Price List - Pivya -Antibiotics - Beta-lactams.xlsx
XLSX spreadsheet 47 KB Posted
- Solicitation number
- HT9402-26-Q-9202
- Issued by
-
Defense Health Agency
About this file
This is a pricing template and submission form for the Department of War (DoW) Pharmacy Uniform Formulary (UF) Blanket Purchase Agreement (BPA) for beta-lactam antibiotics. The document is part of Solicitation HT9402-26-Q-9202 and is designed for the May 6-7, 2026 P&T Committee meeting, with quotes due March 26, 2026. The template covers ten newly approved drugs within the beta-lactams subclass and includes multiple pricing appendices for different reimbursement scenarios: BPA submissions for Uniform Formulary and Non-Formulary categories at Military Treatment Facilities and Mail Order venues, ADP (non-FAMP Discount) submissions with pricing based on Federal Ceiling Price (FCP) calculations, and ADP (WAC Discount) submissions using Wholesale Acquisition Cost pricing. Manufacturers must provide pricing per unit of measure that remains consistent across all package sizes within a given dispensing venue and must submit completed Quote Submission Checklists and fully executed signature pages alongside pricing information.
The document establishes formulary notes indicating that agents will be reviewed quarterly per 32 CFR 199.21(g)(5), with potential Prior Authorization requirements and consideration for preferential tier placement or complete exclusion from the TRICARE pharmacy benefit program. For BPA submissions, manufacturers must quote both Uniform Formulary and Non-Formulary pricing scenarios. For ADP (non-FAMP) submissions, manufacturers quote the Non-FAMP price of the drug and an additional offered refund percentage, with total calculated refunds derived from the current annual FCP. For ADP (WAC) submissions, manufacturers provide a WAC discount percentage that remains static throughout the agreement term. All pricing fields highlighted in red require confirmation of intent not to submit a quote if left blank, and step therapy designations may apply to agents with unsubmitted or unselected quotes.
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BPA
| UF BPA NDC Price List for the May 2026 DoW P&T Meeting | |||
| DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 |
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 |
| 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 the Quote Submission 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
| #1 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 | 263ABBLG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 263ABBLG1NF1M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 | 263ABBLG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 263ABBLG1NF1M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 | 263ABBLG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 263ABBLG1NF1M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 | 263ABBLG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 263ABBLG1NF1M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 | 263ABBLG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 263ABBLG1NF1M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 | 263ABBLG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 263ABBLG1NF1M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 | 263ABBLG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 263ABBLG1NF1M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 | 263ABBLG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 263ABBLG1NF1M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 | 263ABBLG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 263ABBLG1NF1M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 | 263ABBLG1UF1M | Uniform Formulary | 1 or more | NO QUOTE | |
| 263ABBLG1NF1M | 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 May 2026 DoW P&T Meeting | |||
| DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 |
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 |
| 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 the Quote Submission 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
| #1 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | |||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 | ||||
| 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 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | |||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 | ||||
| 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 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | |||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 | ||||
| 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 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | |||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 | ||||
| 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 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | |||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 | ||||
| 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 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | |||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 | ||||
| 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 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | |||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 | ||||
| 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 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | |||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 | ||||
| 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 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | |||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 | ||||
| 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 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | |||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 | ||||
| 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 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 May 2026 DoW P&T Meeting | |||
| DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 |
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 2026 |
| 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 the Quote Submission 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
| #1 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 | DOW Uniform Formulary Class: | ANTIBIOTICS | P&T Committee Meeting: | May 6-7, 2026 | ||
| DOW Uniform Formulary Subclass: | BETA-LACTAMS | Quotes due: | March 26, 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 WAC Price of Drug WAC Discount* Total Calculated Retail Refund per Package
| Scenario 1 | 263ABBLG1T21M | Tier 2 | 1 or more | |
| 263ABBLG1T31M | 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 .