CHANGE DATECLASS
VA VA PRODUCT ADDITIONAL RESTRICTIONS COMMENTS
Oct-98 CV200 R AMLODIPINE ORAL Refer to PBM/MAP criteria for use of Long-Acting Dihydropyridine
Calcium Antagonists
Oct-98 DE801 DELETED ETRETINATE ORAL No longer manufactured
Oct-98 GA301 DELETED FAMOTIDINE ORAL No longer formulary use cimetidine or ranitidine
Oct-98 AM800 * EFAVIRENZ ORAL Refer to HIV/AIDS TAG treatment guidelines for use
Oct-98 CN609 * TRAZADONE ORAL
Oct-98 AM800 * DELAVIRDINE ORAL Refer to HIV/AIDS TAG treatment guidelines for use
Oct-98 AM800 * LAMIVUDINE/ZIDOVUDINE ORAL Refer to HIV/AIDS TAG treatment guidelines for use
Oct-98 CN609 VENLAFAXINNE ORAL
Oct-98 CN609 NEFAZODONE ORAL
Oct-98 CN609 SERTRALINE ORAL
Oct-98 CN609 PAROXETINE ORAL
Oct-98 CN609 FLUOXETINE ORAL
Oct-98 CV200 FELODIPINE ORAL Refer to PBM/MAP criteria for use of Long-Acting Dihydropyridine
Calcium Antagonists
Oct-98 GA301 RANITIDINE ORAL
Oct-98 DE801 ACITRETIN ORAL
Additions 13 Deletions 2
May-99 AM800 R ABACAVIR ORAL (Refer to HIV/AIDS TAG treatment guidelines for use)
May-99 AM900 R LEVOFLOXACIN ORAL
May-99 AM900 DELETED OFLOXACIN ORAL Levofloxacin added
May-99 AM900 DELETED OFLOXACIN INJ Levofloxacin added
Additions 2 Deletions 2
Jul-99 IM700 DELETED INTERFERON ALFA-2A INJ Changed to Interferon Alfa only
Jul-99 IM700 DELETED INTERFERON ALFA-2B, RECOMBINATNT INJ Changed to Interferon Alfa only
Jul-99 IM700 DELETED INTERFERON ALFA-3N INJ Changed to Interferon Alfa only
Jul-99 AN100 DELETED BUSULFAN Changed to oral and inj
Jul-99 VISNs WILL DETERMINE WHICH INTERFERON ALFA PRODUCTS Changed to Interferon Alfa only
IM700 * INTERFERON ALFA INJ ARE NECESSARY TO MEET PATIENT NEEDS.
Jul-99 AN100 * BUSULFAN ORAL Changed to oral and inj
Jul-99 AN100 * BUSULFAN INJ Changed to oral and inj
Additions 3 deletion 4 0
Aug-99 CV800 FOSINOPRIL ORAL (Refer to PBM/MAP Hypertension, CHF and PBM/TAG Diabetes Error should have been changed earlier
treatment guidelines for use)
Additions 1 deletion 0 0
Sep-99 CN609 CITALOPRAM HCL ORAL
Sep-99 MS102 ETODOLAC ORAL
Sep-99 VT103 NIACIN SUSTAINED RELEASE (Rx ONLY)
Sep-99 VT103 NIACIN IMMEDIATE RELEASE (Rx ONLY)
Sep-99 VT103 DELETED NIACIN ORAL (OTC) Changed to Rx Only
Additions 4 Deletion 1
Dec-99 CN201 * ISOFLURANE INHALATION
Dec-99 CN201 * HALOTHANE INHALATION
Dec-99 CN201 * ENFLURANE INHALATION
Dec-99 CN202 * THIOPENTAL INJ
Dec-99 CN203 * KETAMINE INJ
Dec-99 CN203 * PROPOFOL INJ
Dec-99 CN203 * ETOMIDATE
Dec-99 CN203 * DESFLURANE INHALATION
Dec-99 CN203 * SERVOFLURANE INHLATION
Dec-99 CV300 * AMIODARONE ORAL
Dec-99 CV300 * PROCAINAMIDE ORAL
Dec-99 CV300 * QUINIDINE ORAL
Dec-99 CV300 * AMIODARONE INJ
Dec-99 CV300 * PROCAINAMIDE INJ
Dec-99 OP101 TIMOLOL OPH SOLN
Dec-99 OP101 TIMOLOL OPH GEL
Dec-99 OP101 LEVOBUNOLOL OPH SOLN
Additions 17 Deletions 0
Feb-00 AH600 * FEXOFENADINE IMMEDIATE RELEASE ORAL
Additions 1 Deletions 0
May-00 GA900 DELETE CISAPRIDE ORAL Manufacture removed from market
May-00 CN709 QUETIAPINE FUMARATE ORAL
May-00 BL700 * CLOPIDOGREL BISULFATE ORAL
May-00 GA700 * ONDANSETRON ORAL Refer to protocol for use of Antiemetics
Additions 3 Deletions 1
Sep-00 GA103 Deleted ALGINIC AC/ALOH/CA STEAR/MG TRI CHEW ORAL (OTC) Switched to NA Bicarbonate product. This product no longer manufactured.
Sep-00 GA103 ALGINIC AC/NA BICARB/CA STEAR/MG TRI CHEW ORAL (OTC)
Sep-00 VT802 PRENATAL VITAMIN TAB
Additions 2 Deletions 1
Oct-00 CN400 DELETE MEPHENYTOIN ORAL Removed from Market
Oct-00 RE109 ALBUTEROL/IPRATROPIUM ORAL INHALER
Additions 1 Deletion 1
Nov-00 CN701 DELETED ACETOPHENAZINE MALEATE ORAL Removed from market
Nov-00 DE802 DELETED ANTHRALIN 0.25% TOP CREAM Removed from market
Nov-00 IM400 DELETED ANTIRABIES SERUM,EQUINE INJ Removed from market
Nov-00 CN205 DELETED ATROPINE SO4/NEOSTIGMINE INJ Removed from market
Nov-00 CN701 DELETED CHLORPROTHIXENE INJ Removed from market
Nov-00 CN701 DELETED CHLORPROTHIXENE ORAL Removed from market
Nov-00 DE900 DELETED DESOXYRIBONUCLEASE/FIBRINOLYSIN TOP OINT Removed from market
Nov-00 CN701 DELETED PIPERACETAZINE ORAL Removed from market
Nov-00 DE900 DELETED SUTILAINS TOP OINT Removed from market
Nov-00 AN100 DELETED URACIL MUSTARD ORAL Removed from market
Nov-00 AM800 DELETED VIDARABINE INJ Removed from market
Additions 0 Deletion 12
Dec-00 DE802 COAL TAR TOPICAL
Dec-00 DE802 COAL TAR SHAMPOO
Dec-00 DE802 COAL TAR/SALICYLIC ACID/SULFUR TOPICAL
Dec-00 DE802 COAL TAR /SALICYLIC ACID TOPICAL
Dec-00 IM900 CROMOLYN SODIUM INHALATION
Dec-00 DE200 HYDROCORTISONE (PLAIN OR ACETATE) TOPICAL
Dec-00 DE350 AMMONIUM LACTATE TOPICAL
Dec-00 HS900 NONOXYNOL-9 VAGINAL
Dec-00 DE500 SALICYLIC ACID TOPICAL
Dec-00 DE500 SALICYLIC ACID/SULFUR TOPICAL
Dec-00 DE400 SELENIUM SULFIDE TOPICAL
Dec-00 DE802 * ANTHRALIN TOPICAL
Dec-00 DE752 * BENZOYL PEROXIDE TOPICAL
Dec-00 DE200 * CLOBETASOL PROPIONATE TOPICAL
Dec-00 BL700 * DIPYRIDAMOLE ORAL
Dec-00 DE200 * TRIAMCINOLONE ACETONIDE TOPICAL
Dec-00 DE752 * TRETINOIN TOPICAL
Dec-00 VT109 * VITAMIN B COMPLEX ORAL (OTC)
Dec-00 DE802 DELETED ANTHRALIN 0.1% TOP CREAM Changed to Anthralin topical
Dec-00 DE802 DELETED ANTHRALIN 0.5% TOP CREAM Changed to Anthralin topical
