SCA Addendum 1 Medications in Accordance with SCA

Drugs/drug categories that are marked with an X under the In accordance with
the Standard Care Arrangement must have their prescribing designation
determined jointly between the CTP holder and his/her collaborating physician or
podiatrist and specified within the Standard Care Arrangement, e.g., documented as
may prescribe, physician consult, physician initiated, or may not prescribe.
The prescribing designation is to be consistent with the CTP holders practice
specialty, and cannot exceed the prescriptive authority of the collaborating
physician or podiatrist.
Therefore the APRN and Collaborator are to review the list below, mark an X in the
appropriate category and initial each page.
May
Prescrib
e
NUTRIENTS & NUTRITIONAL AGENTS
Dialysis Solutions
Peritoneal Dialysis
Hemodialysis
HEMATOLOGICAL AGENTS
Hematopoietic Agents
Thrombopoietin Receptor
Agonist: Eltrombopag
Thrombopoietin Mimetic
Agents: Romiplostim Injection
Antiplatelet agents
Glycoprotein Inhibitors
Anticoagulants
Antithrombin Agents
Thrombin Inhibitors:
Dabigatran Etexilate
Mesylate Oral (Pradaxa)
Direct Factor Xa Inhibitor
Coumarin Anticoagulants:
Warfarin Sodium
Coagulants
Heparin Antagonist
Protamine Sulfate
Antisickling Agents
Hydroxyurea
Protein C1 Inhibitor
Initials_______/_______

Physicia
n
Consult

Physicia
n
Initiated

May
NOT
Prescrib
e

X
X

X
X

X
X
X

X
X

X
X
X

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May
Prescrib
e

Antihemophilic Agents
Antihemophilic Factor Combinations
Hemostatics
Prothrombin Complex
Concentrate
Kallikrein Inhibitors
Ecallantide
Bradykinin Inhibitors
Icatibant
ENDOCRINE & METABOLIC AGENTS
Sex Hormones
Androgens
Danazol
Uterine-Active Agents
Agent for Cervical Ripening
Dinoprostone
Growth Hormone Releasing Factor
Tesamorelin Acetate Injection
Insulin-like Growth factor
Growth Hormone
Vasopressin Receptor Antagonist
Velaglucerase Alfa Injection
Cabergoline
Detoxification agents
Chelating Agents
Succimer
Deferasirox
CARDIOVASCULAR AGENTS
Vasodilators
Endothelin Receptor Antagonist
Epoprostenol Sodium Injection
Treprostinil Sodium Injection
Treprostinil Inhalations
Prostacylin Analog
Iloprost
Agents for Patent Ductus Arteriosus
RESPIRATORY AGENTS
Monoclonal Antibodies
Omalizumab (Xolair)
Respiratory Enzymes
CENTRAL NERVOUS SYSTEM AGENTS
Initials_______/_______

Physicia
n
Consult

Physicia
n
Initiated

May
NOT
Prescrib
e

X
X
X

X
X

X
X
X
X
X
X
X
X
X
X

X
X
X
X
X

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X
X
X

May
Prescrib
e

Physicia
n
Consult

Physicia
n
Initiated

May
NOT
Prescrib
e

CNS Stimulants
Amphetamines;
Methylphenidate HCL (without
formal established diagnosis)
Schedule II Analgesics
(The standard care arrangement must
state that initial prescriptions for more
than a 14 day supply require physician
initiation or consultation)
Antidepressants
Nefazodone
MAO Inhibitors
Antipsychotic Agents
Clozapine
Lithium
Miscellaneous Psychotherapeutic
Agents
Sodium Oxybate
Adenosine Phosphate
Riluzole
Botulinum Toxins
GASTROINTESTINAL AGENTS
Gallstone Solubilizing Agents
ANTI-INFECTIVES, SYSTEMIC
Glycyclines
Tigecycline
Streptogramins
Synercid
Lipopeptides
Daptomycin
Lipoglycopeptides
Telavancin Hydrochloride Injection
Oxazolidinones
Linezolid
Antifungal Agents
IV route of administration
Micafungin Sodium inject
Triazole Antifungals
Antituberculosis Agents
Antiviral Agents
Foscarnet Sodium (IV)
Initials_______/_______

X
X
X
X

X
X
X
X
X
X
X
X
X
X

X
X
X
X
X

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May
Prescrib
e
Ganciclovir (IV)
Valganciclovir (IV)
Telaprevir (Oral)
Boceprevir (Oral)
Ribavirin
Adefovir Dipivoxil
Entecavir
Antiretroviral Agents
Protease Inhibitors
Nucleotide Analog Reverse
Transcriptase Inhibitors
Nucleoside Reverse Transcriptase
Inhibitors
Non-Nucleoside Reverse
Transcriptase Inhibitors
Cellular Chemokine Receptor
Antagonist
Maraviroc
Integrase Inhibitors
Fusion Inhibitors
Leprostatics
BIOLOGIC/IMMUNOLOGIC AGENTS
Immune Globulins
Agents for primary immune
Deficiency
Vivaglobin
Monoclonal Antibodies
Eculizumab Injection
Soliris
Belimumab (Benlysta)
Immunologic Agents
Immunostimulants
Immunosuppressives
Immunomodulators
Revlimid
Antirheumatic Agents
Keratinocyte Growth Factors
Palifermin
Anti-Psoriatic Agents
Methotrexate
Initials_______/_______

Physicia
n
Consult

Physicia
n
Initiated

X
X
X
x

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X
X
x
X
X

X
X
X
X
X

X
X
X
X
X
X

May
NOT
Prescrib
e

May
Prescrib
e

Physicia
n
Consult

Physicia
n
Initiated

May
NOT
Prescrib
e

Photochemotherapy
Methoxsalen Oral & Topical
Aminolevulinic Acid
Levulan Kerastick
First Generation Retinoids
Isotretinoin
Rexinoids
Bexarotene Oral, Topical
OPHTHALMIC & OTIC AGENTS
Cystine-Depleting Agents
Ophthalmic Antifungals
Antiviral Agents
ANTINEOPLASTIC AGENTS
Antiandrogens
Antiestrogens
Gonadotropin-Releasing Hormone
Analog
Leuprolide Acetate
Goserelin Acetate
Aromatase Inhibitors
Exemestane,
Anastrozole
Letrozole
(ONLY for prescribers who have and
maintain a Standard Care Arrangement
with a collaborating
Hematologist/Oncologist)
Kinase Inhibitors
Everolimus (Zortress)
Ruxolitinib

APRN Signature: _________________________________

X
X

X
X
X
X
x
X
X
X

Date: _______________________

Collaborator Signature: ___________________________ Date: _______________________

Initials_______/_______

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