S02 - Attachment 25 - Local Pharmacy Limited Formulary of Emergent Items.xlsx

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Attached to
Bonner County, Idaho, Community Based Outpatient Clinic
Solicitation number
36C26019R0032
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S06 - 36C26019R0032 0005.pdf PDF
S06 - 36C26019R0032 0004.pdf PDF
S06 - 36C26019R0032 0003.pdf PDF
S06 - 36C26019R0032 0002.pdf PDF
S06 - 36C26019R0032 0001.pdf PDF
S02 - Attachment 5 - Number Memorandum 11-91-17 Medication Reconciliation.docx DOCX document
S02 - Attachment 7 - Numbered Memorandum 114-02-19 Reporting Imaging Exam Results.docx DOCX document
S02 - Attachment 18 - Sample Patient Handbook.pdf PDF
S02 - Attachment 9 - Ancillary Testing Policy and Provider-Performed Microscopy (PPM) Testing Policy.docx DOCX document
S02 - Attachment 10 - Numbered Memorandum 116-09-13 Suicide Risk Management Program.docx DOCX document
S02 - Attachment 21 - VA Outpatient Radiology Scheduling Policy and Guidance.pdf PDF
S02 - Attachment 37 - Past Performance.docx DOCX document
S02 - Attachment 11 - Home Telehealth Operations Manual.pdf PDF
S02 - Attachment 32 - Workload History_Projections.docx DOCX document
S02 - Attachment 4 - VHA Directive 1330.01(2), Health Care Services for Women Veterans.pdf PDF
S02 - Attachment 27 - Numbered Memorandum 11-68-18 Maternity Healthcare and Coordination.pdf PDF
S02 - Attachment 34 - DBA WD ID20200010 (Mod.-5) 11-20-20.pdf PDF
S02 - Attachment 36 - Past Performance Reference List.docx DOCX document
S02 - Attachment 16 - VHA Directive 2012-030 Credentialing of Health Care Professionals.pdf PDF
S02 - Attachment 12 - Numbered Memorandum 136-27-13 Medical Records.doc DOC document
S02 - Attachment 19 - Specimen Collection Containers.docx DOCX document
S02 - Attachment 2 - VHA Handbook 1660.3 Appendix A Conflict of Interest Acknowledgement Form.pdf PDF
S02 - 36C26019R0032.pdf PDF
S02 - Attachment 23 - VHA Directive 1088 Communicating Test Results to Providers and Patients.pdf PDF
S02 - Attachment 8 - Spokane Laboratory Users Guide 2013.docx DOCX document
S02 - Attachment 15 - FY21 EPRP Sampling Cohorts v1.0.docx DOCX document
S02 - Attachment 35 - Quality Assurance Surveillance Plan.docx DOCX document
S02 - Attachment 1 - VA Handbook 6500.6 Appendix D Contractor Rules of Behavior.pdf PDF
S02 - Attachment 28 - VHA Handbook 1101.11(3) Coordinated Care for Traveling Veterans.pdf PDF
S02 - Attachment 14 - VHA Directive 1608 Comprehensive Environment of Care (CEOC) Program.pdf PDF
S02 - Attachment 29 - MGVAMC SOP COS-2018-002 Mann-Grandstaff IVF-ART Consult Processing.pdf PDF
S02 - Attachment 6 - VHA Directive 1104 Radiology Picture Archiving and Communication Systems (PACS).pdf PDF
S02 - Attachment 20 - One Consult Model Imaging Training.pdf PDF
S02 - Attachment 26 - VAMC SOP COS-2018-001 Mann-Grandstaff Mammogram Screening and Breast Cancer Management.pdf PDF
S02 - Attachment 22 - Radiology and Nuclear Medicine Orders Management.pdf PDF