Dec-00 DE802 DELETED ANTHRALIN 1% TOP CREAM Changed to Anthralin topical
Dec-00 DE752 DELETED BENZOYL PEROXIDE 10% LOTION (OTC) Changed to Benzoyl Peroxide topical
Dec-00 DE752 DELETED BENZOYL PEROXIDE 10% TOP GEL Changed to Benzoyl Peroxide topical
Dec-00 DE752 DELETED BENZOYL PEROXIDE 5% LOTION (OTC) Changed to Benzoyl Peroxide topical
Dec-00 DE752 DELETED BENZOYL PEROXIDE 5% TOP GEL Changed to Benzoyl Peroxide topical
Dec-00 DE802 DELETED COAL TAR 1% SHAMPOO (OTC) Changed to Coal Tar Shampoo
Dec-00 DE802 DELETED COAL TAR 2% OINT (OTC) Changed to Coal Tar Topical
Dec-00 DE802 DELETED COAL TAR 2.5% TOP SOLN (OTC) Changed to Coal Tar Topical
Dec-00 DE802 DELETED COAL TAR 5% TOP GEL (OTC) Changed to Coal Tar Topical
Dec-00 DE802 DELETED COAL TAR 8.75% SHAMPOO (OTC) Changed to Coal Tar Shampoo
Dec-00 DE802 DELETED COAL TAR 0.5%/SAL AC 2%/SULFUR 2% RINSE (OTC) Changed to Coal Tar/Salicylic Acid/Sulfur topical
Dec-00 DE802 DELETED COAL TAR 0.5/%SAL AC 2%/SULFUR 2% SHAMPOO (OTC) Changed to Coal Tar/Salicylic Acid/Sulfur topical
Dec-00 DE802 DELETED COAL TAR 10%/SALICYLIC ACID 4% SHAMPOO (OTC) Changed to Coal Tar/Salicylic Acid topical
Dec-00 DE200 DELETED CLOBETASOL PROPIONATE 0.05% OINT Changed to Clobetasol Propionate topical
Dec-00 DE200 DELETED CLOBETASOL PROPIONATE 0.05% TOP SOLN Changed to Clobetasol Propionate topical
Dec-00 BL700 DELETED DIPYRIDAMOLE 75MG ORAL Changed to Dipyridamole Oral
Dec-00 DE200 DELETED HYDROCORTISONE 1% CREAM (OTC) Changed to Hydrocortisone Topical
Dec-00 DE200 DELETED HYDROCORTISONE 1% LOTION (OTC) Changed to Hydrocortisone Topical
Dec-00 DE200 DELETED HYDROCORTISONE 1% OINT (OTC) Changed to Hydrocortisone Topical
Dec-00 DE200 DELETED HYDROCORTISONE 2.5% CREAM Changed to Hydrocortisone Topical
Dec-00 DE350 DELETED LACTIC ACID 5% LOTION (OTC) Changed to Ammonium Lactate Topical
Dec-00 DE900 DELETED LACTIC ACID 5% TOP CREAM (OTC)
Dec-00 HS900 DELETED NONOXYNOL 100MG VAG SUPP (OTC) Changed to Nonoxynol-9 Vaginal
Dec-00 DE500 DELETED SALICYLIC ACID 2% SHAMPOO (OTC) Changed to Salicylic Acid Topical
Dec-00 DE752 DELETED SALICYLIC ACID 2% TOP CREAM (OTC) Changed to Salicylic Acid Topical
Dec-00 DE500 DELETED SALICYLIC ACID 40% PLASTER (OTC) Changed to Salicylic Acid Topical
Dec-00 DE500 DELETED SALICYLIC ACID 2%/SULFUR 2% SHAMPOO (OTC) Changed to Salicylic Acid/Sulfur Topical
Dec-00 DE500 DELETED SALICYLIC ACID 2%/SULFUR 2% SOAP (OTC) Changed to Salicylic Acid/Sulfur Topical
Dec-00 DE400 DELETED SELENIUM SULFIDE 2.5% SHAMPOO Changed to Selenium Topical
Dec-00 DE200 DELETED TRIAMCINOLONE ACETONIDE 0.1% CREAM Changed to Triamcinolone Acetonide topical
Dec-00 DE200 DELETED TRIAMCINOLONE ACETONIDE 0.1% OINT Changed to Triamcinolone Acetonide topical
Dec-00 DE752 DELETED TRETINOIN 0.025% TOP CREAM Changed to Tretinoin Topical
Dec-00 DE752 DELETED TRETINOIN 0.025% TOP GEL Changed to Tretinoin Topical
Dec-00 DE752 DELETED TRETINOIN 0.05% TOP CREAM Changed to Tretinoin Topical
Dec-00 DE752 DELETED TRETINOIN 0.1% TOP CREAM Changed to Tretinoin Topical
Dec-00 DE350 DELETED UREA 10% CREAM (OTC) Changed to Urea topical
Dec-00 DE350 DELETED UREA 10% LOTION (OTC) Changed to Urea topical
Dec-00 DE350 DELETED UREA 20% CREAM (OTC) Changed to Urea topical
Dec-00 DE350 UREA TOPICAL
Dec-00 VT109 DELETED VITAMIN B COMPLEX CAP (OTC) Changed to Vitamin B Complex Oral
Additions 18 Deletion 42
Jan-01 OP900 DELETED CHYMOTRYPSIN OPH SOLN No longer manufactured
Jan-01 OP105 DORZOLAMIDE/TIMOLOL OPHTHALIC SOLUTION
Additions 1 Deletion 1
Feb-01 AN900 DELETE CLASS REVIEW:NONSTEROIDAL ANTIANDROGENS
Feb-01 AN900 NONSTEROIDAL ANTIANDROGENS VISN's must make at least one product available to patients.
Feb-01 AM800 R ABACAVIR/LAMIVUDINE/ZIDOVUDINE ORAL Refer to HIV/AIDS-TAG Treatment Guidelines
Feb-01 AM800 R LOPINAVIR/RITONAVIR ORAL Refer to HIV/AIDS-TAG Treatment Guidelines
Feb-01 AM800 R AMPRENAVIR ORAL Refer to HIV/AIDS-TAG Treatment Guidelines
Feb-01 DE650 DELETE CAPSAICIN 0.025% CREAM (OTC) Changed to Capsaicin Topical
Feb-01 DE650 DELETE CAPSAICIN 0.075% CREAM (OTC) Changed to Capsaicin Topical
Feb-01 DE650 CAPSAICIN TOPICAL (OTC)
Feb-01 AM900 R LINEZOLID INJ
Feb-01 AM900 R LINEZOLID ORAL
Additions 7 Deletion 3
Mar-01 AH600 Delete FEXOFENADINE IMMEDIATE RELEASE ORAL Changed to Oral
Mar-01 AH600 FEXOFENADINE ORAL
RE101 FLUNISOLIDE ORAL INHALER Refer to PBM/MAP and VHA/DoD COPD treatment guidelines for use
Mar-01
Additions 1 Deletion 1
Apr-01 CN609 MIRTAZAPINE ORAL Voted on 4/01 but not added to Web page until 9/01
Additions 1 Deletion 0
Jun-01 CN400 Delete CARBAMAZEPINE (TEGRETOL) ORAL No longer restricted to Tegretol only
Jun-01 CN400 CARBAMAZEPINE ORAL
Jun-01 RE103 ALBUTEROL IMMEDIATE RELEASE ORAL
Jun-01 RE103 TERBUTALINE SULFATE IMMEDIATE RELEASE ORAL
Jun-01 IM700 * PEGINTERFERON ALPHA-2B INJ Refer to criteria for use of Peginterferon
Jun-01 HS200 ETHINYL ESTRADIOL 35MCG/ETHYNODIOL 1MG TAB,28
Jun-01 HS200 NORETHINDRONE 0.35MG TAB,28
CV805 Delete CLASS REVIEW: ANGIOTENSIN II INHIBITORS Refer to VHA/DoD Hypertension guideline and pharmacologic No Angiotension II inhibitor added to formulary.
