Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

Pharmacy Benefits Management Services

Menu
Menu

Quick Links

Veterans Crisis Line Badge
My healthevet badge
EBenefits Badge
 

Clinical Guidance - Criteria For Use

The content on this page has been incorporated into the VA National Formulary Search Tool.  Please click on the link below to search for individual criteria for use.
http://www.pbm.va.gov/apps/VANationalFormulary/

Abiraterone_Criteria_For_Use.pdf 
Acetaminophen Injection Criteria for Use
Acetylcholinesterase Inhibitors Criteria for Use 2014 rev Dec_2015
Ado Trasuzumab Emtansine Kadcyla Criteria for Use
Agalsidase Criteria for Non Formulary Use
Alemtuzumab Lemtrada Criteria for Use
Aliskiren Criteria for Use updated
Alpha Blocker and Finasteride Combination Therapy for BPH Criteriafor Use
Alvimopan_ENTEREG_Criteria_for_Use_Rev_Oct_2016
Anticoagulants_Direct_Oral_DOACs_CFU_and_Algorithm_for_Venous_Thromboembolism_VTE_Treatment_Rev_Dec_2016
Anticoagulants_Direct_Oral_DOACs_CFU_for_Venous_Thromboembolism_VTE_Prophylaxis_in_Ortho_Surgery_Rev_Dec_2016
AnticoagulantsDirect_Oral_DOACs_CFU_and_Algorithm_for_Nonvalvular_Atrial_Fibrillation_Rev_Dec_2016
AntiTNF_DMARDs_for_Rheumatoid_Arthritis_Criteria_for_Use_Rev_Apr_2017
Apremilast_(OTEZLA)_Criteria_for_Use_in_Psoriasis_and_Psoriatic_Arthritis
Atezolizumab_TECENTRIQ_Prior_Auth_Facility_PAF_CFU
Azacitidine Criteria for Formulary Use
Becaplermin Regranex Criteriafor NF Use
Belatacept Nulojix Criteria For Use
Benzocaine
BevacizumabCriteriaforUse
Biologics_in_Psoriasis_and_Psoriatic_Arthritis_Criteria_for_Use_Rev_Apr_2017
Botulinum_Toxins_Criteria_For_Use
Brimonidine_MIRVASO_Topical_Gel_Criteria_for_Use
Budesonide_UCERIS_ER_Tab_Criteria_for_Use
Buprenorphine_and_Buprenorphine_Naloxone_for_Opioid_Use_Disorder_CFU
Buprenorphine_TDS_Butrans_Criteria_for_Use
C1_Inhibitor_BERINERT_CINRYZE_RUCONEST_Ecallantide_Icatibant_for_Hereditary_Angioedema_Criteria_for_Use_Rev_June_2015
Cabazitaxel Criteria For Use
CalcitriolOintmentCriteriaforUse 
Capecitabine_Criteria_for_Use
Carbidopa_Levodopa_Extended_release_Capsules_Rytary_Criteria_for_Use
Carbidopa_Levodopa_Intestinal_Gel_Duopa_CFU
Carfilzomib_KYPROLIS_Criteria_for_Use
CilostazolNonFormularyCriteriaForUse
Cinacalcet_Criteria_for_Use_rev_Jan_2016
Clopidogrel012010
CyclosporineOphthalmicRestasisCFU
Daclatasvir_and_Sofosbuvir_Criteria_rev_Sept_2016
Daclizumab_ZINBRYTA_Criteria_for_Use
Dalfampridine_Ampyra_Criteria_for_Use
Daratumumab_DARZALEX_Criteria_for_Use
Deferasirox Criteria for Non formulary Use
DenosumabProliaCriteriaForUse
DexmedetomidineICUCriteriaforFormularyUse
DexmedetomidinePeriOperativeCriteriaforFormularyUse
Diclofenac_Topical_Patch_Gel_Solution_Monograph
Dimethyl_Fumarate_Tecfidera_CFU_update_March_2014
Dipeptidyl_Peptidase_4_DPP_4_Inhibitor_CFU_rev_May_2016
DMARDs_for_Rheumatoid_Arthritis_anti_TNF_DMARD_CFU
Dofetilide_Criteria_for_Use
Dronedarone_Criteria_for_Use_Rev_Aug_2016
DrotrecoginAlfaCriteriaforNonFormularyUse
EculizumabCritieraforNonformularyUse
Elbasvir_Grazoprevir_Zepatier_CFU
Elotuzumab_EMPLICITI_Criteria_for_Use 
Elvitegravir_cobicistat_emtricitabine_tenofivir_alafenamide_Genvoya_NME
Empagliflozin_Jardiance_Criteria_for_Use
