VA National Formulary June

DEPARTMENT OF VETERANS AFFAIRS PHARMACY BENEFITS MANAGEMENT STRATEGIC HEALTH GROUP http://www.pbm.va.gov/ http://vaww.pbm.va.gov VHA NATIONAL FORMULARY Jun-08 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 entity may be included as formulary). Dosage forms such as TAB and CAP, ORAL are considered immediate release. Sustained release products are listed individua also be available in many dosage forms and strengths. In the case of products with multiple dosage forms and strengths, not all forms and strengths need to be stock those dosages available that are necessary to meet their patient needs.” 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 The restriction for all other products is as otherwise noted. VA Restriction Class DE350 AM800 R AM800 R AM800 R AM800 R BL117 Generic A & D OINT (OTC) ABACAVIR ABACAVIR ABACAVIR/LAMIVUDINE ABACAVIR/LAMIVUDINE/ZIDOVUDINE ABCIXIMAB Dosage Form TOP,OINT SOLN,ORAL TAB TAB TAB INJ,SOLN HS502 CN103 CN103 CN103 CN103 CN101 CN101 CN101 CN101 ACARBOSE ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN/BUTALBITAL/CAFFEINE ACETAMINOPHEN/HYDROCODONE ACETAMINOPHEN/HYDROCODONE ACETAMINOPHEN/OXYCODONE HCL ACETAMINOPHEN/OXYCODONE HCL TAB LIQUID,ORAL SUPP,RTL TAB TAB LIQUID,ORAL TAB CAP,ORAL LIQUID,ORAL d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 1 CN101 CV703 CV703 IR100 OT109 OT109 OT250 DE102 OP102 AD600 RE400 DE810 AM800 AM800 DE103 AM800 AM800 CV300 XA603 XA603 XA699 OP500 AP200 BL500 RE102 RE102 RE103 RE109 RE109 DE101 TN900 TN101 IM700 HS900 CN101 GA199 IM900 MS400 GA199 GA199 CN302 HS875 R R R R ACETAMINOPHEN/OXYCODONE HCL ACETAZOLAMIDE ACETAZOLAMIDE ACETIC ACID ACETIC ACID ACETIC ACID/ALUMINUM ACETATE ACETIC ACID/HYDROCORTISONE ACETONE/BASIC FUCHSIN/BORIC ACID/RESORCINOL ACETYLCHOLINE CHLORIDE ACETYLCYSTEINE ACETYLCYSTEINE ACITRETIN ACYCLOVIR ACYCLOVIR ACYCLOVIR ACYCLOVIR ADEFOVIR ADENOSINE ADHESIVE AEROSOL ADHESIVE CEMENT ADHESIVE REMOVER AK-RINSE ALBENDAZOLE ALBUMIN,HUMAN ALBUTEROL ALBUTEROL ALBUTEROL ALBUTEROL/IPRATROPIUM ALBUTEROL/IPRATROPIUM ALCOHOL ISOPROPYL 70% ALCOHOL, ABSOLUTE ALCOHOL/DEXTROSE ALDESLEUKIN ALENDRONATE ALFENTANIL HCL ALGINIC AC/NA BICARB/CA STEAR/MG TRI (OTC) ALLERGENIC EXTRACT (VARIOUS) ALLOPURINOL ALOH/MG CARB/NA ALGINATE (OTC) ALOH/MGOH/SIMTH (OTC) ALPRAZOLAM ALPROSTADIL TAB INJ TAB SOLN,IRRG SOLN,OTIC SOLN,OTIC SOLN,OTIC LIQUID,TOP SOLN,OPH INJ,SOLN SOLN,INHL/ORAL CAP,ORAL CAP,ORAL INJ OINT,TOP TAB TAB INJ,SOLN SPRAY,TOP LIQUID,TOP LIQUID,TOP SOLN,OPH IRRG TAB INJ INHALANT SOLN,INHL TAB INHL,ORAL INHL,SOLN LIQUID,TOP INJ,SOLN INJ INJ TAB INJ,SOLN TAB,CHEWABLE INJ,SOLN TAB TAB LIQUID,ORAL TAB INJ d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 2 HS875 BL115 DE450 GA101 GA101 DE900 AM800 R AM800 R AM300 R TN501 TN501 BL116 BL116 RE104 CV300 CV300 CN601 CV200 RE900 TN499 DE350 DE350 AM111 AM111 AM111 AM111 AM700 AM700 AM111 AM111 CV250 BL400 AN900 DE820 BL500 OT400 IM900 IM900 IM300 CN500 ALPROSTADIL URETHRAL ALTEPLASE, RECOMBINANT ALUMINUM CHLORIDE (HEXAHYDRATE) ALUMINUM HYDROXIDE ALUMINUM HYDROXIDE ALUMINUM SULFATE/CALCIUM ACETATE (OTC) AMANTADINE HCL AMANTADINE HCL AMIKACIN SULFATE AMINO ACIDS AMINO ACIDS/DEXTROSE AMINOCAPROIC ACID AMINOCAPROIC ACID AMINOPHYLLINE DIHYDRATE AMIODARONE AMIODARONE AMITRIPTYLINE HCL AMLODIPINE AMMONIA,AROMATIC AMMONIUM CHLORIDE AMMONIUM LACTATE AMMONIUM LACTATE AMOXICILLIN AMOXICILLIN AMOXICILLIN/CLAVULANATE K AMOXICILLIN/CLAVULANATE K AMPHOTERICIN B AMPHOTERICIN B LIPID COMPLEX AMPICILLIN NA AMPICILLIN NA/SULBACTAM NA AMYL NITRITE ANAGRELIDE ANASTROZOLE ANTHRALIN ANTIHEMOPHILIC FACTOR,HUMAN ANTIPYRINE/BENZOCAINE/GLYCERIN OTIC ANTI-THYMOCYTE GLOBULIN ANTI-THYMOCYTE GLOBULIN ANTIVENIN,CROTALIDAE POLYVALENT APOMORPHINE SUPPOSITORY INJ,PWDR SOLN,TOP CAP,ORAL LIQUID,ORAL POWDER,TOP CAP,ORAL SYRUP INJ,SOLN INJ,SOLN INJ,SOLN INJ,SOLN TAB INJ,SOLN INJ,SOLN TAB TAB TAB INHL,NASAL INJ,SOLN CREAM LOTION CAP,ORAL PWDR,RENST-ORAL PWDR,RENST-ORAL TAB INJ INJ INJ INJ INHALANT CAP,ORAL TAB CREAM,TOP INJ SOLN,OTIC INJ,PWDR INJ,SOLN INJ INJ,SOLN R R R R R R R R d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 3 XA900 OP900 BL116 BL110 CN709 CN709 APPLIANCE CLEANSING SUPPLIES APRACLONIDINE HCL APROTININ ARGATROBAN ARIPIPRAZOLE ARIPIPRAZOLE SUPPLY SOLN,OPH INJ,SOLN INJ,SOLN INJ,SOLN TAB OR500 OP500 OP500 OP500 VT400 VT400 AN900 CN103 CN103 CN103 CN103 CN103 CN103 CN103 BL117 AM800 R CV100 CV100 CV400 AP109 MS300 AU350 GA208 OP600 OP600 MS160 MS160 AN300 IM600 IM600 AM200 AM200 AM200 AM119 ARTIFICIAL SALIVA (OTC) ARTIFICIAL TEARS METHYLCELLULOSE (OTC) ARTIFICIAL TEARS POLYVINYL ALCOHOL (PF) (OTC) ARTIFICIAL TEARS SOLN (OTC) ASCORBIC ACID INJ ASCORBIC ACID ORAL (OTC) ASPARAGINASE ASPIRIN ASPIRIN (OTC) ASPIRIN (OTC) ASPIRIN (OTC) ASPIRIN BUFFERED (OTC) ASPIRIN/BUTALBITAL/CAFFEINE ASPIRIN/BUTALBITAL/CAFFEINE ASPIRIN/DIPYRIDAMOLE ATAZANIVIR ATENOLOL ATENOLOL ATENOLOL/CHLORTHALIDONE ATOVAQUONE ATRACURIUM ATROPINE SO4 ATROPINE SO4 /DIPHENOXYLATE HCL ORAL ATROPINE SULFATE ATROPINE SULFATE AURANOFIN AUROTHIOGLUCOSE AZACITIDINE AZATHIOPRINE AZATHIOPRINE AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZTREONAM SOLN,ORAL SOLN,OPH SOLN,OPH SOLN,OPH INJ,SOLN TAB INJ SUPP,RTL TAB TAB,CHEWABLE TAB,EC TAB CAP,ORAL TAB CAP,SA CAP,ORAL INJ TAB TAB SUSP INJ INJ,SOLN TAB OINT,OPH SOLN,OPH CAP,ORAL INJ,SUSP INJ,SUSP INJ,SOLN TAB INJ,PWDR PWDR,RENST-ORAL TAB INJ R R R R d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 4 AM900 R OP210 DE101 DE109 DE109 OP350 OP219 OP219 MS200 MS200 XA501 XA799 XA607 XA508 XA508 XA508 XA508 GA900 DE900 XA108 XA108 XA109 XA104 XA604 IM600 DE350 IM100 AN900 XA900 CN101 XA605 CV800 OP900 OP900 NT300 NT300 XA604 DE900 RE302 DE752 DE752 DE752 AU350 AU350 BACITRACIN BACITRACIN BACITRACIN (OTC) BACITRACIN 500/POLYMYXIN 10000U/GM (OTC) BACITRACIN 500/POLYMYXIN 10000U/GM (OTC) BACITRACIN/HC /NEO/POLYMYX BACITRACIN/NEOMYCIN/POLYMYXIN BACITRACIN/POLYMYXIN BACLOFEN BACLOFEN BAG BEDSIDE URINARY BAG BAG FEEDING W/TUBE BAG IRRIGATOR W/CONE BAG LEG DISPOSABLE BAG LEG DISPOSABLE, FLIP-FLOW BAG LEG REUSABLE BAG LEG REUSABLE W/VALVE BALSALAZIDE DISODIUM BALSAM PERU/CASTOR OIL/TRYPSIN BANDAGE ELASTIC BANDAGE ELASTIC ADHESIVE BANDAGE TUBULAR ELASTIC BANDAGE,ADHESIVE (1IN X 3IN) (PLASTIC, FABRIC) BARRIER OSTOMY TWO-PIECE FLANGE SIZE 1 1/2" - 4" BASILIXIMAB BATH OIL (OTC) BCG VACCINE BCG,TICE VACCINE BEDPAN DISPOSABLE BELLADONA/OPIUM BELT OSTOMY BENAZEPRIL BENOXINATE HCL/FLUORESCEIN NA BENZALKONIUM CHLORIDE/TYLOXAPOL OPH SOLN (OTC) BENZOCAINE (OTC) BENZOCAINE /CETYLPYRIDINIUM CL LOZENGE (OTC) BENZOIN BENZOIN COMPOUND 30%/ISOPROPYL ALCOHOL 44.8% SPRAY (OTC) BENZONATATE BENZOYL PEROXIDE BENZOYL PEROXIDE BENZOYL PEROXIDE 5%/ERYTHROMYCIN 3% TOP GEL BENZTROPINE MESYLATE BENZTROPINE MESYLATE INJ OINT,OPH OINT,TOP OINT,TOP POWDER,TOP OINT,OPH OINT,OPH OINT,OPH INJ TAB SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY CAP,ORAL AEROSOL,TOP SUPPLY SUPPLY SUPPLY BANDAGE SUPPLY INJ OIL,TOP INJ INJ,LYPHL SUPPLY SUPP,RTL SUPPLY TAB SOLN,OPH SOLN,OPH GEL,DENT LOZENGE TINCTURE,TOP LIQUID,AEROSOL CAP,ORAL GEL,TOP LOTION GEL,TOP INJ TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 5 DE200 DE200 DE200 DE200 DE200 OP101 AU300 AU300 AN900 RS300 RS300 GA204 GA209 GA208 GA208 CV100 BL110 AN200 DX900 DX900 DX900 XA502 IM300 XA900 XA305 OP109 AU900 AU900 CV702 CV702 CN204 CN204 CN204 CN101 BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE VALERATE BETAMETHASONE VALERATE BETAMETHASONE VALERATE BETAXOLOL BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE BICALUTAMIDE BISACODYL BISACODYL (OTC) BISACODYL (OTC) BISACODYL/PHOSPHO SODA BISMUTH SUBSALICYLATE BISMUTH SUBSALICYLATE BISOPROLOL BIVALIRUDIN BLEOMYCIN SO4 BLOOD GLUCOSE MONITORING BLOOD GLUCOSE MONITORING BLOOD GLUCOSE MONITORING BOTTLES/OTHER BEDSIDE URINARY COLLECTION DEVICES BOTULISM ANTITOXIN BOWEL MANAGEMENT TOOL BRIEF/PANT INCONTINENCE MALE BRIMONIDINE TARTRATE BROMOCRIPTINE MESYLATE BROMOCRIPTINE MESYLATE BUMETANIDE BUMETANIDE BUPIVACAINE HCL BUPIVACAINE/DEXTROSE BUPIVACAINE/EPINEPHRINE BUPRENORPHINE CREAM,TOP OINT,TOP CREAM,TOP LOTION,TOP OINT,TOP SUSP,OPH INJ TAB TAB ENEMA,RTL SUPP,RTL TAB,EC KIT *(TAB/SUPP/LIQUID) SUSP,ORAL TAB,CHEWABLE TAB INJ,PWDR INJ,SOLN DEVICE TEST SOLUTION TEST STRIP SUPPLY INJ,SOLN SUPPLY SUPPLY SOLN,OPH CAP,ORAL TAB INJ TAB INJ,SOLN INJ,SOLN INJ,SOLN TAB,SUBLINGUAL CN101 BUPRENORPHINE/NALOXONE TAB,SUBLINGUAL CN609 BUPROPION HCL TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 6 CN609 CN309 AN100 AN100 CN101 CN105 CN105 CN809 DE900 DE820 HS900 HS900 VT502 VT502 TN420 TN420 TN420 TN420 TN420 VT802 DE900 DX300 AM500 R DE650 CV800 OP102 CN400 CN400 CN400 OT300 CN500 CN500 AN900 AN100 DE900 DE900 DE900 CV100 DE102 GA204 XA513 XA513 XA509 BUPROPION HCL BUSPIRONE HCL BUSULFAN BUSULFAN BUTORPHANOL TARTRATE CAFFEINE/ERGOTAMINE CAFFEINE/ERGOTAMINE CAFFEINE/SODIUM BENZOATE CALAMINE (OTC) CALCIPOTRIENE 0.005% CALCITONIN CALCITONIN CALCITRIOL CALCITRIOL CALCIUM ACETATE CALCIUM CARBONATE (OTC) CALCIUM CARBONATE (OTC) CALCIUM