A-3 PL - Atopy - Topical Agents.xlsx

XLSX spreadsheet 45 KB Posted Aug 6, 2026

Attached to: Department of War Pharmacy Uniform Formulary Blanket Purchase Agreement/Uniform Formulary Additional Discount Program
Solicitation number: HT9402-26-Q-9401
Issued by: Defense Health Agency

About this file

Written by GovTribe AI · Aug 6, 2026

This is a Blanket Purchase Agreement (BPA) and Uniform Formulary Additional Discount Program (ADP) pricing template for pharmaceutical agents in the Atopy - Topical Agents therapeutic class under the Department of War (DoW) Pharmacy and Therapeutics (P&T) Committee. The solicitation (HT9402-26-Q-9401) is issued by the Defense Health Agency and requires pharmaceutical manufacturers to submit quotes for products including Anzupgo, Eucrisa, Opzelura, Vtama, and Zoryve for the November 4-5, 2026 P&T Committee meeting. Quotes are due by October 1, 2026, with a pre-quotation teleconference scheduled for August 12, 2026. Manufacturers must submit the Quote Review Checklist and fully executed signature pages along with pricing information.

The pricing template contains multiple class review scenarios with NDC-specific pricing requirements for both Military Treatment Facility & Mail Order and TRICARE Retail channels. Manufacturers must provide pricing per unit of measure (each, gram, mL, etc.) that applies uniformly across all package sizes within a given dispensing venue. The BPA appendix addresses Uniform Formulary (UF) categorization with before-step and after-step therapy options, while the ADP appendix focuses on Tier 2 and Tier 3 classification for retail refunds, including calculations based on Federal Ceiling Price (FCP) and non-FAMP pricing. The agreement incorporates step therapy provisions with grandfathering options and may include prior authorization requirements. Agents not selected or without submitted quotes may be designated non-step preferred (after-step), and the P&T Committee may recommend preferential pricing status or complete exclusion from the TRICARE pharmacy benefit program.

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BPA

UF BPA NDC Price List for the November 2026 DoW P&T Meeting
DoW Uniform Formulary Class:	ATOPY	P&T Committee Meeting:	November 4-5, 2026
DoW Uniform Formulary Subclass:	TOPICAL AGENTS	Quotes due:	October 1, 2026
Formulary Notes
Class Note(s): Prior Authorization (PA) may apply. Agents may be identified as possible candidates for special reimbursement methods, amounts, and procedures to encourage use of high-value products and discourage use of low-value products. The P&T Committee may recommend consideration of preferential status to any non-generic pharmaceutical agent by treating it for purposes of cost sharing as a generic product (Tier 1). Similarly, the P&T Committee may identify candidates to recommend for complete exclusion from the TRICARE pharmacy benefit program.

Step Therapy Addendum: Grandfathering: a prior authorization process that allows current patients to remain on current therapy and requires new patients to complete an adequate trial of the step-preferred (before-step) agent before a non-step-preferred (after-step) agent is provided to the patient at any MTF, Retail, or Mail point of service. The P&T Committee may consider approving specialist bypass for the step-preferred (before-step) agent.

*Note:Step Therapy may be applicable if agents share the same FDA-approved indication(s).

Agents with RFQ not submitted or selected may be designated non-step preferred (after-step).

Notes to Manufacturers: Do not forget to submit the Quote Review Checklist and fully executed signature pages, along with quote information.

The price per unit of measure for a given dosage form and strength (each, gram, mL, etc.) of the pharmaceutical agent will be the same for all available package sizes (e.g., 30s, 100s, 1000s) within a given dispensing venue.

Blanket Purchase Agreement Appendix – Class Review

#1	DoW Uniform Formulary Class:	ATOPY		P&T Committee Meeting:	November 4-5, 2026
	DoW Uniform Formulary Subclass:	TOPICAL AGENTS		Quotes due:	October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order

		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent may be UF and before the step.
		Scenario 1	271ATTOG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			271ATTOG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			271ATTOG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents may be UF.
		Scenario 2	271ATTOG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			271ATTOG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#2	DoW Uniform Formulary Class:	ATOPY		P&T Committee Meeting:	November 4-5, 2026
	DoW Uniform Formulary Subclass:	TOPICAL AGENTS		Quotes due:	October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order

		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent may be UF and before the step.
		Scenario 1	271ATTOG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			271ATTOG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			271ATTOG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents may be UF.
		Scenario 2	271ATTOG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			271ATTOG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#3	DoW Uniform Formulary Class:	ATOPY		P&T Committee Meeting:	November 4-5, 2026
	DoW Uniform Formulary Subclass:	TOPICAL AGENTS		Quotes due:	October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order

