Pharmacy Medication Formulary List.xls

XLS spreadsheet 87 KB Posted Sep 16, 2021

Attached to: Q517--Pharmacy Benefit Management services Federal contract opportunity
Solicitation number: 36C24621Q0974
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 6

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File	Type	Posted
Business Associate Agreement (BAA).docx	DOCX document	Sep 16, 2021
QASP.doc	DOC document	Sep 16, 2021
wage determination (hampton).pdf	PDF	Sep 16, 2021
36C24621Q0974_2.docx	DOCX document	Sep 16, 2021

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Sheet 1

Community Pharmacy Medication List
Generic	Dosage Form	Strength	Route	Max supply	NDC #
ALLERGY/ASTHMA/PRURITUS
Albuterol HFA	MDI	90mcg/actuation	INH	1 canister	00085-1132-01
Cetirizine	Tablet	10mg	PO	10 days
Diphenhydramine HCL	Capsule	25 mg	PO	10 days	00182-0492-10
Diphenhydramine HCL	Capsule	50 mg	PO	10 days	00904-5307-80
Flunisolide Nasal Spray	Nasal INH	25 mcg/spray	Nasal	1 container	24208-0344-25
Hydroxyzine HCL	Tablet	10 mg	PO	10 days	50111-0307-02
Hydroxyzine Pamoate	Tablet	25 mg	PO	10 days	00185-0613-05
Loratadine	Tablet	10 mg	PO	10 days	00904-5728-89
Methylprednisolone packet of # 21	Tablet	4 mg	PO	1 pack # 21	00781-5022-07
Psudoephedrine/Triprolidine - Aprodine	Tablet	60mg/2.5mg	PO	10 days	00904-0250-59
ANTI--BIOTICS/VIRALS/FUNGALS
Acyclovir	Capsule	200 mg	PO	10 days	00093-8940-05
Amoxicillin	Capsule	500 mg	PO	10 days	00029-6007-32
Amoxicillin/Clavulanate	Tablet	875mg/125mg	PO	10 days	66685-1001-00
Amoxicillin/clavulanate	Tablet	500mg/125mg	PO	10 days
Azithromycin	Tablet	250 mg	PO	10 days	00781-1496-31
Azithromycin	Tablet	600 mg	PO	10 days	00781-1497-31
Cefdinir	Capsule	300mg	PO	10 days
Cefuroxime	Tablet	250mg	PO	10 days
Cephalexin	Capsule	250 mg	PO	10 days	00093-3145-05
Ciprofloxacin	Tablet	250 mg	PO	10 days	00172-5311-60
Ciprofloxacin	Tablet	500 mg	PO	10 days	00172-5312-60
Ciprofloxacin	Tablet	750 mg	PO	10 days	00172-5313-60
Ciprofloxacin/dexamethasone	Solution	0.3%/0.1% opht soln	TOP	7.5mL
Clarithromycin	Tablet	500 mg	PO	H. Pylori	68774-0122-60
Dicloxacillin	Capsule	250 mg	PO	10 days	00093-3123-01
Doxycycline Hyclate	Capsule	50 mg	PO	10 days	00172-2984-48
Doxycycline Hyclate	Tablet	20 mg	PO	10 days	64682-0008-02
Doxycycline Na	Capsule	100 mg	PO	10 days	00172-2985-70
Erythromycin Base	Tablet	250 mg	PO	10 days	00074-6326-13
Fluconazole	Tablet	50 mg	PO	10 days	51672-4064-06
Fluconazole	Tablet	200 mg	PO	10 days	51672-4067-06
