VISN 8 Emergent First Fill Formulary 8-2020.xlsx

XLSX spreadsheet 18 KB Posted

Attached to
Q517--Emergent First Fill Pharmacy Prescription Services Base plus four (4) Twelve (12) Month Option Years
Solicitation number
36C24821Q0166
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Sheet1

Drug_NameDOSAGE_FORMcomments
ALLERGIES/ALLERGIC REACTION (ANTIHISTAMINES, MEDROL DOSEPAK, TOPICAL STEROIDS)
DIPHENHYDRAMINE HCL 25 MG CAPTAB/CAPKEY
HYDROXYZINETAB/CAP
LORATADINETABALL INHALERS = 1 UNIT
MECLIZINETAB
FLUTICASONE 50MCG/SPRAY 120D NASAL INHL SPRAYNASAL INHALERALL TOPICAL = 1 TUBE WHEN APPLICABLE
METHYLPREDNISOLONE 4 MG DOSE PACKTAB
HYDROCORTISONE TOPICAL (LOW POTENCY)TOPICAL CREAM
TRIAMCINOLONE 0.1% (MODERATE POTENCY)TOPICAL CREAM
FLUOCINONIDE CREAM 0.05% (HIGH POTENCY)TOPICALCREAM
EPI-PENINJECTION
ANTI-INFECTIVES (ANTIBIOTICS, ANTIVIRALS, ANTIFUNGALS)
POLYMYXIN/TRIMETHOPRIM 0.1%OPH SOLUTION
OFLOXACIN 0.3%OPH SOLUTION
AZITHROMYCINTAB/CAP/SUSPENSION
AMOXICILLIN & K CLAVULANATETAB/CAP/SUSPENSION
AMOXICILLIN (TRIHYDRATE)TAB/CAP/SUSPENSION
CEPHALEXINTAB
CIPROFLOXACIN HCLTAB/CAP/SUSPENSION
CLINDAMYCINTAB/CAP
DOXYCYCLINETAB
LEVOFLOXACINCAP/TAB
NITROFURANTOINTAB/CAP (MACROBID PREFERRED)
TRIMETHOPRIM/SULFAMETHOXAZOLETAB
METRONIDAZOLETAB
MUPIROCIN OINTMENTOINTMENT
PENICILLIN VKTAB
NYSTATIN 100,000 UNITS/ML ORAL SUSPSUSPENSION
PERMETHRIN 5%CREAM
ACYCLOVIRTAB/CAPonly 200mg or 800mg
OSELTAMIVIR PHOSPHATETAB/CAP
VALACYCLOVIRTAB/CAP
CLOTRIMAZOLE CREAMCREAM
CLOTRIMAZOLE TROCHETAB
FLUCONAZOLETAB/CREAM
KETOCONAZOLE CREAM 2%VAGINAL CREAM
METRONIDAZOLE VAGINALVAGINAL CREAM
MICONAZOLE NITRATE VAGINAL CREAM 2%TAB
PHENAZOPYRIDINE HCLTAB
SILVADENE TOPICALCREAM
ANTICOAGULATION
WARFARIN 2MG AND 5MGTAB
APIXABANTAB
DABIGATRANTAB
RIVAROXABANTAB
PHYTONADIONE (VITAMIN K) 5mgTAB
ENOXAPARIN SODIUMINJ
ANTI-DEPRESSANTS
BUPROPION SRTAB
BUPROPION IRTAB
BUSPIRONETAB
CITALOPRAM HYDROBROMIDE TAB 10 MG (BASE EQUIV)TAB
ESCITALOPRAMTAB/CAP
FLUOXETINETAB/CAP
SERTRALINETAB
TRAZODONETAB/CAP
DULOXETINETAB/CAP
LITHIUMTAB/CAP
ANTI-PSYCHOTICS
HALOPERIDOL ORALTAB/CAP/SOLN
OLANZAPINE ORAL TABSTAB/CAP
QUETIAPINE FUMARATETAB
RISPERIDONETAB
ASTHMA/COPD
ALBUTEROL SULFATE INHALATIONNEBS
IPRATROPRIUM INHAL SOLNEBS
ALBUTEROL SULFATE INHAL AEROSOLORAL INHALER
IPRATROPRIUM INHALERORAL INHALER
IPRATROPRIUM/ALBUTEROL INHALERORAL INHALER
TIOTROPRIUM INHALERORAL INHALER
MOMETASONE INHALERORAL INHALER
PREDNISONETAB/CAP
CARDIOVASCULAR/HYPERTENSION
AMLODIPINE BESYLATETAB
DILTIAZEM HCL SR 24HRTAB/CAP
CARVEDILOLTAB
CLONIDINETAB
HYDRALAZINETAB
LISINOPRILTAB
LOSARTANTAB
METOPROLOL TARTRATETAB
VALSARTANTAB
TRIAM/HCTZTAB/CAP