CHLORIDE CALCIUM GLUCONATE CALCIUM/VITAMIN D (OTC) CAMPHOR 0.5%/MENTHOL 0.5% CANDIDA 1:100 SKIN TEST CAPREOMYCIN INJ CAPSAICIN CAPTOPRIL CARBACHOL CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBAMIDE PEROXIDE/GLYCERIN (OTC) CARBIDOPA /LEVODOPA CARBIDOPA/LEVODOPA CARBOPLATIN INJ CARMUSTINE CARRAKLENZ SKIN & WOUND CLEANSER (OTC) CARRINGTON (OTC) CARRINGTON DRESSING (OTC) CARVEDILOL CASTELLANI PAINT (OTC) CASTOR OIL CATHETER EXTERNAL W/ADHESIVE LATEX CATHETER EXTERNAL W/ADHESIVE NON-LATEX CATHETER STRAIGHT BALLOON 30CC TAB,SA (12HR) TAB INJ TAB INJ,SOLN SUPP,RTL TAB INJ LOTION CREAM,TOP SOLN,NASAL INJ,SOLN CAP,ORAL INJ,SOLN CAP,ORAL TAB TAB,CHEWABLE INJ,SOLN INJ,SOLN TAB LOTION INJ INJ CREAM,TOP TAB SOLN,OPH SUSP,ORAL TAB TAB,CHEWABLE SOLN,OTIC TAB,SA TAB INJ INJ,SOLN SPRAY,TOP GEL,TOP SPRAY,TOP TAB TINCTURE,TOP EMULSION SUPPLY SUPPLY SUPPLY d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 7 XA509 XA512 XA512 XA900 XA510 XA513 XA512 XA599 XA599 AM116 AM115 AM118 AM117 AM117 AM116 AM116 AM116 AM117 AM117 AM117 AM116 GA201 AM115 OR500 NT900 AD900 AD900 CN309 CN309 AN100 AM150 OP210 CN302 OR500 DE101 DE101 CN204 AH104 AH104 AH104 CN701 CN701 CN701 CV701 R R R R R R R R R R R R R R CATHETER STRAIGHT BALLOON 5CC CATHETER STRAIGHT RUBBER CATHETER STRAIGHT SILICONE CATHETER SUCTION 14FR CATHETER,COUDE-TIP CATHETER,EXTERNAL URINARY CATHETER,RED RUBBER CATHETERIZATION TRAY W/CATHETER CATHETERIZATION TRAY W/O CATHETER CEFACLOR CEFAZOLIN CEFEPIME CEFIXIME CEFOTAXIME CEFOTETAN CEFOXITIN NA CEFPODOXIME PROXETIL CEFTAZIDIME CEFTIZOXIME CEFTRIAXONE NA CEFUROXIME AXETIL CELLULOSE,OXIDIZED CEPHALEXIN CETYLPYRIDINIUM CL (OTC) CETYLPYRIDINIUM CL/MENTHOL (OTC) CHARCOAL ACTIVATED (OTC) CHARCOAL ACTIVATED IN SORBITOL (OTC) CHLORAL HYDRATE CHLORAL HYDRATE CHLORAMBUCIL CHLORAMPHENICOL CHLORAMPHENICOL CHLORDIAZEPOXIDE HCL CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE (OTC) CHLORHEXIDINE GLUCONATE (OTC) CHLOROPROCAINE HCL CHLORPHENIRAMINE MALEATE (OTC) CHLORPHENIRAMINE MALEATE (OTC) CHLORPHENIRAMINE MALEATE (OTC) CHLORPROMAZINE CHLORPROMAZINE CHLORPROMAZINE CHLORTHALIDONE SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY CAP,ORAL INJ INJ,PWDR TAB INJ INJ INJ TAB INJ INJ INJ TAB POWDER,ORAL CAP OR TAB MOUTHWASH LOZENGE LIQUID LIQUID CAP,ORAL SYRUP TAB INJ,SOLN SOLN,OPH CAP,ORAL MOUTHWASH LIQUID,TOP SURGICAL SCRUB INJ,SOLN CAP,SA TAB TAB,SA SOLN,ORAL TAB INJ,SOLN TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 8 CV350 OP900 OP900 TN499 AM800 GA301 GA301 GA301 AM900 OP210 AM900 MS300 MS300 AN900 CN609 CN609 IR100 TN478 IR100 TN478 TN478 TN478 AN300 XA699 XA599 AM200 AM350 AM350 GU300 DE752 AM350 DE200 DE200 DE200 HS400 CN601 CN400 CV490 CN103 CV490 BL117 CHOLESTYRAMINE CHONDROITIN/HYALURONATE CHONDROITIN/HYALURONATE CHROMIUM CIDOFOVIR CIMETIDINE CIMETIDINE CIMETIDINE HCL CIPROFLOXACIN CIPROFLOXACIN HCL CIPROFLOXACIN HCL CISATRACURIUM CISATRACURIUM CISPLATIN CITALOPRAM HYDROBROMIDE CITALOPRAM HYDROBROMIDE CITRIC ACID/GLUCONO-DELTA/LACTONE/MAGNESIUM CARBONATE CITRIC ACID/K CITRATE/NA CITRATE CITRIC ACID/MAGNESIUM OXIDE/SODIUM CARBONATE CITRIC ACID/NA CITRATE CITRIC ACID/POTASSIUM CITRATE CITRIC ACID/POTASSIUM CITRATE CLADRIBINE CLAMP BAG CLAMP CUNNINGHAM REGULAR CLARITHROMYCIN CLINDAMYCIN CLINDAMYCIN PALMITATE SOLN CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLOBETASOL CLOBETASOL CLOBETASOL CLOMIPHENE CLOMIPRAMINE CLONAZEPAM CLONIDINE CLONIDINE HCL CLONIDINE HCL CLOPIDOGREL BISULFATE POWDER,ORAL INJ INJ,OPH INJ INJ LIQUID,ORAL TAB INJ,SOLN INJ,SOLN SOLN,OPH TAB INJ INJ INJ,SOLN SOLN,ORAL TAB SOLN,IRRG SYRUP SOLN,IRRG SOLN,ORAL SOLN,ORAL POWDER,ORAL INJ SUPPLY SUPPLY TAB CAP,ORAL GRNL,RCNST-ORAL CREAM,VAG SOLN,TOP INJ,SOLN CREAM,TOP OINT,TOP SOLN,TOP TAB CAP,ORAL TAB PATCH INJ TAB TAB R R R R R R R d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 9 NT900 GU300 DE102 DE102 DE102 CN709 CLOTRIMAZOLE CLOTRIMAZOLE (OTC) CLOTRIMAZOLE 1% CLOTRIMAZOLE 1% CLOTRIMAZOLE 1% CLOZAPINE TROCHE CREAM,VAG CREAM,TOP LOTION,TOP TOP,SOLN TAB DE820 DE820 DE820 DE820 DE820 DE820 DE820 DE820 DE820 DE820 NT300 DX300 CN101 CN101 CN101 RE301 MS400 MS400 CV350 CV350 DE900 XA900 XA900 XA900 HS900 DX102 DX101 XA602 TN499 HS701 DX900 XA900 OP900 IM900 COAL TAR COAL TAR COAL TAR COAL TAR COAL TAR COAL TAR COAL TAR COAL TAR COAL TAR /SALICYLIC ACID COAL TAR/SALICYLIC ACID/SULFUR COCAINE HCL COCCIDIODIN 1:100 SKIN TEST CODEINE CODEINE/ACETAMINOPHEN CODEINE/ACETAMINOPHEN CODEINE/GUAIFENESIN COLCHICINE COLCHICINE COLESTIPOL COLESTIPOL COLLAGENASE CONDOM FEMALE CONDOM LATEX LUBRICATED CONDOM LATEX PLAIN CONJUGATED ESTROGENS/MEDROXYPROGESTERONE (PREMPRO/PREMPHASE) CONTRAST MEDIA IONIC CONTRAST MEDIA NON-IONIC CONVEX INSERT ID 1" - 1 3/8" COPPER INJ CORTICOTROPIN INJ COSYNTROPIN INJ COTTON-TIP APPLICATOR STERILE CROMOLYN NA OPH SOLN CROMOLYN SODIUM EMULSION,TOP LIQUID,TOP LOTION,TOP OIL,TOP OINT,TOP SHAMPOO SOAP/DETERGENT SOLN,TOP SHAMPOO SHAMPOO SOLN,TOP INJ TAB ELIXIR TAB LIQUID,ORAL INJ TAB GRNL,RCNST-ORAL TAB OINT,TOP SUPPLY SUPPLY SUPPLY TAB INJ INJ SUPPLY INJ INJ INJ SUPPLY SOLN,OPH CAP,ORAL d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 10 RE109 RE109 NT900 AD200 VT101 VT101 MS200 OP600 OP600 AN100 AN100 AM500 R IM599 IM600 IM600 AN107 AN300 IM500 AN900 IM600 AN200 AM900 R BL110 HS100 MS200 MS200 AM900 R AM900 R BL400 AM800 R CROMOLYN SODIUM CROMOLYN SODIUM CROMOLYN SODIUM CYANIDE ANTIDOTE PACKAGE CYANOCOBALAMIN AEROSOL,ORAL SOLN,INHL SOLN,NASAL KIT INJ,SOLN CYANOCOBALAMIN CYCLOBENZAPRINE CYCLOPENTOLATE HCL CYCLOPENTOLATE/PHENYLEPHRINE CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE CYCLOSERINE CYCLOSPORINE CYCLOSPORINE CYCLOSPORINE CYPROHEPTADINE CYTARABINE CYTOMEGALOVIRUS IMMUNE GLOBULIN HUMAN DACARBAZINE DACLIZUMAB DACTINOMYCIN DALFOPRISTIN/QUINUPRISTIN DALTEPARIN DANAZOL DANTROLENE DANTROLENE DAPSONE DAPTOMYCIN DARBEPOETIN ALFA RECOMBINANT W/ALBUMIN DARUNAVIR ETHANOLATE TAB TAB SOLN,OPH SOLN,OPH INJ TAB CAP,ORAL CAP,ORAL INJ,SOLN SOLN,ORAL TAB INJ INJ INJ INJ INJ INJ INJ,SOLN CAP,ORAL CAP,ORAL INJ,SOLN TAB INJ,LYPHL INJ,SOLN TAB AN200 AD300 AM800 R AM250 R CN203 CN601 HS702 HS702 HS200 DAUNORUBICIN DEFEROXAMINE MESYLATE DELAVIRDINE DEMECLOCYCLINE HCL DESFLURANE DESIPRAMINE HCL DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE DESOGESTREL0.15MG/ETHINYL ESTRADIOL 30MCG,28 (MONO) (EQVRECLIPSEN) INJ,SOLN INJ,SOLN TAB TAB SOLN,INHL TAB SOLN,SPRAY,NASAL INJ,SOLN TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 11 DE200 HS051 HS051 HS051 HS051 HS051 OP350 OP300 OP350 OP350 OP350 CN309 AN700 AD900 BL800 BL800 OP600 BL800 BL800 CN801 CN801 CN801 CN801 RE302 RE302 TN101 PH000 HS503 TN102 TN102 TN102 IR200 TN102 TN102 XA305 XA900 CN302 CN302 DE700 OP300 MS102 AM112 R AU350 AU350 AU350 DESONIDE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE NA PHOS/NEOMYCIN DEXAMETHASONE NA PHOSPHATE DEXAMETHASONE/NEO/POLYMX DEXAMETHASONE/TOBRAMYCIN DEXAMETHASONE/TOBRAMYCIN DEXMEDETOMIDINE DEXRAZOXANE DEXTRAN 1 DEXTRAN 40 DEXTRAN 70 DEXTRAN 70/HYPROMELLOSE (EQV OCUCOAT) DEXTRAN 75 DEXTRAN HM DEXTROAMPHETAMINE DEXTROAMPHETAMINE DEXTROAMPHETAMINE DEXTROAMPHETAMINE DEXTROMETHORPHAN/GUAIFENESIN (OTC) DEXTROMETHORPHAN/GUAIFENESIN (SF) (OTC) DEXTROSE DEXTROSE 25% DEXTROSE SQUEEZE TUBE (OTC) DEXTROSE/ISOLYTE DEXTROSE/KCL DEXTROSE/LACTATED RINGERS DEXTROSE/PERITONEAL DIALYSIS DEXTROSE/SODIUM CHLORIDE DEXTROSE/SODIUM CHLORIDE/KCL DIAPER W/ELASTIC STRAPS DIAPHRAGM DIAZEPAM DIAZEPAM DIBUCAINE 1% (OTC) DICLOFENAC NA DICLOFENAC NA DICLOXACILLIN NA DICYCLOMINE HCL DICYCLOMINE HCL DICYCLOMINE HCL CREAM,TOP INJ,SUSP INJ,SUSP,SA TAB INJ,SOLN LIQUID,ORAL SOLN,OPH SOLN,OPH OINT,OPH SUSP,OPH OINT,OPH INJ,SOLN INJ INJ,SOLN INJ,SOLN INJ,SOLN SOLN,OPH INJ,SOLN INJ,SOLN CAP,ORAL CAP,SA ELIXIR TAB LIQUID,ORAL LIQUID,ORAL INJ,SOLN INJ,SOLN LIQUID,ORAL INJ,SOLN INJ,SOLN INJ,SOLN INJ,SOLN INJ,SOLN INJ,SOLN SUPPLY SUPPLY TAB INJ OINT,TOP SOLN,OPH TAB,EC CAP,ORAL CAP,ORAL INJ,SOLN SYRUP d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 12 AU350 AM800 R CV050 CV050 CV050 AD900 CN105 VT503 VT503 VT503 CV200 CV200 CV200 AD300 GU900 AH200 AH200 AH200 IM109 IM200 OP103 DX900 BL117 XA305 XA301 AD100 CN400 DICYCLOMINE HCL DIDANOSINE DIGOXIN DIGOXIN DIGOXIN DIGOXIN IMMUNE FAB (OVINE) DIHYDROERGOTAMINE MESYLATE DIHYDROTACHYSTEROL DIHYDROTACHYSTEROL DIHYDROTACHYSTEROL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DIMERCAPROL DIMETHYLSULFOXIDE DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL (OTC) DIPHENHYDRAMINE HCL (OTC) TAB CAP,EC ELIXIR INJ,SOLN TAB INJ,SOLN INJ,SOLN CAP,ORAL SOLN,ORAL TAB CAP,SA INJ TAB INJ,SOLN SOLN,URH INJ,SOLN CAP,ORAL TAB INJ,SUSP DIPHTHERIA TOXOID/PERTUSSIS /TETANUS TOXOID DIPHTHERIA/TETANUS TOXOID DIPIVEFRIN HCL DIPYRIDAMOLE DIPYRIDAMOLE DISPOSABLE DIAPER DISPOSABLE UNDERPAD DISULFIRAM DIVALPROEX NA INJ,SUSP SOLN,OPH INJ,SOLN TAB SUPPLY SUPPLY TAB TAB,SA,24HR AU100 AN900 GA205 RS300 GA206 GA204 CN900 AU100 OP109 OP105 RE900 DOBUTAMINE DOCETAXEL DOCUSATE (OTC) DOCUSATE (OTC) DOCUSATE (OTC) DOCUSATE/SENNOSIDES DONEPEZIL DOPAMINE