S02 - Attachment 31 - Soiled RME.pdf PDF
S02 - Attachment 33 - SCA WD 15-5511 (Rev.-11) 6-9-20.docx DOCX document
S02 - Attachment 38 - Numbered Memorandum 119-30-18 Anticoagulation Management Program.docx DOCX document
S02 - Attachment 3 - Contractor Certification - Immigration and Nationality Act of 1952 as amended.docx DOCX document
S02 - Attachment 13 - Numbered Memorandum 00-53-116 Patient Rights_Responsibilities.docx DOCX document
S02 - Attachment 30 - VHA Directive 1341 Providing Health Care for Transgender and Intersex Veterans.pdf PDF
S02 - Attachment 24 - VAMC Numbered Memorandum 113-03-14 Reporting Critical Tests and Critical Test Results.docx DOCX document
S02 - Attachment 17 - USCIS Form I-9 Employment Eligibility Verification.pdf PDF
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Drug Coverage

Heritage VISN 20 FORMULARY (All Accounts)
GPIMEDICATION NAMENOTES
012000101003**AMOXICILLIN (TRIHYDRATE) TAB
659910020520**ACETAMINOPHEN W/ CODEINE SOLN
659910020503**ACETAMINOPHEN W/ CODEINE TAB
371000100003**ACETAZOLAMIDE TAB
1240501000****ACYCLOVIR TAB/CAP
44201010103410ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT30 DAY SUPPLY/PROVENTIL EXCLUDED
44201010102515ALBUTEROL SULFATE SOLN NEBU 0.083%
680000100003**ALLOPURINOL TAB
571000100003**ALPRAZOLAM TAB
732000101001**AMANTADINE HCL CAP
732000101003**AMANTADINE HCL TAB
582000101003**AMITRIPTYLINE HCL TAB
340000031003**AMLODIPINE BESYLATE TAB
019900022003**AMOXICILLIN & K CLAVULANATE TAB
012000101001**AMOXICILLIN (TRIHYDRATE) CAP
833700100003**APIXABAN TAB
332000200003**ATENOLOL TAB
034000100003**AZITHROMYCIN TAB
861099021042**BACITRACIN-POLYMYXIN B OPHTH OINT
86109902104200BACITRACIN-POLYMYXIN B OPHTH OINT
751000100003**BACLOFEN TAB
431020100001**BENZONATATE CAP
731000101003**BENZTROPINE MESYLATE TAB
866020201020**BRIMONIDINE TARTRATE OPHTH SOLN
442099024132**BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL (SYMBICORT)
726000200003**CARBAMAZEPINE TAB
333000070003**CARVEDILOL TAB
021000200001**CEPHALEXIN CAP
021000200003**CEPHALEXIN TAB
415500201003**CETIRIZINE HCL TAB
411000201503**CHLORPHENIRAMINE MALEATE TABOTC
411000201504**CHLORPHENIRAMINE MALEATE TAB EROTC
376000250003**CHLORTHALIDONE TA
87100012102020CIPROFLOXACIN HCL OTIC SOLN 0.2% (BASE EQUIVALENT)
050000201003**CIPROFLOXACIN HCL TAB
87991002361820CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP
581600201003**CITALOPRAM HYDROBROMIDE TAB
162200201001**CLINDAMYCIN HCL CAP
721000100003**CLONAZEPAM TAB
362010101003**CLONIDINE HCL TAB
85158020100320CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)
90154020003705CLOTRIMAZOLE CREAM 1%
88100020004805CLOTRIMAZOLE TROCHE 10 MG
55104020003705CLOTRIMAZOLE VAGINAL CREAM 1%
55104020003710CLOTRIMAZOLE VAGINAL CREAM 2%
68000020000120COLCHICINE CAP 0.6 MGMAX 10 CAPSULES
680000200003**COLCHICINE TABMAX 10 TABLETS
751000501003**CYCLOBENZAPRINE HCL TAB
833370302001**DABIGATRAN ETEXILATE MESYLATE CAP