Hydroxychloroquine	Tablet	200mg	PO	10 days
Linezolid	Tablet	600mg	PO	10 days
Metronidazole	Tablet	250 mg	PO	10 days	00093-0851-05
Moxifloxacin HCL	Tablet	400 mg	PO	10 days	00085-1733-01
Nitrofurantoin monohydrate/macrocrystalline	Capsule	100mg	PO	10 days
Ofloxacin	Solution	0.3% opht soln	TOP	10 days
Oseltamivir	Capsule	30mg	PO	10 days
Oseltamivir	Capsule	75mg	PO	10 days
Polytrim (Polymyxin & Trimethoprim)	Solution	0.1% opht soln	TOP	10 days
Sulfamethoxazole/Trimethoprim	Tablet	800/160	PO	10 days	00904-2725-40
Tobramycin	Solution	0.3% opht soln	TOP	10 days
Tobramycin/Dexamethasone	Solution	0.3% opht soln	TOP	10 days
Trifluridine	Solution	1% opht soln	TOP	10 days
Valacyclovir	Tablet	500mg	PO	10 days
Vancomycin	Capsule	125mg	PO	10 days
ANTIHYPERTENSIVES/CARDIO
Amlodipine Besylate	Tablet	2.5 mg	PO	10 days	00069-1520-68
Amlodipine Besylate	Tablet	5 mg	PO	10 days	00378-5209-05
Amlodipine Besylate	Tablet	10 mg	PO	10 days	00378-5210-05
Aspirin	Tablet	81mg	PO	10 days
Atenolol	Tablet	25 mg	PO	10 days	53489-0536-01
Atenolol	Tablet	50 mg	PO	10 days	00781-1506-01
Atenolol	Tablet	100 mg	PO	10 days	00781-1078-01
Bumetanide	Tablet	0.5mg	PO	10 days
Bisoprolol	Tablet	5mg	PO	10 days
Carvedilol	Tablet	3.125mg	PO	10 days
Clopidogrel	Tablet	75mg	PO	10 days
Clonidine HCL	Tablet	0.1 mg	PO	10 days	54738-0907-03
Digoxin (Lanoxin)	Tablet	0.125 mg	PO	10 days	00173-0242-75
Digoxin (Lanoxin)	Tablet	0.25 mg	PO	10 days	00173-0249-75
Diltiazem HCL	Tablet	30 mg	PO	10 days	00093-0318-01
Diltiazem HCL	Tablet	60 mg	PO	10 days	00093-0319-01
Diltiazem SA	Capsule	120 mg	PO	10 days	00258-3687-90
Diltiazem SA	Capsule	180 mg	PO	10 days	00258-3688-90
Diltiazem SA	Capsule	240 mg	PO	10 days	00258-3689-90
Furosemide	Tablet	20 mg	PO	10 days	00039-0067-70
Furosemide	Tablet	40 mg	PO	10 days	51079-0073-20
Furosemide	Tablet	80 mg	PO	10 days	00054-4301-29
Hydralazine	Tablet	10mg	PO	10 days
Hydralazine	Tablet	25mg	PO	10 days
Hydrochlorothiazide	Tablet	25 mg	PO	10 days	00603-3856-21
Isosorbide Dinitrate	Tablet	5 mg	PO	10 days	00143-1769-01
Isosorbide Dinitrate	Tablet	10 mg	PO	10 days	00143-1771-10
Isosorbide Dinitrate	Tablet	20 mg	PO	10 days	00603-4118-32
Isosorbide Mononitrate	Tablet	20 mg	PO	10 days	62175-0107-01
Isosorbide Mononitrate	Tablet	30 mg	PO	10 days	62175-0128-37
Isosorbide Mononitrate	Tablet	60 mg	PO	10 days	62175-0119-37
Labetalol	Tablet	100mg	PO	10 days
Lisinopril	Tablet	5 mg	PO	10 days	00143-1266-10
Lisinopril	Tablet	10 mg	PO	10 days	00143-1267-10
