Price List - Hympavzi - Antihemophilic Factors - NA.xlsx
XLSX spreadsheet 47 KB Posted
- Solicitation number
- HT9402-25-Q-9103
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Defense Health Agency
About this file
This is a pricing template spreadsheet for manufacturers to submit quotes for antihemophilic factor drugs being considered for the Department of Defense (DoD) Uniform Formulary. The template includes sections for Blanket Purchase Agreement (BPA) pricing and Additional Discount Program (ADP) quotes for up to 10 newly approved drugs, with quotes due by January 16, 2025 for review at the DoD Pharmacy & Therapeutics Committee meeting on February 5-6, 2025.
The template requires manufacturers to provide pricing information for both Military Treatment Facility/Mail Order scenarios (uniform formulary vs. non-formulary) and TRICARE retail refund scenarios (Tier 2 vs. Tier 3). Manufacturers must submit pricing per NDC package size and unit, with options for additional refunds based on Federal Ceiling Price (FCP) or Wholesale Acquisition Cost (WAC) discounts. The template includes notes that prior authorization may apply and that drugs may be considered for special reimbursement methods or formulary exclusion based on the P&T Committee's review.
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BPA
| UF BPA NDC Price List for the February 2025 DoD P&T Meeting | |||
| DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 |
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 |
| Formulary Notes | |||
| Class Note(s): This agent will be reviewed at the upcoming quarterly P&T Committee meeting according to 32 CFR 199.21(g)(5). 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 complete exclusion from the TRICARE pharmacy benefit program. |
Step Therapy Addendum: Agents with RFQ not submitted or selected may be designated non-step preferred (after-step).
Notes to Manufacturers: Do not forget to submit fully executed signature pages along with quote information.
The price per unit of measure for a given dosage form and strength (each, gram, mL, etc.) of the pharmaceutical agent will be the same for all available package sizes (e.g., 30s, 100s, 1000s) within a given dispensing venue.
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #1 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 | 252AFNAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 252AFNAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #2 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 | 252AFNAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 252AFNAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #3 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 | 252AFNAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 252AFNAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #4 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 | 252AFNAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 252AFNAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #5 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 | 252AFNAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 252AFNAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #6 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 | 252AFNAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 252AFNAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #7 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 | 252AFNAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 252AFNAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #8 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 | 252AFNAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 252AFNAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #9 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 | 252AFNAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 252AFNAG1NF1M | Non-Formulary | 1 or more | NO QUOTE | ||
| If cell highlights red, please confirm intent not to submit a quote |
Blanket Purchase Agreement Appendix – Newly Approved Drug
| #10 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 | 252AFNAG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 252AFNAG1NF1M | 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 February 2025 DoD P&T Meeting | |||
| DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 |
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 |
| Formulary Notes | |||
| Class Note(s): This agent will be reviewed at the upcoming quarterly P&T Committee meeting according to 32 CFR 199.21(g)(5). 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 complete exclusion from the TRICARE pharmacy benefit program. |
Step Therapy Addendum: Agents with RFQ not submitted or selected may be designated non-step preferred (after-step).
Notes to Manufacturers: Do not forget to submit fully executed signature pages along with quote information.
* Total Calculated Refund Per FCP is calculated as: ((non-FAMP-FCP)+(non-FAMP*Y%)) = Total Calculated Refund **Based on the most recent annual non-FAMP (reported to the Department of Veterans Affairs) from which the current annual Federal Ceiling Price (FCP) calculated ceiling is derived. The current annual FCP and the annual non-FAMP from which it is derived will be applicable to all prescriptions filled during a calendar year. The quoted additional refund percentage will remain static during the life of the agreement but the most recent annual non-FAMP, and thus the calculated refund, may change each calendar year.