		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent may be UF and before the step.
		Scenario 1	271ATTOG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			271ATTOG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			271ATTOG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents may be UF.
		Scenario 2	271ATTOG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			271ATTOG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#4	DoW Uniform Formulary Class:	ATOPY		P&T Committee Meeting:	November 4-5, 2026
	DoW Uniform Formulary Subclass:	TOPICAL AGENTS		Quotes due:	October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order

		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent may be UF and before the step.
		Scenario 1	271ATTOG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			271ATTOG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			271ATTOG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents may be UF.
		Scenario 2	271ATTOG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			271ATTOG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

		#5	DoW Uniform Formulary Class:	ATOPY		P&T Committee Meeting:	November 4-5, 2026
			DoW Uniform Formulary Subclass:	TOPICAL AGENTS		Quotes due:	October 1, 2026
			NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order
							1.00
		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent may be UF and before the step.
		Scenario 1	271ATTOG1UFBS1	Uniform Formulary
Before-Step Therapy	1		1.00	NO QUOTE
			271ATTOG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more		1.00	NO QUOTE
			271ATTOG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more		1.00	NO QUOTE
		Scenario 2: One or more agents may be UF.
		Scenario 2	271ATTOG1UF1M	Uniform Formulary	1 or more		1.00	NO QUOTE
			271ATTOG1NF1M	Non-Formulary	1 or more		1.00	NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#6	DoW Uniform Formulary Class:	ATOPY		P&T Committee Meeting:	November 4-5, 2026
	DoW Uniform Formulary Subclass:	TOPICAL AGENTS		Quotes due:	October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order

		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent may be UF and before the step.
		Scenario 1	271ATTOG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			271ATTOG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			271ATTOG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents may be UF.
		Scenario 2	271ATTOG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			271ATTOG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#7	DoW Uniform Formulary Class:	ATOPY		P&T Committee Meeting:	November 4-5, 2026
	DoW Uniform Formulary Subclass:	TOPICAL AGENTS		Quotes due:	October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order

		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent may be UF and before the step.
		Scenario 1	271ATTOG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			271ATTOG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			271ATTOG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents may be UF.
		Scenario 2	271ATTOG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			271ATTOG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#8	DoW Uniform Formulary Class:	ATOPY		P&T Committee Meeting:	November 4-5, 2026
	DoW Uniform Formulary Subclass:	TOPICAL AGENTS		Quotes due:	October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order

		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent may be UF and before the step.
		Scenario 1	271ATTOG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			271ATTOG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			271ATTOG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents may be UF.
		Scenario 2	271ATTOG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			271ATTOG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#9	DoW Uniform Formulary Class:	ATOPY		P&T Committee Meeting:	November 4-5, 2026
	DoW Uniform Formulary Subclass:	TOPICAL AGENTS		Quotes due:	October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order

		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent may be UF and before the step.
		Scenario 1	271ATTOG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			271ATTOG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			271ATTOG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents may be UF.
		Scenario 2	271ATTOG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			271ATTOG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#10	DoW Uniform Formulary Class:	ATOPY		P&T Committee Meeting:	November 4-5, 2026
	DoW Uniform Formulary Subclass:	TOPICAL AGENTS		Quotes due:	October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order

		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent may be UF and before the step.
		Scenario 1	271ATTOG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			271ATTOG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			271ATTOG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents may be UF.
		Scenario 2	271ATTOG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			271ATTOG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

&"-,Italic"Use or disclosure of data contained on this sheet is subject to the restriction on the title page of this quote.

ADP (non-FAMP Discount)

UF ADP Appendix for the November 2026 DoW P&T Meeting
DoW Uniform Formulary Class:	ATOPY	P&T Committee Meeting:	November 4-5, 2026
DoW Uniform Formulary Subclass:	TOPICAL AGENTS	Quotes due:	October 1, 2026
Formulary Notes
Class Note(s): Prior Authorization (PA) may apply. Agents may be identified as possible candidates for special reimbursement methods, amounts, and procedures to encourage use of high-value products and discourage use of low-value products. The DoW P&T Committee may recommend consideration of preferential status to any non-generic pharmaceutical agent by treating it for purposes of cost sharing as a generic product (Tier 1). Similarly, the DoW P&T Committee may identify candidates to recommend for complete exclusion from the TRICARE pharmacy benefit program.