DORZOLAMIDE HCL DORZOLAMIDE/TIMOLOL DOXAPRAM HCL INJ,SOLN INJ CAP,ORAL ENEMA,RTL LIQUID,ORAL TAB TAB INJ,SOLN SOLN,OPH SOLN,OPH INJ,SOLN d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 13 CV150 CN601 CN601 AN200 AM250 AM250 AM250 XA199 XA199 XA199 XA103 XA199 CN205 OP102 AD300 AU300 AM800 AM800 AM800 AM800 DOXAZOSIN MESYLATE DOXEPIN HCL DOXEPIN HCL DOXORUBICIN DOXYCYCLINE DOXYCYCLINE DOXYCYCLINE HYCLATE DRESSING ALGINATE DRESSING HYDROCOLLOID DRESSING HYDROGEL DRESSING NON-ADHESIVE OIL/EMULSION DRESSING TRAYS DROPERIDOL ECHOTHIOPHATE IODIDE EDETATE CALCIUM DISODIUM EDROPHONIUM CHLORIDE EFAVIRENZ EFAVIRENZ EFAVIRENZ/EMTRICITABINE/TENOFOVIR EMTRICITABINE EMTRICITABINE/TENOFOVIR ENALAPRIL ENALAPRILAT ENEMA BAG ENFLURANE ENFUVIRTIDE ENOXAPARIN ENTACAPONE ENTECAVIR TAB CAP,ORAL LIQUID,ORAL INJ,SOLN CAP OR TAB SUSP INJ SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY INJ,SOLN SOLN,OPH INJ INJ TAB CAP,ORAL TAB CAP,ORAL TAB TAB INJ,SOLN SUPPLY LIQUID,INHL INJ,PWDR INJ TAB SOLN,ORAL R R R R R R R AM800 R CV800 CV800 XA900 CN201 AM800 R BL110 CN500 AM800 R AM800 R ENTECAVIR TAB AU100 AU100 AU100 BL400 BL110 CN900 GU600 EPHEDRINE EPHEDRINE EPINEPHRINE EPOETIN ALFA,RECOMBINANT EPTIFIBATIDE ERGOLOID MESYLATES ERGONOVINE MALEATE INJ,SOLN INJ,SOLN INJ,SOLN INJ,SOLN INJ TAB,ORAL INJ d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 14 AM119 R AM200 OP210 AM200 AM200 AM200 DE752 DE752 AM200 CV100 HS300 HS300 HS300 AN900 HS300 GU500 HS300 HS300 CV702 CV702 R R R R ERTAPENEM ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN 2% TOP GEL ERYTHROMYCIN 2% TOP SOLN ERYTHROMYCIN LACTOBIONATE ESMOLOL HCL ESTRADIOL ESTRADIOL ESTRADIOL ESTRAMUSTINE ESTROGENS ESTROGENS CONJUGATED ESTROGENS CONJUGATED ESTROGENS CONJUGATED ETHACRYNATE NA ETHACRYNIC ACID ETHAMBUTOL HCL ETHANOLAMINE OLEATE ETHINYL ESTRADIOL 0.12MG/ETONOGESTREL 0.015MG (EQV-NUVARING) ETHINYL ESTRADIOL 20MCG ETHINYL ESTRADIOL 20MCG/LEVONORGESTREL 0.1MG,28 (MONO) (EQVLUTERA) ETHINYL ESTRADIOL 30MCG/LEVONORGESTREL 0.15MG,28 (MONO) (EQVLEVLEN) ETHINYL ESTRADIOL 30MCG/LEVONORGESTREL,28 (TRI) (EQV-TRI-LEVLEN) ETHINYL ESTRADIOL 35MCG/NORETHINDRONE 1MG,28 (MONO) (EQVNORINYL 1 +35) ETHINYL ESTRADIOL 35MCG/NORETHINDRONE,28 (TRI) (EQV-NECON 7/7/7) ETHINYL ESTRADIOL 35MCG/NORGESTIMATE 25MCG,28 (MONO) (EQVMONONESSA) ETHINYL ESTRADIOL 5MCG/NORETHINDRONE ACETATE 1MG ORAL (FEMHRT) ETHINYL ESTRADIOL/NORGESTIMATE,28 (TRI) (EQV-TRINESSA) ETHIONAMIDE ETHYL CHLORIDE 100% ETIDRONATE ETIDRONATE ETODOLAC INJ,PWDR CAP,EC OINT,OPH SUSP TAB TAB,EC GEL,TOP SOLN,TOP INJ INJ INJ PATCH TAB CAP,ORAL INJ CREAM,VAG INJ TAB INJ TAB TAB INJ,SOLN RING,VAG TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB AEROSOL,TOP INJ TAB CAP,ORAL R AM500 R CV600 HS200 HS300 HS200 HS200 HS200 HS200 HS200 HS200 HS900 HS200 AM500 R DE700 HS900 HS900 MS102 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 15 MS102 CN203 AN900 AN900 AM800 R XA101 OP500 XA900 BL500 AM800 R GA301 TN300 XA900 CN400 CN400 CV200 AU100 CN101 CN101 TN410 TN410 TN410 TN410 BL400 HS900 AM700 AM700 AM700 AM700 AN300 HS052 AD900 RE101 NT200 DE200 DE200 DE200 DE200 OP900 OP900 R R R R ETODOLAC ETOMIDATE ETOPOSIDE ETOPOSIDE ETRAVIRINE EYE PAD STERILE EYE RINSE (OTC) FACE PLATE FACTOR IX COMPLEX, HUMAN FAMCICLOVIR FAMOTIDINE FAT EMULSION FECAL INCONTINENCE COLLECTOR FELBAMATE FELBAMATE FELODIPINE FENOLDOPAM FENTANYL FENTANYL CITRATE FERRIC NA GLUCONATE FERROUS GLUCONATE FERROUS SULFATE (OTC) FERROUS SULFATE (OTC) FILGRASTIM FINASTERIDE FLUCONAZOLE FLUCONAZOLE FLUCONAZOLE FLUCYTOSINE FLUDARABINE FLUDROCORTISONE ACETATE FLUMAZENIL FLUNISOLIDE FLUNISOLIDE FLUOCINOLONE ACETONIDE 0.01% FLUOCINONIDE FLUOCINONIDE FLUOCINONIDE FLUORESCEIN FLUORESCEIN TAB INJ CAP,ORL INJ,SOLN TAB SOLN,OPH IRRG SUPPLY INJ TAB INJ,SOLN INJ SUPPLY SUSP,ORAL TAB TAB,SA INJ PATCH INJ,SOLN INJ,SOLN TAB LIQUID,ORAL TAB INJ,SOLN TAB INJ PWDR,RENST-ORAL TAB CAP,ORAL INJ TAB INJ INHL,ORAL INHL,NASAL SOLN,TOP CREAM,TOP OINT,TOP SOLN,TOP INJ,SOLN SOLN,OPH d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 16 OP900 OP900 OP300 AN300 DE600 DE600 DE600 CN609 CN609 CN609 HS100 CN701 CN701 CN701 CN701 DE200 OP900 AN900 VT102 VT102 AD900 BL110 RE102 AM800 R OP900 CV800 CN400 CV702 CV702 CV702 CN400 CN400 CN400 CN900 CN900 HS900 OP230 AM800 R FLUORESCEIN FLUORESCEIN NA /PROPARACAINE FLUOROMETHOLONE FLUOROURACIL FLUOROURACIL 2% FLUOROURACIL 5% FLUOROURACIL 5% FLUOXETINE FLUOXETINE FLUOXETINE FLUOXYMESTERONE FLUPHENAZINE FLUPHENAZINE FLUPHENAZINE FLUPHENAZINE DECONATE FLURANDRENOLIDE 4MCG/SQCM FLURBIPROFEN NA FLUTAMIDE FOLIC ACID FOLIC ACID FOMEPIZOLE FONDAPARINUX FORMOTEROL FOSAMPRENAVIR FOSCARNET NA FOSINOPRIL FOSPHENYTOIN NA FUROSEMIDE FUROSEMIDE FUROSEMIDE GABAPENTIN GABAPENTIN GABAPENTIN GALANTAMINE GALANTAMINE GALLIUM GANCICLOVIR GANCICLOVIR STRIP,OPH SOLN,OPH SUSP,OPH INJ,SOLN SOLN,TOP CREAM,TOP SOLN,TOP CAP,ORAL SOLN,ORAL TAB TAB LIQUID,ORAL INJ TAB INJ TAPE SOLN,OPH CAP INJ,SOLN TAB INJ INJ,SOLN CAP,INHL TAB INJ TAB INJ INJ,SOLN SOLN,ORAL TAB CAP,ORAL SOLN,ORAL TAB CAP,SA TAB INJ,SOLN IMPLANT INJ,SOLN d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 17 XA109 XA109 XA106 XA103 XA112 XA111 XA102 XA101 BL116 BL116 OP900 BL116 BL116 AN900 CV350 DE101 AM300 R OP210 OP210 OP350 DE109 DE109 MS900 HS502 IM500 XA900 XA900 XA900 HS503 HS503 HS502 RS300 IR100 DE900 AU350 MS160 AN500 OP219 AM700 R AM700 R GAUZE ELASTIC STERILE GAUZE ELASTIC NONSTERILE GAUZE FINE MESH STERILE GAUZE NON-ADHESIVE PETROLATUM GAUZE PACKING MEDICATED GAUZE PACKING PLAIN GAUZE PAD NONSTERILE GAUZE PAD STERILE GELATIN,ABSORBABLE GELATIN,ABSORBABLE GELATIN,ABSORBABLE GELATIN,ABSORBABLE GELATIN,ABSORBABLE GEMCITABINE GEMFIBROZIL GENTAMICIN SO4 GENTAMICIN SO4 GENTAMICIN SO4 GENTAMICIN SO4 GENTAMICIN/PREDNISOLONE GENTIAN VIOLET 1% (OTC) GENTIAN VIOLET 2% (OTC) GLATIRAMER ACETATE GLIPIZIDE GLOBULIN, IMMUNE GLOVE LATEX NONSTERILE GLOVE LATEX, STERILE GLOVE VINYL NONSTERILE GLUCAGON GLUCOSE (OTC) GLYBURIDE GLYCERIN (ADULT) (OTC) GLYCINE GLYCOLIC ACID 12% (OTC) GLYCOPYRROLATE GOLD NA THIOMALATE GOSERELIN ACETATE GRAMICIDIN/NEOMYCIN/POLYMYXIN GRISEOFULVIN GRISEOFULVIN SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY CONE FILM FILM POWDER SPONGE INJ TAB,ORAL CREAM,TOP INJ SOLN,OPH OINT,OPH SUSP,OPH SOLN,TOP SOLN,TOP INJ,LYPHL TAB INJ,SOLN SUPPLY SUPPLY SUPPLY INJ TAB,CHEWABLE TAB SUPP,RTL SOLN,IRRG LOTION,TOP INJ,SOLN INJ INJ,IMPLANT SOLN,OPH SUSP TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 18 RE302 RE302 RE302 CN709 CN709 GUAIFENESIN GUAIFENESIN GUAIFENESIN HALOPERIDOL HALOPERIDOL TAB TAB,SA LIQUID,ORAL INJ,SOLN LIQUID,ORAL CN709 HALOPERIDOL TAB CN709 CN201 DE900 OT250 IM100 RS201 RS201 RS202 BL110 IM100 IM100 IM500 IM100 BL800 BL800 OP500 DX300 OP600 XA900 OP900 XX000 CV490 CV490 HALOPERIDOL DECANOATE HALOTHANE INHALATION HAMAMELIS WATER 50% (OTC) HC/NEOMYCIN/POLYMYXIN OTIC HEMOPHILUS B CONJUGATE VACCINE HEMORRHOIDAL (OTC) HEMORRHOIDAL (OTC) HEMORRHOIDAL/HC RTL HEPARIN HEPATITIS A VACCINE HEPATITIS A/HEPATITIS B VACCINE HEPATITIS B IMMUNE GLOBULIN HEPATITIS B VACCINE (RECOMBINANT) HETASTARCH HETASTARCH/ELECTROLYTES HIGH VISCOSITY ARTIFICIAL TEARS (OTC) HISTOPLASMIN 1:100 SKIN TEST HOMATROPINE HYDROBROMIDE HOSE ANTI-EMBOLISM HYALURONATE NA HYALURONIDASE HYDRALAZINE HCL HYDRALAZINE HCL INJ LIQUID,IHNL PAD SUSP,OTIC INJ,LYPHL OINT,RTL SUPP,RTL OINT,RTL INJ,SOLN INJ,SUSP INJ,SUSP INJ INJ,SUPS INJ INJ SOLN,OPH INJ,SOLN SOLN,OPH SUPPLY INJ,OPH INJ INJ,SOLN TAB CV701 CV701 CV400 CV704 CV704 CV704 RS100 HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE/LISINOPRIL HYDROCHLOROTHIAZIDE/SPIRONOLACTONE HYDROCHLOROTHIAZIDE/TRIAMTERENE HYDROCHLOROTHIAZIDE/TRIAMTERENE HYDROCORTISONE CAP,ORAL TAB TAB TAB CAP,ORAL TAB AEROSOL,RTL d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 19 DE200 RS100 HS051 HS051 DE200 DE200 DE200 RS202 RS202 RS202 DE101 CN101 CN101 DE350 DE900 AP101 AN300 AH105 AH105 AH105 MS102 MS102 CV300 AN200 AN100 AN100 AN900 HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE (PLAIN OR ACETATE) HYDROCORTISONE (PLAIN OR ACETATE) HYDROCORTISONE (PLAIN OR ACETATE) HYDROCORTISONE/PRAMOXINE HYDROCORTISONE/PRAMOXINE HYDROCORTISONE/PRAMOXINE HYDROGEN PEROXIDE (OTC) HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROPHILIC HYDROQUINONE 4% HYDROXYCHLOROQUINE SULFATE HYDROXYUREA HYDROXYZINE HYDROXYZINE HYDROXYZINE IBUPROFEN IBUPROFEN IBUTILIDE IDARUBICIN IFOSFAMIDE IFOSFAMIDE/MESNA IMATINIB MESYLATE AEROSOL,TOP ENEMA INJ,SOLN TAB CREAM,TOP OINT,TOP LOTION,TOP AEROSOL,RTL CREAM,RTL OINT,RTL SOLN,TOP INJ,SOLN TAB OINT,TOP CREAM,TOP TAB CAP,ORAL CAP OR TAB INJ,SOLN LIQUID,ORAL SUSP TAB INJ INJ,SOLN INJ INJ TAB AM119 R CN601 IM900 CV900 XA304 CV701 AM800 R DX101 MS102 IM100 AD900 XA854 IMIPENEM/CILASTATIN NA IMIPRAMINE HCL IMIQUIMOD INAMRINONE INCONTINENCE LINER INDAPAMIDE INDINAVIR S04 INDOCYANINE GREEN INDOMETHACIN INFLUENZA VIRUS VACCINE INSECT STING TREATMENT KIT INSULIN INJ TAB CREAM,TOP INJ SUPPLY TAB CAP,ORAL INJ,SOLN CAP INJ KIT SYRINGE d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 20 HS501 HS501 