ATTACHMENT 1 - CBOCs FORMULARY-Rev. 2.xlsx

XLSX spreadsheet 31 KB Posted

Attached to
Q517--LOCUM-Pharmacy Benefits Management (PBM) Services VISN 9 Wide
Solicitation number
36C24922Q0555
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File Type Posted
ATTACHMENT 2 - LOCATION OF CBOCs-Rev. 1.docx DOCX document
36C24922Q0555 0001.docx DOCX document
ATTACHMENT 6 - CONTRACTOR RULES OF BEHAVIOR.docx DOCX document
ATTACHMENT 3 - ESTIMATED QUANTITIES.docx DOCX document
36C24922Q0555_1.docx DOCX document
ATTACHMENT 2 - LOCATION OF CBOCs.docx DOCX document
ATTACHMENT 7 - WAGE DETERMINATION.docx DOCX document
ATTACHMENT 4 - ADDENDUM TO STATEMENT OF WORK.docx DOCX document
ATTACHMENT 5 - CONTRACTOR CERTIFICATION OF IMMIGRATION.docx DOCX document

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Drug Coverage

GPIGENERIC NAMEDay Supply ExceptionsMessage
ACETAMINOPHEN TAB 500 MG
12405010000330ACYCLOVIR TAB 800 MG
44201010103410ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90M30 Day Supply
AMOXICILLIN CAP 500 MG
01990002200320AMOXICILLIN & K CLAVULANATE TAB 500-125 MG
AMOXICILLIN & K CLAVULANATE TAB 875-125 MG
03400010000320AZITHROMYCIN TAB 250 MG
BENZONATATE CAP 100 MG
BUPRENORPHINE/NALOXONE TAB 2 MG-0.5 MG
BUPRENORPHINE/NALOXONE TAB 8 MG-2 MG
58300040107520BUPROPION HCL TAB SR 24HR 150 MG
58300040107420BUPROPION HCL TAB SR 12HR 100 MG
02100020000105CEPHALEXIN CAP 250 MG
02100020000110CEPHALEXIN CAP 500 MG
16220020100110CLINDAMYCIN HCL CAP 150 MG
36201010100305CLONIDINE HCL TAB 0.1 MG
68000020000310COLCHICINE TAB 0.6 MG
68000020000120COLCHICINE CAP 0.6 MG
75100050100305CYCLOBENZAPRINE HCL TAB 10 MG
DEXTROMETHROPHAN/GUAIFENESING 20MG-200MG/5ML SYRUP 120ML
31200010000305DIGOXIN TAB 0.125 MG
31200010000310DIGOXIN TAB 0.25 MG
04000020000105DOXYCYCLINE MONOHYDRATE CAP 50 MG
04000020000110DOXYCYCLINE MONOHYDRATE CAP 100 MG
03100010100305ERYTHROMYCIN STEARATE TAB 250 MG
03100005000605ERYTHROMYCIN TAB DELAYED RELEASE 250 MG
58160040000120FLUOXETINE HCL CAP 20 MG
FLURBIPROFEN 0.03% 2.5ml OPTHALMIC DROPS
37200030000310FUROSEMIDE TAB 40 MG
86101030002005GENTAMICIN SULFATE OPHTH SOLN 0.3%
27200030000305GLIPIZIDE TAB 5 MG
GUAIFENESIN SR TAB 600MG
37600040000305HYDROCHLOROTHIAZIDE TAB 25 MG
HYDROXYZINE HCL TAB 25 MG
IBUPROFEN TAB 400 MG
32100025007520ISOSORBIDE MONONITRATE TAB SR 24HR 30 MG
32100025007530ISOSORBIDE MONONITRATE TAB SR 24HR 60 MG
27104020001805INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML-HUMULIN N & NOVOLIN N
27104090001810INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100-HUMULIN 70/30 & NOVOLIN 70/30
27104010002005INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML- HUMULIN R & NOVOLIN R
25400040000340LEVONORGESTREL TAB 1.5 MG
281000101003**LEVOTHYROXINE SODIUM TABSBRAND ONLY
36100030000310LISINOPRIL TAB 10 MG
LORAZEPAM TAB 0.5 MGLimit quantity to 5 tablets per fill.
