VA National Formulary - Pharmacy Benefits Management Services

DEPARTMENT OF VETERANS AFFAIRS

PHARMACY BENEFITS MANAGEMENT STRATEGIC HEALTH GROUP

http://www.pbm.va.gov/

http://vaww.pbm.va.gov

VHA NATIONAL FORMULARY

Oct-10









The VANF is dosage form specific. If a specific dosage form is not listed, the specific product in question should be considered non-formulary (although other dosage

Dosage forms such as TAB and CAP, ORAL are considered immediate release. Sustained release products are listed individually. Formulary products may also be a

products with multiple dosage forms and strengths, not all forms and strengths need to be stocked. Facilities should make those dosages available that are necessary









R The national restriction for antibiotics is that all decisions regarding which agents to carry in these classes will be made at the local or VISN level. These decisions should be based on local c

otherwise noted.









VA Restriction Generic Dosage Form

Class

DE350 A & D OINT (OTC) TOP,OINT

AM800 R ABACAVIR SOLN,ORAL

AM800 R ABACAVIR TAB

AM800 R ABACAVIR/LAMIVUDINE TAB

AM800 R ABACAVIR/LAMIVUDINE/ZIDOVUDINE TAB

BL117 ABCIXIMAB INJ,SOLN







HS502 ACARBOSE TAB

CN103 ACETAMINOPHEN LIQUID,ORAL

CN103 ACETAMINOPHEN SUPP,RTL

CN103 ACETAMINOPHEN TAB

CN103 ACETAMINOPHEN/BUTALBITAL/CAFFEINE TAB

CN101 ACETAMINOPHEN/HYDROCODONE LIQUID,ORAL

CN101 ACETAMINOPHEN/HYDROCODONE TAB

CN101 ACETAMINOPHEN/OXYCODONE HCL CAP,ORAL







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CN101 ACETAMINOPHEN/OXYCODONE HCL LIQUID,ORAL

CN101 ACETAMINOPHEN/OXYCODONE HCL TAB

CV703 ACETAZOLAMIDE INJ

CV703 ACETAZOLAMIDE TAB

IR100 ACETIC ACID SOLN,IRRG

OT109 ACETIC ACID/ALUMINUM ACETATE SOLN,OTIC

DE102 ACETONE/BASIC FUCHSIN/BORIC ACID/RESORCINOL LIQUID,TOP

OP102 ACETYLCHOLINE CHLORIDE SOLN,OPH

AD600 ACETYLCYSTEINE INJ,SOLN

RE400 ACETYLCYSTEINE SOLN,INHL/ORAL

DE810 ACITRETIN CAP,ORAL

AM800 R ACYCLOVIR CAP,ORAL

AM800 R ACYCLOVIR INJ

AM800 R ACYCLOVIR TAB

DE103 ACYCLOVIR OINT,TOP

AM800 R ADEFOVIR TAB

CV300 ADENOSINE INJ,SOLN

XA603 ADHESIVE AEROSOL SPRAY,TOP

XA603 ADHESIVE CEMENT LIQUID,TOP

XA699 ADHESIVE REMOVER LIQUID,TOP

AP200 ALBENDAZOLE TAB

BL500 ALBUMIN,HUMAN INJ

RE102 ALBUTEROL INHALANT

RE102 ALBUTEROL SOLN,INHL

RE103 ALBUTEROL TAB

RE109 ALBUTEROL/IPRATROPIUM INHL,ORAL

RE109 ALBUTEROL/IPRATROPIUM INHL,SOLN

DE101 ALCOHOL ISOPROPYL 70% LIQUID,TOP

TN900 ALCOHOL, ABSOLUTE INJ,SOLN

TN101 ALCOHOL/DEXTROSE INJ

IM700 ALDESLEUKIN INJ

HS900 ALENDRONATE TAB

CN101 ALFENTANIL HCL INJ,SOLN

GA199 ALGINIC AC/NA BICARB/CA STEAR/MG TRI (OTC) TAB,CHEWABLE

IM900 ALLERGENIC EXTRACT (VARIOUS) INJ,SOLN

MS400 ALLOPURINOL TAB

GA199 ALOH/MG CARB/NA ALGINATE (OTC) TAB

GA199 ALOH/MGOH/SIMTH (OTC) LIQUID,ORAL

CN302 ALPRAZOLAM TAB

HS875 ALPROSTADIL INJ





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HS875 ALPROSTADIL URETHRAL SUPPOSITORY

BL115 ALTEPLASE, RECOMBINANT INJ,PWDR

DE450 ALUMINUM CHLORIDE (HEXAHYDRATE) SOLN,TOP

GA101 ALUMINUM HYDROXIDE CAP,ORAL

GA101 ALUMINUM HYDROXIDE LIQUID,ORAL

DE900 ALUMINUM SULFATE/CALCIUM ACETATE (OTC) POWDER,TOP

AM800 R AMANTADINE HCL CAP,ORAL

AM800 R AMANTADINE HCL SYRUP

AM300 R AMIKACIN SULFATE INJ,SOLN

TN501 AMINO ACIDS INJ,SOLN

TN501 AMINO ACIDS/DEXTROSE INJ,SOLN

BL116 AMINOCAPROIC ACID INJ,SOLN

BL116 AMINOCAPROIC ACID TAB

RE104 AMINOPHYLLINE DIHYDRATE INJ,SOLN

CV300 AMIODARONE INJ,SOLN

CV300 AMIODARONE TAB

CN601 AMITRIPTYLINE HCL TAB

CV200 AMLODIPINE TAB









RE900 AMMONIA,AROMATIC INHL,NASAL

TN499 AMMONIUM CHLORIDE INJ,SOLN

DE350 AMMONIUM LACTATE CREAM

DE350 AMMONIUM LACTATE LOTION

AM111 R AMOXICILLIN CAP,ORAL

AM111 R AMOXICILLIN PWDR,RENST-ORAL

AM111 R AMOXICILLIN/CLAVULANATE K PWDR,RENST-ORAL

AM111 R AMOXICILLIN/CLAVULANATE K TAB

AM700 R AMPHOTERICIN B INJ

AM700 R AMPHOTERICIN B LIPID COMPLEX INJ

AM111 R AMPICILLIN NA INJ

AM111 R AMPICILLIN NA/SULBACTAM NA INJ

CV250 AMYL NITRITE INHALANT

BL400 ANAGRELIDE CAP,ORAL

AN900 ANASTROZOLE TAB

DE820 ANTHRALIN CREAM,TOP

BL500 ANTIHEMOPHILIC FACTOR,HUMAN INJ

OT400 ANTIPYRINE/BENZOCAINE/GLYCERIN OTIC SOLN,OTIC

IM900 ANTI-THYMOCYTE GLOBULIN INJ,PWDR





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IM900 ANTI-THYMOCYTE GLOBULIN INJ,SOLN

IM300 ANTIVENIN,CROTALIDAE POLYVALENT INJ

CN500 APOMORPHINE INJ,SOLN





XA900 APPLIANCE CLEANSING SUPPLIES SUPPLY

OP900 APRACLONIDINE HCL SOLN,OPH

GA605 APREPITANT CAP,ORAL









BL110 ARGATROBAN INJ,SOLN









CN709 ARIPIPRAZOLE INJ,SOLN

CN709 ARIPIPRAZOLE TAB









OR500 ARTIFICIAL SALIVA (OTC) SOLN,ORAL

OP500 ARTIFICIAL TEARS METHYLCELLULOSE (OTC) SOLN,OPH

OP500 ARTIFICIAL TEARS POLYVINYL ALCOHOL (PF) (OTC) SOLN,OPH

OP500 ARTIFICIAL TEARS SOLN (OTC) SOLN,OPH

VT400 ASCORBIC ACID INJ INJ,SOLN

VT400 ASCORBIC ACID ORAL (OTC) TAB

AN900 ASPARAGINASE INJ

CN103 ASPIRIN SUPP,RTL

CN103 ASPIRIN (OTC) TAB

CN103 ASPIRIN (OTC) TAB,CHEWABLE

CN103 ASPIRIN (OTC) TAB,EC

CN103 ASPIRIN BUFFERED (OTC) TAB

CN103 ASPIRIN/BUTALBITAL/CAFFEINE CAP,ORAL

CN103 ASPIRIN/BUTALBITAL/CAFFEINE TAB

BL117 ASPIRIN/DIPYRIDAMOLE CAP,SA

AM800 R ATAZANIVIR CAP,ORAL









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CV100 ATENOLOL INJ

CV100 ATENOLOL TAB

CV400 ATENOLOL/CHLORTHALIDONE TAB

AP109 ATOVAQUONE SUSP

MS300 ATRACURIUM INJ

AU350 ATROPINE SO4 INJ,SOLN

GA208 ATROPINE SO4 /DIPHENOXYLATE HCL ORAL TAB

OP600 ATROPINE SULFATE OINT,OPH

OP600 ATROPINE SULFATE SOLN,OPH

MS160 AURANOFIN CAP,ORAL

MS160 AUROTHIOGLUCOSE INJ,SUSP

AN300 AZACITIDINE INJ,SUSP





IM600 AZATHIOPRINE INJ,SOLN

IM600 AZATHIOPRINE TAB

AM200 R AZITHROMYCIN INJ,PWDR

AM200 R AZITHROMYCIN PWDR,RENST-ORAL

AM200 R AZITHROMYCIN TAB

AM119 R AZTREONAM INJ

AM900 R BACITRACIN INJ

DE101 BACITRACIN (OTC) OINT,TOP

DE109 BACITRACIN 500/POLYMYXIN 10000U/GM (OTC) OINT,TOP

DE109 BACITRACIN 500/POLYMYXIN 10000U/GM (OTC) POWDER,TOP

OP350 BACITRACIN/HC /NEO/POLYMYX OINT,OPH

OP219 BACITRACIN/NEOMYCIN/POLYMYXIN OINT,OPH

OP219 BACITRACIN/POLYMYXIN OINT,OPH

MS200 BACLOFEN INJ

MS200 BACLOFEN TAB

XA501 BAG BEDSIDE URINARY BAG SUPPLY

XA799 BAG FEEDING W/TUBE SUPPLY

XA607 BAG IRRIGATOR W/CONE SUPPLY

XA508 BAG LEG DISPOSABLE SUPPLY

XA508 BAG LEG DISPOSABLE, FLIP-FLOW SUPPLY

XA508 BAG LEG REUSABLE SUPPLY

XA508 BAG LEG REUSABLE W/VALVE SUPPLY

GA900 BALSALAZIDE DISODIUM CAP,ORAL

DE900 BALSAM PERU/CASTOR OIL/TRYPSIN AEROSOL,TOP

XA108 BANDAGE ELASTIC SUPPLY

XA108 BANDAGE ELASTIC ADHESIVE SUPPLY

XA109 BANDAGE TUBULAR ELASTIC SUPPLY





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XA104 BANDAGE,ADHESIVE (1IN X 3IN) (PLASTIC, FABRIC) BANDAGE

XA104 BANDAGE,ADHESIVE FLEXIBLE FABRIC 2IN X 3-1/2IN BANDAGE

XA604 BARRIER OSTOMY TWO-PIECE FLANGE SIZE 1 1/2" - 4" SUPPLY

IM600 BASILIXIMAB INJ

DE350 BATH OIL (OTC) OIL,TOP

IM100 BCG VACCINE INJ

AN900 BCG,TICE VACCINE INJ,LYPHL

CN101 BELLADONA/OPIUM SUPP,RTL

XA605 BELT OSTOMY SUPPLY







CV800 BENAZEPRIL TAB

OP900 BENOXINATE HCL/FLUORESCEIN NA SOLN,OPH

OP900 BENZALKONIUM CHLORIDE/TYLOXAPOL OPH SOLN (OTC) SOLN,OPH

NT300 BENZOCAINE (OTC) GEL,DENT

XA604 BENZOIN TINCTURE,TOP

DE900 BENZOIN COMPOUND 30%/ISOPROPYL ALCOHOL 44.8% SPRAY (OTC) LIQUID,AEROSOL

RE302 BENZONATATE CAP,ORAL

DE752 BENZOYL PEROXIDE GEL,TOP

DE752 BENZOYL PEROXIDE LOTION

DE752 BENZOYL PEROXIDE 5%/ERYTHROMYCIN 3% TOP GEL GEL,TOP

AU350 BENZTROPINE MESYLATE INJ

AU350 BENZTROPINE MESYLATE TAB

DE200 BETAMETHASONE DIPROPIONATE CREAM,TOP

DE200 BETAMETHASONE DIPROPIONATE OINT,TOP

DE200 BETAMETHASONE VALERATE CREAM,TOP

DE200 BETAMETHASONE VALERATE LOTION,TOP

DE200 BETAMETHASONE VALERATE OINT,TOP

OP101 BETAXOLOL SOLN,OPH

OP101 BETAXOLOL SUSP,OPH

AU300 BETHANECHOL CHLORIDE INJ

AU300 BETHANECHOL CHLORIDE TAB

AN900 BEVACIZUMAB INJ,SOLN







AN900 BICALUTAMIDE TAB

RS300 BISACODYL ENEMA,RTL

GA204 BISACODYL (OTC) TAB,EC

RS300 BISACODYL (OTC) SUPP,RTL

GA208 BISMUTH SUBSALICYLATE SUSP,ORAL





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GA208 BISMUTH SUBSALICYLATE TAB,CHEWABLE

CV100 BISOPROLOL TAB









BL110 BIVALIRUDIN INJ,PWDR

AN200 BLEOMYCIN SO4 INJ,SOLN

DX900 BLOOD GLUCOSE MONITORING DEVICE

DX900 BLOOD GLUCOSE MONITORING TEST SOLUTION

DX900 BLOOD GLUCOSE MONITORING TEST STRIP

AN900 BORTEZOMIB INJ,PWDR









XA502 BOTTLES/OTHER BEDSIDE URINARY COLLECTION DEVICES SUPPLY

IM300 BOTULISM ANTITOXIN INJ,SOLN

XA900 BOWEL MANAGEMENT TOOL SUPPLY

XA305 BRIEF/PANT INCONTINENCE MALE SUPPLY

OP109 BRIMONIDINE TARTRATE SOLN,OPH

AU900 BROMOCRIPTINE MESYLATE CAP,ORAL





AU900 BROMOCRIPTINE MESYLATE TAB





CV702 BUMETANIDE INJ







CV702 BUMETANIDE TAB







CN204 BUPIVACAINE HCL INJ,SOLN

CN204 BUPIVACAINE/DEXTROSE INJ,SOLN

CN204 BUPIVACAINE/EPINEPHRINE INJ,SOLN

CN101 BUPRENORPHINE TAB,SUBLINGUAL







CN101 BUPRENORPHINE/NALOXONE TAB,SUBLINGUAL









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CN609 BUPROPION HCL TAB

CN609 BUPROPION HCL TAB,SA (12HR)