HS501 HS501 HS501 HS501 HS501 XA854 IM700 AM800 R IM700 IM900 IM700 DX102 GA600 RE105 RE105 NT900 AN900 TN410 OP500 XA900 XA900 XA607 CN201 AM500 R AM500 R AM500 R AU100 CV250 CV250 CV250 INSULIN ASPART INSULIN HUMAN 50/50 (NPH/REG) (OTC) INSULIN HUMAN 70/30 (NPH/REG) (OTC) INSULIN HUMAN LENTE 100U/ML (OTC) INSULIN HUMAN NPH 100U/ML (OTC) INSULIN HUMAN REGULAR 100U/ML (OTC) INSULIN LONG ACTING ANALOG INSULIN LOW DOSE INTERFERON ALFA INTERFERON ALFA-2B INJ/RIBAVIRIN INTERFERON BETA-1A INTERFERON BETA-1B INTERFERON GAMMA-1B IOTHALAMATE IPECAC SYRUP (OTC) IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE IRINOTECAN IRON DEXTRAN COMPLEX IRRIGATING EYE IRRIGATING SYRINGE CATHETER TIP 60ML IRRIGATING SYRINGE,BULB CATHETER TIP 60ML IRRIGATOR DRAIN /SLEEVE ISOFLURANE ISONIAZID ISONIAZID ISONIAZID/RIFAMPIN ISOPROTERENOL ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE INJ,SOLN INJ,SUSP INJ,SUSP INJ,SUSP INJ,SUSP INJ,SOLN INJ,SOLN SYRINGE INJ INJ/CAP INJ INJ INJ INJ,SOLN SYRUP INHALANT SOLN,INHL SOLN,SPRAY,NASAL INJ INJ,SOLN SOLN,OPH SUPPLY SUPPLY SUPPLY LIQUID,INHL INJ TAB CAP,ORAL INJ,SOLN CAP/TAB,SA TAB TAB,SA d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 21 DE751 AM700 R AM700 R XA809 AP200 TN475 AM300 R CN203 DE102 AM700 DE102 DX900 MS102 OP300 OP900 CV100 GA500 IR100 TN102 DE500 GA208 GA202 XA900 AM800 AM800 AM800 CN400 XA900 DE350 XA599 BL110 AN900 VT102 VT102 CN400 CN400 OP101 AM900 HS200 HS851 HS851 DE700 DE700 CN204 R ISOTRETINOIN ORAL ITRACONAZOLE ITRACONAZOLE ORAL IV SET SECONDARY IVERMECTIN K PHOSPHATE /NA BIPHOSPHATE/NA PHOSPHATE KANAMYCIN KETAMINE KETOCONAZOLE KETOCONAZOLE KETOCONAZOLE 2% KETODIASTIX GLUCOSE KETONE TEST STRIP KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOTIFEN LABETALOL HCL LACTASE (OTC) LACTATED RINGERS LACTATED RINGER'S LACTIC ACID 16.7%/SAL AC 16.7%/COLLODION (OTC) LACTOBACILLUS (OTC) LACTULOSE LAMBS WOOL LAMIVUDINE LAMIVUDINE LAMIVUDINE/ZIDOVUDINE LAMOTRIGINE LANCET LANOLIN HYDROUS (OTC) LEG BAG STRAP ELASTIC LEPIRUDIN LETROZOLE LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM LEVETIRACETAM LEVETIRACETAM LEVOBUNOLOL OPH LEVOFLOXACIN LEVONORGESTREL (EQV. PLAN B) LEVOTHYROXINE LEVOTHYROXINE NA LIDOCAINE 2.5%/PRILOCAINE 2.5% LIDOCAINE 5% LIDOCAINE HCL CAP,ORAL INJ,SOLN CAP,ORAL SUPPLY TAB TAB INJ INJ,SOLN SHAMPOO TAB CREAM,TOP TEST STRIP INJ SOLN,OPH SOLN,OPH INJ,SOLN TAB SOLN,IRRG INJ,SOLN LIQUID,TOP TAB,CHEWABLE SYRUP SUPPLY SOLN,ORAL TAB TAB TAB SUPPLY OINT,TOP SUPPLY INJ,PWDR TAB INJ TAB INJ,SOLN TAB SOLN,OPH INJ,SOLN TAB INJ TAB CREAM,TOP OINT,TOP INJ R R R R d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 22 DE700 NT300 DE700 DE700 GU900 CN204 AM900 R AM900 R AM900 R CV800 CN750 CN750 CN750 CN750 OP900 AN100 GA208 GA208 AM800 R AH109 CN302 CN302 CV805 LIDOCAINE HCL 2% LIDOCAINE HCL 2% VISCOUS LIDOCAINE HCL 4% LIDOCAINE HCL 5% LIDOCAINE HCL URH LIDOCAINE HCL/EPINEPHRINE LINEZOLID LINEZOLID LINEZOLID LISINOPRIL LITHIUM LITHIUM LITHIUM LITHIUM LODOXAMIDE TROMETHAMINE LOMUSTINE LOPERAMIDE HCL LOPERAMIDE HCL LOPINAVIR/RITONAVIR LORATIDINE LORAZEPAM INJ LORAZEPAM ORAL LOSARTAN JELLY LIQUID,ORAL SOLN,TOP OINT,TOP SOLN,TOP INJ INJ PWDR,RENST-ORAL TAB TAB CAP,ORAL SYRUP TAB TAB,SA SOLN,OPH CAP,ORAL CAP,ORAL LIQUID,ORAL TAB TAB INJ TAB TAB CV350 LOVASTATIN TAB CN709 DE900 OP500 GA202 GA202 TN460 TN460 CV709 AM800 R LOXAPINE LUBRICATING (OTC) LUBRICATING (PF) (OTC) MAGNESIUM CITRATE (OTC) MAGNESIUM HYDROXIDE (OTC) MAGNESIUM OXIDE (OTC) MAGNESIUM SULFATE MANNITOL MARAVIROC CAP,ORAL JELLY,TOP OINT,OPH LIQUID,ORAL SUSP,ORAL TAB INJ,SOLN INJ,SOLN TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 23 XA900 IM100 AP200 AN100 CN550 XA900 HS800 HS800 HS800 HS800 AN100 AN100 CN900 IM100 DE650 DE650 CN101 CN204 AN300 GA900 RS100 GA900 AD900 HS200 RE102 RE102 HS502 CN101 MASK,SURGICAL MEASLES/MUMPS/RUBELLA VIRUS VACCINE MEBENDAZOLE MECHLORETHAMINE MECLIZINE HCL (OTC) MEDICATION ORGANIZER MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEGESTROL ACETATE MEGESTROL ACETATE MELPHALAN MELPHALAN HCL MEMANTINE HCL MENINGOCOCCAL POLYSACCHARIDE VACCINE MENTHOL/METHYL SALICYLATE 10-15% (LOW CONC) MENTHOL/METHYL SALICYLATE 16-30% (HIGH CONC) MEPERIDINE HCL MEPIVACAINE HCL MERCAPTOPURINE MESALAMINE MESALAMINE MESALAMINE MESNA MESTRANOL 50MCG/NORETHINDRONE 1MG,28 (MONO) (EQV-NORINYL 1+50) METAPROTERENOL METAPROTERENOL METFORMIN HCL METHADONE HCL SUPPLY INJ TAB,CHEWABLE INJ TAB MISCELLANEOUS INJ,SUSP TAB SUSP,ORAL TAB TAB INJ TAB INJ CREAM,TOP CREAM,TOP INJ INJ TAB CAP,SA SUPP,RTL TAB,SA INJ TAB INHL,ORAL SOLN,INHL TAB LIQUID,ORAL CN101 METHADONE HCL TAB CV703 AM550 R HS852 MS200 METHAZOLAMIDE METHENAMINE MANDELATE METHIMAZOLE METHOCARBAMOL TAB TAB TAB TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 24 CN202 AN300 AN300 DE900 DE810 CV490 CV490 AD200 CN802 CN802 CN802 HS051 HS051 HS051 AU300 AU300 AU300 CV701 CV100 CV100 CV100 AM900 R AM900 R DE101 GU300 DE752 DX900 AM700 R DE102 DE102 DE102 CN302 CV900 CV900 RS300 GA203 DE900 DE350 DE350 METHOHEXITAL METHOTREXATE NA METHOTREXATE NA METHOXSALEN METHOXSALEN METHYLDOPA METHYLDOPATE HCL METHYLENE BLUE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL INJ METOLAZONE METOPROLOL TARTRATE METOPROLOL TARTRATE METOPROLOL SUCCINATE SUSTAINED ACTION METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE 0.75% METYRAPONE MICAFUNGIN MICONAZOLE MICONAZOLE NITRATE 2% MICONAZOLE NITRATE 2% MIDAZOLAM HCL MIDODRINE MILRINONE MINERAL OIL (OTC) MINERAL OIL,HEAVY 100% (OTC) MINERAL OIL,LIGHT (OTC) MINERAL OIL/MINERAL WAX/PETROLATUM/WOOL WAX ALCOHOL (OTC) MINERAL OIL/MINERAL WAX/PETROLATUM/WOOL WAX ALCOHOL(OTC) INJ INJ TAB LIQUID,TOP CAP TAB INJ INJ CAP,SA TAB TAB,SA INJ,SOLN INJ,SUSP TAB LIQUID,ORAL TAB INJ TAB INJ TAB TAB,SA INJ,SOLN TAB GEL,TOP GEL,VAG CREAM,TOP CAP,ORAL INJ,LYPHL CREAM,TOP TINCTURE,TOP POWDER,TOP INJ,SOLN TAB INJ,SOLN ENEMA LIQUID,ORAL LIQUID,ORAL LOTION,TOP OINT,TOP d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 25 AM250 R CV490 CN609 GA309 AN200 AN900 AN900 XA604 DE350 CN709 RE101 RE109 MINOCYCLINE HCL MINOXIDIL MIRTAZAPINE MISOPROSTOL MITOMYCIN MITOTANE MITOXANTRONE MOISTURE BARRIER SKIN OINT MOISTURIZING (OTC) MOLINDONE HCL MOMETASONE FUROATE MONTELUKAST CAP,ORAL TAB TAB TAB INJ TAB INJ SUPPLY LOTION,TOP TAB INHL,ORAL TAB XA205 CN101 CN101 CN101 CN101 CN101 CN101 CN101 CV600 CV600 AM900 R OP210 AM900 R VT801 VT802 VT802 DX300 IM100 DE101 IM600 IM600 IM600 IM600 IM600 AM112 R CN102 CN102 HS100 OP800 OP900 MONTGOMERY STRAPS MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORPHINE MORRHUATE MORRHUATE SODIUM MOXIFLOXACIN MOXIFLOXACIN MOXIFLOXACIN MULTIVITAMIN MULTIVITAMIN/MINERALS (OTC) MULTIVITAMIN/MINERALS (OTC) MUMPS SKIN TEST (MSTA) ANTIGEN MUMPS VIRUS VACCINE,LIVE MUPIROCIN MUROMONAB-CD3 MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL MYCOPHENOLIC ACID NAFCILLIN NA NALOXONE HCL NALTREXONE HCL NANDROLONE DECONATE NAPHAZOLINE NAPHAZOLINE/PHENIRAMINE SUPPLY CAP,IR CAP,SA INJ,SOLN LIQUID,ORAL SOLN,CONC TAB,IR TAB,SA INJ,SOLN INJ,SOLN INJ,SOLN SOLN,OPH TAB INJ CAP OR TAB LIQUID,ORAL INJ INJ OINT,TOP INJ CAP,ORAL INJ,LYPHL TAB TAB,EC INJ INJ,SOLN TAB INJ SOLN,OPH SOLN,OPH d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 26 MS102 IM700 OP220 XA856 XA856 AM800 R IR100 AM300 R AU300 AU300 AM800 R VT103 VT103 VT103 VT103 AD900 AD900 AD900 CV200 DX900 AM600 R CV250 CV250 CV250 CV250 HS900 AU100 HS200 CN601 CN601 TN200 TN200 TN200 TN200 DE102 AM700 R NAPROXEN NATALIZUMAB NATAMYCIN NEEDLE NEEDLE PEN NELFINAVIR NEO /POLYMYX NEOMYCIN SULFATE NEOSTIGMINE BROMIDE NEOSTIGMINE METHYLSULFATE NEVIRAPINE NIACIN NIACIN (Rx ONLY) NIACIN (Rx ONLY) NIACINAMIDE NICOTINE NICOTINE NICOTINE POLACRILEX NIFEDIPINE NITRAZINE (pH) TEST STRIP NITROFURANTOIN MONOHYDRATE/MACROCRYSTALLINE NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NONOXYNOL NOREPINEPHRINE NORETHINDRONE 0.35MG (EQV-NOR QD),28 NORTRIPTYLINE NORTRIPTYLINE NUTRITION SUPL ENSURE PLUS/VANILLA (OTC) NUTRITION SUPL ENSURE/VANILLA (OTC) NUTRITION SUPL JEVITY (1.0 CAL) NUTRITION SUPL NUTREN (1.0, 1.5) NYSTATIN NYSTATIN TAB INJ,SOLN SUSP,OPH SUPPLY SUPPLY TAB SOLN,IRRG TAB TAB INJ TAB INJ,SOLN TAB,SA TAB TAB GUM, CHEWABLE PATCH LOZENGE TAB,SA TEST STRIP CAP,SA INJ,SOLN OINT,TOP PATCH TAB,SUBLINGUAL GEL,VAG INJ TAB CAP,ORAL SOLN,ORAL LIQUID,NUTRITIONAL SUPPLEMENT POWDER,ORAL LIQUID,NUTRITIONAL SUPPLEMENT LIQUID,NUTRITIONAL SUPPLEMENT CREAM,TOP SUSP,ORAL d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 27 AM700 R DE102 DE350 GA208 GA208 OP210 CN709 NYSTATIN NYSTATIN 100000UNT/GM OATMEAL,COLLOIDAL 43% OILATED BATH PWDR (OTC) OCTREOTIDE ACETATE OCTREOTIDE ACETATE OFLOXACIN OLANZAPINE TAB,ORAL/VAG OINT,TOP PWDR,TOP INJ INJ,SA SOLN,OPH INJ,PWDR CN709 OLANZAPINE TAB GA900 GA605 GA605 OP500 OR200 AM800 R XA604 XA606 XA604 AM112 R AN900 GU201 CN101 OMEPRAZOLE ONDANSETRON ONDANSETRON OPHTH LUBRICATING OINTMENT (PF) (OTC) ORABASE PLAIN PASTE (OTC) OSELTAMIVIR OSTOMY PASTE OSTOMY POUCH DEODORANT OSTOMY SKIN PROTECTIVE POWDER OXACILLIN OXALIPLATIN OXYBUTYNIN CHLORIDE