Jun-01 supplement, PBM/MAP CHF treatment guidelines for use
Jun-01 CV400 HYDROCHLOROTHIAZIDE/LISINOPRIL ORAL
Jun-01 CV400 ATENOLOL/CHLORTHALIDONE ORAL
Additions 8 Deletion 8
Jul-01 GA900 * RABEPRAZOLE NA ORAL
Jul-01 MS102 DICLOFENAC NA ORAL
Additions 2 Deletion 0
CV800 ENALAPRIL ORAL Refer to VHA/DoD Hypertension guideline and pharmacologic
supplement, PBM/MAP CHF and VHA/DoD Diabetes treatment
Sep-01 guidelines for use
GU900 SILDENAFIL CITRATE ORAL Refer to Erectile Dysfunction treatment guidelines for use, as well as
Sep-01 the Sildenafil dosing guidelines.
Additions 2 Deletion 0
Nov-01 AM800 RIBAVIRIN ORAL Refer to Hepatitis C TAG Treatment Guidelines
Nov-01 CV050 DIGOXIN ORAL Changed to generic entry
Nov-01 AM800 VALGANCICLOVIR Restricted to CMV retinitis
Additions 2 Deletion 0
Dec-01 TN200 DELETE NUTRITION SUPL OSMOLITE HN LIQUID (OTC) CHANGED TO ISSOURCE STARNDARD
Dec-01 TN200 * NUTRITION SUPL ISOSOURCE STANDARD LIQUID (OTC)
CV100 DELETE METOPROLOL ORAL Refer to VHA/DoD Hypertension guideline and pharmacologic
Dec-01 supplement, PBM/MAP CHF treatment guidelines for use CHANGED TO INCLUDE METOPROLOL SUCCINATE SUSTAINED ACTION
Dec-01 CV100 * METOPROLOL SUCCINATE SUSTAINED ACTION ORAL Restricted to CHF patients
CV100 METOPROLOL TARTRATE IMMEDIATE RELEASE ORAL Refer to VHA/DoD Hypertension guideline and pharmacologic
Dec-01 supplement, PBM/MAP CHF treatment guidelines for use
Dec-01 AM800 R TENOFOVIR DISOPROXIL FUMARATE ORAL Refer to HIV/AIDS-TAG Treatment Guidelines
Additions 3 Deletion 1
Jan-02 CN101 OXYCODONE HCL ORAL For sustained action products refer to PBM criteria for use Criteria added
Additions 0 Deletion 0
Mar-02 AN900 * IMATINIB MESYLATE ORAL See Criteria for Use of Imatinib Mesylate (Gleevec)
Mar-02 IM100 HEPATITIS A/HEPATITIS B VACCINE
Mar-02 CN500 * ENTACAPONE 200MG TAB Restricted to PADRECC Centers
Additions 3 Deletion 0
May-02 CV300 Delete PROCAINAMIDE ORAL Changed to 12 hour release product only
May-02 CV300 * PROCAINAMIDE ORAL 12 HOUR SUSTAINED ACTION Refer to Procainamide Drug Monitoring Recommendations.
May-02 GA400 Delete OPIUM 10% TINCTURE
HS501 Delete INSULIN LISPRO 100U/ML INJ Refer to PBM/MAP and VHA/DoD Diabetes treatment guidelines for use Changed to Ultra Short Acting Insulin
May-02
HS501 * INSULIN ULTRA SHORT ACTING INJ Refer to PBM/MAP and VHA/DoD Diabetes treatment guidelines for use.
VISN's should have at least one Ultra Short Acting insulin on their formulary.
May-02
May-02 CN709 ZIPRASIDONE ORAL
Additions 1 Deletion 1
Aug-02 RE109 MONTELUKAST ORAL Refer to Leukotriene inhibitor criteria for use
Additions 1 Deletion 0
Oct-02 GA209 delete CASANTHRANOL/DOCUSATE NA CAP (OTC) No longer manufactured after 11/02
Oct-02 GA204 delete CASCARA SAGRADA ORAL FLUID EXTRACT (OTC) No longer manufactured after 11/02
Oct-02 GA204 SENNOSIDES ORAL (OTC) Name change
Oct-02 AM700 R ITRACONAZOLE INJ
Additions 1 Deletion 2
Dec-02 IM700 * PEGINTERFERON ALFA-2A INJ Refer to criteria for use of Peginterferon
Dec-02 MS106 * GOLD NA THIOMALATE
Dec-02 MS102 DELETE TOLMETIN ORAL
Dec-02 DE450 DELETE ALUMINUM HYDROXYCHLORIDE LOTION Replace with Aluminum Chloride (hexahydrate) topical
Dec-02 DE450 * ALUMINUM CHLORIDE (HEXAHYDRATE) TOPICAL
Dec-02 HS300 DELETE DIETHYLSTILBESTROL ORAL
Dec-02 AU350 GLYCOPYRROLATE INJ
Dec-02 AP200 IVERMECTIN ORAL
DE650 DELETE MENTHOL 2%/METHYL SALICYLATE 10% TOP OINT(OTC)
Dec-02
Dec-02 DE650 MENTHOL 2%/METHYL SALICYLATE 10% TOP (OTC)
Dec-02 DE650 DELETE ANALGESIC OINT (OTC)
Dec-02 CN105 DELETE METHYSERGIDE MALEATE ORAL Product removed from market effect 02/03.
CV150 DOXAZOSIN MESYLATE ORAL Refer to PBM/MAP Benign Prostatic Hyperplasia and Hypertension
Dec-02 treatment guidelines for use
Additions 7 Deletion 6
Mar-03 CV800 R RAMIPRIL ORAL Refer to criteria for use of Ramipril
BL700 * ABCIXIMAB INJ In addition to abciximab, VISNs are required to add either eptifibatide Additional Restriction added.
or tirofiban to their VISN formulary. Refer to VA/DoD IHD treatment
Mar-03 guideline.
Additions 1 Deletion 0
TN200 * NUTRITION SUPL ENSURE PLUS/VANILLA LIQUID (OTC)
Apr-03
Apr-03 BL400 * DARBEPOETIN ALFA RECOMBINANT INJ
Additions 2 Deletion 0
May-03 AH600 DELETE FEXOFENADINE ORAL
May-03 AH109 LORATIDINE ORAL
BL600 * TENECTEPLASE,RECOMBINANT INJ Refer to VA directive “Treatment of Acute Myocardial Infarction (AMI)
and Unstable Angina” #2003-017; April 8, 2003.
May-03 http://www.va.gov/publ/direc/health/direct/12003017.pdf
May-03 GA209 DELETE CASCARA/MAGNESIUM HYDROXIDE CONC SUSP (OTC) Removed from market by FDA
May-03 GA400 DELETE ATTAPULGITE ORAL (OTC) Removed from market by FDA
Additions 2 Deletion 3
Jul-03 CN105 ZOLMITRIPTAN ORAL
Jul-03 NT200 FLUNISOLIDE NASAL INHL
Jul-03 CV250 ISOSORBIDE MONONITRATE ORAL, SA TAB
Jul-03 OP109 TRAVOPROST OPTH SOLN
Jul-03 NT200 DELETE CLASS REVIEW: ANTI-INFLAMMATORIES,NASAL Flunsolide added
Jul-03 DX900 DELETE PENTAGASTRIN INJ No longer manufactured
Jul-03 CN701 DELETE MESORIDAZINE BESYLATE INJ No longer manufactured
Jul-03 AU100 DELETE METHOXAMINE HCL INJ No longer manufactured
Additions 3 Deletion 4
Aug-03 OP109 Delete LATANOPROST OPH SOLN
Aug-03 AP300 Delete LINDANE CREAM
Aug-03 AP300 Delete LINDANE LOTION
Aug-03 AP300 Delete LINDANE SHAMPOO
Aug-03 CN105 Delete SUMATRIPTAN SUCCINATE ORAL
Aug-03 AM800 ENFUVIRTIDE INJ Refer to PBM/MAP criteria for use for Enfuvirtide.
