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Prescription Renewal - UW Health – Adult/Pediatric - Ambulatory

Prescription Renewal - UW Health – Adult/Pediatric - Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Prescription Renewal Delegation Protocols


Delegation Protocol Title: Prescription Renewal - UW Health – Adult/Pediatric - Ambulatory

Delegation Protocol Applies To: UW Health Primary and Specialty Care Clinics

Target Patient Population:
Patients with prescriptions written by providers in the UW Health Primary Care and Specialty Care Clinics

Delegation Protocol Champion:
Matt Anderson, MD ‐ Senior Medical Director, Primary Care 
Michael Sloan, MD ‐ Senior Medical Director, Specialty Care 

Responsible Department:
UW Health Primary Care
UW Health Specialty Care

Purpose Statement:
To delegate authority from providers in UW Health Clinics to clinical staff to renew prescriptions for the
medications identified in this protocol and to order the laboratory tests identified in this protocol if needed
to renew the prescription.

Who May Carry Out This Delegation Protocol:
Registered nurses (RNs), medical assistants (MAs), and pharmacists (RPhs) in UW Health Clinics who
have successfully completed training in the prescription renewal process.

Guidelines for Implementation:
1. The staff will review the medical record to verify:
1.1. The order details of the requested renewal match the original order details, including dose, route,
frequency, provider and any additional instructions for use. If the details in the requested
renewal are different than the original order, the provider will be contacted for clarification before
any orders are placed.
1.2. The patient meets all of the renewal requirements specified in the medication catalog, including
any office visit, laboratory result or vital sign criteria (see Appendices A and B).
2. If all requirements are met, the prescription may be renewed for a quantity sufficient to provide
medication up to the next office visit or as specified for the medication.
3. If the patient is overdue for an office visit or any required testing, a bridging supply, as specified, may
be ordered to prevent interruption of therapy. In addition, staff will order any overdue laboratory tests
and contact the patient to have the laboratory work done, or to schedule an office visit if needed.
4. If any of the required laboratory tests or vital signs are outside of the defined limits, a provider must
be consulted before placing any orders.
5. The following cannot be renewed by staff under this protocol and must be routed to a provider for
signature.
5.1. Medications not specified in this protocol
5.2. Controlled substances

Order Signing Mode:
Medication Orders Laboratory/Diagnostic Test Orders
RNs, RPHs Protocol/policy without Cosign Cosign required Protocol/Policy
MAs Cosign required Protocol/Policy Cosign required Protocol/Policy

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org


Approved By:
UW Health Ambulatory Protocol Committee – August 2014
UW Health Laboratory Committee – November 2014
UWHC Pharmacy and Therapeutics Committee – December 2014
UWHC Medical Board – February 2015

Effective Date: February 2015

Scheduled for Review: February 2018


Appendix A. UW Health Clinics - Medications Sorted by Generic Name
Appendix B. UW Health Clinics - Medications Sorted by Common Brand Name

Appendix C. UW Health Maximum Supply Allowances Based on Last Visit Date – See Appendix A or B
for exclusions

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Appendix A. UW Health Clinics - Medications Sorted by Generic Name
Generic Name Common Brand Names Labs
Interval Between
Office Visits Other Max Supply
abacavir/ lamivudine EPZICOM Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
abacavir/ lamivudine/ zidovudine TRIZIVIR Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
abatacept (injectable only) ORENCIA 12 months
Injectable only, infusion
must be forwarded to
provider
90 days with
4 refills
abiraterone ZYTIGA Forward to provider
acarbose PRECOSE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• ALT <80 U/L - in last 12 months
6 months 90 days with
2 refills
acebutolol SECTRAL 12 months 90 days with
4 refills
acetaminophen TYLENOL 12 months 90 days with 4 refills
acetazolamide DIAMOX
Every 12 months and within normal
limits
• CBC
• Na, K, chloride, CO2
12 months 90 days with
4 refills
aclidinium TUDORZA 12 months 90 days with
4 refills
acyclovir ZOVIRAX 12 months May refill when being
used for prophylaxis
90 days with
4 refills
acyclovir topical ZOVIRAX 12 months 90 days with
4 refills
adalimumab HUMIRA
Every 6 months and within normal
limits
• CBC
• ALT
12 months Refill by RN only 90 days with
1 refill
adapalene topical DIFFERIN 12 months 90 days with
4 refills
albiglutide TANZEUM
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
albuterol
PROAIR, PROVENTIL,
VENTOLIN 12 months
3 inhalers
0 refills
albuterol oral PROVENTIL 12 months 90 days with
4 refills
albuterol-ipratropium COMBIVENT, DUONEB 12 months 90 days with
4 refills
alclometasone ACLOVATE 12 months 90 days with
4 refills
alendronate FOSAMAX 12 months
If patient has been on
medication for 5 or
more years (review
medication history),
send to physician for
review
90 days with
4 refills
alfuzosin UROXATRAL 12 months 90 days with
4 refills
aliskiren TEKTURNA
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
aliskiren-amlodipine TEKAMLO
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
aliskiren-amlodipine-HCTZ AMTURNIDE
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
aliskiren-valsartan VALTURNA
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
allopurinol ZYLOPRIM
Every 12 months and within normal
limits
• Cr
12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

almotriptan AXERT 12 months Amount of previous
prescription
alogliptin NESINA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
alogliptin-metformin KAZANO
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
alogliptin-pioglitazone OSENI
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months Forward to provider
alprazolam XANAX Forward to provider
alprostadil CAVERJECT 12 months 90 days with
4 refills
alprostadil-papaverine-phentolamine TRI-MIX 12 months 90 days with
4 refills
aluminum chloride DRYSOL 12 months 90 days with
4 refills
amantadine SYMMETREL 12 months 90 days with
4 refills
ambrisentan LETAIRIS • Negative pregnancy test in past month 6 months
Must have scheduled
follow-up appointment
Sufficient to reach
scheduled appointment
amcinonide amcinonide 12 months 90 days with
4 refills
amiloride amiloride
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
amiloride-HCTZ amiloride-HCTZ
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
aminocaproic acid AMICAR 12 months 90 days with
4 refills
amitriptyline ELAVIL 12 months 90 days with
4 refills
amlodipine NORVASC 12 months 90 days with
4 refills
ammonium lactate topical AM-LACTIN, LAC HYDRIN,
various
12 months 90 days with
4 refills
amoxicillin amoxicillin 12 months
May refill when being
used for dental or
procedural prophylaxis
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
Amount of original
prescription
2 weeks supply
0 refills
amoxicillin-clavulanate AUGMENTIN 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
2 weeks supply
0 refills
anakinra KINERET
Monthly x 3 months, then every 3
months x3, then yearly
• CBC
12 months Refill by RN only 90 days with
4 refills
anastrozole ARIMIDEX 12 months 90 days with
4 refills
antacids
MYLANTA, MAALOX,
various
12 months 90 days with
4 refills
apixaban ELIQUIS
Every 12 months and within normal
limits
• Cr
• CBC without diff
• ALT
12 months 90 days with
4 refills
apremilast OTESLA
Every 12 months and within normal
limits
• Cr
12 months
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

arformoterol BROVANA 12 months Current prescription for
albuterol
90 days with
4 refills
aripiprazole ABILIFY Forward to provider
artificial tears artificial tears
90 days with
3 refills
ascorbic acid Vitamin C 12 months 90 days with
4 refills
aspirin aspirin 12 months 90 days with
4 refills
aspirin-dipyridamole AGGRENOX 12 months 90 days with
1 refill
ataovaquone/ proguanil MALARONE 12 months
May refill if seen in the
Travel Clinic in the last
year for antimalarial
prophylaxis
Per Travax medicine
software
recommendations for
area of travel and length
of stay
atazanavir REYATAZ Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
atenolol TENORMIN 12 months 90 days with
4 refills
atorvastatin LIPITOR 12 months 90 days with
4 refills
atovaquone 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
atropine atropine 12 months 90 days with
4 refills
azathioprine IMURAN
Initiation of therapy or after dose
change
• CBC and ALT every 2 weeks X 1
month, then monthly X 2 months,
then move to maintenance
Maintenance - every 3 months and
within normal limits
• CBC
• ALT
12 months RN only 90 days with 0 refills
azelaic acid topical timolol 12 months 90 days with
4 refills
azelastine OPTIVAR 12 months 90 days with
4 refills
azelastine nasal ASTELIN, ASTAPRO 12 months 90 days with
4 refills
azelastine-fluticasone DYMISTA 12 months 90 days with
4 refills
azilsartan EDARBI
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
azithromycin ZITHROMAX 12 months
May refill when being
used for dental or
procedural prophylaxis
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
May refill for traveler's
diarrhea if seen in the
Travel Clinic in the last
year
Amount of original
prescription
2 weeks supply
0 refills
Per Travax medicine
software
recommendations for
area of travel and length
of stay
aztreonam aztreonam 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

bacitracin ophthalmic Amount of original
prescription
bacitracin topical bacitracin topical 3 months Amount of original
prescription
bacitracin-ploymyxin B ophthalmic Amount of original
prescription
baclofen LIORESAL 12 months 90 days with
4 refills
balsalazide COLAZAL 12 months 90 days with
4 refills
becaplermin topical REGRANEX Forward to provider
beclomethasone QVAR 12 months Current prescription for
albuterol
90 days with
4 refills
beclomethasone nasal BECONASE AQ 12 months 90 days with
4 refills
benazepril LOTENSIN
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
benazepril-HCTZ LOTENSIN HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
benzonatate TESSALON 12 months 90 days with
4 refills
benzoyl peroxide-containing topical VARIOUS 12 months 90 days with
4 refills
benztropine COGENTIN 12 months 90 days with
4 refills
betamethasone dipropionate DIPROLENE 12 months 90 days with
0 refills
betamethasone valerate VALISONE 12 months 90 days with
4 refills
betaxolol BETO PTIC S 90 days with
3 refills
bethanechol URECHOLINE 12 months 90 days with
4 refills
bicalutamide CASODEX 12 months 90 days with
4 refills
bisacodyl DULCOLAX 12 months 90 days with
4 refills
bisoprolol ZEBETA 12 months 90 days with
4 refills
bosentan TRACLEER
• ALT and AST in last month and
WNL
• Negative pregnancy test in past
month
6 months Must have scheduled
follow-up appointment
Sufficient to reach
scheduled appointment
brimonidine-timolol COMBIGAN 90 days with
3 refills
brimonoprost LUMIGAN 90 days with
3 refills
brinzolamide AZOPT 90 days with
3 refills
bromfenac XIBRAM Amount of original
prescription
bromocriptine PARLODEL
Every 12 months and within normal
limits
• prolactin
12 months 90 days with
4 refills
budesonide ENTOCORT
Every 6 months and within normal
limits
• K
• Na
12 months 90 days with
4 refills
budesonide PULMICORT 12 months Current prescription for
albuterol
90 days with
4 refills
budesonide nasal RHINOCORT AQ 12 months 90 days with
4 refills
budesonide-formoterol SYMBICORT 12 months Current prescription for
albuterol
90 days with
4 refills
bumetanide BUMEX
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
bupropion SR ZYBAN (Not WELLBUTRIN) 12 months 30 days with
2 refills
bupropion, SR WELLBUTRIN (not ZYBAN) 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

buspirone BUSPAR 12 months 90 days with
4 refills
butalbital-acetaminophen-caffeine ESGIC, ESGIC-PLUS,
FIORICET Forward to provider
butalbital-aspirin-caffeine FIORINAL Forward to provider
cabergoline cabergoline
Every 12 months and within normal
limits
• prolactin
12 months 90 days with
4 refills
calcipotriene DOVONEX, SORILUX 12 months Maximum 120 g/month 90 days with
4 refills
calcipotriene-betamethasone TACLONEX 12 months 90 days with
4 refills
calcipotriene-betamethasone topical TACLONEX 12 months 90 days with
4 refills
calcitriol ROCALTROL
Every 6 months and within normal
limits
• Phosphorous
• PTH
6 months 90 days with
2 refills
calcitriol topical VECTICAL 12 months 90 days with
4 refills
calcium calcium 12 months 90 days with
4 refills
calcium acetate PHOSLO
Every 6 months and within normal
limits
• Ca
• PO4
6 months 90 days with
2 refills
canagliflozin INVOKANA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Every 12 months and within normal
limits
• Cr
• LDL-C
• Mg
• PO4
6 months 90 days with
2 refills
canakinumab ILARIS
Monthly x 3 months, then every 3
months x3, then yearly
• CBC
12 months 90 days with
4 refills
candesartan ATACAND
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
candesartan-HCTZ ATACAND HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
capsacin patch, cram, liquid, topical capsacin patch, cram, liquid,
topical
12 months 90 days with
4 refills
captopril CAPOTEN
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
captopril-HCTZ CAPOZIDE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
carbachol ISOPTOCARPINE 90 days with
3 refills
carbamazepine TEGRETOL, TEGRETOL XL,
EPITOL, CARBATROL
Every 12 months and within
normal/therapeutic range
• Na
• CBC with diff
• carbamazepine level
12 months 90 days with
4 refills
carbidopa LODOSYN 12 months 90 days with
4 refills
carbidopa-levodopa
SINEMET, PARCOPA,
RYTARY 12 months
90 days with
4 refills
carbidopa-levodopa-entacapone STALEVO 12 months 90 days with
4 refills
carnitine, levocarnitine CARNITOR 12 months 90 days with
4 refills
carvedilol COREG, COREG CR 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

celecoxib CELEBREX 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
cephalexin KEFLEX 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
Amount of original
prescription
certolizumab CIMZIA
Every 6 months and within normal
limits
• CBC
• ALT
12 months Refill by RN only 90 days with
1 refill
cetirizine ZYRTEC, ZYRTEC D 12 months
Forward to provider if
decongestant ("D")
formula
90 days with
4 refills
chlordiazepoxide LIBRIUM Forward to provider
chlorhexidine PERIDEX 12 months 90 days with
4 refills
chloroquine 12 months
May refill if seen in the
Travel Clinic in the last
year for antimalarial
prophylaxis
Per Travax medicine
software
recommendations for
area of travel and length
of stay
chlorpheniramine CHLOR-TRIMETON 12 months 90 days with
4 refills
chlorthalidone THALITONE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
cholecalciferol VITAMIN D3 12 months 90 days with
4 refills
cholestyramine resin QUESTRAN, QUESTRAN
LITE
12 months 90 days with
4 refills
choline fenofibrate TRILIPIX 12 months 90 days with
4 refills
ciclesonide ALVESCO 12 months 90 days with
4 refills
ciclopirox LOPROX, PENLAC 12 months 90 days with
4 refills
cilostazol PLETAL 12 months 90 days with
1 refill
cimetidine TAGAMET Forward to provider
cinacalcet SENSIPAR
Every 3 months and within normal
limits
• Ca
6 months 90 days with
2 refills
ciprofloxacin CIPRO 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
May refill for traveler's
diarrhea if seen in the
Travel Clinic in the last
year
2 weeks supply
0 refills
Per Travax medicine
software
recommendations for
area of travel and length
of stay
ciprofloxacin ophth ointment CILOXAN 3 months Amount of original
prescription
ciprofloxacin-dexamethasone CIPRODEX 6 months 90 days with
2 refills
citalopram CELEXA 12 months 90 days with
4 refills
clarithromycin BIAXIN 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
2 weeks supply
0 refills
clindamycin CLEOCIN 12 months
May refill when being
used for dental or
procedural prophylaxis
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
Amount of original
prescription
2 weeks supply
0 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

