Approved AIS Formulary

	Primary Column	Brand Name	HCPCS Code	Notes	Created Date	Modified Date
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1	Acyclovir	Zovirax	J0133		05/30/23 10:17 AM	05/30/23 10:17 AM
2	Albumin		P9047		09/16/22 3:10 PM	09/16/22 3:10 PM
3	Alteplase	Cathflo	J2997		09/16/22 3:10 PM	09/16/22 3:10 PM
4	Bezlotoxumab	Zinplava	J0565	3 business day to obtain	09/16/22 3:10 PM	01/22/25 3:49 PM
5	Calcium Gluconate		J0610		11/10/22 2:45 PM	11/10/22 2:45 PM
6	Cefazolin	Ancef	J0690		11/10/22 2:45 PM	11/10/22 2:45 PM
7	Cefepime	Maxipime	J0692	verify availability with Rx	01/05/24 11:35 AM	01/05/24 11:35 AM
8	Ceftriaxone	Rocephin	J0696		09/16/22 3:10 PM	09/16/22 3:10 PM
9	Cosyntropin	Cortrosyn	J0834		10/17/22 11:09 AM	10/17/22 11:09 AM
10	Cyanocobalamin	Vitamin B-12	J3420		10/17/22 11:09 AM	10/17/22 11:09 AM
11	Dalbavancin	Dalvance	J0875		09/16/22 3:10 PM	09/16/22 3:10 PM
12	Daptomycin	Cubicin	J0878		09/16/22 3:10 PM	09/16/22 3:10 PM
13	Darbepoetin Alfa	Aranesp	J0881		09/16/22 3:10 PM	09/16/22 3:10 PM
14	Denosumab	Prolia	J0897		09/16/22 3:10 PM	09/16/22 3:10 PM
15	Eptinezumab-JJMR	Vyepti	J3032	3 business days to obtain	07/31/24 4:52 PM	01/22/25 3:49 PM
16	Ertapenem	Invanz	J1335		09/16/22 3:10 PM	10/18/22 10:05 AM
17	Ferric Carboxymaltose	Injectafer	J1439	2 business days to obtain	09/16/22 3:10 PM	01/22/25 3:49 PM
18	Ferrous Gluconate Complex	Ferrlecit	J2916		09/16/22 3:10 PM	09/16/22 3:10 PM
19	Ferumoxytol	Feraheme	Q0138	2 business days to obtain	09/16/22 3:10 PM	01/22/25 3:49 PM
20	Filgrastim-AYOW	Releuko	Q5125		09/16/22 3:10 PM	04/19/24 12:08 PM
21	Fluids	IV Fluids, all	no code		09/16/22 3:10 PM	09/16/22 3:10 PM
22	Folic Acid		no code		02/27/25 11:15 AM	02/27/25 11:15 AM
23	Furosemide	Lasix	J1940		09/16/22 3:10 PM	09/16/22 3:10 PM
24	Gentamicin		J1580		09/16/22 3:10 PM	09/16/22 3:10 PM
25	Immune Globulin (IVIG)	Gammagard	J1569	3 business days to obtain	09/16/22 3:10 PM	01/22/25 3:49 PM
26	Inclisiran	Leqvio	J1306	4 business days to obtain	11/22/24 1:23 PM	01/22/25 3:49 PM
27	Infliximab	Remicade	J1745	2 business days to obtain	09/16/22 3:10 PM	01/22/25 3:49 PM
28	Infliximab-DYYB	Inflectra	Q5103	2 business days to obtain	09/16/22 3:10 PM	01/22/25 3:49 PM
29	Iron Sucrose Complex	Venofer	J1756		09/19/22 3:29 PM	03/08/23 11:15 AM
30	Levofloxacin	Levaquin	J1956		04/03/24 2:46 PM	04/03/24 2:46 PM
31	Magnesium Sulfate		J3475		11/10/22 2:45 PM	11/10/22 2:45 PM
32	Methylprednisolone	Solu-Medrol	J2919		09/16/22 3:10 PM	05/22/24 12:48 PM
33	Naltrexone microspheres	Vivitrol	J2315	2 business days to obtain	12/19/24 12:16 PM	01/22/25 3:49 PM
34	Omalizumab	Xolair	J2357	3 business days to obtain	09/19/22 3:29 PM	01/22/25 3:49 PM
35	Pegfilgrastim-PBBK	Fylnetra	Q5130	2 business days to obtain	01/28/25 3:53 PM	02/27/25 11:15 AM
36	Penicillin G Benzathine	Bicillin LA	J0561		09/27/22 2:02 PM	09/27/22 2:02 PM
37	Potassium Chloride		J3480		06/06/23 11:29 AM	06/06/23 11:29 AM
38	Rabies Vaccine		90675	CPT code	09/16/22 3:10 PM	09/16/22 3:10 PM
39	Rituximab	Rituxan	J9312	3 business days to obtain	11/09/22 10:47 AM	01/22/25 3:49 PM
40	Rituximab-pvvr	Ruxience	Q5119	3 business days to obtain	05/18/23 1:56 PM	01/22/25 3:49 PM
41	Vancomycin		J3370		09/16/22 3:10 PM	09/16/22 3:10 PM
42	Vedolizumab	Entyvio	J3380	3 business days to obtain	09/26/22 1:09 PM	01/22/25 3:49 PM
43	Zoledronic Acid	Reclast, Zometa	J3489		09/16/22 3:10 PM	09/07/23 11:41 AM