Aug-03 CV350 FLUVASTATIN ORAL Refer to PBM/MAP criteria for use for Fluvastatin
Additions 2 Deletion 5
Sep-03 CV100 * METOPROLOL TARTRATE INJ Refer to VHA/DoD Hypertension guideline and pharmacologic supplement,
Sep-03 HS900 ALENDRONATE ORAL
Sep-03 RE109 DELETE CLASS REVIEW: ANTIASTHMA,OTHER-INCLUDING
Sep-03 HS900 DELETE CLASS REVIEW: HORMONES/MODIFIERS/OTHER
Sep-03 RE101 DELETE CLASS REVIEW: INHALED CORTICOSTEROIDS Refer to PBM/MAP and VHA/DoD COPD treatment guidelines for use
Sep-03 DX102 DELETE CLASS REVIEW: IONIC CONTRAST MEDIA
Sep-03 MS300 DELETE CLASS REVIEW: NEUROMUSCULAR BLOCKING AGENTS
Sep-03 DX101 DELETE CLASS REVIEW: NON-IONIC CONTRAST MEDIA
Sep-03 AN200 DELETE PLICAMYCIN INJ No longer manufactured
Sep-03 CN701 DELETE PERPHENAZINE INJ No longer manufactured
Sep-03 VT501 DELETE CALCIFEDIOL ORAL No longer manufactured
Sep-03 HS702 DELETE LYPRESSIN NASAL INHL SOLN No longer manufactured
Sep-03 GU300 DELETE TRIPLE SULFA VAG TAB No longer manufactured
Sep-03 DE890 DELETE TRIOXSALEN ORAL No longer manufactured
Sep-03 CN500 DELETE LEVODOPA ORAL No longer manufactured
Sep-03 CN105 DELETE ERGOTAMINE TARTRATE SL ORAL No longer manufactured
Sep-03 AN400 DELETE LEVAMISOLE ORAL No longer manufactured
Sep-03 OP106 DELETE ISOSORBIDE ORAL SOLN No longer manufactured
Additions 2 Deletion 15
Nov-03 AD900 NICOTINE GUM Refer to VA/DoD guidelines for Tobacco Use Cessation. Additional Restrictions were edited
Nov-03 AD900 NICOTINE PATCH Refer to VA/DoD guidelines for Tobacco Use Cessation. Additional Restrictions were edited
Nov-03 CV350 * FLUVASTATIN ORAL Refer to PBM/MAP criteria for use for Fluvastatin Edited to include both IR and SA products
Nov-03 CV350 * FLUVASTATIN IMMEDIATE RELEASE ORAL Refer to PBM/MAP criteria for use for Fluvastatin
Nov-03 CV350 * FLUVASTATIN SUSTAINED ACTION ORAL Refer to PBM/MAP criteria for use for Fluvastatin
Nov-03 GA900 OMEPRAZOLE ORAL
Nov-03 DE900 Delete ZINC OXIDE 20% OINT (OTC)
Nov-03 DE900 Delete ZINC OXIDE 25% PASTE (OTC)
Nov-03 DE900 ZINC OXIDE TOPICAL (OTC)
Nov-03 CN900 * GALANTAMINE ORAL
RE102 Delete SALMETEROL ORAL INHL Refer to PBM/MAP and VHA/DoD COPD treatment guidelines for use
Nov-03
Nov-03 AM800 R ATAZANAVIR ORAL Refer to criteria for use of Atazanavir
Nov-03 HS502 * ROSIGLITAZONE ORAL Refer to criteria for use for Thiazolidines
HS900 CONJUGATED ESTROGENS/MEDROXYPROGESTERONE ORAL
Nov-03 (PREMPRO/PREMPHASE)
HS900 ETHINYL ESTRADIOL 5MG/NORETHINDRONE ACETATE 1MCG
Nov-03 ORAL (FEMHRT)
Additions 7 Deletion 3
Dec-03 GA900 Delete LANSOPRAZOLE ORAL
Additions 0 Deletion 1
Feb-04 AM900 Delete LOMEFLOXACIN HCL ORAL Replaced with gatifloxacin
Feb-04 AM900 Delete LEVOFLOXACIN ORAL Replaced with gatifloxacin
Feb-04 XX000 Delete HYALURONIDASE INJ No longer manufactured
Feb-04 TN402 Delete CALCIUM ACETATE TAB Changed to Calcium Acetate Oral
Feb-04 TN402 CALCIUM ACETATE ORAL
Feb-04 HS900 RISEDRONATE NA ORAL
Feb-04 CN103 TRAMADOL HCL ORAL
Feb-04 AM900 GATIFLOXACIN ORAL
Additions 3 Deletion 3
Mar-04 CN900 * MEMANTINE HCL Refer to criteria for use of Memantine
Mar-04 DE900 PAPAIN/UREA/CHLOROPHYLL TOPICAL
Mar-04 DE900 PAPAIN/UREA TOPICAL
Mar-04 AM900 R GATIFLOXACIN INJ
Additions 3 Deletion 0
Apr-04 CN709 * ARIPIPRAZOLE ORAL Refer to treatment guidelines for the Pharmacologic Management of Atypical
Additions 1 Deletion 0
May-04 CN709 R RISPERIDONE INJ SUSTAINED ACTION Refer to criteria for use for Risperidone long-acting injection
Additions 1 Deletion 0
Jun-04 AN900 OXALIPLATIN INJ For metastatic colorectal carcinoma
Jun-04 DE200 DELETE FLUOCINONIDE 0.05% CREAM
Jun-04 DE200 DELETE FLUOCINONIDE 0.05% OINT
Jun-04 DE200 * FLUOCINONIDE TOPICAL
Additions 2 Deletion 2
Aug-04 CV200 Delete NIFEDIPINE ORAL IMMEDIATE RELEASE For spinal cord injury patients to treat hypertension due to autonomic
Aug-04 CN701 Delete MESORIDAZINE BESYLATE ORAL No longer manufactured
Aug-04 OP103 Delete EPINEPHRINE HCL OPH SOLN No longer manufactured
Additions 0 Deletion 3
Oct-04 CN500 * APOMORPHINE INJ Restricted to neurology for treatment of acute hypomobility episode of
Oct-04 GA700 * TRIMETHOBENZAMIDE ORAL Restricted to use with Apomorphine
Oct-04 DX101 CONTRAST MEDIA NON-IONIC INJ
Oct-04 DX102 CONTRAST MEDIA IONIC INJ
Oct-04 CN709 * OLANZAPINE INJ Restricted to monotherapy for the treatment of acute agitation associated
Oct-04 AM800 * FOSAMPRENAVIR ORAL
Oct-04 DE700 PENTAFLUOROPROPANE/TETRAFLUOROETHANE AEROSOL SPRAY AND STRETCH TOP AEROSOL
Additions 6 Deletion 0
Nov-04 GA900 Delete RABEPRAZOLE NA ORAL
Nov-04 NT300 Delete LIDOCAINE 10% ORAL AEROSOL No longer manufactured
Nov-04 AM103 Delete CEFIXIME ORAL No longer manufactured
Nov-04 AM800 R ABACAVIR/LAMIVUDINE ORAL
Nov-04 AM800 R EMTRICITABINE ORAL
Nov-04 AM800 R EMTRICITABINE/TENOFOVIR ORAL
Additions 3 Deletion 3
Dec-04 CV800 Delete RAMIPRIL ORAL Refer to criteria for use of Ramipril
Dec-04 HS501 Delete INSULIN SHORT ACTING INJ Refer to PBM/MAP and VHA/DoD Diabetes treatment guidelines for use.
Dec-04 HS501 * INSULIN ASPART INJ Refer to PBM/MAP and VHA/DoD Diabetes treatment guidelines for use.
Dec-04 OP900 Delete LEVOCABASTINE HCL OPH SUSP No longer manufactured
Dec-04 HS051 Delete PREDNISOLONE ORAL Prednisolone removed to reduce confusion with prednisone.
