A-3 Price List_Lisraya - TIBs - NA.xlsx

BPA

Step Therapy Addendum: Grandfathering will apply. 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.

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 – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Price per NDC Package Size Price per Unit

Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Price per NDC Package Size Price per Unit

Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Price per NDC Package Size Price per Unit

Blanket Purchase Agreement Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Price per NDC Package Size Price per Unit

Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Price per NDC Package Size Price per Unit

Blanket Purchase Agreement Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Price per NDC Package Size Price per Unit

Blanket Purchase Agreement Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Price per NDC Package Size Price per Unit

Blanket Purchase Agreement Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Price per NDC Package Size Price per Unit

Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Price per NDC Package Size Price per Unit

Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Price per NDC Package Size Price per Unit

&"-,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)

Step Therapy Addendum: Grandfathering will apply. 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.

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 – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description 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*

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description 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*

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description 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*

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description 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*

Formulary Scenarios Condition Set # Formulary Category Description 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*

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description 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*

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description 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*

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description 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*

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category Description 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*

Formulary Scenarios Condition Set # Formulary Category Description 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*

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

ADP (WAC Discount)

Step Therapy Addendum: Grandfathering will apply. 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.

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

The Wholesale Acquisition Cost (WAC) is obtained from First Databank via daily price updates; it is maintained at the dispensing unit level to five (5) decimal places. If the WAC changes during a calendar quarter, an average WAC will be calculated on a daily weighted basis (per unit only).

WAC is ONLY used for products that do not have a FCP, such as diabetic supplies (i.e., test strips), and can also be applied to covered drugs.

*The quoted WAC Discount percentage will remain static during the life of the agreement.

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category One of (x) Number of Brand Agents WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category One of (x) Number of Brand Agents WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category One of (x) Number of Brand Agents WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category One of (x) Number of Brand Agents WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category One of (x) Number of Brand Agents WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category One of (x) Number of Brand Agents WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category One of (x) Number of Brand Agents WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category One of (x) Number of Brand Agents WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category One of (x) Number of Brand Agents WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package

Additional Discount Program Appendix – Newly Approved Drug

Formulary Scenarios Condition Set # Formulary Category One of (x) Number of Brand Agents WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package

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