PL - Ophthalmic - Dry Eye.xlsx

XLSX spreadsheet 44 KB Posted Nov 12, 2026

Attached to: Department of War Pharmacy Uniform Formulary Blanket Purchase Agreement/Uniform Formulary Additional Discount Program
Solicitation number: HT9402-27-Q-9101
Issued by: Defense Health Agency

About this file

Written by GovTribe AI · Nov 12, 2026

This file is a Department of War Pharmacy Uniform Formulary (UF) pricing template and request for quotation (RFQ) appendix for ophthalmic dry eye pharmaceutical agents. The solicitation number is HT9402-27-Q-9101, issued by the Defense Health Agency for the February 3-4, 2027 P&T Committee meeting. The quote submission deadline is December 7, 2026, with a pre-quotation teleconference scheduled for November 17, 2026.

The pricing template addresses two procurement vehicles: the UF Blanket Purchase Agreement (BPA) for Military Treatment Facility and Mail Order formularies, and the Uniform Formulary Additional Discount Program (ADP) for TRICARE Retail refunds. For the BPA, manufacturers must submit pricing for multiple formulary scenarios including Uniform Formulary Before-Step and After-Step Therapy designations, as well as Non-Formulary designations. For the ADP, pricing is required based on Non-FAMP pricing, additional offered refunds per FCP package, and current annual Federal Ceiling Price per FCP package across Tier 2 and Tier 3 cost-sharing categories. The template includes ten class reviews with identical scenario structures. Manufacturers must also submit a completed Quote Review Checklist and fully executed signature pages. The pricing per unit must be uniform across all available package sizes within a given dispensing venue. Generic agents are eligible for use before step therapy and will be evaluated at the lowest available price. Step therapy grandfathering provisions allow current patients to remain on existing therapy while requiring new patients to trial step-preferred agents first.

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BPA

UF BPA NDC Price List for the February 2027 DoW P&T Meeting
DoW Uniform Formulary Class:	OPHTHALMIC	P&T Committee Meeting:	February 3-4, 2027
DoW Uniform Formulary Subclass:	DRY EYE	Quotes due:	December 7, 2026
Formulary Notes
Class Note(s): 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 for complete exclusion from the TRICARE pharmacy benefit program.

Step Therapy Addendum: Grandfathering: a prior authorization process that allows current patients to remain on current therapy and requires new patients to complete an adequate trial of the step-preferred (before-step) agent before a non-step-preferred (after-step) agent is provided to the patient at any MTF, Retail, or Mail point of service. A current user is defined as a patient who has had a prescription for an agent in this Dry Eye Subclass within the past 365 days. The P&T Committee may consider approving specialist bypass for the step-preferred (before-step) agent.

All generic agents are eligible to be used before the step therapy and are not included in the Condition Set scenarios. Generic agents will be used in cost analysis at the lowest available price. If a generic formulation of a branded product becomes available, the government reserves the right to use the generic formulation of the branded product as the step-preferred agent.

*Note: Step Therapy may be applicable to agents that share the same FDA-approved indication(s).

Agents with RFQ not submitted or selected may be designated non-step preferred (after-step).

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 – Class Review

#1	DoW Uniform Formulary Class:	OPHTHALMIC		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	DRY EYE		Quotes due:	December 7, 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: One agent UF and before the step.
		Scenario 1	272OPDEG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272OPDEG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272OPDEG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272OPDEG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			272OPDEG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#2	DoW Uniform Formulary Class:	OPHTHALMIC		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	DRY EYE		Quotes due:	December 7, 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: One agent UF and before the step.
		Scenario 1	272OPDEG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272OPDEG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272OPDEG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272OPDEG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			272OPDEG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#3	DoW Uniform Formulary Class:	OPHTHALMIC		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	DRY EYE		Quotes due:	December 7, 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: One agent UF and before the step.
		Scenario 1	272OPDEG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272OPDEG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272OPDEG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272OPDEG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			272OPDEG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#4	DoW Uniform Formulary Class:	OPHTHALMIC		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	DRY EYE		Quotes due:	December 7, 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: One agent UF and before the step.
		Scenario 1	272OPDEG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272OPDEG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272OPDEG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272OPDEG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			272OPDEG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

		#5	DoW Uniform Formulary Class:	OPHTHALMIC		P&T Committee Meeting:	February 3-4, 2027
			DoW Uniform Formulary Subclass:	DRY EYE		Quotes due:	December 7, 2026
			NDC Number	Drug Name	Strength	Dosage Form	Package Size	Military Treatment Facility & Mail Order
							1.00
		Formulary Scenarios	Condition Set #	Formulary Category Description	One of (x) Number of Brand Agents	Price per NDC	Package Size	Price per Unit
		Scenario 1: One agent UF and before the step.
		Scenario 1	272OPDEG1UFBS1	Uniform Formulary
Before-Step Therapy	1		1.00	NO QUOTE
			272OPDEG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more		1.00	NO QUOTE
			272OPDEG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more		1.00	NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272OPDEG1UF1M	Uniform Formulary	1 or more		1.00	NO QUOTE
			272OPDEG1NF1M	Non-Formulary	1 or more		1.00	NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#6	DoW Uniform Formulary Class:	OPHTHALMIC		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	DRY EYE		Quotes due:	December 7, 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: One agent UF and before the step.
		Scenario 1	272OPDEG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272OPDEG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272OPDEG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272OPDEG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			272OPDEG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#7	DoW Uniform Formulary Class:	OPHTHALMIC		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	DRY EYE		Quotes due:	December 7, 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: One agent UF and before the step.
		Scenario 1	272OPDEG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272OPDEG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272OPDEG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272OPDEG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			272OPDEG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#8	DoW Uniform Formulary Class:	OPHTHALMIC		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	DRY EYE		Quotes due:	December 7, 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: One agent UF and before the step.
		Scenario 1	272OPDEG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272OPDEG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272OPDEG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272OPDEG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			272OPDEG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#9	DoW Uniform Formulary Class:	OPHTHALMIC		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	DRY EYE		Quotes due:	December 7, 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: One agent UF and before the step.
		Scenario 1	272OPDEG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272OPDEG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272OPDEG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272OPDEG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			272OPDEG1NF1M	Non-Formulary	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Class Review

