The file's text, extracted by GovTribe without its formatting.
BPA
| UF BPA NDC Price List for the August 2026 DoW P&T Meeting | | | |
| DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | P&T Committee Meeting: | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | Quotes due: | June 29, 2026 |
| 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 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 for complete exclusion from the TRICARE pharmacy benefit program. | | | |
Step Therapy Addendum: Grandfathering: a prior authorization process that allows current patients to remain on current therapy and requires new patients to complete an adequate trial of the step-preferred (before-step) regimen before a non-step-preferred (after-step) regimen is provided to the patient at any MTF, Retail, or Mail point of service. The P&T Committee may consider approving specialist bypass for the step-preferred (before-step) regimen.
The condition set is specific for a combination chemotherapy regimen which consists of a BRAF inhibitor and a MEK inhibitor.
*Note: Step Therapy may be applicable to agents that share the same FDA-approved indication(s).
Agents with RFQ not submitted or selected may be designated non-step preferred (after-step).
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 – Class Review
| #1 | DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | Aug 5-6, 2026 | |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | | Quotes due: | June 29, 2026 | |
| 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 BRAF-inhibitor and MEK-inhibitor Combination UF and before the step. | | | | | | |
| | Scenario 1 | 264OABMG1UFBS1 | Uniform Formulary | | | | |
| Before-Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 264OABMG1UFAS1M | Uniform Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 264OABMG1NFAS1M | Non-Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combination UF. | | | | | | |
| | Scenario 2 | 264OABMG1UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 264OABMG1NF1M | 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 | DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | Aug 5-6, 2026 | |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | | Quotes due: | June 29, 2026 | |
| 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 BRAF-inhibitor and MEK-inhibitor Combination UF and before the step. | | | | | | |
| | Scenario 1 | 264OABMG1UFBS1 | Uniform Formulary | | | | |
| Before-Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 264OABMG1UFAS1M | Uniform Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 264OABMG1NFAS1M | Non-Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combination UF. | | | | | | |
| | Scenario 2 | 264OABMG1UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 264OABMG1NF1M | 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 | DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | Aug 5-6, 2026 | |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | | Quotes due: | June 29, 2026 | |
| 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 BRAF-inhibitor and MEK-inhibitor Combination UF and before the step. | | | | | | |
| | Scenario 1 | 264OABMG1UFBS1 | Uniform Formulary | | | | |
| Before-Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 264OABMG1UFAS1M | Uniform Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 264OABMG1NFAS1M | Non-Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combination UF. | | | | | | |
| | Scenario 2 | 264OABMG1UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 264OABMG1NF1M | 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 | DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | Aug 5-6, 2026 | |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | | Quotes due: | June 29, 2026 | |
| 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 BRAF-inhibitor and MEK-inhibitor Combination UF and before the step. | | | | | | |
| | Scenario 1 | 264OABMG1UFBS1 | Uniform Formulary | | | | |
| Before-Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 264OABMG1UFAS1M | Uniform Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 264OABMG1NFAS1M | Non-Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combination UF. | | | | | | |
| | Scenario 2 | 264OABMG1UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 264OABMG1NF1M | 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 | DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | Aug 5-6, 2026 | |
| | | DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | | Quotes due: | June 29, 2026 | |
| | | 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 BRAF-inhibitor and MEK-inhibitor Combination UF and before the step. | | | | | | |
| | Scenario 1 | 264OABMG1UFBS1 | Uniform Formulary | | | | |
| Before-Step Therapy | 1 | | 1.00 | NO QUOTE | | | | |
| | | 264OABMG1UFAS1M | Uniform Formulary | | | | |
| After-Step Therapy | 1 or more | | 1.00 | NO QUOTE | | | | |
| | | 264OABMG1NFAS1M | Non-Formulary | | | | |
| After-Step Therapy | 1 or more | | 1.00 | NO QUOTE | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combination UF. | | | | | | |
