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BPA
| UF BPA NDC Price List for the November 2025 DoD P&T Meeting | | | |
| DOD Uniform Formulary Class: | METABOLIC DYSFUNCTION AGENTS | P&T Committee Meeting: | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | Quotes due: | September 22, 2025 |
| 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: No grandfathering: a prior authorization process requires all new and current 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.
All Scenarios: Agents with RFQ not submitted or selected may be designated non-step preferred (i.e. 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 – Class Review
| #1 | DOD Uniform Formulary Class: | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | November 5-6, 2025 | |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | September 22, 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: One agent UF and before the step | | | | | | |
| | Scenario 1 | 261MDIWG0UFBS1 | Uniform Formulary | | | | |
| Before Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 261MDIWG0UFAS1M | Uniform Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 261MDIWG0NFAS1M | Non-Formulary | | | | |
| After Step Formulary | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF | | | | | | |
| | Scenario 2 | 261MDIWG0UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 261MDIWG0NF1M | 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: | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | November 5-6, 2025 | |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | September 22, 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: One agent UF and before the step | | | | | | |
| | Scenario 1 | 261MDIWG0UFBS1 | Uniform Formulary | | | | |
| Before Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 261MDIWG0UFAS1M | Uniform Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 261MDIWG0NFAS1M | Non-Formulary | | | | |
| After Step Formulary | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF | | | | | | |
| | Scenario 2 | 261MDIWG0UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 261MDIWG0NF1M | 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: | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | November 5-6, 2025 | |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | September 22, 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: One agent UF and before the step | | | | | | |
| | Scenario 1 | 261MDIWG0UFBS1 | Uniform Formulary | | | | |
| Before Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 261MDIWG0UFAS1M | Uniform Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 261MDIWG0NFAS1M | Non-Formulary | | | | |
| After Step Formulary | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF | | | | | | |
| | Scenario 2 | 261MDIWG0UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 261MDIWG0NF1M | 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: | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | November 5-6, 2025 | |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | September 22, 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: One agent UF and before the step | | | | | | |
| | Scenario 1 | 261MDIWG0UFBS1 | Uniform Formulary | | | | |
| Before Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 261MDIWG0UFAS1M | Uniform Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 261MDIWG0NFAS1M | Non-Formulary | | | | |
| After Step Formulary | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF | | | | | | |
| | Scenario 2 | 261MDIWG0UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 261MDIWG0NF1M | 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: | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | November 5-6, 2025 | |
| | | DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | September 22, 2025 | |
| | | 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 | 261MDIWG0UFBS1 | Uniform Formulary | | | | |
| Before Step Therapy | 1 | | 1.00 | NO QUOTE | | | | |
| | | 261MDIWG0UFAS1M | Uniform Formulary | | | | |
| After Step Therapy | 1 or more | | 1.00 | NO QUOTE | | | | |
| | | 261MDIWG0NFAS1M | Non-Formulary | | | | |
| After Step Formulary | 1 or more | | 1.00 | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF | | | | | | |
| | Scenario 2 | 261MDIWG0UF1M | Uniform Formulary | 1 or more | | 1.00 | NO QUOTE |
| | | 261MDIWG0NF1M | 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: | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | November 5-6, 2025 | |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | September 22, 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: One agent UF and before the step | | | | | | |
| | Scenario 1 | 261MDIWG0UFBS1 | Uniform Formulary | | | | |
| Before Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 261MDIWG0UFAS1M | Uniform Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 261MDIWG0NFAS1M | Non-Formulary | | | | |
| After Step Formulary | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF | | | | | | |
| | Scenario 2 | 261MDIWG0UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 261MDIWG0NF1M | 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: | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | November 5-6, 2025 | |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | September 22, 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: One agent UF and before the step | | | | | | |
| | Scenario 1 | 261MDIWG0UFBS1 | Uniform Formulary | | | | |
| Before Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 261MDIWG0UFAS1M | Uniform Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 261MDIWG0NFAS1M | Non-Formulary | | | | |
| After Step Formulary | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF | | | | | | |
| | Scenario 2 | 261MDIWG0UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 261MDIWG0NF1M | 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: | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | November 5-6, 2025 | |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | September 22, 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: One agent UF and before the step | | | | | | |
| | Scenario 1 | 261MDIWG0UFBS1 | Uniform Formulary | | | | |
| Before Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 261MDIWG0UFAS1M | Uniform Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 261MDIWG0NFAS1M | Non-Formulary | | | | |
| After Step Formulary | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF | | | | | | |
| | Scenario 2 | 261MDIWG0UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 261MDIWG0NF1M | 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: | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | November 5-6, 2025 | |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | September 22, 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: One agent UF and before the step | | | | | | |
| | Scenario 1 | 261MDIWG0UFBS1 | Uniform Formulary | | | | |
| Before Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 261MDIWG0UFAS1M | Uniform Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 261MDIWG0NFAS1M | Non-Formulary | | | | |
| After Step Formulary | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF | | | | | | |
| | Scenario 2 | 261MDIWG0UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 261MDIWG0NF1M | 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: | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | November 5-6, 2025 | |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | September 22, 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: One agent UF and before the step | | | | | | |
| | Scenario 1 | 261MDIWG0UFBS1 | Uniform Formulary | | | | |
| Before Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 261MDIWG0UFAS1M | Uniform Formulary | | | | |
| After Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 261MDIWG0NFAS1M | Non-Formulary | | | | |
| After Step Formulary | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more agents UF | | | | | | |
| | Scenario 2 | 261MDIWG0UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 261MDIWG0NF1M | 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 2025 DoD P&T Meeting | | | |
| DOD Uniform Formulary Class: | METABOLIC DYSFUNCTION AGENTS | P&T Committee Meeting: | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | INJECTABLE WEIGHT LOSS AGENTS | Quotes due: | September 22, 2025 |
| 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: No grandfathering: a prior authorization process requires all new and current 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.
