36C25820R0031 0002.docx

5. PROJECT NUMBER (if applicable)

CODE

7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER

3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO.

1. CONTRACT ID CODE

FACILITY CODE

CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office.

is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER

16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30

PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243 (Type or print) (Type or print) (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code) (If other than Item 6) (Specify type of modification and authority) (such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer) 11-17-2020 None Y Department of Veterans Affairs NCO22-Gilbert Network Contracting New Mexico VA Health Care System 1501 San Pedro Drive SE Albuquerque

NM

87108 Department of Veterans Affairs NCO22-Gilbert Network Contracting New Mexico VA Health Care System 1501 San Pedro Drive SE Albuquerque

NM

87108 To all Offerors/Bidders

36C25820R0031 09-18-2020

X X X

X The purpose of this solicitation amendment is to answer questions pertaining to this solicitation.

See continuation pages for additional information.

Nonya Montano Contracting Officer

CONTINUATION PAGE

1. Will the new contractor inherit the patient’s last Primary Care vesting visit and be allowed to bill for one year from that date upon contract award? It will be inherited.

1. Does the current facility meet the requirements of the new contract? Yes. If it is determined that modifications/improvements are needed, the Government will add a line item to cover those costs.

1. Does the current facility meet the PACT Team requirements? Yes. If it is determined that modifications/improvements are needed, the Government will add a line item to cover those costs.

1. Does the Contractor or VA provide the Licensed Clinical Social Worker described in paragraph 2.4.3.? The Contractor provides the social worker.

1. In paragraph 4.6.3.1 it states that the Contractor will provide all medication, including any necessary vaccines that are to be administered to patients in the clinic. Will the Vaccines be provided to the clinic at the cost of the Contractor or the VA? The Contractor is responsible to provide all medications, including vaccines. That responsibility includes the cost of the medications.

1. If the cost of vaccines discussed in question 3 above are the responsibility of the contractor, please confirm that the following list of Vaccines are the responsibility of the contractor? Any and all vaccines kept on hand shall be at the contractor’s expense. The VA is no longer authorized to provide medications to contracted CBOCs.

5. TDAP

5. Pneumovax 23

5. Prevnar 13

5. TD

5. Flu, High dose flu

5. Shingrix

5. Twinrix (Hep A&B)

5. Hep A

5. Hep B

5. HPV

5. Depo

1. If the cost of vaccines is the responsibility of the contractor…. Are there any additional Vaccines required to be supplied by the contractor other than those listed in question 4 above? Yes, there will be additional vaccines required, to be supplied by the Contractor. This will depend on patient specific needs. There are also patient specific psych injections that would need to be provided by the Contractor. This is included in the CBOC Ward” list below:

1. If the cost of vaccines is the responsibility of the contractor…. What is the number of Vaccines, by type as listed in question 4 and any additional Vaccines added by the government pursuant to question 5, that was provided to the Durango CBOC Enrolled Veterans in the last 12 months?

1. Pursuant to paragraph 4.6.3.1 please provide a list of Medications the government expects the contractor to dispense (at the cost of the Contractor) from the clinic that would not be a routine medication dispensed through the VA or an urgent/emergent medication dispensed through the contracted local pharmacy. View the listing provided for question #7. This is a standard list subject to change clinic to clinic depending on their usage and veterans’ needs. Additional medications may be needed depending on the situation. The Contractor’s clinical expertise would determine this. The NMVAHCS works with CBOC contractors to fine tune issues such as these.

1. How many VA staffed personnel will be providing services at the Durango CBOC? Please list by job title and number of days per month. None. Note that VA personnel performing support roles for the Durango CBOC perform these duties from an alternate site, generally the parent facility.

1. How many offices will be needed at the Durango CBOC for the VA provided staff (by position/function) identified in question 8? None, all VA support staff perform these duties from an alternate site.

1. How many veterans using the Durango CBOC are currently on the Primary Care billable roster? 1791 as of September 2020. In non-COVID times, it is estimated at 2060.

1. Is the Contractor or VA responsible for the cost of sub-contracting urgent and emergent x-ray services as described in paragraph 4.5.4.1? Yes, the Contractor is responsible for the cost of urgent and emergent x-rays.

