Price List - Lerochol - Antilipidemics-1 - PCSK-9.xlsx

BPA

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

Uniform Formulary (UF) and/or Tier 2 candidacy may be considered if ingredient cost < $250 per 30 day supply.

UF/Tier 2 candidates may have fewer HMG-CoA reductase inhibitor products to step through relative to NF/Tier 3 candidates. Annual PA renewal criteria will be removed for UF/Tier 2.

Non-Formulary (NF)/Tier 3, as well as Complete Exclusion may be considered if ingredient cost is > $250 for 30 day supply. Additional PA requirement may include trial of the preferred agent.

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 a new user at any MTF, Retail, or Mail point of service. Unless otherwise noted, patients must have tried an agent in the class in the previous 180 or 365 days (as determined by the P&T Committee) in order to be excluded from the prior authorization process.

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

ADP (non-FAMP Discount)

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

Uniform Formulary (UF) and/or Tier 2 candidacy may be considered if ingredient cost < $250 per 30 day supply.

UF/Tier 2 candidates may have fewer HMG-CoA reductase inhibitor products to step through relative to NF/Tier 3 candidates. Annual PA renewal criteria will be removed for UF/Tier 2.

Non-Formulary (NF)/Tier 3, as well as Complete Exclusion may be considered if ingredient cost is > $250 for 30 day supply. Additional PA requirement may include trial of the preferred agent.

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 a new user at any MTF, Retail, or Mail point of service. Unless otherwise noted, patients must have tried an agent in the class in the previous 180 or 365 days (as determined by the P&T Committee) in order to be excluded from the prior authorization process.

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

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

ADP (WAC Discount)

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

Uniform Formulary (UF) and/or Tier 2 candidacy may be considered if ingredient cost < $250 per 30 day supply.

UF/Tier 2 candidates may have fewer HMG-CoA reductase inhibitor products to step through relative to NF/Tier 3 candidates. Annual PA renewal criteria will be removed for UF/Tier 2.

Non-Formulary (NF)/Tier 3, as well as Complete Exclusion may be considered if ingredient cost is > $250 for 30 day supply. Additional PA requirement may include trial of the preferred agent.

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 a new user at any MTF, Retail, or Mail point of service. Unless otherwise noted, patients must have tried an agent in the class in the previous 180 or 365 days (as determined by the P&T Committee) in order to be excluded from the prior authorization process.

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

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug

Additional Discount Program Appendix – Newly Approved Drug