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BPA
| UF BPA NDC Price List for the November 2024 DoD P&T Meeting | | | |
| DOD Uniform Formulary Class: | MIGRAINE AGENTS | P&T Committee Meeting: | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | ORAL CGRP | Quotes due: | September 12, 2024 |
| 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 DoD 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 DoD 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 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.
Based on available government prices and historical information, the band of prices for net ingredient cost may trigger formulary considerations.
Scenario 1:
Uniform Formulary and/or Tier 2 one or two before step therapy may be considered if the average monthly cost is competitive with the published average National Contract cost of brand-name injectables CGRPs.
Uniform Formulary and/or Tier 2 one or more after step therapy may be considered if average monthly cost is not competitive with the published average National Contract cost of brand-name injectables CGRPs.
Note: UF/Tier 2 before step selection will either be one that covers both acute and preventive treatment or two agents that together cover acute and preventive treatment.
All Scenarios: Agents with RFQ not submitted or selected 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 – Class Review
| #1 | DOD Uniform Formulary Class: | MIGRAINE AGENTS | | P&T Committee Meeting: | November 6-7, 2024 | |
| DOD Uniform Formulary Subclass: | ORAL CGRP | | Quotes due: | September 12, 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: Up to Two agents UF and before the step. | | | | | | |
| | Scenario 1 | 251MAOCG1UFBS12 | Uniform Formulary | | | | |
| Before Step Therapy | 1 or 2 | | | NO QUOTE | | | | |
| | | 251MAOCG1NFAS1M | Non-Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF. | | | | | | |
| | Scenario 2 | 251MAOCG1UF1M | Uniform Formulary | | | | |
| 1 or more | | | NO QUOTE | | | | |
| | | 251MAOCG1NF1M | 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 | DOD Uniform Formulary Class: | MIGRAINE AGENTS | | P&T Committee Meeting: | November 6-7, 2024 | |
| DOD Uniform Formulary Subclass: | ORAL CGRP | | Quotes due: | September 12, 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: Up to Two agents UF and before the step. | | | | | | |
| | Scenario 1 | 251MAOCG1UFBS12 | Uniform Formulary | | | | |
| Before Step Therapy | 1 or 2 | | | NO QUOTE | | | | |
| | | 251MAOCG1NFAS1M | Non-Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF. | | | | | | |
| | Scenario 2 | 251MAOCG1UF1M | Uniform Formulary | | | | |
| 1 or more | | | NO QUOTE | | | | |
| | | 251MAOCG1NF1M | 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 | DOD Uniform Formulary Class: | MIGRAINE AGENTS | | P&T Committee Meeting: | November 6-7, 2024 | |
| DOD Uniform Formulary Subclass: | ORAL CGRP | | Quotes due: | September 12, 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: Up to Two agents UF and before the step. | | | | | | |
| | Scenario 1 | 251MAOCG1UFBS12 | Uniform Formulary | | | | |
| Before Step Therapy | 1 or 2 | | | NO QUOTE | | | | |
| | | 251MAOCG1NFAS1M | Non-Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF. | | | | | | |
| | Scenario 2 | 251MAOCG1UF1M | Uniform Formulary | | | | |
| 1 or more | | | NO QUOTE | | | | |
| | | 251MAOCG1NF1M | 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 | DOD Uniform Formulary Class: | MIGRAINE AGENTS | | P&T Committee Meeting: | November 6-7, 2024 | |
| DOD Uniform Formulary Subclass: | ORAL CGRP | | Quotes due: | September 12, 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: Up to Two agents UF and before the step. | | | | | | |
| | Scenario 1 | 251MAOCG1UFBS12 | Uniform Formulary | | | | |
| Before Step Therapy | 1 or 2 | | | NO QUOTE | | | | |
| | | 251MAOCG1NFAS1M | Non-Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF. | | | | | | |
| | Scenario 2 | 251MAOCG1UF1M | Uniform Formulary | | | | |
| 1 or more | | | NO QUOTE | | | | |
| | | 251MAOCG1NF1M | 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 | DOD Uniform Formulary Class: | MIGRAINE AGENTS | | P&T Committee Meeting: | November 6-7, 2024 | |
| | | DOD Uniform Formulary Subclass: | ORAL CGRP | | Quotes due: | September 12, 2024 | |
| | | 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: Up to Two agents UF and before the step. | | | | | | |
| | Scenario 1 | 251MAOCG1UFBS12 | Uniform Formulary | | | | |
| Before Step Therapy | 1 or 2 | | 1.00 | NO QUOTE | | | | |
| | | 251MAOCG1NFAS1M | Non-Formulary | | | | |
| After Step Therapy | 1 or more | | 1.00 | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF. | | | | | | |
| | Scenario 2 | 251MAOCG1UF1M | Uniform Formulary | | | | |
| 1 or more | | 1.00 | NO QUOTE | | | | |
| | | 251MAOCG1NF1M | 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 | DOD Uniform Formulary Class: | MIGRAINE AGENTS | | P&T Committee Meeting: | November 6-7, 2024 | |
| DOD Uniform Formulary Subclass: | ORAL CGRP | | Quotes due: | September 12, 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: Up to Two agents UF and before the step. | | | | | | |
| | Scenario 1 | 251MAOCG1UFBS12 | Uniform Formulary | | | | |
| Before Step Therapy | 1 or 2 | | | NO QUOTE | | | | |
| | | 251MAOCG1NFAS1M | Non-Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF. | | | | | | |
| | Scenario 2 | 251MAOCG1UF1M | Uniform Formulary | | | | |
| 1 or more | | | NO QUOTE | | | | |
| | | 251MAOCG1NF1M | 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 | DOD Uniform Formulary Class: | MIGRAINE AGENTS | | P&T Committee Meeting: | November 6-7, 2024 | |
| DOD Uniform Formulary Subclass: | ORAL CGRP | | Quotes due: | September 12, 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: Up to Two agents UF and before the step. | | | | | | |
| | Scenario 1 | 251MAOCG1UFBS12 | Uniform Formulary | | | | |
| Before Step Therapy | 1 or 2 | | | NO QUOTE | | | | |
| | | 251MAOCG1NFAS1M | Non-Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF. | | | | | | |
| | Scenario 2 | 251MAOCG1UF1M | Uniform Formulary | | | | |
| 1 or more | | | NO QUOTE | | | | |
| | | 251MAOCG1NF1M | 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 | DOD Uniform Formulary Class: | MIGRAINE AGENTS | | P&T Committee Meeting: | November 6-7, 2024 | |