CN309 BUSPIRONE HCL TAB

AN100 BUSULFAN INJ

AN100 BUSULFAN TAB

CN101 BUTORPHANOL TARTRATE INJ,SOLN

DE101 CADEXOMER IODINE GEL,TOP

CN105 CAFFEINE/ERGOTAMINE SUPP,RTL

CN105 CAFFEINE/ERGOTAMINE TAB

CN809 CAFFEINE/SODIUM BENZOATE INJ

DE900 CALAMINE (OTC) LOTION

DE820 CALCIPOTRIENE 0.005% CREAM,TOP

HS900 CALCITONIN SOLN,NASAL

HS900 CALCITONIN INJ,SOLN

DE820 CALCITRIOL OINT,TOP







VT502 CALCITRIOL CAP,ORAL

VT502 CALCITRIOL INJ,SOLN

TN420 CALCIUM ACETATE CAP,ORAL

TN420 CALCIUM CARBONATE (OTC) TAB

TN420 CALCIUM CARBONATE (OTC) TAB,CHEWABLE

TN420 CALCIUM CHLORIDE INJ,SOLN

TN420 CALCIUM GLUCONATE INJ,SOLN

VT802 CALCIUM/VITAMIN D (OTC) TAB

DE900 CAMPHOR 0.5%/MENTHOL 0.5% LOTION

DX300 CANDIDA 1:100 SKIN TEST INJ

AM500 R CAPREOMYCIN INJ INJ

DE650 CAPSAICIN CREAM,TOP

CV800 CAPTOPRIL TAB







OP102 CARBACHOL SOLN,OPH

CN400 CARBAMAZEPINE SUSP,ORAL

CN400 CARBAMAZEPINE TAB

CN400 CARBAMAZEPINE TAB,CHEWABLE

OT300 CARBAMIDE PEROXIDE/GLYCERIN (OTC) SOLN,OTIC

CN500 CARBIDOPA /LEVODOPA TAB,SA

CN500 CARBIDOPA/LEVODOPA TAB

AN900 CARBOPLATIN INJ INJ





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AN100 CARMUSTINE INJ,SOLN

DE900 CARRAKLENZ SKIN & WOUND CLEANSER (OTC) SPRAY,TOP

DE900 CARRINGTON (OTC) GEL,TOP

DE900 CARRINGTON DRESSING (OTC) SPRAY,TOP

CV100 CARVEDILOL TAB









DE102 CASTELLANI PAINT (OTC) TINCTURE,TOP

GA204 CASTOR OIL EMULSION

XA513 CATHETER EXTERNAL W/ADHESIVE LATEX SUPPLY

XA513 CATHETER EXTERNAL W/ADHESIVE NON-LATEX SUPPLY

XA509 CATHETER STRAIGHT BALLOON 30CC SUPPLY

XA509 CATHETER STRAIGHT BALLOON 5CC SUPPLY

XA512 CATHETER STRAIGHT RUBBER SUPPLY

XA512 CATHETER STRAIGHT SILICONE SUPPLY

XA900 CATHETER SUCTION 14FR SUPPLY

XA510 CATHETER,COUDE-TIP SUPPLY

XA513 CATHETER,EXTERNAL URINARY SUPPLY

XA512 CATHETER,RED RUBBER SUPPLY

XA599 CATHETERIZATION TRAY W/CATHETER SUPPLY

XA599 CATHETERIZATION TRAY W/O CATHETER SUPPLY

AM116 R CEFACLOR CAP,ORAL

AM115 R CEFAZOLIN INJ

AM118 R CEFEPIME INJ,PWDR

AM117 R CEFIXIME TAB

AM117 R CEFOTAXIME INJ

AM116 R CEFOTETAN INJ

AM116 R CEFOXITIN NA INJ

AM116 R CEFPODOXIME PROXETIL TAB

AM117 R CEFTAZIDIME INJ

AM117 R CEFTIZOXIME INJ

AM117 R CEFTRIAXONE NA INJ

AM116 R CEFUROXIME AXETIL TAB

GA201 CELLULOSE,OXIDIZED POWDER,ORAL

AM115 R CEPHALEXIN CAP OR TAB

AN105 CETIRIZINE TAB

AD900 CHARCOAL ACTIVATED (OTC) LIQUID

AD900 CHARCOAL ACTIVATED IN SORBITOL (OTC) LIQUID

CN309 CHLORAL HYDRATE CAP,ORAL





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CN309 CHLORAL HYDRATE SYRUP

AN100 CHLORAMBUCIL TAB

AM150 R CHLORAMPHENICOL INJ,SOLN

OP210 CHLORAMPHENICOL SOLN,OPH

CN302 CHLORDIAZEPOXIDE HCL CAP,ORAL

OR500 CHLORHEXIDINE GLUCONATE MOUTHWASH

DE101 CHLORHEXIDINE GLUCONATE (OTC) LIQUID,TOP

DE101 CHLORHEXIDINE GLUCONATE (OTC) SURGICAL SCRUB

CN204 CHLOROPROCAINE HCL INJ,SOLN

AH104 CHLORPHENIRAMINE MALEATE (OTC) CAP,SA

AH104 CHLORPHENIRAMINE MALEATE (OTC) TAB

AH104 CHLORPHENIRAMINE MALEATE (OTC) TAB,SA

CN701 CHLORPROMAZINE SOLN,ORAL

CN701 CHLORPROMAZINE TAB

CN701 CHLORPROMAZINE INJ,SOLN

CV701 CHLORTHALIDONE TAB





CV350 CHOLESTYRAMINE POWDER,ORAL

OP900 CHONDROITIN/HYALURONATE INJ

OP900 CHONDROITIN/HYALURONATE INJ,OPH

TN499 CHROMIUM INJ

AM800 R CIDOFOVIR INJ

GA301 CIMETIDINE LIQUID,ORAL

GA301 CIMETIDINE TAB

GA301 CIMETIDINE HCL INJ,SOLN

AM900 R CIPROFLOXACIN INJ,SOLN

AM900 R CIPROFLOXACIN HCL TAB

OP210 CIPROFLOXACIN HCL SOLN,OPH

MS300 CISATRACURIUM INJ

AN900 CISPLATIN INJ,SOLN

CN609 CITALOPRAM HYDROBROMIDE SOLN,ORAL

CN609 CITALOPRAM HYDROBROMIDE TAB

IR100 CITRIC ACID/GLUCONO-DELTA/LACTONE/MAGNESIUM CARBONATE SOLN,IRRG

TN478 CITRIC ACID/K CITRATE/NA CITRATE SYRUP

IR100 CITRIC ACID/MAGNESIUM OXIDE/SODIUM CARBONATE SOLN,IRRG

TN478 CITRIC ACID/NA CITRATE SOLN,ORAL

TN478 CITRIC ACID/POTASSIUM CITRATE SOLN,ORAL

TN478 CITRIC ACID/POTASSIUM CITRATE POWDER,ORAL

AN300 CLADRIBINE INJ

XA699 CLAMP BAG SUPPLY





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XA599 CLAMP CUNNINGHAM REGULAR SUPPLY

AM200 R CLARITHROMYCIN TAB

AM350 R CLINDAMYCIN CAP,ORAL

AM350 R CLINDAMYCIN PALMITATE SOLN GRNL,RCNST-ORAL

DE752 CLINDAMYCIN PHOSPHATE SOLN,TOP

GU300 CLINDAMYCIN PHOSPHATE CREAM,VAG

AM350 R CLINDAMYCIN PHOSPHATE INJ,SOLN

DE200 CLOBETASOL CREAM,TOP

DE200 CLOBETASOL OINT,TOP

DE200 CLOBETASOL SOLN,TOP

HS400 CLOMIPHENE TAB

CN601 CLOMIPRAMINE CAP,ORAL

CN400 CLONAZEPAM TAB

CV490 CLONIDINE PATCH





CN103 CLONIDINE HCL INJ

CV490 CLONIDINE HCL TAB





BL117 CLOPIDOGREL BISULFATE TAB





NT900 CLOTRIMAZOLE TROCHE

GU300 CLOTRIMAZOLE (OTC) CREAM,VAG

DE102 CLOTRIMAZOLE 1% CREAM,TOP

DE102 CLOTRIMAZOLE 1% LOTION,TOP

DE102 CLOTRIMAZOLE 1% TOP,SOLN

CN709 CLOZAPINE TAB







DE820 COAL TAR EMULSION,TOP

DE820 COAL TAR LIQUID,TOP

DE820 COAL TAR LOTION,TOP

DE820 COAL TAR OIL,TOP

DE820 COAL TAR OINT,TOP

DE820 COAL TAR SHAMPOO

DE820 COAL TAR SOAP/DETERGENT

DE820 COAL TAR SOLN,TOP

DE820 COAL TAR /SALICYLIC ACID SHAMPOO

DE820 COAL TAR/SALICYLIC ACID/SULFUR SHAMPOO

NT300 COCAINE HCL SOLN,TOP

DX300 COCCIDIODIN 1:100 SKIN TEST INJ





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CN101 CODEINE TAB

CN101 CODEINE/ACETAMINOPHEN ELIXIR

CN101 CODEINE/ACETAMINOPHEN TAB

RE301 CODEINE/GUAIFENESIN LIQUID,ORAL

MS400 COLCHICINE TAB

CV350 COLESTIPOL GRNL,RCNST-ORAL

CV350 COLESTIPOL TAB

DE900 COLLAGENASE OINT,TOP

XA900 CONDOM FEMALE SUPPLY

XA900 CONDOM LATEX LUBRICATED SUPPLY

XA900 CONDOM LATEX PLAIN SUPPLY

HS900 CONJUGATED ESTROGENS/MEDROXYPROGESTERONE (PREMPRO/PREMPHASE) TAB

DX102 CONTRAST MEDIA IONIC INJ

DX101 CONTRAST MEDIA NON-IONIC INJ

XA602 CONVEX INSERT ID 1" - 1 3/8" SUPPLY

TN499 COPPER INJ INJ

HS701 CORTICOTROPIN INJ INJ

DX900 COSYNTROPIN INJ INJ

XA900 COTTON-TIP APPLICATOR STERILE SUPPLY

OP900 CROMOLYN NA OPH SOLN SOLN,OPH

IM900 CROMOLYN SODIUM CAP,ORAL

NT900 CROMOLYN SODIUM SOLN,NASAL

RE109 CROMOLYN SODIUM SOLN,INHL

AD200 CYANIDE ANTIDOTE PACKAGE KIT

VT101 CYANOCOBALAMIN INJ,SOLN

VT101 CYANOCOBALAMIN TAB

MS200 CYCLOBENZAPRINE TAB

OP600 CYCLOPENTOLATE HCL SOLN,OPH

OP600 CYCLOPENTOLATE/PHENYLEPHRINE SOLN,OPH

AN100 CYCLOPHOSPHAMIDE INJ

AN100 CYCLOPHOSPHAMIDE TAB

AM500 R CYCLOSERINE CAP,ORAL

IM599 CYCLOSPORINE CAP,ORAL

IM600 CYCLOSPORINE INJ,SOLN

IM600 CYCLOSPORINE SOLN,ORAL

AH107 CYPROHEPTADINE TAB

AN300 CYTARABINE INJ

IM500 CYTOMEGALOVIRUS IMMUNE GLOBULIN HUMAN INJ

AN900 DACARBAZINE INJ

IM600 DACLIZUMAB INJ





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AN200 DACTINOMYCIN INJ









AM900 R DALFOPRISTIN/QUINUPRISTIN INJ

BL110 DALTEPARIN INJ,SOLN







HS100 DANAZOL CAP,ORAL

MS200 DANTROLENE CAP,ORAL

MS200 DANTROLENE INJ,SOLN

AM900 R DAPSONE TAB

AM900 R DAPTOMYCIN INJ,LYPHL









BL400 DARBEPOETIN ALFA RECOMBINANT W/ALBUMIN INJ,SOLN

AM800 R DARUNAVIR ETHANOLATE TAB









AN200 DAUNORUBICIN INJ,SOLN

AD300 DEFEROXAMINE MESYLATE INJ,SOLN

AM800 R DELAVIRDINE TAB

AM250 R DEMECLOCYCLINE HCL TAB

CN203 DESFLURANE SOLN,INHL

CN601 DESIPRAMINE HCL TAB

HS702 DESMOPRESSIN ACETATE SOLN,SPRAY,NASAL

HS702 DESMOPRESSIN ACETATE INJ,SOLN









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HS200 DESOGESTREL0.15MG/ETHINYL ESTRADIOL 30MCG,28 (MONO) (EQV-RECLIPSEN) TAB