Additions 2 Deletion 4
Mar-05 GA700 Delete THIETHYLPERAZINE MALEATE ORAL No longer Manufactured
Additions 0 Deletion 1
Jun-05 CV900 Delete AMRINONE INJ No longer manufactured
Jun-05 CN701 Delete CHLORPROMAZINE SUPP RTL No longer manufactured
Jun-05 CV350 CHOLESTYRAMINE ORAL Refer to PBM/MAP Hyperlipidemia treatment guidelines for use
Jun-05 MS300 * CISATRACURIUM INJ
Jun-05 IR100 Delete CITRIC ACID/GLUCONIC ACID No longer manufactured
Jun-05 GU300 Delete CLOTRIMAZOLE VAG TAB (OTC) No longer manufactured
Jun-05 CN101 Delete FENTANYL/DROPERIDOL INJ No longer manufactured
Jun-05 DE700 Delete FLUORI-METHANE TOP SPRAY 120ML No longer manufactured
Jun-05 OP900 Delete GLYCERIN OPH SOLN No longer manufactured
Jun-05 XX000 HYALURONIDASE INJ
Jun-05 TN499 Delete HYDROCHLORIC ACID INJ No longer manufactured
Jun-05 TN499 Delete HYDROCHLORIC ACID ORAL LIQUID No longer manufactured
Jun-05 CN102 Delete LEVOMETHADYL ACETATE HCL SOLN No longer manufactured
Jun-05 DE700 Delete LIDOCAINE 2.5% OINT No longer manufactured
Jun-05 NT300 Delete LIDOCAINE 5% DENTAL OINT No longer manufactured
Jun-05 NT300 Delete LIDOCAINE 5% DENTAL SOLN No longer manufactured
Jun-05 CV805 * LOSARTAN ORAL Refer to criteria for use for Angiotensin II receptor antagonist
Jun-05 CN709 Delete LOXAPINE INJ No longer manufactured
Jun-05 AU100 Delete METHOXAMINE HCL INJ No longer manufactured
Jun-05 AM250 Delete TETRACYCLINE HCL ORAL No longer manufactured
Jun-05 BL117 Delete TICLOPIDINE HCL ORAL
Jun-05 CN701 Delete TRIFLUOPERAZINE INJ No longer manufactured
Jun-05 CV805 * VALSARTAN ORAL Refer to criteria for use for Angiotensin II receptor antagonist
Additions 4 Deletion 18
Sep-05 AM250 TETRACYCLINE HCL ORAL Deleted by mistake instead of tetracaine opth oint
Sep-05 OP700 Delete TETRACAINE HCL OPH OINT No longer manufactured
Sep-05 CV900 INAMRINONE INJ Name change from Amrinone to Inamrinone
Sep-05 AN300 * AZACITIDINE INJ
Sep-05 AM800 * TIPRANAVIR ORAL
Additions 2 Deletion 1
Oct-05 VT801 RENAL MULTIVITAMIN WITH < OR =1MG FOLIC ACID ORAL
CV805 * LOSARTAN ORAL Restrictions changed from; Refer to criteria for use for Angiotensin II receptor
Oct-05 Restricted for treatment of type 2 diabetic nephropathy in patients with HTN antagonist
Oct-05 PH000 Delete HYDROCHLORIC ACID LIQUID
Oct-05 PH000 Delete ACETIC ACID,GLACIAL LIQUID
Oct-05 AD900 NICOTINE POLACRILEX LOZENGE Refer to VA/DoD guidelines for Tobacco Use Cessation.
Oct-05 OR100 STANNOUS FLUORIDE FOAM,DENT
Oct-05 OR100 STANNOUS FLUORIDE LIQUID,DENT
Oct-05 OR100 STANNOUS FLUORIDE VARNISH,DENT
Additions 5 Deletion 2
*Switch to Dosage Form Formulary
VA Class Restrict Non- Generic Dosage Form Reference
PH000 NF SODIUM THIOSULFATE CRYSTAL Removed from Formulary
PH000 NF POTASSIUM PERMANGANATE GRANULES Removed from Formulary
PH000 NF PODOPHYLLIN POWDER Removed from Formulary
PH000 NF LACTOSE POWDER Removed from Formulary
PH000 NF GLYCOLIC ACID (OTC) LIQUID,TOP Removed from Formulary
PH000 NF KARAYA GUM POWDER Removed from Formulary
AM800 R NF AMPRENAVIR CAP,ORAL Removed from Formulary
BL117 NF ASPIRIN/DIPYRIDAMOLE CAP,SA REVIEWED
HS900 NF CALCIUM/RISEDRONATE TAB REVIEWED
CN900 NF DONEPEZIL TAB,RAPID DISTEGRATING REVIEWED
Additions 0 Deletion 6
Jan-06 GU900 Delete SILDENAFIL CITRATE TAB TAB
Jan-06 GU900 * VARDENAFIL HCL TAB TAB
Additions 1 Deletion 1
Feb-06 AM800 * OSELTAMIVIR CAP,ORAL
Feb-06 RE101 MOMETASONE FUROATE INHL,ORAL
Feb-06 GU900 Delete PARAGARD T (Cu380A) IUD IUD's are a prosthetic item
Feb-06 AN900 * DOCETAXEL INJ
Feb-06 AM150 ERTAPENEM INJ,PWDR http://www.pbm.va.gov/monograph/Ertapenemmonograph.pdf
Feb-06 AN900 * RITUXIMAB INJ,SOLN Restricted to oncology
Feb-06 CN400 DIVALPROEX NA TAB,EC SA Tab is the only formulary product
Additions 5 Deletion 2
Mar-06 AM900 R GATIFLOXACIN INJ
Mar-06 AM900 R GATIFLOXACIN TAB http://vaww.pbm.va.gov/criteria/Gatifloxacin.pdf
Mar-06 AM900 R MOXIFLOXACIN INJ,SOLN http://vaww.pbm.va.gov/criteria/FluoroquinoloneCriteriaforUse.
Mar-06 AM900 R MOXIFLOXACIN TAB pdf
http://vaww.pbm.va.gov/criteria/FluoroquinoloneCriteriaforUse.
pdf
Additions 2 Deletion 2
Apr-06 CV350 OMEGA-3 ACID CAP,ORAL
Apr-06 CN300 RAMELTEON TAB http://www.pbm.va.gov/monograph/Ramelteon.pdf
Apr-06 TN499 SELENIUM TAB Removed from VANF
Apr-06 CN101 BUPRENORPHINE TAB,SUBLINGUAL http://vaww.pbm.va.gov/criteria/Buprenorphine.pdf
Apr-06 CN101 BUPRENORPHINE/NALOXONE TAB,SUBLINGUAL http://vaww.pbm.va.gov/drugmonograph/BUPMonograph%20(Rev%2009Jun
03).pdf
Apr-06 VT509 PARICALCITOL CAP,ORAL
Apr-06 VT509 PARICALCITOL INJ,SOLN
Apr-06 RE102 LEVALBUTEROL INHL,ORAL
Additions 2 Deletion 1
May-06 XX000 PLACEBO CAP/TAB Removed from formulary
May-06 TN420 CALCIUM ACETATE TAB Changed to capsule formulation
May-06 TN420 CALCIUM ACETATE CAP,ORAL
May-06 CV704 HYDROCHLOROTHIAZIDE/SPIRONOLACTONE TAB
Additions 2 Deletion 2 0
Jun-06 HS900 ALENDRONATE/CHOLECALCIFEROL TAB
Jun-06 IM900 * DIPHTHERIA TOXOID/PERTUSSIS /TETANUS TOXOID INJ,SUSP http://www.pbm.va.gov/monograph/TetanusDiptheriaPertussisTdapVaccine.p
Jun-06 CV400 HYDRALAZINE/ISOSORBIDE TAB df