OXYCODONE HCL CAP,EC INJ,SOLN TAB OINT,OPH PASTE CAP,ORAL SUPPLY SUPPLY SUPPLY INJ INJ,LYPHL TAB LIQUID,ORAL CN101 OXYCODONE HCL TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 28 NT100 AN900 XA102 XA101 XA105 XA105 XA103 XA104 XA110 XA103 HS900 GA500 MS300 GA900 DE900 DE900 DE900 IM100 GA208 CN609 IM700 OXYMETAZOLINE HCL (OTC) PACLITAXEL PAD ABDOMINAL NONSTERILE PAD ABDOMINAL STERILE PAD ALCOHOL PREP PAD ANTISEPTIC PAD NON-ADHESIVE STERILE PAD W/ADHESIVE STERILE PAD,FOAM SELF-ADHERE PADS,NON-ADHERING PAMIDRONATE PANCREATIC ENZYMES PANCURONIUM BROMIDE PANTOPRAZOLE PAPAIN/UREA PAPAIN/UREA/CHLOROPHYLL PAPAIN/UREA/CHLOROPHYLL PAPILLOMAVIRUS HUMAN PAREGORIC PAROXETINE PEGINTERFERON ALFA-2A SOLN,NASAL INJ,CONC SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY INJ CAP OR TAB INJ,SOLN INJ,PWDR OINT,TOP OINT,TOP SPRAY,TOP INJ,SOLN LIQUID,ORAL TAB INJ IM700 MS140 AM110 AM110 AM110 AM110 AM110 DE700 AP109 AM900 AN900 AN900 DE900 AP300 AP300 CN701 DE350 GU100 CN602 R R R R R R R PEGINTERFERON ALFA-2B PENICILLAMINE PENICILLIN PENICILLIN PENICILLIN G BENZATHINE PENICILLIN G POTASSIUM PENICILLIN G PROCAINE PENTAFLUOROPROPANE/TETRAFLUOROETHANE PENTAMIDINE ISETHIONATE PENTAMIDINE ISETHIONATE PENTOSTATIN PENTOSTATIN/MANNITOL PERINEAL WASH (OTC) PERMETHRIN (OTC) PERMETHRIN (OTC) PERPHENAZINE PETROLATUM(OTC) PHENAZOPYRIDINE HCL PHENELZINE SULFATE INJ CAP,ORAL PWDR,RENST-ORAL TAB INJ,SUSP INJ INJ,SUSP AEROSOL,TOP INHALANT INJ,SOLN INJ INJ SOLN CREAM,TOP LOTION,TOP TAB OINT,TOP TAB TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 29 CN301 CN301 CN301 NT300 PH000 AU200 AU200 AU100 OP600 NT100 CN400 CN400 CN400 CN400 TN475 TN475 TN475 TN475 AU300 VT702 VT702 OP102 OP102 AU300 CN900 AM113 R AM113 R MS102 BL500 XA514 IM100 DE500 DE500 IM100 GA202 GA202 AM900 R OP219 AN900 TN430 TN430 TN430 TN430 TN430 TN430 PHENOBARBITAL PHENOBARBITAL PHENOBARBITAL PHENOL PHENOL PHENOXYBENZAMINE HCL PHENTOLAMINE MESYLATE PHENYLEPHRINE PHENYLEPHRINE HCL PHENYLEPHRINE HCL (OTC) PHENYTOIN (DILANTIN) PHENYTOIN (DILANTIN) PHENYTOIN (DILANTIN) PHENYTOIN (DILANTIN) NA PHOSPHORUS/K/NA (OTC) PHOSPHORUS/POTASSIUM PHOSPHORUS/POTASSIUM PHOSPHORUS/SODIUM PHYSOSTIGMINE SALICYLATE PHYTONADIONE PHYTONADIONE PILOCARPINE PILOCARPINE PILOCARPINE HCL PIMOZIDE PIPERACILLIN NA PIPERACILLIN NA/TAZOBACTAM PIROXICAM PLASMA PROTEIN FRACTION 5% PLUG CATHETER PNEUMOCOCCAL POLYSCCHARIDE VACCINE PODOFILOX 0.5% PODOPHYLLIN 25%/BENZOIN POLIOVIRUS VACCINE INACTIVATED POLYETHYLENE GLYCOL 3350 (PEG-3350) POLYETHYLENE GLYCOL 3350 (PEG-3350)/ELECTROLYTES POLYMYXIN B SO4 POLYMYXIN/TRIMETHOPRIM PORFIMER SODIUM POTASSIUM POTASSIUM ACETATE POTASSIUM BICARBONATE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE ELIXIR INJ TAB LIQUID,ORAL LIQUID,TOP CAP,ORAL INJ INJ SOLN,OPH SOLN,NASAL TAB,CHEWABLE CAP,SA SUSP INJ,SOLN PWDR,ORAL PWDR,RENST-ORAL INJ INJ INJ,SOLN TAB INJ GEL,OPH SOLN,OPH TAB TAB INJ INJ CAP,ORAL INJ SUPPLY INJ SOLN,TOP TINCTURE,TOP INJ POWDER,ORAL PWDR,RENST-ORAL INJ,SOLN SOLN,OPH INJ CAP OR TAB INJ,SOLN TAB,EFFERVSC CAP OR TAB,SA INJ,CONC-SOLN PWDR,EFFERVSC d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 30 TN102 TN478 RE302 XA403 XA404 XA505 XA401 XA402 XA504 XA599 OP400 DE101 DE101 DE101 DE101 DE400 AD900 DE700 DE700 CV350 CV150 POTASSIUM CHLORIDE INJ POTASSIUM CITRATE POTASSIUM IODIDE POUCH CLOSED ONE-PIECE W/ADHESIVE POUCH CLOSED TWO-PIECE W/O ADHESIVE FLANGE SIZE 1 3/4" - 2 1/4" POUCH DRAINABLE 2-PC W/O ADHESIVE UROST FLANGE SZ 1 1/2"-2 1/4" POUCH DRAINABLE ONE PIECE CUSTOM-CUT W/ADHESIVE POUCH DRAINABLE TWO- PIECE W/O ADHESIVE FLANGE SIZE 1 1/2" - 4" POUCH DRAINABLE W/ADHESIVE UROSTOMY POUCH RETRACTED PENIS POVIDONE IODINE POVIDONE IODINE POVIDONE IODINE (OTC) POVIDONE IODINE (OTC) POVIDONE IODINE (OTC) POVIDONE IODINE 10% (OTC) PRALIDOXIME CL PRAMOXINE HCL 1% (OTC) PRAMOXINE HCL 1% (OTC) PRAVASTATIN PRAZOSIN HCL INJ,SOLN TAB,SA SOLN,ORAL SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SOLN,OPH OINT,TOP SOLN,SCRUB PAD SOLN,TOP STICK,TOP INJ,SOLN CREAM,TOP LOTION,TOP TAB CAP,ORAL OP300 OP350 HS051 VT802 CN204 CN204 AP101 CN400 MS400 CV300 CN204 AN900 GA605 GA605 GA605 AH100 AH100 AH100 AH100 AU350 OP700 PREDNISOLONE PREDNISOLONE NA PHOSPHATE/SULFACETAMIDE PREDNISONE PRENATAL VITAMIN PRILOCAINE PRILOCAINE HCL/EPINEPHRINE PRIMAQUINE PHOSPHATE PRIMIDONE PROBENECID PROCAINAMIDE PROCAINE HCL PROCARBAZINE PROCHLORPERAZINE PROCHLORPERAZINE PROCHLORPERAZINE MALEATE PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROPANTHELINE BR PROPARACAINE SUSP,OPH SOLN,OPH TAB CAP OR TAB INJ,SOLN INJ,SOLN TAB TAB TAB INJ,SOLN INJ CAP,ORAL INJ SUPP,RTL TAB INJ SUPP,RTL TAB SYRUP TAB SOLN,OPH d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 31 CN203 CV100 CV100 PH000 HS852 BL118 DX900 RE200 RE501 RE501 GA201 GA201 AM500 R AU300 AU300 AU300 VT104 VT104 AP101 CN709 PROPOFOL PROPRANOLOL HCL PROPRANOLOL HCL PROPYLENE GLYCOL PROPYLTHIOURACIL PROTAMINE SO4 PROTIRELIN PSEUDOEPHEDRINE HCL (OTC) PSEUDOEPHEDRINE/TRIPROLIDINE PSEUDOEPHEDRINE/TRIPROLIDINE PSYLLIUM (OTC) PSYLLIUM (SF) (OTC) PYRAZINAMIDE PYRIDOSTIGMINE PYRIDOSTIGMINE PYRIDOSTIGMINE BROMIDE PYRIDOXINE HCL PYRIDOXINE HCL (OTC) PYRIMETHAMINE QUETIAPINE FUMARATE INJ CAP,SA TAB LIQUID,TOP TAB INJ,SOLN INJ,SOLN TAB CAP,ORAL TAB POWDER,ORAL POWDER,ORAL TAB TAB TAB,SA INJ,SOLN INJ TAB TAB TAB CV300 CV300 IM500 IM100 AM800 R QUINIDINE QUINIDINE RABIES IMMUNE GLOBULIN,HUMAN RABIES VACCINE RALTEGRAVIR TAB TAB,SA INJ INJ TAB OP900 RANIBIZUMAB INJ,SOLN GA301 GA301 CN101 VT801 RANITIDINE RANITIDINE REMIFENTANIL RENAL MULTIVITAMIN WITH < OR = 1MG FOLIC ACID INJ TAB INJ,LYPHL ORAL d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 32 CV490 BL115 AM800 AM800 AM900 AM500 AM500 AM800 OP300 TN102 IR100 HS900 CN709 RESERPINE RETEPLASE RIBAVIRIN RIBAVIRIN RIFABUTIN RIFAMPIN RIFAMPIN RIMANTADINE HCL RIMEXOLONE OPH RINGER'S RINGER'S RISEDRONATE NA RISPERIDONE TAB INJ CAP,ORAL TAB CAP,ORAL CAP,ORAL INJ TAB SUSP,OPH INJ,SOLN SOLN,IRRG TAB INJ,SUSP,SA R R R R R R CN709 RISPERIDONE SOLN,ORAL d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 33 CN709 RISPERIDONE TAB AM800 R AM800 R AN900 RITONAVIR RITONAVIR RITUXIMAB CAP,ORAL SOLN,ORAL INJ,SOLN MS300 CN500 CN204 OP900 IM100 DE500 DE500 DE500 DE500 DE500 RE102 MS101 AM800 R AM800 R BL400 AU350 OP600 DX900 CN602 CN500 TN499 DE400 ROCURONIUM BROMIDE ROPINIROLE ROPIVACAINE ROSE BENGAL (OTC) RUBELLA VIRUS VACCINE SALICYLIC ACID SALICYLIC ACID SALICYLIC ACID SALICYLIC ACID SALICYLIC ACID/SULFUR SALMETEROL SALSALATE SAQUINAVIR SAQUINAVIR SARGRAMOSTIM SCOPOLAMINE HBR SCOPOLAMINE HBR SECRETIN SELEGILINE SELEGILINE HCL SELENIUM SELENIUM INJ,SOLN TAB INJ SPRIP,OPH INJ CREAM,TOP PLASTER,TOP SHAMPOO SOLN,TOP CREAM,TOP INHL,ORAL TAB CAP,ORAL TAB INJ INJ,SOLN SOLN,OPH INJ,SOLN PATCH TAB INJ,SOLN LOTION d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 34 DE400 GA204 CN609 CN609 GU900 R CN203 XA900 XA900 DE500 DE101 GA900 CV350 SELENIUM SENNOSIDES (OTC) SERTRALINE SERTRALINE SEVELAMER SEVOFLURANE SHARPS DISPOSABLE CONTAINER SHEATH HOLDER WITH VELCRO/FOAM SILVER NITRATE SILVER SULFADIAZINE SIMETHICONE (OTC) SIMVASTATIN SHAMPOO TAB SOLN,ORAL TAB TAB LIQUID,INHL SUPPLY SUPPLY APPLICATOR CREAM,TOP TAB,CHEWABLE TAB IM600 IM600 XA604 XA900 XA199 TN440 TN476 GA110 RS300 GA202 TN102 IR100 RE900 OP900 NT900 OP900 PH000 TN440 PH000 DE101 TN102 CV490 AD400 AD400 PH000 CV100 XA900 SIROLIMUS SIROLIMUS SKIN BARRIER SKIN CLEANSER, INTACT SOCK, STUMP SODIUM ACETATE SODIUM BICARBONATE SODIUM BICARBONATE (OTC) SODIUM BIPHOSPHATE/SODIUM PHOSPHATE (OTC) SODIUM BIPHOSPHATE/SODIUM PHOSPHATE (OTC) SODIUM CHLORIDE SODIUM CHLORIDE SODIUM CHLORIDE (OTC) SODIUM CHLORIDE (OTC) SODIUM CHLORIDE (OTC) SODIUM CHLORIDE (OTC) SODIUM CITRATE SODIUM CITRATE SODIUM CITRATE SODIUM HYPOCHLORITE (OTC) SODIUM LACTATE SODIUM NITROPRUSSIDE SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE SORBITOL 70% SOTALOL HCL SPACER-INHALER SOLN,ORAL TAB SUPPLY SUPPLY SUPPLY INJ,SOLN INJ,SOLN TAB ENEMA LIQUID,ORAL INJ,SOLN SOLN,IRRG SOLN,INHL OINT,OPH SOLN,NASAL SOLN,OPH INJ INJ,SOLN POWDER SOLN,TOP INJ,SOLN INJ SUSP SUSP,RTL SOLN,ORAL TAB CHAMBER d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 35 CV704 OR100 OR100 OR100 OR100 AM800 R XA199 XA608 BL115 AM300 R AN200 MS300 GA302 GA302 CN101 OP210 OP210 DE500 AM650 AM650 AM650 AM650 GA900 GA900 GA900 MS102 CN105 DE300 XA900 XA900 XA900 XA852 IM600 IM600 DE900 AN500 XA202 XA204 XA201 XA299 XA203 XA299 XA206 SPIRONOLACTONE STANNOUS FLUORIDE STANNOUS FLUORIDE STANNOUS FLUORIDE STANNOUS FLUORIDE STAVUDINE (d4T) STERI-STRIPS STOMA CAP STREPTOKINASE STREPTOMYCIN SULFATE STREPTOZOCIN SUCCINYLCHOLINE SUCRALFATE SUCRALFATE SUFENTANIL CITRATE SULFACETAMIDE NA SULFACETAMIDE NA SULFACETAMIDE NA 10%/SULFUR 5% SULFADIAZINE SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM SULFASALAZINE SULFASALAZINE SULFASALAZINE SULINDAC SUMATRIPTAN SUCCINATE SUNSCREEN-30 PABA-FREE COMBINATION SUPPLIES,OTHER SUSPENSORY SUPPORTER SYRINGE MAGNIFIER SYRINGE, LUER LOCK TACROLIMUS TACROLIMUS TALC TOP(OTC) TAMOXIFEN CITRATE TAPE