D.2 VA Central Iowa Health Care System Pharmacy Prescriber and Medication Formulary List.xlsx

XLSX spreadsheet 28 KB Posted

Attached to
Q517--Pharmacy Benefit Management First Fill Services at the CIVAHCS
Solicitation number
36C26325Q0772
Issued by

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Written by GovTribe AI ·

This file is a pharmacy formulary list for the VA Central Iowa Health Care System, detailing a comprehensive medication inventory across various drug categories. The formulary includes over 200 different medications, spanning antibiotics, pain medications, mental health drugs, cardiovascular treatments, and other therapeutic classes. Each entry lists the drug name, generic code, and sometimes includes specific notes like maximum supply limits or prior authorization requirements.

The related federal contract opportunity (Solicitation Number 36C26325Q0772) is for Pharmacy Benefit Management First Fill Services at the Central Iowa VA Health Care System. The solicitation requires vendors to submit documentation including a signed SF 1449, completed price schedule, DEA and state pharmacy licenses, proof of pharmacist credentials, and drug discount guarantees. The contract is a single award Indefinite Delivery/Indefinite Quantity (IDIQ) contract managed by the Department of Veterans Affairs Veterans Health Administration, with specific requirements for pharmacy network management, oversight plan, and quality control program.

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36C26325Q0772_1.docx DOCX document
36C26325Q0772.pdf PDF
D.1 WD 15-4979.pdf PDF