| DOD Uniform Formulary Subclass: | ORAL CGRP | | Quotes due: | September 12, 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: Up to Two agents UF and before the step. | | | | | | |
| | Scenario 1 | 251MAOCG1UFBS12 | Uniform Formulary | | | | |
| Before Step Therapy | 1 or 2 | | | NO QUOTE | | | | |
| | | 251MAOCG1NFAS1M | Non-Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF. | | | | | | |
| | Scenario 2 | 251MAOCG1UF1M | Uniform Formulary | | | | |
| 1 or more | | | NO QUOTE | | | | |
| | | 251MAOCG1NF1M | 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 | DOD Uniform Formulary Class: | MIGRAINE AGENTS | | P&T Committee Meeting: | November 6-7, 2024 | |
| DOD Uniform Formulary Subclass: | ORAL CGRP | | Quotes due: | September 12, 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: Up to Two agents UF and before the step. | | | | | | |
| | Scenario 1 | 251MAOCG1UFBS12 | Uniform Formulary | | | | |
| Before Step Therapy | 1 or 2 | | | NO QUOTE | | | | |
| | | 251MAOCG1NFAS1M | Non-Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF. | | | | | | |
| | Scenario 2 | 251MAOCG1UF1M | Uniform Formulary | | | | |
| 1 or more | | | NO QUOTE | | | | |
| | | 251MAOCG1NF1M | 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 | DOD Uniform Formulary Class: | MIGRAINE AGENTS | | P&T Committee Meeting: | November 6-7, 2024 | |
| DOD Uniform Formulary Subclass: | ORAL CGRP | | Quotes due: | September 12, 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: Up to Two agents UF and before the step. | | | | | | |
| | Scenario 1 | 251MAOCG1UFBS12 | Uniform Formulary | | | | |
| Before Step Therapy | 1 or 2 | | | NO QUOTE | | | | |
| | | 251MAOCG1NFAS1M | Non-Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF. | | | | | | |
| | Scenario 2 | 251MAOCG1UF1M | Uniform Formulary | | | | |
| 1 or more | | | NO QUOTE | | | | |
| | | 251MAOCG1NF1M | 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 November 2024 DoD P&T Meeting | | | |
| DOD Uniform Formulary Class: | MIGRAINE AGENTS | P&T Committee Meeting: | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | ORAL CGRP | Quotes due: | September 12, 2024 |
| 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 DoD 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 DoD 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 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.
Based on available government prices and historical information, the band of prices for net ingredient cost may trigger formulary considerations.
Scenario 1:
Uniform Formulary and/or Tier 2 one or two before step therapy may be considered if the average monthly cost is competitive with the published average National Contract cost of brand-name injectables CGRPs.
Uniform Formulary and/or Tier 2 one or more after step therapy may be considered if average monthly cost is not competitive with the published average National Contract cost of brand-name injectables CGRPs.
Note: UF/Tier 2 before step selection will either be one that covers both acute and preventive treatment or two agents that together cover acute and preventive treatment.
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 – Class Review
| #1 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #2 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #3 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #4 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #5 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #6 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #7 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #8 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #9 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #10 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
ADP (WAC Discount)
| UF ADP Appendix for the November 2024 DoD P&T Meeting | | | |
| DOD Uniform Formulary Class: | MIGRAINE AGENTS | P&T Committee Meeting: | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | ORAL CGRP | Quotes due: | September 12, 2024 |
| 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 DoD 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 DoD 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 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.
Based on available government prices and historical information, the band of prices for net ingredient cost may trigger formulary considerations.
Scenario 1:
Uniform Formulary and/or Tier 2 one or two before step therapy may be considered if the average monthly cost is competitive with the published average National Contract cost of brand-name injectables CGRPs.
Uniform Formulary and/or Tier 2 one or more after step therapy may be considered if average monthly cost is not competitive with the published average National Contract cost of brand-name injectables CGRPs.
Note: UF/Tier 2 before step selection will either be one that covers both acute and preventive treatment or two agents that together cover acute and preventive treatment.
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 – Class Review
| #1 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #2 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #3 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #4 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #5 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #6 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #7 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #8 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #9 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #10 | DOD Uniform Formulary Class: | | MIGRAINE AGENTS | | P&T Committee Meeting: | | November 6-7, 2024 |
| DOD Uniform Formulary Subclass: | | ORAL CGRP | | Quotes due: | | September 12, 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 | 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: Up to Two agents T2 and before the step. | | | | | | | | |
| | Scenario 1 | 251MAOCG1T2BS12 | Tier 2 | | | | | | |
| Before Step Therapy | 1 or 2 | | | | | | | | | |
| | | 251MAOCG1T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 251MAOCG1T21M | Tier 2 | 1 or more | | | | | |
| | | 251MAOCG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Defense Health Agency