Lisinopril	Tablet	20 mg	PO	10 days	00143-1268-10
Lisinopril	Tablet	40 mg	PO	10 days	00143-1270-10
Losartan	Tablet	25mg	PO	10 days
Metolazone	Tablet	2.5 mg	PO	10 days	65580-0643-71
Metolazone	Tablet	5 mg	PO	10 days	65580-0644-71
Metolazone	Tablet	10 mg	PO	10 days	65580-0645-71
Metoprolol Tartrate	Tablet	25 mg	PO	10 days	57664-0506-18
Metoprolol Tartrate	Tablet	50 mg	PO	10 days	57664-0477-18
Nitroglycerin	SL Tablet	0.4 mg	PO	1 bottle	58177-0324-04
Propranolol	Tablet	10mg	PO	10 days
Sotalol	Tablet	80mg	PO	10 days
Sotalol	Tablet	120mg	PO	10 days
Spironolactone	Tablet	25mg	PO	10 days
Terazosin HCL	Capsule	1 mg	PO	10 days	59746-0383-09
Terazosin HCL	Capsule	2 mg	PO	10 days	59746-0384-09
Terazosin HCL	Capsule	5 mg	PO	10 days	59746-0385-09
Terazosin HCL	Capsule	10 mg	PO	10 days	59746-0386-06
Torsemide	Tablet	5mg	PO	10 days
Warfarin (Coumadin)	Tablet	2 mg	PO	10 days	00056-0170-90
Warfarin (Coumadin)	Tablet	5 mg	PO	10 days	00056-0172-90
COUGH SUPPRESS/EXPECTO
Dextromethorphan/Guaifenesin	Syrup	10/100 per 5 ml	PO	120 ml	0012106-38-10
Guaifenesin	Tablet	200 mg	PO	10 days	00904-5154-60
Guaifenesin with Codeine	Syrup	100/10 per 5 ml	PO	120 ml	00121-1775-05
DIARRHEA/CONSTIPATION
Bisacodyl 10 mg RCT Supp	Supp	10 mg	PR	10 days	00245-0104-05
Bisacodyl EC	Tablet	5 mg	PO	10 days	00904-7927-80
Diphenoxylate/Atropine	Tablet	2.5mg/0.025mg	PO	10 days	00172-3966-80
Docusate NA	Capsule	100 mg	PO	10 days	54629-0600-01
Golytely Pwdr, renst-oral	Powder	PEG 3350	PO	4 gallon	52268-0100-01
Loperamide HCL	Capsule	2 mg	PO	10 days	00093-0311-05
Magnesium Citrate	Liquid	1.75gm/30ml	PO	10 oz bottle	00869-2635-08
CREAMS/GELS/OINTMENTS
Clotrimazole 1%	Cream	1%	TOP	30 gm	45802-0434-11
Metronidazole 0.75% VAG GEL	Gel	VAG 0.75%	TOP	70 gm	00245-0860-70
Metronidazole 1 %	Gel	1%	TOP	60 gm	00299-3820-60
Permethrin 5%	Cream	5%	TOP	60 gm	00472-0242-60
Triamcinolone Acetonide 0.025%	Cream	0.025% Cream	TOP	15 gm	45802-0063-35
Triamcinolone Acetonide 0.025%	Ointment	0.025% Oint	TOP	15 gm	00168-0003-80
Triamcinolone Acetonide 0.1%	Cream	0.1% Cream	TOP	15 gm	00472-0301-15
Triamcinolone Acetonide 0.1%	Ointment	0.1% Oint	TOP	15 gm	45802-0055-36
Triamcinolone Acetonide 0.5%	Cream	0.5% Cream	TOP	15 gm	45802-0065-35
Triamcinolone Acetonide 0.5%	Ointment	0.5% Oint	TOP	15 gm	45802-0049-35
Hydrocortisone 2.5/Pramoxine 1% RTL Cream		2.5%/1% Cream	RTL	30 gm	00496-0778-04
PAIN / HA
Acetaminophen	Tablet	325 mg	PO	10 days	10135-0123-10
Acetaminophen-Hydrocodone	Tablet	500mg-5mg	PO	10 days	00406-0357-01
