A-3 Price List - Fasenra 10mg - Atopy - NA.xlsx
XLSX spreadsheet 48 KB Posted
- Solicitation number
- HT9402-24-Q-9304
- Issued by
-
Defense Health Agency
About this file
This document is a Request for Quotation (RFQ) from the Defense Health Agency (DHA) for Uniform Formulary Blanket Purchase Agreements (UF BPA) and Uniform Formulary Additional Discount Program Agreements (UF ADP) for newly approved pharmaceutical agents. The RFQ covers drugs in the Atopy drug class that will be reviewed at the August 2024 DoD Pharmacy and Therapeutics (P&T) Committee meeting. Manufacturers must provide pricing quotes by July 18, 2024 for Uniform Formulary and Non-Formulary status, as well as additional discounts and refunds for the TRICARE Retail program. The RFQ outlines the process, requirements, and templates for the quotation submission. A pre-quotation teleconference will be held on July 10, 2024. The DHA may award BPAs and ADP agreements based on the P&T Committee's formulary decisions.
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BPA
| UF BPA NDC Price List for the August 2024 DoD P&T Meeting | |||
| DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 |
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 |
| Formulary Notes | |||
| Class Note(s): Prior Authorization (PA) may apply and allows for a step that includes any/all generic agents for all new and current users. Agents where no brand currently exists may be considered for tier designation. 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 complete exclusion from the TRICARE pharmacy benefit program. This class may have an identified Joint National Contract at MTF and Mail that will be designated outside of the P&T committee process. |
Step Therapy Addendum: Agents designated for Non-Formulary 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 – Newly Approved Drug
| #1 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 211RINAG1NF1M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 211RINAG1NF1M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 211RINAG1NF1M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 211RINAG1NF1M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 211RINAG1NF1M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 211RINAG1NF1M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 211RINAG1NF1M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 211RINAG1NF1M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 211RINAG1NF1M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 211RINAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
ADP (non-FAMP Discount)
| UF ADP Appendix for the August 2024 DoD P&T Meeting | |||
| DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 |
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 |
| Formulary Notes | |||
| Class Note(s): Prior Authorization (PA) may apply and allows for a step that includes any/all generic agents for all new and current users. Agents where no brand currently exists may be considered for tier designation. 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 complete exclusion from the TRICARE pharmacy benefit program. This class may have an identified Joint National Contract at MTF and Mail that will be designated outside of the P&T committee 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
| #1 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | |||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | ||||
| 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 | 211RINAG1T21M | Tier 2 | 1 or more | |
| 211RINAG1T31M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | |||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | ||||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #3 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | |||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | ||||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #4 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | |||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | ||||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #5 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | |||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | ||||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #6 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | |||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | ||||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #7 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | |||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | ||||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #8 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | |||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | ||||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #9 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | |||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | ||||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #10 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | |||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | ||||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
ADP (WAC Discount)
| UF ADP Appendix for the August 2024 DoD P&T Meeting | |||
| DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 |
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 |
| Formulary Notes | |||
| Class Note(s): Prior Authorization (PA) may apply and allows for a step that includes any/all generic agents for all new and current users. Agents where no brand currently exists may be considered for tier designation. 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 complete exclusion from the TRICARE pharmacy benefit program. This class may have an identified Joint National Contract at MTF and Mail that will be designated outside of the P&T committee 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
| #1 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1T21M | Tier 2 | 1 or more | |
| 211RINAG1T31M | 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 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #3 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #4 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #5 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #6 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #7 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #8 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #9 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #10 | DOD Uniform Formulary Class: | Atopy | P&T Committee Meeting: | August 7-8, 2024 | ||
| DOD Uniform Formulary Subclass: | NA | Quotes due: | July 18, 2024 | |||
| 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 | 211RINAG1T21M | Tier 2 | 0 | |
| 211RINAG1T31M | Tier 3 | 0 | ||
| If cell highlights red, please confirm intent not to submit a quote |
File details come from the government source that posted it. Updated .