A-3 Price List - Mimrylo - Hematological Agents - NA.xlsx
XLSX spreadsheet 45 KB Posted
- Solicitation number
- HT9402-26-Q-9404
- Issued by
-
Defense Health Agency
About this file
This is a price list template for the Department of War (DoW) Pharmacy Uniform Formulary Blanket Purchase Agreement for Mimrylo, a hematological agent, in support of the November 4-5, 2026 Pharmacy and Therapeutics (P&T) Committee meeting. The document establishes pricing submission requirements for pharmaceutical manufacturers with a quotes due date of October 26, 2026. Manufacturers must submit pricing for multiple newly approved drug entries (identified as Newly Approved Drugs #1 through #10) across three distinct pricing mechanisms: BPA pricing, ADP non-FAMP discount pricing, and ADP WAC discount pricing. Each pricing section includes scenarios for both Uniform Formulary and Non-Formulary classifications, requiring manufacturers to provide price per NDC package size and price per unit information for Military Treatment Facility and Mail Order dispensing venues.
The pricing template includes multiple appendices requiring manufacturers to provide specific pricing data based on the selected reimbursement methodology. For BPA submissions, manufacturers must indicate pricing for each newly approved drug across formulary categories. For ADP submissions using non-FAMP methodology, manufacturers must provide the Non-FAMP Price of Drug per Federal Ceiling Price (FCP) package, additional offered refund percentages per FCP package, current annual FCP per package, and standard refund calculations, with the quoted additional refund percentage remaining static during the agreement's life. For ADP submissions using WAC methodology, manufacturers must provide Wholesale Acquisition Cost pricing and corresponding discount percentages. Manufacturers are required to submit the Quote Review Checklist and fully executed signature pages along with all quote information. The note to manufacturers emphasizes that price per unit of measure for a given dosage form and strength must be the same across all available package sizes (30s, 100s, 1000s) within each dispensing venue, and agents with RFQ submissions not submitted or selected may be designated as non-step-preferred per the Step Therapy Addendum.
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Text version
BPA
| UF BPA NDC Price List for the November 2026 DoW P&T Meeting | |||
| DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 |
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 |
| Formulary Notes | |||
| Class Note(s): This agent will be reviewed at the upcoming quarterly P&T Committee meeting according to 32 CFR 199.21(g)(5). 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 Completely Excluded from the TRICARE pharmacy benefit program. |
Step Therapy Addendum: Agents with RFQ not submitted or selected may be designated non step-preferred.
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
| #1 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 | 271HANAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 271HANAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote | |||||
| Blanket Purchase Agreement Appendix – Newly Approved Drug |
| #2 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 | 271HANAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 271HANAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote | |||||
| Blanket Purchase Agreement Appendix – Newly Approved Drug |
| #3 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 | 271HANAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 271HANAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #4 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 | 271HANAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 271HANAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote | |||||
| Blanket Purchase Agreement Appendix – Newly Approved Drug |
| #5 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 | 271HANAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 271HANAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #6 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 | 271HANAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 271HANAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #7 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 | 271HANAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 271HANAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #8 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 | 271HANAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 271HANAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote | |||||
| Blanket Purchase Agreement Appendix – Newly Approved Drug |
| #9 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 | 271HANAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 271HANAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote | |||||
| Blanket Purchase Agreement Appendix – Newly Approved Drug |
| #10 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 | 271HANAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 271HANAG1NF1M | 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: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 |
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 |
| Formulary Notes | |||
| Class Note(s): This agent will be reviewed at the upcoming quarterly P&T Committee meeting according to 32 CFR 199.21(g)(5). 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 Completely Excluded from the TRICARE pharmacy benefit program. |
Step Therapy Addendum: Agents with RFQ not submitted or selected may be designated non step-preferred.
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
| #1 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | |||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
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*
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #2 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | |||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
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*
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #3 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | |||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
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*
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #4 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | |||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
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*
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote | ||||
| Additional Discount Program Appendix – Newly Approved Drug |
| #5 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | |||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
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*
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #6 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | |||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
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*
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #7 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | |||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
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*
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #8 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | |||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
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*
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #9 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | |||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
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*
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote | ||||
| Additional Discount Program Appendix – Newly Approved Drug |
| #10 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | |||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
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*
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | 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.
ADP (WAC Discount)
| UF ADP Appendix for the November 2026 DoW P&T Meeting | |||
| DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 |
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 2026 |
| Formulary Notes | |||
| Class Note(s): This agent will be reviewed at the upcoming quarterly P&T Committee meeting according to 32 CFR 199.21(g)(5). 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 Completely Excluded from the TRICARE pharmacy benefit program. |
Step Therapy Addendum: Agents with RFQ not submitted or selected may be designated non step-preferred.
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
| #1 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #2 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #3 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #4 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #5 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #6 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #7 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #8 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #9 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #10 | DoW Uniform Formulary Class: | HEMATOLOGICAL AGENTS | P&T Committee Meeting: | November 4-5, 2026 | ||
| DoW Uniform Formulary Subclass: | NA | Quotes due: | October 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 271HANAG1T21M | Tier 2 | 1 or more | |
| 271HANAG1T31M | 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.
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