DE200 DESONIDE CREAM,TOP

HS051 DEXAMETHASONE INJ,SUSP

HS051 DEXAMETHASONE INJ,SUSP,SA

HS051 DEXAMETHASONE TAB

HS051 DEXAMETHASONE INJ,SOLN

HS051 DEXAMETHASONE LIQUID,ORAL

OP350 DEXAMETHASONE NA PHOS/NEOMYCIN SOLN,OPH

OP300 DEXAMETHASONE NA PHOSPHATE SOLN,OPH

OP350 DEXAMETHASONE/NEO/POLYMX OINT,OPH

OP350 DEXAMETHASONE/TOBRAMYCIN SUSP,OPH

OP350 DEXAMETHASONE/TOBRAMYCIN OINT,OPH









CN309 DEXMEDETOMIDINE INJ,SOLN

AN700 DEXRAZOXANE INJ

AD900 DEXTRAN 1 INJ,SOLN

BL800 DEXTRAN 40 INJ,SOLN

BL800 DEXTRAN 70 INJ,SOLN

OP600 DEXTRAN 70/HYPROMELLOSE (EQV OCUCOAT) SOLN,OPH

BL800 DEXTRAN 75 INJ,SOLN

BL800 DEXTRAN HM INJ,SOLN

CN801 DEXTROAMPHETAMINE CAP,ORAL

CN801 DEXTROAMPHETAMINE CAP,SA

CN801 DEXTROAMPHETAMINE ELIXIR

CN801 DEXTROAMPHETAMINE TAB

RE302 DEXTROMETHORPHAN/GUAIFENESIN (OTC) LIQUID,ORAL

RE302 DEXTROMETHORPHAN/GUAIFENESIN (SF) (OTC) LIQUID,ORAL

TN101 DEXTROSE INJ,SOLN

PH000 DEXTROSE 25% INJ,SOLN

HS503 DEXTROSE SQUEEZE TUBE (OTC) LIQUID,ORAL

TN102 DEXTROSE/ISOLYTE INJ,SOLN

TN102 DEXTROSE/KCL INJ,SOLN

TN102 DEXTROSE/LACTATED RINGERS INJ,SOLN

IR200 DEXTROSE/PERITONEAL DIALYSIS INJ,SOLN

TN102 DEXTROSE/SODIUM CHLORIDE INJ,SOLN





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 14

TN102 DEXTROSE/SODIUM CHLORIDE/KCL INJ,SOLN

XA305 DIAPER W/ELASTIC STRAPS SUPPLY

XA900 DIAPHRAGM SUPPLY

CN302 DIAZEPAM TAB

CN302 DIAZEPAM INJ

DE700 DIBUCAINE 1% (OTC) OINT,TOP

MS102 DICLOFENAC NA TAB,EC

OP300 DICLOFENAC NA SOLN,OPH







AM112 R DICLOXACILLIN NA CAP,ORAL

AU350 DICYCLOMINE HCL CAP,ORAL

AU350 DICYCLOMINE HCL INJ,SOLN

AU350 DICYCLOMINE HCL SYRUP

AU350 DICYCLOMINE HCL TAB

AM800 R DIDANOSINE CAP,EC

CV050 DIGOXIN ELIXIR

CV050 DIGOXIN INJ,SOLN

CV050 DIGOXIN TAB





AD900 DIGOXIN IMMUNE FAB (OVINE) INJ,SOLN

CN105 DIHYDROERGOTAMINE MESYLATE INJ,SOLN

VT503 DIHYDROTACHYSTEROL CAP,ORAL

VT503 DIHYDROTACHYSTEROL SOLN,ORAL

VT503 DIHYDROTACHYSTEROL TAB

CV200 DILTIAZEM HCL CAP,SA





CV200 DILTIAZEM HCL INJ

CV200 DILTIAZEM HCL TAB





AD300 DIMERCAPROL INJ,SOLN

GU900 DIMETHYLSULFOXIDE SOLN,URH

AH200 DIPHENHYDRAMINE HCL INJ,SOLN

AH200 DIPHENHYDRAMINE HCL (OTC) CAP,ORAL

AH200 DIPHENHYDRAMINE HCL (OTC) TAB

IM109 INJ,SUSP

DIPHTHERIA TOXOID/PERTUSSIS /TETANUS TOXOID

IM200 DIPHTHERIA/TETANUS TOXOID INJ,SUSP





OP103 DIPIVEFRIN HCL SOLN,OPH





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 15

DX900 DIPYRIDAMOLE INJ,SOLN

BL117 DIPYRIDAMOLE TAB

XA305 DISPOSABLE DIAPER SUPPLY

XA301 DISPOSABLE UNDERPAD SUPPLY

AD100 DISULFIRAM TAB

CN400 DIVALPROEX NA TAB,SA,24HR





AU100 DOBUTAMINE INJ,SOLN

AN900 DOCETAXEL INJ

GA205 DOCUSATE (OTC) CAP,ORAL

GA206 DOCUSATE (OTC) LIQUID,ORAL

RS300 DOCUSATE (OTC) ENEMA,RTL

GA204 DOCUSATE/SENNOSIDES TAB

CN900 DONEPEZIL TAB







AU100 DOPAMINE INJ,SOLN

OP109 DORZOLAMIDE HCL SOLN,OPH

OP105 DORZOLAMIDE/TIMOLOL SOLN,OPH

RE900 DOXAPRAM HCL INJ,SOLN

CV150 DOXAZOSIN MESYLATE TAB

CN601 DOXEPIN HCL CAP,ORAL

CN601 DOXEPIN HCL LIQUID,ORAL

AN200 DOXORUBICIN INJ,SOLN

AM250 R DOXYCYCLINE CAP OR TAB

AM250 R DOXYCYCLINE SUSP

AM250 R DOXYCYCLINE HYCLATE INJ

XA199 DRESSING ALGINATE SUPPLY

XA199 DRESSING HYDROCOLLOID SUPPLY

XA199 DRESSING HYDROGEL SUPPLY

XA103 DRESSING NON-ADHESIVE OIL/EMULSION SUPPLY

XA199 DRESSING TRAYS SUPPLY

XA199 DRESSING,PROFORE-LF 4-LAYER SN#66020626 DRESSING,PROFORE

CN205 DROPERIDOL INJ,SOLN

OP102 ECHOTHIOPHATE IODIDE SOLN,OPH

AD300 EDETATE CALCIUM DISODIUM INJ

AU300 EDROPHONIUM CHLORIDE INJ

AM800 R EFAVIRENZ TAB

AM800 R EFAVIRENZ CAP,ORAL

AM800 R EFAVIRENZ/EMTRICITABINE/TENOFOVIR TAB





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 16

AM800 R EMTRICITABINE CAP,ORAL

AM800 R EMTRICITABINE/TENOFOVIR TAB

CV800 ENALAPRIL TAB







CV800 ENALAPRILAT INJ,SOLN

XA900 ENEMA BAG SUPPLY

CN201 ENFLURANE LIQUID,INHL

AM800 R ENFUVIRTIDE INJ,PWDR

BL110 ENOXAPARIN INJ







CN500 ENTACAPONE TAB

AM800 R ENTECAVIR SOLN,ORAL

AM800 R ENTECAVIR TAB

AU100 EPHEDRINE INJ,SOLN

AU100 EPINEPHRINE INJ,SOLN

BL400 EPOETIN ALFA,RECOMBINANT INJ,SOLN

BL110 EPTIFIBATIDE INJ

CN900 ERGOLOID MESYLATES TAB,ORAL

GU600 ERGONOVINE MALEATE INJ

AM119 R ERTAPENEM INJ,PWDR

AM200 R ERYTHROMYCIN SUSP

AM200 R ERYTHROMYCIN TAB

AM200 R ERYTHROMYCIN TAB,EC

OP210 ERYTHROMYCIN OINT,OPH

DE752 ERYTHROMYCIN 2% TOP GEL GEL,TOP

DE752 ERYTHROMYCIN 2% TOP SOLN SOLN,TOP

AM200 R ERYTHROMYCIN LACTOBIONATE INJ

CV100 ESMOLOL HCL INJ

HS300 ESTRADIOL INJ

HS300 ESTRADIOL PATCH

HS300 ESTRADIOL TAB

AN900 ESTRAMUSTINE CAP,ORAL

HS300 ESTROGENS INJ

GU500 ESTROGENS CONJUGATED CREAM,VAG

HS300 ESTROGENS CONJUGATED INJ

HS300 ESTROGENS CONJUGATED TAB

CV702 ETHACRYNATE NA INJ









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 17

CV702 ETHACRYNIC ACID TAB





AM500 R ETHAMBUTOL HCL TAB

CV600 ETHANOLAMINE OLEATE INJ,SOLN

HS200 ETHINYL ESTRADIOL 0.12MG/ETONOGESTREL 0.015MG (EQV-NUVARING) RING,VAG

HS300 ETHINYL ESTRADIOL 20MCG TAB

HS200 ETHINYL ESTRADIOL 20MCG/LEVONORGESTREL 0.1MG,28 (MONO) (EQV-LUTERA) TAB







HS200 ETHINYL ESTRADIOL 30MCG/LEVONORGESTREL 0.15MG,28 (MONO) (EQV-LEVLEN) TAB







HS200 ETHINYL ESTRADIOL 30MCG/LEVONORGESTREL,28 (TRI) (EQV-TRI-LEVLEN) TAB







HS200 ETHINYL ESTRADIOL 35MCG/NORETHINDRONE 1MG,28 (MONO) (EQV-NORINYL 1 TAB

+35)





HS200 ETHINYL ESTRADIOL 35MCG/NORETHINDRONE,28 (TRI) (EQV-NECON 7/7/7) TAB







HS200 ETHINYL ESTRADIOL 35MCG/NORGESTIMATE 0.25MG,28 (MONO) (EQV- TAB

MONONESSA)