1. With reference to Section E, Solicitation Provisions, Factor 1 – Technical Capability, Sub Factor B – Management, Experience and Staffing, and Transition Plan, 7: Proposed Staffing, b) Providers, ii) Provide copies of the following information on any physician to be assigned to this solicitation. Include physicians providing coverage relief – page 107. The point asks for the following information but there is no information listed. The CVs are requested in iii). Is this a numbering glitch or was there additional information the Government would like included? This is a numbering glitch; however, the Government requires a CV for proposed providers not currently performing services at the Durango CBOC.

1. With reference to Section E, Solicitation Provisions, Factor 1 – Technical Capability, Sub Factor B – Management, Experience and Staffing, and Transition Plan, 8: Nurse Practitioners - page 107: Transcripts from an Accredited Nurse Practitioner Program. Question: Due to the length of time it takes to get transcripts from the educational sites, will the Government accept CV and Licenses at this proposal stage, with transcripts submitted upon award? Yes, the Government will accept transcripts upon award.

1. With reference to Section E, Solicitation Provisions, Factor 1 – Technical Capability, Sub Factor B – Management, Experience and Staffing, and Transition Plan, 7: Proposed Staffing, b) Providers and 8: Nurse Practitioners - page 107: Question: As the numbering of these sections is somewhat confusing, would the Government like us to follow this numbering exactly or renumber these sections to be more concise? For consistency, follow the numbering exactly.

1. With reference to Section E, Solicitation Provisions, Factor 1 – Technical Capability, Sub Factor B – Management, Experience and Staffing, and Transition Plan, 3) Describe the Offeror’s length and breadth of experience in providing healthcare and 9) Entity Information, Identify all relevant company experience in providing the same/similar types of services identified in this solicitation, including VA experience, and other government and/or private sector experience. Provide a clinical and administrative contact point for each experience episode provided, Question: is the Government requesting duplicative information or can the Government clarify the difference(s) in the requested information? It is not duplicative; the intention is to ensure the completeness of information. If the information requested is part of an item submitted in another section, the Contractor should reference it. For example, a curriculum vitae might include experience older than typical so as to note VA experience, or might provide contact points for each experience. If the information requested is not provided by the Contractor elsewhere, it needs to be included in this part of Section E. Note that Factor 1 Sub-factor 2 component 2 is requesting an overview on an offeror’s length and breadth of experience in providing healthcare. Factor 1 Sub-factor 2, component 9) i-iv is asking for specific entity information.

1. What is the current vested roster as of October 2020? 1422. This number is lower than usual due to the pandemic. Typically it is no less than 1700.

1. Can the government provide the current utilization rates for the clinic? The Government pays the Contractor based on capitation rates per member per month with an estimated 2,060 vested patients per month. See question #12, #18, and #20 regarding current and potential enrollment. Utilization rates vary and are not a reliable measure during the COVID-19 pandemic.

1. Can the government provide the number of veterans living in the catchment area? The 8 surrounding counties have an estimated 5000 veterans. La Plata County has 1626 per last U.S. Census.

1. How many women veterans are assigned to the clinic? 91

1. Can the government clarify who will provide the expanded PACT members Social Work? The Contractor.

1. Does the government require any office space for expanded PACT members? For example, Social Worker or Dietitian? If so, how many office spaces? No, any VA staff will tele-work.

1. Is the PACT model designed required for this opportunity to include on-stage off-stage design? No.

1. Does the current facility meet contract requirements? Yes. If it is determined that modifications/improvements are needed, VA will add a line item to cover those costs.

1. Does the government want vendors to proposal new or alternate clinical locations? Proposing new or alternate clinical locations is fully permissible but not mandatory. The existing location is the preferred option. Also note that there is currently no evaluation factor for Geographical Location/alternate clinic location.

1. With regard to physical security the VA references attachment Real Property Memorandum 2018-02 Physical Security Standards for Leased Facilities (Existing Space and Lease Construction Projects) VAIQ 7866496. This document addresses window film added to existing glazing to protect the perimeter shell, in doing so the document under Structure references the GSA guidelines for performances standards. The GSA guidelines for physical security require barriers to protect or defend the perimeter at entrance points. Are both window film and barriers required? Window film as specified in Memorandum 2018-02 is required. Barriers are not required, but preferred. Per section 1.4.6 of the U.S. Department of Veterans Affairs Office of Construction & Facilities Management Physical Security and Resiliency Design Manual: “Leased facilities are not required to comply with physical security and resiliency requirements in this manual. For further information, please contact the Office of Real Property within the Office of Construction & Facilities Management.”

