Copy-of-VA_National_Formulary_December_2015.xls
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DEPARTMENT OF VETERANS AFFAIRS
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PHARMACY BENEFITS MANAGEMENT STRATEGIC HEALTH GROUP
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http://www.pbm.va.gov/
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http://vaww.pbm.va.gov
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VHA NATIONAL FORMULARY
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Dec-15
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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 forms of that molecular entity may be included as formulary). Dosage forms such as TAB and CAP, ORAL are considered immediate release. Sustained release products are listed individually. Formulary products may 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 stocked. Facilities should make those dosages available that are necessary to meet their patient needs.”
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PA- There are three levels of Prior Authorization
• Prior Authorization-National (PA-N) refers to medications that are formulary, but require prior approval at the national level before dispensing.
• Prior Authorization-VISN (PA-V) refers to medications that are formulary, but require prior approval at the VISN level before dispensing.
• Prior Authorization-Facility (PA-F) refers to medications that are formulary, but require prior approval at the facility level before dispensing.
Prior Authorization is used to insure that the medication is appropriate for each individual Veteran.
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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 culture and sensitivity patterns. The restriction for all other products is as otherwise noted.
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VA ClassRestrictionGenericDosage FormCommentsClinical GuidanceSpecial Handling
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AM800RABACAVIRSOLN,ORAL
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AM800RABACAVIRTAB
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AM800RABACAVIR/DOLUTEGRAVIR/LAMIVUDINETABMonograph
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AM800RABACAVIR/LAMIVUDINETAB
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AM800RABACAVIR/LAMIVUDINE/ZIDOVUDINETAB
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BL117ABCIXIMABINJ,SOLN
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AD100ACAMPROSATETAB,ECClin Recs
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HS502ACARBOSETAB
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CN103ACETAMINOPHENI NJ
Restricted to post-op use and PACU areas
Criteriahttp://vaww.mirecc.va.gov/miamiproject/
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CN103ACETAMINOPHENLIQUID,ORAL
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CN103ACETAMINOPHENSUPP,RTL
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CN103ACETAMINOPHENTAB
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CN103ACETAMINOPHEN/BUTALBITAL/CAFFEINETAB
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CN101ACETAMINOPHEN/HYDROCODONELIQUID,ORAL
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CN101ACETAMINOPHEN/HYDROCODONETAB
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CN101ACETAMINOPHEN/OXYCODONE HCLCAP,ORAL
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CN101ACETAMINOPHEN/OXYCODONE HCLLIQUID,ORAL
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CN101ACETAMINOPHEN/OXYCODONE HCLTAB
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CV703ACETAZOLAMIDEINJ
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CV703ACETAZOLAMIDETAB
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IR100ACETIC ACIDSOLN,IRRG
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OT109ACETIC ACID/ALUMINUM ACETATE SOLN,OTIC
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OP102ACETYLCHOLINE CHLORIDESOLN,OPH
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AD600ACETYLCYSTEINEINJ,SOLN
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RE400ACETYLCYSTEINESOLN,INHL/ORAL
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DE810ACITRETINCAP,ORALCriteria
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AM800RACYCLOVIRCAP,ORAL
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AM800RACYCLOVIRINJ
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AM800RACYCLOVIRTAB
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AM800RADEFOVIRTABRestricted to GI and ID
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CV300ADENOSINEINJ,SOLN
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XA603ADHESIVE AEROSOLSPRAY,TOP
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XA603ADHESIVE CEMENTLIQUID,TOP
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XA699ADHESIVE REMOVERLIQUID,TOP
