Advisories: Oncologist/ Hematologist Use Only Non-Formulary Use Criteria:1. Adjunctive therapy for cancer chemotherapy. a. Chemotherapy primary prophylaxis for “dose dense” treatment regimen. b Chemotherapy primary prophylaxis for treatment regimen with 20% or higher risk of febrile neutropenia. c. Chemotherapy primary prophylaxis for patient older than 65, poor performance status, combined chemoradiotherapy, poor nutritional status, advanced cancer, or other serious comorbidities. d. Chemotherapy secondary prophylaxis for patient with history of prior neutropenic complications. 2. All of the following must be true for patient to be eligible for tbo-filgrastim treatment of hepatitis C treatment-related neutropenia: a. Patient receiving hepatitis C therapy ; AND b. Patient develops neutropenia defined as either i. ANC < 250/mm3; or ii. ANC < 500mm3 with one of the following risk factors for developing infection; a. Cirrhosis, biopsy proven or clinically evident; b. Pre-or post-liver transplant; c. HIV/HCV co-infection d. Receiving HCV triple therapy; AND c. Patient has failed to respond (i.e. neutropenia persists) despite at least two weeks of peginterferon dose reduction. Medical Referral Center (MRC) Use Only MLP Requires Cosign

Non-Formulary Use Criteria: 1. For narcolepsy: Documented verification of the inmate’s report, to include polysomnography obtained and provided 2. For narcolepsy: Patient has failed non-pharmacologic management strategies 3. For narcolepsy: Functional impairment with work assignment, institution security, academic needs 4. For narcolepsy: Failed treatment with modafinil and fluoxetine (for cataplexy) Formulary Restrictions: Not for use in Narcolepsy ( See NFR Use Criteria)

Advisories: Oncologist/ Hematologist Use Only Non-Formulary Use Criteria:1. Adjunctive therapy for cancer chemotherapy. a. Chemotherapy primary prophylaxis for “dose dense” treatment regimen. b Chemotherapy primary prophylaxis for treatment regimen with 20% or higher risk of febrile neutropenia. c. Chemotherapy primary prophylaxis for patient older than 65, poor performance status, combined chemoradiotherapy, poor nutritional status, advanced cancer, or other serious comorbidities. d. Chemotherapy secondary prophylaxis for patient with history of prior neutropenic complications. 2. All of the following must be true for patient to be eligible for tbo-filgrastim treatment of hepatitis C treatment-related neutropenia: a. Patient receiving hepatitis C therapy ; AND b. Patient develops neutropenia defined as either i. ANC < 250/mm3; or ii. ANC < 500mm3 with one of the following risk factors for developing infection; a. Cirrhosis, biopsy proven or clinically evident; b. Pre-or post-liver transplant; c. HIV/HCV co-infection d. Receiving HCV triple therapy; AND c. Patient has failed to respond (i.e. neutropenia persists) despite at least two weeks of peginterferon dose reduction. Medical Referral Center (MRC) Use Only MLP Requires Cosign

Non-Formulary Use Criteria: 1. For narcolepsy: Documented verification of the inmate’s report, to include polysomnography obtained and provided 2. For narcolepsy: Patient has failed non-pharmacologic management strategies 3. For narcolepsy: Functional impairment with work assignment, institution security, academic needs 4. For narcolepsy: Failed treatment with modafinil and fluoxetine (for cataplexy) Formulary Restrictions: Not for use in Narcolepsy ( See NFR Use Criteria)

Non-Formulary Use Criteria: **1. Failure to achieve target HbA1c goals in type 2 diabetes despite compliance with and adequate duration of a treatment regimen of sulfonylurea plus metformin, insulin plus metformin, insulin plus a sulfonylurea (when metformin is contraindicated), or insulin plus metformin plus a sulfonylurea.** **2. Current total insulin dose must be > 1 unit / kg / day of body weight. OR** **3. A type 2 diabetic inmate newly-incarcerated in the BOP who arrives on a glitazone with good glycemic control and a past history of failed therapy with or contraindication to metformin. (NOTE: If the inmate has never received treatment with metformin and has no contraindication, metformin should be added to the regimen and the glitazone approved by non-formulary request for 6 months to allow for an adequate trial and titration of metformin.)** **4. Pioglitazone is the preferred glitazone when non-formulary use criteria are met. Documentation to be included in non-formulary request: type of diabetes (1 or 2), current treatment regimen and duration at current doses, and most recent HbA1c value with date.**