1. Does the current facility meet security requirements? Yes. If it is determined that modifications/improvements are needed, VA will add a line item to cover those costs.

1. Can the government clarify that the name of the clinic will be “VA Clinic” vs Durango VA Clinic or any other name? The name will remain unchanged, so as to be most clear to VA patients: Durango VA Clinic.

1. Will the government allow the “Property Improvements/ buildout requirements” of the proposed space to be calculated in CLIN 001 vs. amortized over the life of the contract? If it is determined that modifications/improvements are needed, VA will add a line item to cover those costs.

1. Will the government provide phones for the clinic? No.

1. Can the government extend the proposal due date by 30 days to allow vendors adequate time to respond to the solicitation requirements and allow time for answers to questions? Yes, it will be extended by no less than 30 days.

1. Will a site visit be conducted? If so, will the site visit be used as part of the source selection evaluation criteria? If a new location is proposed a site visit will be conducted to determine if the proposed new location meets/exceeds the contract requirements.

1. Will the contractor inherit the existing vesting date of all currently enrolled Veterans or will the new contractor be required to vest every patient beginning on day 1 of the new contract? Duplicate question (#1). It will be inherited.

1. Is there a page limit for the technical response? No. Be as concise as possible.

1. If offeror is proposing incumbent personnel, is a response required for item numbers 7 & 8 of Sub Factor B? No; simply state the specific incumbent personnel being proposed for which PACT member.

1. What is the estimated timeline for award? Realistic estimate timeline for award is between February 1 and March 1, 2021. Awardee will be provided with at least 90 days between contract award and period of performance start date to allow adequate time for any required transition period.

1. Will the contractor inherit the patient’s last vesting visit under the new contract (or will enrollment start at zero, requiring every patient to have to have a revesting visit)? Duplicate question (#1). It will be inherited.

1. The statement on the coversheet of the RFP, “Note that build out is not anticipated due to an acceptable facility currently exists in Durango, CO.” seems to be in direct conflict with section 4.9 of the RFP (Space Requirements) because the existing clinic does not meet PACT Design Guide Standards.

38. Please confirm no buildout would be required at the existing facility.

38. Please confirm that a submitted design meeting PACT Requirements at a different location would not be given preference over the existing floor plan.

If it is determined that modifications/improvements are needed, VA will add a line item to cover those costs.

1. Who is responsible for courier expenses? The Contractor.

1. Does the VA require the contractor to purchase a refrigerated centrifuge? No, there is no requirement for the centrifuge to be refrigerated.

1. Pg 13, 2.2: Will VA accept Board Eligible physician candidates? Yes.

1. Pg 14, Option 1: under position responsibilities, do we need to add “VVC” in the sentence “. . . ensuring the pt has same day access for f2f and telephone care visits . . .” No. Same day access via video teleconference is not required.

1. Pg 26, 4.6.1.1.2: Does this include use of remote visits from outside the clinic using telephone or VVC in the case of provider call-outs or shortages? Yes.

1. Pg 37, 4.6.4.3: Will all contractor EKGs be reviewed by NMVAHCS cardiology? Yes, the EKGs will be over read by VA doctors. The results will go into the electronic medical record and alert the provider.

1. Pg 39, 4.6.6.2.1.2: Does the provider also complete a PHQ9 in addition to the Columbia? No.

1. Pg 52, 4.6.8.4: Will NMVAHCS pharmacists be doing in person, on-site care periodically at the Durango CBOC? No.

1. Pg 55, 4.7.2.2: What is the duration of the removal of billing roster? 6 mos? 1 year? What if, during this period, the patient requests to return to the Durango CBOC? What is the process to resume billing roster? New patients will automatically be disenrolled after 12 months with no encounters by the assigned provider or RN. Existing/vested patients will automatically be disenrolled after 24 months with no encounters by the assigned provider or RN.

