P03 Attachment_13_Pharmacuetical-Baxalta(FEIBA)-2020-08-19 Signed MKS Signed.pdf

Customer Service Guide/Procurement Package

Attachment 13: Pharmaceutical requirements between Micro-Purchase and under the Simplified Acquisition Threshold

Purpose: Complete this checklist and submit it with your procurement request for pharmaceutical requirements between Micro-Purchase and under the Simplified Acquisition threshold.

ALL DOCUMENTS ARE TO BE SUBMITTED ELECTRONICALLY THROUGH FORCE

DATE: 8/19/2020

1. PROVIDE REQUESTOR'S NAME AND PHONE NUMBER

Name: Michael Shioji Phone Number: 562-826-8000 x13933

2. SUBMIT FUNDED 2237#: 600-21-1-119-0007

Is the 2237 corresponding to this request funded at this moment?

YES r NO P' (CHECK ONE)

In almost all cases, the project needs to be funded before moving forward. If it is unfunded, please speak to the Fiscal Department.

3. REQUIREMENTS

Name/Description of requested drug: FEIBA NF, Anti-inhibitor coagulant complex Quantity Required: 60,000 IU Special Packaging Requirements: 2° - 25°C Date Needed:1/1/2021

Is the requested drug available for purchase against the VA National contract for Pharmaceuticals?

YES P' NO r (CHECK ONE)

If assistance is needed to answer the question above, check the Pharmaceutical Catalog at:

https://www. vendorportal .ecms. va.gov/NAC/Pharma/List

For further guidance, speak with the local Medical Center Director of Pharmacy, VISN Pharmacy Executives, the NAC or the Pharmacy Benefits Management (PBM) Services. The NAC provides a Contract Catalog Search Tool (CCST) at: http://www1.va.gov/nac/

If the answer is yes to the question above, provide the vendor's name, contract number, and expiration date of contract in the section below; or check the box that the information was provided on VA Form 2237.

Vendor Name: Baxalta US, Inc Contract Number: V797P-2140D Expiration Date of Contract: 1/31/2021 r Information referenced above is submitted on the 2237.

If the answer to the question above was yes and the vendor and contract information was provided, skip the remaining questions on this form and forward the requirement to the Network Contractina Office.

Customer Reference Guide Detailed Customer Procedures Revision 03 Date: 05/29/2020