HS200 ETHINYL ESTRADIOL 35MCG/NORGESTIMATE,28 (TRI) (EQV-TRINESSA) TAB







HS900 ETHINYL ESTRADIOL 5MCG/NORETHINDRONE ACETATE 1MG ORAL (FEMHRT) TAB

AM500 R ETHIONAMIDE TAB

DE700 ETHYL CHLORIDE 100% AEROSOL,TOP

HS900 ETIDRONATE INJ

HS900 ETIDRONATE TAB

MS102 ETODOLAC CAP,ORAL

MS102 ETODOLAC TAB

CN203 ETOMIDATE INJ

AN900 ETOPOSIDE CAP,ORL

AN900 ETOPOSIDE INJ,SOLN

AM800 R ETRAVIRINE TAB









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 18

XA101 EYE PAD STERILE

OP500 EYE RINSE (OTC) SOLN,OPH IRRG

XA900 FACE PLATE SUPPLY

BL500 FACTOR IX COMPLEX, HUMAN INJ

AM800 R FAMCICLOVIR TAB

GA301 FAMOTIDINE INJ,SOLN

TN300 FAT EMULSION INJ

XA900 FECAL INCONTINENCE COLLECTOR SUPPLY

CN400 FELBAMATE SUSP,ORAL

CN400 FELBAMATE TAB

CV200 FELODIPINE TAB,SA





AU100 FENOLDOPAM INJ

CN101 FENTANYL PATCH





CN101 FENTANYL CITRATE INJ,SOLN

TN410 FERRIC NA GLUCONATE INJ,SOLN

TN410 FERROUS GLUCONATE TAB

TN410 FERROUS SULFATE (OTC) LIQUID,ORAL

TN410 FERROUS SULFATE (OTC) TAB

BL400 FILGRASTIM INJ,SOLN

HS900 FINASTERIDE TAB





CV300 FLECAINIDE TAB









AM700 R FLUCONAZOLE INJ

AM700 R FLUCONAZOLE PWDR,RENST-ORAL

AM700 R FLUCONAZOLE TAB

AM700 R FLUCYTOSINE CAP,ORAL

AN300 FLUDARABINE INJ

HS052 FLUDROCORTISONE ACETATE TAB

AD900 FLUMAZENIL INJ

RE101 FLUNISOLIDE INHL,ORAL

NT200 FLUNISOLIDE INHL,NASAL





DE200 FLUOCINOLONE ACETONIDE 0.01% SOLN,TOP

DE200 FLUOCINONIDE CREAM,TOP

DE200 FLUOCINONIDE OINT,TOP





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 19

DE200 FLUOCINONIDE SOLN,TOP

OP900 FLUORESCEIN INJ,SOLN

OP900 FLUORESCEIN SOLN,OPH

OP900 FLUORESCEIN STRIP,OPH

OP900 FLUORESCEIN NA /PROPARACAINE SOLN,OPH

OP300 FLUOROMETHOLONE SUSP,OPH

AN300 FLUOROURACIL INJ,SOLN

DE600 FLUOROURACIL CREAM,TOP

DE600 FLUOROURACIL SOLN,TOP

CN609 FLUOXETINE CAP,ORAL

CN609 FLUOXETINE SOLN,ORAL

CN609 FLUOXETINE TAB

HS100 FLUOXYMESTERONE TAB

CN701 FLUPHENAZINE LIQUID,ORAL

CN701 FLUPHENAZINE INJ

CN701 FLUPHENAZINE TAB

CN701 FLUPHENAZINE DECONATE INJ

DE200 FLURANDRENOLIDE 4MCG/SQCM TAPE

OP900 FLURBIPROFEN NA SOLN,OPH







AN900 FLUTAMIDE CAP

NT200 FLUTICASONE (PROPRIONATE ONLY) INHL,NASAL





VT102 FOLIC ACID INJ,SOLN

VT102 FOLIC ACID TAB

AD900 FOMEPIZOLE INJ

BL110 FONDAPARINUX INJ,SOLN









RE102 FORMOTEROL CAP,INHL

AM800 R FOSAMPRENAVIR TAB

OP900 FOSCARNET NA INJ

CV800 FOSINOPRIL TAB







CN400 FOSPHENYTOIN NA INJ









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 20

CV702 FUROSEMIDE INJ,SOLN







CV702 FUROSEMIDE SOLN,ORAL







CV702 FUROSEMIDE TAB







CN400 GABAPENTIN CAP,ORAL

CN400 GABAPENTIN SOLN,ORAL

CN400 GABAPENTIN TAB

CN900 GALANTAMINE CAP,SA





CN900 GALANTAMINE TAB





HS900 GALLIUM INJ,SOLN

AM800 R GANCICLOVIR INJ,SOLN

OP230 GANCICLOVIR IMPLANT

XA109 GAUZE ELASTIC STERILE SUPPLY

XA109 GAUZE ELASTIC NONSTERILE SUPPLY

XA106 GAUZE FINE MESH STERILE SUPPLY

XA103 GAUZE NON-ADHESIVE PETROLATUM SUPPLY

XA112 GAUZE PACKING MEDICATED SUPPLY

XA111 GAUZE PACKING PLAIN SUPPLY

XA102 GAUZE PAD NONSTERILE SUPPLY

XA101 GAUZE PAD STERILE SUPPLY

BL116 GELATIN,ABSORBABLE CONE

BL116 GELATIN,ABSORBABLE FILM

BL116 GELATIN,ABSORBABLE POWDER

BL116 GELATIN,ABSORBABLE SPONGE

OP900 GELATIN,ABSORBABLE FILM

AN900 GEMCITABINE INJ

CV350 GEMFIBROZIL TAB,ORAL





AM300 R GENTAMICIN SO4 INJ

DE101 GENTAMICIN SO4 CREAM,TOP

OP210 GENTAMICIN SO4 SOLN,OPH

OP210 GENTAMICIN SO4 OINT,OPH

OP350 GENTAMICIN/PREDNISOLONE SUSP,OPH





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 21

DE109 GENTIAN VIOLET 1% (OTC) SOLN,TOP

DE109 GENTIAN VIOLET 2% (OTC) SOLN,TOP

MS900 GLATIRAMER ACETATE INJ,LYPHL

HS502 GLIPIZIDE TAB

IM500 GLOBULIN, IMMUNE INJ,SOLN

XA900 GLOVE LATEX NONSTERILE SUPPLY

XA900 GLOVE LATEX, STERILE SUPPLY

XA900 GLOVE VINYL NONSTERILE SUPPLY

HS503 GLUCAGON INJ

HS503 GLUCOSE (OTC) TAB,CHEWABLE

HS502 GLYBURIDE TAB

RS300 GLYCERIN (ADULT) (OTC) SUPP,RTL

IR100 GLYCINE SOLN,IRRG

DE900 GLYCOLIC ACID 12% (OTC) LOTION,TOP

AU350 GLYCOPYRROLATE INJ,SOLN

MS160 GOLD NA THIOMALATE INJ

AN500 GOSERELIN ACETATE INJ,IMPLANT

OP219 GRAMICIDIN/NEOMYCIN/POLYMYXIN SOLN,OPH

RE302 GUAIFENESIN TAB

RE302 GUAIFENESIN TAB,SA

RE302 GUAIFENESIN LIQUID,ORAL

IM100 HAEMOPHILUS B CONJUGATE VACCINE INJ,LYPHL

CN709 HALOPERIDOL INJ,SOLN

CN709 HALOPERIDOL LIQUID,ORAL

CN709 HALOPERIDOL TAB

CN709 HALOPERIDOL DECANOATE INJ

CN201 HALOTHANE INHALATION LIQUID,IHNL

DE900 HAMAMELIS WATER 50% (OTC) PAD

OT250 HC/NEOMYCIN/POLYMYXIN OTIC SUSP,OTIC

RS201 HEMORRHOIDAL (OTC) OINT,RTL

RS201 HEMORRHOIDAL (OTC) SUPP,RTL

RS202 HEMORRHOIDAL/HC RTL OINT,RTL

BL110 HEPARIN INJ,SOLN







IM100 HEPATITIS A VACCINE INJ,SUSP





IM100 HEPATITIS A/HEPATITIS B VACCINE INJ,SUSP





IM500 HEPATITIS B IMMUNE GLOBULIN INJ





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 22

IM100 HEPATITIS B VACCINE (RECOMBINANT) INJ,SUPS





BL800 HETASTARCH INJ

BL800 HETASTARCH/ELECTROLYTES INJ

OP500 HIGH VISCOSITY ARTIFICIAL TEARS (OTC) SOLN,OPH

DX300 HISTOPLASMIN 1:100 SKIN TEST INJ,SOLN

OP600 HOMATROPINE HYDROBROMIDE SOLN,OPH

OP900 HYALURONATE NA INJ,OPH

XX000 HYALURONIDASE INJ









CV490 HYDRALAZINE HCL INJ,SOLN

CV490 HYDRALAZINE HCL TAB







CV701 HYDROCHLOROTHIAZIDE CAP,ORAL





CV701 HYDROCHLOROTHIAZIDE TAB





CV400 HYDROCHLOROTHIAZIDE/LISINOPRIL TAB

CV704 HYDROCHLOROTHIAZIDE/SPIRONOLACTONE TAB





CV704 HYDROCHLOROTHIAZIDE/TRIAMTERENE CAP,ORAL





CV704 HYDROCHLOROTHIAZIDE/TRIAMTERENE TAB





DE200 HYDROCORTISONE AEROSOL,TOP

HS051 HYDROCORTISONE INJ,SOLN

HS051 HYDROCORTISONE TAB

RS100 HYDROCORTISONE AEROSOL,RTL

RS100 HYDROCORTISONE ENEMA

DE200 HYDROCORTISONE (PLAIN OR ACETATE) CREAM,TOP

DE200 HYDROCORTISONE (PLAIN OR ACETATE) OINT,TOP

DE200 HYDROCORTISONE (PLAIN OR ACETATE) LOTION,TOP

RS202 HYDROCORTISONE/PRAMOXINE AEROSOL,RTL

RS202 HYDROCORTISONE/PRAMOXINE CREAM,RTL

RS202 HYDROCORTISONE/PRAMOXINE OINT,RTL

DE101 HYDROGEN PEROXIDE (OTC) SOLN,TOP





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 23

CN101 HYDROMORPHONE HCL INJ,SOLN

CN101 HYDROMORPHONE HCL TAB

DE350 HYDROPHILIC OINT,TOP

DE900 HYDROQUINONE 4% CREAM,TOP

AP101 HYDROXYCHLOROQUINE SULFATE TAB

AN300 HYDROXYUREA CAP,ORAL

AH105 HYDROXYZINE CAP OR TAB

AH105 HYDROXYZINE INJ,SOLN

AH105 HYDROXYZINE LIQUID,ORAL

MS102 IBUPROFEN SUSP

MS102 IBUPROFEN TAB

CV300 IBUTILIDE INJ

AN200 IDARUBICIN INJ,SOLN

AN100 IFOSFAMIDE INJ

AN100 IFOSFAMIDE/MESNA INJ

AN900 IMATINIB MESYLATE TAB





AM119 R IMIPENEM/CILASTATIN NA INJ

CN601 IMIPRAMINE HCL TAB

IM900 IMIQUIMOD CREAM,TOP

CV900 INAMRINONE INJ

XA304 INCONTINENCE LINER SUPPLY

CV701 INDAPAMIDE TAB





AM800 R INDINAVIR S04 CAP,ORAL

DX101 INDOCYANINE GREEN INJ,SOLN

MS102 INDOMETHACIN CAP

IM100 INFLUENZA VIRUS VACCINE INJ









AD900 INSECT STING TREATMENT KIT KIT

XA854 INSULIN SYRINGE

HS501 INSULIN ASPART INJ,SOLN

HS501 INSULIN HUMAN 50/50 (NPH/REG) (OTC) INJ,SUSP

HS501 INSULIN HUMAN 70/30 (NPH/REG) (OTC) INJ,SUSP

HS501 INSULIN HUMAN LENTE 100U/ML (OTC) INJ,SUSP

HS501 INSULIN HUMAN NPH 100U/ML (OTC) INJ,SUSP

HS501 INSULIN HUMAN REGULAR 100U/ML (OTC) INJ,SOLN





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 24

HS501 INSULIN LONG ACTING ANALOG INJ,SOLN

XA854 INSULIN LOW DOSE SYRINGE

IM700 INTERFERON ALFA INJ





AM800 R INTERFERON ALFA-2B INJ/RIBAVIRIN INJ/CAP

IM700 INTERFERON BETA-1A INJ

IM900 INTERFERON BETA-1B INJ

IM700 INTERFERON GAMMA-1B INJ

DX102 IOTHALAMATE INJ,SOLN

GA600 IPECAC SYRUP (OTC) SYRUP

NT900 IPRATROPIUM BROMIDE SOLN,SPRAY,NASAL

RE105 IPRATROPIUM BROMIDE INHALANT

RE105 IPRATROPIUM BROMIDE SOLN,INHL

AN900 IRINOTECAN INJ

TN410 IRON DEXTRAN COMPLEX (LOW MOLECULAR WEIGHT) (EQV INFED) INJ,SOLN

TN410 IRON SUCROSE INJ,SOLN

OP500 IRRIGATING EYE SOLN,OPH

XA900 IRRIGATING SYRINGE CATHETER TIP 60ML SUPPLY

XA900 IRRIGATING SYRINGE,BULB CATHETER TIP 60ML SUPPLY

XA607 IRRIGATOR DRAIN /SLEEVE SUPPLY

CN201 ISOFLURANE LIQUID,INHL

AM500 R ISONIAZID INJ

AM500 R ISONIAZID TAB

AM500 R ISONIAZID/RIFAMPIN CAP,ORAL

AU100 ISOPROTERENOL INJ,SOLN

CV250 ISOSORBIDE DINITRATE CAP/TAB,SA

CV250 ISOSORBIDE DINITRATE TAB

CV250 ISOSORBIDE MONONITRATE TAB,SA

DE751 ISOTRETINOIN ORAL CAP,ORAL





AM700 R ITRACONAZOLE ORAL CAP,ORAL

XA809 IV SET SECONDARY SUPPLY

AP200 IVERMECTIN TAB

TN475 K PHOSPHATE /NA BIPHOSPHATE/NA PHOSPHATE TAB

AM300 R KANAMYCIN INJ

XA109 KERLIX 4.5IN STERILE BANDAGE,GAUZE

XA101 KERLIX SUPER SPONGE MEDIUM STERILE SUPPLY

CN203 KETAMINE INJ,SOLN

AM700 R KETOCONAZOLE TAB

DE102 KETOCONAZOLE SHAMPOO



1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 25

DE102 KETOCONAZOLE 2% CREAM,TOP

DX900 KETODIASTIX GLUCOSE KETONE TEST STRIP TEST STRIP

MS102 KETOROLAC TROMETHAMINE INJ

OP300 KETOROLAC TROMETHAMINE SOLN,OPH







OP900 KETOTIFEN SOLN,OPH

CV100 LABETALOL HCL INJ,SOLN







GA500 LACTASE (OTC) TAB

IR100 LACTATED RINGERS SOLN,IRRG

TN102 LACTATED RINGER'S INJ,SOLN

DE500 LACTIC ACID 16.7%/SAL AC 16.7%/COLLODION (OTC) LIQUID,TOP

GA208 LACTOBACILLUS (OTC) CAP,ORAL

GA208 LACTOBACILLUS (OTC) TAB,CHEWABLE

GA202 LACTULOSE SYRUP

XA900 LAMBS WOOL SUPPLY

AM800 R LAMIVUDINE SOLN,ORAL

AM800 R LAMIVUDINE TAB

AM800 R LAMIVUDINE/ZIDOVUDINE TAB









CN400 LAMOTRIGINE TAB

XA900 LANCET SUPPLY

DE350 LANOLIN HYDROUS (OTC) OINT,TOP







TN490 LANTHANUM CARBONATE TAB,CHEWABLE

XA599 LEG BAG STRAP ELASTIC SUPPLY

IM900 LENALIDOMIDE CAP,ORAL









BL110 LEPIRUDIN INJ,PWDR

AN900 LETROZOLE TAB

VT102 LEUCOVORIN CALCIUM INJ

VT102 LEUCOVORIN CALCIUM TAB

CN400 LEVETIRACETAM INJ,SOLN





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 26

CN400 LEVETIRACETAM TAB

OP101 LEVOBUNOLOL OPH SOLN,OPH

AM900 R LEVOFLOXACIN INJ,SOLN

HS200 LEVONORGESTREL (EQV. PLAN B) TAB

HS851 LEVOTHYROXINE INJ

HS851 LEVOTHYROXINE NA TAB

DE700 LIDOCAINE 2.5%/PRILOCAINE 2.5% CREAM,TOP

DE700 LIDOCAINE 5% OINT,TOP

CN204 LIDOCAINE HCL INJ

DE700 LIDOCAINE HCL 2% JELLY

NT300 LIDOCAINE HCL 2% VISCOUS LIQUID,ORAL

DE700 LIDOCAINE HCL 4% SOLN,TOP

DE700 LIDOCAINE HCL 5% OINT,TOP

GU900 LIDOCAINE HCL URH SOLN,TOP

CN204 LIDOCAINE HCL/EPINEPHRINE INJ

AM900 R LINEZOLID INJ









AM900 R LINEZOLID PWDR,RENST-ORAL

AM900 R LINEZOLID TAB









CV800 LISINOPRIL TAB







CN750 LITHIUM CAP,ORAL

CN750 LITHIUM SYRUP

CN750 LITHIUM TAB

CN750 LITHIUM TAB,SA

OP900 LODOXAMIDE TROMETHAMINE SOLN,OPH

AN100 LOMUSTINE CAP,ORAL

GA208 LOPERAMIDE HCL CAP,ORAL





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 27

GA208 LOPERAMIDE HCL LIQUID,ORAL

AM800 R LOPINAVIR/RITONAVIR TAB

AH109 LORATIDINE TAB

CN302 LORAZEPAM INJ INJ

CN302 LORAZEPAM ORAL TAB

CV805 LOSARTAN TAB

CV350 LOVASTATIN TAB







CN709 LOXAPINE CAP,ORAL