1. Pg 55, 4.7.2.6: Is the NMVAHCS call center aware of the fact that the CBOC is not an ER or UC center? Yes.

1. Pg 61, 4.9.1: Are the consultation rooms also serving as Woman’s Health rooms? Consultation rooms can also serve as Women’s Health rooms, if they meet the requirements for a Women’s Health room. The premise is that staff are to move to the patient, not the patient moving to various rooms to see staff.

1. What procedures are supported or required for use of a designated procedure room? Can this room also serve as a Women’s Health room? Procedure rooms would not serve well as Women’s Health rooms. Appropriate procedures of a designated procedure room are non-emergent outpatient care, within the professional privileges of the specific provider.

1. On page 34 under 4.6.3.2 it states: The Contractor is responsible to ensure all medications are subject to routine inspection, as required by VA Pharmacy, proper storage (in a secure and locked location) and meet all VA policy and TJC standards for medication management. Contractor shall ensure all vaccines and medications requiring refrigeration or freezing are stored in pharmaceutical grade purpose-built refrigerators and freezers. Please provide a list of all medications, vaccinations and amounts to be administered in the clinic. This ranges from clinic to clinic depending on the veteran’s needs. Stock will need to be adjusted accordingly depending on usage. The list provided for question #7 is a good start, but again additional vaccines may be needed depending on the patient’s specific need. The Outpatient Critical Medication List below should be considered as a contracted local fill.

1. On page 35 under 4.6.3.3.1 it states: Contractor shall provide clerical support, including scheduling, and ancillary support for VA tele pharmacy services as appropriate. The support services should be consistent for each scheduled clinic to include but not limited to intake vitals by LVN/LPN, Unlicensed Assistive Personnel (health tech or nursing assistant), or similar, downloading of blood sugar from meters, POC INR testing and downloading, teaching patients how to use BP monitors at home, calling patients for lab reminders, scheduling patient visits and contacting patients who no-show for rescheduling. How many clerical and clinical support staff are required for tele-pharmacy support services? A dedicated staff person for VA tele-pharmacy is not needed. The scheduling/support staff in the PACT model can support this workload.

1. On page 32 under 4.6.2.4.6 Emergency contraception (e.g. Levonorgestrel (Plan B) etc.) must be available to all women Veteran patients in a timely manner (same day of their appointment) even if a provider has requested to opt out from providing emergency contraception to the patient because of a Rights of Conscience (ROC) Claim. Will the VA provide this medication? The VA can mail this medication directly to the patient, yet if it is to be for the same day the patient must get it in person from the Albuquerque VA Medical Center’s Pharmacy. The Contractor may want to consider a contracted local pharmacy for a same day situation.

1. Does the VA require the Tele-health tech to be a Medical Assistant or LPN? Either a health technician or an LPN.

1. Is the Women’s Health room required to have a bathroom? No, yet the bathroom should be in close proximity. Patients who are undressed or wearing examination gowns must have access to the bathroom without going through public hallways or waiting rooms. With outside exam room restrooms, consideration must be taken for how men will be kept out of the areas while the gowned female patient is moving to the restroom. Women’s Health rooms must have a door lock, a table with stirrups that face away from the door, a privacy curtain, a sink, and a bathroom in near vicinity.

1. How many contracted clerical support staff are required for the VA staff on-site? None. No VA staff will be on site.

1. How many VA staffed personnel will be providing services at the CBOC? Please list job title and number of days per month. None.

1. Will the VA provided staff require an office at the CBOC? If yes, what type and size? No.

1. Thin-Prep PAP testing supplies are not available for purchase by contractor, will the VA supply? The VA supplies all the PAP kits, via mail directly to the patient. When the sample is collected, the Contractor ships the sample to VA and VA sends it out for testing.

1. Does the VA wish to use a security guard? Armed or Unarmed? No security guard is required.

1. Who is responsible for setting up a contract with a local ambulance company, the VA or the Contractor? Neither. An ambulance contract is not needed. Local, non-contracted emergent ambulance service via calling 911 can serve VA patients just as it serves the general public.

1. Will the VA provide Naxolone for veterans who require it as a precaution? VA Pharmacy would mail medications to the patient directly, with a provider’s order. VA will not provide any medications directly to the Contractor’s clinic.

