Price List - Starjemza - TIBs - IL-23.xlsx

XLSX spreadsheet 51 KB Posted Dec 11, 2025

Attached to: Department of Defense Pharmacy Uniform Formulary Blanket Purchase Agreement/Uniform Formulary Additional Discount Program
Solicitation number: HT9402-26-Q-9103
Issued by: Defense Health Agency

About this file

Written by GovTribe AI · Dec 11, 2025

This is a Price List Excel file for the Department of Defense (DoD) Uniform Formulary Blanket Purchase Agreement (UF BPA) for Targeted Immunomodulatory Biologics, specifically the Interleukin 23 subclass, for the February 2026 Pharmacy and Therapeutics (P&T) Committee Meeting. The document outlines pricing and formulary scenarios for up to 10 newly approved drugs, with quotes due on January 5, 2026, and the P&T Committee meeting scheduled for February 4-5, 2026.

The file includes detailed appendices for Blanket Purchase Agreement (BPA) and Additional Discount Program (ADP) pricing, with multiple formulary scenarios such as Uniform Formulary (UF), Tier 2, and Tier 3 classifications. Key notes indicate that prior authorization may apply, and the P&T Committee may recommend preferential status, cost-sharing adjustments, or exclusion from the TRICARE pharmacy benefit program. The document also includes step therapy provisions, noting that new patients may be required to try step-preferred agents before accessing non-preferred medications, with specific considerations for biosimilars and potential removal of current step preferences for certain indications.

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BPA

UF BPA NDC Price List for the February 2026 DoD P&T Meeting
DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS	P&T Committee Meeting:	February 4-5, 2026
DOD Uniform Formulary Subclass:	INTERLEUKIN 23	Quotes due:	January 5, 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 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: 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 the patient at any MTF, Retail, or Mail point of service.

Biosimilar Step Therapy Addendum: Since biosimilars are equivalent to the reference product, no grandfathering will apply. No Grandfathering: a prior authorization may process require new and current patients to complete an adequate trial of the step-preferred biosimilar(s) before a non-step-preferred biosimilar is provided to the patient at any MTF, Retail, or Mail point of service.

All Scenarios:

•	P&T Committee will consider removing the TIBS class step preference (i.e., adalimumab) for select indications (e.g., psoriasis, IBD).
•	Agents with RFQ not submitted or selected may be designated non-step preferred.

Notes to Manufacturers: Do not forget to submit fully executed signature pages along with quote information.

The price per unit of measure for a given dosage form and strength (each, gram, mL, etc.) of the pharmaceutical agent will be the same for all available package sizes (e.g., 30s, 100s, 1000s) within a given dispensing venue.

Blanket Purchase Agreement Appendix – Newly Approved Drug

#1	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent UF and before the step.
		Scenario 1	251TB23G1UFBS1	Uniform Formulary
Before Step Therapy	1			NO QUOTE
			251TB23G1UFAS1M	Uniform Formulary
After Step Therapy	1 or more			NO QUOTE
			251TB23G1NFAS1M	Non-Formulary
After Step Therapy	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Newly Approved Drug

#2	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent UF and before the step.
		Scenario 1	251TB23G1UFBS1	Uniform Formulary
Before Step Therapy	1			NO QUOTE
			251TB23G1UFAS1M	Uniform Formulary
After Step Therapy	1 or more			NO QUOTE
			251TB23G1NFAS1M	Non-Formulary
After Step Therapy	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote
		Blanket Purchase Agreement Appendix – Newly Approved Drug

#3	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent UF and before the step.
		Scenario 1	251TB23G1UFBS1	Uniform Formulary
Before Step Therapy	1			NO QUOTE
			251TB23G1UFAS1M	Uniform Formulary
After Step Therapy	1 or more			NO QUOTE
			251TB23G1NFAS1M	Non-Formulary
After Step Therapy	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Newly Approved Drug

