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Pharmacy Benefits Management Services

Criteria for Use

Acamprosate, Criteria for Non-Formulary Use
Agalsidase, Criteria for Non-Formulary Use
Alemtuzumab, Criteria For Non-Formulary Use
Aliskiren, Criteria For Non-Formulary Use
Alpha-Adrenergic Blockers in the Management of Patients with HTN (ALLHAT)
Antiviral Agents for Influenza, Criteria For Use
Azacitidine, Criteria for Use
Topical Anesthesia for Surfaces of the Nasopharynx, Oropharynx, Laryngotracheal Region and Airway, Criteria for Use
Cholinesterase Inhibitors, Criteria for Use
Clinically Uroselective Alpha Adrenergic Blockers, Criteria for Non-Formulary Use
Combination Alpha-Blocker & Finasteride Therapy for BPH, Criteria for Use
Consensus Interferon, Criteria for use in Hepatitis C, Criteria for Use
Angiotensin II Receptor Antagonists (AIIRAs), Criteria for Use
Antiemetic, Criteria for Use
Atazanavir, Criteria for Use
Becaplermin, Criteria for Non-Formulary Use
Beta-Adrenergic Blockers (Heart Failure), Clinical Recommendations
Biologics for Psoriasis, Criteria for Non-Formulary Use (Updated)
Buprenorphine, Criteria for Use
Cilostazol, Criteria for Use
Cinacalcet, Criteria for Non-Formulary Use
Clopidogrel, Criteria for Use
Darunavir, Criteria for Use
Dihydropyridine (Long-Acting) Calcium Channel Blockers, Clinical Guidance
Drotrecogin Alfa, Criteria for Use
Drotrecogin Alfa Checklist 
Duloxetine, Criteria for Non-Formulary Use
Enfuvirtide,, Criteria for Use
Endothelin Receptor Antagonists (ERA), Criteria for Use
Enoxaparin, Criteria for Use in Mechanical Heart Valve Patients
Erlotinib, Criteria for Non-Formulary Use
Erythropoietin Criteria for Use for Hepatitis C,, Criteria for Use
Eszopiclone, Criteria for Non-Formulary Use
Etravirine, Criteria for Use
Exenatide, Criteria for Non-Formulary Use
Ezetimibe or Ezetimibe+Simvastatin Criteria for Non-Formulary Use
Fentanyl Transdermal Patch, Criteria for Use
Fondaparinux, Criteria for Use
Fluoroquinolone, Criteria for Use
Fuzeon Criteria for Use
Gabapentin, Criteria for Use
Gefitinib  Criteria for Non-Formulary Use
GSCF Criteria for Use for Hepatitis C  Criteria for Use
Highly Teratogenic Retinoids and High-dose Vitamin A, Criteria for Use
Hyaluronic Acid-Hylan G-F 20, Criteria for Use
Imatinib, Criteria for use
Initiating Therapy In Early Parkinson’s Disease, Criteria for use
Imiquimod, Criteria for Use
Leflunomide and Biologic DMARDs for Rheumatoid Arthritis, Criteria for use
Leukotriene Inhibitor, Criteria for Use
Leuprolide Implantable (Viadur) Criteria for Non-Formulary Use 
Levetiracetam, Criteria for Use
Linezolid, Quinupristin-Dalfopristin, and Daptomycin,, Criteria for Use
Lovaza (formerly Omacor),, Criteria for Use
Lubiprostone Criteria for Non-Formulary Use 
Maraviroc, Criteria for Use (Check-Box Format)
Memantine, Criteria for Use
Meperidine, Criteria for Use
Monoamine Oxidase Inhibitors (MAOI), Criteria for Use
Montelukast, Criteria for Use
Moxifloxacin Ophthalmic Solution, Criteria for Use
Naltrexone Extended-release Injectable Suspension Criteria for Non-formulary Use
Factor VII, Recombinant Activated (Novoseven®) , Criteria for Non-Formulary Use
Omalizumab, Criteria for Non-formulary Use
Orlistat - Criteria for Use
Oxycodone CR, Criteria for use, Treatment Algorithm
Oxymorphone Oral Tablets - Criteria for Use
Pantoprazole I.V. Criteria for Use  Pantoprazole I.V. Literature Review
Pegaptanib, Criteria for Non-Formulary Use
Pegfilgrastim, Criteria for Non-Formulary Use
Pemetrexed, Criteria for Non-Formulary Use
Pharmacologic Management of Primary Pulmonary Hypertension, Criteria for Use
Phosphate binder (Lanthanum, Sevelamer), Criteria for Use
Pramlintide, Criteria for Non-Formulary Use
Pregabalin, Criteria for Non-Formulary Use
Propoxyphene, Criteria for Use
Proton Pump Inhibitors, High-dose, Criteria for Use
Appendix I(Nocturnal Leg Cramps)
Quadrivalent HPV Vaccine (Gardasil), Criteria for Non-Formulary Use
Raltegravir, Criteria for Use
Ramipril, Criteria for Non-Formulary Use
Ranolazine, Criteria for Non-Formulary Use
Rifaximin, Criteria for Non-Formulary Use
Rifaximin, Criteria for Non-Formulary Use (Check-box format)
Risperidone Long-Acting, Criteria for Use
Rituximab, Criteria for Use
Sibutramine - Criteria for Use
Sitagliptin, Criteria for Non-Formulary Use
Statins, Criteria for Non-Formulary Use in Patients Receiving Protease Inhibitor Therapy
Statin (fluvastatin, pravastatin, atorvastatin and rosuvastatin), Criteria for Use
Teriparatide, Criteria for Non-Formulary Use
Thickening Agents for Outpatients, Criteria for Use
Tiotropium, Criteria for Use 
Tipranavir, Criteria for Use
Thiazolidinedione , Criteria for Non-Formulary Use
Vardenafil Non-Responders, Criteria for Non-Formulary Use
Varenicline Criteria for Prescribing
Ziconotide, Criteria for Non-Formulary Use & Ziconotide, Monograph
Ziprasidone IM, Criteria for Non-Formulary Use
Ziprasidone, Criteria for Use
Zoledronic Acid (Reclast), Criteria for Use
Zoster Vaccine, Criteria for Use


If you have a question pertaining to this website and only information contained in this website, please contact the PBM Webmaster. Please note: For questions pertaining to Health Care Benefits, please visit http://www.va.gov/Health_Benefits/. For questions pertaining to prescription renewal, please visit https://www.myhealth.va.gov/. Questions pertaining to your drug therapy or other medical questions should be referred directly to your Health Care Providers located at the VA facilities where you receive care.