Additional Discount Program Appendix – Newly Approved Drug
| #1 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | |||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Non-FAMP Price of Drug Per FCP Package** Additional Offered Refund Per FCP Package** Current Annual Federal Ceiling Price Per FCP Package** Standard Refund Per FCP Total Calculated Retail Refund Per FCP Package*
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #2 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | |||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Non-FAMP Price of Drug Per FCP Package** Additional Offered Refund Per FCP Package** Current Annual Federal Ceiling Price Per FCP Package** Standard Refund Per FCP Total Calculated Retail Refund Per FCP Package*
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #3 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | |||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Non-FAMP Price of Drug Per FCP Package** Additional Offered Refund Per FCP Package** Current Annual Federal Ceiling Price Per FCP Package** Standard Refund Per FCP Total Calculated Retail Refund Per FCP Package*
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #4 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | |||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Non-FAMP Price of Drug Per FCP Package** Additional Offered Refund Per FCP Package** Current Annual Federal Ceiling Price Per FCP Package** Standard Refund Per FCP Total Calculated Retail Refund Per FCP Package*
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #5 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | |||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Non-FAMP Price of Drug Per FCP Package** Additional Offered Refund Per FCP Package** Current Annual Federal Ceiling Price Per FCP Package** Standard Refund Per FCP Total Calculated Retail Refund Per FCP Package*
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #6 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | |||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Non-FAMP Price of Drug Per FCP Package** Additional Offered Refund Per FCP Package** Current Annual Federal Ceiling Price Per FCP Package** Standard Refund Per FCP Total Calculated Retail Refund Per FCP Package*
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #7 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | |||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Non-FAMP Price of Drug Per FCP Package** Additional Offered Refund Per FCP Package** Current Annual Federal Ceiling Price Per FCP Package** Standard Refund Per FCP Total Calculated Retail Refund Per FCP Package*
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #8 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | |||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Non-FAMP Price of Drug Per FCP Package** Additional Offered Refund Per FCP Package** Current Annual Federal Ceiling Price Per FCP Package** Standard Refund Per FCP Total Calculated Retail Refund Per FCP Package*
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #9 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | |||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Non-FAMP Price of Drug Per FCP Package** Additional Offered Refund Per FCP Package** Current Annual Federal Ceiling Price Per FCP Package** Standard Refund Per FCP Total Calculated Retail Refund Per FCP Package*
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #10 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | |||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | ||||
| NDC Number | Drug Name | Strength | Dosage Form | Package Size | TRICARE RETAIL REFUND |
Formulary Scenarios Condition Set # Formulary Category Description One of (x) Number of Brand Agents Non-FAMP Price of Drug Per FCP Package** Additional Offered Refund Per FCP Package** Current Annual Federal Ceiling Price Per FCP Package** Standard Refund Per FCP Total Calculated Retail Refund Per FCP Package*
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | 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 February 2025 DoD P&T Meeting | |||
| DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 |
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 |
| Formulary Notes | |||
| Class Note(s): This agent will be reviewed at the upcoming quarterly P&T Committee meeting according to 32 CFR 199.21(g)(5). 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 complete exclusion from the TRICARE pharmacy benefit program. |
Step Therapy Addendum: Agents with RFQ not submitted or selected may be designated non-step preferred (after-step).
Notes to Manufacturers: Do not forget to submit fully executed signature pages along with quote information.
The Wholesale Acquisition Cost (WAC) is obtained from First Databank via daily price updates; it is maintained at the dispensing unit level to five (5) decimal places. If the WAC changes during a calendar quarter, an average WAC will be calculated on a daily weighted basis (per unit only).
WAC is ONLY used for products that do not have a FCP, such as diabetic supplies (i.e., test strips), and can also be applied to covered drugs.
*The quoted WAC Discount percentage will remain static during the life of the agreement.
Additional Discount Program Appendix – Newly Approved Drug
| #1 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #2 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #3 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #4 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #5 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #6 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #7 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #8 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #9 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
Additional Discount Program Appendix – Newly Approved Drug
| #10 | DOD Uniform Formulary Class: | ANTIHEMOPHILIC FACTORS | P&T Committee Meeting: | February 5-6, 2025 | ||
| DOD Uniform Formulary Subclass: | N/A | Quotes due: | January 16, 2025 | |||
| 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 252AFNAG1T21M | Tier 2 | 1 or more | |
| 252AFNAG1T31M | Tier 3 | 1 or more | ||
| If cell highlights red, please confirm intent not to submit a quote |
File details come from the government source that posted it. Updated .