#4	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent UF and before the step.
		Scenario 1	251TB23G1UFBS1	Uniform Formulary
Before Step Therapy	1			NO QUOTE
			251TB23G1UFAS1M	Uniform Formulary
After Step Therapy	1 or more			NO QUOTE
			251TB23G1NFAS1M	Non-Formulary
After Step Therapy	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote
		Blanket Purchase Agreement Appendix – Newly Approved Drug

#5	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent UF and before the step.
		Scenario 1	251TB23G1UFBS1	Uniform Formulary
Before Step Therapy	1			NO QUOTE
			251TB23G1UFAS1M	Uniform Formulary
After Step Therapy	1 or more			NO QUOTE
			251TB23G1NFAS1M	Non-Formulary
After Step Therapy	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Newly Approved Drug

#6	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent UF and before the step.
		Scenario 1	251TB23G1UFBS1	Uniform Formulary
Before Step Therapy	1			NO QUOTE
			251TB23G1UFAS1M	Uniform Formulary
After Step Therapy	1 or more			NO QUOTE
			251TB23G1NFAS1M	Non-Formulary
After Step Therapy	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Newly Approved Drug

#7	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent UF and before the step.
		Scenario 1	251TB23G1UFBS1	Uniform Formulary
Before Step Therapy	1			NO QUOTE
			251TB23G1UFAS1M	Uniform Formulary
After Step Therapy	1 or more			NO QUOTE
			251TB23G1NFAS1M	Non-Formulary
After Step Therapy	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

Blanket Purchase Agreement Appendix – Newly Approved Drug

#8	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent UF and before the step.
		Scenario 1	251TB23G1UFBS1	Uniform Formulary
Before Step Therapy	1			NO QUOTE
			251TB23G1UFAS1M	Uniform Formulary
After Step Therapy	1 or more			NO QUOTE
			251TB23G1NFAS1M	Non-Formulary
After Step Therapy	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote
		Blanket Purchase Agreement Appendix – Newly Approved Drug

#9	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent UF and before the step.
		Scenario 1	251TB23G1UFBS1	Uniform Formulary
Before Step Therapy	1			NO QUOTE
			251TB23G1UFAS1M	Uniform Formulary
After Step Therapy	1 or more			NO QUOTE
			251TB23G1NFAS1M	Non-Formulary
After Step Therapy	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote
		Blanket Purchase Agreement Appendix – Newly Approved Drug

#10	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent UF and before the step.
		Scenario 1	251TB23G1UFBS1	Uniform Formulary
Before Step Therapy	1			NO QUOTE
			251TB23G1UFAS1M	Uniform Formulary
After Step Therapy	1 or more			NO QUOTE
			251TB23G1NFAS1M	Non-Formulary
After Step Therapy	1 or more			NO QUOTE
						If cell highlights red, please confirm intent not to submit a quote

ADP (non-FAMP Discount)

UF ADP Appendix for the February 2026 DoD P&T Meeting
DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS	P&T Committee Meeting:	February 4-5, 2026
DOD Uniform Formulary Subclass:	INTERLEUKIN 23	Quotes due:	January 5, 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 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.

All Scenarios:

•	P&T Committee will consider removing the TIBS class step preference (i.e., adalimumab) for select indications (e.g., psoriasis, IBD).
•	Agents with RFQ not submitted or selected may be designated non-step preferred.

Notes to Manufacturers: Do not forget to submit fully executed signature pages along with quote information.

* Total Calculated Refund Per FCP is calculated as: ((non-FAMP-FCP)+(non-FAMP*Y%)) = Total Calculated Refund **Based on the most recent annual non-FAMP (reported to the Department of Veterans Affairs) from which the current annual Federal Ceiling Price (FCP) calculated ceiling is derived. The current annual FCP and the annual non-FAMP from which it is derived will be applicable to all prescriptions filled during a calendar year. The quoted additional refund percentage will remain static during the life of the agreement but the most recent annual non-FAMP, and thus the calculated refund, may change each calendar year.