DE900 LUBRICATING (OTC) JELLY,TOP

OP500 LUBRICATING (PF) (OTC) OINT,OPH

GA202 MAGNESIUM CITRATE (OTC) LIQUID,ORAL

GA202 MAGNESIUM HYDROXIDE (OTC) SUSP,ORAL

TN460 MAGNESIUM OXIDE (OTC) TAB

TN460 MAGNESIUM SULFATE INJ,SOLN

CV709 MANNITOL INJ,SOLN

AM800 R MARAVIROC TAB





XA900 MASK,SURGICAL SUPPLY

IM100 MEASLES/MUMPS/RUBELLA VIRUS VACCINE INJ





AP200 MEBENDAZOLE TAB,CHEWABLE

AN100 MECHLORETHAMINE INJ

CN550 MECLIZINE HCL (OTC) TAB

XA900 MEDICATION ORGANIZER MISCELLANEOUS

HS800 MEDROXYPROGESTERONE ACETATE INJ,SUSP

HS800 MEDROXYPROGESTERONE ACETATE TAB

HS800 MEGESTROL ACETATE SUSP,ORAL

HS800 MEGESTROL ACETATE TAB

MS102 MELOXICAM TAB

AN100 MELPHALAN TAB

AN100 MELPHALAN HCL INJ

CN900 MEMANTINE HCL TAB





IM100 MENINGOCOCCAL CONJUGATE VACCINE INJ,SUSP





IM100 MENINGOCOCCAL POLYSACCHARIDE VACCINE INJ





DE650 MENTHOL/METHYL SALICYLATE 10-15% (LOW CONC) CREAM,TOP





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 28

DE650 MENTHOL/METHYL SALICYLATE 16-30% (HIGH CONC) CREAM,TOP

CN101 MEPERIDINE HCL INJ

CN204 MEPIVACAINE HCL INJ

AN300 MERCAPTOPURINE TAB

GA900 MESALAMINE CAP,SA

GA900 MESALAMINE TAB,EC

RS100 MESALAMINE SUPP,RTL

AD900 MESNA INJ

HS200 MESTRANOL 50MCG/NORETHINDRONE 1MG,28 (MONO) (EQV-NORINYL 1+50) TAB







RE102 METAPROTERENOL SOLN,INHL

HS502 METFORMIN HCL TAB





CN101 METHADONE HCL LIQUID,ORAL





CN101 METHADONE HCL TAB





CV703 METHAZOLAMIDE TAB

AM550 R METHENAMINE TAB

HS852 METHIMAZOLE TAB

MS200 METHOCARBAMOL TAB

CN202 METHOHEXITAL INJ

AN300 METHOTREXATE NA INJ

AN300 METHOTREXATE NA TAB

DE900 METHOXSALEN LIQUID,TOP

DE810 METHOXSALEN CAP

CV490 METHYLDOPA TAB





CV490 METHYLDOPATE HCL INJ

AD200 METHYLENE BLUE INJ

CN802 METHYLPHENIDATE CAP,SA

CN802 METHYLPHENIDATE TAB

CN802 METHYLPHENIDATE TAB,SA

HS051 METHYLPREDNISOLONE INJ,SOLN

HS051 METHYLPREDNISOLONE INJ,SUSP

HS051 METHYLPREDNISOLONE TAB

AU300 METOCLOPRAMIDE HCL LIQUID,ORAL

AU300 METOCLOPRAMIDE HCL TAB

AU300 METOCLOPRAMIDE HCL INJ INJ





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 29

CV701 METOLAZONE TAB





CV100 METOPROLOL TARTRATE INJ







CV100 METOPROLOL TARTRATE TAB





CV100 METOPROLOL SUCCINATE SUSTAINED ACTION TAB,SA









AM900 R METRONIDAZOLE INJ,SOLN

AM900 R METRONIDAZOLE TAB

DE101 METRONIDAZOLE GEL,TOP

GU300 METRONIDAZOLE GEL,VAG

DE752 METRONIDAZOLE 0.75% CREAM,TOP

DX900 METYRAPONE CAP,ORAL

AM700 R MICAFUNGIN INJ,LYPHL

DE102 MICONAZOLE CREAM,TOP

DE102 MICONAZOLE NITRATE 2% TINCTURE,TOP

DE102 MICONAZOLE NITRATE 2% POWDER,TOP

CN302 MIDAZOLAM HCL INJ,SOLN

CV900 MIDODRINE TAB

CV900 MILRINONE INJ,SOLN

RS300 MINERAL OIL (OTC) ENEMA

GA203 MINERAL OIL,HEAVY 100% (OTC) LIQUID,ORAL

DE900 MINERAL OIL,LIGHT (OTC) LIQUID,ORAL

DE350 MINERAL OIL/MINERAL WAX/PETROLATUM/WOOL WAX ALCOHOL (OTC) LOTION,TOP

DE350 MINERAL OIL/MINERAL WAX/PETROLATUM/WOOL WAX ALCOHOL(OTC) OINT,TOP

OR900 MINOCYCLINE PWDR,MICROSPHERE

AM250 R MINOCYCLINE HCL CAP,ORAL

CV490 MINOXIDIL TAB





CN609 MIRTAZAPINE TAB

GA309 MISOPROSTOL TAB

AN200 MITOMYCIN INJ

AN900 MITOTANE TAB

AN900 MITOXANTRONE INJ





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 30

XA604 MOISTURE BARRIER SKIN OINT SUPPLY

DE350 MOISTURIZING (OTC) LOTION,TOP

CN709 MOLINDONE HCL TAB

RE101 MOMETASONE FUROATE INHL,ORAL

RE109 MONTELUKAST TAB





XA205 MONTGOMERY STRAPS SUPPLY

CN101 MORPHINE CAP,IR

CN101 MORPHINE CAP,SA

CN101 MORPHINE INJ,SOLN

CN101 MORPHINE LIQUID,ORAL

CN101 MORPHINE SOLN,CONC

CN101 MORPHINE TAB,IR

CN101 MORPHINE TAB,SA

CV600 MORRHUATE INJ,SOLN

CV600 MORRHUATE SODIUM INJ,SOLN

AM900 R MOXIFLOXACIN INJ,SOLN

AM900 R MOXIFLOXACIN TAB





OP210 MOXIFLOXACIN SOLN,OPH

VT801 MULTIVITAMIN INJ

VT801 MULTIVITAMIN OPHTHALMIC (AREDS NON-SMOKER) TAB



VT802 MULTIVITAMIN OPHTHALMIC (SMOKER) TAB



VT802 MULTIVITAMIN/MINERALS (OTC) CAP OR TAB

VT802 MULTIVITAMIN/MINERALS (OTC) LIQUID,ORAL

VT802 MULTIVITAMIN/MINERALS NO IRON (OTC) CAP OR TAB

DX300 MUMPS SKIN TEST (MSTA) ANTIGEN INJ

DE101 MUPIROCIN OINT,TOP

IM600 MUROMONAB-CD3 INJ

IM600 MYCOPHENOLATE MOFETIL CAP,ORAL

IM600 MYCOPHENOLATE MOFETIL INJ,LYPHL

IM600 MYCOPHENOLATE MOFETIL TAB

IM600 MYCOPHENOLIC ACID TAB,EC

AM112 R NAFCILLIN NA INJ

CN102 NALOXONE HCL INJ,SOLN

CN102 NALTREXONE HCL TAB

HS100 NANDROLONE DECONATE INJ

OP800 NAPHAZOLINE SOLN,OPH







1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 31

OP900 NAPHAZOLINE/PHENIRAMINE SOLN,OPH

MS102 NAPROXEN TAB

IM700 NATALIZUMAB INJ,SOLN









OP220 NATAMYCIN SUSP,OPH

XA856 NEEDLE SUPPLY

XA856 NEEDLE PEN SUPPLY

AM800 R NELFINAVIR TAB

IR100 NEO /POLYMYX SOLN,IRRG

AM300 R NEOMYCIN SULFATE TAB

AU300 NEOSTIGMINE BROMIDE TAB

AU300 NEOSTIGMINE METHYLSULFATE INJ

AM800 R NEVIRAPINE TAB

VT103 NIACIN INJ,SOLN

VT103 NIACIN TAB

VT103 NIACIN TAB,SA

VT103 NIACINAMIDE TAB

CV200 NICARDIPINE INJ,SOLN









AD900 NICOTINE GUM, CHEWABLE

AD900 NICOTINE PATCH

AD900 NICOTINE POLACRILEX LOZENGE

CV200 NIFEDIPINE TAB,SA





DX900 NITRAZINE (pH) TEST STRIP TEST STRIP

AM600 R NITROFURANTOIN MONOHYDRATE/MACROCRYSTALLINE CAP,SA

CV250 NITROGLYCERIN INJ,SOLN





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 32

CV250 NITROGLYCERIN OINT,TOP

CV250 NITROGLYCERIN PATCH

CV250 NITROGLYCERIN TAB,SUBLINGUAL

HS900 NONOXYNOL GEL,VAG

AU100 NOREPINEPHRINE INJ

HS200 NORETHINDRONE 0.35MG (EQV-NOR QD),28 TAB







CN601 NORTRIPTYLINE CAP,ORAL

CN601 NORTRIPTYLINE SOLN,ORAL

TN200 NUTRITION SUPL ENSURE PLUS/VANILLA (OTC) LIQUID,NUTRITIONAL

SUPPLEMENT

TN200 NUTRITION SUPL ENSURE/VANILLA (OTC) POWDER,ORAL

TN200 NUTRITION SUPL JEVITY (1.0 CAL) LIQUID,NUTRITIONAL

SUPPLEMENT

TN200 NUTRITION SUPL OSMOLITE (1.0, 1.5) LIQUID,NUTRITIONAL

SUPPLEMENT

AM700 R NYSTATIN SUSP,ORAL

AM700 R NYSTATIN TAB,ORAL/VAG

DE102 NYSTATIN CREAM,TOP

DE102 NYSTATIN 100000UNT/GM OINT,TOP

DE900 OATMEAL,COLLOIDAL PWDR,TOP

GA208 OCTREOTIDE ACETATE INJ

GA208 OCTREOTIDE ACETATE INJ,SA

OT101 OFLOXACIN SOLN,OTIC

OP210 OFLOXACIN SOLN,OPH

CN709 OLANZAPINE INJ,PWDR









CN709 OLANZAPINE TAB









GA900 OMEPRAZOLE CAP,EC

GA605 ONDANSETRON INJ,SOLN

GA605 ONDANSETRON TAB

OP500 OPHTH LUBRICATING OINTMENT (PF) (OTC) OINT,OPH

OR200 ORABASE PLAIN PASTE (OTC) PASTE





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 33

AM800 R OSELTAMIVIR CAP,ORAL







XA604 OSTOMY PASTE SUPPLY

XA606 OSTOMY POUCH DEODORANT SUPPLY

XA604 OSTOMY SKIN PROTECTIVE POWDER SUPPLY

AM112 R OXACILLIN INJ

AN900 OXALIPLATIN INJ,LYPHL





GU201 OXYBUTYNIN CHLORIDE TAB

CN101 OXYCODONE HCL LIQUID,ORAL





CN101 OXYCODONE HCL TAB





NT100 OXYMETAZOLINE HCL (OTC) SOLN,NASAL

AN900 PACLITAXEL INJ,CONC

XA102 PAD ABDOMINAL NONSTERILE SUPPLY

XA101 PAD ABDOMINAL STERILE SUPPLY

XA105 PAD ALCOHOL PREP SUPPLY

XA105 PAD ANTISEPTIC SUPPLY

XA103 PAD NON-ADHESIVE STERILE SUPPLY

XA104 PAD W/ADHESIVE STERILE SUPPLY

XA110 PAD,FOAM SELF-ADHERE SUPPLY

XA103 PADS,NON-ADHERING SUPPLY

CN709 PALIPERIDONE INJ,SUSP,SA









HS900 PAMIDRONATE PALMITATE INJ

GA500 PANCREATIC ENZYMES CAP OR TAB

MS300 PANCURONIUM BROMIDE INJ,SOLN





GA900 PANTOPRAZOLE INJ,PWDR

IM100 PAPILLOMAVIRUS HUMAN INJ,SOLN









GA208 PAREGORIC LIQUID,ORAL

CN609 PAROXETINE TAB

IM700 PEGINTERFERON ALFA-2A INJ





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 34

IM700 PEGINTERFERON ALFA-2B INJ

MS140 PENICILLAMINE CAP,ORAL

AM110 R PENICILLIN PWDR,RENST-ORAL

AM110 R PENICILLIN TAB

AM110 R PENICILLIN G BENZATHINE INJ,SUSP

AM110 R PENICILLIN G POTASSIUM INJ

AM110 R PENICILLIN G PROCAINE INJ,SUSP

DE700 PENTAFLUOROPROPANE/TETRAFLUOROETHANE AEROSOL,TOP

AM900 R PENTAMIDINE ISETHIONATE INJ,SOLN

AP109 R PENTAMIDINE ISETHIONATE INHALANT

AN900 PENTOSTATIN INJ

AN900 PENTOSTATIN/MANNITOL INJ

DE900 PERINEAL WASH (OTC) SOLN

AP300 PERMETHRIN (OTC) CREAM,TOP

AP300 PERMETHRIN (OTC) LOTION,TOP

CN701 PERPHENAZINE TAB

DE350 PETROLATUM(OTC) OINT,TOP

GU100 PHENAZOPYRIDINE HCL TAB

CN602 PHENELZINE SULFATE TAB







CN301 PHENOBARBITAL ELIXIR

CN301 PHENOBARBITAL INJ

CN301 PHENOBARBITAL TAB

NT300 PHENOL LIQUID,ORAL

PH000 PHENOL LIQUID,TOP

AU200 PHENOXYBENZAMINE HCL CAP,ORAL

AU200 PHENTOLAMINE MESYLATE INJ

AU100 PHENYLEPHRINE INJ

OP600 PHENYLEPHRINE HCL SOLN,OPH

NT100 PHENYLEPHRINE HCL (OTC) SOLN,NASAL

CN400 PHENYTOIN (DILANTIN) TAB,CHEWABLE

CN400 PHENYTOIN (DILANTIN) CAP,SA

CN400 PHENYTOIN (DILANTIN) SUSP

CN400 PHENYTOIN (DILANTIN) NA INJ,SOLN

TN475 PHOSPHORUS/K/NA (OTC) PWDR,ORAL

TN475 PHOSPHORUS/POTASSIUM PWDR,RENST-ORAL

TN475 PHOSPHORUS/POTASSIUM INJ

TN475 PHOSPHORUS/SODIUM INJ

AU300 PHYSOSTIGMINE SALICYLATE INJ,SOLN





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 35

VT702 PHYTONADIONE TAB

VT702 PHYTONADIONE INJ

OP102 PILOCARPINE GEL,OPH

OP102 PILOCARPINE SOLN,OPH

AU300 PILOCARPINE HCL TAB

CN900 PIMOZIDE TAB

AM113 R PIPERACILLIN NA INJ

AM113 R PIPERACILLIN NA/TAZOBACTAM INJ

MS102 PIROXICAM CAP,ORAL

BL500 PLASMA PROTEIN FRACTION 5% INJ

XA514 PLUG CATHETER SUPPLY

IM100 PNEUMOCOCCAL POLYSCCHARIDE VACCINE INJ





DE500 PODOFILOX 0.5% SOLN,TOP

DE500 PODOPHYLLIN 25%/BENZOIN TINCTURE,TOP

IM100 POLIOVIRUS VACCINE INACTIVATED INJ

GA202 POLYETHYLENE GLYCOL 3350 (PEG-3350) POWDER,ORAL

GA202 POLYETHYLENE GLYCOL 3350 (PEG-3350)/ELECTROLYTES PWDR,RENST-ORAL

AM900 R POLYMYXIN B SO4 INJ,SOLN

OP219 POLYMYXIN/TRIMETHOPRIM SOLN,OPH

AN900 PORFIMER SODIUM INJ

TN430 POTASSIUM CAP OR TAB

TN430 POTASSIUM ACETATE INJ,SOLN

TN430 POTASSIUM BICARBONATE TAB,EFFERVSC

TN430 POTASSIUM CHLORIDE CAP OR TAB,SA

TN430 POTASSIUM CHLORIDE INJ,CONC-SOLN

TN430 POTASSIUM CHLORIDE PWDR,EFFERVSC

TN102 POTASSIUM CHLORIDE INJ INJ,SOLN

TN478 POTASSIUM CITRATE TAB,SA

RE302 POTASSIUM IODIDE SOLN,ORAL

XA403 POUCH CLOSED ONE-PIECE W/ADHESIVE SUPPLY

XA404 POUCH CLOSED TWO-PIECE W/O ADHESIVE FLANGE SIZE 1 3/4" - 2 1/4" SUPPLY

XA505 POUCH DRAINABLE 2-PC W/O ADHESIVE UROST FLANGE SZ 1 1/2"-2 1/4" SUPPLY

XA401 POUCH DRAINABLE ONE PIECE CUSTOM-CUT W/ADHESIVE SUPPLY

XA402 POUCH DRAINABLE TWO- PIECE W/O ADHESIVE FLANGE SIZE 1 1/2" - 4" SUPPLY

XA504 POUCH DRAINABLE W/ADHESIVE UROSTOMY SUPPLY

XA599 POUCH RETRACTED PENIS SUPPLY

OP400 POVIDONE IODINE SOLN,OPH

DE101 POVIDONE IODINE OINT,TOP

DE101 POVIDONE IODINE (OTC) SOLN,SCRUB





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 36

DE101 POVIDONE IODINE (OTC) PAD

DE101 POVIDONE IODINE (OTC) SOLN,TOP

DE400 POVIDONE IODINE 10% (OTC) STICK,TOP

AD900 PRALIDOXIME CL INJ,SOLN

DE700 PRAMOXINE HCL 1% (OTC) CREAM,TOP

DE700 PRAMOXINE HCL 1% (OTC) LOTION,TOP

CV350 PRAVASTATIN TAB





CV150 PRAZOSIN HCL CAP,ORAL

OP300 PREDNISOLONE SUSP,OPH

OP350 PREDNISOLONE NA PHOSPHATE/SULFACETAMIDE SOLN,OPH

HS051 PREDNISONE TAB

