PL - Testosterone Replacement Therapy - Orals.xlsx

XLSX spreadsheet 45 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 pricing template and request for quotation (RFQ) appendix for pharmaceutical agents in the Testosterone Replacement Therapy – Orals therapeutic class for the Department of War (DoW) Uniform Formulary (UF). The Defense Health Agency is soliciting quotes for oral testosterone replacement therapy agents (Jatenzo, Kyzatrex, and Tlando) to be reviewed by the DoW Pharmacy and Therapeutics (P&T) Committee at its February 3-4, 2027 meeting. Quotes are due by December 7, 2026, with a pre-quotation teleconference scheduled for November 17, 2026. The file contains multiple condition set scenarios across ten class reviews, with pricing templates for both Blanket Purchase Agreement (BPA) and Additional Discount Program (ADP) structures, including Uniform Formulary (UF), Non-Formulary (NF), and tiered pricing categories (Tier 2 and Tier 3).

Manufacturers are required to submit price quotes on a per-unit basis across multiple dispensing venues (Military Treatment Facilities and Mail Order) and must include fully executed signature pages and a Quote Review Checklist with their submissions. The template accommodates step therapy scenarios where agents may be designated as before-step (preferred) or after-step (non-preferred) therapeutic options. For the ADP component, manufacturers must provide non-FAMP (Federal Minimum Advertised Price) pricing, current Federal Ceiling Price (FCP) information, and additional refund percentages for TRICARE retail reimbursement. Prior authorization may apply, and the P&T Committee may recommend preferential tiering for high-value products or complete exclusion from the TRICARE pharmacy benefit program based on clinical and cost effectiveness analysis.

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BPA

UF BPA NDC Price List for the February 2027 DoW P&T Meeting
DoW Uniform Formulary Class:	TESTOSTERONE REPLACEMENT THERAPY	P&T Committee Meeting:	February 3-4, 2027
DoW Uniform Formulary Subclass:	ORALS	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: No Grandfathering: a prior authorization process that requires all current patients and all 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. 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: Prescribing for active-duty service members shall follow current DoW directives.

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:	TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	ORALS		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	272TRORG0UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272TRORG0UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272TRORG0NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272TRORG0UF1M	Uniform Formulary	1 or more			NO QUOTE
			272TRORG0NF1M	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:	TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	ORALS		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	272TRORG0UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272TRORG0UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272TRORG0NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272TRORG0UF1M	Uniform Formulary	1 or more			NO QUOTE
			272TRORG0NF1M	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:	TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	ORALS		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	272TRORG0UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272TRORG0UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272TRORG0NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272TRORG0UF1M	Uniform Formulary	1 or more			NO QUOTE
			272TRORG0NF1M	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:	TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	ORALS		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	272TRORG0UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272TRORG0UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272TRORG0NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272TRORG0UF1M	Uniform Formulary	1 or more			NO QUOTE
			272TRORG0NF1M	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:	TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:	February 3-4, 2027
			DoW Uniform Formulary Subclass:	ORALS		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	272TRORG0UFBS1	Uniform Formulary
Before-Step Therapy	1		1.00	NO QUOTE
			272TRORG0UFAS1M	Uniform Formulary
After-Step Therapy	1 or more		1.00	NO QUOTE
			272TRORG0NFAS1M	Non-Formulary
After-Step Therapy	1 or more		1.00	NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272TRORG0UF1M	Uniform Formulary	1 or more		1.00	NO QUOTE
			272TRORG0NF1M	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:	TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	ORALS		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	272TRORG0UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272TRORG0UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272TRORG0NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272TRORG0UF1M	Uniform Formulary	1 or more			NO QUOTE
			272TRORG0NF1M	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:	TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	ORALS		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	272TRORG0UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272TRORG0UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272TRORG0NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272TRORG0UF1M	Uniform Formulary	1 or more			NO QUOTE
			272TRORG0NF1M	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:	TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	ORALS		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	272TRORG0UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272TRORG0UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272TRORG0NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272TRORG0UF1M	Uniform Formulary	1 or more			NO QUOTE
			272TRORG0NF1M	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:	TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	ORALS		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	272TRORG0UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272TRORG0UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272TRORG0NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272TRORG0UF1M	Uniform Formulary	1 or more			NO QUOTE
			272TRORG0NF1M	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:	TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:	February 3-4, 2027
	DoW Uniform Formulary Subclass:	ORALS		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	272TRORG0UFBS1	Uniform Formulary
Before-Step Therapy	1			NO QUOTE
			272TRORG0UFAS1M	Uniform Formulary
After-Step Therapy	1 or more			NO QUOTE
			272TRORG0NFAS1M	Non-Formulary
After-Step Therapy	1 or more			NO QUOTE
		Scenario 2: One or more agents UF.
		Scenario 2	272TRORG0UF1M	Uniform Formulary	1 or more			NO QUOTE
			272TRORG0NF1M	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:	TESTOSTERONE REPLACEMENT THERAPY	P&T Committee Meeting:	February 3-4, 2027
DoW Uniform Formulary Subclass:	ORALS	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: *Prescribing for active-duty service members shall follow current DoW directives.