Additional Discount Program Appendix – Newly Approved Drug

#1	DOD Uniform Formulary Class:		TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:		February 4-5, 2026
	DOD Uniform Formulary Subclass:		INTERLEUKIN 23		Quotes due:		January 5, 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*
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#2	DOD Uniform Formulary Class:		TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:		February 4-5, 2026
	DOD Uniform Formulary Subclass:		INTERLEUKIN 23		Quotes due:		January 5, 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*
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#3	DOD Uniform Formulary Class:		TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:		February 4-5, 2026
	DOD Uniform Formulary Subclass:		INTERLEUKIN 23		Quotes due:		January 5, 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*
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#4	DOD Uniform Formulary Class:		TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:		February 4-5, 2026
	DOD Uniform Formulary Subclass:		INTERLEUKIN 23		Quotes due:		January 5, 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*
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#5	DOD Uniform Formulary Class:		TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:		February 4-5, 2026
	DOD Uniform Formulary Subclass:		INTERLEUKIN 23		Quotes due:		January 5, 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*
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#6	DOD Uniform Formulary Class:		TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:		February 4-5, 2026
	DOD Uniform Formulary Subclass:		INTERLEUKIN 23		Quotes due:		January 5, 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*
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#7	DOD Uniform Formulary Class:		TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:		February 4-5, 2026
	DOD Uniform Formulary Subclass:		INTERLEUKIN 23		Quotes due:		January 5, 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*
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#8	DOD Uniform Formulary Class:		TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:		February 4-5, 2026
	DOD Uniform Formulary Subclass:		INTERLEUKIN 23		Quotes due:		January 5, 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*
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#9	DOD Uniform Formulary Class:		TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:		February 4-5, 2026
	DOD Uniform Formulary Subclass:		INTERLEUKIN 23		Quotes due:		January 5, 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*
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#10	DOD Uniform Formulary Class:		TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:		February 4-5, 2026
	DOD Uniform Formulary Subclass:		INTERLEUKIN 23		Quotes due:		January 5, 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*
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

ADP (WAC Discount)

UF ADP Appendix for the February 2026 DoD P&T Meeting
DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS	P&T Committee Meeting:	February 4-5, 2026
DOD Uniform Formulary Subclass:	INTERLEUKIN 23	Quotes due:	January 5, 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 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.

All Scenarios:

•	P&T Committee will consider removing the TIBS class step preference (i.e., adalimumab) for select indications (e.g., psoriasis, IBD).
•	Agents with RFQ not submitted or selected may be designated non-step preferred.

Notes to Manufacturers: Do not forget to submit fully executed signature pages along with quote information.

The Wholesale Acquisition Cost (WAC) is obtained from First Databank via daily price updates; it is maintained at the dispensing unit level to five (5) decimal places. If the WAC changes during a calendar quarter, an average WAC will be calculated on a daily weighted basis (per unit only).

WAC is ONLY used for products that do not have a FCP, such as diabetic supplies (i.e., test strips), and can also be applied to covered drugs.

*The quoted WAC Discount percentage will remain static during the life of the agreement.

Additional Discount Program Appendix – Newly Approved Drug

#1	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#2	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#3	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#4	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#5	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#6	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#7	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#8	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#9	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	1 or more
							If cell highlights red, please confirm intent not to submit a quote

Additional Discount Program Appendix – Newly Approved Drug

#10	DOD Uniform Formulary Class:	TARGETED IMMUNOMODULATORY BIOLOGICS		P&T Committee Meeting:	February 4-5, 2026
	DOD Uniform Formulary Subclass:	INTERLEUKIN 23		Quotes due:	January 5, 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
		One agent T2 and before the step.
		Scenario 1	251TB23G1T2BS1	Tier 2
Before Step Therapy	1
			251TB23G1T2AS1M	Tier 2
After Step Therapy	1 or more
			251TB23G1T3AS1M	Tier 3
After Step Therapy	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 Dec 11, 2025.