAZINE
DTIC 200 MG INJ
Oncologist ONLY
DACARBAZINE
DTIC 100 MG INJ
Oncologist ONLY
ALFA/ALBUMIN
DAUNORUBICIN
CERUBIDINE 20 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
Mount Auburn Hospital Formulary Updated 10/8/03
DOCETAXEL
TAXOTERE 20 MG INJ
Oncologist ONLY
DOXORUBICIN
DOXIL 20 MG INJ
Oncologist ONLY
DOXORUBICIN
ADRIAMYCIN 10 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
ENOXAPARIN
LOVENOX INJ
Restricted
EPIRUBICIN
ELLENCE 50 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
ETOPOSIDE
VEPESID 50 MG CAPSULE
Oncologist ONLY
FINASTERIDE
PROSCAR 5 MG TABLET
Oncologist ONLY
FLUCONAZOLE
DIFLUCAN 200 MG IV BAG
ID Approval Required
FLUDARABINE
FLUDARA 50 MG INJ
Oncologist ONLY
FLUOROURACIL
FLUOROURACIL 500 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
HYDROBROMIDE
GANCICLOVIR
CYTOVENE 500 MG INJ
Oncologist ONLY
GEMCITABINE
GEMZAR 1000 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
Mount Auburn Hospital Formulary Updated 10/8/03
METHYLCELLULOSE
HYDROXYUREA
HYDREA 500 MG CAPSULE
Oncologist ONLY
IDARUBICIN
IDAMYCIN 5 MG INJ
Oncologist ONLY
IDARUBICIN
IDAMYCIN 10 MG INJ
Oncologist ONLY
IFOSFAMIDE
IFEX 1000 MG INJ
Oncologist ONLY
IMIPENEM/CILASTATIN
PRIMAXIN 500 MG INJ
ID Approval Required
ULTRALENTE
INSULIN LISPRO
HUMALOG 100 UN INJ
Restricted
INTERFERON ALPHA-2A
ROFERON 3 MU INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
IRINOTECAN
CAMPTOSAR 100 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
LEUPROLIDE
LUPRON DEPOT 7.5 MG INJ
Oncologist ONLY
LEUPROLIDE
LUPRON DEPOT 30 MG INJ
Oncologist ONLY
LEUPROLIDE
LUPRON DEPOT 3.75 MG INJ
Oncologist ONLY
LEUPROLIDE
LUPRON DEPOT 22.5 MG INJ
Oncologist ONLY
LEVOFLOXACIN
LEVAQUIN 500 MG
ID Approval Required
LEVOFLOXACIN
LEVAQUIN 250 MG
ID Approval Required
LINEZOLID
ZYVOX 600 MG TABLET
ID Approval Required
LINEZOLID
ZYVOX 600 MG IV BAG
ID Approval Required
Mount Auburn Hospital Formulary Updated 10/8/03
LOMUSTINE
CCNU 40 MG CAPSULE
Oncologist ONLY
LOMUSTINE
CCNU 100 MG CAPSULE
Oncologist ONLY
LOMUSTINE
CCNU 10 MG CAPSULE
Oncologist ONLY
VACCINE
MECHLORETHAMINE
MUSTARGEN 10 MG INJ
Oncologist ONLY
MEGESTROL ACETATE
MEGACE 4800 MG SUSPENSION
Oncologist ONLY
MEGESTROL ACETATE
MEGACE 40 MG TABLET
Oncologist ONLY
MELPHALAN
ALKERAN 2 MG TABLET
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
MERCAPTOPURINE
PURINETHOL 50 MG TABLET
Oncologist ONLY
MESNEX 200 MG INJ
Oncologist ONLY
MESNEX 1000 MG INJ
Oncologist ONLY
METHOTREXATE
RHEUMATREX 200 MG INJ
Oncologist ONLY
METHOTREXATE
RHEUMATREX 2.5 MG TABLET
Oncologist ONLY
METHOTREXATE
RHEUMATREX 1000 MG INJ
Oncologist ONLY
METHOTREXATE LPF
RHEUMATREX 50 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
MITOMYCIN
MUTAMYCIN 20 MG INJ
Oncologist ONLY
MITOXANTRONE
NOVANTRONE 20 MG INJ
Oncologist ONLY
MUTAMYCIN 5 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
NESIRITIDE
NATRECOR 1.5 MG INJ
Restricted
Mount Auburn Hospital Formulary Updated 10/8/03
OMEPRAZOLE
PRILOSEC 20 MG CAPSULE
Restricted
PACLITAXEL
TAXOL 30 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
GI Approval Required
PANTOPRAZOLE
PROTONIX 40 MG INJ
Before Use
PENTOSTATIN
NIPENT 10 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
PIPERACILLIN/
ZOSYN 3.375 GM INJ
ID Approval Required
TAZOBACTAM
PLICAMYCIN

MITHRACIN 2500 MCG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
Mount Auburn Hospital Formulary Updated 10/8/03
RITUXIMAB
RITUXAN 100 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
Mount Auburn Hospital Formulary Updated 10/8/03
STREPTOZOCIN
ZANOSAR 1000 MG INJ
Oncologist ONLY
TAMOXIFEN
NOLVADEX 10 MG TABLET
Oncologist ONLY
FORTAZ 6 GM INJ
ID Approval Required
TENECTEPLASE
TNKase 50 MG INJ KIT
Restricted
Mount Auburn Hospital Formulary Updated 10/8/03
THIOGUANINE
THIOGUANINE 40 MG TABLET
Oncologist ONLY
THIOTEPA
THIOPLEX 15 MG INJ
Oncologist ONLY
TOBRAMYCIN
TROBRAMYCIN 1.2 GM *POWDER*
OR Use Only
TOBRAMYCIN
NEBCIN 80 MG INJ
ID Approval Required
TOBRAMYCIN
NEBCIN 1200 MG INJ
ID Approval Required
TOPOTECAN
HYCAMTIN 4 MG INJ
Oncologist ONLY
TRASTUZUMAB
HERCEPTIN 440 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03
VANCOMYCIN
VANCOMYCIN 125 MG CAP
ID Approval Required
VANCOMYCIN ORAL
VANCOMYCIN ORAL 500 MG SOL
ID Approval Required
VP-16 100 MG INJ
Oncologist ONLY
VIDARABINE
VIRA-A 200 MG INJ
Oncologist ONLY
VINBLASTINE
VELBAN 10 MG INJ
Oncologist ONLY
VINCRISTINE
ONCOVIN 1 MG INJ
Oncologist ONLY
VINORELBINE
NAVELBINE 50 MG INJ
Oncologist ONLY
VINORELBINE
NAVELBINE 10 MG INJ
Oncologist ONLY
Mount Auburn Hospital Formulary Updated 10/8/03

Source: http://portal.mah.harvard.edu/templatesnew/departments/MTA/rx/uploaded_documents/FORMULARY%2010-03.pdf

Prmt22782-10.ahp.090915

The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list,you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. PLEASE NOTE: The symbol * nex

Objective:

Tuality Health Alliance Policy # IV-2 Subject: Tobacco Cessation Page 1 of 7 Objective: To ensure implementation of a standardized tobacco cessation program for all, Tuality Health Alliance (THA) members who wish assistance with their tobacco cessation efforts. The THA Quality Improvement (QI) Department will monitor member participation, compliance, and quit rates annually. T

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