Attachment D.12 - VA_National_Formulary_JAN_2023.pdf

DEPARTMENT OF VETERANS AFFAIRS

PHARMACY BENEFITS MANAGEMENT STRATEGIC HEALTH GROUP

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

VHA NATIONAL FORMULARY

Jan-23

VA

Class

Restriction Generic Dosage Form

AM800 PA-F ABACAVIR SOLN,ORAL

AM800 PA-F ABACAVIR TAB

AM800 PA-F ABACAVIR/DOLUTEGRAVIR/LAMIVUDINE TAB

AM800 PA-F ABACAVIR/LAMIVUDINE TAB

AM800 PA-F ABACAVIR/LAMIVUDINE/ZIDOVUDINE TAB

HS600 PA-F ABALOPARATIDE INJ,SOLN

AN900 PA-F ABEMACICLIB TAB

AN500 PA-F ABIRATERONE TAB

AN900 PA-F ACALABRUTINIB CAP/TAB

AD100 ACAMPROSATE TAB,EC

HS502 ACARBOSE TAB

CN103 PA-F ACETAMINOPHEN I NJ

CN103 ACETAMINOPHEN LIQUID,ORAL

CN103 ACETAMINOPHEN SUPP,RTL

CN103 ACETAMINOPHEN TAB

CN103 ACETAMINOPHEN/ASPIRIN/CAFFEINE TAB TAB

CN103 ACETAMINOPHEN/CAFFEINE TAB TAB

CN101 ACETAMINOPHEN/HYDROCODONE LIQUID,ORAL

CN101 ACETAMINOPHEN/HYDROCODONE TAB

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.”

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.

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.

U/E- Urgent Emergent formulary. The drugs with a “yes” in that field are on the urgent emergent formulary for the Community Care Network

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36C24923R0047 - Helena CBOC

Attachment D.12 - VA National Formulary JAN 2023 http://www.pbm.va.gov/ http://vaww.pbm.va.gov/

CN101 ACETAMINOPHEN/OXYCODONE HCL LIQUID,ORAL

CN101 ACETAMINOPHEN/OXYCODONE HCL TAB

CV703 ACETAZOLAMIDE INJ

CV703 ACETAZOLAMIDE TAB

CV703 ACETAZOLAMIDE CAP,SA

IR100 ACETIC ACID SOLN,IRRG

OT109 ACETIC ACID SOLN,OTIC

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 TAB

AM800 R ACYCLOVIR INJ

MS190 PA-F ADALIMUMAB INJ,SOLN

DE752 ADAPALENE GEL,TOP

AM800 PA-F ADEFOVIR TAB

CV300 ADENOSINE INJ,SOLN

XA603 ADHESIVE AEROSOL SPRAY,TOP

XA603 ADHESIVE CEMENT LIQUID,TOP

XA699 ADHESIVE REMOVER LIQUID,TOP

AN900 PA-F ADO-TRASTUZUMAB EMTANSINE INJ

OP900 AFLIBERCEPT INJ.OPH

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 PA-F ALDESLEUKIN INJ

HS900 ALENDRONATE TAB

CN101 ALFENTANIL HCL INJ,SOLN

CV150 ALFUZOSIN TAB,SA

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

CV350 PA-F ALIROCUMAB INJ,SOLN

IM900 ALLERGENIC EXTRACT (VARIOUS) INJ,SOLN

MS400 ALLOPURINOL TAB

HS502 ALOGLIPTIN TAB

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

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

CN302 ALPRAZOLAM TAB

CN302 PA-F ALPRAZOLAM TAB,SA

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 LIQUID,ORAL

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

GA900 PA-F ALVIMOPAN CAP

AM800 R AMANTADINE HCL CAP/TAB

AM800 R AMANTADINE HCL SYRUP

RE900 PA-F AMIKACIN LIPOSOME SUSP,INHL

AM300 R AMIKACIN SULFATE INJ,SOLN

CV704 AMILORIDE TAB

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

AN900 PA-F AMIVANTAMAB-VMJW INJ, SOLN

CV200 AMLODIPINE TAB

CV400 AMLODIPINE/BENAZEPRIL CAP,ORAL

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

CN801 AMPHETAMINE/DEXTROAMPHETAMINE (EQV-ADDERALL) TAB

CN801 AMPHETAMINE/DEXTROAMPHETAMINE RESIN COMPLEX (EQV-ADDERALL XR) CAP,SA

AM700 R AMPHOTERICIN B INJ

AM700 R AMPHOTERICIN B LIPOSOMAL 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

BL116 ANTIHEMOPHILIC FACTOR,RECOMBINANT INJ,LYPHL

IM900 ANTI-THYMOCYTE GLOBULIN INJ,PWDR

IM900 ANTI-THYMOCYTE GLOBULIN INJ,SOLN

IM300 ANTIVENIN,CROTALIDAE POLYVALENT INJ

AN900 PA-F APALUTAMIDE TAB,ORAL

BL110 PA-F APIXABAN TAB,ORAL

VA_National_Formulary_JAN_2023 Page 3

CN500

PA-F

APOMORPHINE INJ,SOLN

GA600 PA-F APOMORPHINE FILM,SUBLINGUAL

XA900 APPLIANCE CLEANSING SUPPLIES SUPPLY

OP900 APRACLONIDINE HCL SOLN,OPH

MS190 PA-F APREMILAST TAB

GA605 APREPITANT CAP,ORAL

BL110 ARGATROBAN INJ,SOLN

CN709 PA-F ARIPIPRAZOLE INJ,SUSP,SA

CN709 ARIPIPRAZOLE TAB

CN809 ARMODAFINIL TAB

CN204 ARTICAINE/EPINEPHRINE INJ,SOLN

OR500 ARTIFICIAL SALIVA (OTC) SPRAY,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 PA-F 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/CAFFEINE TAB TAB

BL117 PA-F ASPIRIN/DIPYRIDAMOLE CAP,SA

AM800 PA-F ATAZANIVIR CAP,ORAL

CV100 ATENOLOL TAB

CV400 ATENOLOL/CHLORTHALIDONE TAB

AN900 PA-F ATEZOLIZUMAB INJ,SOLN

CN900 PA-F ATOMOXETINE CAP,ORAL

CV350 ATORVASTATIN TAB

AP109 ATOVAQUONE SUSP

AP101 ATOVAQUONE/PROGUANIL TAB

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

XA900 AUTOINJECTOR (FOR MULTIPLE SCLEROSIS MEDICATIONS) DEVICE

BL116 PA-F AVATROMBOPAG TAB

AN900 PA-F AXITINIB TAB

AN300

PA-F

AZACITIDINE INJ,SUSP

IM600 AZATHIOPRINE INJ,SOLN

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IM600 AZATHIOPRINE TAB

NT400 AZELASTINE INHL,NASAL

AM200 R AZITHROMYCIN PWDR,RENST-ORAL

AM200 R AZITHROMYCIN TAB

AM200 R AZITHROMYCIN INJ,PWDR

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

DE109 BACITRACIN/NEOMYCIN/POLYMYXIN B OINT,TOP

OP219 BACITRACIN/POLYMYXIN OINT,OPH

MS200 BACLOFEN TAB

MS200 BACLOFEN INJ

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

AM800 PA-F BALOXAVIR TAB

GA900 BALSALAZIDE DISODIUM CAP,ORAL

XA108 BANDAGE ELASTIC SUPPLY

XA108 BANDAGE ELASTIC ADHESIVE SUPPLY

XA109 BANDAGE TUBULAR ELASTIC SUPPLY

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 PA-F BCG,TICE VACCINE INJ,LYPHL

IM600 PA-F BELATACEPT INJ,LYPHL

XA605 BELT OSTOMY SUPPLY

CV800 BENAZEPRIL TAB

AN100 PA-F BENDAMUSTINE INJ,LYPHL

OP900 BENOXINATE HCL/FLUORESCEIN NA SOLN,OPH

RE109 PA-F BENRALIZUMAB INJ,SOLN

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

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DE752 BENZOYL PEROXIDE LOTION