clindamycin topical CLEOCIN T 12 months 90 days with
4 refills
clobetasol
CLOBEX, OLUX,
TEMOVATE 12 months
90 days with
4 refills
clomipramine ANAFANIL 12 months 90 days with
4 refills
clonazepam KLONOPIN Forward to provider
clonidine CATAPRES 12 months 90 days with
4 refills
clopidogrel PLAVIX 12 months
If patient on clopidogrel
(Plavix) and
pantoprazole, may refill.
If on clopidogrel and
any other PPIs forward
request to provider
90 days with
4 refills
clorazepate TRANXENE Forward to provider
clotrimazole LOTRIMIN 12 months 90 days with
4 refills
clotrimazole-betamethasone LOTRISONE Forward to provider
colchicine colchicine
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
colesevelam WELCHOL 12 months 90 days with
4 refills
colestipol COLESTID 12 months 90 days with
4 refills
colistimethate colistimethate 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
collagenase topical SANTYL Forward to provider
conjugated estrogens PREMARIN 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
conjugated estrogens-medroxyprogesterone PREMPRO, PREPHASE 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
cromolyn INTAL 12 months 90 days with
4 refills
cromolyn nasal NASALCROM 12 months 90 days with
4 refills
cromolyn ophth OPTICROM, CROLOM 12 months 90 days with
4 refills
cyanocobalamin Vitamin B12 12 months 90 days with
4 refills
cyclobenzaprine FLEXERIL 12 months 90 days with
4 refills
cyclosporine RESTASIS 12 months 90 days with
4 refills
cyproheptadine PERIACTIN 12 months 90 days with
4 refills
dabigatran PRADAXA
Every 12 months and within normal
limits
• Cr
• CBC without diff
• ALT
12 months 90 days with
4 refills
dalfampridine AMPYRA
Every 12 months and within normal
limits
• Cr
12 months 90 days with
1 refill
dantrolene DANTRIUM Forward to provider
dapagliflozin FARXIGA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Every 12 months and within normal
limits
• Cr
• LDL-C
6 months 90 days with
2 refills
dapsone topical ACZONE 12 months 90 days with
4 refills
darbepoetin ARANESP Forward to provider
darifenacin ENABLEX 12 months 90 days with
4 refills
darunavir PREZISTA Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

desipramine NORPRAMIN 12 months 90 days with
4 refills
desloratadine CLARINEX 12 months 90 days with
4 refills
desmopressin DDAVP
Every 12 months and within normal
limits
• CBC
• ALT
12 months 90 days with
4 refills
desonide topical
DESO NATE, DESOWEN,
VERDESO 12 months
90 days with
4 refills
desoximetasone TOPICORT 12 months 90 days with
4 refills
desvenlafaxine PRESTIQ 12 months 90 days with
4 refills
dexamethasone dexamethasone
Every 6 months and within normal
limits
• K
• Na
12 months
May refill if does not
require titration and
used for maintenance
at <4 mg/day OR used
as premedication for
chemo or as directed
by Beacon treatment
plan or supportive care
plan
Amount of original
prescription
dexamethasone-tobramycin TOBRADEX Amount of original
prescription
dexlansoprazole DEXILANT 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
diazepam VALIUM Forward to provider
dibucaine NUPERCAINAL 12 months 90 days with
4 refills
diclofenac VOLTERAN Amount of original
prescription
diclofenac VOLTAREN 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
diclofenac-misoprostol ARTHROTEC 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
dicyclomine BENTYL 12 months 90 days with
4 refills
diflunisal DOLOBID 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
digoxin LANOXIN
Every 12 months and within normal
limits
• K
• Cr
• digoxin level Note: digoxin level
should be obtained at least 6 hours
after oral dose
12 months 90 days with
4 refills
dihydroergotamine nasal MIGRANAL Forward to provider
diltiazem
CARDIZEM, CARTIA,
DILACOR XR, DILTIA XT,
TIAZAC
12 months 90 days with
4 refills
diltiazem topical diltiazem topical 12 months 90 days with
4 refills
dimethyl fumarate TECFIDERA
Every 12 months and within normal
limits
• CBC
12 months 90 days with
4 refills
diphenhydramine BENADRYL 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
diphenhyramine-lidocaine-al&mag-
simethicone
MAGIC MOUTHWASH,
MAALIDOBEN 12 months
90 days with
4 refills
diphenoxylate-atropine LOMOTIL Forward to provider
dipivifrin PROPINE 90 days with
3 refills
dipyridamole PERSANTINE 12 months 90 days with
1 refill
divalproex DEPAKOTE
Every 12 months and within
normal/therapeutic range
• ALT/AST
• CBC
• valproate level
12 months 90 days with
4 refills
docusate COLACE 12 months 90 days with
4 refills
docusate-casanthranol PERI-COLACE 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

donepezil ARICEPT 12 months 90 days with
4 refills
dornase alfa PULMOZYME 12 months 90 days with
4 refills
dorzolamide TRUSOPT 90 days with
3 refills
dorzolamide-timolol COSOPT 90 days with
3 refills
doxazosin CARDURA, CARDURA XL 12 months 90 days with
4 refills
doxepin SILENOR 12 months 90 days with
4 refills
doxercalciferol HECTOROL
Every 6 months and within normal
limits
• Calcium
• Phosporous
• PTH
6 months 90 days with
2 refills
doxycycline VIBRAMYCIN 12 months
May refill only when
being used for chronic
condition
90 days with
4 refills
droxidopa NORTHERA 12 months 90 days with
4 refills
dulaglutide TRULICITY
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
duloxetine CYMBALTA 12 months 90 days with
4 refills
econazole topical ECOZA 12 months 90 days with
4 refills
ecothiphate PHOSPHOLINE IODINE 90 days with
3 refills
edoxaban SAVAYSA
Every 12 months and within normal
limits
• Cr
• CBC without diff
• ALT
12 months 90 days with
4 refills
efavirenz SUSTIVA Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
efavirenz/ emtricitabine/ tenofovir ALTRIPLA Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
eflornithine topical VANIQA 12 months 90 days with
4 refills
eletriptan RELPAX 12 months Amount of previous
prescription
emedastine EMADINE 12 months 90 days with
4 refills
empagliflozin JARDIANCE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Every 12 months and within normal
limits
• Cr
• LDL-C
6 months 90 days with
2 refills
emtricitabine/ tenofovir TRUVADA Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
enalapril VASOTEC
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
enalapril-HCTZ VASERETIC
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
enfuvirtide FUZEON Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
entacapone COMTAN 12 months 90 days with
4 refills
enzalutamide XTANDI Forward to provider
epinastine ELESTAT 12 months 90 days with
4 refills
epinephrine EPIPEN 12 months Amount of original
prescription
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

epinephrine ophth EPIFRIN 12 months 90 days with
4 refills
eplerenone INSPRA
Every 12 months and within normal
limits
• K
12 months 90 days with
4 refills
epoetin EPOG EN, PROCRIT Forward to provider
ergocalciferol Vitamin D2 12 months 90 days with
4 refills
ergotamine-caffeine CAFERGOT Forward to provider
erythromycin erythromycin 12 months
May refill only when
being used for
procedural prophylaxis
Amount of original
prescription
erythromycin ERYTAB 12 months
May refill only when
being used for chronic
condition
90 days with
4 refills
erythromycin/benzoyl peroxide topical BENZAMYCIN 12 months 90 days with
4 refills
erythromycin-containing topical ERYDERM, ERY-PAD 12 months 90 days with
4 refills
escitalopram LEXAPRO 12 months 90 days with
4 refills
eslicarbazepine APTIOM 12 months 90 days with
4 refills
esomeprazole NEXIUM 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
estazolam estazolam Forward to provider
esterified estrogens MENEST 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
estradiol oral ESTRACE, FEMTRACE 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
estradiol patch
ALORA, CLIMARA,
MENOSTAR, VIVELLE 12 months
Pap screening per age
appropriate guideline
90 days with
4 refills
estradiol ring FEMRING, ESTRING 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
estradiol topical or vaginal
ESTROGEL, ESTRASORB,
ESTRACE, VAGIFEM 12 months
Pap screening per age
appropriate guideline
90 days with
4 refills
estradiol-drospirenone ANGELIQ 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
estradiol-norethindrone FEMHRT, ACTIVELLA 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
estropipate OGEN, ORTHO-EST 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
etanercept ENBREL
Every 6 months and within normal
limits
• CBC
12 months Refill by RN only 90 days with
1 refill
ethosuximide ZARONTIN
Every 12 months and within
normal/therapeutic range
• ALT/AST
• CBC
• Cr
• ethosuximide level
12 months 90 days with
4 refills
etidronate DIDRONEL
Every 6 months and within normal
limits
• Cr
12 months
If patient has been on
medication for 5 or
more years (review
medication history),
send to physician for
review
90 days with
4 refills
etodolac LODINE 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
etonogestrel-ethinyl estradiol NUVARING
Every 12 months
• Chlamydia screening if < 25 yrs of
age
12 months 90 days with
4 refills
exemestane AROMASIN 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

exenatide BYETTA, BYDUREON
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
ezetimibe ZETIA 12 months 90 days with
4 refills
ezetimibe-simvastatin VYTORIN 12 months 90 days with
4 refills
Factor IX Factor IX 12 months 90 days with
4 refills
Factor VIIa Factor VIIa 12 months 90 days with
4 refills
Factor VIII Factor VIII 12 months 90 days with
4 refills
Factor VIII/vWF complex concentrate Factor VIII/vWF complex
concentrate
12 months 90 days with
4 refills
Factor XIIIa Factor XIIIa 12 months 90 days with
4 refills
famciclovir FAMVIR 12 months May refill if being used
for prophylaxis
90 days with
4 refills
famotidine PEPCID 12 months 90 days with
4 refills
febuxostat ULORIC 12 months 90 days with
4 refills
felbamate FELBATOL
Every 6 months and within
normal/therapeutic range
• ALT/AST
• CBC
• felbamate level
12 months 90 days with
4 refills
felodipine PLENDIL 12 months 90 days with
4 refills
fenofibrate
TRICOR, ANTARA,
FENOGLIDE, LIPOFEN,
LOFIBRA, TRIGLIDE
12 months 90 days with
4 refills
fenofibric acid TRILIPIX 12 months 90 days with
4 refills
fenoprofen NALFON 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
ferrous sulfate, ferrous gluconate, iron
ferrous sulfate, ferrous
gluconate, iron
12 months 90 days with
4 refills
fesoterodine TOVIAZ 12 months 90 days with
4 refills
fexofenadine ALLEGRA, ALLEGRA D 12 months
Forward to provider if
decongestant ("D")
formula
90 days with
4 refills
filgrastim NEUPOGEN Forward to provider
finasteride PROPECIA, PROSCAR 12 months 90 days with
4 refills
fingolimod GILENYA
Every 6 months and within normal
limits
• CBC
90 days with
3 refills
fish oil MULTIPLE 12 months 90 days with
4 refills
fluconazole DIFLUCAN
Every 12 months and within normal
limits
• K
• Cr
• AST, ALT, Alk Phos, Bilirubin
12 months 90 days with
4 refills
fludrocortisone FLORINEF
Every 6 months and within normal
limits
• K
• Na
12 months Amount of original
prescription
flunisolide AEROBID 12 months Current prescription for
albuterol
90 days with
4 refills
fluocinolone topical SYNALAR 12 months 90 days with
4 refills
fluocinolone-hydroquinone-tretinoin topical TRI-LUMA 12 months 90 days with
4 refills
fluocinonide LIDEX, VANOS 12 months 90 days with
4 refills
fluoride fluoride 12 months Forward to provider 90 days with
4 refills
fluorouracil topical EFUDEX, CARAC Forward to provider
fluoxetine PROZAC 12 months 90 days with
4 refills
flurandrenolide CORDRAN 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

flurazepam DALMANE Forward to provider
flurbiprofen flurbiprofen 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
flurbiprofen ophth OCUFEN Amount of original
prescription
flurometholone FML Amount of original
prescription
flutamide EULEXIN 12 months 90 days with
4 refills
fluticasone FLOVENT 12 months Current prescription for
albuterol
90 days with
4 refills
fluticasone nasal FLONASE, VERAMYST 12 months 90 days with
4 refills
fluticasone topical CUTIVATE 12 months 90 days with
4 refills
fluticasone-salmeterol ADVAIR 12 months Current prescription for
albuterol
90 days with
4 refills
fluticasone-vilanterol BREO 12 months Current prescription for
albuterol
90 days with
4 refills
fluvastatin LESCOL 12 months 90 days with
4 refills
fluvoxamine LUVOX 12 months 90 days with
4 refills
folic acid folate 12 months 90 days with
4 refills
formoterol FORADIL, PERFORMIST 12 months Current prescription for
albuterol
90 days with
4 refills
fosinopril MONOPRIL
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
frovatriptan FROVA 12 months Amount of previous
prescription
fulvestrant fulvestrant 12 months 90 days with
4 refills
furosemide LASIX
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months 90 days with
4 refills
gabapentin NEURONTIN 12 months 90 days with
4 refills
galantamine RAZADYNE 12 months 90 days with
4 refills
gemfibrozil LOPID 12 months 90 days with
4 refills
gentamicin instillation solution gentamicin instillation solution 12 months 90 days with
4 refills
glatiramer COPAXONE, GLATOPA 12 months 90 days with
4 refills
glimepiride AMARYL
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
glipizide, ER GLUCOTROL
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
glipizide-metformin METAGLIP
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
glucagon glucagon 6 months Amount of original
prescription
glutamine glutamine
Every 6 months and within normal
limits
• ALT, AST
• K, Cr
6 months 90 days with
2 refills
glyburide
DIABETA, GLYNASE,
PRESTAB, MICRONASE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

glyburide-metformin GLUCOVANCE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
glycerin enema glycerin enema 12 months 90 days with
4 refills
glycopyrrolate ROBINUL 12 months 90 days with
4 refills
golimumab SIMPONI
Every 6 months and within normal
limits
• CBC
• ALT
12 months Refill by RN only 90 days with
1 refill
griseofulvin griseofulvin Forward to provider
guaifenesin Mucinex, various 12 months 90 days with
4 refills
guanfacine INTUNIV, TENEX 12 months 90 days with
4 refills
guar gum BENEFIBER 12 months 90 days with
4 refills
halcinonide HALOG 12 months 90 days with
4 refills
halobetasol ULTRAVATE 12 months 90 days with
4 refills
haloperidol HALDOL Forward to provider
heparin flushes heparin flushes 12 months 90 days with
4 refills
hydralazine APRESOLINE 12 months
Forward to provider if
total dose > 100
mg/day
BP meets goal
indicated in chart. If
none listed BP should
be < 140/90 mmHg
90 days with
4 refills
hydrochlorothiazide (HCTZ) MICROZIDE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
hydrocortisone CORTAID 12 months 90 days with
4 refills
hydrocortisone oral hydrocortisone
Every 6 months and within normal
limits
• K
• Na
12 months
May refill if does not
require titration and
used for maintenance
at <40 mg/day or stress
Amount of original
prescription
hydrocortisone rectal
CORTIFOAM, PROCTOCOL-
HC 12 months
90 days with
4 refills
hydroquinone topical CLARIPEL, LUSTRA, various 12 months 90 days with
4 refills
hydroxychloroquine PLAQUENIL 12 months
Refill by RN only.
Annual ophthamologic
exam (including visual
field test or ocular CT)
for patients on
hydroxychloroquine for
> 5 years, taking > 6.5
mg/kg, with history of
retinal disease, age >/=
60 yrs or liver disease
90 days with
4 refills
hydroxyzine ATARAX,VISTARIL 12 months 90 days with
4 refills
hyoscyamine ANASPAZ, LEVSIN 12 months 90 days with
4 refills
ibandronate BONIVA 12 months
If patient has been on
medication for 5 or
more years (review
medication history),
send to physician for
review
90 days with
4 refills
ibuprofen MOTRIN 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