Endothelin_Receptor_Antagonists_ERA_Criteria_for_Use_Feb_2017 
EnfuvirtideCriteriaforFormularyUse
Enzalutamide_XTANDI_Criteria_for_Use_rev_Jan_2017
Erlotinib_Prior_Authorization_Facility_PA_F_Criteria_for_Use
Erythropoiesis_Stimulating_Agent_CFU_for_Hepatitis_C_treatment_related_anemia 
Eszopiclone_CFU_FINAL_Internet
EtravirineCriteriaforUse
Ezetimibe_Ezetimibe_Simvastatin_Criteria_for_Use_Rev_11_2015
FactorVIIRecombinantActivatedNovoSevenCriteriaforNonFormularyUse 
FentanylTransdermalPatchCriteriaforUse
Fidaxomicin_DIFICID_Criteria_for_Use
Filgrastim_for_Hepatitis_C_Treatment_Related_Neutropenia
Fingolimod_Gilenya_Criteria_for_Use_rev_March_2017
Fluphenazine_decanoate_Prolixin_Criteria_for_Use_Evidence_Summary
FondaparinuxCriteriaForUse
Glucagon_Like_Peptide1_Agonist_CFU_rev_May_2017
Haloperidol_decanoate_Haldol_Criteria_for_Use_and_Evidence_Summary
HPV9_Criteria_for_Use
Hyaluronic_Acid_Hylan_GF_20_Criteria_for_Use_Rev_July_2017
Ibrutinib_IMBRUVICA_Criteria_for_Use_Update_Mar_2016 
Idelalisib_ZYDELIG_Criteria_for_Use
ImatinibCriteriaforFormularyUse
ImiquimodCriteriaforFormularyUse
ImmuneGlobulinSubcutaneousCFU
Inhaled_Insulin_Afrezza_Criteria_for_Use
Insulin_Degludec_TRESIBA_Criteria_for_Use
Insulin_Glargine_300_units_per_mL_TOUJEO_Criteria_for_Use 
Interferonalfacon1ConsensusInterferoninHepatitisC
IpilimumabCriteriaForUse
Ivabradine_CORLANOR_Criteria_for_Use_Rev_Aug_2016
Ivermectin_Cream_SOOLANTRA_Criteria_for_Use
Ixazomib_NINLARO_Criteria_for_Use
Lacosamide_Vimpat_CFU_Oral_Tablet
Lesinurad_ZURAMPIC_Criteria_for_Use
Lidocaine_Topical_Criteria_for_Use_rev_Jan_2016
Lifitegrast_XIIDRA_Criteria_for_Use
Linaclotide_Lubiprostone_Criteria_for_Use
LiothyronineCriteriaForUse
Liraglutide_SAXENDA_Criteria_for_Use_Rev_May_2017
Lomitapide_Juxtapid_Criteria_for_Use_Final_March_2014
Lorcaserin_Belviq_Criteria_for_Use_Updated_July_2016
MaravirocCriteriaforFormularyUse
Memantine_CFU_2014_INTERnet
MeperidineCriteriaforUse
Mepolizumab_Nucala_Criteria_for_Use
Metformin_Revised_Warnings_NATIONAL_PBM_BULLETIN_041816_FINAL
Methylnaltrexone_Injection_and_Tablet_Criteria_for_Use_Rev_Jan_2017
Mipomersen_KYNAMRO_Criteria_for_Use_Final 
Mirabegron_Criteria_for_Use
Modafinil_Criteria_For_Use_in_Fatigue_Rev_March_2015
MonoamineOxidaseInhibitorsMAOICriteriaforUse
MoxifloxacinOphthalmicSolutionCriteriaforFormularyUse
Naloxegol_MOVANTIK_Criteria_for_Use
Naltrexone_Bupropion_CONTRAVE_Criteria_for_Use
Naltrexone_ER_Inj_Criteria_for_Use_Updated_2014_01_15
Natalizumab_Tysabri_Criteria_for_Use_Update_March_2014
NicardipineIVCriteriaforUse
Nintedanib_OFEV_Criteria_for_Use
Nivolumab_OPDIVO_Criteria_for_Use
Obeticholic_Acid_OCALIVA_Criteria_for_Use
Obinutuzumab_GAZYVA_Criteria_for_Use
Ocriplasmin_Criteria_For_Use
Omalizumab_XOLAIR_Criteria_for_Use_in_Asthma
Omalizumab_Xolair_Criteria_for_Use_in_Chronic_Idiopathic_or_Spontaneous_Urticaria_Final
Omega_3_Fatty_Acid_Prescription_Products_Lovaza_Omtryg_Epanova_and_Vascepa_Revised_February_2015)
Orally_Disintegrating_Tablets_Critera_For_Use_Rev_Oct_2014
Orlistat_XENICAL_Criteria_for_Use_Updated_July_2016
OxyCODONE_Tab_Sustained_Action_SA_12_H_Criteria_for_Use
OxyMORPHONE_Tab_Immediate_Release_IR_Criteria_for_Use
OxyMORPHONE_Tab_Sustained_Action_SA_12_H_Criteria_for_Use