DE752 BENZOYL PEROXIDE SOAP/DETERGENT

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

AU350 BENZTROPINE MESYLATE TAB

AU350 BENZTROPINE MESYLATE INJ

DX300 BENZYLPENICILLOYL POLYLYSINE INJ

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 TAB

AN900 PA-F BEVACIZUMAB-BVZR INJ,SOLN

IM600 PA-F BEZLOTOXUMAB INJ,SOLN

AN900 PA-F BICALUTAMIDE TAB

AM800 PA-F BICTEGRAVIR/EMTRICITABINE/TENOFOVIR AF (EQV-BIKTARVY) TAB

RS300 BISACODYL ENEMA,RTL

GA204 BISACODYL (OTC) TAB,EC

RS300 BISACODYL (OTC) SUPP,RTL

GA208 BISMUTH SUBSALICYLATE SUSP,ORAL

GA208 BISMUTH SUBSALICYLATE TAB,CHEWABLE

CV100 BISOPROLOL TAB

BL110 BIVALIRUDIN INJ,PWDR

AN200 PA-F BLEOMYCIN SO4 INJ,SOLN

DX900 BLOOD GLUCOSE MONITORING DEVICE

DX900 BLOOD GLUCOSE MONITORING TEST SOLUTION

DX900 BLOOD GLUCOSE MONITORING TEST STRIP

AN900 PA-F BORTEZOMIB INJ,PWDR

XA502 BOTTLES/OTHER BEDSIDE URINARY COLLECTION DEVICES SUPPLY

MS900 PA-F BOTULINUM TOXIN INJ

IM300 BOTULISM ANTITOXIN INJ,SOLN

XA900 BOWEL MANAGEMENT TOOL SUPPLY

XA900 BREAST MILK STORAGE BAGS BAG

XA305 BRIEF/PANT INCONTINENCE MALE SUPPLY

OP900 BRILLIANT BLUE G SOLN,OPH

DE900 PA-F BRIMONIDINE GEL,TOP

OP109 BRIMONIDINE TARTRATE SOLN,OPH

OP105 BRIMONIDINE/BRINZOLAMIDE SUSP,OPH

AU900 BROMOCRIPTINE MESYLATE CAP,ORAL

AU900 BROMOCRIPTINE MESYLATE TAB

HS051 PA-F BUDESONIDE TAB,SA

RE109 PA-F BUDESONIDE/GLYCOPYRROLATE/FORMOTEROL INH,ORAL

CV702 BUMETANIDE INJ

VA_National_Formulary_JAN_2023 Page 6

CV702 BUMETANIDE TAB

CN204 BUPIVACAINE HCL INJ,SOLN

CN204 BUPIVACAINE/DEXTROSE INJ,SOLN

CN204 BUPIVACAINE/EPINEPHRINE INJ,SOLN

CN101 BUPRENORPHINE FILM,BUCCAL

CN101 PA-F BUPRENORPHINE INJ,SOLN,SA

CN101 BUPRENORPHINE PATCH

CN101 BUPRENORPHINE TAB,SUBLINGUAL

CN101 BUPRENORPHINE/NALOXONE TAB,SUBLINGUAL

CN609 BUPROPION HCL TAB

CN609 BUPROPION HCL TAB,SA (12HR-SR)

CN609 BUPROPION HCL TAB,SA (24HR-XL)

CN900 PA-F BUPROPION/NALTREXONE TAB,SA

CN309 BUSPIRONE HCL TAB

AN100 PA-F BUSULFAN INJ

AN100 PA-F BUSULFAN TAB

CN101 BUTORPHANOL TARTRATE INJ,SOLN

AN900 PA-F CABAZITAXEL INJ,SOLN

AU900 PA-F CABERGOLINE TAB

AM800 PA-F CABOTEGRAVIR INJ,SUSP,SA

AM800 PA-F CABOTEGRAVIR/RILPIVIRINE INJ,SUSP,SA

DE101 CADEXOMER IODINE GEL,TOP

CN105 CAFFEINE/ERGOTAMINE SUPP,RTL

CN809 CAFFEINE/SODIUM BENZOATE INJ

DE900 CALAMINE (OTC) LOTION

DE900 CALAMINE/LANOLIN/MENTHOL/ZINC OXIDE OINT, TOP

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/TAB

TN420 CALCIUM CARBONATE (OTC) TAB

TN420 CALCIUM CARBONATE (OTC) TAB,CHEWABLE

TN420 CALCIUM CHLORIDE INJ,SOLN

TN420 CALCIUM CITRATE TAB

TN420 CALCIUM GLUCONATE INJ,SOLN

GA201 CALCIUM POLYCARBOPHIL TAB

CN900 PA-F CALCIUM/MAGNESIUM/POTASSIUM/SODIUM OXYBATE SOLN,ORAL

VT802 CALCIUM/VITAMIN D (OTC) TAB

DE900 CAMPHOR 0.5%/MENTHOL 0.5% LOTION

DE650 CAMPHOR/MENTHOL/METHYL SALICYLATE PATCH

CV805 CANDESARTAN TAB

AN300 PA-F CAPECITABINE TAB

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AN900 PA-F CAPMATINIB TAB

AM500 R CAPREOMYCIN INJ INJ

DE650 CAPSAICIN CREAM,TOP

CV800 CAPTOPRIL TAB

OP102 CARBACHOL SOLN,OPH

CN400 CARBAMAZEPINE TAB

CN400 CARBAMAZEPINE CAP/TAB,SA

CN400 CARBAMAZEPINE SUSP,ORAL

CN400 CARBAMAZEPINE TAB,CHEWABLE

OT300 CARBAMIDE PEROXIDE/GLYCERIN (OTC) SOLN,OTIC

CN500 CARBIDOPA /LEVODOPA TAB,SA

CN500 PA-F CARBIDOPA/LEVODOPA CAP,SA

CN500 PA-F CARBIDOPA/LEVODOPA SUSP,INTESTINAL

CN500 CARBIDOPA/LEVODOPA TAB

AN900 PA-F CARBOPLATIN INJ INJ

OP500 CARBOXYMETHYLCELLULOSE SODIUM SOLN,OPH

OP500 CARBOXYMETHYLCELLULOSE SODIUM GEL,OPH

AN900 PA-F CARFILZOMIB INJ

AN100 PA-F 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 CEFADROXIL CAP,ORAL

AM115 R CEFAZOLIN INJ

AM117 R CEFDINIR CAP,ORAL

AM118 R CEFEPIME INJ,PWDR

AM118 PA-F CEFIDEROCOL INJ,PWDR

AM117 R CEFIXIME CAP,ORAL

AM117 R CEFOTAXIME INJ

AM116 R CEFOTETAN INJ

AM116 R CEFOXITIN NA INJ

VA_National_Formulary_JAN_2023 Page 8

AM116 R CEFPODOXIME PROXETIL TAB

AM119 R CEFTAROLINE INJ,PWDR

AM117 R CEFTAZIDIME INJ

AM117 PA-F CEFTAZIDIME/AVIBACTAM INJ

AM117 PA-F CEFTOLOZANE/TAZOBACTAM INJ

AM117 R CEFTRIAXONE NA INJ

AM116 R CEFUROXIME INJ

AM116 R CEFUROXIME AXETIL TAB

MS102 CELECOXIB CAP,ORAL

AN900 PA-F CEMIPLIMAB-RWLC INJ,SOLN

AM115 R CEPHALEXIN CAP OR TAB

GA400 PA-F CERTOLIZUMAB INJ,SOLN

AH105 CETIRIZINE TAB

HS701 PA-F CETRORELIX INJ,PWDR

AN900 PA-F CETUXIMAB INJ,SOLN

AD900 CHARCOAL ACTIVATED (OTC) LIQUID

AD900 CHARCOAL ACTIVATED IN SORBITOL (OTC) LIQUID

AN100 PA-F CHLORAMBUCIL TAB

AM150 R CHLORAMPHENICOL INJ,SOLN

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) TAB

CN701 CHLORPROMAZINE TAB

CN701 CHLORPROMAZINE INJ,SOLN

CV701 CHLORTHALIDONE TAB

IM100 CHOLERA VACCINE LIVE POWDER,ORAL

CV350 CHOLESTYRAMINE POWDER,ORAL

OP900 CHONDROITIN/HYALURONATE INJ

OP900 CHONDROITIN/HYALURONATE INJ,OPH

HS400 PA-F CHORIOGONADOTROPIN ALFA INJ

TN499 CHROMIUM INJ

RE101 CICLESONIDE INHL,ORAL

DE102 CICLOPIROX 8% SOLN,TOP

AM800 R CIDOFOVIR INJ

CV900 PA-F CILOSTAZOL TAB

HS900 PA-F CINACALCET TAB

AM400 R CIPROFLOXACIN INJ,SOLN

AM400 R CIPROFLOXACIN HCL TAB

OP210 CIPROFLOXACIN HCL SOLN,OPH

OT250 CIPROFLOXACIN/DEXAMETHASONE SUSP,OTIC

VA_National_Formulary_JAN_2023 Page 9

MS300 CISATRACURIUM INJ

AN900 PA-F 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

TN478 CITRIC ACID/NA CITRATE SOLN,ORAL

TN478 CITRIC ACID/POTASSIUM CITRATE SOLN,ORAL

TN478 CITRIC ACID/POTASSIUM CITRATE POWDER,ORAL

AN300 PA-F CLADRIBINE INJ

XA699 CLAMP BAG SUPPLY

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 LOTION,TOP

DE752 CLINDAMYCIN PHOSPHATE SOLN,TOP/TOP SWAB

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

CN302 PA-F CLONAZEPAM TAB,ORAL DISINTEGRATING

CN302 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% 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