LISINOPRIL / HCTZTAB
TAMSULOSIN HCLCAP
PRAZOSINCAP
ASPIRINTAB
CLOPIDOGREL BISULFATE 75 MGTAB
DIGOXIN TAB 0.125 MGTAB
CHLORTHALIDONETAB
FUROSEMIDETAB
HYDROCHLOROTHIAZIDETAB
SPIRONOLACTONETAB
ISOSORBIDE MONONITRATE SR 24HRTAB
NITROGLYCERIN SLTAB
POTASSIUM CHLORIDETAB
COUGH/COLD
BENZONATATECAP
GUAIFENESINTAB
GUAIFENESIN DM LIQUID 100 MG/5 ML (may prescribe sugar free)LIQUID
GUAIFENESIN LIQUID 100 MG/5 ML (may prescribe sugar free)LIQUID
DIABETES
EMPAGLIFLOZINTAB
METFORMIN HCLTAB
GLIPIZIDETAB
INSULIN ASPARTINJECTION
INSULIN GLARGINEINJECTION
INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (70-30)INJECTION
INSULIN ISOPHANE NPH (HUMAN) INJ 100 UNIT/MLINJECTION
INSULIN REGULAR (HUMAN) INJ 100 UNIT/MLINJECTION
PEN NEEDLESINJECTION DEVICE
INSULIN SYRINGESNEEDLES
GASTROINTESTINAL
SENNOSIDESTAB/CAP
DOCUSATETAB/CAP
GLYCERIN SUPPOSITORIESSUPPOSITORY
LOPERAMIDE 2 MG TABCAP
METAMUCILTAB/POWDER
HEMORRHOIDAL CREAMCREAM
HEMORRHOIDAL SUPPOSITORIESSUPPOSITORY
ALOH/MGOH/SIMETH EXTRA STRENGTH SUSPSUSPENSION
SIMETHICONETAB
FAMOTIDINE HCLTAB
OMEPRAZOLE DELAYED RELEASE CAP 20 MGTAB/CAP
PANTOPRAZOLETAB/CAP
ONDANSETRON HCL TAB 4 MGTAB
PROCHLORPERAZINE TABSTAB
PROMETHAZINETAB/CAP/SUPPOSITORY
PROMETHAZINE LIQUIDLIQUID
GOUT
COLCHICINE Limit #10TAB
MISC
Diphenhydramine liquid-magic mouthwashLIQUID
Lidocaine (viscous)-magic mouthwashLIQUID
ONDANSETRON HCL TAB 4 MGTAB
LEVONORGESTREL (Plan B) & Ulipristal (Ella)TAB
ULIPRISTAL (ELLA)TAB
OPHTHALMICS/OTICS
CYCLOPENTOLATE HCL 1%SOLN
ATROPINE SULFATE 1%OINTMENT
ERYTHROMYCIN (5MG/GM)GEL SOLN
POLYMYCIN B/TRIMETHOPRIMOPHTH SOLN/SUSP
PREDNISOLONE ACETATE 1%SUSPENSION
TIMOLOL MALEATE 0.5%OPH SOLUTION
DORZOLAMIDE 2%OPH
LATANOPROSTOPH SOLUTION
TOBRAMYCIN 0.3%OPH SOLUTION
TOBRAMYCIN/DEXAMETHASONE (0.3/0.1%)OPH SOLUTION
NEOMYCIN/POLYMIXIN/HC 1%OTIC SOLN/SUSP
PAIN/NEUROPATHY
ACETAMINOPHEN WITH CODEINETAB
CYCLOBENZAPRINE HCLTAB
METHOCARBAMOLTAB
BACLOFENTAB/CAP
ACETAMINOPHENTAB
IBUPROFENTAB/CAP
INDOMETHACINTAB
MELOXICAMTAB/CAP
NAPROXENTAB
LIDOCAINE TOPICALCR/OINT
CAPSAICIN CREAMCREAM
GABAPENTINTAB/CAP
NALOXONE REVERSAL KITNASAL INHALER
MIGRAINE
SUMATRIPTANTAB
SEIZURES
CARBAMAZEPINETAB/CAP
DIVALPROEX SODIUMTAB/CAP
PHENYTOIN SODIUMCAP
THYROID
LEVOTHYROXINE SODIUMTAB
WELLNESS VACCINATIONS (If clinical indicated):INJ
HEPATITIS A VACCINE (HAVRIX, VAQTA)INJ
INFLUENZA VACCINE, INJINJ
PNEUMOCOCCAL 13-VALENT CONJUGATE VACCINE (PREVNAR 13)INJ
PNEUMOCOCCAL 23-VALENT POLYSACC VACCINE (PNEUMOVAX)INJ
TETANUS/DIPHTH. 0.5ML SYR (TENIVAC) - TdINJ
ZOSTER VACCINE LIVE (OKA/MERCK) INJ (ZOSTAVAX) - ShinglesINJ
List Updated 7/2020

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