1. Are sliding doors required for the CBOC? Does the VA require or prefer swinging doors or sliding doors on Primary Care Exam Rooms? Is a sliding door required on offstage side of the exam room? Sliding doors are not required in either area. Swing doors are better for patient privacy. Sliding doors are encouraged on the staff side. To maximize floor space, it is better if at least one of the doors is a sliding door.

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Outpatient Critical Medication List_7.2016.pdf

Allergy/Asthma/COPD Medications

*Medication with multiple indications **Refer to pharmacist for review Updated April 2015 1

Generic Name Brand Name Status

Cetirizine Zyrtec Noncritical Diphenhydramine Benadryl Noncritical** Epinephrine Epi-Pen Critical Flunisolide Nasal Spray Aerobid; Nasalide; Nasrel Noncritical Fluticasone Nasal Spray Flonase Noncritical Hydroxyzine Vistaril Noncritical* Loratadine Claritin Noncritical Pseudoephedrine Sudafed Noncritical Sodium Chloride Nasal Spray Ocean Spray Noncritical

Albuterol/Ipratropium Combivent Critical Albuterol ProAir; Proventil; Ventolin Critical Mometasone Asmanex Noncritical Budesonide/Formoterol Symbicort Noncritical Tiotropium Spiriva Noncritical

Prednisone Deltasone Critical* Montelukast Singulair Noncritical

Allergy

Asthma/COPD Inhalers

Asthma/COPD Oral Agents

Cardiovascular Medications

**Refer to pharmacist for review Updated April 2015 2

Amiodarone Pacerone Critical Digoxin Digitek Critical

Amlodipine Norvasc Critical Atenolol Tenormin Critical Chlorthalidone Thalitone Critical Clonidine Catapres Critical Diltiazem Cardiazem Critical Doxazosin Cardura Critical* HCTZ/Lisonpril Prinzide Critical Hydrochlorothiazide (HCTZ) Hydro-Diuril; Microzide Critical Hydralazine Apresoline Critical Lisinopril Prinivil; Zestril Critical Losartan Cozaar Critical Metoprolol Succinate XL Toprol XL Critical Metoprolol Tartrate Lopressor Critical Terazosin Hytrin Critical* Prazosin Minipress Critical*

Apixaban Eliquis Critical Aspirin Noncritical Clopidogrel Plavix Critical Dabigatran Pradaxa Critical Enoxaparin Lovenox Critical Prasugrel Effient Critical Rivaroxaban Xarelto Critical Ticagrelor Brillinta Critical Warfarin Coumadin Critical

Antiarrhythmics

Antihypertensives

Antiplatelets/Anticoagulants

Cardiovascular Medications

**Refer to pharmacist for review Updated April 2015 3

Isosorbide Mononitrate Imdur Critical Nitroglycerin Nitrostat Critical

Atorvastatin Lipitor Noncritical Ezetimibe Zetia Noncritical Fenofibric Acid Tricor Noncritical Fish oil Lovaza Noncritical Gemfibrozil Lopid Noncritical Lovastatin Mevacor Noncritical Niacin Slo Niacin Noncritical Pravastatin Pravachol Noncritical Simvastatin Zocor Noncritical

Furosemide Lasix Critical

Diuretics

Cholesterol

Chest Pain

Diabetes Medications

**Refer to pharmacist for review Updated April 2015 4

Insulin Glargine Lantus Critical Insulin Human Isophane (NPH) Novolin N Critical Insulin Aspart Novolog Critical

Glipizide Glucotrol Critical Glyburide Diabeta Critical Metformin Glucophage Critical

Insulin Syringe Critical Lancets Softclick Lancets Noncritical Pen Needles Novolin Pen Needles Noncritical

Test Strips Accu-Chek Aviva Plus Test Strips Noncritical**

Supplies

Orals

Injectables

Immunological Medications

**Refer to pharmacist for review Updated April 2015 5

Azathioprine Imuran Critical Cyclosporine Sandimmune, Gengraf, Neoral Critical Hydroxychloroquine Plaquenil Critical Methotrexate Trexall RPh** Mycophenolate CellCept, Myfortic Critical Prednisone Deltasone Critical* Sirolimus Rapamune Critical Tacrolimus Prograf Critical