AM800 PA-F COBICISTAT/DARUNAVIR TAB

VA_National_Formulary_JAN_2023 Page 10

AM800 PA-F COBICISTAT/DARUNAVIR/EMTRICITABINE/TENOFOVIR (SYMTUZA) TAB

AM800 PA-F COBICISTAT/ELVITEGRAVIR/EMTRICITABINE/TENOFOVIR AF (EQV-GENVOYA) TAB

AM800 PA-F COBICISTAT/ELVITEGRAVIR/EMTRICITABINE/TENOFOVIR DF (EQV-STRIBILD) TAB

NT300 COCAINE HCL SOLN,TOP

DX300 COCCIDIODIN 1:100 SKIN TEST INJ

CN101 CODEINE TAB

CN101 CODEINE/ACETAMINOPHEN ELIXIR

CN101 CODEINE/ACETAMINOPHEN TAB

RE301 CODEINE/GUAIFENESIN LIQUID,ORAL

MS400 COLCHICINE CAP

MS400 COLCHICINE TAB

CV350 COLESTIPOL GRNL,RCNST-ORAL

CV350 COLESTIPOL TAB

DE900 COLLAGENASE OINT,TOP

XA900 CONDOM INTERNAL SUPPLY

XA900 CONDOM LATEX LUBRICATED EXTERNAL SUPPLY

XA900 CONDOM LATEX PLAIN EXTERNAL SUPPLY

HS900 CONJUGATED ESTROGENS/MEDROXYPROGESTERONE (PREMPRO/PREMPHASE) TAB

OP400 PA-F CONTACT LENS SOLUTION SOLN,OPH

DX900 CONTRAST MEDIA: ULTRASOUND MISC

DX900 CONTRAST MEDIA: MAGNETIC RESONANCE MISC

DX101 CONTRAST MEDIA: X-RAY MISC

DX201 CONTRAST MEDIA/IMAGING MISC

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

TN499 COPPER INJ INJ

DX900 COSYNTROPIN INJ INJ

XA900 COTTON-TIP APPLICATOR STERILE SUPPLY

IM100 COVID-19 VACCINE (PFIZER/COMIRNATY) INJ,SUSP

OP900 CROMOLYN NA OPH SOLN SOLN,OPH

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 CAP

AN100 CYCLOPHOSPHAMIDE INJ

AM500 R CYCLOSERINE CAP,ORAL

IM599 CYCLOSPORINE CAP,ORAL

IM600 CYCLOSPORINE INJ,SOLN

IM600 CYCLOSPORINE SOLN,ORAL

OP300 PA-F CYCLOSPORINE EMULSION,OPH

AH107 CYPROHEPTADINE TAB

AN300 PA-F CYTARABINE INJ

AN300 PA-F CYTARABINE/DAUNORUBICIN INJ,LYPHL

VA_National_Formulary_JAN_2023 Page 11

IM500 CYTOMEGALOVIRUS IMMUNE GLOBULIN HUMAN INJ

BL110 PA-F DABIGATRAN CAP,ORAL

AN900 PA-F DABRAFENIB CAP,ORAL

AN900 PA-F DACARBAZINE INJ

AN200 PA-F DACTINOMYCIN INJ

MS900 PA-F DALFAMPRIDINE TAB,SA

AM900 R DALFOPRISTIN/QUINUPRISTIN INJ

BL110 DALTEPARIN INJ,SOLN

HS100 DANAZOL CAP,ORAL

MS200 PA-F DANTROLENE CAP,ORAL

MS200 PA-F DANTROLENE (i.e. Ryanodex) INJ,SUSP

AM900 R DAPSONE TAB

AM900 R DAPTOMYCIN INJ,LYPHL

AN900 PA-F DARATUMUMAB INJ,SOLN

AN900 PA-F DARATUMUMAB/HYALURONIDASE-FIHJ INJ,SOLN

BL400 DARBEPOETIN ALFA RECOMBINANT INJ,SOLN

AN900 PA-F DAROLUTAMIDE TAB

AM800 PA-F DARUNAVIR ETHANOLATE TAB

AN200 PA-F DAUNORUBICIN INJ,SOLN

AN200 PA-F DAUNORUBICIN/CYTARABINE LIPOSOME INJ,LYPHL

AD300 PA-F DEFERASIROX TAB,EFFERVSC

AD300 DEFEROXAMINE MESYLATE INJ,SOLN

AM250 R DEMECLOCYCLINE HCL TAB

IM900 PA-F DENOSUMAB INJ,SOLN

CN203 DESFLURANE SOLN,INHL

CN601 DESIPRAMINE HCL TAB

HS702 PA-F DESMOPRESSIN ACETATE SOLN,SPRAY,NASAL

HS702 DESMOPRESSIN ACETATE SOLN,SPRAY,NASAL

HS702 DESMOPRESSIN ACETATE INJ,SOLN

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

DE200 DESONIDE CREAM,TOP

CN609 PA-F DESVENLAFAXINE (EQV-PRISTIQ) TAB,SA

HS051 DEXAMETHASONE TAB

HS051 DEXAMETHASONE INJ,SUSP

HS051 DEXAMETHASONE INJ,SUSP,SA

OP900

PA-F

DEXAMETHASONE IMPLANT,OPH

HS051 DEXAMETHASONE INJ,SOLN

HS051 DEXAMETHASONE LIQUID,ORAL

OP300 DEXAMETHASONE NA PHOSPHATE SOLN,OPH

OP350 DEXAMETHASONE/NEO/POLYMX OINT,OPH

OP350 DEXAMETHASONE/NEOMYCIN/POLYMYXIN B SUSP,OPH

OP350 DEXAMETHASONE/TOBRAMYCIN SUSP,OPH

OP350 DEXAMETHASONE/TOBRAMYCIN OINT,OPH

CN309 PA-F DEXMEDETOMIDINE INJ,SOLN

VA_National_Formulary_JAN_2023 Page 12

AN700 DEXRAZOXANE INJ

BL800 DEXTRAN 40 INJ,SOLN

BL800 DEXTRAN 70 INJ,SOLN

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

CN801 DEXTROAMPHETAMINE CAP,SA

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

HS503 DEXTROSE SQUEEZE PKT (OTC) GEL,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