imipramine TOFRANIL 12 months 90 days with
4 refills
imiquimod topical ALDARA 12 months 90 days with
4 refills
indacaterol ARCAPTA 12 months Current prescription for
albuterol
90 days with
4 refills
indomethacin INDOCIN, INDOCIN CR 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
insulin aspart NOVOLOG
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin aspart protamine-aspart mix NOVOLOG MIX 70/30
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin detemir LEVEMIR
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin glargine LANTUS
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin glulisine APIDRA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin isophane NPH NOVOLIN N, HUMULIN, N
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin isophane NPH-regular mix HUMULIN 70/30, NOVOLIN
70/30
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin lispro HUMALOG
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin lispro protamine-insulin lispro mix HUMALOG MIX 50/50, HUMALOG MIX 75/25
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin regular NOVOLIN R, HUMULIN R
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
interferon beta 1a AVONEX, REBIF
Every 12 months and within normal
limits
• TSH, T4
• ALT, AST
• CBC
12 months 90 days with
4 refills
interferon beta 1b BETASERON, EXTAVIA
Every 12 months and within normal
limits
• TSH, T4
• ALT, AST
• CBC
12 months 90 days with
4 refills
ipratropium ATROVENT 12 months Current prescription for
albuterol
90 days with
4 refills
irbesartan AVAPRO
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
irbesartan-HCTZ AVALIDE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
isometheptene-dichloral-phenazone-
acetaminophen DURADRIN, MIDRIN Forward to provider
isosorbide dinitrate ISORDIL 12 months Systolic blood pressure
> 90 mmHg
90 days with
4 refills
isosorbide mononitrate IMDUR, ISMO, MONOKET 12 months Systolic blood pressure
> 90 mmHg
90 days with
4 refills
isradipine isradipine 12 months 90 days with
4 refills
itraconazole SPORANOX Forward to provider
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

ivacaftor KALYDECO • ALT and AST in last month and WNL 12 months
90 days with
4 refills
ivermectin SKLICE, STROMECTOL Forward to provider
ketoconazole NIZORAL Forward to provider
ketoconazole topical NIZORAL 12 months 90 days with
4 refills
ketoprofen ketoprofen 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
ketorolac ketorolac Forward to provider
ketorolac ophth ACULAR, ACUVAIL 12 months 90 days with
4 refills
ketotifen ZADITOR, ALAWAY 12 months 90 days with
4 refills
labetalol TRANDATE 12 months 90 days with
4 refills
lacosamide VIMPAT 12 months 90 days with
4 refills
lactulose lactulose 12 months 90 days with
4 refills
lamivudine/ zidovudine COMBIVIR Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
lamotrigine LAMICTAL
Every 12 months and within
therapeutic range
• lamotrigene level
12 months 90 days with
4 refills
lansoprazole PREVACID 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
lanthanum FOSRENOL
Every 6 months and within normal
limits
• Ca
• PO4
6 months 90 days with
2 refills
latanoprost XALATAN 90 days with
3 refills
leflunomide ARAVA
Initiation of therapy or after dose
change
• CBC, Cr, ALT monthly X 6 months,
then move to maintenance
Maintenance - every 3 months and
within normal limits
• CBC
• ALT
12 months Refill by RN only 90 days with
1 refill
letrozole FEMARA 12 months 90 days with
4 refills
levalbuterol XOPENEX 12 months 3 inhalers
0 refills
levetiracetam KEPPRA, KEPPRA XR
Every 12 months and within
therapeutic range
• levetirazetam level
12 months 90 days with
4 refills
levobunolol BETAGAN 90 days with
3 refills
levocetirizine XYZAL 12 months 90 days with
4 refills
levothyroxine
SYNTHROID,
LEVOTHROID, LEVOXYL
• TSH - every 12 months and within
normal range (or less than provider
specified goal)
12 months
If pregnant or history of
thyroid cancer forward
to provider
90 days with
4 refills
lidocaine patch LIDODERM 12 months 90 days with
4 refills
lidocaine topical LMX 12 months Amount of original
prescription
lidocaine-prilocaine EMLA 12 months 90 days with
4 refills
linaclotide LINZESS 12 months 90 days with
4 refills
linagliptin TRADJENTA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
linagliptin-metformin JENTADUETO
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

liothyronine CYTOMEL
• TSH - every 12 months and within
normal range (or less than provider
specified goal)
12 months
If pregnant or history of
thyroid cancer forward
to provider
90 days with
4 refills
liraglutide VICTOZA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
lisinopril PRINIVIL, ZESTRIL
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
lisinopril-HCTZ PRINZIDE, ZESTORETIC
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
lithium LITHOBID, ESKALITH Forward to provider
lodoxamine ALOMIDE 90 days with
3 refills
loperamide IMODIUM, IMODIUM AD 12 months 90 days with
4 refills
lopinavir/ ritonavir KALETRA Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
loratadine CLARITIN 12 months
Forward to provider if
decongestant ("D")
formula
90 days with
4 refills
lorazepam ATIVAN Forward to provider
losartan COZAAR
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
losartan-HCTZ HYZAAR
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
loteprednol LOTOMAX, ALREX Amount of original
prescription
loteprednol-tobramycin ZYLET Amount of original
prescription
lovastatin MEVACOR 12 months 90 days with
4 refills
lovastatin-niacin ADVICOR •ALT - in last 12 months and <3x
upper limit of normal 12 months
90 days with
4 refills
lubiprostone AMITIZA 12 months 90 days with
4 refills
macitentan OPSUMIT • Negative pregnancy test in past month 6 months
Must have scheduled
follow-up appointment
Sufficient to reach
scheduled appointment
magnesium magnesium 12 months 90 days with
4 refills
maraviroc SELZENTRY Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
meclizine ANTIVERT, BONINE 12 months 90 days with
4 refills
meclofenamate meclofenamate 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
medroxyprogesterone PROVERA 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
mefenamic acid mefenamic acid 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
mefloquine LARIUM 12 months
May refill if seen in the
Travel Clinic in the last
year for antimalarial
prophylaxis
Per Travax medicine
software
recommendations for
area of travel and length
of stay
megestrol MEGACE 12 months 90 days with
4 refills
meloxicam MOBIC 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

memantine NAMENDA 12 months 90 days with
4 refills
mercaptopurine PURINETHOL, PURIXAN, 6-MP
Initiation of therapy or after dose
change
• CBC and ALT every 2 weeks X 1
month, then monthly X 2 months,
then move to maintenance
Maintenance - every 3 months and
within normal limits
• CBC
• ALT
12 months Refill by RN only 90 days with 0 refills
mesalamine ASACOL, PENTASA, others 12 months 90 days with
4 refills
mesalamine rectal CANASA, ROWASA 12 months 90 days with
4 refills
metaproterenol ALUPENT 12 months 90 days with
4 refills
metaxalone SKELAXIN 12 months 90 days with
4 refills
metformin, ER GLUCOPHAGE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
methazolamide NEPTAZAN 90 days with
3 refills
methenamine HIPREX 12 months 90 days with
4 refills
methimazole TAPAZOLE, NORTHYX
Every 12 months and within normal
limits
• TSH
12 months
If pregnant or history of
thyroid cancer forward
to provider
90 days with
4 refills
methocarbamol ROBAXIN 12 months 90 days with
4 refills
methotrexate methotrexate
Initiation of therapy or after dose
change
• CBC with diff, Cr, ALT monthly x 3
months, then move to maintenance
Maintenance - every 3 months and
within normal limits
• CBC with diff
• Cr
• ALT
12 months
RN only
May not refill if being
used for chemotherapy
90 days with 0 refills
methylcellulose CITRUCEL 12 months 90 days with
4 refills
methyldopa ALDOMET 12 months 90 days with
4 refills
methylprednisolone methylprednisolone
Every 6 months and within normal
limits
• K
• Na
12 months
May refill if does not
require titration and
used for maintenance
at <8 mg/day or stress
Amount of original
prescription
metipranolol metipranolol 90 days with
3 refills
metoclopramide REGLAN 12 months 90 days with
4 refills
metoprolol LOPRESSOR, TOPROL XL 12 months 90 days with
4 refills
metronidazole FLAGYL 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
2 weeks supply
0 refills
metronidazole topical METROCREAM, METROGEL 12 months
90 days with
4 refills
midodrine PROAMATINE 12 months 90 days with
4 refills
miglitol GLYSET
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
milk of magnesia milk of magnesia 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

milnacipran SAVELLA 12 months 90 days with
4 refills
minocycline MINOCIN 12 months
May refill only when
being used for chronic
condition
90 days with
4 refills
minoxidil LONITEN
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
minoxidil topical ROGAINE 12 months 90 days with
4 refills
mirtazapine REMERON 12 months 90 days with
4 refills
mometasone ELOCON 12 months 90 days with
4 refills
mometasone ASMANEX 12 months Current prescription for
albuterol
90 days with
4 refills
mometasone nasal NASONEX 12 months 90 days with
4 refills
mometasone-formoterol DULERA 12 months Current prescription for
albuterol
90 days with
4 refills
montelukast SINGULAIR 12 months 90 days with
4 refills
multivitamins MVI, ABDEK, various 12 months 90 days with
4 refills
mupirocin topical BACTROBAN 3 months Amount of original
prescription
mycophenolate CELLCEPT, MYFORTIC
nabumetone RELAFEN 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
nadolol CORGARD 12 months 90 days with
4 refills
naftifine topical NAFTIN 12 months 90 days with
4 refills
naphazoline/pheniramine NAPHCON A 90 days with
3 refills
naphazoline-antazolline VASCON A 90 days with
3 refills
naproxen NAPROSYN, ANAPROX 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
naratriptan AMERGE 12 months Amount of previous
prescription
nateglinide STARLIX
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
nebivolol BYSTOLIC 12 months 90 days with
4 refills
nedocromil ALOCRIL 90 days with
3 refills
nefazodone SERZONE 12 months 90 days with
4 refills
neomycin neomycin 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
neomycin-polymyxin-bacitracin NEOSPORIN topical 12 months 90 days with
4 refills
niacin NIASPAN, NIACOR 12 months 90 days with
4 refills
nicardipine CARDENE 12 months 90 days with
4 refills
nicotine patch, tablet, spray
NICOTROL, NICODERM,
NICORETTE, COMMIT,
various
12 months 30 days with
2 refills
nifedipine, SR/ER ADALAT CC, PROCARDIA
XL
12 months 90 days with
4 refills
nilutamide nilutamide 12 months 90 days with
4 refills
nisoldipine SULAR 12 months 90 days with
4 refills
nitrofurantoin MACROBID
Every 12 months and within normal
limits
• K, Cr
• AST, ALT
• CBC
• Chest X-ray
12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

nitroglycerin patch, tablet, spray, ointment
NITROSTAT, NITRO-BID,
NITRO-DUR, MINITRAN,
NITROMIST, various
12 months Systolic blood pressure
> 90 mmHg
90 days with
4 refills
nizatidine AXID 12 months 90 days with
4 refills
norelgestromin/ethinyl estradiol patch ORTHO EVRA
Every 12 months
• Chlamydia screening if < 25 yrs of
age
12 months 90 days with
4 refills
nortriptyline PAMELOR 12 months 90 days with
4 refills
nystatin suspension nystatin suspension 12 months 90 days with
4 refills
nystatin topical nystatin topical 12 months 90 days with
4 refills
octreotide SANDOSTATIN
Every 12 months and within normal
limits
• TSH
• B12
12 months 90 days with
4 refills
ofloxacin FLOXIN 6 months 90 days with
2 refills
olanzapine/fluoxetine SYMBAX Forward to provider
olmesartan BENICAR
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
olmesartan-HCTZ BENICAR HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
olopatadine PATANOL, PATADAY 12 months 90 days with
4 refills
olopatadine nasal PATANASE 12 months 90 days with
4 refills
olsalazine DIPENTUM 12 months 90 days with
4 refills
omega-3-acid LOVAZA 12 months 90 days with
4 refills
omeprazole PRILOSEC 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
ondansetron ZOFRAN 12 months 90 days with
4 refills
ophthalmic vitamins OCUVITE, PRESERVISION 90 days with
3 refills
oral contraceptives MANY
Every 12 months
• Chlamydia screening if < 25 yrs of
age
12 months 90 days with
4 refills
orphenadrine NORFLEX 12 months 90 days with
4 refills
oxaprozin DAYPRO 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
oxazepam oxazepam Forward to provider
oxcarbazepine TRILEPTAL
Every 12 months and within
normal/therapeutic range
• ALT/AST
• CBC
• Na
12 months 90 days with
4 refills
oxiconazole OXISTAT 12 months 90 days with
4 refills
oxybutynin
DITROPAN,DITROPAN XL,
OXYTROL 12 months
90 days with
4 refills
pancrelipase
CREON, PANCREASE,
ULTRASE 12 months
90 days with
4 refills
pantoprazole PROTONIX 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
papaverine papaverine 12 months 90 days with
4 refills
paricalcitol ZEMPLAR
Every 6 months and within normal
limits
• Ca
• PO4
• PTH
6 months 90 days with
2 refills
paroxetine PAXIL 12 months 90 days with
4 refills
pegfilgrastim NEULASTA Forward to provider
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

peginterferon beta-1a PLEGRIDY
Every 12 months and within normal
limits
• ALT, AST
• CBC
12 months 90 days with
4 refills
pentosan pentosan
Every 12 months and within normal
limits
• LFTs
• CBC
12 months 90 days with
4 refills
perindopril ACEON
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
permethrin topical ELIMITIN, various Forward to provider
phenobarbital phenobarbital Forward to provider
phenytoin DILANTIN
Every 12 months and within
therapeutic range
• phenytoin level
12 months 90 days with
4 refills
phosphate NEUTRA-PHOS
Every 12 months and within normal
limits
• Phos
12 months 90 days with
4 refills
pilocarpine ISOPTOCARPINE 90 days with
3 refills
pimecrolimus topical ELIDEL 12 months 90 days with
4 refills
pindolol VISKEN 12 months 90 days with
4 refills
pioglitazone ACTOS
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months Forward to provider
pioglitazone-glimepiride DUETACT
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months Forward to provider
pioglitazone-metformin ACTOSPLS MET
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months Forward to provider
pirbuterol MAXAIR 12 months 3 inhalers
0 refills
piroxicam FELDENE 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
pitavastatin LIVALO 12 months 90 days with
4 refills
polycarbophil FIBER CON 12 months 90 days with
4 refills
polyethylene glycol MIRALAX 12 months 90 days with
4 refills
potassium chloride K-LOR, K-TAB, KAON-CL, MICROK
Every 12 months and within normal
limits
• K
12 months 90 days with
4 refills
potassium citrate potassium citrate
Every 12 months and within normal
limits
• Na, K, chloride, CO2, Cr
• CBC
• urinary citrate/pH
12 months 90 days with
4 refills
pramipexole MIRAPEX 12 months 90 days with
4 refills
pramlintide SYMLIN
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
pravastatin PRAVACHOL 12 months 90 days with
4 refills
prazosin MINIPRESS 12 months 90 days with
4 refills
prednisolone ophthalmic OMNIPRED, PRED FORTE,
PRED MILD
Amount of original
prescription
prednisone prednisone
Every 6 months and within normal
limits
• K
• Na
12 months
May refill if dose is
stable (not being
tapered) and used for
maintenance at <10
mg/day or stress mg x1
Amount of previous
prescription
pregabalin LYRICA Forward to provider
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