Immunosuppressive Agents

Gastrointestinal/urinary Medications

**Refer to pharmacist for review Updated April 2015 6

AlOH/MgOH/Simethicone Mylanta Noncritical Omeprazole Nexium Noncritical Pantoprazole Protonix Noncritical Ranitidine Zantac Noncritical Simethicone Drops Gas-X Noncritical

Alfluzosin Uroxatral Critical Doxazosin Cardura Critical* Finasteride Proscar Noncritical Prazosin Minipress Critical* Tamsulosin Flomax Critical Terazosin Hytrin Critical*

Dicyclomine Bentyl Noncritical Mesalamine Apriso, Asacol HD, Delzicol, Pentasa Noncritical

Docusate Colace Noncritical Docusate/Sennosides Doc-Q-Lax Noncritical Lactulose syrup Generlac RPh** Magnesium Citrate Liquid Citroma Noncritical Polyethylene Glycol GoLytely Noncritical Psyllium Oral Powder Metamucil Noncritical

Meclizine Antivert Noncritical Ondansetron Zofran Noncritical** Promethazine Phenergan Noncritical

Oxybutinin Oxytrol Noncritical

Acid Reflux/Gas

Laxatives

BPH

Urinary Incontinence

Intestinal Disorders

Nausea

Musculoskeletal Health Medications

**Refer to pharmacist for review Updated April 2015 7

Prednisone Deltasone Critical*

Allopurinol Zyloprim Noncritical Colchicine Colcrys Critical** Naproxen Alleve, Naprosyn Noncritical* Prednisone Deltasone Critical* Probenecid Noncritical Ibuprofen Motrin Noncritical*

Alendronate Fosamax Noncritical Calcium/Vitamin D Noncritical*

Anti-Inflammatory

Gout

Osteoporosis

Neurological Medications

**Refer to pharmacist for review Updated April 2015 8

Carbamazepine Tegretol Critical* Divalproex sodium Depakote Critical* Felbamate Felbatol Critical Lacosamide Vimpat Critical Lamotrigine Lamictal Critical* Levetiracetam Keppra Critical* Gabapentin Neurontin RPh** Oxcarbazepine Trileptal Critical Pregabalin Lyrica RPh** Phenobarbital Luminal Critical Phenytoin Dilantin Critical Primidone Mysoline Critical Topiramate Topamax Critical* Valproic acid Depakene Critical Zonisamide Zonegran Critical

Aspirin/Butalbital/Caffeine Fiorinal Critical Butalbital/APAP/Caffeine Fioricet Critical Caffeine/Ergotamine Cafergot Critical Sumatriptan Imitrex Critical

Amantadine Symmetrel Critical Benztropine Cogentin Critical Bromocriptine Parlodel Critical Carbidopa/Levodopa Sinemet Critical Entacapone Comtan Critical Pramipexole Mirapex Critical Rasagiline Azilect Critical Ropinirole Requip Critical Selegiline Eldepryl Critical Trihexyphenidyl Artane Critical

Anti-Convulsants (used for epilepsy or psychiatric indications)

Migraine Headache

Parkinson's Disease

Ophthalmic Medications

**Refer to pharmacist for review Updated April 2015 9

Brimonidine Alphagan P Critical Latanoprost Xalatan Critical

Artificial Tears Noncritical Carboxymethylcellulose Noncritical Ocular Lubricant Ointment Noncritical

Ketotifen Zaditor Noncritical Prednisolone ophthalmic suspension Pred Forte Noncritical

Glaucoma

Lubricant

Allergy

Pain Medications

**Refer to pharmacist for review Updated April 2015 10

Baclofen Lioresal Critical Cyclobenzaprine Flexeril Noncritical Methocarbamol Robaxin Noncritical Tizanidine Zanaflex Noncritical

Acetaminophen Tylenol Noncritical Ibuprofen Motrin, Advil Noncritical* Meloxicam Mobic Noncritical Naproxen Alleve, Naprosyn Noncritical*