*Note: Step Therapy may be applicable if agents share the same FDA-approved indication(s).

Agents with RFQ not submitted or selected may be designated non-step preferred (after-step).

Notes to Manufacturers: Do not forget to submit the Quote Review Checklist and fully executed signature pages, along with quote information.

* Total Calculated Refund Per FCP is calculated as: ((non-FAMP-FCP)+(non-FAMP*Y%)) = Total Calculated Refund **Based on the most recent annual non-FAMP (reported to the Department of Veterans Affairs) from which the current annual Federal Ceiling Price (FCP) calculated ceiling is derived. The current annual FCP and the annual non-FAMP from which it is derived will be applicable to all prescriptions filled during a calendar year. The quoted additional refund percentage will remain static during the life of the agreement but the most recent annual non-FAMP, and thus the calculated refund, may change each calendar year.

Additional Discount Program Appendix – Class Review

#1	DoW Uniform Formulary Class:		ATOPY		P&T Committee Meeting:		November 4-5, 2026
	DoW Uniform Formulary Subclass:		TOPICAL AGENTS		Quotes due:		October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Brand Agents	Non-FAMP Price of Drug Per FCP Package**	Additional Offered Refund Per FCP Package**	Current Annual Federal Ceiling Price Per FCP Package**	Standard Refund Per FCP	Total Calculated Retail Refund Per FCP Package*
		Scenario 1: One agent may be T2 and before the step.
		Scenario 1	271ATTOG1T2BS1	Tier 2
Before-Step Therapy	1
			271ATTOG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			271ATTOG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents may be T2.
		Scenario 2	271ATTOG1T21M	Tier 2	1 or more
			271ATTOG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#2	DoW Uniform Formulary Class:		ATOPY		P&T Committee Meeting:		November 4-5, 2026
	DoW Uniform Formulary Subclass:		TOPICAL AGENTS		Quotes due:		October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Brand Agents	Non-FAMP Price of Drug Per FCP Package**	Additional Offered Refund Per FCP Package**	Current Annual Federal Ceiling Price Per FCP Package**	Standard Refund Per FCP	Total Calculated Retail Refund Per FCP Package*
		Scenario 1: One agent may be T2 and before the step.
		Scenario 1	271ATTOG1T2BS1	Tier 2
Before-Step Therapy	1
			271ATTOG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			271ATTOG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents may be T2.
		Scenario 2	271ATTOG1T21M	Tier 2	1 or more
			271ATTOG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#3	DoW Uniform Formulary Class:		ATOPY		P&T Committee Meeting:		November 4-5, 2026
	DoW Uniform Formulary Subclass:		TOPICAL AGENTS		Quotes due:		October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Brand Agents	Non-FAMP Price of Drug Per FCP Package**	Additional Offered Refund Per FCP Package**	Current Annual Federal Ceiling Price Per FCP Package**	Standard Refund Per FCP	Total Calculated Retail Refund Per FCP Package*
		Scenario 1: One agent may be T2 and before the step.
		Scenario 1	271ATTOG1T2BS1	Tier 2
Before-Step Therapy	1
			271ATTOG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			271ATTOG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents may be T2.
		Scenario 2	271ATTOG1T21M	Tier 2	1 or more
			271ATTOG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#4	DoW Uniform Formulary Class:		ATOPY		P&T Committee Meeting:		November 4-5, 2026
	DoW Uniform Formulary Subclass:		TOPICAL AGENTS		Quotes due:		October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Brand Agents	Non-FAMP Price of Drug Per FCP Package**	Additional Offered Refund Per FCP Package**	Current Annual Federal Ceiling Price Per FCP Package**	Standard Refund Per FCP	Total Calculated Retail Refund Per FCP Package*
		Scenario 1: One agent may be T2 and before the step.
		Scenario 1	271ATTOG1T2BS1	Tier 2
Before-Step Therapy	1
			271ATTOG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			271ATTOG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents may be T2.
		Scenario 2	271ATTOG1T21M	Tier 2	1 or more
			271ATTOG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#5	DoW Uniform Formulary Class:		ATOPY		P&T Committee Meeting:		November 4-5, 2026
	DoW Uniform Formulary Subclass:		TOPICAL AGENTS		Quotes due:		October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Brand Agents	Non-FAMP Price of Drug Per FCP Package**	Additional Offered Refund Per FCP Package**	Current Annual Federal Ceiling Price Per FCP Package**	Standard Refund Per FCP	Total Calculated Retail Refund Per FCP Package*