prenatal vitamins prenatal vitamins 12 months 90 days with
4 refills
primidone MYSOLINE
Every 12 months and within
normal/therapeutic range
• CBC
• primidone level
12 months 90 days with
4 refills
prochlorperazine COMPAZINE 12 months 90 days with
4 refills
progesterone PROMETRIUM 12 months 90 days with
4 refills
promethazine PHENERGAN 12 months 90 days with
4 refills
propranolol INDERAL, INNOPRAN XL 12 months 90 days with
4 refills
propylthiouracil PTU
Every 12 months and within normal
limits
• TSH
12 months
If pregnant or history of
thyroid cancer forward
to provider
90 days with
4 refills
psyllium METAMUCIL 12 months 90 days with
4 refills
pyridostigmine MESTINON 12 months 90 days with
4 refills
pyridoxine VITAMIN B6 12 months 90 days with
4 refills
quazepam QUESTCOR Forward to provider
quetiapine SEROQUEL TBD TBD TBD
quinapril ACCUPRIL
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
rabeprazole ACIPHEX 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
racepinephrine racepinephrine 12 months 3 inhalers
0 refills
raltegravir ISENTRESS Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
ramipril ALTACE
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
ramipril-HCTZ ALTACE HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
ranitidine ZANTAC 12 months 90 days with
4 refills
rasagiline AZILECT 12 months 90 days with
4 refills
repaglinide PRANDIN
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
repaglinide-metformin PRANDIMET
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
riboflavin VITAMIN B2 12 months 90 days with
4 refills
rifaximin XIFAXAN 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
May refill for traveler's
diarrhea if seen in the
Travel Clinic in the last
year
2 weeks supply
0 refills
Per Travax medicine
software
recommendations for
area of travel and length
of stay
rilonacept ARACALYST
Every 6 months and within normal
limits
• CBC
12 months 90 days with
1 refill
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

riluzole RILUTEK
Every 6 months and within normal
limits
• ALT, AST
6 months 90 days with
2 refills
rimexolone VEXOL Amount of original
prescription
riociguat ADEMPAS
12 months for
erectile dysfunction
6 months for chronic
conditions such as
pulmonary
hypertension
Forward to provider if
patient on any
nitroglycerin products
If used for erectile
dysfunction patient
preference (usually 5-
6) with 11 refills
If used for maintenance
therapy provide 90 days
with with 3 refills
risedronate ACTONEL 12 months
If patient has been on
medication for 5 or
more years (review
medication history),
send to physician for
review
90 days with
4 refills
risperidone RISPERDOL TBD TBD TBD
ritonavir NORVIR Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
rivaroxaban XARELTO
Every 12 months and within normal
limits
• Cr
• CBC without diff
• ALT
12 months 90 days with
4 refills
rivastigmine EXELON 12 months 90 days with
4 refills
rizatriptan MAXALT 12 months Amount of previous
prescription
ropinirole REQUIP 12 months 90 days with
4 refills
rosiglitazone AVANDIA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months Forward to provider
rosiglitazone-glimepiride AVANDARYL
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months Forward to provider
rosiglitazone-metformin AVANDAMET
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months Forward to provider
rosuvastatin CRESTOR 12 months 90 days with
4 refills
rotigotine NEUPRO 12 months 90 days with
4 refills
rufinamide BANZEL 12 months 90 days with
4 refills
salicylic acid-containing topical AVEENO CLEAR 12 months 90 days with
4 refills
salmeterol SEREVENT 12 months Current prescription for
albuterol
90 days with
4 refills
salsalate DISALCID 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
saxagliptin ONGLYZA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
saxagliptin-metformin KOMBIGLYZE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
scopolamine TRANSDERM-SCOP 12 months 90 days with
4 refills
selegiline ELDEPRYL, ZELAPAR 12 months 90 days with
4 refills
selenium sulfide topical SELSUN, various 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

selexipag UPTRAVI
12 months for
erectile dysfunction
6 months for chronic
conditions such as
pulmonary
hypertension
Forward to provider if
patient on any
nitroglycerin products
If used for erectile
dysfunction patient
preference (usually 5-
6) with 11 refills
If used for maintenance
therapy provide 90 days
with with 3 refills
senna-docusate SENOKOT-S 12 months 90 days with
4 refills
sennosides SENNA 12 months 90 days with
4 refills
sertraline ZOLOFT 12 months 90 days with
4 refills
sevelamer RENAGEL, RENVELA
Every 6 months and within normal
limits
• Ca
• PO4
• CO2
• chloride
6 months 90 days with
2 refills
sildenafil VIAGRA, REVATIO
12 months for
erectile dysfunction
6 months for chronic
conditions such as
pulmonary
hypertension
Forward to provider if
patient on any
nitroglycerin products
If used for erectile
dysfunction patient
preference (usually 5-
6) with 11 refills
If used for maintenance
therapy provide 90 days
with with 3 refills
silodosin RAPAFLO 12 months 90 days with
4 refills
silver sulfadiazine SILVADENE 12 months Amount of original
prescription
silver topical silver topical 12 months 90 days with
4 refills
simvastatin ZOCOR 12 months 90 days with
4 refills
simvastatin-niacin SIMCOR •ALT - in last 12 months and <3x
upper limit of normal 12 months
90 days with
4 refills
sirolimus RAPAMUNE
Every 1 month and within normal
limits
• Cr
• Glucose
Every 12 months and within normal
limits
• ALT, AST, Alk Phos, Bilirubin
• Lipid panel
6 months Forward to provider 90 days with
2 refills
sitagliptin JANUVIA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
sitagliptin-metformin JANUMET
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
sodium sodium
Every 12 months and within normal
limits
• Na
12 months 90 days with
4 refills
sodium bicarbonate sodium bicarbonate
Every 12 months and within normal
limits
• CO2
12 months
90 days
3 refills
sodium chloride 0.9% flushes sodium chloride 0.9% flushes 12 months 90 days with
4 refills
sodium chloride 7% HYPERSAL 12 months 90 days with
4 refills
sodium chloride hypertonic MURO 128 90 days with
3 refills
solifenacin VESICARE 12 months 90 days with
4 refills
sorbitol sorbitol 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

spironolactone ALDACTONE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
If used for hypertension
BP meets goal
indicated in chart. If
none listed BP should
be < 140/90 mmHg
90 days with
4 refills
spironolactone-HCTZ ALDACTAZIDE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
If used for hypertension
BP meets goal
indicated in chart. If
none listed BP should
be < 140/90 mmHg
90 days with
4 refills
sucralfate CARAFATE 12 months 90 days with
4 refills
sucroferric oxyhydroxide VELPHORO
Every 6 months and within normal
limits
• Ca
• PO4
6 months 90 days with
2 refills
sulfacetamide-containing topical VARIOUS 12 months 90 days with
4 refills
sulfamethoxazole-trimethoprim BACTRIM, TMP/SULFA 12 months
May refill only when
being used for chronic
condition
90 days with
4 refills
sulfasalazine AZULFIDINE
Initiation of therapy or after dose
change
• CBC with diff, Cr, ALT monthly x 3
months, then move to maintenance
Maintenance - every 3 months and
within normal limits
• CBC with diff
• Cr
• ALT
12 months 90 days with
0 refills
sulindac CLINORIL 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
sumatriptan IMITREX 12 months Amount of previous
prescription
supplies, diabetic: meters, test strips,
needles/syringes, lancets, insulin pump
supplies, diabetic: meters,
test strips, needles/syringes,
lancets, insulin pump
12 months 90 days with
4 refills
supplies: breast prosthesis supplies: breast prosthesis 12 months 1 per affected
breast/year
supplies: compression sleeves supplies: compression
sleeves
12 months 3 pair/year
supplies: compression stockings supplies: compression
stockings
12 months 2 pair/year
supplies: dressings supplies: dressings 12 months 90 days with
4 refills
supplies: injectable medications supplies: injectable medications 12 months
90 days with
4 refills
supplies: line/drain/airway
E.g., feeding tubes,
catheters, venous access
devices
12 months 90 days with
4 refills
supplies: mastectomy bras supplies: mastectomy bras 12 months 2/year
supplies: ostomy supplies: ostomy 12 months 90 days with
4 refills
supplies: respiratory Aerochamber, spacer 12 months
supplies: testing supplies: testing 12 months 90 days with
4 refills
supplies: urinary care supplies: urinary care 12 months 90 days with
4 refills
supplies: wig supplies: wig 12 months 1/year
synthetic conjugated estrogens A, B CENESTIN, ENJUVIA 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
tacrine COGNEX 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

tacrolimus PROGRAF
Every 1 month and within normal
limits
• CBC
• Cr
• K, Mg, Ca
• Glucose
• Cyclosporine level
Every 12 months and within normal
limits
• ALT, AST, Alk Phos, Bilirubin
• Lipid panel
6 months Forward to provider 90 days with
2 refills
tacrolimus topical PROTOPIC 12 months 90 days with
4 refills
tadalafil CIALIS
12 months for
erectile dysfunction
6 months for chronic
conditions such as
pulmonary
hypertension
Forward to provider if
patient on any
nitroglycerin products
If used for erectile
dysfunction patient
preference (usually 5-
6) with 11 refills
If used for maintenance
therapy provide 90 days
with with 3 refills
tamoxifen NOLVADEX 12 months 90 days with
4 refills
tamsulosin FLOMAX 12 months 90 days with
4 refills
tazarotene topical TAZORAC 12 months 90 days with
4 refills
TBO-filgrastim GRANIX Forward to provider
telmisartan MYCARDIS
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
telmisartan-HCTZ MYCARDIS HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
temazepam RESTORIL Forward to provider
tenofovir VIREAD Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
terazosin HYTRIN 12 months 90 days with
4 refills
terbinafine LAMISIL Forward to provider
terbinafine topical LAMISIL 12 months 90 days with
4 refills
teriflunomide AUBAGIO
Every 6 months and within normal
limits
• ALT, AST
• CBC
6 months 90 days with
2 refills
tetrabenazine XENAZINE 12 months 90 days with
4 refills
theophylline various
Every 12 months and normal
• Theophylline
12 months 90 days with
4 refills
thyroid extract ARMOUR THYROID
• TSH - every 12 months and within
normal range (or less than provider
specified goal)
12 months
If pregnant or history of
thyroid cancer forward
to provider
90 days with
4 refills
tiagabine GABITRIL
Every 12 months and within
normal/therapeutic range
• ALT/AST
• tiagabine level
12 months 90 days with
4 refills
ticlopidine TICLID 12 months 90 days with
4 refills
tiludronate SKELID 12 months
If patient has been on
medication for 5 or
more years (review
medication history),
send to physician for
review
90 days with
4 refills
timolol TIMOPTIC, TIMOPTIC XE 90 days with
3 refills
tiotropium SPIRIVA 12 months Current prescription for
albuterol
90 days with
4 refills
tizanidine ZANAFLEX 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

tobramycin TOBI 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
tocilizumab (injectable only) ACTEMRA
Every 3 months and within normal
limits
• CBC
• ALT
12 months
Injectable only, infusion
must be forwarded to
provider
90 days with
4 refills
tofacitinib XELJANZ
Every 3 months
• CBC
Every 12 months and within normal
limits
• Lipids
• ALT
• Cr
12 months Refill by RN only
tolmetin TOLECTIN 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
tolterodine DETROL, DETROL XL 12 months 90 days with
4 refills
topiramate TOPAMAX
Every 12 months and within
normal/therapeutic range
• NaHCO3 (CO2onate)
• Cr
• topiramate level
12 months 90 days with
4 refills
toremifene FARESTON 12 months 90 days with
4 refills
torsemide DEMADEX
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
trandolapril MAVIK
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
tranexamic acid tranexamic acid 12 months 90 days with
4 refills
travoprost TRAVATAN Z 90 days with
3 refills
trazodone OLEPTRO 12 months 90 days with
4 refills
tretinoin topical AVITA 12 months 90 days with
4 refills
triamcinolone AZMACORT 12 months Current prescription for
albuterol
90 days with
4 refills
triamcinolone nasal NASACORT AQ 12 months 90 days with
4 refills
triamcinolone topical KENALOG 12 months 90 days with
4 refills
triamterene DYRENIUM
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
triamterene-HCTZ DYAZIDE, MAXIDE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
triazolam HALCION Forward to provider
trifluridine VIROPTIC Amount of original
prescription
trihexyphenidyl ARTANE 12 months 90 days with
4 refills
trimethobenzamide TIGAN Forward to provider
trospium SANCTURA, SANCTURA
XR 12 months
90 days with
4 refills
trypsin-castor oil-peru balsam XENADERM, 12 months 90 days with
4 refills
umeclidinium INCRUSE 12 months 90 days with
4 refills
umeclidinium-vilanterol ANORO 12 months 90 days with
4 refills
unoprostine RESCULA 90 days with
3 refills
urea instillation urea instillation 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

urea topical urea topical 12 months 90 days with
4 refills
ursodiol URSO, ACTIGALL 12 months 90 days with
4 refills
valacyclovir VALTREX 12 months May refill if being used
for prophylaxis
90 days with
4 refills
valproic acid DEPAKENE, STAVZOR
Every 12 months and within
normal/therapeutic range
• ALT/AST
• CBC
• valproate level
12 months 90 days with
4 refills
valsartan DIOVAN
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
valsartan-HCTZ DIOVAN HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
vancomycin VANCOCIN 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
2 weeks supply
0 refills
vardenafil LEVITRA 12 months
Forward to provider if
patient on any
nitroglycerin products
If used for erectile
dysfunction patient
preference (usually 5-
6) with 11 refills
If used for maintenance
therapy provide 90 days
with with 3 refills
varenicline CHANTIX Forward to provider
vedolizumab ENTYVIO
Every 6 months and within normal
limits
• CBC
• ALT
12 months Refill by RN only 90 days with
4 refills
venlafaxine EFFEXOR 12 months 90 days with
4 refills
verapamil CALAN, COVERA-HS,
ISOPTIN, VERELAN 12 months
90 days with
4 refills
vigabatrin SABRIL 6 months Ophth exam every 3 months
90 days with
2 refills
vilazodone VIBRYD 12 months 90 days with
4 refills
vitamin B complex NEPHROCAPS 12 months 90 days with
4 refills
warfarin COUMADIN, JANTOVEN 12 Months
If Anticoagulation Clinic
pt, then AC clinic refills
All other clinics - may
only refill if patient is
enrolled in
Anticoagulation
protocol and may only
be refilled by
RNs/RPhs. Refills for
all other patients must
be forwarded to
physician.
90 days with
4 refills
zafirlukast ACCOLATE 12 months 90 days with
4 refills
zinc zinc 12 months 90 days with
4 refills
zolmitriptan ZOMIG 12 months Amount of previous
prescription
zonisamide ZONEGRAN
Every 12 months and within
therapeutic range
• zonisamide level
12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Appendix B. UW Health Clinics - Medications Sorted by Common Brand Name
Generic Name Common Brand Names Labs
Interval Between
Office Visits Other Max Supply
aripiprazole ABILIFY Forward to provider
zafirlukast ACCOLATE 12 months 90 days with
4 refills
quinapril ACCUPRIL
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
perindopril ACEON
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
rabeprazole ACIPHEX 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
alclometasone ACLOVATE 12 months 90 days with
4 refills
tocilizumab (injectable only) ACTEMRA
Every 3 months and within normal
limits
• CBC
• ALT
12 months
Injectable only, infusion
must be forwarded to
provider
90 days with
4 refills
risedronate ACTONEL 12 months
If patient has been on
medication for 5 or
more years (review
medication history),
send to physician for
review
90 days with
4 refills
pioglitazone ACTOS
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months Forward to provider
pioglitazone-metformin ACTOSPLS MET
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months Forward to provider
ketorolac ophth ACULAR, ACUVAIL 12 months 90 days with
4 refills
dapsone topical ACZONE 12 months 90 days with
4 refills
nifedipine, SR/ER ADALAT CC, PROCARDIA
XL
12 months 90 days with
4 refills
riociguat ADEMPAS
12 months for
erectile dysfunction
6 months for chronic
conditions such as
pulmonary
hypertension
Forward to provider if
patient on any
nitroglycerin products
If used for erectile
dysfunction patient
preference (usually 5-
6) with 11 refills
If used for maintenance
therapy provide 90 days
with with 3 refills
fluticasone-salmeterol ADVAIR 12 months Current prescription for
albuterol
90 days with
4 refills
lovastatin-niacin ADVICOR •ALT - in last 12 months and <3x
upper limit of normal 12 months
90 days with
4 refills
flunisolide AEROBID 12 months Current prescription for
albuterol
90 days with
4 refills
supplies: respiratory Aerochamber, spacer 12 months
aspirin-dipyridamole AGGRENOX 12 months 90 days with
1 refill
spironolactone-HCTZ ALDACTAZIDE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
If used for hypertension
BP meets goal
indicated in chart. If
none listed BP should
be < 140/90 mmHg
90 days with
4 refills
spironolactone ALDACTONE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
If used for hypertension
BP meets goal
indicated in chart. If
none listed BP should
be < 140/90 mmHg
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