Paliperidone_Long_acting_Injection_Invega_Sustenna_and_Trinza_CFU_Evidence_Summary
PantoprazoleIVCriteriaforUseandLiteratureReview 
Parkinsons_Disease_Treatment_Recommendations
Patiromer_VELTASSA_Criteria_for_Use_Rev_Feb_2017
PCSK9_Inhibitor_Proprotein_Convertase_Subtilisin_Kexin_Type_9_Alirocumab_or_Evolocumab_Criteria_for_Use_Rev_Sept_2016_2
PegaptanibCriteriaforNonFormularyUse
PegloticaseKrystexxaCriteriaforUseFinal
Pembrolizumab_KEYTRUDA_Criteria_for_Use
PemetrexedCriteriaforNonFormularyUse
Perampanel_Fycompa_Criteria_for_use
Pertuzumab_PERJETA_Criteria_for_Use
Phentermine_Topiramate_Qsymia_Criteria_for_Use_Updated_July_2016
Pimavanserin_NUPLAZID_Crtieria_for_Use
Pirfenidone_ESBRIET_Criteria_for_Use_rev_Mar_15
Pneumococcal_13_Valent_Conjugate_Vaccine_Criteria_for_Use
Pomalidomide_POMALYST_Criteria_for_Use
PramlintideCriteriaforUse
PrasugrelCriteriaforNonFormularyUse
Pregabalin_Lyrica_Criteria_for_Use
ProstacyclinsInhaledTreprostinilandIloprostCriteriaforUse
Prothrombin_Complex_Concentrate_4_Factor_Kcentra_Recommendations_for_Use
ProtonPumpInhibitorsHighdoseCriteriaforUse
Provent_Criteria_for_use
Ramucirumab_CYRAMZA_Criteria_For_Use 
RanolazineCriteriaforNonFormularyUse
Recombinant_Human_Parathyroid_Hormone_1_84_NATPARA_Criteria_for_Use
Regorafenib_Criteria_For_Use
Reslizumab_CINQAIR_Criteria_for_Use
RetinoidsandHighdoseVitaminAHighlyTeratogenicCriteriaforUse
Rifaximin_for_Hepatic_Encephalopathy_Criteria_for_Use
Risperidione_Long_acting_Injection_Risperdal_Consta_Criteria_for_Use_Evidence_Summary_Rev_Apr_2015
RituximabCriteriaforUse
Roflumilast_Criteria_for_Use_02_rev_Apr_2015
Sacubitril_Valsartan_ENTRESTO_Criteria_for_Use_Rev_Mar_2017
Siltuximab_SYLVANT_Criteria_for_Use
Simeprevir_plus_Sofosbuvir_Criteria_for_Use_rev_April_2015
SinecatechinsCriteriaforUse 
SipuleucelTCriteriaForUse
SorafenibinHepatocellularCarcinomaCriteriaForUse
StatinCriteriaforNonFormularyUseinPatientsReceivingProteaseInhibitorTherapy
Suvorexant_CFU_FINAL
Tapentadol_Immediate_Release_IR_Tablets_Criteria_for_Use
Tapentadol_Sustained_Action_SA_Tablets_Criteria_for_Use 
Tasimelteon_CFU
Tenofovir_alafenamide_fumarate_Vemlidy_CFU
Teriflunomide_Criteria_for_Use_Rev_March_2017 
TeriparatideCriteriaForUse
Testosterone_Replacement_in_Adult_Males_Criteria_for_Use
TetrabenazineCriteriaforUse
ThickeningAgentsforOutpatientsCriteriaforUse
ThrombopoietinAgonistForHepatitisCrelatedThrombocytopenia
Ticagrelor_BRILINTA_Criteria_for_Use_Aug_2016
Tipranavir_Criteria_for_Formulary_Use 
Tocilizumab_ACTEMRA_Criteria_For_Use_Rev_2014_11_21
TranexamicAcidOralLystedaCFUJuly2012
Transgender_Cross_Sex_Hormone_Therapy_in_FtM_Female_to_Male_CFU
Transgender_Cross_Sex_Hormone_Therapy_in_MtF_Male_to_Female_CFU
Trastuzumab_HERCEPTIN_Criteria_for_Use
Trifluridine_tipiracil_LONSURF_Criteria_for_Use
Uridine_triacetate_VISTOGARD_Criteria_for_Use
Varenicline_Criteria_For_Use 
Vedolizumab_ENTYVIO_Injection_Criteria_for_Use
VemurafenibCriteriaforUse
Venetoclax_VENCLEXTA_Criteria_for_Use
Viekira_XR_and_Technive_Criteria_for_Use_rev_Jan_2017
Vismodegib_Criteria_for_Use
VitaminSupplementsforMacularDegenerationCriteriaForUse
ZiconotideCriteriaforNonFormularyUse  
Ziv_Aflibercept_PA_N_CFU 
ZoledronicAcidReclastCriteriaForUse  
ZosterVaccineCriteriaforUse