Attachment 18 - VISN-09 PBM CBOB Formulary.xlsx

XLSX spreadsheet 25 KB Posted May 22, 2020

Attached to: MSO-2020-CMP-0025 Bowling Green CBOC Federal contract opportunity
Solicitation number: 36C24920R0048
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9

About this file

Written by GovTribe AI · Dec 30, 2023

This document contains a formulary listing approved prescription drugs covered by VISN-09 and details for a federal contract opportunity with the Department of Veterans Affairs. The formulary lists over 200 generic and brand name drugs approved for coverage including antibiotics, antidepressants, diabetes medications, inhalers, opioids, steroids, and warfarin products. Limits and exceptions are noted for some drugs.

The related federal contract opportunity is for solicitation number 36C24920R0048 for construction services for a new Community Based Outpatient Clinic in Bowling Green, Kentucky. The solicitation was issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The document provides high-level details on the opportunity but does not include pricing terms, response dates, set asides, incumbents or other contract-specific information.

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Other files for this federal contract opportunity

Other files attached to MSO-2020-CMP-0025 Bowling Green CBOC, newest first.
File	Type	Posted
36C24920R0048 0004.docx	DOCX document	Jul 15, 2020
S06 - 36C24920R0048 0003 Extending Due Date.docx	DOCX document	Jul 3, 2020
36C24920R0048 0002.docx	DOCX document	Jun 19, 2020
36C24920R0048 0001.docx	DOCX document	Jun 8, 2020
Attachment 7a - VSC - Security_CompletePacket.pdf	PDF	May 22, 2020
Attachment 8b - OIT Design Guide templates.pdf	PDF	May 22, 2020
PACT Space Module Design Guide.pdf	PDF	May 22, 2020
Attachment 9 - WDOL 2015-4677 Rev 10 07-16-2019.pdf	PDF	May 22, 2020
Attachment 2 - Contractor Organizational Conflict of Interest.pdf	PDF	May 22, 2020
Attachment 4 - Contractor Rules of Behavior 2019.pdf	PDF	May 22, 2020
Attachment 12 - TVHS Memoradum 626-18-11-30 Anticoagalation management.pdf	PDF	May 22, 2020
Attachment 7d - VSC - Self Cert.pdf	PDF	May 22, 2020
36C24920R0048.docx	DOCX document	May 22, 2020
Attachment 16 - Management of the Impaired Practioner.pdf	PDF	May 22, 2020
Attachment 7b - VSC - 306.pdf	PDF	May 22, 2020
VA Form 0710 AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED UNDER THE FAIR CREDIT REPORTING ACT TITLE 15 SECTION 1681.pdf	PDF	May 22, 2020
Infrastructure Standard for Telecommunications Spaces.pdf	PDF	May 22, 2020
Attachment 10 - TVHS Memorandums - 626.pdf	PDF	May 22, 2020
Attachment 6 - Deliverables-Reports Table - updating.pdf	PDF	May 22, 2020
Attachment 11 - SB Goals FY 20.pdf	PDF	May 22, 2020
IB 10-441 Enrollment Priority Group.pdf	PDF	May 22, 2020
Attachment 17 - Past Performance Questionnaire.pdf	PDF	May 22, 2020
Attachment 1 - Quality Assurance Surveillance Plan.docx	DOCX document	May 22, 2020
Attachment 8 - CFM- CBOC Prototype Design.pdf	PDF	May 22, 2020
Attachment 7 - VSC Security Package Flowchart.pdf	PDF	May 22, 2020
Attachment 3 - Contractor Certification of Immigration and Nationality Act of 1952 - As amended.pdf	PDF	May 22, 2020