831010101020**DALTEPARIN SODIUM INJ
431020305009**DEXTROMETHORPHAN HBR LIQUIDOTC
431020305012**DEXTROMETHORPHAN HBR SYRUPOTC
439970025209**DEXTROMETHORPHAN-GUAIFENESIN LIQUIDOTC
439970025212**DEXTROMETHORPHAN-GUAIFENESIN SYRUPOTC
571000400003**DIAZEPAM TAB
661000072006**DICLOFENAC SODIUM TAB DELAYED RELEASE
013000201001**DICLOXACILLIN SODIUM CAP
312000100003**DIGOXIN TAB
340000101069**DILTIAZEM HCL CAP ER 12HR
340000101070**DILTIAZEM HCL CAP ER 24HR
340000101270**DILTIAZEM HCL COATED BEADS CAP ER 24HR
340000101170**DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR
340000101003**DILTIAZEM HCL TAB
412000301003**DIPHENHYDRAMINE HCL TAB
47100010100310DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG
725000101075**DIVALPROEX SODIUM TAB ER 24 HR
465000101001**DOCUSATE CALCIUM CAPOTC
465000103001**DOCUSATE SODIUM CAPOTC
86802340102020DORZOLAMIDE HCL OPHTH SOLN 2%
362020051003**DOXAZOSIN MESYLATE TAB
582000401001**DOXEPIN HCL CAP
040000201001**DOXYCYCLINE HYCLATE CAP
040000201003**DOXYCYCLINE HYCLATE TAB
040000200001**DOXYCYCLINE MONOHYDRATE CAP
040000200003**DOXYCYCLINE MONOHYDRATE TAB
581800251067**DULOXETINE HCL ENTERIC COATED PELLETS CAP
831010201020**ENOXAPARIN SODIUM INJ
86101025004210ERYTHROMYCIN OPHTH OINT 5 MG/GM
031000050006**ERYTHROMYCIN TAB DELAYED RELEASE
661000080001**ETODOLAC CAP
661000080003**ETODOLAC TAB
340000130075**FELODIPINE TAB ER 24HR
114070150003**FLUCONAZOLE TAB
581600400001**FLUOXETINE HCL CAP
581600400003**FLUOXETINE HCL TAB
42200032301810FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT30 DAY SUPPLY
372000300003**FUROSEMIDE TABS
726000300001**GABAPENTIN CAP
726000300003**GABAPENTIN TAB
86101030004205GENTAMICIN SULFATE OPHTH OINT 0.3%
86101030002005GENTAMICIN SULFATE OPHTH SOLN 0.3%
272000300003**GLIPIZIDE TAB
432000100009**GUAIFENESIN LIQUID
OTC
432000100003**GUAIFENESIN TABOTC
432000100074**GUAIFENESIN TAB ER 12HR
439970022809**GUAIFENESIN-CODEINE LIQUID
439970022820**GUAIFENESIN-CODEINE SOLN
591000101003**HALOPERIDOL TAB
899940032242**
HEMORRHOIDAL OINT (PHENYLEPH-SHARK LIVER OIL-COCOA BUTTER)OTC
89994003255220
HEMORRHOIDAL SUPP (PHENYLEPH-SHARK LIVER OIL-COCOA BUTTER SUPP)
OTC
863500301020**HOMATROPINE HBR OPHTH SOLN
376000400001**HYDROCHLOROTHIAZIDE CAP
376000400003**HYDROCHLOROTHIAZIDE TABS
65991702102024HYDROCODONE-ACETAMINOPHEN SOLN 10-300 MG/15ML
659917021003**HYDROCODONE-ACETAMINOPHEN TAB
89150010103905HYDROCORTISONE ACETATE RECTAL FOAM 10%
89100010105230HYDROCORTISONE ACETATE SUPPOS 25 MG
89991002313910HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL FOAM
905500750037**HYDROCORTISONE CREAMOTC
905500750042**HYDROCORTISONE OINTOTC
572000401003**HYDROXYZINE HCL TAB
572000402001**HYDROXYZINE PAMOATE CAPS
661000200003**IBUPROFEN TABOTC
661000300002**INDOMETHACIN CAP ER
661000300001**INDOMETHACIN CAPS
27104002002020INSULIN ASPART INJ 100 UNIT/ML1 VIAL ONLY/30 DAY SUPPLY
27104006002020INSULIN DETEMIR INJ 100 UNIT/ML1 VIAL ONLY/30 DAY SUPPLY