		Scenario 1: One agent may be T2 and before the step.
		Scenario 1	271ATTOG1T2BS1	Tier 2
Before-Step Therapy	1
			271ATTOG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			271ATTOG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents may be T2.
		Scenario 2	271ATTOG1T21M	Tier 2	1 or more
			271ATTOG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#6	DoW Uniform Formulary Class:		ATOPY		P&T Committee Meeting:		November 4-5, 2026
	DoW Uniform Formulary Subclass:		TOPICAL AGENTS		Quotes due:		October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Brand Agents	Non-FAMP Price of Drug Per FCP Package**	Additional Offered Refund Per FCP Package**	Current Annual Federal Ceiling Price Per FCP Package**	Standard Refund Per FCP	Total Calculated Retail Refund Per FCP Package*
		Scenario 1: One agent may be T2 and before the step.
		Scenario 1	271ATTOG1T2BS1	Tier 2
Before-Step Therapy	1
			271ATTOG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			271ATTOG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents may be T2.
		Scenario 2	271ATTOG1T21M	Tier 2	1 or more
			271ATTOG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#7	DoW Uniform Formulary Class:		ATOPY		P&T Committee Meeting:		November 4-5, 2026
	DoW Uniform Formulary Subclass:		TOPICAL AGENTS		Quotes due:		October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Brand Agents	Non-FAMP Price of Drug Per FCP Package**	Additional Offered Refund Per FCP Package**	Current Annual Federal Ceiling Price Per FCP Package**	Standard Refund Per FCP	Total Calculated Retail Refund Per FCP Package*
		Scenario 1: One agent may be T2 and before the step.
		Scenario 1	271ATTOG1T2BS1	Tier 2
Before-Step Therapy	1
			271ATTOG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			271ATTOG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents may be T2.
		Scenario 2	271ATTOG1T21M	Tier 2	1 or more
			271ATTOG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#8	DoW Uniform Formulary Class:		ATOPY		P&T Committee Meeting:		November 4-5, 2026
	DoW Uniform Formulary Subclass:		TOPICAL AGENTS		Quotes due:		October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Brand Agents	Non-FAMP Price of Drug Per FCP Package**	Additional Offered Refund Per FCP Package**	Current Annual Federal Ceiling Price Per FCP Package**	Standard Refund Per FCP	Total Calculated Retail Refund Per FCP Package*
		Scenario 1: One agent may be T2 and before the step.
		Scenario 1	271ATTOG1T2BS1	Tier 2
Before-Step Therapy	1
			271ATTOG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			271ATTOG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents may be T2.
		Scenario 2	271ATTOG1T21M	Tier 2	1 or more
			271ATTOG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#9	DoW Uniform Formulary Class:		ATOPY		P&T Committee Meeting:		November 4-5, 2026
	DoW Uniform Formulary Subclass:		TOPICAL AGENTS		Quotes due:		October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Brand Agents	Non-FAMP Price of Drug Per FCP Package**	Additional Offered Refund Per FCP Package**	Current Annual Federal Ceiling Price Per FCP Package**	Standard Refund Per FCP	Total Calculated Retail Refund Per FCP Package*
		Scenario 1: One agent may be T2 and before the step.
		Scenario 1	271ATTOG1T2BS1	Tier 2
Before-Step Therapy	1
			271ATTOG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			271ATTOG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents may be T2.
		Scenario 2	271ATTOG1T21M	Tier 2	1 or more
			271ATTOG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#10	DoW Uniform Formulary Class:		ATOPY		P&T Committee Meeting:		November 4-5, 2026
	DoW Uniform Formulary Subclass:		TOPICAL AGENTS		Quotes due:		October 1, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Branded Agents	Non-FAMP Price of Drug Per FCP Package**	Additional Offered Refund Per FCP Package**	Current Annual Federal Ceiling Price Per FCP Package**	Standard Refund Per FCP	Total Calculated Retail Refund Per FCP Package*
		Scenario 1: One agent may be T2 and before the step.
		Scenario 1	271ATTOG1T2BS1	Tier 2
Before-Step Therapy	1
			271ATTOG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			271ATTOG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents may be T2.
		Scenario 2	271ATTOG1T21M	Tier 2	1 or more
			271ATTOG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

&"-,Italic"Use or disclosure of data contained on this sheet is subject to the restriction on the title page of this quote.

File details come from the government source that posted it. Updated Aug 6, 2026.