All Scenarios: Agents with RFQ not submitted or selected may be designated non-step preferred (i.e. 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 – Class Review
| #1 | DOD Uniform Formulary Class: | | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | | September 22, 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 | 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 | 261MDIWG0T2BS1 | Tier 2 | | | | | | |
| Before Step | 1 | | | | | | | | | |
| | | 261MDIWG0T2AS1M | Tier 2 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | | 261MDIWG0T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 261MDIWG0T21M | Tier 2 | 1 or more | | | | | |
| | | 261MDIWG0T31M | 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: | | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | | September 22, 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 | 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 | 261MDIWG0T2BS1 | Tier 2 | | | | | | |
| Before Step | 1 | | | | | | | | | |
| | | 261MDIWG0T2AS1M | Tier 2 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | | 261MDIWG0T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 261MDIWG0T21M | Tier 2 | 1 or more | | | | | |
| | | 261MDIWG0T31M | 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: | | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | | September 22, 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 | 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 | 261MDIWG0T2BS1 | Tier 2 | | | | | | |
| Before Step | 1 | | | | | | | | | |
| | | 261MDIWG0T2AS1M | Tier 2 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | | 261MDIWG0T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 261MDIWG0T21M | Tier 2 | 1 or more | | | | | |
| | | 261MDIWG0T31M | 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: | | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | | September 22, 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 | 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 | 261MDIWG0T2BS1 | Tier 2 | | | | | | |
| Before Step | 1 | | | | | | | | | |
| | | 261MDIWG0T2AS1M | Tier 2 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | | 261MDIWG0T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 261MDIWG0T21M | Tier 2 | 1 or more | | | | | |
| | | 261MDIWG0T31M | 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: | | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | | September 22, 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 | 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 | 261MDIWG0T2BS1 | Tier 2 | | | | | | |
| Before Step | 1 | | | | | | | | | |
| | | 261MDIWG0T2AS1M | Tier 2 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | | 261MDIWG0T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 261MDIWG0T21M | Tier 2 | 1 or more | | | | | |
| | | 261MDIWG0T31M | 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: | | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | | September 22, 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 | 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 | 261MDIWG0T2BS1 | Tier 2 | | | | | | |
| Before Step | 1 | | | | | | | | | |
| | | 261MDIWG0T2AS1M | Tier 2 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | | 261MDIWG0T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 261MDIWG0T21M | Tier 2 | 1 or more | | | | | |
| | | 261MDIWG0T31M | 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: | | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | | September 22, 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 | 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 | 261MDIWG0T2BS1 | Tier 2 | | | | | | |
| Before Step | 1 | | | | | | | | | |
| | | 261MDIWG0T2AS1M | Tier 2 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | | 261MDIWG0T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 261MDIWG0T21M | Tier 2 | 1 or more | | | | | |
| | | 261MDIWG0T31M | 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: | | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | | September 22, 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 | 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 | 261MDIWG0T2BS1 | Tier 2 | | | | | | |
| Before Step | 1 | | | | | | | | | |
| | | 261MDIWG0T2AS1M | Tier 2 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | | 261MDIWG0T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 261MDIWG0T21M | Tier 2 | 1 or more | | | | | |
| | | 261MDIWG0T31M | 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: | | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | | September 22, 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 | 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 | 261MDIWG0T2BS1 | Tier 2 | | | | | | |
| Before Step | 1 | | | | | | | | | |
| | | 261MDIWG0T2AS1M | Tier 2 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | | 261MDIWG0T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 261MDIWG0T21M | Tier 2 | 1 or more | | | | | |
| | | 261MDIWG0T31M | 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: | | METABOLIC DYSFUNCTION AGENTS | | P&T Committee Meeting: | | November 5-6, 2025 |
| DOD Uniform Formulary Subclass: | | INJECTABLE WEIGHT LOSS AGENTS | | Quotes due: | | September 22, 2025 |
| 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 | 261MDIWG0T2BS1 | Tier 2 | | | | | | |
| Before Step | 1 | | | | | | | | | |
| | | 261MDIWG0T2AS1M | Tier 2 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | | 261MDIWG0T3AS1M | Tier 3 | | | | | | |
| After Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more agents T2 | | | | | | | | |
| | Scenario 2 | 261MDIWG0T21M | Tier 2 | 1 or more | | | | | |
| | | 261MDIWG0T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Defense Health Agency