ATTACHMENT A - PRICE WORKSHEET.xlsx
XLSX spreadsheet 14 KB Posted
- Attached to
- R408--PHARMACY BENEFIT MANAGEMENT: VISN 22
- Solicitation number
- 36C26221R0017
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Other files
| File | Type | Posted |
|---|---|---|
| 36C26221R0017 0002.docx | DOCX document | |
| 36C26221R0017 0001.docx | DOCX document | |
| ATTACHMENT C - BUSINESS ASSOCIATE AGREEMENT.docx | DOCX document | |
| ATTACHMENT B - PARTICIPATING FACILITIES.docx | DOCX document | |
| 36C26221R0017.docx | DOCX document | |
| ATTACHMENT G - WD LA 2015-5613 REV. 16.pdf | ||
| ATTACHMENT E - DOCTORS ORDERS.doc | DOC document | |
| ATTACHMENT F - PRESCRIPTION FORM.doc | DOC document | |
| ATTACHMENT D - IT CONTRACT SECURITY.pdf | ||
| ATTACHMENT I - WD SD 2015-5635 REV. 14.pdf | ||
| ATTACHMENT H - WD SB 2015-5629 REV. 14.pdf |
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Text version
Sheet1
| Generic Top 15 (14 day supply) | Strength | Dosage Form | Est 5 year Qty | Unit | AWP (e.g Red Book) | % Discount | Unit Price Prescription (each w/ discount) | Unit Price Administrative Fee | Extended Price |
| Example ABC | 10mg | Tablet | 150 | Each | $ 20.00 | 35% | $ 13.00 | $ 5.00 | $ 2,700.00 |
| AMLODIPINE BESYLATE | 10 mg | Tablet | 3300 | Each | $ - 0 | $ - 0 | |||
| AMOXICILLIN | 500mg | Capsule | 3100 | Each | $ - 0 | $ - 0 | |||
| AMOXICILLIN/CLAVULANATE POTASSIUM | 875mg | Tablet | 2500 | Each | $ - 0 | $ - 0 | |||
| AZITHROMYCIN | 250mg | Tablet | 5100 | Each | $ - 0 | $ - 0 | |||
| CEPHALEXIN | 250 & 500mg | Capsule | 3500 | Each | $ - 0 | $ - 0 | |||
| CIPROFLOXACIN HYDROCHLORIDE | 500mg | Tablet | 1500 | Each | $ - 0 | $ - 0 | |||
| COLCHICINE VA Formulary colchicine tablets Utilized for Colcrys tablets | 0.6mg | Tablet | 200 | Each | $ - 0 | $ - 0 | |||
| DOXYCYCLINE HYCLATE | 100mg | Capsule | 2700 | Each | $ - 0 | $ - 0 | |||
| HYDROCHLOROTHIAZIDE | 50mg | Tablet | 1775 | Each | $ - 0 | $ - 0 | |||
| IBUPROFEN | 800mg | Tablet | 1600 | Each | $ - 0 | $ - 0 | |||
| LISINOPRIL | 40mg | Tablet | 3600 | Each | $ - 0 | $ - 0 | |||
| LOSARTAN POTASSIUM | 100mg | Tablet | 2100 | Each | $ - 0 | $ - 0 | |||
| ONDANSERTRON | 4mg | Oral Disintegrating Tablet | 1000 | Each | $ - 0 | $ - 0 | |||
| PREDNISONE | 20mg | Tablet | 3700 | Each | $ - 0 | $ - 0 | |||
| SULFAMETHOXAZOLE/TRIMETHOPRIM DS | 800-160mg | Tablet | 3050 | Each | $ - 0 | $ - 0 | |||
| TRIAMCINOLONE ACETONIDE | 0.10% | Topical Cream | 1250 | Each | $ - 0 | $ - 0 | |||
| Aggregated Five Year Total (Generic ) | $ - 0 |
| Brand Name Top 8 (14 day supply) | Strength | Dosage Form | Est 5 year Qty | Unit | AWP (e.g Red Book) | % Discount | Unit Price Prescription (each w/ discount) | Unit Price Administrative Fee | Extended Price |
| Example ABC | 10mg | Tablet | 150 | Each | $ 50.00 | 40% | $ 30.00 | $ 5.00 | $ 5,250.00 |
| ATROVENT HFA | 12.9gm | Inhaler | 150 | Each | $ - 0 | $ - 0 | |||
| BD INSULIN SYRINGE ULTRA-FINE | 0.5ML/31G X 8MM | Supply | 200 | Each | $ - 0 | $ - 0 | |||
| ELIQUIS | 5mg | Tablet | 200 | Each | $ - 0 | $ - 0 | |||
| LANTUS INSULIN VIAL | 100U/mL | Injectable | 450 | Each | $ - 0 | $ - 0 | |||
| NOVOLOG MIX 70/30 | 100U/mL | Injectable | 170 | Each | $ - 0 | $ - 0 | |||
| PROAIR HFA VA Formulary albuterol inhaler Utilized for Albuterol HFA, Ventolin HFA | 90mcg | Inhaler | 3430 | Each | $ - 0 | $ - 0 | |||
| SYMBICORT MDI | 160/4.5mcg | Inhaler | 150 | Each | $ - 0 | $ - 0 | |||
| XARELTO | 20mg | Tablet | 300 | Each | $ - 0 | $ - 0 | |||
| Aggregated Five Year Total (Brand Name ) | $ - 0 |
Aggregated Five Year Total (Generic & Brand Name) $ - 0
File details come from the government source that posted it. Updated .