27104003002020INSULIN GLARGINE INJ 100 UNIT/ML1 VIAL ONLY/30 DAY SUPPLY
27104020001805INSULIN NPH (HUMAN) (ISOPHANE) INJ 100 UNIT/ML1 VIAL ONLY/30 DAY SUPPLY
27104010002005INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML1 VIAL ONLY/30 DAY SUPPLY
9705103090****INSULIN SYRINGE/NEEDLE
44100030123420IPRATROPIUM BROMIDE HFA INHAL AEROSOL 17 MCG/ACT (ATROVENT)30 DAY SUPPLY
44100030102020IPRATROPIUM BROMIDE INHAL SOLN 0.02%
44209902013420IPRATROPIUM-ALBUTEROL INHAL AEROSOL SOLN 20-100 MCG/ACT (COMBIVENT)30 DAY SUPPLY
44209902012015IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG
32100020000405ISOSORBIDE DINITRATE TAB CR 40 MG
321000250003**ISOSORBIDE MONONITRATE TAB
90154045003710KETOCONAZOLE CREAM
868050351020**KETOROLAC TROMETHAMINE OPHTH SOLN30 DAY SUPPLY
86802040102010KETOTIFEN FUMARATE OPHTH SOLN30 DAY SUPPLY
726000400003**LAMOTRIGINE TAB
86330050002020LATANOPROST OPHTH SOLN 0.005%
050000340003**LEVOFLOXACIN TAB
2810001010****LEVOTHYROXINE SODIUM
89200025003720LIDOCAINE ANORECTAL CREAM 5%
908500600040**LIDOCAINE GEL
90850060103730LIDOCAINE HCL CREAM 3%
90850060004210LIDOCAINE OINT 5%
90859902903710LIDOCAINE-PRILOCAINE CREAM 2.5-2.5%
361000300003**LISINOPRIL TAB
595000101001**LITHIUM CARBONATE CAP
595000101004**LITHIUM CARBONATE TAB ER
471000201003**LOPERAMIDE HCL TAB
415500300003**LORATADINE TAB
571000600003**LORAZEPAM TAB
361500402003**LOSARTAN POTASSIUM
5020005000****MECLIZINE HCL
661000520003**MELOXICAM TABS
272500500075**METFORMIN HCL TAB ER
272500500003**METFORMIN HCL TABS
65100050100305METHADONE HCL TAB 5 MG
751000700003**METHOCARBAMOL TAB
2210003000B705METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)
523000201003**METOCLOPRAMIDE HCL TAB
376000600003**METOLAZONE TAB
332000300575**METOPROLOL SUCCINATE TAB ER 24HR
332000301003**METOPROLOL TARTRATE TABS
160000350001**METRONIDAZOLE CAP
160000350003**METRONIDAZOLE TAB
901540501037**MICONAZOLE NITRATE CREAMOTC
901540501029**MICONAZOLE NITRATE POWDER
444000362080**MOMETASONE FUROATE INHAL POWD (ASMANEX)30 DAY SUPPLY
651000551020**MORPHINE SULFATE (CONCENTRATE) ORAL SOLN
651000551004**MORPHINE SULFATE TAB ER
651000551003**MORPHINE SULFATE TABS
861010381020**MOXIFLOXACIN HCL OPHTH SOLN
90100065203710MUPIROCIN CALCIUM CREAM 2%
90100065104210MUPIROCIN OINT 2%
864099021420**NAPHAZOLINE W/ PHENIRAMINE OPHTH SOLN
661000600003**NAPROXEN TABS
879910031020**NEOMYCIN-POLYMYXIN-HC OTIC SOLN
879910031018**NEOMYCIN-POLYMYXIN-HC OTIC SUSP
340000200001**NIFEDIPINE CAP
340000200075**NIFEDIPINE TAB ER 24HR
530000501001**NITROFURANTOIN MACROCRYSTALLINE CAP (MACRODANTIN)
530000501501**NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP (MACROBID)
321000300007**NITROGLYCERIN SL TAB
582000601001**NORTRIPTYLINE HCL CAPS
901500800037**NYSTATIN CREAM
901500800042**NYSTATIN OINT
88100010001805NYSTATIN SUSP 100000 UNIT/ML
86101047002020OFLOXACIN OPHTH SOLN 0.3%
492700600065**OMEPRAZOLE CAP DELAYED RELEASE
502500650503**ONDANSETRON HCL TAB