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Drug Coverage

GPI	GENERIC NAME	Day Supply Exceptions	Message
12405010000330	ACYCLOVIR TAB 800 MG
44201010103410	ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90M	30 Day Supply
	AMOXICILLIN CAP 500 MG
01990002200320	AMOXICILLIN & K CLAVULANATE TAB 500-125 MG
	AMOXICILLIN & K CLAVULANATE TAB 875-125 MG
03400010000320	AZITHROMYCIN TAB 250 MG
	BENZONATATE CAP 100 MG
	BUPRENORPHINE/NALOXONE TAB 2 MG-0.5 MG
	BUPRENORPHINE/NALOXONE TAB 8 MG-2 MG
58300040107520	BUPROPION HCL TAB SR 24HR 150 MG
58300040107420	BUPROPION HCL TAB SR 12HR 100 MG
02100020000105	CEPHALEXIN CAP 250 MG
02100020000110	CEPHALEXIN CAP 500 MG
16220020100110	CLINDAMYCIN HCL CAP 150 MG
36201010100305	CLONIDINE HCL TAB 0.1 MG
68000020000310	COLCHICINE TAB 0.6 MG
68000020000120	COLCHICINE CAP 0.6 MG
75100050100305	CYCLOBENZAPRINE HCL TAB 10 MG
31200010000305	DIGOXIN TAB 0.125 MG
31200010000310	DIGOXIN TAB 0.25 MG
04000020000105	DOXYCYCLINE MONOHYDRATE CAP 50 MG
04000020000110	DOXYCYCLINE MONOHYDRATE CAP 100 MG
03100010100305	ERYTHROMYCIN STEARATE TAB 250 MG
03100005000605	ERYTHROMYCIN TAB DELAYED RELEASE 250 MG
58160040000120	FLUOXETINE HCL CAP 20 MG
	FLURBIPROFEN 0.03% 2.5ml OPTHALMIC DROPS
37200030000310	FUROSEMIDE TAB 40 MG
86101030002005	GENTAMICIN SULFATE OPHTH SOLN 0.3%
27200030000305	GLIPIZIDE TAB 5 MG
37600040000305	HYDROCHLOROTHIAZIDE TAB 25 MG
	HYDROXYZINE HCL TAB 25 MG
32100025007520	ISOSORBIDE MONONITRATE TAB SR 24HR 30 MG
32100025007530	ISOSORBIDE MONONITRATE TAB SR 24HR 60 MG
27104020001805	INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML-HUMULIN N & NOVOLIN N
27104090001810	INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100-HUMULIN 70/30 & NOVOLIN 70/30
27104010002005	INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML- HUMULIN R & NOVOLIN R
25400040000340	LEVONORGESTREL TAB 1.5 MG
281000101003**	LEVOTHYROXINE SODIUM TABS		BRAND ONLY
36100030000310	LISINOPRIL TAB 10 MG
	LORAZEPAM TAB 0.5 MG	Limit quantity to 5 tablets per fill.
22100030000310	METHYLPREDNISOLONE TAB 4 MG
52300020100305	METOCLOPRAMIDE HCL TAB 10 MG
33200030100310	METOPROLOL TARTRATE TAB 50 MG
16000035000305	METRONIDAZOLE TAB 250 MG
65100055100310	MORPHINE SULFATE TAB 15 MG	Limit to 3 day supply
65100055100315	MORPHINE SULFATE TAB 30 MG	Limit to 3 day supply
66100060000315	NAPROXEN TAB 500 MG
87991003102010	NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1%
	NITROFURANTOIN 50MG CAP
	NITROFURANTOIN 100MG CAP
32100030000715	NITROGLYCERIN SL TAB 0.4 MG
	OFLOXACIN 0.3% 5ML OPTHALMIC DROPS
12504060200120	OSELTAMIVIR PHOSPHATE CAP 75 MG-TAMIFLU
12504060201910	OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML-TAMIFLU
65990002200310	OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG	Limit to 3 day supply
01100040100315	PENICILLIN V POTASSIUM TAB 500 MG
72200030200110	PHENYTOIN SODIUM EXTENDED CAP 100 MG		BRAND ONLY
22100045000320	PREDNISONE TAB 10 MG
22100045000315	PREDNISONE TAB 5 MG
22100045006405	PREDNISONE TAB 5 MG DOSE PACK
41400020105210	PROMETHAZINE HCL SUPPOS 25 MG
41400020100310	PROMETHAZINE HCL TAB 25 MG
58160070100310	SERTRALINE HCL TAB 50 MG
90450030003710	SILVER SULFADIAZINE CREAM 1%
16990002300320	SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG
36202040100110	TERAZOSIN HCL CAP 2 MG
36202040100115	TERAZOSIN HCL CAP 5 MG
58180090107030	VENLAFAXINE HCL CAP SR 24HR 75 MG
34000030107025	VERAPAMIL HCL CAP SR 24HR 180 MG
34000030107035	VERAPAMIL HCL CAP SR 24HR 240 MG

VA Warfarin Drug List Solution
NDC	Drug 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 (Exelan)
76282-0328-**	WARFARIN SODIUM TAB 2 MG (Exelan)
76282-0329-**	WARFARIN SODIUM TAB 2.5 MG (Exelan)
76282-0330-**	WARFARIN SODIUM TAB 3 MG (Exelan)
76282-0331-**	WARFARIN SODIUM TAB 4 MG (Exelan)
76282-0332-**	WARFARIN SODIUM TAB 5 MG (Exelan)
76282-0333-**	WARFARIN SODIUM TAB 6 MG (Exelan)
76282-0334-**	WARFARIN TAB 7.5MG (Exelan)
76282-0335-**	WARFARIN SODIUM TAB 10 MG (Exelan)
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

File details come from the government source that posted it. Updated May 22, 2020.