A-3 Price List - Tryptyr - Ophthalmic - Dry Eye.xlsx

BPA

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

Uniform Formulary (UF) and/or Tier 2 candidacy may be considered if ingredient cost < $200 per 30 day supply.

Non-Formulary (NF)/Tier 3, as well as Complete Exclusion may be considered if ingredient cost is > $200 for 30 day supply.

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 a new and current user at any MTF, Retail, or Mail point of service. Unless otherwise noted, patients must have tried an agent in the class in the previous 180 or 365 days (as determined by the P&T Committee) in order to be excluded from the prior authorization process.

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 – 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

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

ADP (non-FAMP Discount)

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

Uniform Formulary (UF) and/or Tier 2 candidacy may be considered if ingredient cost < $200 per 30 day supply.

Non-Formulary (NF)/Tier 3, as well as Complete Exclusion may be considered if ingredient cost is > $200 for 30 day supply.

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 a new and current user at any MTF, Retail, or Mail point of service. Unless otherwise noted, patients must have tried an agent in the class in the previous 180 or 365 days (as determined by the P&T Committee) in order to be excluded from the prior authorization process.

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 – 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*

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*

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*

ADP (WAC Discount)

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

Uniform Formulary (UF) and/or Tier 2 candidacy may be considered if ingredient cost < $200 per 30 day supply.

Non-Formulary (NF)/Tier 3, as well as Complete Exclusion may be considered if ingredient cost is > $200 for 30 day supply.

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 a new and current user at any MTF, Retail, or Mail point of service. Unless otherwise noted, patients must have tried an agent in the class in the previous 180 or 365 days (as determined by the P&T Committee) in order to be excluded from the prior authorization process.

Notes to Manufacturers: Do not forget to submit 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