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

DE200 DICLOFENAC NA 1% GEL,TOP

MS102 DICLOFENAC POTASSIUM TAB

MS900 DICLOFENAC/MISOPROSTOL TAB

AM112 R DICLOXACILLIN NA CAP,ORAL

AU350 DICYCLOMINE HCL CAP,ORAL

AU350 DICYCLOMINE HCL TAB

AU350 DICYCLOMINE HCL INJ,SOLN

AU350 DICYCLOMINE HCL SOLN

AM800 PA-F DIDANOSINE CAP,EC

OP300 DIFLUPREDNATE EMULSION,OPH

CV050 DIGOXIN ELIXIR

CV050 DIGOXIN INJ,SOLN

CV050 DIGOXIN TAB

AD900 DIGOXIN IMMUNE FAB (OVINE) INJ,SOLN

CN105 DIHYDROERGOTAMINE MESYLATE INJ,SOLN

CV200 DILTIAZEM HCL CAP,SA

CV200 DILTIAZEM HCL INJ

CV200 DILTIAZEM HCL TAB

AD300 DIMERCAPROL INJ,SOLN

DE900 DIMETHICONE CREAM,TOP

IM700 PA-F DIMETHYL FUMARATE CAP,EC

AH102 DIPHENHYDRAMINE HCL INJ,SOLN

VA_National_Formulary_JAN_2023 Page 13

AH102 DIPHENHYDRAMINE HCL (OTC) CAP,ORAL

AH200 DIPHENHYDRAMINE HCL (OTC) TAB

IM109 DIPHTHERIA TOXOID/PERTUSSIS /TETANUS TOXOID INJ,SUSP

IM200 DIPHTHERIA/TETANUS TOXOID INJ,SUSP

BL117 DIPYRIDAMOLE INJ,SOLN

XA305 DISPOSABLE DIAPER SUPPLY

XA301 DISPOSABLE UNDERPAD SUPPLY

AD100 DISULFIRAM TAB

CN400 PA-F DIVALPROEX CAP,SPRINKLE

CN400 DIVALPROEX NA TAB,SA,24HR

AU100 DOBUTAMINE INJ,SOLN

AN900 PA-F DOCETAXEL INJ

GA205 DOCUSATE (OTC) CAP,ORAL

GA206 DOCUSATE (OTC) LIQUID,ORAL

RS300 DOCUSATE (OTC) ENEMA,RTL

GA204 DOCUSATE/SENNOSIDES TAB

CV300 PA-F DOFETILIDE CAP,ORAL

AM800 PA-F DOLUTEGRAVIR TAB

AM800 PA-F DOLUTEGRAVIR/LAMIVUDINE TAB

AM800 PA-F DOLUTEGRAVIR/RILPIVIRINE TAB

CN900 DONEPEZIL (5MG AND 10MG ONLY) TAB

AU100 DOPAMINE INJ,SOLN

AM800 PA-F DORAVIRINE TAB

AM800 PA-F DORAVIRINE/LAMIVUDINE/TENOFOVIR TAB

OP109 DORZOLAMIDE HCL SOLN,OPH

OP105 DORZOLAMIDE/TIMOLOL SOLN,OPH

RE900 DOXAPRAM HCL INJ,SOLN

CV150 DOXAZOSIN MESYLATE TAB

CN601 PA-F DOXEPIN TAB

CN601 P DOXEPIN HCL CAP,ORAL

CN601 DOXEPIN HCL LIQUID,ORAL

AN200 PA-F DOXORUBICIN INJ,SOLN

AM250 R DOXYCYCLINE CAP OR TAB

AM250 R DOXYCYCLINE SUSP

AM250 R DOXYCYCLINE HYCLATE INJ

GA605 DOXYLAMINE TAB

GA605 DOXYLAMINE/PYRIDOXINE (DICLEGIS-EQV) TAB, EC

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

CV300 PA-F DRONEDARONE TAB

CN205 DROPERIDOL INJ,SOLN

VA_National_Formulary_JAN_2023 Page 14

HS200 DROSPIRENONE 3MG/ETHINYL ESTRADIOL 20MCG (EQV-YAZ) TAB

HS200 DROSPIRENONE 3MG/ETHINYL ESTRADIOL 30MCG (EQV-YASMIN) TAB

CN609 DULOXETINE CAP,EC

AN900 PA-F DURVALUMAB INJ,SOLN

CN900 PA-N EDARAVONE INJ,SOLN

CN900 PA-N EDARAVONE SUSP,ORAL

AD300 EDETATE CALCIUM DISODIUM INJ

BL110 PA-F EDOXABAN TAB

AM800 PA-F EFAVIRENZ TAB

AM800 PA-F EFAVIRENZ CAP,ORAL

AM800 PA-F EFAVIRENZ/EMTRICITABINE/TENOFOVIR TAB

AM800 PA-F EFAVIRENZ/LAMIVUDINE/TENOFOVIR DF (EQV-SYMFI) (SYMFI only not SYMFI LO) TAB

AM800 PA-F ELBASVIR/GRAZOPREVIR TAB

CN105 ELETRIPTAN TAB

AN900 PA-F ELOTUZUMAB INJ,LYPHL

BL116 PA-F ELTROMBOPAG TAB

HS502 EMPAGLIFLOZIN TAB

HS502 EMPAGLIFLOZIN/METFORMIN TAB,ORAL

HS502 EMPAGLIFLOZIN/METFORMIN TAB,SA

AM800 PA-F EMTRICITABINE CAP,ORAL

AM800 PA-F EMTRICITABINE/RILPIVIRINE/TENOFOVIR AF (EQV-ODEFSEY) TAB,ORAL

AM800 PA-F EMTRICITABINE/RILPIVIRINE/TENOFOVIR (EQV COMPLERA) TAB,ORAL

AM800 PA-F EMTRICITABINE/TENOFOVIR TAB

AM800 PA-F EMTRICITABINE/TENOFOVIR AF TAB

CV800 ENALAPRIL TAB

CV800 ENALAPRILAT INJ,SOLN

AN900 PA-F ENASIDENIB TAB

XA900 ENEMA BAG SUPPLY

CN201 ENFLURANE LIQUID,INHL

AM800 PA-F ENFUVIRTIDE INJ,PWDR

BL110 ENOXAPARIN INJ

TN200 ENSURE CLEAR

LIQUID,NUTRITIONAL

SUPPLEMENT

CN500 ENTACAPONE TAB

AM800 PA-F ENTECAVIR SOLN,ORAL

AM800 PA-F ENTECAVIR TAB

AN900 PA-F ENZALUTAMIDE CAP/TAB

AU100 EPHEDRINE INJ,SOLN

AU100 EPINEPHRINE INJ,SOLN

CV704 PA-F EPLERENONE TAB

BL400 EPOETIN ALFA-EPBX INJ,SOLN

BL110 EPTIFIBATIDE INJ

AM250 PA-F ERAVACYCLINE INJ,LYPHL

CN105 PA-F ERENUMAB-AOOE INJ

CN900 ERGOLOID MESYLATES TAB,ORAL

VA_National_Formulary_JAN_2023 Page 15

AN900 PA-F ERLOTINIB TAB

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

CN609 ESCITALOPRAM TAB

CV100 ESMOLOL HCL INJ

GA900 ESOMEPRAZOLE INJ,PWDR

MS102 PA-F ESOMEPRAZOLE/NAPROXEN TAB,EC

GU500 ESTRADIOL CREAM, VAG

GU500 ESTRADIOL TAB,VAG

HS300 ESTRADIOL INJ

HS300 ESTRADIOL PATCH

HS300 ESTRADIOL TAB

HS300 ESTRADIOL/LEVONORGESTREL (EQV-CLIMARA PRO) PATCH

HS900 ESTRADIOL/NORETHINDRONE (EQV-COMBIPATCH) PATCH

AN900 PA-F ESTRAMUSTINE CAP,ORAL

HS300 ESTROGENS INJ

GU500 ESTROGENS CONJUGATED CREAM,VAG

HS300 ESTROGENS CONJUGATED INJ

HS300 ESTROGENS CONJUGATED (EQUINE) TAB

HS300 ESTROGENS ESTERIFIED TAB

CN309 PA-F ESZOPICLONE TAB

MS190 PA-F ETANERCEPT INJ,SOLN

HS900 PA-F ETELCALCETIDE INJ,SOLN

CV702 ETHACRYNATE NA INJ

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

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 0.15MG,91 (MONO) (EQV-SEASONALE) TAB