imiquimod topical ALDARA 12 months 90 days with
4 refills
methyldopa ALDOMET 12 months 90 days with
4 refills
fexofenadine ALLEGRA, ALLEGRA D 12 months
Forward to provider if
decongestant ("D")
formula
90 days with
4 refills
nedocromil ALOCRIL 90 days with
3 refills
lodoxamine ALOMIDE 90 days with
3 refills
estradiol patch
ALORA, CLIMARA,
MENOSTAR, VIVELLE 12 months
Pap screening per age
appropriate guideline
90 days with
4 refills
ramipril ALTACE
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
ramipril-HCTZ ALTACE HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
efavirenz/ emtricitabine/ tenofovir ALTRIPLA Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
metaproterenol ALUPENT 12 months 90 days with
4 refills
ciclesonide ALVESCO 12 months 90 days with
4 refills
glimepiride AMARYL
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
amcinonide amcinonide 12 months 90 days with
4 refills
naratriptan AMERGE 12 months Amount of previous
prescription
aminocaproic acid AMICAR 12 months 90 days with
4 refills
amiloride amiloride
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
amiloride-HCTZ amiloride-HCTZ
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
lubiprostone AMITIZA 12 months 90 days with
4 refills
ammonium lactate topical AM-LACTIN, LAC HYDRIN,
various
12 months 90 days with
4 refills
amoxicillin amoxicillin 12 months
May refill when being
used for dental or
procedural prophylaxis
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
Amount of original
prescription
2 weeks supply
0 refills
dalfampridine AMPYRA
Every 12 months and within normal
limits
• Cr
12 months 90 days with
1 refill
aliskiren-amlodipine-HCTZ AMTURNIDE
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
clomipramine ANAFANIL 12 months 90 days with
4 refills
hyoscyamine ANASPAZ, LEVSIN 12 months 90 days with
4 refills
estradiol-drospirenone ANGELIQ 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
umeclidinium-vilanterol ANORO 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

meclizine ANTIVERT, BONINE 12 months 90 days with
4 refills
insulin glulisine APIDRA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
hydralazine APRESOLINE 12 months
Forward to provider if
total dose > 100
mg/day
BP meets goal
indicated in chart. If
none listed BP should
be < 140/90 mmHg
90 days with
4 refills
eslicarbazepine APTIOM 12 months 90 days with
4 refills
rilonacept ARACALYST
Every 6 months and within normal
limits
• CBC
12 months 90 days with
1 refill
darbepoetin ARANESP Forward to provider
leflunomide ARAVA
Initiation of therapy or after dose
change
• CBC, Cr, ALT monthly X 6 months,
then move to maintenance
Maintenance - every 3 months and
within normal limits
• CBC
• ALT
12 months Refill by RN only 90 days with
1 refill
indacaterol ARCAPTA 12 months Current prescription for
albuterol
90 days with
4 refills
donepezil ARICEPT 12 months 90 days with
4 refills
anastrozole ARIMIDEX 12 months 90 days with
4 refills
thyroid extract ARMOUR THYROID
• TSH - every 12 months and within
normal range (or less than provider
specified goal)
12 months
If pregnant or history of
thyroid cancer forward
to provider
90 days with
4 refills
exemestane AROMASIN 12 months 90 days with
4 refills
trihexyphenidyl ARTANE 12 months 90 days with
4 refills
diclofenac-misoprostol ARTHROTEC 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
artificial tears artificial tears
90 days with
3 refills
mesalamine ASACOL, PENTASA, others 12 months 90 days with
4 refills
mometasone ASMANEX 12 months Current prescription for
albuterol
90 days with
4 refills
aspirin aspirin 12 months 90 days with
4 refills
azelastine nasal ASTELIN, ASTAPRO 12 months 90 days with
4 refills
candesartan ATACAND
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
candesartan-HCTZ ATACAND HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
hydroxyzine ATARAX,VISTARIL 12 months 90 days with
4 refills
lorazepam ATIVAN Forward to provider
atropine atropine 12 months 90 days with
4 refills
ipratropium ATROVENT 12 months Current prescription for
albuterol
90 days with
4 refills
teriflunomide AUBAGIO
Every 6 months and within normal
limits
• ALT, AST
• CBC
6 months 90 days with
2 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

amoxicillin-clavulanate AUGMENTIN 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
2 weeks supply
0 refills
irbesartan-HCTZ AVALIDE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
rosiglitazone-metformin AVANDAMET
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months Forward to provider
rosiglitazone-glimepiride AVANDARYL
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months Forward to provider
rosiglitazone AVANDIA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months Forward to provider
irbesartan AVAPRO
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
salicylic acid-containing topical AVEENO CLEAR 12 months 90 days with
4 refills
tretinoin topical AVITA 12 months 90 days with
4 refills
interferon beta 1a AVONEX, REBIF
Every 12 months and within normal
limits
• TSH, T4
• ALT, AST
• CBC
12 months 90 days with
4 refills
almotriptan AXERT 12 months Amount of previous
prescription
nizatidine AXID 12 months 90 days with
4 refills
rasagiline AZILECT 12 months 90 days with
4 refills
triamcinolone AZMACORT 12 months Current prescription for
albuterol
90 days with
4 refills
brinzolamide AZOPT 90 days with
3 refills
aztreonam aztreonam 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
sulfasalazine AZULFIDINE
Initiation of therapy or after dose
change
• CBC with diff, Cr, ALT monthly x 3
months, then move to maintenance
Maintenance - every 3 months and
within normal limits
• CBC with diff
• Cr
• ALT
12 months 90 days with
0 refills
bacitracin topical bacitracin topical 3 months Amount of original
prescription
sulfamethoxazole-trimethoprim BACTRIM, TMP/SULFA 12 months
May refill only when
being used for chronic
condition
90 days with
4 refills
mupirocin topical BACTROBAN 3 months Amount of original
prescription
rufinamide BANZEL 12 months 90 days with
4 refills
beclomethasone nasal BECONASE AQ 12 months 90 days with
4 refills
diphenhydramine BENADRYL 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

guar gum BENEFIBER 12 months 90 days with
4 refills
olmesartan BENICAR
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
olmesartan-HCTZ BENICAR HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
dicyclomine BENTYL 12 months 90 days with
4 refills
erythromycin/benzoyl peroxide topical BENZAMYCIN 12 months 90 days with
4 refills
levobunolol BETAGAN 90 days with
3 refills
interferon beta 1b BETASERON, EXTAVIA
Every 12 months and within normal
limits
• TSH, T4
• ALT, AST
• CBC
12 months 90 days with
4 refills
betaxolol BETO PTIC S 90 days with
3 refills
clarithromycin BIAXIN 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
2 weeks supply
0 refills
ibandronate BONIVA 12 months
If patient has been on
medication for 5 or
more years (review
medication history),
send to physician for
review
90 days with
4 refills
fluticasone-vilanterol BREO 12 months Current prescription for
albuterol
90 days with
4 refills
arformoterol BROVANA 12 months Current prescription for
albuterol
90 days with
4 refills
bumetanide BUMEX
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
buspirone BUSPAR 12 months 90 days with
4 refills
exenatide BYETTA, BYDUREON
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
nebivolol BYSTOLIC 12 months 90 days with
4 refills
cabergoline cabergoline
Every 12 months and within normal
limits
• prolactin
12 months 90 days with
4 refills
ergotamine-caffeine CAFERGOT Forward to provider
verapamil CALAN, COVERA-HS,
ISOPTIN, VERELAN 12 months
90 days with
4 refills
calcium calcium 12 months 90 days with
4 refills
mesalamine rectal CANASA, ROWASA 12 months 90 days with
4 refills
captopril CAPOTEN
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
captopril-HCTZ CAPOZIDE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
capsacin patch, cram, liquid, topical capsacin patch, cram, liquid,
topical
12 months 90 days with
4 refills
sucralfate CARAFATE 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

nicardipine CARDENE 12 months 90 days with
4 refills
diltiazem
CARDIZEM, CARTIA,
DILACOR XR, DILTIA XT,
TIAZAC
12 months 90 days with
4 refills
doxazosin CARDURA, CARDURA XL 12 months 90 days with
4 refills
carnitine, levocarnitine CARNITOR 12 months 90 days with
4 refills
bicalutamide CASODEX 12 months 90 days with
4 refills
clonidine CATAPRES 12 months 90 days with
4 refills
alprostadil CAVERJECT 12 months 90 days with
4 refills
celecoxib CELEBREX 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
citalopram CELEXA 12 months 90 days with
4 refills
mycophenolate CELLCEPT, MYFORTIC
synthetic conjugated estrogens A, B CENESTIN, ENJUVIA 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
varenicline CHANTIX Forward to provider
chlorpheniramine CHLOR-TRIMETON 12 months 90 days with
4 refills
tadalafil CIALIS
12 months for
erectile dysfunction
6 months for chronic
conditions such as
pulmonary
hypertension
Forward to provider if
patient on any
nitroglycerin products
If used for erectile
dysfunction patient
preference (usually 5-
6) with 11 refills
If used for maintenance
therapy provide 90 days
with with 3 refills
ciprofloxacin ophth ointment CILOXAN 3 months Amount of original
prescription
certolizumab CIMZIA
Every 6 months and within normal
limits
• CBC
• ALT
12 months Refill by RN only 90 days with
1 refill
ciprofloxacin CIPRO 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
May refill for traveler's
diarrhea if seen in the
Travel Clinic in the last
year
2 weeks supply
0 refills
Per Travax medicine
software
recommendations for
area of travel and length
of stay
ciprofloxacin-dexamethasone CIPRODEX 6 months 90 days with
2 refills
methylcellulose CITRUCEL 12 months 90 days with
4 refills
desloratadine CLARINEX 12 months 90 days with
4 refills
hydroquinone topical CLARIPEL, LUSTRA, various 12 months 90 days with
4 refills
loratadine CLARITIN 12 months
Forward to provider if
decongestant ("D")
formula
90 days with
4 refills
clindamycin CLEOCIN 12 months
May refill when being
used for dental or
procedural prophylaxis
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
Amount of original
prescription
2 weeks supply
0 refills
clindamycin topical CLEOCIN T 12 months 90 days with
4 refills
sulindac CLINORIL 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

clobetasol
CLOBEX, OLUX,
TEMOVATE 12 months
90 days with
4 refills
benztropine COGENTIN 12 months 90 days with
4 refills
tacrine COGNEX 12 months 90 days with
4 refills
docusate COLACE 12 months 90 days with
4 refills
balsalazide COLAZAL 12 months 90 days with
4 refills
colchicine colchicine
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
colestipol COLESTID 12 months 90 days with
4 refills
colistimethate colistimethate 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
brimonidine-timolol COMBIGAN 90 days with
3 refills
albuterol-ipratropium COMBIVENT, DUONEB 12 months 90 days with
4 refills
lamivudine/ zidovudine COMBIVIR Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
prochlorperazine COMPAZINE 12 months 90 days with
4 refills
entacapone COMTAN 12 months 90 days with
4 refills
glatiramer COPAXONE, GLATOPA 12 months 90 days with
4 refills
flurandrenolide CORDRAN 12 months 90 days with
4 refills
carvedilol COREG, COREG CR 12 months 90 days with
4 refills
nadolol CORGARD 12 months 90 days with
4 refills
hydrocortisone CORTAID 12 months 90 days with
4 refills
hydrocortisone rectal
CORTIFOAM, PROCTOCOL-
HC 12 months
90 days with
4 refills
dorzolamide-timolol COSOPT 90 days with
3 refills
warfarin COUMADIN, JANTOVEN 12 Months
If Anticoagulation Clinic
pt, then AC clinic refills
All other clinics - may
only refill if patient is
enrolled in
Anticoagulation
protocol and may only
be refilled by
RNs/RPhs. Refills for
all other patients must
be forwarded to
physician.
90 days with
4 refills
losartan COZAAR
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
pancrelipase
CREON, PANCREASE,
ULTRASE 12 months
90 days with
4 refills
rosuvastatin CRESTOR 12 months 90 days with
4 refills
fluticasone topical CUTIVATE 12 months 90 days with
4 refills
duloxetine CYMBALTA 12 months 90 days with
4 refills
liothyronine CYTOMEL
• TSH - every 12 months and within
normal range (or less than provider
specified goal)
12 months
If pregnant or history of
thyroid cancer forward
to provider
90 days with
4 refills
flurazepam DALMANE Forward to provider
dantrolene DANTRIUM Forward to provider
oxaprozin DAYPRO 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