| | Scenario 2 | 264OABMG1UF1M | Uniform Formulary | 1 or more | | 1.00 | NO QUOTE |
| | | 264OABMG1NF1M | 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 | DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | Aug 5-6, 2026 | |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | | Quotes due: | June 29, 2026 | |
| 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 BRAF-inhibitor and MEK-inhibitor Combination UF and before the step. | | | | | | |
| | Scenario 1 | 264OABMG1UFBS1 | Uniform Formulary | | | | |
| Before-Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 264OABMG1UFAS1M | Uniform Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 264OABMG1NFAS1M | Non-Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combination UF. | | | | | | |
| | Scenario 2 | 264OABMG1UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 264OABMG1NF1M | 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 | DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | Aug 5-6, 2026 | |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | | Quotes due: | June 29, 2026 | |
| 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 BRAF-inhibitor and MEK-inhibitor Combination UF and before the step. | | | | | | |
| | Scenario 1 | 264OABMG1UFBS1 | Uniform Formulary | | | | |
| Before-Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 264OABMG1UFAS1M | Uniform Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 264OABMG1NFAS1M | Non-Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combination UF. | | | | | | |
| | Scenario 2 | 264OABMG1UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 264OABMG1NF1M | 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 | DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | Aug 5-6, 2026 | |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | | Quotes due: | June 29, 2026 | |
| 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 BRAF-inhibitor and MEK-inhibitor Combination UF and before the step. | | | | | | |
| | Scenario 1 | 264OABMG1UFBS1 | Uniform Formulary | | | | |
| Before-Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 264OABMG1UFAS1M | Uniform Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 264OABMG1NFAS1M | Non-Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combination UF. | | | | | | |
| | Scenario 2 | 264OABMG1UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 264OABMG1NF1M | 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 | DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | Aug 5-6, 2026 | |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | | Quotes due: | June 29, 2026 | |
| 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 BRAF-inhibitor and MEK-inhibitor Combination UF and before the step. | | | | | | |
| | Scenario 1 | 264OABMG1UFBS1 | Uniform Formulary | | | | |
| Before-Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 264OABMG1UFAS1M | Uniform Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 264OABMG1NFAS1M | Non-Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combination UF. | | | | | | |
| | Scenario 2 | 264OABMG1UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 264OABMG1NF1M | 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 | DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | Aug 5-6, 2026 | |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | | Quotes due: | June 29, 2026 | |
| 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 BRAF-inhibitor and MEK-inhibitor Combination UF and before the step. | | | | | | |
| | Scenario 1 | 264OABMG1UFBS1 | Uniform Formulary | | | | |
| Before-Step Therapy | 1 | | | NO QUOTE | | | | |
| | | 264OABMG1UFAS1M | Uniform Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | | 264OABMG1NFAS1M | Non-Formulary | | | | |
| After-Step Therapy | 1 or more | | | NO QUOTE | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combination UF. | | | | | | |
| | Scenario 2 | 264OABMG1UF1M | Uniform Formulary | 1 or more | | | NO QUOTE |
| | | 264OABMG1NF1M | Non-Formulary | 1 or more | | | NO QUOTE |
| | | | | | If cell highlights red, please confirm intent not to submit a quote | | |
&"-,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)
| UF ADP Appendix for the August 2026 DoW P&T Meeting | | | |
| DoW Uniform Formulary Class: | ONCOLOGICAL AGENTS | P&T Committee Meeting: | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | BRAF-MEK INHIBITORS | Quotes due: | June 29, 2026 |
| 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 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 for complete exclusion from the TRICARE pharmacy benefit program. | | | |
Step Therapy Addendum: Grandfathering: a prior authorization process that allows current patients to remain on current therapy and requires new patients to complete an adequate trial of the step-preferred (before-step) regimen before a non-step-preferred (after-step) regimen is provided to the patient at any MTF, Retail, or Mail point of service. The P&T Committee may consider approving specialist bypass for the step-preferred (before-step) regimen.
The condition set is specific for a combination chemotherapy regimen which consists of a BRAF inhibitor and a MEK inhibitor.