CLOTH TAPE FOAM TAPE PAPER TAPE PINK TAPE PLASTIC TAPE RETENTION SHEET TAPE TRACH TAB FOAM,DENT GEL,DENT LIQUID,DENT VARNISH,DENT CAP,ORAL SUPPLY SUPPLY INJ INJ INJ INJ,SOLN SUSP,ORAL TAB INJ,SOLN OINT,OPH SOLN,OPH LOTION,TOP TAB INJ,SOLN SUSP TAB SUSP TAB TAB,EC TAB INJ LOTION,TOP SUPPLY SUPPLY SUPPLY SUPPLY INJ,SOLN CAP,ORAL POWDER,TOP TAB SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY R R R R d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 36 CN302 BL115 TEMAZEPAM TENECTEPLASE,RECOMBINANT CAP,ORAL INJ AN900 AM800 R CV150 TENIPOSIDE TENOFOVIR DISOPROXIL FUMARATE TERAZOSIN HCL INJ TAB CAP,ORAL AM700 R DE102 RE103 AU100 AN500 HS100 HS100 IM300 IM500 IM200 CN204 OP700 AM250 R RE104 RE104 RE104 RE104 RE104 RE104 RE104 AP200 VT105 VT105 TN200 TERBINAFINE HCL TERBINAFINE HCL 1% TERBUTALINE SULFATE TERBUTALINE SULFATE TESTOLACTONE TESTOSTERONE TESTOSTERONE (IN OIL) TETANUS ANTITOXIN TETANUS IMMUNE GLOBULIN TETANUS TOXOID TETRACAINE HCL TETRACAINE HCL TETRACYCLINE HCL THEOPHYLLINE THEOPHYLLINE THEOPHYLLINE THEOPHYLLINE THEOPHYLLINE THEOPHYLLINE THEOPHYLLINE THIABENDAZOLE THIAMINE THIAMINE HCL (OTC) THICKENING AGENT TAB CREAM,TOP TAB INJ TAB PATCH INJ (IN OIL) INJ,SOLN INJ INJ INJ SOLN,OPH CAP,ORAL CAP,ORAL CAP,SA INJ SOLN,ORAL SYRUP TAB TAB,SA TAB,CHEWABLE INJ,SOLN TAB PWDR,ORAL d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 37 AN300 CN202 CN701 CN701 AN100 CN701 BL116 AM113 R AM250 R OP101 OP101 RE105 THIOGUANINE THIOPENTAL THIORIDAZINE THIORIDAZINE THIOTEPA THIOTHIXENE THROMBIN TICARCILLIN/CLAVULANATE K TIGECYCLINE TIMOLOL TIMOLOL TIOTROPIUM TAB INJ,SOLN SOLN,ORAL TAB,EC INJ CAP,ORAL POWDER,TOP INJ INJ,LYPHL GEL,OPH SOLN,OPH CAP,INHL AM800 R BL110 R MS200 TIPRANAVIR TIROFIBAN TIZANIDINE CAP,ORAL INJ,SOLN TAB OP210 AM300 R XA900 CN400 AN900 TN490 TN490 XA900 XA900 XA199 XA900 CN103 XA107 CN602 OP109 CN609 DE752 DE200 HS051 DE200 OR900 CV704 TOBRAMYCIN TOBRAMYCIN SULFATE TONGUE DEPRESSOR TOPIRAMATE TOPOTECAN TPN ELECTROLYTE TRACE ELEMENTS TRACH SUCTION KIT 2 GLOVES 14FR TRACHEOSTOMY CARE KIT TRACHEOSTOMY PAD TRACHEOSTOMY TUBE TRAMADOL HCL TRANSPARENT DRESSING TRANYLCYPROMINE SULFATE TRAVOPROST TRAZODONE TRETINOIN TRIAMCINOLONE TRIAMCINOLONE TRIAMCINOLONE TRIAMCINOLONE ACETONIDE DENTAL TRIAMTERENE SOLN,OPH INJ,SOLN SUPPLY TAB INJ INJ INJ SUPPLY SUPPLY SUPPLY SUPPLY TAB SUPPLY TAB SOLN,OPH TAB CREAM,TOP CREAM,TOP INJ,SUSP OINT,TOP PASTE CAP,ORAL d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 38 DE500 IM900 CN701 OP230 AU350 GA605 AM900 R TN900 OP600 OP900 DX300 XA853 XA900 IM100 XA199 DE350 DE350 XA502 XA502 DX900 BL115 GA900 GA900 AM800 R AM800 R CN400 CN400 CV805 TRICHLOROACETIC ACID 80% TRICHOPHYTON TRIFLUOPERAZINE TRIFLURIDINE TRIHEXYPHENIDYL TRIMETHOBENZAMIDE TRIMETHOPRIM TROMETHAMINE TROPICAMIDE TRYPAN BLUE TUBERBULIN,PURIFIED PROTEIN DERIVATIVE TUBERCULIN SYRINGE TUBING LATEX TYPHOID VACCINE UNNA BOOT UREA UREA URINAL FEMALE URINAL MALE URINE GLUCOSE MONITORING DEVICES UROKINASE 5000U URSODIOL URSODIOL VALACYCLOVIR VALGANCICLOVIR HCL VALPROIC ACID VALPROIC ACID VALSARTAN SOLN,TOP INJ TAB SOLN,OPH TAB CAP,ORAL TAB INJ SOLN,OPH SOLN,OPH INJ SUPPLY SUPPLY INJ SUPPLY CREAM/EMULSION,TOP LOTION/SUSPENSION,TOP SUPPLY SUPPLY DEVICE INJ CAP,ORAL TAB TAB TAB CAP,ORAL SYRUP TAB AM900 R AM900 R GU900 AD900 IM500 HS702 MS300 CN609 CN609 CV200 CV200 VANCOMYCIN VANCOMYCIN HCL VARDENAFIL HCL VARENICLINE TARTRATE VARICELLA ZOSTER IMMUNE GLOBULIN (HUMAN) VASOPRESSIN VECURONIUM VENLAFAXINE VENLAFAXINE VERAPAMIL HCL VERAPAMIL HCL INJ CAP,ORAL TAB TAB INJ INJ,SOLN INJ CAP,SA TAB INJ,SOLN TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 39 CV200 OP230 AN900 AN900 AN900 VT050 VT109 VT504 VT504 VT600 BL110 BL110 PH000 RE900 IR100 XA900 DX900 XA900 AM800 R AM800 R AM800 R TN450 DE900 DE900 DE400 TN450 TN450 CN709 VERAPAMIL HCL VIDARABINE VINBLASTINE VINCRISTINE VINORELBINE VITAMIN A (OTC) VITAMIN B COMPLEX (OTC) VITAMIN D (CHOLECALCIFEROL OR ERGOCALCIFEROL 400 IU to 2000 IU) TAB,SA OINT,OPH INJ INJ INJ CAP,ORAL CAP OR TAB CAP OR TAB CAP OR TAB VITAMIN D, HIGH DOSE (CHOLECALCIFEROL OR ERGOCALCIFEROL 50,000 IU) VITAMIN E CAP,ORAL WARFARIN NA (COUMADIN) WARFARIN NA (COUMADIN) WATER WATER WATER WOUND CLEANSER XYLOSE (OTC) YANKAUER ZIDOVUDINE ZIDOVUDINE ZIDOVUDINE ZINC CHLORIDE ZINC OXIDE (OTC) ZINC OXIDE (OTC) ZINC PYRITHIONE 1% (OTC) ZINC SULFATE ZINC SULFATE ZIPRASIDONE INJ TAB INJ,SOLN SOLN,INHL SOLN,IRRG SUPPLY POWDER SUPPLY CAP,ORAL INJ TAB INJ,SOLN OINT,TOP PASTE SHAMPOO CAP,ORAL INJ,SOLN CAP,ORAL HS900 CN105 CN105 CN309 ZOLEDRONIC ZOLMITRIPTAN ZOLMITRIPTAN ZOLPIDEM INJ,PWDR TAB TAB,ORAL DISINTEGRATING TAB d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 40 IM100 ZOSTER VACCINE INJ,LYPHL d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 41 e considered non-formulary (although other dosage forms of that molecular se. Sustained release products are listed individually. Formulary products may ngths, not all forms and strengths need to be stocked. Facilities should make l or VISN level. These decisions should be based on local culture and sensitivity patterns. Reference In addition to abciximab, VISNs are required to add either eptifibatide or tirofiban to their VISN formulary. Refer to VA/DoD IHD treatment guideline. http://www.pbm.va.gov/reviews/g lycoproteinreview.pdf http://www.oqp.med.va.gov/cpg/DM/DM_base.h tm d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 42 Restricted to GI and ID http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://www.pbm.va.gov/reviews/Bisphos3.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 43 http://www.pbm.va.gov/criteria/Parkinson.pdf http://www.pbm.va.gov/criteria/Parkinson.pdf http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://www.pbm.va.gov/monitoring/amiodaron.htm http://www.pbm.va.gov/tig/felodipine.pdf http://www.pbm.va.gov/criteria/all hatstatement.pdf Restricted to neurology for treatment of acute hypomobility episode of advanced Parkinson's disease. http://www.pbm.va.gov/m onograph/apomorphine.p df d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 44 http://www.pbm.va.gov/monograph/Aripiprazole%20IM%20M onogragh.doc http://www.pbm.va.gov/monograph/Aripiprazole. pdf http://www.pbm.va.gov/guideline s/Atypical%20AntipsychoticsME. pdf http://www.pbm.va.gov/criteria/antiplateletcriteria.pdf http://www.pbm.va.gov/criteria/antiplateletcriteria.pdf http://www.pbm.va.gov/criteria/antiplateletcriteria.pdf http://www.pbm.va.gov/criteria/antiplateletcriteria.pdf http://www.pbm.va.gov/criteria/atazanavir.pdf http://vaww.pbm.med.va.gov/criteria/allhatstatement.pdf http://www.pbm.va.gov/drugmonograph/9paerfAzacitidine.pd http://vaww.pbm.va.gov/criteria/8 f 7wry73Azacitidine.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 45 http://www.pbm.va.gov/criteria/Parkinson.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 46 Rrestricted to patients with heart failure http://vaww.pbm.va.gov/criteria/b blockerscriteria.pdf http://www.pbm.va.gov/criteria/Parkinson.pdf http://www.pbm.va.gov/criteria/Parkinson.pdf http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://vaww.pbm.va.gov/criteria/Buprenorphine.pdf http://vaww.pbm.va.gov/drugmon http://vaww.pbm.va.gov/archive/Buprenorp http://vaww.pbm.va. ograph/BUPMonograph%20(Rev hine.pdf gov/archive/BUPM %2009Jun03).pdf onograph%20(Rev %2009Jun03).pdf http://vaww.pbm.va.gov/drugmon ograph/BUPMonograph%20(Rev %2009Jun03).pdf http://vaww.pbm.va.gov/criteria/Buprenorphine.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 47 http://www.pbm.va.gov/reviews/aceinhibitorsreview.pdf http://www.pbm.va.gov/criteria/Parkinson.pdf http://vaww.pbm.va.gov/criteria/bblockerscriteria.pdf http://vaww.pbm.va.gov/archive/ bblockerscriteria.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 48 http://www.pbm.va.gov/criteria/allhatstatement.pdf http://www.pbm.va.gov/tig/felodip ine.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 49 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 http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://www.pbm.va.gov/criteria/allhatstatement.pdf http://vaww.pbm.va.gov/criteria/antiplateletcriteria.pdf http://vaww.pbm.va.gov/criteria/c http://vaww.pbm.va.gov/monitoring/clopido lopidogrelcriteria.pdf grel.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 50 http://www.pbm.va.gov/archive/atypicalantiguidelines.pdf http://www.pbm.va.gov/guideline s/Atypical%20AntipsychoticsME. pdf 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 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 51 Restricted to spinal cord injury, neurology, and rehabilitation Restricted to spinal cord injury, neurology, and rehabilitation Restricted to ID Restricted to ID specialist in compliance with national criteria for use http://www.hiv.va.gov/vahi v?page=cm1002_tables& http://www.pbm.va.gov/reviews/CombinHT.