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

HS200 ETHINYL ESTRADIOL 35MCG/NORELGESTROMIN 150MCG (EQV-XULANE) PATCH

HS200 ETHINYL ESTRADIOL 20MCG/NORETHINDRONE 1MG,21 (EQV-LOESTRIN 1/20) TAB

HS200 ETHINYL ESTRADIOL 30MCG/NORETHINDRONE 1.5MG,21 (EQV-LOESTRIN 1/35) TAB

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

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

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

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

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

AM500 R ETHIONAMIDE TAB

VA_National_Formulary_JAN_2023 Page 16

DE700 ETHYL CHLORIDE 100% AEROSOL,TOP

MS102 ETODOLAC CAP/TAB

CN203 ETOMIDATE INJ

AN900 ETOPOSIDE CAP,ORL

AN900 PA-F ETOPOSIDE INJ,SOLN

AM800 PA-F ETRAVIRINE TAB

CV350 PA-F EVOLOCUMAB INJ,SOLN

AN900 EXEMESTANE TAB

XA101 EYE PAD STERILE

OP500 EYE RINSE (OTC) SOLN,OPH IRRG

CV350 EZETIMIBE TAB

XA900 FACE PLATE SUPPLY

BL500 FACTOR IX, HUMAN INJ

BL500 FACTOR IX, RECOMBINANT INJ,LYPHL

BL500 FACTOR XA,INACTIVATED-ZHZO INJ,LYPHL

AN900 PA-F FAM-TRASTUZUMAB DERUXTECAN-NXKI INJ

AM800 R FAMCICLOVIR TAB

GA301 FAMOTIDINE TAB

GA301 FAMOTIDINE INJ,SOLN

GA301 FAMOTIDINE SUSP

OP900 PA-F FARICIMAB-SVOA INJ, SOLN

TN300 FAT EMULSION INJ

XA900 FECAL INCONTINENCE COLLECTOR SUPPLY

CN400 FELBAMATE SUSP,ORAL

CN400 FELBAMATE TAB

CV200 FELODIPINE TAB,SA

CV350 FENOFIBRATE TAB

AU100 FENOLDOPAM INJ

CN101 PA-F 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

AH106 FEXOFENADINE TAB

AM200 PA-F FIDAXOMICIN TAB

BL400 FILGRASTIM-SNDZ INJ,SOLN

HS900 FINASTERIDE 5MG TAB

MS900 PA-F FINGOLIMOD CAP,ORAL

HA000 FISH OIL CAP,ORAL

CV300 FLECAINIDE TAB

AM700 R FLUCONAZOLE PWDR,RENST-ORAL

AM700 R FLUCONAZOLE TAB

AM700 R FLUCONAZOLE INJ

AM700 R FLUCYTOSINE CAP,ORAL

AN300 PA-F FLUDARABINE INJ

HS052 FLUDROCORTISONE ACETATE TAB

VA_National_Formulary_JAN_2023 Page 17

AD900 FLUMAZENIL INJ

DE200 FLUOCINOLONE ACETONIDE 0.01% SOLN,TOP

DE200 FLUOCINONIDE CREAM,TOP

DE200 FLUOCINONIDE OINT,TOP

DE200 FLUOCINONIDE SOLN,TOP

OP900 FLUORESCEIN INJ,SOLN

OP900 FLUORESCEIN SOLN,OPH

OP900 FLUORESCEIN STRIP,OPH

OP900 FLUORESCEIN NA /PROPARACAINE SOLN,OPH

OP300 FLUOROMETHOLONE OINT,OPH

OP300 FLUOROMETHOLONE SUSP,OPH

AN300 PA-F FLUOROURACIL INJ,SOLN

DE600 FLUOROURACIL CREAM,TOP

DE600 FLUOROURACIL SOLN,TOP

CN609 FLUOXETINE CAP,ORAL

CN609 FLUOXETINE SOLN,ORAL

CN609 FLUOXETINE TAB

CN701 FLUPHENAZINE LIQUID,ORAL

CN701 FLUPHENAZINE INJ

CN701 FLUPHENAZINE TAB

CN701 PA-F FLUPHENAZINE DECONATE INJ

OP900 FLURBIPROFEN NA SOLN,OPH

AN900 PA-F FLUTAMIDE CAP

NT200 FLUTICASONE (PROPRIONATE ONLY) INHL,NASAL

RE109 FLUTICASONE/SALMETEROL INHL,ORAL

CN609 FLUVOXAMINE TAB

VT102 FOLIC ACID INJ,SOLN

VT102 FOLIC ACID TAB

HS400 PA-F FOLLICLE STIMULATING HORMONE/LUTEINIZING HORMONE (MENOTROPINS) INJ,SOLN

HS400 PA-F FOLLITROPIN ALFA INJ

HS400 PA-F FOLLITROPIN BETA INJ

AD900 FOMEPIZOLE INJ

BL110 FONDAPARINUX INJ,SOLN

AM800 PA-F FOSAMPRENAVIR TAB

GA605 FOSAPREPITANT INJ,LYPHL

OP900 FOSCARNET NA INJ

CV800 FOSINOPRIL TAB

CN400 FOSPHENYTOIN NA INJ

BL116 PA-F FOSTAMATINIB TAB

AM800 PA-F FOSTEMSAVIR TAB,SA

CV702 FUROSEMIDE TAB

CV702 FUROSEMIDE INJ,SOLN

CV702 FUROSEMIDE SOLN,ORAL

CN400 GABAPENTIN CAP,ORAL

CN400 GABAPENTIN SOLN,ORAL

CN400 GABAPENTIN TAB

CN900 GALANTAMINE CAP,SA

VA_National_Formulary_JAN_2023 Page 18

CN900 GALANTAMINE TAB

HS900 GALLIUM INJ,SOLN

AM800 R GANCICLOVIR INJ,SOLN

OP230 PA-F GANCICLOVIR GEL,OPH

HS400 PA-F GANIRELIX INJ,SOLN

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 PA-F GEMCITABINE INJ

CV350 GEMFIBROZIL TAB,ORAL

AN900 PA-F GEMTUZUMAB INJ

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

DE109 GENTIAN VIOLET 1% (OTC) SOLN,TOP

DE109 GENTIAN VIOLET 2% (OTC) SOLN,TOP

AN900 PA-F GILTERITINIB TAB

MS900 GLATIRAMER ACETATE INJ,LYPHL

AM800 PA-F GLECAPREVIR/PIBRENTASVIR TAB

HS502 GLIMEPIRIDE TAB

HS502 GLIPIZIDE TAB

IM500 GLOBULIN, IMMUNE INJ,SOLN

IM500 PA-F GLOBULIN, IMMUNE SUBCUTANEOUS INJ,SOLN

XA900 GLOVE LATEX NONSTERILE SUPPLY

XA900 GLOVE LATEX, STERILE SUPPLY

XA900 GLOVE VINYL NONSTERILE SUPPLY

HS503 GLUCAGON INJ

TN200

PA-F

GLUCERNA THERAPEUTIC (SHAKE) LIQUID,NUTRITIONAL

SUPPLEMENT

HS503 GLUCOSE (OTC) TAB,CHEWABLE

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

VA_National_Formulary_JAN_2023 Page 19

HS400 PA-F GONADOTROPIN,CHORIONIC HUMAN INJ

OP219 GRAMICIDIN/NEOMYCIN/POLYMYXIN SOLN,OPH

RE302 GUAIFENESIN TAB

RE302 GUAIFENESIN TAB,SA

RE302 GUAIFENESIN LIQUID,ORAL

AU100 PA-F GUANFACINE TAB,SA

IM100 HAEMOPHILUS B CONJUGATE VACCINE INJ,LYPHL

DE200 HALOBETASOL CREAM,TOP

DE200 HALOBETASOL OINT,TOP

CN709 HALOPERIDOL LIQUID,ORAL

CN709 HALOPERIDOL TAB

CN709 HALOPERIDOL INJ,SOLN

CN709 PA-F HALOPERIDOL DECANOATE INJ

CN201 HALOTHANE INHALATION LIQUID,INHL

DE900 HAMAMELIS WATER 50% (OTC) PAD

OT250 HC/NEOMYCIN/POLYMYXIN OTIC SUSP,OTIC

RS201 HEMORRHOIDAL (OTC) OINT,RTL

RS201 HEMORRHOIDAL (OTC) SUPP,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

