EXHIBIT__L-1_Table_L-1_TPharm4_-_Ammendment_3_(Aug_13 _2013).docx
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EXHIBIT_ L-1_Retail Network Reimbursement Table L-1 - Ammendment 3 (Aug 13 2013)
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Exhibit L-1 TRICARE Pharmacy Program
Retail Network Reimbursement Table L-1
Guaranteed
| Average |
| Guaranteed |
| Average |
| Estimated |
| Price Adjustment |
| Average |
| Drug |
| Total |
| Estimated |
| Average |
| Percentage |
| Dispensing |
| Cost |
| Drug Costs |
| Option Period |
| Type of Rx |
| Quantity |
| WAC |
| ( + / – ) to 2 places |
| Fee |
| (a) |
| (b) |
| (c) |
| (d) |
| (e) = [(b) x (1 + (c))] + (d) |
| (f) = (a) x (e) |
| 1 |
| Non-Specialty Brand |
18,500,000
$280.00
| 1 |
| Non-Specialty Generic |
| 50,900,000 |
| $40.00 |
| 1 |
| Specialty Brand |
| 218,800 |
| $3,784.00 |
| 1 |
| Specialty Generic |
| 28,400 |
| $569.00 |
Subtotal Option Period 1
| 2 |
| Non-Specialty Brand |
19,900,000
$292.00
| 2 |
| Non-Specialty Generic |
| 53,000,000 |
| $42.00 |
| 2 |
| Specialty Brand |
| 227,500 |
| $3,943.00 |
| 2 |
| Specialty Generic |
| 29,500 |
| $593.00 |
Subtotal Option Period 2
| 3 |
| Non-Specialty Brand |
21,300,000
$304.00
| 3 |
| Non-Specialty Generic |
| 57,200,000 |
| $44.00 |
| 3 |
| Specialty Brand |
| 245,700 |
| $4,109.00 |
| 3 |
| Specialty Generic |
| 31,800 |
| $617.00 |
Subtotal Option Period 3
| 4 |
| Non-Specialty Brand |
21,900,000
$317.00
| 4 |
| Non-Specialty Generic |
| 59,500,000 |
| $46.00 |
| 4 |
| Specialty Brand |
| 255,500 |
| $4,281.00 |
| 4 |
| Specialty Generic |
| 33,100 |
| $643.00 |
Subtotal Option Period 4
| 5 |
| Non-Specialty Brand |
22,600,000
$330.00
| 5 |
| Non-Specialty Generic |
| 61,900,000 |
| $48.00 |
| 5 |
| Specialty Brand |
| 265,800 |
| $4,461.00 |
| 5 |
| Specialty Generic |
| 34,400 |
| $670.00 |
Subtotal Option Period 5
| 6 |
| Non-Specialty Brand |
23,300,000
$344.00
| 6 |
| Non-Specialty Generic |
| 64,400,000 |
| $50.00 |
| 6 |
| Specialty Brand |
| 276,400 |
| $4,648.00 |
| 6 |
| Specialty Generic |
| 35,800 |
| $699.00 |
Subtotal Option Period 6
Non-Specialty Brand
24,000,000
$358.00
| 7 |
| Non-Specialty Generic |
| 66,900,000 |
| $51.00 |
| 7 |
| Specialty Brand |
| 287,500 |
| $4,843.00 |
| 7 |
| Specialty Generic |
| 37,300 |
| $728.00 |
Subtotal Option Period 7
(g) Total Expected Government Cost for Reimbursement of Retail Network Pharmacy Costs for Option Periods 1 through 7
See Exhibit L-12 "Instructions for Completing Retail Network Reimbursement Table L-1" and Exhibit L-13 "Background Information for Retail Network Reimbursement, Table L-1".
HT9402-13-R-0001 Page 1
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