125040602001**OSELTAMIVIR PHOSPHATE CAP
65100075100110OXYCODONE HCL CAP 5 MG
651000751003**OXYCODONE HCL TABS
659900022003**OXYCODONE W/ ACETAMINOPHEN TAB
492700701006**PANTOPRAZOLE SODIUM EC TAB
581600600003**PAROXETINE HCL TAB
011000401003**PENICILLIN V POTASSIUM TAB
90900035003720PERMETHRIN CREAM 5%
909000350041**PERMETHRIN LOTIONOTC
563000101003**PHENAZOPYRIDINE HCL TABSOTC
722000302001**PHENYTOIN SODIUM EXTENDED CAP
772040300003**PHYTONADIONE TABS
865010301020**PILOCARPINE HCL OPHTH SOLN
46600033002910POLYETHYLENE GLYCOL 3350 ORAL POWDER
797000300002**POTASSIUM CHLORIDE CAP ER
797000301004**POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB
797000300004**POTASSIUM CHLORIDE SA TAB
362020301001**PRAZOSIN HCL CAP
863000501018**PREDNISOLONE ACETATE OPHTH SUSP
221000450003**PREDNISONE TABS
592000551003**PROCHLORPERAZINE MALEATE TAB
592000550052**PROCHLORPERAZINE SUPP
414000201052**PROMETHAZINE HCL SUPP
414000201003**PROMETHAZINE HCL TABS
331000401003**PROPRANOLOL HCL TABS
421010201003**PSEUDOEPHEDRINE HCL TABS
591530701003**QUETIAPINE FUMARATE TABS
492000201001**RANITIDINE HCL CAPS
492000201003**RANITIDINE HCL TAB
590700700003**RISPERIDONE TABS
833700600003**RIVAROXABAN TAB
641000750003**SALSALATE TAB
275500651003**SAXAGLIPTIN HCL TAB
462000602003**SENNOSIDES TAB
469910027703**SENNOSIDES-DOCUSATE SODIUM TABOTC
581600701003**SERTRALINE HCL TABS
99450010001840SODIUM POLYSTYRENE SULFONATE ORAL SUSP
99450010002900SODIUM POLYSTYRENE SULFONATE POWDER
375000200003**SPIRONOLACTONE TAB
493000100003**SUCRALFATE TAB
86102010104205SULFACETAMIDE SODIUM OPHTH OINT
861020101020**SULFACETAMIDE SODIUM OPHTH SOLN
16990002301810SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML
16990002300310SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG
16990002300320SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG
674060701003**SUMATRIPTAN SUCCINATE TABS
56852070100110TAMSULOSIN HCL CAP
602010300001**TEMAZEPAM CAP
362020401001**TERAZOSIN HCL CAPS
90150087103710TERBINAFINE HCL CREAM 1%
862500301020**TIMOLOL MALEATE OPHTH SOLN
862500300020**TIMOLOL OPHTH SOLN
4410008010****TIOTROPIUM BROMIDE MONOHYDRATE INHAL (SPIRVA)30 DAY SUPPLY
65100095100320TRAMADOL HCL TAB 50 MG
581200801003**TRAZODONE HCL TAB
905500851037**TRIAMCINOLONE ACETONIDE CREAM
905500851042**TRIAMCINOLONE ACETONIDE OINT
3799000230****TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP/TAB
86103020002005TRIFLURIDINE OPHTH SOLN
439930028003**TRIPROLIDINE & PSEUDOEPHEDRINE TAB
541000652003**TROSPIUM CHLORIDE TAB
25400070100320ULIPRISTAL ACETATE TAB 30 MG (ELLA)
725000300001**VALPROIC ACID CAP
581800901070**VENLAFAXINE HCL CAP ER 24HR
581800901003**VENLAFAXINE HCL TAB
340000301070**VERAPAMIL HCL CAP ER 24HR
340000301003**VERAPAMIL HCL TAB
340000301004**VERAPAMIL HCL TAB ER
832000302003**WARFARIN SODIUM TAB
602040801003**ZOLPIDEM TARTRATE TAB
17100095101920ZOSTER VACCINE

Attachment 25

File details come from the government source that posted it. Updated .