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 52 http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 53 http://www.pbm.va.gov/tig/felodipine.pdf http://www.pbm.va.gov/tig/felodipine.pdf http://www.pbm.va.gov/monitoring/antiemeticdosing.pdf http://www.pbm.va.gov/monitoring/antiemeticdosing.pdf http://www.pbm.va.gov/monograph/TetanusDiptheriaPertuss isTdapVaccine.pdf http://www.pbm.va.gov/tig/DepakotTIG.pdf http://www.pbm.va.gov/tig /DepakoteProviderLetter. pdf http://vaww.pbm.va.gov/criteria/cholinest%20Inhib.pdf http://vaww.pbm.va.gov/archive/ http://vaww.pbm.va.gov/reviews/CholinestI alzheimersguidelines.pdf nh.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 54 http://vaww.pbm.va.gov/archive/alphablockersreview.pdf http://vaww.pbm.va.gov/criteria/a llhatstatement.pdf Replaces separate CAP OR TAB entry http://www.pbm.va.gov/criteria/antiemeticdosing.pdf http://www.pbm.va.gov/monograph/9857emtricitabine.pdf http://www.pbm.va.gov/monograph/9857emtricitabine.pdf http://vaww.pbm.va.gov/reviews/aceinhibitorsreview.pdf http://www.pbm.va.gov/criteria/fuzeon.pdf http://www.pbm.va.gov/criteria/enoxaparincriteria.pdf Neurologist treating Parkinson http://www.pbm.va.gov/monogra ph/Entecavir,%20Monograph.pdf http://www.pbm.va.gov/monogra ph/Entecavir,%20Monograph.pdf Restricted to GI and ID d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 55 http://www.pbm.va.gov/monograph/Ertapenemmonograph.p df http://www.pbm.va.gov/reviews/CombinHT.pdf http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://www.pbm.va.gov/reviews/CombinHT.pdf http://www.pbm.va.gov/reviews/CombinHT.pdf http://www.pbm.va.gov/reviews/CombinHT.pdf http://www.pbm.va.gov/reviews/CombinHT.pdf http://www.pbm.va.gov/reviews/CombinHT.pdf http://www.pbm.va.gov/reviews/CombinHT.pdf http://www.pbm.va.gov/reviews/CombinHT.pdf http://www.pbm.va.gov/reviews/CombinHT.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 56 Restricted ID Practitioners or providers that provide care to HIV patients http://www.pbm.va.gov/reviews/h2review.pdf Restricted to neurology service http://vaww.pbm.va.gov/criteria/dhpcriteria92000%20.pdf http://vaww.pbm.va.gov/archive/ dhpcriteria%20.pdf http://www.pbm.va.gov/criteria/alphablocker%20%20finasteri de.pdf http://www.pbm.va.gov/reviews/oralinhaledsteroids.pdf http://www.pbm.va.gov/reviews/intranasalsteroidreview.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 57 http://www.pbm.va.gov/archive/ssrireview.pdf http://www.pbm.va.gov/archive/ssrireview.pdf http://www.pbm.va.gov/archive/ssrireview.pdf http://www.pbm.va.gov/CriteriaForUse.aspx http://vaww.pbm.va.gov/reviews/aceinhibitorsreview.pdf http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm 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://vaww.pbm.va.gov/criteria/cholinest%20Inhib.pdf http://vaww.pbm.va.gov/criteria/cholinest%20Inhib.pdf http://vaww.pbm.va.gov/reviews/ CholinestInh.pdf http://vaww.pbm.va.gov/reviews/ CholinestInh.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 58 http://www.pbm.va.gov/Safety%20Reports/87ry38statinfibrate-Final.pdf http://www.pbm.va.gov/criteria/multiplesclerosis.pdf http://www.oqp.med.va.gov/cpg/DM/DM_base.h tm http://www.oqp.med.va.gov/cpg/DM/DM_base.h tm http://www.pbm.va.gov/reviews/LHRH(Jan%2003).pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 59 http://www.pbm.va.gov/monitoring/antiemeticdosing.pdf http://www.pbm.va.gov/guidelines/Atypical%20Antipsychotic sME.pdf http://www.pbm.va.gov/monitoring/antiemeticdosing.pdf http://www.pbm.va.gov/guidelines/Atypical%20Antipsychotic sME.pdf http://www.pbm.va.gov/criteria/allhatstatement.pdf Refer to VHA/DoD Hypertension guideline and pharmacologic supplement http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://www.pbm.va.gov/tig/felodipine.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 60 http://vaww.pbm.va.gov/archive/imatinibcriteria.pdf http://vaww.pbm.va.gov/drugmon http://vaww.pbm.va.gov/drugmonograph/i ograph/Gleevec.pdf matinibcmonograph.pdf http://vaww.pbm.va. gov/criteria/Gleeve c%20Criteria.pdf http://www.pbm.va.gov/criteria/Imiquimod.pdf http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 61 http://www.oqp.med.va.gov/cpg/DM/DM_base.h tm http://www.oqp.med.va.gov/cpg/DM/DM_base.h tm http://www.oqp.med.va.gov/cpg/DM/DM_base.h tm http://www.oqp.med.va.gov/cpg/DM/DM_base.h tm http://www.oqp.med.va.gov/cpg/DM/DM_base.h tm http://www.oqp.med.va.gov/cpg/DM/DM_base.h tm http://www.oqp.med.va.gov/cpg/DM/DM_base.h tm 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/guidelines/Chronicobstr upulmonary.pdf http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 62 http://www.pbm.va.gov/criteria/HighlyTeratogenicRetinoidsA ndHigh-DoseVitaminACFU.pdf http://vaww.pbm.va.gov/criteria/Levetiracetam.pdf http://www.pbm.va.gov/reviews/obabreview.pdf http://www.pbm.va.gov/criteria/Fluoroquinolone.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 63 http://www.pbm.va.gov/criteria/linezolidcriteria1.pdf http://www.pbm.va.gov/criteria/linezolidcriteria1.pdf http://vaww.pbm.va.gov/reviews/aceinhibitorsreview.pdf http://www.pbm.va.gov/reviews/nonsedatingantihistaminesre view.pdf Restricted for treatment of type 2 diabetic nephropathy in patients with HTN http://vaww.pbm.va.gov/reviews/ AIIRA%20Drug%20Class.pdf http://vaww.pbm.va. gov/archive/angiote nsinaiicriteria.pdf http://www.pbm.va.gov/reviews/HMGStatAppendix1.pdf http://www.pbm.va.gov/faq%20s http://www.pbm.va.gov/reviews/HMGStatin heets/REVERSAL%20AND%20 s04-09-03.pdf PROVEIT%20FAQ%20Sheet.pdf Restricted ID Practitioners or providers that provide care to HIV patients http://www.pbm.va.gov/m http://www.pbm.va.gov/criteria/Ma onograph/Maraviroc,%20 raviroc,%20Criteria%20for%20Us Drug%20Monograph.pdf e%20(Check-Box%20Format).pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 64 http://www.pbm.va.gov/reviews/CombinHT.pdf http://vaww.pbm.va.gov/drugmonograph/3453memantinemo http://vaww.pbm.va.gov/criteria/ nof.pdf memantine.pdf http://www.pbm.va.gov/criteria/meperidine.pdf http://www.pbm.va.gov/reviews/CombinHT.pdf http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://www.oqp.med.va.gov/cpg/DM/DM_base.htm http://vaww.pbm.va.gov/archive/methadonedosing.pdf http://www.pbm.va.gov/criteria/T ZD%20criteria.pdf http://vaww.pbm.va.gov/monitori ng/Methadone%20Dosing%20Fi nal%20(Rev%20081103).pdf http://vaww.pbm.va.gov/monitori ng/Methadone%20Dosing%20Fi nal%20(Rev%20081103).pdf http://vaww.pbm.va.gov/archive/methadonedosing.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 65 Refer to VHA/DoD Hypertension guideline and pharmacologic supplement http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://vaww.pbm.va.gov/criteria/bblockerscriteria.pdf Restricted to CHF patients http://vaww.pbm.va.gov/criteria/b blockerscriteria.pdf http://www.pbm.va.gov/monograph/Micafungin. pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 66 http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://vaww.pbm.va.gov/criteria/Leukotriene.pdf http://vaww.pbm.va.gov/drugmon ograph/Montelukast%20AR.pdf http://www.pbm.va.gov/criteria/Fluoroquinolone.pdf http://www.pbm.va.gov/criteria/Fluoroquinolone.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 67 Restricted to neurology or practitioners who treat multiple sclerosis patients. http://www.pbm.va.gov/reviews/niacinreview.pdf http://www.pbm.va.gov/reviews/niacinreview.pdf http://www.oqp.med.va.gov/cpg/TUC3/TUC_Ba se.htm http://www.oqp.med.va.gov/cpg/TUC3/TUC_Ba se.htm http://www.oqp.med.va.gov/cpg/TUC3/TUC_Ba se.htm http://www.pbm.va.gov/tig/felodipine.pdf For patients unable to tolerate nicotine gum http://www.pbm.va.gov/criteria/d http://www.pbm.va.gov/reviews/ccbreviews hpcriteria92000%20.pdf .pdf http://www.pbm.va.gov/archive/nitroglycerinreview.pdf http://www.pbm.va.gov/reviews/CombinHT.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 68 http://vaww.pbm.va.gov/drugmonograph/21389Olanzapine% http://www.pbm.va.gov/guideline 20IM.pdf s/Atypical%20AntipsychoticsME. pdf http://vaww.pbm.va.gov/drugmonograph/21389Olanzapine% http://www.pbm.va.gov/guideline 20IM.pdf s/Atypical%20AntipsychoticsME. pdf http://www.pbm.va.gov/guidelines /Recommendations%20for%20At ypical%20Antipsychotic%20Use %20in%20Schizophrenia%20and %20Schizoaffective%20Disorder s.pdf http://www.pbm.va.gov/guidelines /Recommendations%20for%20At ypical%20Antipsychotic%20Use %20in%20Schizophrenia%20and %20Schizoaffective%20Disorder s.pdf http://www.pbm.va.gov/archive/ppiabbreviatedreview.pdf http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf http://www.pbm.va.gov/monograph/985e98uosletamivir.pdf http://vaww.pbm.va.gov/drugmonograph/98472Oxaliplatin% http://vaww.pbm.va.gov/drugmon 20Addedn.pdf ograph/Oxaliplatin2.pdf http://vaww.pbm.va.gov/criteria/Oxycodone%20Final%20Alg http://vaww.pbm.va.gov/criteria/o http://vaww.pbm.va.gov/archive/oxycodone http://vaww.pbm.va. orithm%20(Rev%2020Aug03).pdf xycodonecriteria.pdf algorithmcriteria.pdf gov/archive/Oxycod one%20(Rev%200 71603).pdf http://vaww.pbm.va.gov/criteria/Oxycodone%20Final%20Alg http://vaww.pbm.va.gov/criteria/o http://vaww.pbm.va.gov/archive/oxycodone http://vaww.pbm.va. orithm%20(Rev%2020Aug03).pdf xycodonecriteria.pdf algorithmcriteria.pdf gov/archive/Oxycod one%20(Rev%200 71603).pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 69 http://www.pbm.va.gov/monograph/8756Papain%20urea.pdf http://www.pbm.va.gov/criteria/Quadrivalent%20 http://www.pbm.va.gov/m HPV%20Vaccine%20(Gardasil).pdf onograph/Gardasil.pdf http://www.pbm.va.gov/archive/ssrireview.pdf http://vaww.pbm.va.gov/criteria/Pegylated.pdf http://vaww.pbm.va.gov/drugmon ograph/pegasysmon1202.pdf http://vaww.pbm.va.gov/criteria/Pegylated.pdf SPRAY AND STRETCH TOP AEROSOL Restricted to psychiatry/mental health providers http://www.pbm.va.gov/criteria/Monoamine%20Oxidase%20Inhibitors%20(MAOI).pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 70 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 71 http://vaww.pbm.va.gov/criteria/allhatstatement.pdf http://vaww.pbm.va.gov/archive/ alphablockersreview.pdf http://vaww.pbm.va.gov/criteria/antiemeticdosing.pdf http://vaww.pbm.va.gov/criteria/a http://vaww.pbm.va.gov/criteria/antiemetic ntiemeticdosing.pdf dosing.