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OP900AFLIBERCEPTINJ.OPH
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AP200ALBENDAZOLETAB
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BL500ALBUMIN,HUMANINJ
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RE102ALBUTEROLINHALANT
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RE102ALBUTEROLSOLN,INHL
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RE103ALBUTEROLTAB
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RE109ALBUTEROL/IPRATROPIUMINHL,ORAL
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RE109ALBUTEROL/IPRATROPIUMINHL,SOLN
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DE101ALCOHOL ISOPROPYL 70% LIQUID,TOP
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TN900ALCOHOL, ABSOLUTEINJ,SOLN
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TN101ALCOHOL/DEXTROSEINJ
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IM700ALDESLEUKININJ
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HS900ALENDRONATETAB
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CN101ALFENTANIL HCLINJ,SOLN
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CV150ALFUZOSINTAB,SA
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GA199ALGINIC AC/NA BICARB/CA STEAR/MG TRI (OTC)TAB,CHEWABLE
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IM900ALLERGENIC EXTRACT (VARIOUS)INJ,SOLN
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MS400ALLOPURINOLTAB
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GA199ALOH/MG CARB/NA ALGINATE (OTC)TAB
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GA199ALOH/MGOH/SIMTH (OTC)LIQUID,ORAL
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CN302ALPRAZOLAMTAB
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HS875ALPROSTADILINJ
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HS875ALPROSTADIL URETHRALSUPPOSITORY
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BL115ALTEPLASE, RECOMBINANTINJ,PWDR
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DE450ALUMINUM CHLORIDE (HEXAHYDRATE)SOLN,TOP
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GA101ALUMINUM HYDROXIDECAP,ORAL
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GA101ALUMINUM HYDROXIDELIQUID,ORAL
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DE900ALUMINUM SULFATE/CALCIUM ACETATE (OTC)POWDER,TOP
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AM800RAMANTADINE HCLCAP/TABCriteria
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AM800RAMANTADINE HCLSYRUPCriteria
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AM300RAMIKACIN SULFATEINJ,SOLN
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TN501AMINO ACIDSINJ,SOLN
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TN501AMINO ACIDS/DEXTROSEINJ,SOLN
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BL116AMINOCAPROIC ACIDINJ,SOLN
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BL116AMINOCAPROIC ACIDTAB
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RE104AMINOPHYLLINE DIHYDRATEINJ,SOLN
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CV300AMIODARONEINJ,SOLN
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CV300AMIODARONETAB
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CN601AMITRIPTYLINE HCLTAB
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CV200AMLODIPINETAB
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CV400AMLODIPINE/BENAZEPRILCAP,ORALhttps://vaww.cmopnational.va.gov/cmop/PBM/Clinical Guidance/Forms/AllItems.aspx?RootFolder=%2Fcmop%2FPBM%2FClinical%20Guidance%2FClinical%20Recommendations&FolderCTID=0x0120006BA3B2280F536A41A2C5A1B0F4AFC943&View=%7b43999405-C9A2-47A4-AE17-15518717FA3E%25https://vaww.cmopnational.va.gov/cmop/PBM/Clinical Guidance/Forms/AllItems.aspx?RootFolder=%2Fcmop%2FPBM%2FClinical%20Guidance%2FDrug%20Monitoring&FolderCTID=0x0120006BA3B2280F536A41A2C5A1B0F4AFC943&View=%7b43999405-C9A2-47A4-AE17-15518717FA3E%7d
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RE900AMMONIA,AROMATICINHL,NASAL
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TN499AMMONIUM CHLORIDEINJ,SOLN
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DE350AMMONIUM LACTATECREAM
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DE350AMMONIUM LACTATELOTION
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AM111RAMOXICILLINCAP,ORAL
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AM111RAMOXICILLINPWDR,RENST-ORAL
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AM111RAMOXICILLIN/CLAVULANATE KPWDR,RENST-ORAL
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AM111RAMOXICILLIN/CLAVULANATE KTAB
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CN801AMPHETAMINE/DEXTROAMPHETAMINE (EQV-ADDERALL)TAB
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CN801
AMPHETAMINE/DEXTROAMPHETAMINE RESIN COMPLEX (EQV-ADDERALL XR)
CAP,SA
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Formulary