desmopressin DDAVP
Every 12 months and within normal
limits
• CBC
• ALT
12 months 90 days with
4 refills
torsemide DEMADEX
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
valproic acid DEPAKENE, STAVZOR
Every 12 months and within
normal/therapeutic range
• ALT/AST
• CBC
• valproate level
12 months 90 days with
4 refills
divalproex DEPAKOTE
Every 12 months and within
normal/therapeutic range
• ALT/AST
• CBC
• valproate level
12 months 90 days with
4 refills
desonide topical
DESO NATE, DESOWEN,
VERDESO 12 months
90 days with
4 refills
tolterodine DETROL, DETROL XL 12 months 90 days with
4 refills
dexamethasone dexamethasone
Every 6 months and within normal
limits
• K
• Na
12 months
May refill if does not
require titration and
used for maintenance
at <4 mg/day OR used
as premedication for
chemo or as directed
by Beacon treatment
plan or supportive care
plan
Amount of original
prescription
dexlansoprazole DEXILANT 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
glyburide
DIABETA, GLYNASE,
PRESTAB, MICRONASE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
acetazolamide DIAMOX
Every 12 months and within normal
limits
• CBC
• Na, K, chloride, CO2
12 months 90 days with
4 refills
etidronate DIDRONEL
Every 6 months and within normal
limits
• Cr
12 months
If patient has been on
medication for 5 or
more years (review
medication history),
send to physician for
review
90 days with
4 refills
adapalene topical DIFFERIN 12 months 90 days with
4 refills
fluconazole DIFLUCAN
Every 12 months and within normal
limits
• K
• Cr
• AST, ALT, Alk Phos, Bilirubin
12 months 90 days with
4 refills
phenytoin DILANTIN
Every 12 months and within
therapeutic range
• phenytoin level
12 months 90 days with
4 refills
diltiazem topical diltiazem topical 12 months 90 days with
4 refills
valsartan DIOVAN
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
valsartan-HCTZ DIOVAN HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
olsalazine DIPENTUM 12 months 90 days with
4 refills
betamethasone dipropionate DIPROLENE 12 months 90 days with
0 refills
salsalate DISALCID 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
oxybutynin
DITROPAN,DITROPAN XL,
OXYTROL 12 months
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

diflunisal DOLOBID 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
calcipotriene DOVONEX, SORILUX 12 months Maximum 120 g/month 90 days with
4 refills
aluminum chloride DRYSOL 12 months 90 days with
4 refills
pioglitazone-glimepiride DUETACT
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months Forward to provider
bisacodyl DULCOLAX 12 months 90 days with
4 refills
mometasone-formoterol DULERA 12 months Current prescription for
albuterol
90 days with
4 refills
isometheptene-dichloral-phenazone-
acetaminophen DURADRIN, MIDRIN Forward to provider
triamterene-HCTZ DYAZIDE, MAXIDE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
azelastine-fluticasone DYMISTA 12 months 90 days with
4 refills
triamterene DYRENIUM
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
supplies: line/drain/airway
E.g., feeding tubes,
catheters, venous access
devices
12 months 90 days with
4 refills
econazole topical ECOZA 12 months 90 days with
4 refills
azilsartan EDARBI
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
venlafaxine EFFEXOR 12 months 90 days with
4 refills
fluorouracil topical EFUDEX, CARAC Forward to provider
amitriptyline ELAVIL 12 months 90 days with
4 refills
selegiline ELDEPRYL, ZELAPAR 12 months 90 days with
4 refills
epinastine ELESTAT 12 months 90 days with
4 refills
pimecrolimus topical ELIDEL 12 months 90 days with
4 refills
permethrin topical ELIMITIN, various Forward to provider
apixaban ELIQUIS
Every 12 months and within normal
limits
• Cr
• CBC without diff
• ALT
12 months 90 days with
4 refills
mometasone ELOCON 12 months 90 days with
4 refills
emedastine EMADINE 12 months 90 days with
4 refills
lidocaine-prilocaine EMLA 12 months 90 days with
4 refills
darifenacin ENABLEX 12 months 90 days with
4 refills
etanercept ENBREL
Every 6 months and within normal
limits
• CBC
12 months Refill by RN only 90 days with
1 refill
budesonide ENTOCORT
Every 6 months and within normal
limits
• K
• Na
12 months 90 days with
4 refills
vedolizumab ENTYVIO
Every 6 months and within normal
limits
• CBC
• ALT
12 months Refill by RN only 90 days with
4 refills
epinephrine ophth EPIFRIN 12 months 90 days with
4 refills
epinephrine EPIPEN 12 months Amount of original
prescription
epoetin EPOG EN, PROCRIT Forward to provider
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

abacavir/ lamivudine EPZICOM Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
erythromycin-containing topical ERYDERM, ERY-PAD 12 months 90 days with
4 refills
erythromycin ERYTAB 12 months
May refill only when
being used for chronic
condition
90 days with
4 refills
erythromycin erythromycin 12 months
May refill only when
being used for
procedural prophylaxis
Amount of original
prescription
butalbital-acetaminophen-caffeine ESGIC, ESGIC-PLUS,
FIORICET Forward to provider
estazolam estazolam Forward to provider
estradiol oral ESTRACE, FEMTRACE 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
estradiol topical or vaginal
ESTROGEL, ESTRASORB,
ESTRACE, VAGIFEM 12 months
Pap screening per age
appropriate guideline
90 days with
4 refills
flutamide EULEXIN 12 months 90 days with
4 refills
rivastigmine EXELON 12 months 90 days with
4 refills
Factor IX Factor IX 12 months 90 days with
4 refills
Factor VIIa Factor VIIa 12 months 90 days with
4 refills
Factor VIII Factor VIII 12 months 90 days with
4 refills
Factor VIII/vWF complex concentrate Factor VIII/vWF complex
concentrate
12 months 90 days with
4 refills
Factor XIIIa Factor XIIIa 12 months 90 days with
4 refills
famciclovir FAMVIR 12 months May refill if being used
for prophylaxis
90 days with
4 refills
toremifene FARESTON 12 months 90 days with
4 refills
dapagliflozin FARXIGA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Every 12 months and within normal
limits
• Cr
• LDL-C
6 months 90 days with
2 refills
felbamate FELBATOL
Every 6 months and within
normal/therapeutic range
• ALT/AST
• CBC
• felbamate level
12 months 90 days with
4 refills
piroxicam FELDENE 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
letrozole FEMARA 12 months 90 days with
4 refills
estradiol-norethindrone FEMHRT, ACTIVELLA 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
estradiol ring FEMRING, ESTRING 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
ferrous sulfate, ferrous gluconate, iron
ferrous sulfate, ferrous
gluconate, iron
12 months 90 days with
4 refills
polycarbophil FIBER CON 12 months 90 days with
4 refills
butalbital-aspirin-caffeine FIORINAL Forward to provider
metronidazole FLAGYL 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
2 weeks supply
0 refills
cyclobenzaprine FLEXERIL 12 months 90 days with
4 refills
tamsulosin FLOMAX 12 months 90 days with
4 refills
fluticasone nasal FLONASE, VERAMYST 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

fludrocortisone FLORINEF
Every 6 months and within normal
limits
• K
• Na
12 months Amount of original
prescription
fluticasone FLOVENT 12 months Current prescription for
albuterol
90 days with
4 refills
ofloxacin FLOXIN 6 months 90 days with
2 refills
fluoride fluoride 12 months Forward to provider 90 days with
4 refills
flurbiprofen flurbiprofen 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
flurometholone FML Amount of original
prescription
folic acid folate 12 months 90 days with
4 refills
formoterol FORADIL, PERFORMIST 12 months Current prescription for
albuterol
90 days with
4 refills
alendronate FOSAMAX 12 months
If patient has been on
medication for 5 or
more years (review
medication history),
send to physician for
review
90 days with
4 refills
lanthanum FOSRENOL
Every 6 months and within normal
limits
• Ca
• PO4
6 months 90 days with
2 refills
frovatriptan FROVA 12 months Amount of previous
prescription
fulvestrant fulvestrant 12 months 90 days with
4 refills
enfuvirtide FUZEON Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
tiagabine GABITRIL
Every 12 months and within
normal/therapeutic range
• ALT/AST
• tiagabine level
12 months 90 days with
4 refills
gentamicin instillation solution gentamicin instillation solution 12 months 90 days with
4 refills
fingolimod GILENYA
Every 6 months and within normal
limits
• CBC
90 days with
3 refills
glucagon glucagon 6 months Amount of original
prescription
metformin, ER GLUCOPHAGE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
glipizide, ER GLUCOTROL
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
glyburide-metformin GLUCOVANCE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
glutamine glutamine
Every 6 months and within normal
limits
• ALT, AST
• K, Cr
6 months 90 days with
2 refills
glycerin enema glycerin enema 12 months 90 days with
4 refills
miglitol GLYSET
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
TBO-filgrastim GRANIX Forward to provider
griseofulvin griseofulvin Forward to provider
triazolam HALCION Forward to provider
haloperidol HALDOL Forward to provider
halcinonide HALOG 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

doxercalciferol HECTOROL
Every 6 months and within normal
limits
• Calcium
• Phosporous
• PTH
6 months 90 days with
2 refills
heparin flushes heparin flushes 12 months 90 days with
4 refills
methenamine HIPREX 12 months 90 days with
4 refills
insulin lispro HUMALOG
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin lispro protamine-insulin lispro mix HUMALOG MIX 50/50, HUMALOG MIX 75/25
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
adalimumab HUMIRA
Every 6 months and within normal
limits
• CBC
• ALT
12 months Refill by RN only 90 days with
1 refill
insulin isophane NPH-regular mix HUMULIN 70/30, NOVOLIN
70/30
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
hydrocortisone oral hydrocortisone
Every 6 months and within normal
limits
• K
• Na
12 months
May refill if does not
require titration and
used for maintenance
at <40 mg/day or stress
Amount of original
prescription
sodium chloride 7% HYPERSAL 12 months 90 days with
4 refills
terazosin HYTRIN 12 months 90 days with
4 refills
losartan-HCTZ HYZAAR
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
canakinumab ILARIS
Monthly x 3 months, then every 3
months x3, then yearly
• CBC
12 months 90 days with
4 refills
isosorbide mononitrate IMDUR, ISMO, MONOKET 12 months Systolic blood pressure
> 90 mmHg
90 days with
4 refills
sumatriptan IMITREX 12 months Amount of previous
prescription
loperamide IMODIUM, IMODIUM AD 12 months 90 days with
4 refills
azathioprine IMURAN
Initiation of therapy or after dose
change
• CBC and ALT every 2 weeks X 1
month, then monthly X 2 months,
then move to maintenance
Maintenance - every 3 months and
within normal limits
• CBC
• ALT
12 months RN only 90 days with 0 refills
umeclidinium INCRUSE 12 months 90 days with
4 refills
propranolol INDERAL, INNOPRAN XL 12 months 90 days with
4 refills
indomethacin INDOCIN, INDOCIN CR 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
eplerenone INSPRA
Every 12 months and within normal
limits
• K
12 months 90 days with
4 refills
cromolyn INTAL 12 months 90 days with
4 refills
guanfacine INTUNIV, TENEX 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

canagliflozin INVOKANA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Every 12 months and within normal
limits
• Cr
• LDL-C
• Mg
• PO4
6 months 90 days with
2 refills
raltegravir ISENTRESS Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
carbachol ISOPTOCARPINE 90 days with
3 refills
pilocarpine ISOPTOCARPINE 90 days with
3 refills
isosorbide dinitrate ISORDIL 12 months Systolic blood pressure
> 90 mmHg
90 days with
4 refills
isradipine isradipine 12 months 90 days with
4 refills
sitagliptin-metformin JANUMET
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
sitagliptin JANUVIA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
empagliflozin JARDIANCE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Every 12 months and within normal
limits
• Cr
• LDL-C
6 months 90 days with
2 refills
linagliptin-metformin JENTADUETO
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
lopinavir/ ritonavir KALETRA Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
ivacaftor KALYDECO • ALT and AST in last month and WNL 12 months
90 days with
4 refills
alogliptin-metformin KAZANO
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
cephalexin KEFLEX 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
Amount of original
prescription
triamcinolone topical KENALOG 12 months 90 days with
4 refills
levetiracetam KEPPRA, KEPPRA XR
Every 12 months and within
therapeutic range
• levetirazetam level
12 months 90 days with
4 refills
ketoprofen ketoprofen 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
ketorolac ketorolac Forward to provider
anakinra KINERET
Monthly x 3 months, then every 3
months x3, then yearly
• CBC
12 months Refill by RN only 90 days with
4 refills
clonazepam KLONOPIN Forward to provider
potassium chloride K-LOR, K-TAB, KAON-CL, MICROK
Every 12 months and within normal
limits
• K
12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

saxagliptin-metformin KOMBIGLYZE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
lactulose lactulose 12 months 90 days with
4 refills
lamotrigine LAMICTAL
Every 12 months and within
therapeutic range
• lamotrigene level
12 months 90 days with
4 refills
terbinafine LAMISIL Forward to provider
terbinafine topical LAMISIL 12 months 90 days with
4 refills
digoxin LANOXIN
Every 12 months and within normal
limits
• K
• Cr
• digoxin level Note: digoxin level
should be obtained at least 6 hours
after oral dose
12 months 90 days with
4 refills
insulin glargine LANTUS
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
mefloquine LARIUM 12 months
May refill if seen in the
Travel Clinic in the last
year for antimalarial
prophylaxis
Per Travax medicine
software
recommendations for
area of travel and length
of stay
furosemide LASIX
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months 90 days with
4 refills
fluvastatin LESCOL 12 months 90 days with
4 refills
ambrisentan LETAIRIS • Negative pregnancy test in past month 6 months
Must have scheduled
follow-up appointment
Sufficient to reach
scheduled appointment
insulin detemir LEVEMIR
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
vardenafil LEVITRA 12 months
Forward to provider if
patient on any
nitroglycerin products
If used for erectile
dysfunction patient
preference (usually 5-
6) with 11 refills
If used for maintenance
therapy provide 90 days
with with 3 refills
escitalopram LEXAPRO 12 months 90 days with
4 refills
chlordiazepoxide LIBRIUM Forward to provider
fluocinonide LIDEX, VANOS 12 months 90 days with
4 refills
lidocaine patch LIDODERM 12 months 90 days with
4 refills
linaclotide LINZESS 12 months 90 days with
4 refills
baclofen LIORESAL 12 months 90 days with
4 refills
atorvastatin LIPITOR 12 months 90 days with
4 refills
lithium LITHOBID, ESKALITH Forward to provider
pitavastatin LIVALO 12 months 90 days with
4 refills
lidocaine topical LMX 12 months Amount of original
prescription
etodolac LODINE 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
carbidopa LODOSYN 12 months 90 days with
4 refills
diphenoxylate-atropine LOMOTIL Forward to provider
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

minoxidil LONITEN
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
gemfibrozil LOPID 12 months 90 days with
4 refills
metoprolol LOPRESSOR, TOPROL XL 12 months 90 days with
4 refills
ciclopirox LOPROX, PENLAC 12 months 90 days with
4 refills
benazepril LOTENSIN
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
benazepril-HCTZ LOTENSIN HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
loteprednol LOTOMAX, ALREX Amount of original
prescription
clotrimazole LOTRIMIN 12 months 90 days with
4 refills
clotrimazole-betamethasone LOTRISONE Forward to provider
omega-3-acid LOVAZA 12 months 90 days with
4 refills
brimonoprost LUMIGAN 90 days with
3 refills
fluvoxamine LUVOX 12 months 90 days with
4 refills
pregabalin LYRICA Forward to provider
nitrofurantoin MACROBID
Every 12 months and within normal
limits
• K, Cr
• AST, ALT
• CBC
• Chest X-ray
12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
diphenhyramine-lidocaine-al&mag-
simethicone
MAGIC MOUTHWASH,
MAALIDOBEN 12 months
90 days with
4 refills
magnesium magnesium 12 months 90 days with
4 refills
ataovaquone/ proguanil MALARONE 12 months
May refill if seen in the
Travel Clinic in the last
year for antimalarial
prophylaxis
Per Travax medicine
software
recommendations for
area of travel and length
of stay
oral contraceptives MANY
Every 12 months
• Chlamydia screening if < 25 yrs of
age
12 months 90 days with
4 refills
trandolapril MAVIK
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
pirbuterol MAXAIR 12 months 3 inhalers
0 refills
rizatriptan MAXALT 12 months Amount of previous
prescription
meclofenamate meclofenamate 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
mefenamic acid mefenamic acid 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
megestrol MEGACE 12 months 90 days with
4 refills
esterified estrogens MENEST 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
pyridostigmine MESTINON 12 months 90 days with
4 refills
glipizide-metformin METAGLIP
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