#10	DoW Uniform Formulary Class:	OPHTHALMIC		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	DRY EYE		Quotes due:	December 7, 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: One agent UF and before the step.
		Scenario 1	272OPDEG1UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272OPDEG1UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272OPDEG1NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272OPDEG1UF1M	Uniform Formulary	1 or more			NO QUOTE
			272OPDEG1NF1M	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 February 2027 DoW P&T Meeting
DoW Uniform Formulary Class:	OPHTHALMIC	P&T Committee Meeting:	February 3-4, 2027
DoW Uniform Formulary Subclass:	DRY EYE	Quotes due:	December 7, 2026
Formulary Notes
Class Note(s): 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 for complete exclusion from the TRICARE pharmacy benefit program.

*Note: Step Therapy may be applicable to agents that share the same FDA-approved indication(s).

Agents with RFQ not submitted or selected may be designated non-step preferred (after-step).

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 – Class Review

#1	DoW Uniform Formulary Class:		OPHTHALMIC		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		DRY EYE		Quotes due:		December 7, 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	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: One agent T2 and before the step.
		Scenario 1	272OPDEG1T2BS1	Tier 2
Before-Step Therapy	1
			272OPDEG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			272OPDEG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272OPDEG1T21M	Tier 2	1 or more
			272OPDEG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#2	DoW Uniform Formulary Class:		OPHTHALMIC		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		DRY EYE		Quotes due:		December 7, 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	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: One agent T2 and before the step.
		Scenario 1	272OPDEG1T2BS1	Tier 2
Before-Step Therapy	1
			272OPDEG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			272OPDEG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272OPDEG1T21M	Tier 2	1 or more
			272OPDEG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#3	DoW Uniform Formulary Class:		OPHTHALMIC		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		DRY EYE		Quotes due:		December 7, 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	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: One agent T2 and before the step.
		Scenario 1	272OPDEG1T2BS1	Tier 2
Before-Step Therapy	1
			272OPDEG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			272OPDEG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272OPDEG1T21M	Tier 2	1 or more
			272OPDEG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#4	DoW Uniform Formulary Class:		OPHTHALMIC		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		DRY EYE		Quotes due:		December 7, 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	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: One agent T2 and before the step.
		Scenario 1	272OPDEG1T2BS1	Tier 2
Before-Step Therapy	1
			272OPDEG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			272OPDEG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272OPDEG1T21M	Tier 2	1 or more
			272OPDEG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#5	DoW Uniform Formulary Class:		OPHTHALMIC		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		DRY EYE		Quotes due:		December 7, 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	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: One agent T2 and before the step.
		Scenario 1	272OPDEG1T2BS1	Tier 2
Before-Step Therapy	1
			272OPDEG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			272OPDEG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272OPDEG1T21M	Tier 2	1 or more
			272OPDEG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#6	DoW Uniform Formulary Class:		OPHTHALMIC		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		DRY EYE		Quotes due:		December 7, 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	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: One agent T2 and before the step.
		Scenario 1	272OPDEG1T2BS1	Tier 2
Before-Step Therapy	1
			272OPDEG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			272OPDEG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272OPDEG1T21M	Tier 2	1 or more
			272OPDEG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#7	DoW Uniform Formulary Class:		OPHTHALMIC		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		DRY EYE		Quotes due:		December 7, 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	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: One agent T2 and before the step.
		Scenario 1	272OPDEG1T2BS1	Tier 2
Before-Step Therapy	1
			272OPDEG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			272OPDEG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272OPDEG1T21M	Tier 2	1 or more
			272OPDEG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#8	DoW Uniform Formulary Class:		OPHTHALMIC		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		DRY EYE		Quotes due:		December 7, 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	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: One agent T2 and before the step.
		Scenario 1	272OPDEG1T2BS1	Tier 2
Before-Step Therapy	1
			272OPDEG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			272OPDEG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272OPDEG1T21M	Tier 2	1 or more
			272OPDEG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#9	DoW Uniform Formulary Class:		OPHTHALMIC		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		DRY EYE		Quotes due:		December 7, 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	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: One agent T2 and before the step.
		Scenario 1	272OPDEG1T2BS1	Tier 2
Before-Step Therapy	1
			272OPDEG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			272OPDEG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272OPDEG1T21M	Tier 2	1 or more
			272OPDEG1T31M	Tier 3	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Class Review

#10	DoW Uniform Formulary Class:		OPHTHALMIC		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		DRY EYE		Quotes due:		December 7, 2026
	NDC Number	Drug Name	Strength	Dosage Form	Package Size	TRICARE RETAIL REFUND

		Formulary Scenarios	Condition Set #	Formulary Category	One of (x) Number of Branded 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: One agent T2 and before the step.
		Scenario 1	272OPDEG1T2BS1	Tier 2
Before-Step Therapy	1
			272OPDEG1T2AS1M	Tier 2
After-Step Therapy	1 or more
			272OPDEG1T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272OPDEG1T21M	Tier 2	1 or more
			272OPDEG1T31M	Tier 3	1 or more
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&"-,Italic"Use or disclosure of data contained on this sheet is subject to the restriction on the title page of this quote.

File details come from the government source that posted it. Updated Nov 12, 2026.