Jun-06 DE751 ISOTRETINOIN CAP,ORAL http://www.pbm.va.gov/criteria/HighlyTeratogenicRetinoidsAndHigh-
Jun-06 IM900 * LENALIDOMIDE CAP,ORAL DoseVitaminACFU.pdf
http://vaww.pbm.va.gov/pbm/Revlimid.htm
Jun-06 XA900 MEDICATION ORGANIZER MISCELLANEOUS
Jun-06 AN900 * SORAFENIB TAB
Jun-06 TN200 THICKENING AGENT PWDR,ORAL http://vaww.pbm.va.gov/clinicians/ClinicalGuidanceForMedicationAssessment
InDysphagia.pdf
Additions 3 Deletion 0
Aug-06 AM250 Delete DOXYCYCLINE CAP,ORAL Replaced by Cap/Tab entry
Aug-06 AM250 Delete DOXYCYCLINE TAB Replaced by Cap/Tab entry
Aug-06 AN900 Delete NONSTEROIDAL ANTIANDROGENS CAP/TAB Replaced by individual product entries
Aug-06 AD900 FOMEPIZOLE INJ
Aug-06 AM054 R TICARCILLIN INJ
Aug-06 AM112 R OXACILLIN INJ
Aug-06 AM113 R TIROFIBAN INJ,SOLN
Aug-06 AM117 R CEFTIZOXIME INJ
Aug-06 AM250 R DOXYCYCLINE CAP/TAB Replaces separate Cap/Tab entry
Aug-06 AM900 R DALFOPRISTIN/QUINUPRISTIN INJ
Aug-06 AN900 * BICALUTAMIDE TAB
Aug-06 AN900 * FLUTAMIDE CAP
Aug-06 AN900 * PENTOSTATIN INJ
Aug-06 AN900 * PORFIMER SODIUM INJ
Aug-06 AN900 * TRICHOPHYTON INJ
Aug-06 AU100 FENOLDOPAM INJ
Aug-06 BL110 BIVALIRUDIN INJ,PWDR
Aug-06 BL110 EPTIFIBATIDE INJ
Aug-06 BL110 LEPIRUDIN INJ,PWDR
Aug-06 BL110 TOPOTECAN INJ
Aug-06 BL115 RETEPLASE INJ
Aug-06 BL116 APROTININ INJ,SOLN
Aug-06 BL117 ASPIRIN/DIPYRIDAMOLE CAP,SA
Aug-06 BL900 HETASTARCH/ELECTROLYTES INJ
Aug-06 CN202 * METHOHEXITAL INJ
Aug-06 CN204 PRILOCAINE INJ,SOLN
Aug-06 CN204 ROPIVACAINE INJ
Aug-06 CN309 DEXMEDETOMIDINE INJ,SOLN
Aug-06 CN400 LEVETIRACETAM TAB
Aug-06 CN809 CAFFEINE/SODIUM BENZOATE INJ
Aug-06 CV300 IBUTILIDE INJ
Aug-06 CV600 ETHANOLAMINE OLEATE INJ,SOLN
Aug-06 CV600 MORRHUATE SODIUM INJ,SOLN
Aug-06 CV800 BENAZEPRIL TAB
Aug-06 DE102 MICONAZOLE CREAM,TOP
Aug-06 DE200 BETAMETHASONE DIPROPIONATE CREAM,TOP
Aug-06 DE200 BETAMETHASONE DIPROPIONATE OINT,TOP
Aug-06 DE200 BETAMETHASONE VALERATE CREAM,TOP
Aug-06 DE200 BETAMETHASONE VALERATE LOTION,TOP
Aug-06 DE200 BETAMETHASONE VALERATE OINT,TOP
Aug-06 DE200 DESONIDE CREAM,TOP
Aug-06 DE900 ALUMINUM ACETATE PWDR,TOP
Aug-06 DX102 IOTHALAMATE INJ,SOLN
Aug-06 GA201 CELLULOSE,OXIDIZED POWDER,ORAL
Aug-06 GA204 DOCUSATE/SENNOSIDES TAB
Aug-06 GA209 BISACODYL/PHOSPHO SODA KIT *(TAB/SUPP/LIQUID)
Aug-06 GA900 PANTOPRAZOLE INJ,PWDR
Aug-06 HS200 ETHINYL ESTRADIOL 20MCG TAB
Aug-06 HS200 RING,VAG
ETHINYL ESTRADIOL 0.12MG/ETONOGESTREL 0.15MG (EQV-NUVARING)
Aug-06 HS400 CLOMIPHENE TAB
Aug-06 HS900 ZOLEDRONIC INJ,PWDR
Aug-06 IM600 SIROLIMUS SOLN,ORAL
Aug-06 IM600 SIROLIMUS TAB
Aug-06 IM600 BASILIXIMAB INJ
Aug-06 IM600 DACLIZUMAB INJ
Aug-06 IM900 ANTI-THYMOCYTE GLOBULIN INJ,PWDR
Aug-06 IM900 TRIETHANOLAMINE LIQUID,OTIC
Aug-06 MS300 VINORELBINE INJ
Aug-06 MS300 ATRACURIUM INJ
Aug-06 MS300 CISATRACURIUM INJ
Aug-06 MS300 MIVACURIUM CHLORIDE INJ,SOLN
Aug-06 MS300 PANCURONIUM BROMIDE INJ,SOLN
Aug-06 MS300 ROCURONIUM BROMIDE INJ,SOLN
Aug-06 MS300 SUCCINYLCHOLINE INJ,SOLN
Aug-06 OP101 BETAXOLOL SUSP,OPH
Aug-06 OP210 MOXIFLOXACIN SOLN,OPH
Aug-06 OP800 NAPHAZOLINE SOLN,OPH
Aug-06 OP900 NAPHAZOLINE/PHENIRAMINE SOLN,OPH
Aug-06 OT300 TROMETHAMINE INJ
Aug-06 PH000 SODIUM CITRATE INJ
Aug-06 PH000 SODIUM CITRATE POWDER
Aug-06 RE102 FORMOTEROL CAP,INHL
Aug-06 TN410 FERROUS GLUCONATE TAB
Aug-06 TN440 SODIUM CITRATE INJ,SOLN
Aug-06 TN450 ZINC SULFATE CAP,ORAL
Aug-06 TN450 ZINC SULFATE INJ,SOLN
Aug-06 TN478 POTASSIUM CITRATE TAB,SA
Aug-06 TN499 AMMONIUM CHLORIDE INJ,SOLN
Aug-06 TN900 VECURONIUM INJ
Aug-06 XA900 SPACER-INHALER CHAMBER
Aug-06 XX000 SODIUM CITRATE SOLN
Aug-06 HS200 DELETE TRIPHASIC ORAL CONTRACEPTIVE,28 (EQV-ORTHO-NOVUM TAB NAME CHANGE
Aug-06 HS200 7/7/7)
ETHINYL ESTRADIOL 35MCG/NORETHINDRONE,28 (TRI) (EQV- TAB NAME CHANGE
Aug-06 HS200 DELETE NECON 7/7/7)
ETHINYL ESTRADIOL 30MCG/NORGESTREL 0.3MG TAB
Aug-06 HS200 DELETE ETHINYL ESTRADIOL 35MCG/ETHYNODIOL 1MG (EQV-ZOVIA TAB
Aug-06 HS200 1/35E),28 ESTRADIOL 20MCG/LEVONORGESTREL 0.1MG,28
ETHINYL TAB http://www.pbm.va.gov/reviews/CombinHT.pdf
Aug-06 HS200 (MONO) (EQV-LUTERA)
ETHINYL ESTRADIOL 30MCG/LEVONORGESTREL 0.15MG,28 TAB http://www.pbm.va.gov/reviews/CombinHT.pdf
Aug-06 HS200 (MONO) (EQV-LEVLEN)
ETHINYL ESTRADIOL 30MCG/LEVONORGESTREL,28 (TRI) TAB http://www.pbm.va.gov/reviews/CombinHT.pdf
Aug-06 TN410 FERRIC NA GLUCONATE
(EQV-TRI-LEVLEN) INJ,SOLN
Additions 81 Deletion 5
Oct-06 AM250 R TIGECYCLINE INJ,LYPHL http://www.pbm.va.gov/monograph/Tigecycline.pdf
Oct-06 AM800 R EFAVIRENZ/EMTRICITABINE/TENOFOVIR TAB
Oct-06 CV250 ISOSORBIDE DINITRATE CAP\TAB,SA Both CAP and TAB SA formulations are formulary sites can choose
Oct-06 MS300 DELETE MIVACURIUM CHLORIDE INJ,SOLN No longer manufactured
Additions 2 Deletion 1
Nov-06 CN400 LEVETIRACETAM INJ,SOLN
Nov-06 GU900 SEVELAMER TAB
Nov-06 AM900 R LEVOFLOXACIN INJ,SOLN http://www.pbm.va.gov/reviews/fluoroquinolones.pdf
Nov-06 AM900 R LINEZOLID PWDR,RENST-ORAL
Nov-06 CN609 BUPROPION HCL TAB,SA (12HR)
Nov-06 VT101 CYANOCOBALAMIN TAB
Nov-06 DE102 KETOCONAZOLE SHAMPOO
Nov-06 DE102 NYSTATIN CREAM,TOP
Nov-06 BL116 THROMBIN POWDER,TOP
Additions 9 Deletion 0
Dec-06 GU900 Delete PARAGARD T (Cu380A) IUD IUD's not dispensed by pharmacy.