IM100 HEPATITIS B VACCINE (RECOMBINANT) INJ,SUSP

IM100 HEPATITIS B, ADJUVANTED VACCINE (EQV-HEPLISAV-B) INJ

BL800 HETASTARCH INJ

BL800 HETASTARCH/ELECTROLYTES INJ

OP500 HIGH VISCOSITY ARTIFICIAL TEARS (OTC) SOLN,OPH

OP600 HOMATROPINE HYDROBROMIDE SOLN,OPH

OP900 HYALURONATE NA INJ,OPH

XX000 HYALURONIDASE INJ

CV490 HYDRALAZINE HCL INJ,SOLN

CV490 HYDRALAZINE HCL TAB

CV490 PA-F HYDRALAZINE/ISOSORBIDE TAB

CV701 HYDROCHLOROTHIAZIDE CAP,ORAL

CV701 HYDROCHLOROTHIAZIDE TAB

CV400 HYDROCHLOROTHIAZIDE/LISINOPRIL TAB

CV400 HYDROCHLOROTHIAZIDE/LOSARTAN TAB

CV704 HYDROCHLOROTHIAZIDE/SPIRONOLACTONE TAB

CV704 HYDROCHLOROTHIAZIDE/TRIAMTERENE CAP,ORAL

CV704 HYDROCHLOROTHIAZIDE/TRIAMTERENE TAB

CN101 PA-F HYDROCODONE/IBUPROFEN TAB

DE200 HYDROCORTISONE AEROSOL,TOP

HS051 HYDROCORTISONE TAB

HS051 HYDROCORTISONE INJ,SOLN

RS100 HYDROCORTISONE AEROSOL,RTL

RS100 HYDROCORTISONE ENEMA

VA_National_Formulary_JAN_2023 Page 20

RS202 HYDROCORTISONE CREAM,RTL

RS202 HYDROCORTISONE SUPP,RTL

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 OINT,RTL

DE101 HYDROGEN PEROXIDE (OTC) SOLN,TOP

CN101 HYDROMORPHONE HCL TAB

CN101 HYDROMORPHONE HCL INJ,SOLN

DE350 HYDROPHILIC OINT,TOP

DE900 HYDROQUINONE 4% CREAM,TOP

AP101 HYDROXYCHLOROQUINE SULFATE TAB

AN300 PA-F HYDROXYUREA CAP,ORAL

AH105 HYDROXYZINE CAP OR TAB

AH105 HYDROXYZINE INJ,SOLN

AH105 HYDROXYZINE LIQUID,ORAL

IM800 PA-F IBALIZUMAB-UIYK INJ,SOLN

AN900 PA-F IBRUTINIB CAP

AN900 PA-F IBRUTINIB TAB

MS102 IBUPROFEN TAB

MS102 IBUPROFEN SUSP

CV300 IBUTILIDE INJ

AN200 PA-F IDARUBICIN INJ,SOLN

BL116 IDARUCIZUMAB INJ.SOLN

AN100 PA-F IFOSFAMIDE INJ

AN100 PA-F IFOSFAMIDE/MESNA INJ

AN900 PA-F 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

DX101 INDOCYANINE GREEN INJ,SOLN

MS102 PA-F INDOMETHACIN SUPP,RTL

MS102 INDOMETHACIN CAP

MS102 INDOMETHACIN CAP,SA

IM600 PA-F INFLIXIMAB-ABDA INJ,LYPHL

IM100 INFLUENZA VIRUS VACCINE INJ

AD900 INSECT STING TREATMENT KIT KIT

XA854 INSULIN SYRINGE

HS501 INSULIN ASPART INJ,SOLN

HS501 INSULIN ASPART PROTAMINE/INSULIN ASPART (70/30) INJ,SUSP

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

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

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

VA_National_Formulary_JAN_2023 Page 21

HS501 INSULIN HUMAN REGULAR 500U/ML (PENS) INJ,SOLN

HS501 INSULIN LONG ACTING ANALOG INJ,SOLN

XA854 INSULIN LOW DOSE SYRINGE

HS501 PA-F INSULIN,DEGLUDEC INJ

HS501 PA-F INSULIN,GLARGINE U-300 (TOUJEO) INJ

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

IM100 INV-COVID-19 VACCINE (MODERNA) INJ,SUSP

DX102 IOTHALAMATE INJ,SOLN

IM900 PA-F IPILIMUMAB INJ,SOLN

NT900 IPRATROPIUM BROMIDE SOLN,SPRAY,NASAL

RE105 IPRATROPIUM BROMIDE INHALANT

RE105 IPRATROPIUM BROMIDE SOLN,INHL

CV805 IRBESARTAN TAB

AN900 PA-F IRINOTECAN INJ

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

VT802 IRON/MULTIVITAMINS CAP,ORAL

VT802 IRON/MULTIVITAMINS TAB,CHEWABLE

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 TAB

AM500 R ISONIAZID INJ

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 ITRACONAZOLE ORAL,SOLN

AM700 ITRACONAZOLE ORAL CAP,ORAL

XA809 IV SET SECONDARY SUPPLY

CV900 PA-F IVABRADINE TAB

AP200 PA-F IVERMECTIN TAB

AN900 PA-F IVOSIDENIB TAB

AN900 PA-F IXAZOMIB CAP,ORAL

TN200 JEVITY 1.5CAL LIQUID,NUTRITIONAL

SUPPLEMENT

TN475 K PHOSPHATE /NA BIPHOSPHATE/NA PHOSPHATE TAB

XA109 KERLIX 4.5IN STERILE BANDAGE,GAUZE

XA101 KERLIX SUPER SPONGE MEDIUM STERILE SUPPLY

VA_National_Formulary_JAN_2023 Page 22

CN203 KETAMINE INJ,SOLN

AM700 PA-F KETOCONAZOLE TAB

DE102 KETOCONAZOLE SHAMPOO

DE102 KETOCONAZOLE 2% CREAM,TOP

DX900 KETODIASTIX GLUCOSE KETONE TEST STRIP TEST STRIP

MS102 PA-F KETOPROFEN CAP,ORAL

MS102 KETOROLAC TROMETHAMINE INJ

OP300 KETOROLAC TROMETHAMINE SOLN,OPH

OP900 PA-F KETOROLAC/PHENYLEPHRINE OPH IRR

OP900 KETOTIFEN SOLN,OPH

CV100 LABETALOL TAB

CV100 LABETALOL HCL INJ,SOLN

CN400 LACOSAMIDE INJ.SOLN

CN400 PA-F LACOSAMIDE TAB

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 PA-F LAMIVUDINE SOLN,ORAL

AM800 PA-F LAMIVUDINE TAB

AM800 PA-F LAMIVUDINE/TENOFOVIR DF (EQV-CIMDUO) TAB

AM800 PA-F LAMIVUDINE/ZIDOVUDINE TAB

CN400 LAMOTRIGINE TAB

XA900 LANCET SUPPLY

DE350 LANOLIN CREAM,TOP

DE350 LANOLIN HYDROUS (OTC) OINT,TOP

HS701 LANREOTIDE INJ,SUSP,SA

TN490 PA-F LANTHANUM CARBONATE TAB,CHEWABLE

OP109 LATANOPROST SOLN,OPH

AM800 PA-F LEDIPASVIR/SOFOSBUVIR TAB

AM900 PA-F LEFAMULIN TAB,ORAL

AM900 PA-F LEFAMULIN INJ,SOLN

MS190 LEFLUNOMIDE TAB

XA599 LEG BAG STRAP ELASTIC SUPPLY

IM900

PA-F

LENALIDOMIDE CAP,ORAL

AN900 PA-F LENVATINIB CAP,ORAL

AN900 LETROZOLE TAB

VT102 LEUCOVORIN CALCIUM TAB

VT102 LEUCOVORIN CALCIUM INJ

AN500 LEUPROLIDE (EQV-ELIGARD) INJ,SUSP,LA

VA_National_Formulary_JAN_2023 Page 23

CN400 LEVETIRACETAM INJ,SOLN

CN400 LEVETIRACETAM TAB

OP101 LEVOBUNOLOL OPH SOLN,OPH

CN500 PA-F LEVODOPA CAP,INHL

AM400 R LEVOFLOXACIN TAB

AM400 R LEVOFLOXACIN INJ,SOLN

HS200 LEVONORGESTREL (EQV. PLAN B and PLAN B ONE STEP) TAB

HS851 LEVOTHYROXINE INJ

HS851 LEVOTHYROXINE NA TAB

DE700 LIDOCAINE PATCH

DE700 LIDOCAINE CREAM/OINTMENT TOP

DE700 LIDOCAINE 2.5%/PRILOCAINE 2.5% CREAM,TOP

CN204 LIDOCAINE HCL INJ

DE700 LIDOCAINE HCL 2% JELLY

NT300 LIDOCAINE HCL 2% VISCOUS LIQUID,ORAL

OP700 LIDOCAINE HCL 3.5% GEL,OPH

DE700 LIDOCAINE HCL 4% SOLN,TOP

GU900 LIDOCAINE HCL URH SOLN,TOP

CN204 LIDOCAINE HCL/EPINEPHRINE INJ

OP300 PA-F LIFITEGRAST SOLN,OPH

AM900 R LINEZOLID PWDR,RENST-ORAL

AM900 R LINEZOLID TAB

AM900 R LINEZOLID INJ

HS851 LIOTHYRONINE TAB

CN801 PA-F LISDEXAMFETAMINE CAP,ORAL

CV800 LISINOPRIL TAB

CN750 LITHIUM CAP,ORAL

CN750 LITHIUM SYRUP

CN750 LITHIUM TAB

CN750 LITHIUM TAB,SA

CV350 PA-N LOMITAPIDE CAP,ORAL

AN100 PA-F LOMUSTINE CAP,ORAL

GA208 LOPERAMIDE HCL CAP/TAB

GA208 LOPERAMIDE HCL LIQUID,ORAL

AM800 PA-F LOPINAVIR/RITONAVIR TAB

AH109 LORATADINE 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

CN709 PA-F LURASIDONE TAB

GA202 MAGNESIUM CITRATE (OTC) LIQUID,ORAL

GA202 MAGNESIUM HYDROXIDE (OTC) SUSP,ORAL

TN460 MAGNESIUM OXIDE (OTC) TAB

VA_National_Formulary_JAN_2023 Page 24

TN460 MAGNESIUM SULFATE INJ,SOLN

CV709 MANNITOL INJ,SOLN

AM800 PA-F MARAVIROC TAB

XA900 MASK,SURGICAL SUPPLY

IM100 MEASLES/MUMPS/RUBELLA VIRUS VACCINE INJ

CN550 MECLIZINE HCL (OTC) CHEW TAB/TAB

XA900 MEDICATION ORGANIZER MISCELLANEOUS

HS800 MEDROXYPROGESTERONE ACETATE INJ,SUSP

HS800 MEDROXYPROGESTERONE ACETATE TAB

HS800 MEGESTROL ACETATE SUSP,ORAL

HS800 MEGESTROL ACETATE TAB

HA000 MELATONIN CAP/TAB

MS102 MELOXICAM TAB

AN100 PA-F MELPHALAN TAB

AN100 PA-F MELPHALAN HCL INJ

CN900 MEMANTINE HCL TAB

IM100 MENINGOCOCCAL B CONJUGATE VACCINE (EQV-BEXSERO) INJ,SUSP

IM100 MENINGOCOCCAL OLIGOSACCHARIDE CONJUGATE (EQV-MENVEO) INJ,LYPHL

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

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

CN101 PA-F MEPERIDINE HCL INJ

CN204 PA-F MEPIVACAINE HCL INJ

AN300 MERCAPTOPURINE TAB

AM119 R MEROPENEM INJ,PWDR

GA900 MESALAMINE CAP,SA

GA900 MESALAMINE SUSP,RTL

GA900 MESALAMINE TAB,EC

RS100 MESALAMINE SUPP,RTL

AD900 MESNA INJ

HS502 METFORMIN TAB,SA

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

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

VA_National_Formulary_JAN_2023 Page 25

CN802 METHYLPHENIDATE (EQV-CONCERTA) TAB,SA

CN802 METHYLPHENIDATE (EQV-METADATE CD) CAP,SA

CN802 METHYLPHENIDATE (EQV-RITALIN LA) CAP,SA

HS051 METHYLPREDNISOLONE TAB

HS051 METHYLPREDNISOLONE INJ,SOLN

HS051 METHYLPREDNISOLONE INJ,SUSP

AU300 METOCLOPRAMIDE HCL LIQUID,ORAL

AU300 METOCLOPRAMIDE HCL TAB

AU300 METOCLOPRAMIDE HCL INJ INJ

CV701 METOLAZONE TAB

CV100 METOPROLOL TARTRATE INJ

CV100 METOPROLOL TARTRATE TAB

CV100 METOPROLOL SUCCINATE SUSTAINED ACTION TAB,SA

AM900 R METRONIDAZOLE TAB

AM900 R METRONIDAZOLE INJ,SOLN

DE752 METRONIDAZOLE CREAM,TOP

DE101 METRONIDAZOLE GEL,TOP

GU300 METRONIDAZOLE GEL,VAG

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 PA-F MIDAZOLAM SPRAY,NASAL

CN302 MIDAZOLAM HCL INJ,SOLN

CV900 MIDODRINE TAB

AN900 PA-F MIDOSTAURIN CAP,ORAL

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 PA-F MINOCYCLINE PWDR,MICROSPHERE

