Price List - Wezlana - Targeted Immunomodulatory Biologics - IL-23.xlsx

BPA

Step Therapy Addendum: Grandfathering: 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 the patient at any MTF, Retail, or Mail point of service.

Biosimilar Step Therapy Addendum: Since biosimilars are equivalent to the reference product, no grandfathering will apply. No Grandfathering: a prior authorization may process require new and current patients to complete an adequate trial of the step-preferred biosimilar(s) before a non-step-preferred biosimilar is provided to the patient at any MTF, Retail, or Mail point of service.

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)

Step Therapy Addendum: Grandfathering: 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 the patient at any MTF, Retail, or Mail point of service.

Biosimilar Step Therapy Addendum: Since biosimilars are equivalent to the reference product, no grandfathering will apply. No Grandfathering: a prior authorization process may require new and current patients to complete an adequate trial of the step-preferred biosimilar(s) before a non-step-preferred biosimilar is provided to the patient at any MTF, Retail, or Mail point of service.

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)

Step Therapy Addendum: Grandfathering: 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 the patient at any MTF, Retail, or Mail point of service.

Biosimilar Step Therapy Addendum: Since biosimilars are equivalent to the reference product, no grandfathering will apply. No Grandfathering: a prior authorization process may require new and current patients to complete an adequate trial of the step-preferred biosimilar(s) before a non-step-preferred biosimilar is provided to the patient at any MTF, Retail, or Mail point of service.

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