*Note: Step Therapy may be applicable to agents that share the same FDA-approved indication(s).
Agents with RFQ not submitted or selected may be designated non-step preferred (after-step).
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 – Class Review
| #1 | DoW Uniform Formulary Class: | | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | | BRAF-MEK INHIBITORS | | Quotes due: | | June 29, 2026 |
| 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 BRAF-inhibitor and MEK-inhibitor Combination T2 and before the step. | | | | | | | | |
| | Scenario 1 | 264OABMG1T2BS1 | Tier 2 | | | | | | |
| Before-Step Therapy | 1 | | | | | | | | | |
| | | 264OABMG1T2AS1M | Tier 2 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | | 264OABMG1T3AS1M | Tier 3 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combinations T2. | | | | | | | | |
| | Scenario 2 | 264OABMG1T21M | Tier 2 | 1 or more | | | | | |
| | | 264OABMG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #2 | DoW Uniform Formulary Class: | | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | | BRAF-MEK INHIBITORS | | Quotes due: | | June 29, 2026 |
| 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 BRAF-inhibitor and MEK-inhibitor Combination T2 and before the step. | | | | | | | | |
| | Scenario 1 | 264OABMG1T2BS1 | Tier 2 | | | | | | |
| Before-Step Therapy | 1 | | | | | | | | | |
| | | 264OABMG1T2AS1M | Tier 2 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | | 264OABMG1T3AS1M | Tier 3 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combinations T2. | | | | | | | | |
| | Scenario 2 | 264OABMG1T21M | Tier 2 | 1 or more | | | | | |
| | | 264OABMG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #3 | DoW Uniform Formulary Class: | | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | | BRAF-MEK INHIBITORS | | Quotes due: | | June 29, 2026 |
| 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 BRAF-inhibitor and MEK-inhibitor Combination T2 and before the step. | | | | | | | | |
| | Scenario 1 | 264OABMG1T2BS1 | Tier 2 | | | | | | |
| Before-Step Therapy | 1 | | | | | | | | | |
| | | 264OABMG1T2AS1M | Tier 2 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | | 264OABMG1T3AS1M | Tier 3 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combinations T2. | | | | | | | | |
| | Scenario 2 | 264OABMG1T21M | Tier 2 | 1 or more | | | | | |
| | | 264OABMG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #4 | DoW Uniform Formulary Class: | | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | | BRAF-MEK INHIBITORS | | Quotes due: | | June 29, 2026 |
| 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 BRAF-inhibitor and MEK-inhibitor Combination T2 and before the step. | | | | | | | | |
| | Scenario 1 | 264OABMG1T2BS1 | Tier 2 | | | | | | |
| Before-Step Therapy | 1 | | | | | | | | | |
| | | 264OABMG1T2AS1M | Tier 2 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | | 264OABMG1T3AS1M | Tier 3 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combinations T2. | | | | | | | | |
| | Scenario 2 | 264OABMG1T21M | Tier 2 | 1 or more | | | | | |
| | | 264OABMG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #5 | DoW Uniform Formulary Class: | | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | | BRAF-MEK INHIBITORS | | Quotes due: | | June 29, 2026 |
| 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 BRAF-inhibitor and MEK-inhibitor Combination T2 and before the step. | | | | | | | | |
| | Scenario 1 | 264OABMG1T2BS1 | Tier 2 | | | | | | |
| Before-Step Therapy | 1 | | | | | | | | | |
| | | 264OABMG1T2AS1M | Tier 2 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | | 264OABMG1T3AS1M | Tier 3 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combinations T2. | | | | | | | | |
| | Scenario 2 | 264OABMG1T21M | Tier 2 | 1 or more | | | | | |
| | | 264OABMG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #6 | DoW Uniform Formulary Class: | | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | | BRAF-MEK INHIBITORS | | Quotes due: | | June 29, 2026 |