AM250 R MINOCYCLINE HCL CAP/TAB

CV490 MINOXIDIL TAB

GU201 PA-F MIRABEGRON TAB,SA

CN609 MIRTAZAPINE TAB

CN609 PA-F MIRTAZAPINE TAB,ORAL DISINTEGRATING

GA309 MISOPROSTOL TAB

AN200 PA-F MITOMYCIN INJ

OP109 MITOMYCIN SOLN,OPH,IRRG

AN900 PA-F MITOTANE TAB

AN900 PA-F MITOXANTRONE INJ

AN900 PA-F MOBOCERTINIB CAP,ORAL

CN809 MODAFINIL TAB

XA604 MOISTURE BARRIER SKIN OINT SUPPLY

VA_National_Formulary_JAN_2023 Page 26

GU900 MOISTURIZER, VAGINAL (EQV-REPLENS) GEL,VAG

DE350 MOISTURIZING (OTC) LOTION,TOP

RE101 MOMETASONE FUROATE INHL,ORAL

RE109 MONTELUKAST TAB

XA205 MONTGOMERY STRAPS SUPPLY

CN101 MORPHINE CAP,SA

CN101 MORPHINE LIQUID,ORAL

CN101 MORPHINE SOLN,CONC

CN101 MORPHINE TAB,IR

CN101 MORPHINE TAB,SA

CN101 MORPHINE INJ,SOLN

CV600 MORRHUATE INJ,SOLN

CV600 MORRHUATE SODIUM INJ,SOLN

AM400 R MOXIFLOXACIN TAB

AM400 R MOXIFLOXACIN INJ,SOLN

OP210 MOXIFLOXACIN SOLN,OPH

VT801 MULTIVITAMIN INJ

VT801 MULTIVITAMIN OPHTHALMIC (NO BETA CAROTENE) CAP/TAB

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

VT802 MULTIVITAMIN/MINERALS (OTC) CAP OR TAB

VT802 MULTIVITAMIN/MINERALS (OTC) LIQUID,ORAL

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

VT802 MULTIVITAMIN/MINERALS PRENATAL CAP OR TAB

VT802 MULTIVITAMIN/MINERALS SENIOR (OTC) CAP OR TAB

VT801 MULTIVITAMINS (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

MS102 NABUMETONE TAB

AM112 R NAFCILLIN NA INJ

CN102 NALOXONE HCL INJ

CN102 NALOXONE HCL INJ,SOLN

CN102 NALOXONE HCL SPRAY,NASAL

CN102 NALOXONE RESCUE INTRAMUSCULAR KIT

CN102 NALOXONE RESCUE INTRANASAL KIT

AD100 PA-F NALTREXONE INJ,SUSP,SA

CN102 NALTREXONE HCL TAB

OP800 NAPHAZOLINE SOLN,OPH

OP900 NAPHAZOLINE/PHENIRAMINE SOLN,OPH

MS102 NAPROXEN TAB

CN105 PA-F NAPROXEN/SUMATRIPTAN TAB

IM700

PA-F

NATALIZUMAB INJ,SOLN

VA_National_Formulary_JAN_2023 Page 27

OP220 NATAMYCIN SUSP,OPH

XA856 NEEDLE SUPPLY

XA856 NEEDLE PEN SUPPLY

AM800 PA-F NELFINAVIR TAB

IR100 NEO /POLYMYX SOLN,IRRG

AM300 R NEOMYCIN SULFATE TAB

AU300 NEOSTIGMINE METHYLSULFATE INJ

TN200 PA-F NEPRO CARB STEADY LIQUID,NUTRITIONAL

SUPPLEMENT

AM800 PA-F NEVIRAPINE TAB

VT103 NIACIN TAB

VT103 NIACIN TAB,SA

VT103 NIACINAMIDE TAB

CV200 NICARDIPINE INJ,SOLN

AD900 NICOTINE GUM, CHEWABLE

AD900 NICOTINE INHL,ORAL

AD900 NICOTINE PATCH

AD900 NICOTINE SOLN,NASAL

AD900 NICOTINE POLACRILEX LOZENGE

CV200 NIFEDIPINE TAB,SA

DX900 NITRAZINE (pH) TEST STRIP TEST STRIP

AM600 R NITROFURANTOIN MONOHYDRATE/MACROCRYSTALLINE CAP,SA

CV250 NITROGLYCERIN TAB,SUBLINGUAL

CV250 NITROGLYCERIN INJ,SOLN

RS900 PA-F NITROGLYCERIN 0.4% OINT,RTL

CV250 NITROGLYCERIN OINT,TOP

CV250 NITROGLYCERIN PATCH

AN300 PA-F NIVOLUMAB INJ,SOLN

HS900 NONOXYNOL GEL,VAG

AU100 NOREPINEPHRINE INJ

HS800 NORETHINDRONE 0.35MG (EQV-NOR QD),28 TAB

CN601 NORTRIPTYLINE CAP,ORAL

CN601 NORTRIPTYLINE SOLN,ORAL

TN200 NUTRITION SUPL ENSURE PLUS 1.5 CAL LIQUID,NUTRITIONAL

SUPPLEMENT

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

AM700 R NYSTATIN SUSP,ORAL

AM700 R NYSTATIN TAB,ORAL

DE102 NYSTATIN CREAM,TOP

DE102 NYSTATIN 100000UNT/GM OINT,TOP

DE900 OATMEAL,COLLOIDAL PWDR,TOP

AN900 PA-F OBINUTUZUMAB INJ,SOLN

MS900 PA-F OCRELIZUMAB INJ,SOLN

GA208 OCTREOTIDE ACETATE INJ

GA208 OCTREOTIDE ACETATE INJ,SA

AN900 PA-F OFATUMUMAB INJ,SOLN

OP210 OFLOXACIN SOLN,OPH

VA_National_Formulary_JAN_2023 Page 28

CN709 PA-F OLANZAPINE TAB,RAPID DISINTEGRATE

CN709 OLANZAPINE INJ,PWDR

CN709 OLANZAPINE TAB

AN900 PA-F OLAPARIB TAB

RE102 OLODATEROL INHL,ORAL

RE109 OLODATEROL/TIOTROPIUM INHL,ORAL

OP900 OLOPATADINE 0.1% SOLN,OPH

OP900 PA-F OLOPATADINE 0.7% SOLN,OPH

IM600 PA-F OMALIZUMAB INJ

GA900 OMEPRAZOLE CAP,EC

GA605 ONDANSETRON TAB

GA605 ONDANSETRON INJ,SOLN

GA605 ONDANSETRON TAB,ORAL DISINTEGRATING

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

OR200 ORABASE PLAIN PASTE (OTC) PASTE

GA900 PA-F ORLISTAT CAP,ORAL

AM800 R OSELTAMIVIR CAP,ORAL

AN900 PA-F OSIMERTINIB TAB

TN200 OSMOLITE 1.5CAL LIQUID,NUTRITIONAL

SUPPLEMENT

XA604 OSTOMY PASTE SUPPLY

XA606 OSTOMY POUCH DEODORANT SUPPLY

XA604 OSTOMY SKIN PROTECTIVE POWDER SUPPLY

DX900 OVULATION PREDICTION (DISPOSABLE) KIT

AM112 R OXACILLIN INJ

AN900 PA-F OXALIPLATIN INJ,LYPHL

MS102 PA-F OXAPROZIN TAB,ORAL

CN400 OXCARBAZEPINE TAB

GU201 OXYBUTYNIN TAB,SA