VT802 PRENATAL VITAMIN CAP OR TAB

CN204 PRILOCAINE INJ,SOLN

CN204 PRILOCAINE HCL/EPINEPHRINE INJ,SOLN

AP101 PRIMAQUINE PHOSPHATE TAB

CN400 PRIMIDONE TAB

MS400 PROBENECID TAB

CV300 PROCAINAMIDE INJ,SOLN

CN204 PROCAINE HCL INJ

AN900 PROCARBAZINE CAP,ORAL

GA605 PROCHLORPERAZINE INJ



GA605 PROCHLORPERAZINE SUPP,RTL

GA605 PROCHLORPERAZINE MALEATE TAB

AH100 PROMETHAZINE HCL SUPP,RTL

AH100 PROMETHAZINE HCL TAB

AH100 PROMETHAZINE HCL SYRUP

CV300 PROPAFENONE TAB









AU350 PROPANTHELINE BR TAB

OP700 PROPARACAINE SOLN,OPH

CN203 PROPOFOL INJ

CV100 PROPRANOLOL HCL CAP,SA





CV100 PROPRANOLOL HCL TAB





PH000 PROPYLENE GLYCOL LIQUID,TOP





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 37

HS852 PROPYLTHIOURACIL TAB

BL118 PROTAMINE SO4 INJ,SOLN

DX900 PROTIRELIN INJ,SOLN

RE200 PSEUDOEPHEDRINE HCL (OTC) TAB

RE501 PSEUDOEPHEDRINE/TRIPROLIDINE CAP,ORAL

RE501 PSEUDOEPHEDRINE/TRIPROLIDINE TAB

GA201 PSYLLIUM (OTC) POWDER,ORAL

GA201 PSYLLIUM (SF) (OTC) POWDER,ORAL

AM500 R PYRAZINAMIDE TAB

AU300 PYRIDOSTIGMINE TAB

AU300 PYRIDOSTIGMINE TAB,SA

AU300 PYRIDOSTIGMINE BROMIDE INJ,SOLN

VT104 PYRIDOXINE HCL INJ

VT104 PYRIDOXINE HCL (OTC) TAB

AP101 PYRIMETHAMINE TAB

CN709 QUETIAPINE FUMARATE TAB









CV300 QUINIDINE TAB

CV300 QUINIDINE TAB,SA

IM500 RABIES IMMUNE GLOBULIN,HUMAN INJ

IM100 RABIES VACCINE INJ

AM800 R RALTEGRAVIR TAB









OP900 RANIBIZUMAB INJ,SOLN





GA301 RANITIDINE INJ

GA301 RANITIDINE TAB

CV900 INJ,SOLN

REGADENOSON

CN101 REMIFENTANIL INJ,LYPHL

VT801 RENAL MULTIVITAMIN WITH < OR = 1MG FOLIC ACID ORAL

CV490 RESERPINE TAB





BL115 RETEPLASE INJ

AM800 R RIBAVIRIN CAP,ORAL





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 38

AM800 R RIBAVIRIN TAB

AM900 R RIFABUTIN CAP,ORAL

AM500 R RIFAMPIN CAP,ORAL

AM500 R RIFAMPIN INJ

CN900 RILUZOLE TAB





AM800 R RIMANTADINE HCL TAB

OP300 RIMEXOLONE OPH SUSP,OPH

IR100 RINGER'S SOLN,IRRG

TN102 RINGER'S INJ,SOLN

HS900 RISEDRONATE NA TAB

CN709 RISPERIDONE INJ,SUSP,SA









CN709 RISPERIDONE SOLN,ORAL







CN709 RISPERIDONE TAB







AM800 R RITONAVIR SOLN,ORAL

AM800 R RITONAVIR TAB

AN900 RITUXIMAB INJ,SOLN









MS300 ROCURONIUM BROMIDE INJ,SOLN

CN500 ROPINIROLE TAB





CN204 ROPIVACAINE INJ

OP900 ROSE BENGAL (OTC) SPRIP,OPH

DE500 SALICYLIC ACID CREAM,TOP

DE500 SALICYLIC ACID PLASTER,TOP

DE500 SALICYLIC ACID SHAMPOO

DE500 SALICYLIC ACID SOLN,TOP

DE500 SALICYLIC ACID/SULFUR CREAM,TOP

MS101 SALSALATE TAB





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 39

AM800 R SAQUINAVIR CAP,ORAL

AM800 R SAQUINAVIR TAB

BL400 SARGRAMOSTIM INJ

AU350 SCOPOLAMINE HBR INJ,SOLN

OP600 SCOPOLAMINE HBR SOLN,OPH

DX900 SECRETIN (HUMAN) INJ,LYPHL

CN602 SELEGILINE PATCH







CN500 SELEGILINE HCL TAB

DE400 SELENIUM LOTION

DE400 SELENIUM SHAMPOO

TN499 SELENIUM INJ,SOLN

GA204 SENNOSIDES (OTC) TAB

CN609 SERTRALINE SOLN,ORAL

CN609 SERTRALINE TAB

GU900 SEVELAMER CARBONATE TAB







CN203 SEVOFLURANE LIQUID,INHL

XA900 SHEATH HOLDER WITH VELCRO/FOAM SUPPLY

DE500 SILVER NITRATE APPLICATOR

DE101 SILVER SULFADIAZINE CREAM,TOP

GA900 SIMETHICONE (OTC) TAB,CHEWABLE

CV350 SIMVASTATIN TAB









IM600 SIROLIMUS SOLN,ORAL

IM600 SIROLIMUS TAB

XA604 SKIN BARRIER SUPPLY

XA900 SKIN CLEANSER, INTACT SUPPLY

XA199 SOCK, STUMP SUPPLY

TN440 SODIUM ACETATE INJ,SOLN

TN476 SODIUM BICARBONATE INJ,SOLN

GA110 SODIUM BICARBONATE (OTC) TAB

RS300 SODIUM BIPHOSPHATE/SODIUM PHOSPHATE (OTC) ENEMA

IR100 SODIUM CHLORIDE SOLN,IRRG

TN102 SODIUM CHLORIDE INJ,SOLN

RE900 SODIUM CHLORIDE (OTC) SOLN,INHL





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 40

NT900 SODIUM CHLORIDE (OTC) SOLN,NASAL

OP900 SODIUM CHLORIDE (OTC) OINT,OPH

OP900 SODIUM CHLORIDE (OTC) SOLN,OPH

PH000 SODIUM CITRATE INJ

PH000 SODIUM CITRATE POWDER

TN440 SODIUM CITRATE INJ,SOLN

OR100 SODIUM FLUORIDE (1.1%) CREAM,ORAL









OR100 SODIUM FLUORIDE (1.1%) GEL,DENT









OR100 SODIUM FLUORIDE (5%) VARNISH,DENT









DE101 SODIUM HYPOCHLORITE (OTC) SOLN,TOP

TN102 SODIUM LACTATE INJ,SOLN

CV490 SODIUM NITROPRUSSIDE INJ

GA202 SODIUM PHOSPHATE (EQV OSMOPREP) TAB

AD400 SODIUM POLYSTYRENE SULFONATE SUSP

AD400 SODIUM POLYSTYRENE SULFONATE SUSP,RTL

PH000 SORBITOL 70% SOLN,ORAL

CV100 SOTALOL HCL TAB

XA900 SPACER-INHALER CHAMBER

CV704 SPIRONOLACTONE TAB





AM800 R STAVUDINE (d4T) CAP,ORAL

XA199 STERI-STRIPS SUPPLY

XA608 STOMA CAP SUPPLY

BL115 STREPTOKINASE INJ

AM300 R STREPTOMYCIN SULFATE INJ





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 41

AN200 STREPTOZOCIN INJ

MS300 SUCCINYLCHOLINE INJ,SOLN

GA302 SUCRALFATE SUSP,ORAL

GA302 SUCRALFATE TAB

CN101 SUFENTANIL CITRATE INJ,SOLN

OP210 SULFACETAMIDE NA OINT,OPH

OP210 SULFACETAMIDE NA SOLN,OPH

DE500 SULFACETAMIDE NA 10%/SULFUR 5% LOTION,TOP

AM650 R SULFADIAZINE TAB

AM650 R SULFAMETHOXAZOLE/TRIMETHOPRIM INJ,SOLN

AM650 R SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP

AM650 R SULFAMETHOXAZOLE/TRIMETHOPRIM TAB

GA900 SULFASALAZINE TAB

GA900 SULFASALAZINE TAB,EC

MS102 SULINDAC TAB

CN105 SUMATRIPTAN SUCCINATE INJ

CN105 SUMATRIPTAN SUCCINATE TAB

DE300 SUNSCREEN SPF 30 OR GREATER PABA-FREE COMBINATION CREAM/LOTION,TOP

XA900 SUPPLIES,OTHER SUPPLY

XA900 SUSPENSORY SUPPORTER SUPPLY

XA900 SYRINGE MAGNIFIER SUPPLY

XA852 SYRINGE, LUER LOCK SUPPLY

IM600 TACROLIMUS INJ,SOLN

IM600 TACROLIMUS CAP,ORAL

DE900 TALC TOP(OTC) POWDER,TOP

AN500 TAMOXIFEN CITRATE TAB

CV150 TAMSULOSIN CAP.ORAL

XA202 TAPE CLOTH SUPPLY

XA204 TAPE FOAM SUPPLY

XA201 TAPE PAPER SUPPLY

XA299 TAPE PINK SUPPLY

XA203 TAPE PLASTIC SUPPLY

XA299 TAPE RETENTION SHEET SUPPLY

XA206 TAPE TRACH SUPPLY

CN302 TEMAZEPAM CAP,ORAL

BL115 TENECTEPLASE,RECOMBINANT INJ

AN900 TENIPOSIDE INJ

AM800 R TENOFOVIR DISOPROXIL FUMARATE TAB





CV150 TERAZOSIN HCL CAP,ORAL





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 42

AM700 R TERBINAFINE HCL TAB

DE102 TERBINAFINE HCL 1% CREAM,TOP

RE103 TERBUTALINE SULFATE TAB

AU100 TERBUTALINE SULFATE INJ

HS100 TESTOSTERONE PATCH

HS100 TESTOSTERONE (IN OIL) INJ (IN OIL)

IM300 TETANUS ANTITOXIN INJ,SOLN

IM500 TETANUS IMMUNE GLOBULIN INJ

CN204 TETRACAINE HCL INJ

OP700 TETRACAINE HCL SOLN,OPH

AM250 R TETRACYCLINE HCL CAP,ORAL

IM900 THALIDOMIDE CAP,ORAL









RE104 THEOPHYLLINE CAP,ORAL

RE104 THEOPHYLLINE CAP,SA

RE104 THEOPHYLLINE INJ

RE104 THEOPHYLLINE SOLN,ORAL

RE104 THEOPHYLLINE SYRUP

RE104 THEOPHYLLINE TAB

RE104 THEOPHYLLINE TAB,SA

AP200 THIABENDAZOLE TAB,CHEWABLE

VT105 THIAMINE INJ,SOLN

VT105 THIAMINE HCL (OTC) TAB

TN200 PWDR,ORAL

THICKENING AGENT

AN300 THIOGUANINE TAB

CN202 THIOPENTAL INJ,SOLN

CN701 THIORIDAZINE SOLN,ORAL

CN701 THIORIDAZINE TAB,EC

AN100 THIOTEPA INJ

CN701 THIOTHIXENE CAP,ORAL

NT300 THROAT LOZENGE LOZENGE

BL116 THROMBIN POWDER,TOP

AM113 R TICARCILLIN/CLAVULANATE K INJ









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 43

AM250 R TIGECYCLINE INJ,LYPHL









OP101 TIMOLOL GEL,OPH

OP101 TIMOLOL SOLN,OPH

RE105 TIOTROPIUM CAP,INHL





AM800 R TIPRANAVIR CAP,ORAL

BL110 TIROFIBAN INJ,SOLN

MS200 TIZANIDINE TAB







OP210 TOBRAMYCIN SOLN,OPH

AM300 R TOBRAMYCIN SULFATE INJ,SOLN

XA900 TONGUE DEPRESSOR SUPPLY

CN400 TOPIRAMATE TAB

AN900 TOPOTECAN INJ

TN490 TPN ELECTROLYTE INJ

TN490 TRACE ELEMENTS INJ

XA900 TRACH SUCTION KIT 2 GLOVES 14FR SUPPLY

XA900 TRACHEOSTOMY CARE KIT SUPPLY

XA199 TRACHEOSTOMY PAD SUPPLY

XA900 TRACHEOSTOMY TUBE SUPPLY

CN103 TRAMADOL HCL TAB

XA107 TRANSPARENT DRESSING SUPPLY

CN602 TRANYLCYPROMINE SULFATE TAB







OP109 TRAVOPROST SOLN,OPH

CN609 TRAZODONE TAB

DE752 TRETINOIN CREAM,TOP

DE752 TRETINOIN GEL,TOP

DE200 TRIAMCINOLONE CREAM,TOP

DE200 TRIAMCINOLONE OINT,TOP

HS051 TRIAMCINOLONE INJ,SUSP









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 44

HS051 TRIAMCINOLONE (PRESERVATIVE FREE) INJ,SUSP







OR900 TRIAMCINOLONE ACETONIDE DENTAL PASTE

CV704 TRIAMTERENE CAP,ORAL





DE500 TRICHLOROACETIC ACID 80% SOLN,TOP

IM900 TRICHOPHYTON INJ

CN701 TRIFLUOPERAZINE TAB

OP230 TRIFLURIDINE SOLN,OPH

AU350 TRIHEXYPHENIDYL TAB

GA605 TRIMETHOBENZAMIDE CAP,ORAL

AM900 R TRIMETHOPRIM TAB

TN900 TROMETHAMINE INJ

OP600 TROPICAMIDE SOLN,OPH

OP900 TRYPAN BLUE SOLN,OPH

DX300 TUBERBULIN,PURIFIED PROTEIN DERIVATIVE INJ

XA853 TUBERCULIN SYRINGE SUPPLY

XA900 TUBING LATEX SUPPLY

IM100 TYPHOID VACCINE INJ

XA199 UNNA BOOT SUPPLY

DE350 UREA CREAM/EMULSION,TOP

DE350 UREA LOTION/SUSPENSION,TOP

XA502 URINAL FEMALE SUPPLY

XA502 URINAL MALE SUPPLY

DX900 URINE GLUCOSE MONITORING DEVICES DEVICE

BL115 UROKINASE 5000U INJ

GA900 URSODIOL CAP,ORAL

GA900 URSODIOL TAB

AM800 R VALACYCLOVIR TAB

AM800 R VALGANCICLOVIR HCL TAB

CN400 VALPROIC ACID CAP,ORAL

CN400 VALPROIC ACID SYRUP

CV805 VALSARTAN TAB





AM900 R VANCOMYCIN INJ

AM900 R VANCOMYCIN HCL CAP,ORAL

GU900 VARDENAFIL HCL TAB









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 45

AD900 VARENICLINE TARTRATE TAB







IM500 VARICELLA ZOSTER IMMUNE GLOBULIN (HUMAN) INJ

HS702 VASOPRESSIN INJ,SOLN

MS300 VECURONIUM INJ

CN609 VENLAFAXINE (ER) TAB,SA

CN609 VENLAFAXINE (IR) TAB

CV200 VERAPAMIL HCL INJ,SOLN

CV200 VERAPAMIL HCL TAB





CV200 VERAPAMIL HCL TAB,SA





OP230 VIDARABINE OINT,OPH

AN900 VINBLASTINE INJ

AN900 VINCRISTINE INJ

AN900 VINORELBINE INJ

VT050 VITAMIN A (OTC) CAP,ORAL





VT109 VITAMIN B COMPLEX (OTC) CAP OR TAB

VT504 VITAMIN D (CHOLECALCIFEROL OR ERGOCALCIFEROL 400 Unit to 2000 Unit) CAP OR TAB

VT504 CAP OR TAB

VITAMIN D, HIGH DOSE (CHOLECALCIFEROL OR ERGOCALCIFEROL 50,000 Unit)

VT600 VITAMIN E CAP,ORAL





BL110 WARFARIN NA (COUMADIN) TAB

IR100 WATER SOLN,IRRG

PH000 WATER INJ,SOLN

RE900 WATER SOLN,INHL

XA900 WOUND CLEANSER SUPPLY

DX900 XYLOSE (OTC) POWDER

XA900 YANKAUER SUPPLY

AM800 R ZANAMIVIR INHL,ORAL







AM800 R ZIDOVUDINE CAP,ORAL

AM800 R ZIDOVUDINE INJ

AM800 R ZIDOVUDINE TAB

TN450 ZINC CHLORIDE INJ,SOLN

DE900 ZINC OXIDE (OTC) OINT,TOP





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 46

DE900 ZINC OXIDE (OTC) PASTE

DE400 ZINC PYRITHIONE 1% (OTC) SHAMPOO

TN450 ZINC SULFATE CAP,ORAL

TN450 ZINC SULFATE INJ,SOLN

CN709 ZIPRASIDONE CAP,ORAL









HS900 ZOLEDRONIC INJ,SOLN

CN105 ZOLMITRIPTAN TAB

CN105 ZOLMITRIPTAN TAB,ORAL DISINTEGRATING

CN309 ZOLPIDEM TAB

IM100 ZOSTER VACCINE INJ,LYPHL









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 47

dered non-formulary (although other dosage forms of that molecular entity may be included as formulary).

dividually. Formulary products may also be available in many dosage forms and strengths. In the case of

e those dosages available that are necessary to meet their patient needs.”









