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Ibuprofen 800 mg tablets #90 for 30 days (NDC: 65162046650)
| Lexapro 10 mg tablets #30 for 30 days (NDC: 00456201001) |
| Ofev 150 mg capsules #60 for 30 days (NDC: 00597014560) |
| Full Pass-Through Pricing Options |
| Non-Specialty Generic Retail |
| Non-Specialty Brand Retail |
| Specialty Brand Mail-Order |
| 1. Pharmacy Submitted Price |
| $72.23 ingredient cost + $10.00 dispensing fee = $82.23 |
| $527.17 ingredient cost + $10.00 dispensing fee = $537.17 |
| $15,595.85 ingredient cost + $20.00 dispensing fee = |
$15,615.85
| 2. OWCP Pharmacy Fee Schedule Price |
| $43.34 ingredient cost + $4.00 dispensing fee = $47.34 |
| $456.59 ingredient cost + $4.00 dispensing fee = $460.59 |
| $13,256.47 ingredient cost + $4.00 dispensing fee = $13,260.47 |
| 3. U&C Rate |
| $10.00 |
| $439.31 |
| None available |
| 4. Maximum Allowable Cost (MAC) |
| $7.50 ingredient cost + $1.00 dispensing fee = $8.50 |
| None available |
| None available |
| 5. AWP Discount |
| $14.45 |
| $421.73 |
| $13,100.51 |
| 6. Any other price |
| None available |
| $395.37 ingredient cost + $5.00 dispensing fee = $400.37 |
| $13,568.39 |
| Lowest Price Cost Basis |
| MAC |
| Any other price |
| AWP Discount |
| Lowest Price |
| $8.50 |
| $400.37 |
| $13,100.51 |
| Final price paid to the pharmacy |
| $8.50 |
| $400.37 |
| $13,100.51 |
| Lowest Price + Service Fee |
| $8.50 + $3.00 = $11.50 |
| $400.37 + $3.00 = $403.37 |
| $13,100.51 + $3.00 = $13,103.51 |
| Lowest Price + Service Fee – Rebate |
| N/A |
| $400.37 + $3.00 - $10.00 = $393.37 |
| $13,100.51 + $3.00 - $10.00 = $13,093.51 |
| Final total price billed to the government |
| $11.50 |
| $393.37 |
| $13,093.51 |
Technical Exhibit 6 Full Pass-through Pricing Examples