GU201 OXYBUTYNIN CHLORIDE TAB

CN101 OXYCODONE HCL TAB

CN101 PA-F OXYCODONE HCL TAB,SA

CN101 OXYCODONE HCL SOLN,ORAL

CN101 OXYCODONE HCL SOLN,CONC

NT100 OXYMETAZOLINE HCL (OTC) SOLN,NASAL

CN101 PA-F OXYMORPHONE TAB

CN101 PA-F OXYMORPHONE TAB,SA

AN900 PA-F 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

XA399 PAD,NURSING PAD

XA103 PADS,NON-ADHERING SUPPLY

VA_National_Formulary_JAN_2023 Page 29

AN900 PA-F PALBOCICLIB CAP,ORAL

AN900 PA-F PALBOCICLIB TAB

CN709 PA-F PALIPERIDONE INJ,SUSP,SA

HS900 PAMIDRONATE INJ

GA500 PANCREATIC ENZYMES CAP OR TAB

MS300 PANCURONIUM BROMIDE INJ,SOLN

AN900 PA-F PANITUMUMAB INJ,SOLN

GA900 PANTOPRAZOLE TAB,EC

GA900 PANTOPRAZOLE INJ,PWDR

IM100 PAPILLOMAVIRUS HUMAN 9-VALENT INJ,SUSP

HS600 PA-F PARATHYROID HORMONE INJ,LYPHL

VT599 PARICALCITOL INJ,SOLN

CN609 PAROXETINE TAB

CN609 PA-F PAROXETINE TAB,SA

AD400 PA-F PATIROMER CALCIUM SORBITEX PWDR,RENST-ORAL

BL400 PEGFILGRASTIM-BMEZ INJ,SOLN

IM700 PEGINTERFERON ALFA-2A INJ

AN900 PA-F PEMBROLIZUMAB INJ

AN300 PA-F PEMETREXED INJ,LYPHL

AN900 PA-F PEMIGATINIB TAB

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 PA-F PENTOSTATIN INJ

AN900 PA-F PENTOSTATIN/MANNITOL INJ

DE900 PERINEAL WASH (OTC) SOLN

AP300 PERMETHRIN (OTC) CREAM,TOP

AP300 PERMETHRIN (OTC) LOTION,TOP

CN701 PERPHENAZINE TAB

AN900 PA-F PERTUZUMAB INJ,SOLN

DE350 PETROLATUM(OTC) OINT,TOP

DE350 PETROLATUM/ZINC OXIDE PASTE

GU100 PHENAZOPYRIDINE HCL TAB

CN602 PA-F 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

GA751 PA-F PHENTERMINE/TOPIRAMATE CAP,SA

VA_National_Formulary_JAN_2023 Page 30

AU200 PHENTOLAMINE MESYLATE INJ

RE200 PHENYLEPHRINE TAB

AU100 PHENYLEPHRINE INJ

OP600 PHENYLEPHRINE HCL SOLN,OPH

NT100 PHENYLEPHRINE HCL (OTC) SOLN,NASAL

CN400 PHENYTOIN SUSP

CN400 PHENYTOIN TAB,CHEWABLE

CN400 PHENYTOIN (MYLAN) CAP,SA

CN400 PHENYTOIN 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

VT702 PHYTONADIONE TAB

VT702 PHYTONADIONE INJ

OP102 PILOCARPINE SOLN,OPH

AU300 PILOCARPINE HCL TAB

CN709 PA-F PIMAVANSERIN CAP OR TAB

CN900 PIMOZIDE TAB

HS502 PIOGLITAZONE TAB

AM113 R PIPERACILLIN NA INJ

AM113 R PIPERACILLIN NA/TAZOBACTAM INJ

MS102 PA-F PIROXICAM CAP,ORAL

BL500 PLASMA PROTEIN FRACTION 5% INJ

XA514 PLUG CATHETER SUPPLY

IM100 PNEUMOCOCCAL 15-VALENT CONJUGATED VACCINE INJ

IM100 PNEUMOCOCCAL 20-VALENT CONJUGATED VACCINE INJ

IM100 PNEUMOCOCCAL POLYSCCHARIDE VACCINE INJ

DE500 PODOFILOX 0.5% SOLN,TOP

IM100 POLIOVIRUS VACCINE INACTIVATED INJ

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

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

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

AM900 R POLYMYXIN B SO4 INJ,SOLN

OP219 POLYMYXIN/TRIMETHOPRIM SOLN,OPH

IM900 PA-F POMALIDOMIDE CAP,ORAL

AN900 PORFIMER SODIUM INJ

AM700 PA-F POSACONAZOLE INJ,SOLN

AM700 PA-F POSACONAZOLE SUSP,ORAL

AM700 PA-F POSACONAZOLE TAB,EC

TN430 POTASSIUM CAP OR TAB

TN430 POTASSIUM ACETATE INJ,SOLN

TN430 POTASSIUM BICARBONATE TAB,EFFERVSC

TN430 POTASSIUM CHLORIDE LIQUID,ORAL

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TN430 POTASSIUM CHLORIDE CAP OR TAB,SA

TN430 POTASSIUM CHLORIDE INJ,CONC-SOLN

TN430 POTASSIUM CHLORIDE PWDR,RENST-ORAL

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

DE101 POVIDONE IODINE (OTC) PAD

DE101 POVIDONE IODINE (OTC) SOLN,TOP

DE400 POVIDONE IODINE 10% (OTC) STICK,TOP

AD900 PRALIDOXIME CL INJ,SOLN

CN500 PRAMIPEXOLE TAB

DE700 PRAMOXINE HCL 1% (OTC) LOTION,TOP

BL117 PA-F PRASUGREL TAB

CV350 PRAVASTATIN TAB

CV150 PRAZOSIN HCL CAP,ORAL

OP300 PREDNISOLONE SUSP,OPH

OP350 PREDNISOLONE NA PHOSPHATE/SULFACETAMIDE SOLN,OPH

HS051 PREDNISONE TAB

CN900 PREGABALIN CAP,ORAL

DX900 PREGNANCY TEST (URINE) KIT

CN204 PRILOCAINE INJ,SOLN

CN204 PRILOCAINE HCL/EPINEPHRINE INJ,SOLN

AP101 PRIMAQUINE PHOSPHATE TAB

CN400 PRIMIDONE TAB

MS400 PROBENECID TAB

CV300 PROCAINAMIDE INJ,SOLN

AN900 PA-F PROCARBAZINE CAP,ORAL

GA605 PROCHLORPERAZINE SUPP,RTL

GA605 PROCHLORPERAZINE INJ

GA605 PROCHLORPERAZINE MALEATE TAB

HS800 PA-F PROGESTERONE GEL,VAG

HS800 PA-F PROGESTERONE INJ

HS800 PA-F PROGESTERONE TAB,VAG

HS800 PROGESTERONE (MICRONIZED) CAP

AH100 PROMETHAZINE HCL SUPP,RTL

AH100 PROMETHAZINE HCL TAB

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AH100…