Butalbital/ASA/Caff	Capsule	325/50/40mg	PO	10 days	00591-3219-01
Eletriptan	Tablet	20mg	PO	6 doses
Etodolac	Tablet	200 mg	PO	10 days	49158-0505-10
Etodolac	Tablet	400 mg	PO	10 days	49158-0507-10
Ibuprofen	Tablet	400 mg	PO	10 days	53746-0131-05
Ibuprofen	Tablet	800 mg	PO	10 days	53746-0137-90
Indomethacin	Capsule	25 mg	PO	10 days	00172-4029-60
Naproxen	Tablet	250 mg	PO	10 days	53746-0188-10
Naproxen	Tablet	375 mg	PO	10 days	53746-0189-10
Piroxicam	Capsule	10 mg	PO	10 days	00093-0756-01
Piroxicam	Capsule	20 mg	PO	10 days	00093-0757-05
Rizatriptan	Tablet	5mg	PO	6 doses
Sumatriptan	Tablet	25mg	PO	6 doses
Tramadol HCL	Tablet	50 mg	PO	10 days	57664-0377-18
Zolmitriptan 2.5 mg package	Tablet	2.5 mg	PO	1 pack	00310-0210-20
GOUTY ATTACKS
Colchicine	Tablet	0.6mg	PO	10 days	00143-1201-10
MUSCLE RELAXANTS
Cyclobenzaprine HCL	Tablet	10 mg	PO	10 days	50111-0563-03
NAUSEA/VOMITING
Meclizine HCL	Tablet	12.5mg	PO	10 days	49884-0034-10
Promethazine HCL	Tablet	25 mg	PO	10 days	00603-5438-21
Prochlorperazine Maleate	Tablet	5 mg	PO	10 days	51991-0196-01
Prochlorperazine Maleate	Tablet	10 mg	PO	10 days	51991-0197-01
PSYCHIATRY
Alprazolam	Tablet	0.25mg	PO	10 days
Amitriptyline	Tablet	10mg	PO	10 days
Aripiprazole	Tablet	5 mg	PO	10 days	59148-0007-13
Aripiprazole	Tablet	10 mg	PO	10 days	59148-0008-13
Aripiprazole	Tablet	15 mg	PO	10 days	59148-0009-13
Aripiprazole	Tablet	20 mg	PO	10 days	59148-0010-13
Bupropion HCL	Tablet	75 mg	PO	10 days	60429-0746-01
Bupropion HCL	Tablet	100 mg	PO	10 days	60429-0747-01
Buproprion 12HR SA	Tablet	100 mg	PO	10 days	00591-0858-60
Buproprion 12HR SA	Tablet	150 mg	PO	10 days	00591-0839-60
Citalopram Hydrobromide	Capsule	10 mg	PO	10 days	57664-0507-88
Citalopram Hydrobromide	Tablet	20 mg	PO	10 days	57664-0508-88
Citalopram Hydrobromide	Tablet	40 mg	PO	10 days	00172-4742-70
Duloxetine	Capsule	20mg	PO	10 days
Escitalopram	Tablet	5mg	PO	10 days
Fluoxetine HCL	Capsule	10 mg	PO	10 days	00406-0661-05
Fluoxetine HCL	Capsule	20 mg	PO	10 days	00406-0663-05
Mirtazapine	Tablet	7.5 mg	PO	10 days	57664-0510-83
Mirtazapine	Tablet	15 mg	PO	10 days	57664-0499-18
Mirtazapine	Tablet	30 mg	PO	10 days	57664-0500-18
Mirtazapine	Tablet	45 mg	PO	10 days	57664-0501-83
Nortriptyline	Capsule	10mg	PO	10 days
Nortriptyline	Capsule	25mg	PO	10 days
Olanzapine	Tablet	2.5 mg	PO	10 days	00002-4112-30
Olanzapine	Tablet	5 mg	PO	10 days	00002-4115-30
Olanzapine	Tablet	7.5 mg	PO	10 days	00002-4116-30
Olanzapine	Tablet	10 mg	PO	10 days	00002-4117-30