N level. These decisions should be based on local culture and sensitivity patterns. The restriction for all other products is as









Reference









In addition to abciximab, VISNs are required to add either http://www.pbm.va.gov/reviews/glycoprot

eptifibatide or tirofiban to their VISN formulary. Refer to VA/DoD einreview.pdf

IHD treatment guideline.

http://www.oqp.med.va.gov/cpg/DM/DM_base.htm









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 48

Restricted to GI and ID









http://www.pbm.va.gov/reviews/Bisphos3.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 49

http://www.pbm.va.gov/criteria/Parkinson.pdf

http://www.pbm.va.gov/criteria/Parkinson.pdf









http://www.pbm.va.gov/guidelines/Chronicobstrupulmonary.pdf



http://www.pbm.va.gov/monitoring/amiodaron.htm



http://www.pbm.va.gov/criteria/Dihydropy

ridine%20(Long-

Acting)%20Calcium%20Channel%20Blo

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm ckers.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 50

Restricted to neurology for treatment of acute hypomobility http://www.pbm.va.gov/monograph/apom

episode of advanced Parkinson's disease. orphine.pdf





RESTRICTED TO CRITERIA AND ONCOLOGY FOR http://vaww.national.cmop.va.gov/PBM/Cl

MODERATE AND HIGHLY EMETOGENIC CHEMOTHERAPY inical%20Guidance/Drug%20Monograph

s/Aprepitant%20Drug%20Monograph.do

c



http://www.pbm.va.gov/guidelines/Recom

mendations%20for%20Atypical%20Antip

sychotic%20Use%20in%20Schizophreni

http://www.pbm.va.gov/monograph/Aripiprazole%20IM%20Monogr a%20and%20Schizoaffective%20Disord

agh.doc ers.pdf

http://www.pbm.va.gov/monograph/Aripiprazole.pdf http://www.pbm.va.gov/guidelines/Recom

mendations%20for%20Atypical%20Antip

sychotic%20Use%20in%20Schizophreni

a%20and%20Schizoaffective%20Disord

ers.pdf









http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Recommendations%20for%20use%20

of%20Protease%20Inhibitors%20in%20HIV-

infected%20Treatment-naïve%20Veterans.doc



1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 51

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm









http://vaww.pbm.va.gov/criteria/87wry73Azacitidine.pdf http://www.pbm.va.gov/monograph/9paer

fAzacitidine.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 52

http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm 07.pdf









http://www.pbm.va.gov/criteria/Parkinson.pdf









http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Crite

ria%20For%20Use/Bevacizumab%20(Avastin)%20Systemic,%20

Criteria%20for%20Formulary%20Use.doc









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 53

See Beta-Adrenergic Blockers (Heart Failure) ,

Restricted to patients with heart failure Clinical Recommendations









http://vaww.national.cmop.va.gov/PBM/Cl

inical%20Guidance/Drug%20Monograph

s/Bortezomib%20Drug%20Monograph.d

Restricted to VA Hematologists and Oncologists oc









http://www.pbm.va.gov/criteria/Parkinson.pdf http://www.pbm.va.gov/reviews/Dopamin

e%20Agonists.pdf

http://www.pbm.va.gov/criteria/Parkinson.pdf http://www.pbm.va.gov/reviews/Dopamin

e%20Agonists.pdf

http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

07.pdf

http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

07.pdf







http://vaww.pbm.va.gov/criteria/Buprenorphine.pdf http://vaww.pbm.va.gov/drugmonograph/

BUPMonograph%20(Rev%2009Jun03).p

df

http://vaww.pbm.va.gov/criteria/Buprenorphine.pdf http://vaww.pbm.va.gov/drugmonograph/

BUPMonograph%20(Rev%2009Jun03).p

df



1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 54

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Crite

ria%20For%20Use/Calcitriol%20Ointment%20Criteria%20for%20

Use.doc









http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm 07.pdf









http://www.pbm.va.gov/criteria/Parkinson.pdf





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 55

http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

See Beta-Adrenergic Blockers (Heart Failure) , Clinical Recommendations 07.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 56

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm



Refer to PBM/MAP Hyperlipidmia treatment guidelines for use









http://www.pbm.va.gov/reviews/h2review.pdf



http://www.pbm.va.gov/criteria/Fluoroquinolone.pdf

http://www.pbm.va.gov/criteria/Fluoroquinolone.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 57

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm





http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm



http://www.pbm.va.gov/Clinical%20Guidance/Criteria%20For%20

Use/Clopidogrel,%20Criteria%20for%20Use.doc









http://www.pbm.va.gov/guidelines/Recommendations%20for%20A

typical%20Antipsychotic%20Use%20in%20Schizophrenia%20and

%20Schizoaffective%20Disorders.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 58

Refer to PBM/MAP Hyperlipidemia treatment guidelines for use

Refer to PBM/MAP Hyperlipidemia treatment guidelines for use









http://www.pbm.va.gov/reviews/CombinHT.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 59

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini http://vaww.national.cmop.va.gov/PBM/Cl

cal%20Recommendations/Gram%20Positive%20Agents%20(Dapt inical%20Guidance/Clinical%20Recomm

omycin,%20Linezolid,%20Quinupristin- endations/Gram%20Positive%20Agents

Dalfopristin,%20Tigecycline),%20Clinical%20Recommendations.d %20(Daptomycin,%20Linezolid,%20Quin

oc upristin-

Dalfopristin,%20Tigecycline),%20Checkb

ox%20Format.doc

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Anticoagulants,%20Selected%20Inject

able%20Agents%20Comparative%20Table.doc



Restricted to spinal cord injury, neurology, and rehabilitation

Restricted to spinal cord injury, neurology, and rehabilitation



http://vaww.national.cmop.va.gov/PBM/Cl

inical%20Guidance/Clinical%20Recomm

endations/Gram%20Positive%20Agents

%20(Daptomycin,%20Linezolid,%20Quin

upristin-

Dalfopristin,%20Tigecycline),%20Clinical

Restricted to ID %20Recommendations.doc



Restricted ID Practitioners or providers that provide care to HIV http://vaww.national.cmop.va.gov/PBM/Cl

patients inical%20Guidance/Clinical%20Recomm

endations/Recommendations%20for%20

use%20of%20Protease%20Inhibitors%2

0in%20HIV-infected%20Treatment-

naïve%20Veterans.doc









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 60

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Contraceptive%20agents,%20Formular

y%20Considerations.doc



http://www.pbm.va.gov/criteria/antiemeticdosing.pdf



http://www.pbm.va.gov/criteria/antiemeticdosing.pdf

http://www.pbm.va.gov/criteria/antiemeticdosing.pdf

http://www.pbm.va.gov/criteria/antiemeticdosing.pdf









http://vaww.national.cmop.va.gov/PBM/Cl

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Crite inical%20Guidance/Criteria%20For%20U

ria%20For%20Use/Dexmedetomidine%20ICU%20Criteria%20for se/Dexmedetomidine%20ICU%20Criteria

%20Formulary%20Use.doc %20for%20Formulary%20Use.doc









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 61

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Drug

%20Class%20Reviews/Ophthalmic%20NSAIDs-

Drug%20Class%20Review-FINAL.doc









http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%202007.pdf









http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm





http://www.pbm.va.gov/criteria/Dihydropyridine%20(Long- http://vaww.oqp.med.va.gov/CPGintra/cp

Acting)%20Calcium%20Channel%20Blockers.pdf g/HTN04/HTN_GOL.htm







http://www.pbm.va.gov/criteria/antiemeticdosing.pdf

http://www.pbm.va.gov/criteria/antiemeticdosing.pdf

http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm http://www.cdc.gov/vaccines/vpd-

vac/tetanus/

http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm http://www.cdc.gov/vaccines/vpd-

vac/tetanus/





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 62

http://www.pbm.va.gov/tig/DepakotTIG.pdf http://www.pbm.va.gov/tig/DepakoteProvi

derLetter.pdf









http://www.pbm.va.gov/criteria/Cholineste

rase%20Inhibitors%20Criteria%20for%2

0Use%20Updated%207.31.08.doc









http://www.pbm.va.gov/criteria/allhatstatement.pdf









http://www.pbm.va.gov/criteria/antiemeticdosing.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 63

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

07.pdf







http://www.pbm.va.gov/criteria/fuzeon.pdf

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Anticoagulants,%20Selected%20Inject

able%20Agents%20Comparative%20Table.doc

Neurologist treating Parkinson

Restricted to GI and ID

Restricted to GI and ID









http://www.pbm.va.gov/reviews/CombinHT.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 64

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm









http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Contraceptive%20agents,%20Formular

y%20Considerations.doc

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Contraceptive%20agents,%20Formular

y%20Considerations.doc

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Contraceptive%20agents,%20Formular

y%20Considerations.doc

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Contraceptive%20agents,%20Formular

y%20Considerations.doc

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Contraceptive%20agents,%20Formular

y%20Considerations.doc

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Contraceptive%20agents,%20Formular

y%20Considerations.doc

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Contraceptive%20agents,%20Formular

y%20Considerations.doc

http://www.pbm.va.gov/reviews/CombinHT.pdf









Restricted ID Practitioners or providers that provide care to HIV http://vaww.national.cmop.va.gov/PBM/Cl

patients inical%20Guidance/Drug%20Monograph

s/Etravirine.doc



1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 65

http://www.pbm.va.gov/reviews/h2review.pdf







Restricted to neurology service

http://www.pbm.va.gov/criteria/Dihydropyridine%20(Long- http://vaww.oqp.med.va.gov/CPGintra/cp

Acting)%20Calcium%20Channel%20Blockers.pdf g/HTN04/HTN_GOL.htm



http://www.pbm.va.gov/criteria/Fentanyl%20Transdermal%20Patc

h,%20Criteria%20for%20Use.doc









http://www.pbm.va.gov/criteria/alphablocker%20%20finasteride.pd

f

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Abbr

eviated%20Reviews/Flecainide%20and%20%20Propafenone%20

for%20Atrial%20Fibrillation,%20Abbreviated%20Review.doc









VISN's may prefer one formulary nasal steroid over another http://www.pbm.va.gov/reviews/intranasal

steroidreview.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 66

http://www.pbm.va.gov/Clinical%20Guidance/Drug%20Class%20

Reviews/Ophthalmic%20Nonsteroidal%20Anti-

Inflammatory%20Drugs%20(NSAIDs)%20Review.pdf



VISN's may prefer one formulary nasal steroid over another http://www.pbm.va.gov/reviews/intranasal

steroidreview.pdf









http://www.pbm.va.gov/monograph/Fond

http://www.pbm.va.gov/criteria/Fondaparinux%20Criteria%20For% aparinux%20Addendum%20(2nd%20upd

20Use.doc ate,%20July%202008).doc







http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

07.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 67

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

07.pdf

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

07.pdf

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

07.pdf

http://www.pbm.va.gov/criteria/Gabapentin.pdf

http://www.pbm.va.gov/criteria/Gabapentin.pdf

http://www.pbm.va.gov/criteria/Gabapentin.pdf

http://www.pbm.va.gov/criteria/Cholinesterase%20Inhibitors%20Cr

iteria%20for%20Use%20Updated%207.31.08.doc

http://www.pbm.va.gov/criteria/Cholinesterase%20Inhibitors%20Cr

iteria%20for%20Use%20Updated%207.31.08.doc









http://www.pbm.va.gov/Safety%20Reports/87ry38statin-fibrate-

Final.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 68

http://www.pbm.va.gov/criteria/multiplesclerosis.pdf

http://www.oqp.med.va.gov/cpg/DM/DM_base.htm









http://www.oqp.med.va.gov/cpg/DM/DM_base.htm









http://www.pbm.va.gov/reviews/LHRH(Jan%2003).pdf









http://www.cdc.gov/vaccines/vpd-vac/hib/









http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Anticoagulants,%20Selected%20Inject

able%20Agents%20Comparative%20Table.doc

http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm



http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 69

http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm









Sites can choose whether to supply bovine or ovine source http://vaww.national.cmop.va.gov/PBM/Cl

inical%20Guidance/Drug%20Monograph

s/Hyaluronidase%20Monograph%20(Am

phadase,%20Hydase,%20Vitrase,%20Hy

lenex)%20Final.doc



http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

07.pdf

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm



http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm





http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm



http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm



http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 70

http://vaww.pbm.va.gov/criteria/Gleevec%20Criteria.pdf http://vaww.pbm.va.gov/drugmonograph/

Gleevec.pdf





http://www.pbm.va.gov/criteria/Imiquimod.pdf





http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm









http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm http://vaww.national.cmop.va.gov/PBM/Cl

inical%20Guidance/Criteria%20For%20U

se/Antiviral%20Agents%20for%20Influen

za%20Criteria%20for%20Formulary%20

Use.doc





http://www.oqp.med.va.gov/cpg/DM/DM_base.htm

http://www.oqp.med.va.gov/cpg/DM/DM_base.htm

http://www.oqp.med.va.gov/cpg/DM/DM_base.htm

http://www.oqp.med.va.gov/cpg/DM/DM_base.htm

http://www.oqp.med.va.gov/cpg/DM/DM_base.htm

http://www.oqp.med.va.gov/cpg/DM/DM_base.htm



1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 71

http://www.oqp.med.va.gov/cpg/DM/DM_base.htm



VISNs will determine which interferon alfa products are necessary

to meet patient needs.



http://www.pbm.va.gov/criteria/multiplesclerosis.pdf

http://www.pbm.va.gov/criteria/multiplesclerosis.pdf









http://www.pbm.va.gov/criteria/HighlyTeratogenicRetinoidsAndHig

h-DoseVitaminACFU.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 72

http://www.pbm.va.gov/Clinical%20Guidance/Drug%20Class%20

Reviews/Ophthalmic%20Nonsteroidal%20Anti-

Inflammatory%20Drugs%20(NSAIDs)%20Review.pdf



http://www.pbm.va.gov/www.pbm.va.gov/criteria/Beta-

Adrenergic%20Blockers%20(Heart%20Failure),%20Clinical%20R

ecommendations.doc









http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Recommendations%20for%20use%20

of%20Protease%20Inhibitors%20in%20HIV-

infected%20Treatment-naïve%20Veterans.doc







http://www.pbm.va.gov/Clinical%20Guidance/Criteria%20For%20

Use/Phosphate%20Binder%20(Lanthanum,%20Sevelamer),%20C

riteria%20for%20Formulary%20Use.doc



http://vaww.national.cmop.va.gov/PBM/Cl

inical%20Guidance/Drug%20Monograph

s/Lenalidomide%20Drug%20Monograph.

Restricted to VA Hematologists and Oncologists doc









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 73

http://vaww.pbm.va.gov/criteria/Levetiracetam.pdf



http://www.pbm.va.gov/criteria/Fluoroquinolone.pdf









http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini http://vaww.national.cmop.va.gov/PBM/Cl

cal%20Recommendations/Gram%20Positive%20Agents%20(Dapt inical%20Guidance/Clinical%20Recomm

omycin,%20Linezolid,%20Quinupristin- endations/Gram%20Positive%20Agents

Dalfopristin,%20Tigecycline),%20Clinical%20Recommendations.d %20(Daptomycin,%20Linezolid,%20Quin

oc upristin-

Dalfopristin,%20Tigecycline),%20Checkb

ox%20Format.doc

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini http://vaww.national.cmop.va.gov/PBM/Cl

cal%20Recommendations/Gram%20Positive%20Agents%20(Dapt inical%20Guidance/Clinical%20Recomm

omycin,%20Linezolid,%20Quinupristin- endations/Gram%20Positive%20Agents

Dalfopristin,%20Tigecycline),%20Clinical%20Recommendations.d %20(Daptomycin,%20Linezolid,%20Quin

oc upristin-

Dalfopristin,%20Tigecycline),%20Checkb

ox%20Format.doc

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%2020

07.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 74

http://www.pbm.va.gov/ClinicalRecommendations.aspx

http://www.pbm.va.gov/reviews/HMGStatAppendix1.pdf http://www.pbm.va.gov/faq%20sheets/RE

VERSAL%20AND%20PROVE-

IT%20FAQ%20Sheet.pdf









Restricted ID Practitioners or providers that provide care to HIV http://www.pbm.va.gov/monograph/Mara

patients viroc,%20Drug%20Monograph.pdf



http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm









http://www.pbm.va.gov/reviews/CombinHT.pdf









http://www.pbm.va.gov/criteria/Memantine%20Criteria%20for%20

Use%20Updated%207.31.08.doc

http://www.cdc.gov/vaccines/recs/schedul

Preferred for ages 2 - 55 years old* for conjugate form es/adult-schedule.htm

Preferred for ages greater than 55 years old http://www.cdc.gov/vaccines/recs/schedul

es/adult-schedule.htm





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 75

http://www.pbm.va.gov/criteria/meperidine.pdf









http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Contraceptive%20agents,%20Formular

y%20Considerations.doc

http://www.pbm.va.gov/guidelines/Chronicobstrupulmonary.pdf

http://www.oqp.med.va.gov/cpg/DM/DM_base.htm http://www.pbm.va.gov/criteria/TZD%20cr

iteria.pdf

http://vaww.pbm.va.gov/monitoring/Methadone%20Dosing%20Fin

al%20(Rev%20081103).pdf

http://vaww.pbm.va.gov/monitoring/Methadone%20Dosing%20Fin

al%20(Rev%20081103).pdf









http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm









http://www.pbm.va.gov/criteria/antiemeticdosing.pdf





1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 76

http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%202007.pdf

http://www.pbm.va.gov/www.pbm.va.gov/criteria/Beta- http://www.pbm.va.gov/guidelines/PBM-