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:		TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		ORALS		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	272TRORG0T2BS1	Tier 2
Before-Step Therapy	1
			272TRORG0T2AS1M	Tier 2
After-Step Therapy	1 or more
			272TRORG0T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272TRORG0T21M	Tier 2	1 or more
			272TRORG0T31M	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:		TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		ORALS		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	272TRORG0T2BS1	Tier 2
Before-Step Therapy	1
			272TRORG0T2AS1M	Tier 2
After-Step Therapy	1 or more
			272TRORG0T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272TRORG0T21M	Tier 2	1 or more
			272TRORG0T31M	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:		TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		ORALS		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	272TRORG0T2BS1	Tier 2
Before-Step Therapy	1
			272TRORG0T2AS1M	Tier 2
After-Step Therapy	1 or more
			272TRORG0T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272TRORG0T21M	Tier 2	1 or more
			272TRORG0T31M	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:		TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		ORALS		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	272TRORG0T2BS1	Tier 2
Before-Step Therapy	1
			272TRORG0T2AS1M	Tier 2
After-Step Therapy	1 or more
			272TRORG0T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272TRORG0T21M	Tier 2	1 or more
			272TRORG0T31M	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:		TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		ORALS		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	272TRORG0T2BS1	Tier 2
Before-Step Therapy	1
			272TRORG0T2AS1M	Tier 2
After-Step Therapy	1 or more
			272TRORG0T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272TRORG0T21M	Tier 2	1 or more
			272TRORG0T31M	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:		TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		ORALS		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	272TRORG0T2BS1	Tier 2
Before-Step Therapy	1
			272TRORG0T2AS1M	Tier 2
After-Step Therapy	1 or more
			272TRORG0T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272TRORG0T21M	Tier 2	1 or more
			272TRORG0T31M	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:		TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		ORALS		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	272TRORG0T2BS1	Tier 2
Before-Step Therapy	1
			272TRORG0T2AS1M	Tier 2
After-Step Therapy	1 or more
			272TRORG0T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272TRORG0T21M	Tier 2	1 or more
			272TRORG0T31M	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:		TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		ORALS		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	272TRORG0T2BS1	Tier 2
Before-Step Therapy	1
			272TRORG0T2AS1M	Tier 2
After-Step Therapy	1 or more
			272TRORG0T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272TRORG0T21M	Tier 2	1 or more
			272TRORG0T31M	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:		TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		ORALS		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	272TRORG0T2BS1	Tier 2
Before-Step Therapy	1
			272TRORG0T2AS1M	Tier 2
After-Step Therapy	1 or more
			272TRORG0T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272TRORG0T21M	Tier 2	1 or more
			272TRORG0T31M	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:		TESTOSTERONE REPLACEMENT THERAPY		P&T Committee Meeting:		February 3-4, 2027
	DoW Uniform Formulary Subclass:		ORALS		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	272TRORG0T2BS1	Tier 2
Before-Step Therapy	1
			272TRORG0T2AS1M	Tier 2
After-Step Therapy	1 or more
			272TRORG0T3AS1M	Tier 3
After-Step Therapy	1 or more
		Scenario 2: One or more agents T2.
		Scenario 2	272TRORG0T21M	Tier 2	1 or more
			272TRORG0T31M	Tier 3	1 or more
							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.

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