Olanzapine	Tablet	15 mg	PO	10 days	00002-4415-30
Olanzapine	Tablet	20 mg	PO	10 days	00002-4420-30
Paroxetine	Tablet	20 mg	PO	10 days
Paroxetine	Tablet	40 mg	PO	10 days
Quetiapine fumarate	Tablet	25 mg	PO	10 days	00310-0275-34
Quetiapine fumarate	Tablet	50 mg	PO	10 days	00310-0278-34
Quetiapine fumarate	Tablet	100 mg	PO	10 days	00310-0271-10
Quetiapine fumarate	Tablet	200 mg	PO	10 days	00310-0272-10
Quetiapine fumarate	Tablet	300 mg	PO	10 days	00310-0274-60
Quetiapine fumarate	Tablet	400 mg	PO	10 days	00310-0279-10
Risperidone	Tablet	0.25mg	PO	10 days
Risperidone	Tablet	0.5 mg	PO	10 days	50458-0302-01
Risperidone	Tablet	1 mg	PO	10 days	50458-0300-50
Risperidone	Tablet	2 mg	PO	10 days	50458-0320-50
Risperidone	Tablet	3 mg	PO	10 days	50458-0330-50
Risperidone	Tablet	4 mg	PO	10 days	50458-0350-06
Sertraline	Tablet	25 mg	PO	10 days
Sertraline	Tablet	50 mg	PO	10 days
Sertraline	Tablet	100 mg	PO	10 days
Trazodone HCL	Tablet	50 mg	PO	10 days	50111-0433-03
Trazodone HCL	Tablet	100 mg	PO	10 days	50111-0434-03
Venlafaxine	Tablet	25 mg	PO	10 days
Venlafaxine	Tablet	37.5 mg	PO	10 days
Venlafaxine	Tablet	75 mg	PO	10 days
Ziprasidone HCL	Capsule	20 mg	PO	10 days	00049-3960-60
Ziprasidone HCL	Capsule	40 mg	PO	10 days	00049-3970-60
Ziprasidone HCL	Capsule	60 mg	PO	10 days	00049-3980-60
Ziprasidone HCL	Capsule	80 mg	PO	10 days	00049-3990-60
EPILEPSY/MOOD/ANXIETY
Carbamazepine	Tablet	200 mg	PO	10 days	49158-0504-01
Carbamazepine (Tegretol-XR)	Tablet	100 mg	PO	10 days	00083-0061-30
Carbamazepine (Tegretol-XR)	Tablet	200 mg	PO	10 days	00083-0062-30
Carbamazepine (Tegretol-XR)	Tablet	400 mg	PO	10 days	00083-0060-30
Clonazepam	Tablet	0.5 mg	PO	10 days
Clonazepam	Tablet	1 mg	PO	10 days
Diazepam	Tablet	2 mg	PO	10 days
Diazepam	Tablet	5 mg	PO	10 days
Diazepam	Tablet	10 mg	PO	10 days
Divalproex EC (Delayed release)	Tablet	250 mg	PO	10 days	00074-6214-53
Divalproex EC (Delayed release)	Tablet	500 mg	PO	10 days	00074-6215-53
Divalproex 24HR (ER) SA	Tablet	250 mg	PO	10 days	00074-3826-13
Divalproex 24HR (ER) SA	Tablet	500 mg	PO	10 days	00074-7126-53
Gabapentin	Capsule	100 mg	PO	10 days	00228-2665-11
Gabapentin	Capsule	300 mg	PO	10 days	00228-2666-50
Levetiracetam	Tablet	250mg	PO	10 days
Lithium	Tablet	300 mg	PO	10 days
Lorazepam	Tablet	1 mg	PO	10 days	00378-2457-01
Lorazepam	Tablet	2 mg	PO	10 days	00378-2777-01
Oxcarbazepine	Tablet	150mg	PO	10 days
Topiramate	Tablet	25mg	PO	10 days
Phenytoin SA	Capsule	30 mg	PO	10 days	00071-0365-24