| 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 BRAF-inhibitor and MEK-inhibitor Combination T2 and before the step. | | | | | | | | |
| | Scenario 1 | 264OABMG1T2BS1 | Tier 2 | | | | | | |
| Before-Step Therapy | 1 | | | | | | | | | |
| | | 264OABMG1T2AS1M | Tier 2 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | | 264OABMG1T3AS1M | Tier 3 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combinations T2. | | | | | | | | |
| | Scenario 2 | 264OABMG1T21M | Tier 2 | 1 or more | | | | | |
| | | 264OABMG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #7 | DoW Uniform Formulary Class: | | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | | BRAF-MEK INHIBITORS | | Quotes due: | | June 29, 2026 |
| 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 BRAF-inhibitor and MEK-inhibitor Combination T2 and before the step. | | | | | | | | |
| | Scenario 1 | 264OABMG1T2BS1 | Tier 2 | | | | | | |
| Before-Step Therapy | 1 | | | | | | | | | |
| | | 264OABMG1T2AS1M | Tier 2 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | | 264OABMG1T3AS1M | Tier 3 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combinations T2. | | | | | | | | |
| | Scenario 2 | 264OABMG1T21M | Tier 2 | 1 or more | | | | | |
| | | 264OABMG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #8 | DoW Uniform Formulary Class: | | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | | BRAF-MEK INHIBITORS | | Quotes due: | | June 29, 2026 |
| 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 BRAF-inhibitor and MEK-inhibitor Combination T2 and before the step. | | | | | | | | |
| | Scenario 1 | 264OABMG1T2BS1 | Tier 2 | | | | | | |
| Before-Step Therapy | 1 | | | | | | | | | |
| | | 264OABMG1T2AS1M | Tier 2 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | | 264OABMG1T3AS1M | Tier 3 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combinations T2. | | | | | | | | |
| | Scenario 2 | 264OABMG1T21M | Tier 2 | 1 or more | | | | | |
| | | 264OABMG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #9 | DoW Uniform Formulary Class: | | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | | BRAF-MEK INHIBITORS | | Quotes due: | | June 29, 2026 |
| 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 BRAF-inhibitor and MEK-inhibitor Combination T2 and before the step. | | | | | | | | |
| | Scenario 1 | 264OABMG1T2BS1 | Tier 2 | | | | | | |
| Before-Step Therapy | 1 | | | | | | | | | |
| | | 264OABMG1T2AS1M | Tier 2 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | | 264OABMG1T3AS1M | Tier 3 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combinations T2. | | | | | | | | |
| | Scenario 2 | 264OABMG1T21M | Tier 2 | 1 or more | | | | | |
| | | 264OABMG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
Additional Discount Program Appendix – Class Review
| #10 | DoW Uniform Formulary Class: | | ONCOLOGICAL AGENTS | | P&T Committee Meeting: | | Aug 5-6, 2026 |
| DoW Uniform Formulary Subclass: | | BRAF-MEK INHIBITORS | | Quotes due: | | June 29, 2026 |
| 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 BRAF-inhibitor and MEK-inhibitor Combination T2 and before the step. | | | | | | | | |
| | Scenario 1 | 264OABMG1T2BS1 | Tier 2 | | | | | | |
| Before-Step Therapy | 1 | | | | | | | | | |
| | | 264OABMG1T2AS1M | Tier 2 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | | 264OABMG1T3AS1M | Tier 3 | | | | | | |
| After-Step Therapy | 1 or more | | | | | | | | | |
| | Scenario 2: One or more BRAF-inhibitor and MEK-inhibitor Combinations T2. | | | | | | | | |
| | Scenario 2 | 264OABMG1T21M | Tier 2 | 1 or more | | | | | |
| | | 264OABMG1T31M | Tier 3 | 1 or more | | | | | |
| | | | | | | If cell highlights red, please confirm intent not to submit a quote | | | |
&"-,Italic"Use or disclosure of data contained on this sheet is subject to the restriction on the title page of this quote.
Defense Health Agency