22100030000310METHYLPREDNISOLONE TAB 4 MG
52300020100305METOCLOPRAMIDE HCL TAB 10 MG
33200030100310METOPROLOL TARTRATE TAB 50 MG
16000035000305METRONIDAZOLE TAB 250 MG
MOLNUPIRAVIREmergency Use Authorization
65100055100310MORPHINE SULFATE TAB 15 MGLimit to 3 day supply
65100055100315MORPHINE SULFATE TAB 30 MGLimit to 3 day supply
66100060000315NAPROXEN TAB 500 MG
87991003102010NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1%
NITROFURANTOIN 50MG CAP
NITROFURANTOIN 100MG CAP
32100030000715NITROGLYCERIN SL TAB 0.4 MG
OFLOXACIN 0.3% 5ML OPTHALMIC DROPS
OSELTAMIVIR PHOSPHATE CAP 30 MG
12504060200120OSELTAMIVIR PHOSPHATE CAP 75 MG
12504060201910OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML-TAMIFLU
65990002200310OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MGLimit to 3 day supply
PAXLOVID™ (NIRMATRELVIR/RITONAVIR)Emergency Use Authorization
01100040100315PENICILLIN V POTASSIUM TAB 500 MG
72200030200110PHENYTOIN SODIUM EXTENDED CAP 100 MGBRAND ONLY
22100045000320PREDNISONE TAB 10 MG
22100045000315PREDNISONE TAB 5 MG
22100045006405PREDNISONE TAB 5 MG DOSE PACK
41400020105210PROMETHAZINE HCL SUPPOS 25 MG
41400020100310PROMETHAZINE HCL TAB 25 MG
58160070100310SERTRALINE HCL TAB 50 MG
90450030003710SILVER SULFADIAZINE CREAM 1%
16990002300320SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG
36202040100110TERAZOSIN HCL CAP 2 MG
36202040100115TERAZOSIN HCL CAP 5 MG
ULIPRISTAL ACETATE 30 MG TAB
58180090107030VENLAFAXINE HCL CAP SR 24HR 75 MG
34000030107025VERAPAMIL HCL CAP SR 24HR 180 MG
34000030107035VERAPAMIL HCL CAP SR 24HR 240 MG
VA Warfarin Drug List Solution
NDCDrug Name
51672-4027-**Warfarin NA (Taro Pharm) 1MG Tab
51672-4028-**Warfarin NA (Taro Pharm) 2MG Tab
51672-4029-**Warfarin NA (Taro Pharm) 2.5MG Tab
51672-4030-**Warfarin NA (Taro Pharm) 3MG Tab
51672-4031-**Warfarin NA (Taro Pharm) 4MG Tab
51672-4032-**Warfarin NA (Taro Pharm) 5MG Tab
51672-4033-**Warfarin NA (Taro Pharm) 6MG Tab
51672-4034-**Warfarin NA (Taro Pharm) 7.5MG Tab
76282-0327-**WARFARIN SODIUM TAB 1 MG (Invagen)
76282-0328-**WARFARIN SODIUM TAB 2 MG (Invagen)
76282-0329-**WARFARIN SODIUM TAB 2.5 MG (Invagen)
76282-0330-**WARFARIN SODIUM TAB 3 MG (Invagen)
76282-0331-**WARFARIN SODIUM TAB 4 MG (Invagen)
76282-0332-**WARFARIN SODIUM TAB 5 MG (Invagen)
76282-0333-**WARFARIN SODIUM TAB 6 MG (Invagen)
76282-0334-**WARFARIN TAB 7.5MG (Invagen)
76282-0335-**WARFARIN SODIUM TAB 10 MG (Invagen)
00056-0169-**Coumadin (Warfarin NA) BMS 1MG Tab
00056-0170-**Coumadin (Warfarin NA) BMS 2MG Tab
00056-0176-**Coumadin (Warfarin NA) BMS 2.5MG Tab
00056-0188-**Coumadin (Warfarin NA) BMS 3MG Tab
00056-0168-**Coumadin (Warfarin NA) BMS 4MG Tab
00056-0172-**Coumadin (Warfarin NA) BMS 5MG Tab
00056-0189-**Coumadin (Warfarin NA) BMS 6MG Tab
00056-0173-**Coumadin (Warfarin NA) BMS 7.5MG Tab

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