Duloxetine Cymbalta RPh** Gabapentin Neurontin RPh** Pregabalin Lyrica RPh**

Acetaminophen w/codeine Tylenol #3 Noncritical Buprenorphine/Naloxone Suboxone Critical Fentanyl Duragesic Critical Hydrocodone/Acetaminophen Vicodin, Lortab Critical Methadone Dolophine Critical Morphine SR MS Contin Critical Oxycodone Roxicodone Critical Oxycodone ER Oxycontin Critical Oxycodone/Acetaminophen Percocet Critical Tramadol Ultram Critical

Lidocaine ointment Xylocaine Noncritical Menthol/M-Salicylate cream Bengay Noncritical

Muscle Relaxants

NSAIDS/APAP

Opioids

Topical Analgesics

Neuropathic Pain

Psychiatric Medications

*Medication with multiple indications Updated April 2015 11

Donepezil Aricept RPh** Memantine Namenda RPh**

Aripiprazole Abilify Critical Clonidine Catapres Critical Clozapine Clozaril Critical Divalproex Sodium Depakote Critical* Haloperidol Haldol Critical Lamotrigine Lamictal Cricial* Lithium Lithobid Critical Lurasidone Latuda Critical Quetiapine Seroquel Critical Olanzapine Zyprexa Critical Risperidone Risperdal Critical Ziprasidone Geodon Critical

Alprazolam Xanax Critical Buspirone Buspar Critical Clonazepam Klonopin Critical Diazepam Valium Critical Hydroxyzine Vistaril Critical Lorazepam Ativan Critical Temazepam Restoril Critical

Bupropion Wellbutrin Critical* Citalopram Celexa Critical Duloxetine Cymbalta Critical* Escitalopram Lexapro Critical Fluoxetine Prozac Critical Mirtazapine Remeron Critical* Sertraline Zoloft Critical Venlafaxine Effexor Critical Trazodone Desyrel Critical*

Antipsychotics

Anxiety

Alzheimer's/Dementia

Depression

Psychiatric Medications

*Medication with multiple indications Updated April 2015 12

Prazosin Minipress Critical*

Melatonin Noncritical Mirtazapine Remeron Noncritical* Trazodone Desyrel Noncritical* Zolpidem Ambien Noncritical

Bupropion Zyban Critical* Nicotine Replacement (patches/lozenges) Noncritical Varenicline Chantix Noncritical**

Sleep

Smoking Cessation

Nightmares Associated with PTSD

Topical Medications

**Refer to pharmacist for review Updated April 2015 13

Clotrimazole Lotrimin Noncritical Terbinafine Lamisil Noncritical

Betamethasone topical Celestone Noncritical Clobetasol topical Clobex Noncritical Hydrocortisone topical Noncritical Triamcinolone cream Kenalog Noncritical

Ammonium Lactate Lotion Amlactin Noncritical Calamine Noncritical Moisturizing Cream Noncritical

Antifungal

Anti-Inflammatory

Dry Skin

Miscellaneous Medications

**Refer to pharmacist for review Updated April 2015 14

Chlorhexidine gluconate mouthwash Peridex Noncritical

Acyclovir Zovirax **RPh Famciclovir Famvir **RPh Fluconazole Diflucan **RPh Ganciclovir Zirgan **RPh Sulfamthoxazole/Trimethoprim Bactrim **RPh Valacyclovir Valtrex **RPh

Guaifenesin Mucinex Noncritical

Sildenafil Viagra Noncritical

Estrogen Premarin, Prempro Noncritical Levothyroxine Synthroid Noncritical Liothyronine Cytomel Noncritical Testosterone injection Depo-Testosterone Noncritical

Lacutulose Generlac RPh**

Calcium/Vitamin D Noncritical* Cholecalciferol Vitamin D3 Noncritical Cyanocobalamin injection Vitamin B12 Noncritical Ferrous sulfate Iron Tablets Noncritical Folic acid Vitamin B9 Noncritical Magnesium oxide Noncritical Multivitamins Noncritical Potassium Klor-Con Critical

Supplement

Erectile Dysfunction

Cough

Antibacterial Mouthwash

Hormone Replacement

Anti-Infectives (with prophylaxis indications)

Liver Failure (Hepatic Encephalopathy)

Allergy-Asthma-COPD

CV

Diabetes

Immunological

GI-GU

Musculoskeletal

Neurological

Ophthalmic

Pain

Psych

Topical

Miscellaneous