A-3 Price List - Leukemia Lymphoma Agents-BTKI.xlsx

BPA

Step Therapy Addendum: Grandfathering. A prior authorization process requires new patients to complete an adequate trial of the step-preferred agent(s) before a non-step-preferred agent is provided to a new user 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:

Uniform Formulary and/or Tier 2 before step therapy for the CLL/SLL indication with a specialist bypass (no PA required) for hematologists and oncologists may be considered if ingredient cost is ≤ $6,000 average per 30 days of therapy.

Uniform Formulary and/or Tier 2 after step therapy may be considered if ingredient cost is > $6,000 average per 30 days of therapy.

Scenario 2:

Uniform Formulary and/or Tier 2 may be considered if ingredient cost is ≤ $7,000 average per 30 days of therapy. Agents meeting the Uniform Formulary price band may be considered for a specialist bypass (no PA required) for hematologists and oncologists.

Non-Formulary and/or Tier 3 may be considered if ingredient cost is > $7,000 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: Grandfathering. A prior authorization process requires new patients to complete an adequate trial of the step-preferred agent(s) before a non-step-preferred agent is provided to a new user 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:

Uniform Formulary and/or Tier 2 before step therapy for the CLL/SLL indication with a specialist bypass (no PA required) for hematologists and oncologists may be considered if ingredient cost is ≤ $6,000 average per 30 days of therapy.

Uniform Formulary and/or Tier 2 after step therapy may be considered if ingredient cost is > $6,000 average per 30 days of therapy.

Scenario 2:

Uniform Formulary and/or Tier 2 may be considered if ingredient cost is ≤ $7,000 average per 30 days of therapy. Agents meeting the Uniform Formulary price band may be considered for a specialist bypass (no PA required) for hematologists and oncologists.

Non-Formulary and/or Tier 3 may be considered if ingredient cost is > $7,000 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