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Formulary

2306 Central Iowa VAHCS - Formulary List
GPIDRUG NAMEMESSAGE/NOTESADDED
65991002050315ACETAMINOPHEN W/ CODEINE TAB 300-30MG
659910020520**ACETAMINOPHEN W/ CODEINE SOLN
124050100001**ACYCLOVIR CAP
124050100003**ACYCLOVIR TAB
442010101034**ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)NO PROVENTIL/30 DAY SUPPLY
44201010102515ALBUTEROL SULFATE NEBU SOLN 0.083%
442099020120**IPRATROPIUM-ALBUTEROL NEBU SOLN
571000100003**ALPRAZOLAM TAB (ALL STRENGTHS)
732000101003**AMANTADINE HCL TAB
732000101001**AMANTADINE HCL CAP
354000050003**AMIODARONE HCL TAB (ALL STRENGTHS)
582000101003**AMITRIPTYLINE HCL TAB (ALL STRENGTHS)
340000031003**AMLODIPINE BESYLATE TAB (ALL STRENGTHS)
012000101001**AMOXICILLIN CAPS
012000101003**AMOXICILLIN TABS
019900022003**AMOXICILLIN & K CLAVULANATE TAB (ALL STRENGTHS)
592500150003**ARIPIPRAZOLE TAB (ALL STRENGTHS)
332000200003**ATENOLOL TAB (ALL STRENGTHS)
034000100003**AZITHROMYCIN TAB (ALL STRENGTHS)
751000100003**BACLOFEN TAB (ALL STRENGTHS)
431020100001**BENZONATATE CAP (ALL STRENGTHS)
731000101003**BENZTROPINE MESYLATE TAB (ALL STRENGTHS)
46200010000610BISACODYL EC TAB 5MG
46200010005205BISACODYL SUPPOSITORY 10MG
372000100003**BUMETANIDE TAB (ALL STRENGTHS)
583000401074**BUPROPION HCL TAB (ALL STRENGTHS) (ALL FORMULATIONS)
572000051003**BUSPIRONE HCL TAB (ALL STRENGTHS)
361000100003**CAPTOPRIL TAB (ALL STRENGTHS)
726000200003**CARBAMAZEPINE TAB (ALL STRENGTHS) (ALL FORMULATIONS)
726000200005**CARBAMAZEPINE CHEW TAB
72600020001810CARBAMAZEPINE SUSPENSION
333000070003**CARVEDILOL TAB (ALL STRENGTHS)
023000400001**CEFDINIR CAP
022000650503**CEFUROXIME TAB (ALL STRENGTHS)
021000200001**CEPHALEXIN CAP (ALL STRENGTHS)
376000250003**CHLORTHALIDONE TAB (ALL STRENGTHS)
050000201003**CIPROFLOXACIN HCL TAB (ALL STRENGTHS)
86101023102010CIPROFLOXACIN HCL OPHTH SOLN 0.3%
87991002361820CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1%
581600201003**CITALOPRAM HYDROBROMIDE TAB (ALL STRENGTHS)
035000100003**CLARITHROMYCIN TAB (ALL STRENGTHS)
162200201001**CLINDAMYCIN HCL CAP (ALL STRENGTHS)
55100018103720CLINDAMYCIN PHOSPHATE VAGINA CREAM
582000251001**CLOMIPRAMINE HCL CAP (ALL STRENGTHS)
721000100003**CLONAZEPAM TAB (ALL STRENGTHS)
362010101003**CLONIDINE HCL TAB (ALL STRENGTHS)
85158020100320CLOPIDOGREL BISULFATE TAB 75MG
90154020003705CLOTRIMAZOLE CREAM 1%
88100020004805CLOTRIMAZOLE TROCHE 10 MG
551040200037**CLOTRIMAZOLE VAGINAL CREAM
68000020000310COLCHICINE TAB 0.6 MGMAX 9 TABLETS
751000501003**CYCLOBENZAPRINE HCL TAB (ALL STRENGTHS)
582000301003**DESIPRAMINE HCL TAB (ALL STRENGTHS)
221000200003**DEXAMETHASONE TAB (ALL STRENGTHS)
571000400003**DIAZEPAM TAB (ALL STRENGTHS)
013000201001**DICLOXACILLIN SODIUM CAP (ALL STRENGTHS)
491030101001**DICYCLOMINE HCL CAP
491030101003**DICYCLOMINE HCL TAB
312000100003**DIGOXIN TAB (ALL STRENGTHS)
340000101003**DILTIAZEM TAB (ALL STRENGTHS)
340000101070**DILTIAZEM SR CAP 24HR (ALL STRENGTHS)
412000301001**DIPHENHYDRAMINE HCL CAP (ALL STRENGTHS)
725000101075**DIVALPROEX SODIUM TAB SR 24 H
12103015100320DOLUTEGRAVIR SODIUM TAB 50 MG (TIVICAY)PA REQUIRED
582000401001**DOXEPIN HCL CAP (ALL STRENGTHS)
040000201001**DOXYCYCLINE HYCLATE CAP
040000201003**DOXYCYCLINE HYCLATE TAB
581800251067**DULOXETINE CAP (ALL STRENGTHS)
12109902300320EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MGPA REQUIRED
12109904300320ELVITEGRAV-COBICIS-EMTRICITAB-TENOFOV TAB 150-150-200-300 MG (STRIBILD)MAX 4 TABLETS
361000201003**ENALAPRIL MALEATE TAB (ALL STRENGTHS)
831010201020**ENOXAPARIN SODIUM INJ (ALL STRENGTHS)MAX 5 DAYS
3890004000D540EPIPEN 2-PAK INJ 0.3MG
86101025004210ERYTHROMYCIN OPHTH OINT 0.5%