Phenytoin SA	Capsule	100 mg	PO	10 days	00071-0362-32
Valproic Acid	Capsule	250 mg	PO	10 days	50111-0852-01
OTHER
Insulin 70/30	vial	70 U/ml-30 U/ml		1 vial
Insulin ASPART	vial	100 U/ml		1 vial
Insulin NPH	vial	100 U/ml		1 vial
Insulin R	vial	100 U/ml		1 vial
Lansoprazole	Capsule	30 mg	PO	H. Pylori	00300-3046-11
Levothyroxine	Tablet	all strengths	PO	10 days
Phytonadione	Tablet	5 mg	PO	10 days	00006-0043-68
Prednisolone Acetate	Solution	1% opht soln	TOP	10 days
Sodium Polystyrene Sulf	Susp	15GM/60ML	PO	10 days	46287-0006-60
Carbamide Peroxide 6.5% OTIC Soln	Solution	6.50%	OTIC	1 bottle	0904-3220-35
Chlorhexadine	Solution	0.12% oral soln	TOP	473mL

Sheet 2

Generic	Dosage Form
Diphenhydramine	Capsule
Albuterol	MDI
Flunisolide	Nasal INH
Hydroxyzine Pamoate	Tablet
Loratadine	Tablet
Psudoephedrine/Tiprolidine	Tablet
Acyclovir	Capsule
Amoxicillin	Capsule
Amoxicillin/Clavulanate	Capsule
Azithromycin	Tablet
Azithromycin - Z-Pack	Tablet
Cephalexin	Capsule
Ciprofloxacin	Tablet
Trimethoprim/Sulfamethoxazole	Tablet
Dicloxacillin	Capsule
Doxycycline	Capsule
Erythromycin	Tablet
Clarithromycin	Tablet	For H. Pylori cases
Lansoprazole	Capsule	For H. Pylori cases
Metronidazole	Tablet
Moxifloxacin	Tablet
Phenytoin	Capsule
Clonidine	Tablet
Diltiazem SA	Capsule
Diltiazem	Tablet
Furosemide	Tablet
Lisinopril	Tablet
Hydrochlorothiazide	Tablet
Atenolol	Tablet
Terazosin	Capsule
Metoprolol Tartrate	Tablet
Metolazone	Tablet
Amlodipine	Tablet
Isosorbide Dinitrate	Tablet
Dextromethorphan/Guaifenesin	Syrup
Guaifenesin	Tablet
Guaifenesin with Codeine	Syrup
Nitroglycerin	Tablet
Digoxin	Tablet
Warfarin	Tablet
Phytonadione	Tablet
Diphenoxylate/Atropine	Tablet
Loperamide	Capsule
Clotrimazole 1%	Cream
Triamcinolone 0.025, 0.5, 0.1%	Cream
Metronidazole 1 %	Cream
Permethrin 5%	Cream
Acetaminophen	Tablet
Acetaminophen-Hydrocodone	Tablet
Acetaminophen-Oxycodone	Tablet
Ibuprofen	Tablet
Etodolac	Tablet
Indomethacin	Capsule
Tramadol	Tablet
Naproxen	Tablet
Piroxicam	Tablet
Colchicine	Tablet
Cyclobenzaprine	Tablet
Meclizine	Tablet
Promethazine	Tablet
Prochlorperazone	Tablet
Fluoxetine	Capsule
Citalopram	Tablet
Mirtazapine	Tablet
Trazodone	Tablet
Bupropion	Tablet
Risperidone	Tablet
Quetiapine	Tablet
Aripiprazole	Tablet
Ziprasidone	Capsule
Olanzapine	Tablet
Divalproex SA	Tablet
Valproic Acid	Capsule
Carbamazepine	Tablet
Lorazepam	Tablet
Acetaminophen/Butalb/Caff	Tablet
Zolmitriptan	Tablet

File details come from the government source that posted it. Updated Sep 16, 2021.