AM800 R ENTECAVIR TAB
Dec-06 Restricted to GI and ID
AM800 R ENTECAVIR SOLN,ORAL
Dec-06 Restricted to GI and ID
OP900 * RANIBIZUMAB INJ,SOLN
Dec-06 Restricted to wet AMD, ophthalmology/retinal specialists
Dec-06 RE105 * TIOTROPIUM CAP,INHL http://www.pbm.va.gov/monograph/23876yTiotropium.pdf
Additions 4 Deletion 1
Aluminum sulfate/calcium acetate (OTC) topical powder remains on the
formulary. Aluminum sulfate/calcium acetate is converted to aluminum acetate
Jan-07 DE900 Delete ALUMINUM ACETATE PWDR,TOP when added to water.
Jan-07 MS200 * BACLOFEN INJ
Jan-07 GA900 * BALSALAZIDE DISODIUM CAP,ORAL
Jan-07 AM116 Delete CEFOTETAN INJ no longer manufactured
Jan-07 CN103 * CLONIDINE HCL INJ
AM800 R DARUNAVIR ETHANOLATE TAB
Jan-07 Restricted to ID specialist in compliance with national criteria for use
Jan-07 AM800 Delete DIDANOSINE TAB,CHEWABLE no longer manufactured
Jan-07 RS202 HYDROCORTISONE SUPP,RTL
Jan-07 AM113 Delete TICARCILLIN INJ no longer manufactured
AD900 * VARENICLINE TARTRATE TAB
Jan-07 Restricted to the VA/DoD Tobacco Use Cessation Clinical Practice Guidelines
Additions 6 Deletion 4
Apr-07 OP900 * CHONDROITIN/HYALURONATE INJ,OPH
Apr-07 CN601 CLOMIPRAMINE CAP,ORAL
HS200 ETHINYL ESTRADIOL 35MCG/NORGESTIMATE 25MCG,28 TAB http://www.pbm.va.gov/reviews/CombinHT.pdf
Apr-07 (MONO) (EQV-MONONESSA)
HS200 ETHINYL ESTRADIOL/NORGESTIMATE,28 (TRI) (EQV- TAB http://www.pbm.va.gov/reviews/CombinHT.pdf
Apr-07 TRINESSA)
Apr-07 IM900 IMIQUIMOD CREAM,TOP
Apr-07 HS501 Delete INSULIN HUMAN ULTRALENTE 100U/ML (OTC) INJ,SUSP No longer manufactured
Apr-07 NT300 Delete LIDOCAINE HCL 2% SOLN,ORAL No longer manufactured
Apr-07 TN200 Delete NUTRITION SUPL ISOSOURCE STANDARD (OTC) LIQUID,ORAL Replaced with Nutren and Jevity
Apr-07 TN200 * NUTRITION SUPL JEVITY 1.0 CAL (OTC) LIQUID,ORAL
Apr-07 TN200 * NUTRITION SUPL NUTREN 1.0 (OTC) LIQUID,ORAL
Apr-07 GA605 * ONDANSETRON INJ,SOLN http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf
Apr-07 OP400 POVIDONE IODINE SOLN,OPH
Apr-07 OP700 PROPARACAINE SOLN,OPH
Additions 10 Deletion 3
May-07 AD600 ACETYLCYSTEINE INJ,SOLN
May-07 BL116 AMINOCAPROIC ACID TAB
May-07 CN103 ASPIRIN SUPP,RTL
May-07 CV100 BISOPROLOL TAB
May-07 OP900 CHONDROITIN/HYALURONATE INJ
May-07 AM900 Delete CLOFAZIMINE CAP,ORAL No longer manufactured
May-07 OP600 CYCLOPENTOLATE/PHENYLEPHRINE SOLN,OPH
May-07 OP600 DEXTRAN 70/HYPROMELLOSE (EQV OCUCOAT) SOLN,OPH
May-07 CV800 ENALAPRILAT INJ,SOLN
May-07 VT504 Delete ERGOCALCIFEROL INJ No longer manufactured
May-07 RS202 Delete HYDROCORTISONE SUPP,RTL
May-07 AH105 HYDROXYZINE SYRUP
May-07 MS102 IBUPROFEN SUSP
May-07 IM600 MYCOPHENOLATE MOFETIL INJ,LYPHL
May-07 IM600 MYCOPHENOLIC ACID TAB,EC
May-07 CN609 Delete NEFAZODONE TAB
May-07 AM600 R NITROFURANTOIN MONOHYDRATE/MACROCRYSTALLINE CAP,SA
May-07 TN200 * NUTRITION SUPL JEVITY (1.0, 1.2, 1.5 CAL) LIQUID,ORAL Edited to include 1.2 and 1.5 Cal cans
May-07 TN200 * NUTRITION SUPL NUTREN (1.0, 1.5) LIQUID,ORAL Edited to include 1.5 cans
IM100 PAPILLOMAVIRUS HUMAN INJ,SOLN http://www.pbm.va.gov/criteria/Quadrivalent%20HPV%20Vacci
May-07 ne%20(Gardasil).pdf
May-07 CN301 PHENOBARBITAL INJ
May-07 GA302 SUCRALFATE SUSP,ORAL
May-07 AM650 SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP
May-07 AM800 Delete ZALCITABINE (ddC) TAB No longer manufactured
Additions 15 Deletion 5
Jun-07 AM800 R ADEFOVIR TAB Restricted to GI and ID
Jun-07 BL400 ANAGRELIDE CAP,ORAL
Jun-07 BL110 ARGATROBAN INJ,SOLN
Jun-07 RE302 BENZONATATE CAP,ORAL
Jun-07 CN204 BUPIVACAINE/DEXTROSE INJ,SOLN
Jun-07 CN204 BUPIVACAINE/EPINEPHRINE INJ,SOLN
Jun-07 DE820 DELETE CALCIPOTRIENE 0.005% OINT,TOP No longer manufactured
Jun-07 DE820 * CALCIPOTRIENE 0.005% CREAM,TOP
Jun-07 AM900 R DAPTOMYCIN INJ,LYPHL Restricted to ID
Jun-07 RE102 DELETE LEVALBUTEROL INHL,ORAL
Jun-07 AM600 DELETE NITROFURANTOIN MACROCRYSTAL CAP,ORAL Use NITROFURANTOIN MONOHYDRATE/MACROCRYSTALLINE
Jun-07 GA202 POLYETHYLENE GLYCOL 3350 (PEG-3350) POWDER,ORAL
Jun-07 CN602 * SELEGILINE PATCH Restricted to psychiatry/mental health providers
Jun-07 CN900 DELETE TACRINE HCL CAP,ORAL
Additions 10 Deletion 4
Aug-07 AN900 * ANASTROZOLE TAB
Aug-07 OP900 KETOTIFEN SOLN,OPH
Aug-07 AN900 * LETROZOLE TAB
Aug-07 TN200 * NUTRITION SUPL JEVITY (1.0 CAL) LIQUID,NUTRITIONAL SUPPLEMENT Jevity 1 cal is the national contract list. Jevity 1.2 and 1.5 were removed from
Aug-07 CN309 ZOLPIDEM TAB the formulary to match the national contract
Additions 4 Deletion 0
Sep-07 CV350 Delete FLUVASTATIN TAB,SA Replaced with Pravastatin
Sep-07 CV350 Delete FLUVASTATIN CAP,ORAL Replaced with Pravastatin
Sep-07 AM700 * MICAFUNGIN INJ,LYPHL http://www.pbm.va.gov/monograph/Micafungin.pdf
Sep-07 CN500 Delete PERGOLIDE MESYLATE TAB No longer manufactured
Sep-07 CV350 * PRAVASTATIN TAB
Sep-07 CN105 * ZOLMITRIPTAN TAB,ORAL DISINTEGRATING
CN500 DELETE PRAMIPEXOLE TAB http://www.pbm.va.gov/criteria/Parkinson.pdf Restricted to neurology service
Sep-07
Sep-07 CN500 * ROPINIROLE TAB http://www.pbm.va.gov/criteria/Parkinson.pdf
Additions 3 Deletion 3
DE810 Delete COAL TAR/SALICYLIC ACID/SULFUR CREAM This product is actually a cream rinse in NDF. However only the shampoo is
marketed. The shampoo is already formulary. Since a shampoo and cream
rinse are equivalent the cream rinse was removed.