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 72 http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://www.pbm.va.gov/guidelines/Atypical%20Antipsychotic http://www.pbm.va.gov/guideline sME.pdf s/Recommendations%20for%20 Atypical%20Antipsychotic%20Us e%20in%20Schizophrenia%20a nd%20Schizoaffective%20Disor ders.pdf Restricted to ID providers or providers that provide care to HIV patients. http://vaww.national.cmop .va.gov/PBM/Clinical%20 Guidance/Criteria%20For %20Use/Raltegravir,%20 Criteria%20for%20Use.d oc http://www.pbm.va.gov/monogra ph/Ranibizumab,%20Monograph .pdf Restricted to wet AMD, ophthalmology/retinal specialists http://www.pbm.va.gov/reviews/h2review.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 73 http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://www.pbm.va.gov/criteria/Pegylated.pdf http://www.pbm.va.gov/criteria/Pegylated.pdf http://www.pbm.va.gov/reviews/Bisphos3.pdf http://www.pbm.va.gov/criteria/Risperidone.pdf http://vaww.pbm.va.gov/drugmon ograph/095809RConstamonogra phfinal.pdf http://www.pbm.va.gov/guidelines /Recommendations%20for%20At ypical%20Antipsychotic%20Use %20in%20Schizophrenia%20and %20Schizoaffective%20Disorder s.pdf http://www.pbm .va.gov/guidelin es/Recommen dations%20for %20Atypical% 20Antipsychoti c%20Use%20i n%20Schizoph renia%20and% 20Schizoaffecti ve%20Disorder s.pdf http://www.pbm.va.gov/criteria/Risperidone.pdf http://vaww.pbm.va.gov/drugmon http://www.pbm.va.gov/guidelines/Atypical ograph/095809RConstamonogra %20AntipsychoticsME.pdf phfinal.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 74 http://www.pbm.va.gov/criteria/Risperidone.pdf http://vaww.pbm.va.gov/drugmon http://www.pbm.va.gov/guidelines/Atypical ograph/095809RConstamonogra %20AntipsychoticsME.pdf phfinal.pdf http://www.pbm .va.gov/guidelin es/Recommen dations%20for %20Atypical% 20Antipsychoti c%20Use%20i n%20Schizoph renia%20and% 20Schizoaffecti ve%20Disorder s.pdf Restricted to oncology and per criteria for Use for Rituximab in Moderate to Severe Rheumatoid Arthritis. http://www.pbm.va.gov/cri http://www.pbm.va.gov/criteria/Rit teria/Criteria%20for%20U uximabCFU.pdf se%20for%20Leflunomid e%20and%20Biologic%2 0DMARDs.pdf http://www.pbm.va.gov/criteria/Parkinson.pdf http://www.pbm.va.gov/monitoring/antiemeticdosing.pdf Restricted to psychiatry/mental health providers http://www.pbm.va.gov/monograph/Selegiline%20Transdermal%20System%20(EMSAM).pdf http://www.pbm.va.gov/criteria/Monoamine%20Oxidase%20Inhibitors%20(MAOI).pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 75 http://www.pbm.va.gov/archive/ssrireview.pdf http://www.pbm.va.gov/archive/ssrireview.pdf http://www.pbm.va.gov/criteria/Phosphate%20bi nder.pdf http://www.pbm.va.gov/faq%20sheets/REVERSAL%20AND http://www.pbm.va.gov/reviews/ %20PROVE-IT%20FAQ%20Sheet.pdf HMGStatAppendix1.pdf http://www.pbm.va.gov/reviews/ HMGStatins04-09-03.pdf http://www.pbm.va.gov/Safety%20Reports/ 87ry38statin-fibrate-Final.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 76 http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://www.pbm.va.gov/reviews/5ht1review.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 77 Refer to VA directive “Treatment of Acute Myocardial Infarction (AMI) and Unstable Angina” #2003-017; April 8, 2003. http://www.va.gov/publ/direc/health/direct/12003017.pdf http://vaww.pbm.va.gov/criteria/a llhatstatement.pdf http://vaww.pbm.va.gov/criteria/allhatstatement.pdf http://vaww.pbm.va.gov/archive/ alphablockersreview.pdf http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://www.pbm.va.gov/guidelines/Chronicobstr upulmonary.pdf http://vaww.pbm.va.gov/clinicians/ClinicalGuidanceForMedic ationAssessmentInDysphagia.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 78 http://www.pbm.va.gov/monograph/Tigecycline.pdf http://www.pbm.va.gov/reviews/obabreview.pdf http://www.pbm.va.gov/reviews/obabreview.pdf http://www.pbm.va.gov/cri http://www.pbm.va.gov/monograph/23876yTiotr teria/Tiotropium%20Criter opium.pdf ia%20for%20Use.doc http://vaww.pbm.va.gov/drugmonograph/67wsr7qTipranavir %20Monograp.pdf Restricted to spinal cord injury, neurology, and rehabilitation. Tizanidine should only be used in failed baclofen cases http://vaww.pbm.va.gov/criteria/e s78wTipranavir.pdf Restricted to psychiatry/mental health providers http://www.pbm.va.gov/criteria/Monoamine%20Oxidase%20Inhibitors%20(MAOI).pdf http://www.pbm.va.gov/reviews/ophthprostopthreview5.pdf http://www.oqp.med.va.gov/cpg/HTN04/HTN_b ase.htm d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 79 http://www.pbm.va.gov/criteria/Parkinson.pdf Restricted to use with Apomorphine Restricted to CMV retinitis Restricted to treatment of patients with systolic heart failure" http://vaww.pbm.va.gov/reviews/ http://vaww.pbm.va.gov/archive/angiotensi AIIRA%20Drug%20Class.pdf naiicriteria.pdf http://www.pbm.va.gov/criteria/Vardenafil%20N on-Responders.pdf Restricted to the VA/DoD Tobacco Use http://www.oqp.med.va.go http://www.oqp.med.va.gov/cpg/T Cessation Clinical Practice Guidelines v/cpg/cpg.htm UC3/TUC_Base.htm http://www.pbm.va.gov/reviews/ccbreviews.pdf http://www.pbm.va.gov/tig/felodip ine.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 80 http://www.pbm.va.gov/reviews/ccbreviews.pdf http://www.pbm.va.gov/tig/felodip ine.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%20EVa%20medsafe.pdf http://vaww.pbm.va.gov/criteria/zipracriteria.pdf http://www.pbm.va.gov/guideline s/Atypical%20AntipsychoticsME. pdf http://www.pbm.va.gov/guidelines /Recommendations%20for%20At ypical%20Antipsychotic%20Use %20in%20Schizophrenia%20and %20Schizoaffective%20Disorder s.pdf http://www.pbm.va.gov/reviews/5ht1review.pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 81 http://www.pbm.va.gov/monograph/Zoster%20V http://www.pbm.va.gov/cri http://www.pbm.va.gov/faq%20sh accine,%20Monograph.pdf teria/Zoster%20Vaccine% eets/Zoster%20Vaccine%20FAQ 20Criteria%20for%20Use %20for%20Patients.pdf .doc d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 82 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 83 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 84 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 85 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 86 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 87 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 88 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 89 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 90 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 91 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 92 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 93 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 94 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 95 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 96 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 97 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 98 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 99 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 100 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 101 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 102 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 103 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 104 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 105 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 106 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 107 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 108 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 109 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 110 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 111 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 112 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 113 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 114 d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 115 I).pdf d667408a-19d1-4bfe-93a1-8debe0b647dd.xls Page 116