03100005000305ERYTHROMYCIN BASE TAB 250MG
581600341003**ESCITALOPRAM TAB (ALL STRENGTHS)
114070150003**FLUCONAZOLE TAB (ALL STRENGTHS)
581600400001**FLUOXETINE HCL CAP (ALL STRENGTHS)
592000251003**FLUPHENAZINE HCL TAB (ALL STRENGTHS)
372000300003**FUROSEMIDE TAB (ALL STRENGTHS)
726000300003**GABAPENTIN TAB
726000300001**GABAPENTIN CAP
86101030004205GENTAMICIN SULFATE OPHTH OINT 0.3%
86101030002005GENTAMICIN SULFATE OPHTH SOLN 0.3%
272000300003**GLIPIZIDE TAB (ALL STRENGTHS)
43997002282020GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML
591000101003**HALOPERIDOL TAB (ALL STRENGTHS)
369918025503**LISINOPRIL & HYDROCHLOROTHIAZIDE TAB
364000101003**HYDRALAZINE HCL TAB (ALL STRENGTHS)
376000400003**HYDROCHLOROTHIAZIDE TAB
376000400001**HYDROCHLOROTHIAZIDE CAP
659917021003**HYDROCODONE-ACETAMINOPHEN TAB (ALL STRENGTHS)
9055007500****HYDROCORTISONE TOPICAL (ALL STRENGTHS) (ALL FORMULATIONS)
651000351003**HYDROMORPHONE HCL TAB (ALL STRENGTHS)
572000401003**HYDROXYZINE HCL TAB (ALL STRENGTHS)
572000402001**HYDROXYZINE PAMOATE CAP (ALL STRENGTHS)
661000200003**IBUPROFEN TAB (PRESCRIPTION STRENGTHS ONLY)
582000501003**IMIPRAMINE HCL TAB (ALL STRENGTHS)
27104002002020INSULIN ASPART INJ 100 UNIT/ML (NOVOLOG)30 DAY SUPPLY
27104006002020INSULIN DETEMIR INJ 100 UNIT/ML (LEVEMIR)30 DAY SUPPLY
27104003002020INSULIN GLARGINE INJ 100 UNIT/ML (LANTUS)30 DAY SUPPLY
27104020001805INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML (HUMULIN/NOVOLIN N)30 DAY SUPPLY
27104010002005INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML (HUMULIN R)30 DAY SUPPLY
97051030906380INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2"
97051030906310INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X 1/2"
321000200003**ISOSORBIDE DINITRATE TAB
321000250075**ISOSORBIDE MONONITRATE SA TAB (ALL STRENGTHS)
86805035102020KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%
46600020002010LACTULOSE SOLUTION 10 GM/15ML
726000400003**LAMOTRIGINE TAB (ALL STRENGTHS)
217550401003**LEUCOVORIN TAB (ALL STRENGTHS)
726000430003**LEVETIRACETAM TAB (ALL STRENGTHS)
050000340003**LEVOFLOXACIN TAB (ALL STRENGTHS)
254000400003**LEVONORGESTREL TAB
281000101003**LEVOTHYROXINE SODIUM TAB (ALL STRENGTHS)
88350065102050LIDOCAINE HCL VISCOUS SOLN 2%
361000300003**LISINOPRIL TAB (ALL STRENGTHS)
5950001010****LITHIUM CARBONATE TAB/CAP (ALL STRENGTHS) (ALL FORMULATIONS)
47100020100105LOPERAMIDE HCL CAP 2 MG
571000600003**LORAZEPAM TAB (ALL STRENGTHS)
361500402003**LOSARTAN TAB (ALL STRENGTHS)
50200050000510MECLIZINE HCL CHEW TAB 25 MG
260000202003**MEDROXYPROGESTERONE ACETATE TAB (ALL STRENGTHS)
661000520003**MELOXICAM TAB (ALL STRENGTHS)
272500500003**METFORMIN HCL TAB (ALL STRENGTHS)
272500500075**METFORMIN HCL SR TAB 24HR (ALL STRENGTHS)
751000700003**METHOCARBAMOL TAB (ALL STRENGTHS)
2210003000B705METHYLPREDNISOLONE THERAPY PACK
221000300003**METHYLPREDNISOLONE TAB (ALL STRENGTHS)
523000201003**METOCLOPRAMIDE HCL TAB (ALL STRENGTHS)
376000600003**METOLAZONE TAB (ALL STRENGTHS)
332000301003**METOPROLOL TARTRATE TAB (ALL STRENGTHS)
332000300575**METOPROLOL SUCCINATE SR TAB (ALL STRENGTHS)
160000350003**METRONIDAZOLE TAB (ALL STRENGTHS)
55100035004020METRONIDAZOLE VAGINAL GEL 0.75%
580300500003**MIRTAZAPINE TAB (ALL STRENGTHS)
651000551003**MORPHINE SULFATE TAB (ALL STRENGTHS)
651000551020**MORPHINE SULFATE ORAL SOLN (ALL STRENGTHS)
05000037100320MOXIFLOXACIN HCL TAB 400 MG
661000600003**NAPROXEN TAB (PRESCRIPTION STRENGTHS ONLY)
8799100310****NEOMYCIN-POLYMYXIN-HC OTIC SUSP/SOLN
8630990332****NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP/OINT
53000050150120NITROFURANTOIN MONO/MACRO SA CAP 100MG (MACROBID)
321000300007**NITROGLYCERIN SL TAB (ALL STRENGTHS)
