Price List - Filkri - White Blood Cell Stimulants - Filgrastims.xlsx

BPA

Step Therapy Addendum: Grandfathering: a prior authorization process requires new patients to complete an adequate trial of the step-preferred agent(s) before a non-step-preferred agent is provided to the patient at any MTF, Retail, or Mail point of service.

Based on available government prices and historical information, the band of prices for net ingredient cost may trigger formulary considerations.

Uniform Formulary before step and/or Tier 2 before step candidacy may be considered if ingredient cost is < $90 per 300mcg. Uniform Formulary after step and/or Tier 2 after step candidacy may be considered if ingredient cost is $90-$130 per 300mcg. Non-Formulary after step and/or Tier 3 after step, as well as completely excluded (not covered) may be considered if ingredient cost is > $130 for 300mcg.

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

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 – Newly Approved Drug

Blanket Purchase Agreement Appendix – Newly Approved Drug

Blanket Purchase Agreement Appendix – Newly Approved Drug

Blanket Purchase Agreement Appendix – Newly Approved Drug

Blanket Purchase Agreement Appendix – Newly Approved Drug

&"-,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)

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.

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 – Newly Approved Drug

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

After Step

After Step

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

After Step

After Step

After Step

After Step

&"-,Italic"Use or disclosure of data contained on this sheet is subject to the restriction on the title page of this quote.

ADP (WAC Discount)

Step Therapy Addendum: Grandfathering: a prior authorization process requires new patients to complete an adequate trial of the step-preferred agent(s) before a non-step-preferred agent is provided to the patient at any MTF, Retail, or Mail point of service.

Based on available government prices and historical information, the band of prices for net ingredient cost may trigger formulary considerations.

Notes to Manufacturers: Do not forget to submit the Quote Review Checklist and fully executed signature pages, along with quote information.

The Wholesale Acquisition Cost (WAC) is obtained from First Databank via daily price updates; it is maintained at the dispensing unit level to five (5) decimal places. If the WAC changes during a calendar quarter, an average WAC will be calculated on a daily weighted basis (per unit only).

WAC is ONLY used for products that do not have a FCP, such as diabetic supplies (i.e., test strips), and can also be applied to covered drugs.

*The quoted WAC Discount percentage will remain static during the life of the agreement.

Additional Discount Program Appendix – Newly Approved Drug

Before Step

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

Before Step

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

Before Step

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

Before Step

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

Before Step

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

Before Step

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

Before Step

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

Before Step

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

Before Step

After Step

After Step

Additional Discount Program Appendix – Newly Approved Drug

Before Step

After Step

After Step

&"-,Italic"Use or disclosure of data contained on this sheet is subject to the restriction on the title page of this quote.