psyllium METAMUCIL 12 months 90 days with
4 refills
methotrexate methotrexate
Initiation of therapy or after dose
change
• CBC with diff, Cr, ALT monthly x 3
months, then move to maintenance
Maintenance - every 3 months and
within normal limits
• CBC with diff
• Cr
• ALT
12 months
RN only
May not refill if being
used for chemotherapy
90 days with 0 refills
methylprednisolone methylprednisolone
Every 6 months and within normal
limits
• K
• Na
12 months
May refill if does not
require titration and
used for maintenance
at <8 mg/day or stress
Amount of original
prescription
metipranolol metipranolol 90 days with
3 refills
metronidazole topical METROCREAM, METROGEL 12 months
90 days with
4 refills
lovastatin MEVACOR 12 months 90 days with
4 refills
hydrochlorothiazide (HCTZ) MICROZIDE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
dihydroergotamine nasal MIGRANAL Forward to provider
milk of magnesia milk of magnesia 12 months 90 days with
4 refills
prazosin MINIPRESS 12 months 90 days with
4 refills
minocycline MINOCIN 12 months
May refill only when
being used for chronic
condition
90 days with
4 refills
polyethylene glycol MIRALAX 12 months 90 days with
4 refills
pramipexole MIRAPEX 12 months 90 days with
4 refills
meloxicam MOBIC 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
fosinopril MONOPRIL
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
ibuprofen MOTRIN 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
guaifenesin Mucinex, various 12 months 90 days with
4 refills
fish oil MULTIPLE 12 months 90 days with
4 refills
sodium chloride hypertonic MURO 128 90 days with
3 refills
multivitamins MVI, ABDEK, various 12 months 90 days with
4 refills
telmisartan MYCARDIS
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
telmisartan-HCTZ MYCARDIS HCT
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
antacids
MYLANTA, MAALOX,
various
12 months 90 days with
4 refills
primidone MYSOLINE
Every 12 months and within
normal/therapeutic range
• CBC
• primidone level
12 months 90 days with
4 refills
naftifine topical NAFTIN 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

fenoprofen NALFON 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
memantine NAMENDA 12 months 90 days with
4 refills
naphazoline/pheniramine NAPHCON A 90 days with
3 refills
naproxen NAPROSYN, ANAPROX 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
triamcinolone nasal NASACORT AQ 12 months 90 days with
4 refills
cromolyn nasal NASALCROM 12 months 90 days with
4 refills
mometasone nasal NASONEX 12 months 90 days with
4 refills
neomycin neomycin 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
neomycin-polymyxin-bacitracin NEOSPORIN topical 12 months 90 days with
4 refills
vitamin B complex NEPHROCAPS 12 months 90 days with
4 refills
methazolamide NEPTAZAN 90 days with
3 refills
alogliptin NESINA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
pegfilgrastim NEULASTA Forward to provider
filgrastim NEUPOGEN Forward to provider
rotigotine NEUPRO 12 months 90 days with
4 refills
gabapentin NEURONTIN 12 months 90 days with
4 refills
phosphate NEUTRA-PHOS
Every 12 months and within normal
limits
• Phos
12 months 90 days with
4 refills
esomeprazole NEXIUM 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
niacin NIASPAN, NIACOR 12 months 90 days with
4 refills
nicotine patch, tablet, spray
NICOTROL, NICODERM,
NICORETTE, COMMIT,
various
12 months 30 days with
2 refills
nilutamide nilutamide 12 months 90 days with
4 refills
nitroglycerin patch, tablet, spray, ointment
NITROSTAT, NITRO-BID,
NITRO-DUR, MINITRAN,
NITROMIST, various
12 months Systolic blood pressure
> 90 mmHg
90 days with
4 refills
ketoconazole NIZORAL Forward to provider
ketoconazole topical NIZORAL 12 months 90 days with
4 refills
tamoxifen NOLVADEX 12 months 90 days with
4 refills
orphenadrine NORFLEX 12 months 90 days with
4 refills
desipramine NORPRAMIN 12 months 90 days with
4 refills
droxidopa NORTHERA 12 months 90 days with
4 refills
amlodipine NORVASC 12 months 90 days with
4 refills
ritonavir NORVIR Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
insulin isophane NPH NOVOLIN N, HUMULIN, N
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin regular NOVOLIN R, HUMULIN R
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
insulin aspart NOVOLOG
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

insulin aspart protamine-aspart mix NOVOLOG MIX 70/30
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
dibucaine NUPERCAINAL 12 months 90 days with
4 refills
etonogestrel-ethinyl estradiol NUVARING
Every 12 months
• Chlamydia screening if < 25 yrs of
age
12 months 90 days with
4 refills
nystatin suspension nystatin suspension 12 months 90 days with
4 refills
nystatin topical nystatin topical 12 months 90 days with
4 refills
flurbiprofen ophth OCUFEN Amount of original
prescription
ophthalmic vitamins OCUVITE, PRESERVISION 90 days with
3 refills
estropipate OGEN, ORTHO-EST 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
trazodone OLEPTRO 12 months 90 days with
4 refills
prednisolone ophthalmic OMNIPRED, PRED FORTE,
PRED MILD
Amount of original
prescription
saxagliptin ONGLYZA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
macitentan OPSUMIT • Negative pregnancy test in past month 6 months
Must have scheduled
follow-up appointment
Sufficient to reach
scheduled appointment
cromolyn ophth OPTICROM, CROLOM 12 months 90 days with
4 refills
azelastine OPTIVAR 12 months 90 days with
4 refills
abatacept (injectable only) ORENCIA 12 months
Injectable only, infusion
must be forwarded to
provider
90 days with
4 refills
norelgestromin/ethinyl estradiol patch ORTHO EVRA
Every 12 months
• Chlamydia screening if < 25 yrs of
age
12 months 90 days with
4 refills
alogliptin-pioglitazone OSENI
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months Forward to provider
apremilast OTESLA
Every 12 months and within normal
limits
• Cr
12 months
oxazepam oxazepam Forward to provider
oxiconazole OXISTAT 12 months 90 days with
4 refills
nortriptyline PAMELOR 12 months 90 days with
4 refills
papaverine papaverine 12 months 90 days with
4 refills
bromocriptine PARLODEL
Every 12 months and within normal
limits
• prolactin
12 months 90 days with
4 refills
olopatadine nasal PATANASE 12 months 90 days with
4 refills
olopatadine PATANOL, PATADAY 12 months 90 days with
4 refills
paroxetine PAXIL 12 months 90 days with
4 refills
pentosan pentosan
Every 12 months and within normal
limits
• LFTs
• CBC
12 months 90 days with
4 refills
famotidine PEPCID 12 months 90 days with
4 refills
cyproheptadine PERIACTIN 12 months 90 days with
4 refills
docusate-casanthranol PERI-COLACE 12 months 90 days with
4 refills
chlorhexidine PERIDEX 12 months 90 days with
4 refills
dipyridamole PERSANTINE 12 months 90 days with
1 refill
promethazine PHENERGAN 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

phenobarbital phenobarbital Forward to provider
calcium acetate PHOSLO
Every 6 months and within normal
limits
• Ca
• PO4
6 months 90 days with
2 refills
ecothiphate PHOSPHOLINE IODINE 90 days with
3 refills
hydroxychloroquine PLAQUENIL 12 months
Refill by RN only.
Annual ophthamologic
exam (including visual
field test or ocular CT)
for patients on
hydroxychloroquine for
> 5 years, taking > 6.5
mg/kg, with history of
retinal disease, age >/=
60 yrs or liver disease
90 days with
4 refills
clopidogrel PLAVIX 12 months
If patient on clopidogrel
(Plavix) and
pantoprazole, may refill.
If on clopidogrel and
any other PPIs forward
request to provider
90 days with
4 refills
peginterferon beta-1a PLEGRIDY
Every 12 months and within normal
limits
• ALT, AST
• CBC
12 months 90 days with
4 refills
felodipine PLENDIL 12 months 90 days with
4 refills
cilostazol PLETAL 12 months 90 days with
1 refill
potassium citrate potassium citrate
Every 12 months and within normal
limits
• Na, K, chloride, CO2, Cr
• CBC
• urinary citrate/pH
12 months 90 days with
4 refills
dabigatran PRADAXA
Every 12 months and within normal
limits
• Cr
• CBC without diff
• ALT
12 months 90 days with
4 refills
repaglinide-metformin PRANDIMET
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
repaglinide PRANDIN
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
pravastatin PRAVACHOL 12 months 90 days with
4 refills
acarbose PRECOSE
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• ALT <80 U/L - in last 12 months
6 months 90 days with
2 refills
prednisone prednisone
Every 6 months and within normal
limits
• K
• Na
12 months
May refill if dose is
stable (not being
tapered) and used for
maintenance at <10
mg/day or stress mg x1
Amount of previous
prescription
conjugated estrogens PREMARIN 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
conjugated estrogens-medroxyprogesterone PREMPRO, PREPHASE 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
prenatal vitamins prenatal vitamins 12 months 90 days with
4 refills
desvenlafaxine PRESTIQ 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

lansoprazole PREVACID 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
darunavir PREZISTA Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
omeprazole PRILOSEC 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
lisinopril PRINIVIL, ZESTRIL
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
lisinopril-HCTZ PRINZIDE, ZESTORETIC
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
albuterol
PROAIR, PROVENTIL,
VENTOLIN 12 months
3 inhalers
0 refills
midodrine PROAMATINE 12 months 90 days with
4 refills
tacrolimus PROGRAF
Every 1 month and within normal
limits
• CBC
• Cr
• K, Mg, Ca
• Glucose
• Cyclosporine level
Every 12 months and within normal
limits
• ALT, AST, Alk Phos, Bilirubin
• Lipid panel
6 months Forward to provider 90 days with
2 refills
progesterone PROMETRIUM 12 months 90 days with
4 refills
finasteride PROPECIA, PROSCAR 12 months 90 days with
4 refills
dipivifrin PROPINE 90 days with
3 refills
pantoprazole PROTONIX 12 months
Forward to provider if
patient is on clopidogrel
(Plavix)
90 days with
4 refills
tacrolimus topical PROTOPIC 12 months 90 days with
4 refills
albuterol oral PROVENTIL 12 months 90 days with
4 refills
medroxyprogesterone PROVERA 12 months Pap screening per age
appropriate guideline
90 days with
4 refills
fluoxetine PROZAC 12 months 90 days with
4 refills
propylthiouracil PTU
Every 12 months and within normal
limits
• TSH
12 months
If pregnant or history of
thyroid cancer forward
to provider
90 days with
4 refills
budesonide PULMICORT 12 months Current prescription for
albuterol
90 days with
4 refills
dornase alfa PULMOZYME 12 months 90 days with
4 refills
mercaptopurine PURINETHOL, PURIXAN, 6-MP
Initiation of therapy or after dose
change
• CBC and ALT every 2 weeks X 1
month, then monthly X 2 months,
then move to maintenance
Maintenance - every 3 months and
within normal limits
• CBC
• ALT
12 months Refill by RN only 90 days with 0 refills
quazepam QUESTCOR Forward to provider
cholestyramine resin QUESTRAN, QUESTRAN
LITE
12 months 90 days with
4 refills
beclomethasone QVAR 12 months Current prescription for
albuterol
90 days with
4 refills
racepinephrine racepinephrine 12 months 3 inhalers
0 refills
silodosin RAPAFLO 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

sirolimus RAPAMUNE
Every 1 month and within normal
limits
• Cr
• Glucose
Every 12 months and within normal
limits
• ALT, AST, Alk Phos, Bilirubin
• Lipid panel
6 months Forward to provider 90 days with
2 refills
galantamine RAZADYNE 12 months 90 days with
4 refills
metoclopramide REGLAN 12 months 90 days with
4 refills
becaplermin topical REGRANEX Forward to provider
nabumetone RELAFEN 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
eletriptan RELPAX 12 months Amount of previous
prescription
mirtazapine REMERON 12 months 90 days with
4 refills
sevelamer RENAGEL, RENVELA
Every 6 months and within normal
limits
• Ca
• PO4
• CO2
• chloride
6 months 90 days with
2 refills
ropinirole REQUIP 12 months 90 days with
4 refills
unoprostine RESCULA 90 days with
3 refills
cyclosporine RESTASIS 12 months 90 days with
4 refills
temazepam RESTORIL Forward to provider
atazanavir REYATAZ Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
budesonide nasal RHINOCORT AQ 12 months 90 days with
4 refills
riluzole RILUTEK
Every 6 months and within normal
limits
• ALT, AST
6 months 90 days with
2 refills
risperidone RISPERDOL TBD TBD TBD
methocarbamol ROBAXIN 12 months 90 days with
4 refills
glycopyrrolate ROBINUL 12 months 90 days with
4 refills
calcitriol ROCALTROL
Every 6 months and within normal
limits
• Phosphorous
• PTH
6 months 90 days with
2 refills
minoxidil topical ROGAINE 12 months 90 days with
4 refills
vigabatrin SABRIL 6 months Ophth exam every 3 months
90 days with
2 refills
trospium SANCTURA, SANCTURA
XR 12 months
90 days with
4 refills
octreotide SANDOSTATIN
Every 12 months and within normal
limits
• TSH
• B12
12 months 90 days with
4 refills
collagenase topical SANTYL Forward to provider
edoxaban SAVAYSA
Every 12 months and within normal
limits
• Cr
• CBC without diff
• ALT
12 months 90 days with
4 refills
milnacipran SAVELLA 12 months 90 days with
4 refills
acebutolol SECTRAL 12 months 90 days with
4 refills
selenium sulfide topical SELSUN, various 12 months 90 days with
4 refills
maraviroc SELZENTRY Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
sennosides SENNA 12 months 90 days with
4 refills
senna-docusate SENOKOT-S 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

cinacalcet SENSIPAR
Every 3 months and within normal
limits
• Ca
6 months 90 days with
2 refills
salmeterol SEREVENT 12 months Current prescription for
albuterol
90 days with
4 refills
quetiapine SEROQUEL TBD TBD TBD
nefazodone SERZONE 12 months 90 days with
4 refills
doxepin SILENOR 12 months 90 days with
4 refills
silver sulfadiazine SILVADENE 12 months Amount of original
prescription
silver topical silver topical 12 months 90 days with
4 refills
simvastatin-niacin SIMCOR •ALT - in last 12 months and <3x
upper limit of normal 12 months
90 days with
4 refills
golimumab SIMPONI
Every 6 months and within normal
limits
• CBC
• ALT
12 months Refill by RN only 90 days with
1 refill
carbidopa-levodopa
SINEMET, PARCOPA,
RYTARY 12 months
90 days with
4 refills
montelukast SINGULAIR 12 months 90 days with
4 refills
metaxalone SKELAXIN 12 months 90 days with
4 refills
tiludronate SKELID 12 months
If patient has been on
medication for 5 or
more years (review
medication history),
send to physician for
review
90 days with
4 refills
ivermectin SKLICE, STROMECTOL Forward to provider
sodium sodium
Every 12 months and within normal
limits
• Na
12 months 90 days with
4 refills
sodium bicarbonate sodium bicarbonate
Every 12 months and within normal
limits
• CO2
12 months
90 days
3 refills
sodium chloride 0.9% flushes sodium chloride 0.9% flushes 12 months 90 days with
4 refills
sorbitol sorbitol 12 months 90 days with
4 refills
tiotropium SPIRIVA 12 months Current prescription for
albuterol
90 days with
4 refills
itraconazole SPORANOX Forward to provider
carbidopa-levodopa-entacapone STALEVO 12 months 90 days with
4 refills
nateglinide STARLIX
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
nisoldipine SULAR 12 months 90 days with
4 refills
supplies, diabetic: meters, test strips,
needles/syringes, lancets, insulin pump
supplies, diabetic: meters,
test strips, needles/syringes,
lancets, insulin pump
12 months 90 days with
4 refills
supplies: breast prosthesis supplies: breast prosthesis 12 months 1 per affected
breast/year
supplies: compression sleeves supplies: compression
sleeves
12 months 3 pair/year
supplies: compression stockings supplies: compression
stockings
12 months 2 pair/year
supplies: dressings supplies: dressings 12 months 90 days with
4 refills
supplies: injectable medications supplies: injectable medications 12 months
90 days with
4 refills
supplies: mastectomy bras supplies: mastectomy bras 12 months 2/year
supplies: ostomy supplies: ostomy 12 months 90 days with
4 refills
supplies: testing supplies: testing 12 months 90 days with
4 refills
supplies: urinary care supplies: urinary care 12 months 90 days with
4 refills
supplies: wig supplies: wig 12 months 1/year
efavirenz SUSTIVA Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
olanzapine/fluoxetine SYMBAX Forward to provider
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