Adrenergic%20Blockers%20(Heart%20Failure),%20Clinical%20R MAP%20HF%20CPG%20Update%2020

ecommendations.doc 07.pdf

http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm



Restricted to CHF patients









See Beta-Adrenergic Blockers (Heart Failure) ,

Clinical Recommendations









Restricted to dentistry



http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 77

http://www.pbm.va.gov/criteria/Montelukast%20Criteria%20for%20

Use.doc









http://www.pbm.va.gov/criteria/Fluoroquinolone.pdf

http://www.pbm.va.gov/criteria/Fluoroquinolone.pdf

http://www.pbm.va.gov/criteria/Moxifloxacin%20Ophthalmic%20So

lution.pdf



http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Criteria%20For%20Us

e/HDVS%20in%20AMD%20update%20jan%202010%20final.doc

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Criteria%20For%20Us

e/HDVS%20in%20AMD%20update%20jan%202010%20final.doc









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 78

http://vaww.national.cmop.va.gov/PBM/Cl

Restricted to neurology or practitioners who treat multiple sclerosis inical%20Guidance/Drug%20Monograph

patients. s/Natalizumab.doc









http://www.pbm.va.gov/reviews/niacinreview.pdf

http://www.pbm.va.gov/reviews/niacinreview.pdf Niaspan and Slo-Niacin only



http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/For

ms/AllItems.aspx?RootFolder=%2fPBM%2fClinical%20Guidance

%2fCriteria%20For%20Use&FolderCTID=&View=%7b786029AE

%2d74D9%2d40BC%2dBCC7%2dBECF18B1B7FD%7d

http://www.oqp.med.va.gov/cpg/TUC3/TUC_Base.htm

http://www.oqp.med.va.gov/cpg/TUC3/TUC_Base.htm

http://www.oqp.med.va.gov/cpg/TUC3/TUC_Base.htm

http://www.pbm.va.gov/criteria/Dihydropyridine%20(Long- http://vaww.oqp.med.va.gov/CPGintra/cp

Acting)%20Calcium%20Channel%20Blockers.pdf g/HTN04/HTN_GOL.htm









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 79

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini

cal%20Recommendations/Contraceptive%20agents,%20Formular

y%20Considerations.doc









http://www.pbm.va.gov/guidelines/Recom

mendations%20for%20Atypical%20Antip

sychotic%20Use%20in%20Schizophreni

a%20and%20Schizoaffective%20Disord

http://www.pbm.va.gov/monograph/21389Olanzapine%20IM.pdf ers.pdf

http://www.pbm.va.gov/guidelines/Recom

mendations%20for%20Atypical%20Antip

sychotic%20Use%20in%20Schizophreni

a%20and%20Schizoaffective%20Disord

ers.pdf



http://www.pbm.va.gov/criteria/antiemeticdosing.pdf

http://www.pbm.va.gov/criteria/antiemeticdosing.pdf







1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 80

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Crite

ria%20For%20Use/Antiviral%20Agents%20for%20Influenza,%20

Criteria%20for%20Formulary%20Use.doc









http://vaww.pbm.va.gov/drugmonograph/98472Oxaliplatin%20Add http://vaww.pbm.va.gov/drugmonograph/

edn.pdf Oxaliplatin2.pdf



http://vaww.pbm.va.gov/criteria/Oxycodone%20Final%20Algorithm http://vaww.pbm.va.gov/criteria/oxycodon

%20(Rev%2020Aug03).pdf ecriteria.pdf

http://vaww.pbm.va.gov/criteria/Oxycodone%20Final%20Algorithm http://vaww.pbm.va.gov/criteria/oxycodon

%20(Rev%2020Aug03).pdf ecriteria.pdf









http://vaww.national.cmop.va.gov/PBM/Cl

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Drug inical%20Guidance/Criteria%20For%20U

%20Monographs/Paliperidone%20palmitate%20IM%20Monograp se/Paliperidone%20palmitate%20IM%20

h.doc Criteria%20for%20Use.doc







http://www.pbm.va.gov/criteria/IV%20PA

http://www.pbm.va.gov/criteria/IV%20PAN%20CFU.pdf N%20CFU%20Lit.pdf

http://www.pbm.va.gov/Clinical%20Guida

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Crite nce/Drug%20Monographs/HPV%20Vacc

ria%20For%20Use/HPV%20Vaccine,%20Quadrivalent%20(Garda ine,%20Quadrivalent%20(Gardasil).pdf

sil),%20Criteria%20for%20Formulary%20Use.doc









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 81

http://vaww.pbm.va.gov/criteria/Pegylated.pdf









SPRAY AND STRETCH TOP AEROSOL









http://www.pbm.va.gov/criteria/Monoamin

e%20Oxidase%20Inhibitors%20(MAOI).p

Restricted to psychiatry/mental health providers df









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 82

http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm







http://www.cdc.gov/vaccines/vpd-vac/polio/









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 83

http://www.pbm.va.gov/criteria/Fluvastatin,%20Pravastatin,%20Ato

rvastatin,%20Rosuvastatin%20Criteria.pdf

http://www.pbm.va.gov/criteria/allhatstatement.pdf









All oral formulations have been discontinued





http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf









http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Abbr

eviated%20Reviews/Flecainide%20and%20%20Propafenone%20

for%20Atrial%20Fibrillation,%20Abbreviated%20Review.doc









http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm



http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm









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http://www.pbm.va.gov/guidelines/Recom

mendations%20for%20Atypical%20Antip

sychotic%20Use%20in%20Schizophreni

a%20and%20Schizoaffective%20Disord

ers.pdf







http://www.cdc.gov/vaccines/vpd-vac/rabies/

Restricted to ID providers or providers that provide care to HIV http://vaww.national.cmop.va.gov/PBM/Cl

patients. inical%20Guidance/Criteria%20For%20U

se/Raltegravir,%20Criteria%20for%20Us

e.doc

http://www.pbm.va.gov/monograph/Ranib

Restricted to wet AMD, ophthalmology/retinal specialists izumab,%20Monograph.pdf



http://www.pbm.va.gov/reviews/h2review.pdf

http://www.pbm.va.gov/Clinical%20Guidance/Drug%20Monograph

s/Regadenoson,%20Drug%20Monograph.doc





http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 85

Restricted to neurology or locally designated subject matter expert

for the treatment of ALS only.









http://www.pbm.va.gov/reviews/Bisphos3.pdf

http://vaww.pbm.va.gov/drugmonograph/

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Crite 095809RConstamonographfinal.pdf

ria%20For%20Use/Risperidone%20Long-

acting%20IM%20Criteria%20for%20Use.doc

http://www.pbm.va.gov/guidelines/Recommendations%20for%20A

typical%20Antipsychotic%20Use%20in%20Schizophrenia%20and

%20Schizoaffective%20Disorders.pdf

http://www.pbm.va.gov/guidelines/Recommendations%20for%20A

typical%20Antipsychotic%20Use%20in%20Schizophrenia%20and

%20Schizoaffective%20Disorders.pdf





Restricted to oncology and per criteria for Use for Rituximab in http://vaww.national.cmop.va.gov/PBM/Cl

Moderate to Severe Rheumatoid Arthritis. inical%20Guidance/Criteria%20For%20U

se/DMARDs%20for%20Rheumatoid%20

Arthritis%20(Leflunomide%20and%20Bio

logic%20Agents),%20Criteria%20for%20

Use.pdf



http://www.pbm.va.gov/criteria/Parkinson.pdf http://www.pbm.va.gov/reviews/Dopamin

e%20Agonists.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 86

http://www.pbm.va.gov/monitoring/antiemeticdosing.pdf





http://www.pbm.va.gov/criteria/Monoamin

e%20Oxidase%20Inhibitors%20(MAOI).p

Restricted to psychiatry/mental health providers df









http://www.pbm.va.gov/Clinical%20Guidance/Criteria%20For%20

Use/Phosphate%20Binder%20(Lanthanum,%20Sevelamer),%20C

riteria%20for%20Formulary%20Use.doc









http://www.pbm.va.gov/faq%20sheets/REVERSAL%20AND%20P http://www.pbm.va.gov/reviews/HMGStat

ROVE-IT%20FAQ%20Sheet.pdf Appendix1.pdf

http://www.pbm.va.gov/reviews/HMGStati

ns04-09-03.pdf









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http://vaww.national.cmop.va.gov/PBM/Cl

inical%20Guidance/Clinical%20Recomm

endations/Recommendations%20for%20

Restrict to Dental according to risk category algorithm in Use%20of%20Fluorides%20in%20Medic

information letter (recommendations for use of fluorides in medical al%20Management%20of%20Dental%20

management of dental caries) Caries.pdf

http://vaww.national.cmop.va.gov/PBM/Cl

inical%20Guidance/Clinical%20Recomm

endations/Recommendations%20for%20

Restricted to Dental for use in patients with head / neck cancer or Use%20of%20Fluorides%20in%20Medic

with custom made trays according to risk category algorithm in al%20Management%20of%20Dental%20

information letter Caries.pdf

http://vaww.national.cmop.va.gov/PBM/Cl

inical%20Guidance/Clinical%20Recomm

endations/Recommendations%20for%20

Restrict to Dental according to risk category algorithm in Use%20of%20Fluorides%20in%20Medic

information letter (recommendations for use of fluorides in medical al%20Management%20of%20Dental%20

management of dental caries) Caries.pdf









http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%202007.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 88

Restricted to ID and GI providers or providers that provide care to

Hepatitis B

http://www.pbm.va.gov/criteria/allhatstatement.pdf



1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 89

http://vaww.national.cmop.va.gov/PBM/Cl

inical%20Guidance/Abbreviated%20Revi

ews/Thalidomide%20Abreviated%20Dru

Restricted to VA Hematologists and Oncologists g%20Monograph.doc









http://www.pbm.va.gov/criteria/Thickening%20Agents%20for%20O

utpatients.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 90

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Clini http://vaww.national.cmop.va.gov/PBM/Cl

cal%20Recommendations/Gram%20Positive%20Agents%20(Dapt inical%20Guidance/Clinical%20Recomm

omycin,%20Linezolid,%20Quinupristin- endations/Gram%20Positive%20Agents

Dalfopristin,%20Tigecycline),%20Clinical%20Recommendations.d %20(Daptomycin,%20Linezolid,%20Quin

oc upristin-

Dalfopristin,%20Tigecycline),%20Checkb

ox%20Format.doc





http://www.pbm.va.gov/criteria/Tiotropium%20Criteria%20for%20U

se.doc

http://vaww.pbm.va.gov/criteria/es78wTipranavir.pdf



Tizanidine is restricted to spinal cord injury, neurology,

rehabilitation, pain management specialists, and traumatic brain

injury clinics









http://www.pbm.va.gov/criteria/Monoamin

e%20Oxidase%20Inhibitors%20(MAOI).p

Restricted to psychiatry/mental health providers df









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 91

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Abbr

eviated%20Reviews/Preservative%20Free%20Triamcinolone%20

Acetonide.doc



http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm









http://www.pbm.va.gov/criteria/Parkinson.pdf

Restricted to use with Apomorphine









http://www.cdc.gov/vaccines/vpd-vac/typhoid/









Restricted to ID and Transplant MD's or transplant providers





Restricted to treatment of patients with systolic heart failure"

http://www.pbm.va.gov/ClinicalRecommendations.aspx





http://www.pbm.va.gov/criteria/Vardenafil%20Non-Responders.pdf









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Restricted to the VA/DoD Tobacco Use Cessation Clinical Practice http://www.pbm.va.gov/criteria/Vareniclin

Guidelines e%20Criteria%20for%20Prescribing.doc









http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm http://www.pbm.va.gov/tig/felodipine.pdf



http://vaww.oqp.med.va.gov/CPGintra/cpg/HTN04/HTN_GOL.htm http://www.pbm.va.gov/tig/felodipine.pdf









http://www.pbm.va.gov/criteria/Highly%20Teratogenic%20Retinoid

s%20and%20High-dose%20Vitamin%20A.pdf



For use as a vitamin supplement

Not a vitamin supplement, restricted to 9 doses per 30 day supply



http://www.pbm.va.gov/vamedsafe/Vitamin%20E-

Va%20medsafe.pdf









http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Crite

ria%20For%20Use/Antiviral%20Agents%20for%20Influenza,%20

Criteria%20for%20Formulary%20Use.doc









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http://www.pbm.va.gov/criteria/zipracriteria.pdf







http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Crite http://vaww.national.cmop.va.gov/PBM/Cl

ria%20For%20Use/Zoledronic%20Acid%20(Reclast),%20Criteria inical%20Guidance/Criteria%20For%20U







http://www.pbm.va.gov/Clinical%20Guidance/Drug%20Monograph http://www.pbm.va.gov/Clinical%20Guida

s/Zoster%20Vaccine.pdf nce/Criteria%20For%20Use/Zoster%20V

accine%20Criteria%20for%20Use%20(R

ev%2020080714).doc









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http://vaww.national.cmop.va.gov/PBM/Clinical%20Guid

ance/Drug%20Monographs/Aprepitant%20Drug%20Mon

ograph.doc









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1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 99

1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 100

http://www.pbm.va

.gov/guidelines/P

BM-

http://www.pbm.va.gov/www.pbm.va.gov/criteria/Beta- MAP%20HF%20

Adrenergic%20Blockers%20(Heart%20Failure),%20Clini CPG%20Update

cal%20Recommendations.doc %202007.pdf









1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 101

1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 102

http://vaww.oqp.m

http://www.pbm.va.gov/www.pbm.va.gov/criteria/Beta- ed.va.gov/CPGintr

Adrenergic%20Blockers%20(Heart%20Failure),%20Clini a/cpg/HTN04/HT

cal%20Recommendations.doc N_GOL.htm









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http://vaww.national.cmop.va.gov/PBM/Clinical%20Guid

ance/Clinical%20Recommendations/Gram%20Positive

%20Agents%20(Daptomycin,%20Linezolid,%20Quinupri

stin-

Dalfopristin,%20Tigecycline),%20Checkbox%20Format.

doc









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http://vaww.national.cmop.va.gov/PBM/Clinical%20Guid

ance/Abbreviated%20Reviews/Dexmedetomidine%20A

bbreviated%20Monograph%20(Update%209-09).doc









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1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 111

http://vaww.national.cmop.va.gov/PBM/Clinical%20Guid

ance/Criteria%20For%20Use/Etravirine,%20Criteria%20

for%20Use.doc



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http://vaww.national.cmop.va.gov/PBM/Clinical%20Guid

ance/Clinical%20Recommendations/Anticoagulants,%2

0Selected%20Injectable%20Agents%20Comparative%2

0Table.doc









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http://www.pbm.va.gov/reviews/HMGStatins04-09-03.pdf









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http://www.cdc.gov/vaccines/vpd-vac/mening/



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1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 125

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1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 130

http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf









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http://www.pbm.va.gov/monograph/Raltegravir.doc









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http://www.pbm.va.gov/monograph/Selegiline%20Trans

dermal%20System%20(EMSAM).pdf









http://www.pbm.va.gov/Safety%20Reports/87ry38statin-

fibrate-Final.pdf









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1a313917-8b56-4b4f-b582-e35c844b5856.xls Page 138

http://www.pbm.va.gov/guidelines/PBM-

MAP%20HF%20CPG%20Update%202007.pdf









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http://www.oqp.med.va.gov/cpg/TUC3/TUC_Base.htm









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http://www.pbm.va.gov/guidelines/Recommendations%2

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http://www.pbm.va.gov/Clinical%20Guidance/FAQ%20S

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