A-3 Price List - Antilipidemics-1 - Non-Statins and Combos.xlsx

BPA

Step Therapy Addendum: No Grandfathering: a prior authorization process requires new and current patients to complete an adequate trial of the step-preferred agent(s) before a non-step-preferred agent is provided to the patient at any MTF, Retail, or Mail point of service.

Based on available government prices and historical information, the band of prices for net ingredient cost may trigger formulary considerations.

Scenario 1:

For ingredient cost ≤ $100 average per 30 days of therapy, the committee will consider Uniform Formulary and/or Tier 2 before step therapy and automate the prior authorization which will approve if there is a trial of ezetimibe and a statin documented in the last 180 days.

Uniform Formulary and/or Tier 2 after step therapy and a manual prior authorization requiring a trial of ezetimibe and a statin may be considered if ingredient cost is > $100 average per 30 days of therapy.

All Scenarios: Agents with RFQ not submitted or selected may be designated non-step preferred.

Notes to Manufacturers: Do not forget to submit 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

Blanket Purchase Agreement Appendix – Class Review

Blanket Purchase Agreement Appendix – Class Review

Blanket Purchase Agreement Appendix – Class Review

Blanket Purchase Agreement Appendix – Class Review

Blanket Purchase Agreement Appendix – Class Review

Blanket Purchase Agreement Appendix – Class Review

Blanket Purchase Agreement Appendix – Class Review

Blanket Purchase Agreement Appendix – Class Review

Blanket Purchase Agreement Appendix – Class Review

ADP (non-FAMP Discount)

Step Therapy Addendum: No Grandfathering: a prior authorization process requires new and current patients to complete an adequate trial of the step-preferred agent(s) before a non-step-preferred agent is provided to the patient at any MTF, Retail, or Mail point of service.

Based on available government prices and historical information, the band of prices for net ingredient cost may trigger formulary considerations.

Scenario 1:

For ingredient cost ≤ $100 average per 30 days of therapy, the committee will consider Uniform Formulary and/or Tier 2 before step therapy and automate the prior authorization which will approve if there is a trial of ezetimibe and a statin documented in the last 180 days.

Uniform Formulary and/or Tier 2 after step therapy and a manual prior authorization requiring a trial of ezetimibe and a statin may be considered if ingredient cost is > $100 average per 30 days of therapy.

All Scenarios: Agents with RFQ not submitted or selected may be designated non-step preferred.

Notes to Manufacturers: Do not forget to submit 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

Additional Discount Program Appendix – Class Review

Additional Discount Program Appendix – Class Review

Additional Discount Program Appendix – Class Review

Additional Discount Program Appendix – Class Review

Additional Discount Program Appendix – Class Review

Additional Discount Program Appendix – Class Review

Additional Discount Program Appendix – Class Review

Additional Discount Program Appendix – Class Review

Additional Discount Program Appendix – Class Review