budesonide-formoterol SYMBICORT 12 months Current prescription for
albuterol
90 days with
4 refills
pramlintide SYMLIN
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
amantadine SYMMETREL 12 months 90 days with
4 refills
fluocinolone topical SYNALAR 12 months 90 days with
4 refills
levothyroxine
SYNTHROID,
LEVOTHROID, LEVOXYL
• TSH - every 12 months and within
normal range (or less than provider
specified goal)
12 months
If pregnant or history of
thyroid cancer forward
to provider
90 days with
4 refills
calcipotriene-betamethasone TACLONEX 12 months 90 days with
4 refills
calcipotriene-betamethasone topical TACLONEX 12 months 90 days with
4 refills
cimetidine TAGAMET Forward to provider
albiglutide TANZEUM
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
methimazole TAPAZOLE, NORTHYX
Every 12 months and within normal
limits
• TSH
12 months
If pregnant or history of
thyroid cancer forward
to provider
90 days with
4 refills
tazarotene topical TAZORAC 12 months 90 days with
4 refills
dimethyl fumarate TECFIDERA
Every 12 months and within normal
limits
• CBC
12 months 90 days with
4 refills
carbamazepine TEGRETOL, TEGRETOL XL,
EPITOL, CARBATROL
Every 12 months and within
normal/therapeutic range
• Na
• CBC with diff
• carbamazepine level
12 months 90 days with
4 refills
aliskiren-amlodipine TEKAMLO
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
aliskiren TEKTURNA
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
atenolol TENORMIN 12 months 90 days with
4 refills
benzonatate TESSALON 12 months 90 days with
4 refills
chlorthalidone THALITONE
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
ticlopidine TICLID 12 months 90 days with
4 refills
trimethobenzamide TIGAN Forward to provider
azelaic acid topical timolol 12 months 90 days with
4 refills
timolol TIMOPTIC, TIMOPTIC XE 90 days with
3 refills
tobramycin TOBI 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
dexamethasone-tobramycin TOBRADEX Amount of original
prescription
imipramine TOFRANIL 12 months 90 days with
4 refills
tolmetin TOLECTIN 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

topiramate TOPAMAX
Every 12 months and within
normal/therapeutic range
• NaHCO3 (CO2onate)
• Cr
• topiramate level
12 months 90 days with
4 refills
desoximetasone TOPICORT 12 months 90 days with
4 refills
fesoterodine TOVIAZ 12 months 90 days with
4 refills
bosentan TRACLEER
• ALT and AST in last month and
WNL
• Negative pregnancy test in past
month
6 months Must have scheduled
follow-up appointment
Sufficient to reach
scheduled appointment
linagliptin TRADJENTA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
6 months 90 days with
2 refills
labetalol TRANDATE 12 months 90 days with
4 refills
tranexamic acid tranexamic acid 12 months 90 days with
4 refills
scopolamine TRANSDERM-SCOP 12 months 90 days with
4 refills
clorazepate TRANXENE Forward to provider
travoprost TRAVATAN Z 90 days with
3 refills
fenofibrate
TRICOR, ANTARA,
FENOGLIDE, LIPOFEN,
LOFIBRA, TRIGLIDE
12 months 90 days with
4 refills
oxcarbazepine TRILEPTAL
Every 12 months and within
normal/therapeutic range
• ALT/AST
• CBC
• Na
12 months 90 days with
4 refills
choline fenofibrate TRILIPIX 12 months 90 days with
4 refills
fenofibric acid TRILIPIX 12 months 90 days with
4 refills
fluocinolone-hydroquinone-tretinoin topical TRI-LUMA 12 months 90 days with
4 refills
alprostadil-papaverine-phentolamine TRI-MIX 12 months 90 days with
4 refills
abacavir/ lamivudine/ zidovudine TRIZIVIR Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
dulaglutide TRULICITY
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
dorzolamide TRUSOPT 90 days with
3 refills
emtricitabine/ tenofovir TRUVADA Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
aclidinium TUDORZA 12 months 90 days with
4 refills
acetaminophen TYLENOL 12 months 90 days with 4 refills
febuxostat ULORIC 12 months 90 days with
4 refills
halobetasol ULTRAVATE 12 months 90 days with
4 refills
selexipag UPTRAVI
12 months for
erectile dysfunction
6 months for chronic
conditions such as
pulmonary
hypertension
Forward to provider if
patient on any
nitroglycerin products
If used for erectile
dysfunction patient
preference (usually 5-
6) with 11 refills
If used for maintenance
therapy provide 90 days
with with 3 refills
urea instillation urea instillation 12 months 90 days with
4 refills
urea topical urea topical 12 months 90 days with
4 refills
bethanechol URECHOLINE 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

alfuzosin UROXATRAL 12 months 90 days with
4 refills
ursodiol URSO, ACTIGALL 12 months 90 days with
4 refills
betamethasone valerate VALISONE 12 months 90 days with
4 refills
diazepam VALIUM Forward to provider
valacyclovir VALTREX 12 months May refill if being used
for prophylaxis
90 days with
4 refills
aliskiren-valsartan VALTURNA
Every 12 months and within normal
limits
• K
• Cr
12 months 90 days with
4 refills
vancomycin VANCOCIN 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
2 weeks supply
0 refills
eflornithine topical VANIQA 12 months 90 days with
4 refills
benzoyl peroxide-containing topical VARIOUS 12 months 90 days with
4 refills
sulfacetamide-containing topical VARIOUS 12 months 90 days with
4 refills
theophylline various
Every 12 months and normal
• Theophylline
12 months 90 days with
4 refills
naphazoline-antazolline VASCON A 90 days with
3 refills
enalapril-HCTZ VASERETIC
Every 12 months and within normal
limits
• K
• Cr
• Na
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
enalapril VASOTEC
Every 12 months and within normal
limits
• K
• Cr
12 months
BP meets goal
indicated in chart. If
none listed BP should
be <140/90 mmHg
90 days with
4 refills
calcitriol topical VECTICAL 12 months 90 days with
4 refills
sucroferric oxyhydroxide VELPHORO
Every 6 months and within normal
limits
• Ca
• PO4
6 months 90 days with
2 refills
solifenacin VESICARE 12 months 90 days with
4 refills
rimexolone VEXOL Amount of original
prescription
sildenafil VIAGRA, REVATIO
12 months for
erectile dysfunction
6 months for chronic
conditions such as
pulmonary
hypertension
Forward to provider if
patient on any
nitroglycerin products
If used for erectile
dysfunction patient
preference (usually 5-
6) with 11 refills
If used for maintenance
therapy provide 90 days
with with 3 refills
doxycycline VIBRAMYCIN 12 months
May refill only when
being used for chronic
condition
90 days with
4 refills
vilazodone VIBRYD 12 months 90 days with
4 refills
liraglutide VICTOZA
• A1c - In last 6 months if A1c meets
goal indicated in chart (or < 8% if
none listed): otherwise in last 3
months
• Cr - in last 12 months and within
normal limits
6 months 90 days with
2 refills
lacosamide VIMPAT 12 months 90 days with
4 refills
tenofovir VIREAD Every 6 months
• HIV monitoring labs 12 months
90 days with
4 refills
trifluridine VIROPTIC Amount of original
prescription
pindolol VISKEN 12 months 90 days with
4 refills
cyanocobalamin Vitamin B12 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

riboflavin VITAMIN B2 12 months 90 days with
4 refills
pyridoxine VITAMIN B6 12 months 90 days with
4 refills
ascorbic acid Vitamin C 12 months 90 days with
4 refills
ergocalciferol Vitamin D2 12 months 90 days with
4 refills
cholecalciferol VITAMIN D3 12 months 90 days with
4 refills
diclofenac VOLTAREN 12 months Forward to provider if
patient age > 65 years
90 days with
4 refills
diclofenac VOLTERAN Amount of original
prescription
ezetimibe-simvastatin VYTORIN 12 months 90 days with
4 refills
colesevelam WELCHOL 12 months 90 days with
4 refills
bupropion, SR WELLBUTRIN (not ZYBAN) 12 months 90 days with
4 refills
latanoprost XALATAN 90 days with
3 refills
alprazolam XANAX Forward to provider
rivaroxaban XARELTO
Every 12 months and within normal
limits
• Cr
• CBC without diff
• ALT
12 months 90 days with
4 refills
tofacitinib XELJANZ
Every 3 months
• CBC
Every 12 months and within normal
limits
• Lipids
• ALT
• Cr
12 months Refill by RN only
trypsin-castor oil-peru balsam XENADERM, 12 months 90 days with
4 refills
tetrabenazine XENAZINE 12 months 90 days with
4 refills
bromfenac XIBRAM Amount of original
prescription
rifaximin XIFAXAN 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
May refill for traveler's
diarrhea if seen in the
Travel Clinic in the last
year
2 weeks supply
0 refills
Per Travax medicine
software
recommendations for
area of travel and length
of stay
levalbuterol XOPENEX 12 months 3 inhalers
0 refills
enzalutamide XTANDI Forward to provider
levocetirizine XYZAL 12 months 90 days with
4 refills
ketotifen ZADITOR, ALAWAY 12 months 90 days with
4 refills
tizanidine ZANAFLEX 12 months 90 days with
4 refills
ranitidine ZANTAC 12 months 90 days with
4 refills
ethosuximide ZARONTIN
Every 12 months and within
normal/therapeutic range
• ALT/AST
• CBC
• Cr
• ethosuximide level
12 months 90 days with
4 refills
bisoprolol ZEBETA 12 months 90 days with
4 refills
paricalcitol ZEMPLAR
Every 6 months and within normal
limits
• Ca
• PO4
• PTH
6 months 90 days with
2 refills
ezetimibe ZETIA 12 months 90 days with
4 refills
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

zinc zinc 12 months 90 days with
4 refills
azithromycin ZITHROMAX 12 months
May refill when being
used for dental or
procedural prophylaxis
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
May refill for traveler's
diarrhea if seen in the
Travel Clinic in the last
year
Amount of original
prescription
2 weeks supply
0 refills
Per Travax medicine
software
recommendations for
area of travel and length
of stay
simvastatin ZOCOR 12 months 90 days with
4 refills
ondansetron ZOFRAN 12 months 90 days with
4 refills
sertraline ZOLOFT 12 months 90 days with
4 refills
zolmitriptan ZOMIG 12 months Amount of previous
prescription
zonisamide ZONEGRAN
Every 12 months and within
therapeutic range
• zonisamide level
12 months 90 days with
4 refills
acyclovir ZOVIRAX 12 months May refill when being
used for prophylaxis
90 days with
4 refills
acyclovir topical ZOVIRAX 12 months 90 days with
4 refills
bupropion SR ZYBAN (Not WELLBUTRIN) 12 months 30 days with
2 refills
loteprednol-tobramycin ZYLET Amount of original
prescription
allopurinol ZYLOPRIM
Every 12 months and within normal
limits
• Cr
12 months 90 days with
4 refills
cetirizine ZYRTEC, ZYRTEC D 12 months
Forward to provider if
decongestant ("D")
formula
90 days with
4 refills
abiraterone ZYTIGA Forward to provider
atovaquone 12 months
May refill only when
being used for
maintenance/prophylaxi
s of chronic condition
90 days with
4 refills
bacitracin ophthalmic Amount of original
prescription
bacitracin-ploymyxin B ophthalmic Amount of original
prescription
chloroquine 12 months
May refill if seen in the
Travel Clinic in the last
year for antimalarial
prophylaxis
Per Travax medicine
software
recommendations for
area of travel and length
of stay
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org



Pr escrip t io n Ref ill Scen arios and Expect ed Action s

Sta ff w ill use the tab l es to d et ermin e r efi ll quan tit y an d actio n s based on dat e sin ce la st offic e vi sit plu s sta tu s of
lab o ra to ry resu lts req u ired fo r refill. Pl eas e s ee Ap p en d ix A or B for exclu sion s.

Refill Actions for Medications requiring a visit every 12 months

< 9 Months Since Last Office Visit
Lab Status N/A Due So o n Or Overdue Abno rm al
Lab Orders N/A Sign order Pend & ro ute
Med Orders Sign order fo r
90 day s with 4 refill
Pend & ro ute order fo r
90 day s with blank refills

9 - 15 Mo nths Since Last Office Visit
Lab Status N/A Due So o n Or Overdue Abno rm al
Lab Orders N/A Sign order Pend & ro ute
Med Orders Sign order fo r
90 day s with 1 refill
Pend & ro ute order fo r
90 day s with blank refills

> 15 Mo nths Since Last Office Visit
Lab Status N/A Due So o n Or Overdue Abno rm al
Lab Orders N/A Sign order Pend & ro ute
Med Orders Pend & ro ute order fo r
90 day s with blank refills

Refill Actions for Medications requiring a visit every 6 months

< 4 Months Since Last Office Visit
Lab Status N/A Due So o n Or Overdue Abno rm al
Lab Orders N/A Sign order Pend & ro ute
Med Orders Sign order fo r
90 day s with 2 refills
Pend & ro ute order fo r
90 day s with blank refills

4 - 7 Mo nths Since Last Office Visit
Lab Status N/A Due So o n Or Overdue Abno rm al
Lab Orders N/A Sign order Pend & ro ute
Med Orders
Sign order fo r
90 day s with 0 refills
Pend & ro ute order fo r
90 day s with blank refills

> 7 Months Since Last Office Visit
Lab Status N/A Due So o n Or Overdue Abno rm al
Lab Orders N/A Sign order Pend & ro ute
Med Orders Pend & ro ute order fo r
90 day s with blank refills

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Refill Actions for Medications requiring a visit every 3 months

< 3 Months Since Last Office Visit
Lab Status N/A Due Soon Or Overdue Abnormal
Lab Orders N/A Sign order Pend & route
Med Orders Sign order for
90 days with 0 refills
Pend & route order for
90 days with blank refills

> 3 Months Since Last Office Visit
Lab Status N/A Due Soon Or Overdue Abnormal
Lab Orders N/A Sign order Pend & route
Med Orders Pend & route order for
3 0 days with blank refills



Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org