Oct-07
Oct-07 HS502 Delete ROSIGLITAZONE ORAL TAB
Additions 0 Deletion 2
DE102 Delete BASIC FUCHIN /BORIC ACID/RESORCINOL/ACETONE TOP LIQUID,TOP No longer manufactured
Dec-07 (OTC)
Dec-07 DE900 Delete GLYCERIN/MINERAL OIL/PHENOL LIQUID,TOP P&S liquid changed their formula to salicylic acid 2%.
Dec-07 HS200 LEVONORGESTREL (EQV. PLAN B) TAB
AM800 * MARAVIROC TAB Restricted ID practitioners or providers that provide care to HIV patients
Dec-07
Dec-07 XA101 Delete PADS,GAUZE,STERILE SUPPLY Duplicate of GAUZE PADS STERILE
CV300 Delete PROCAINAMIDE 12 HOUR SUSTAINED ACTION TAB,SA No longer manufactured (All procainamide products are being removed from
Dec-07 the market)
Dec-07 GU300 Delete TRIPLE SULFA CREAM,VAG No longer manufactured
Dec-07 OP900 TRYPAN BLUE SOLN,OPH
Dec-07 DE350 UREA CREAM,TOP
Dec-07 DE350 UREA CREAM/EMULSION,TOP
Dec-07 DE350 UREA LOTION,TOP
Dec-07 DE350 UREA LOTION/SUSPENSION,TOP
Additions 6 Deletion 7
Jan-08 AM800 * RALTEGRAVIR TAB Restricted to ID providers or providers that provide care to HIV patients.
Jan-08 IM100 ZOSTER VACCINE INJ,LYPHL http://www.pbm.va.gov/criteria/Zoster%20Vaccine%20Criteria
Jan-08 CN709 ARIPIPRAZOLE INJ,SOLN
Additions 3 Deletion 0
Apr-08 AM116 R CEFOTETAN INJ
AM800 R ETRAVIRINE TAB Restricted ID Practitioners or providers that provide care to HIV patients
Apr-08
Apr-08 HS502 INSULIN LONG ACTING ANALOG INJ,SOLN http://www.oqp.med.va.gov/cpg/DM/DM_base.htm
Apr-08 IM700 NATALIZUMAB INJ,SOLN Restricted to neurology or practitioners who treat multiple sclerosis patients.
Additions 4 Deletion 0
Jun-08 XA104 BANDAGE,ADHESIVE (1IN X 3IN) (PLASTIC, FABRIC) BANDAGE
Jun-08 AM117 R CEFIXIME TAB
Jun-08 TN478 CITRIC ACID/POTASSIUM CITRATE SOLN,ORAL
Jun-08 TN478 CITRIC ACID/POTASSIUM CITRATE POWDER,ORAL
Jun-08 BL110 FONDAPARINUX INJ,SOLN http://www.pbm.va.gov/criteria/fondaparinux.pdf
Jun-08 IM500 HEPATITIS B IMMUNE GLOBULIN INJ
Jun-08 IM500 DELETE HEPATITIS B IMMUNE GLOBULIN (IM) INJ
Jun-08 DE650 DELETE MENTHOL 2%/METHYL SALICYLATE 10% (OTC) CREAM,TOP
Jun-08 DE650 MENTHOL/METHYL SALICYLATE 10-15% (LOW CONC) CREAM,TOP
Jun-08 DE650 MENTHOL/METHYL SALICYLATE 16-30% (HIGH CONC) CREAM,TOP
Jun-08 TN430 POTASSIUM BICARBONATE TAB,EFFERVSC
Jun-08 RE102 VITAMIN D (CHOLECALCIFEROL OR ERGOCALCIFEROL 400 IU
SALMETEROL INHL,ORAL
Jun-08 VT504 to 2000 IU) CAP OR TAB For use as a vitamin supplement
Jun-08 VT504 DELETE D HIGH
VITAMIN D,(OTC) DOSE (CHOLECALCIFEROL OR CAP,ORAL
Jun-08 VT504 ERGOCALCIFEROL 50,000 IU) CAP OR TAB Not a vitamin supplement, restricted to 9 doses per 30 day supply
Additions 12 Deletion 2
Aug-08 BL116 DELETE APROTININ INJ,SOLN No longer manufactured
Aug-08 AN105 CETIRIZINE TAB
Aug-08 MS400 DELETE COLCHICINE INJ No longer manufactured
Aug-08 GA900 MESALAMINE TAB,EC
Aug-08 GA900 DELETE MESALAMINE TAB,SA Mesalamine tablets are only available in enteric coated tablets. This is a
Aug-08 DE900 PAPAIN/UREA SPRAY,TOP correction to the VANF and not a change in the product.
Aug-08 HS900 DELETE ZOLEDRONIC INJ,PWDR The dosage form was changed to INJ,SOLN. This is a correction to the VANF
Aug-08 HS900 ZOLEDRONIC INJ,SOLN and not a change in the product.
Additions 4 Deletion 4
Oct-08 GA605 APREPITANT CAP,ORAL
Oct-08 XA104 BANDAGE,ADHESIVE FLEXIBLE FABRIC 2IN X 3-1/2IN BANDAGE
Oct-08 DE101 CADEXOMER IODINE GEL,TOP
Oct-08 XA199 DRESSING,PROFORE-LF 4-LAYER SN#66020626 DRESSING,PROFORE
Oct-08 XA109 KERLIX 4.5IN STERILE BANDAGE,GAUZE
Oct-08 XA101 KERLIX SUPER SPONGE MEDIUM STERILE SUPPLY
Oct-08 GA208 LACTOBACILLUS (OTC) CAP,ORAL
Oct-08 AM550 R METHENAMINE TAB
Oct-08 AM550 Delete METHENAMINE MANDELATE TAB
OR100 SODIUM FLUORIDE (1.1%) CREAM,ORAL Restrict to Dental according to risk category algorithm in
information letter (recommendations for use of fluorides in
Oct-08 medical management of dental caries)
OR100 SODIUM FLUORIDE (1.1%) GEL,DENT Restricted to Dental for use in patients with head / neck cancer
or with custom made trays according to risk category algorithm
Oct-08 in information letter
OR100 SODIUM FLUORIDE (5%) VARNISH,DENT Restrict to Dental according to risk category algorithm in
information letter (recommendations for use of fluorides in
Oct-08 medical management of dental caries)
Oct-08 OR100 Delete STANNOUS FLUORIDE FOAM,DENT Replaced with Sodium Fluoride products
Oct-08 OR100 Delete STANNOUS FLUORIDE GEL,DENT Replaced with Sodium Fluoride products
Oct-08 OR100 Delete STANNOUS FLUORIDE LIQUID,DENT Replaced with Sodium Fluoride products
Oct-08 OR100 Delete STANNOUS FLUORIDE VARNISH,DENT Replaced with Sodium Fluoride products
Oct-08 BL110 Delete WARFARIN NA (COUMADIN) INJ
Additions 11 Deletion 6
Totals 354 206
Reference
http://www.pbm.va.gov/tig/DepakotTIG. http://ww http://ww
pdf w.pbm.va. w.pbm.va.
http://vaww.pbm.va.gov/archive/fluoroquinolones http://vaww.
review.pdf pbm.va.gov/
http://vaww.pbm.va.gov/drugmonograph/BUPMo http://vaww.
nograph%20(Rev%2009Jun03).pdf pbm.va.gov/
Removed from formulary
Changed to capsule formulation
http://www.pbm.va.gov/monograph/Entecavir,%2
0Monograph.pdf
http://www.pbm.va.gov/monograph/Entecavir,%2
0Monograph.pdf
http://www.pbm.va.gov/monograph/Ranibizumab
,%20Monograph.pdf
http://www.hiv.va.gov/vahiv?page=cm-
1002_tables&
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