582000601001**NORTRIPTYLINE HCL CAP (ALL STRENGTHS)
90150080003710NYSTATIN CREAM 100000 UNIT/GM
90150080004215NYSTATIN OINT 100000 UNIT/GM
88100010001805NYSTATIN SUSP 100000 UNIT/mL
86101047002020OFLOXACIN OPHTH SOLN 0.3%
591570600003**OLANZAPINE TAB (ALL STRENGTHS)
502500650503**ONDANSETRON HCL TAB (ALL STRENGTHS)MAX 10 TABLETS
125040602001**OSELTAMIVIR PHOSPHATE CAP (ALL STRENGTHS)
726000460003**OXCARBAZEPINE TAB (ALL STRENGTHS)
651000751003**OXYCODONE HCL TAB (ALL STRENGTHS)
65990002200310OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG
581600600003**PAROXETINE HCL TAB (ALL STRENGTHS)
011000401003**PENICILLIN V POTASSIUM TAB (ALL STRENGTHS)
90900035003720PERMETHRIN CREAM 5%
592000450003**PERPHENAZINE TAB (ALL STRENGTHS)
563000101003**PHENAZOPYRIDINE HCL TAB (ALL STRENGTHS)
601000600003**PHENOBARBITAL TAB (ALL STRENGTHS)
72200030000505PHENYTOIN CHEW TAB 50 MG
722000302001**PHENYTOIN SODIUM SA CAP (ALL STRENGTHS)
72200030001810PHENYTOIN SUSP 125 MG/5mL
772040300003**PHYTONADIONE TAB (ALL STRENGTHS)
79700030000430POTASSIUM CHLORIDE SA TAB 10 MEQ
79700030000445POTASSIUM CHLORIDE SA TAB 20MEQ
362020301001**PRAZOSIN HCL CAP (ALL STRENGTHS)
221000450003**PREDNISONE TAB (ALL STRENGTHS)
863000501018**PREDNISOLONE ACETATE OPHTH SUSP (ALL STRENGTHS)
592000551003**PROCHLORPERAZINE MALEATE TAB (ALL STRENGTHS)
414000201003**PROMETHAZINE HCL TAB (ALL STRENGTHS)
414000201052**PROMETHAZINE HCL SUPPOS (ALL STRENGTHS)
41400020101210PROMETHAZINE HCL SYRUP 6.25 MG
331000401003**PROPRANOLOL HCL TAB (ALL STRENGTHS)
331000401070**PROPRANOLOL HCL SA CAP (ALL STRENGTHS)
28300020000310PROPYLTHIOURACIL TAB 50 MG
591530701003**QUETIAPINE FUMARATE TAB (ALL STRENGTHS)
351000303003**QUINIDINE SULFATE TAB (ALL STRENGTHS)
35100030100403QUINIDINE GLUCONATE TAB CR 324 MG
12103060100320RALTEGRAVIR POTASSIUM TAB 400 MG (BASE EQUIV) (INTRESS)PA REQUIRED
090000800001**RIFAMPIN CAP (ALL STRENGTHS)
590700700003**RISPERIDONE TAB (ALL STRENGTHS)
641000750003**SALSALATE TAB (ALL STRENGTHS)
581600701003**SERTRALINE HCL TAB (ALL STRENGTHS)
90450030003710SILVER SULFADIAZINE CREAM 1%
86102010102010SULFACETAMIDE SODIUM OPHTH SOLN 10%
169900023003**SULFAMETHOXAZOLE-TRIMETHOPRIM TABS (ALL STRENGTHS)
99450010001840SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60mL
331000451003**SOTALOL HCL TAB (ALL STRENGTHS)
375000200003**SPIRONOLACTONE TAB (ALL STRENGTHS)
661000800003**SULINDAC TAB (ALL STRENGTHS)
674060701003**SUMATRIPTAN SUCCINATE TAB (ALL STRENGTHS)
67406070102010SUMATRIPTAN SUCCINATE INJ 6 MG/0.5mL
56852070100110TAMSULOSIN HCL CAP 0.4 MG
602010300001**TEMAZEPAM CAP (ALL STRENGTHS)
593000201001**THIOTHIXENE CAP (ALL STRENGTHS)
86101070002005TOBRAMYCIN OPHTH SOLN 0.3%
8630990280****TOBRAMYCIN/DEXAMETHASONE OPHTH SUSP/OINT
726000750003**TOPIRAMATE TAB (ALL STRENGTHS)
65100095100320TRAMADOL HCL TAB 50MG
581200801003**TRAZODONE HCL TAB (ALL STRENGTHS)
905500851042**TRIAMCINOLONE ACETONIDE OINT
905500851037**TRIAMCINOLONE ACETONIDE CREAM
3799000230****TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB/CAP (ALL STRENGTHS)
731000701003**TRIHEXYPHENIDYL HCL TAB (ALL STRENGTHS)
124050851003**VALACYCLOVIR HCL TAB (ALL STRENGTHS)
72500030000105VALPROIC ACID CAP 250 MG
162800801001**VANCOMYCIN CAP (ALL STRENGTHS)
5818009010****VENLAFAXINE TAB/CAP (ALL STRENGTHS AND FORMULATIONS)
340000301003**VERAPAMIL HCL TAB (ALL STRENGTHS)
340000301004**VERAPAMIL HCL SA TABS (ALL STRENGTHS)
83200030200303WARFARIN SODIUM TAB 1 MG
83200030200305WARFARIN SODIUM TAB 2 MG
83200030200315WARFARIN SODIUM TAB 5 MG
594000851001**ZIPRASIDONE HCL CAP (ALL STRENGTHS)
602040801003**ZOLPIDEM TARTRATE TAB (ALL STRENGTHS)

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