11-PD 1.1 Attachment L- Blinded Claims.xlsx

2 MB Posted

Attached to
Health and Pharmacy Benefits
Solicitation number
RFP 26-008
Issued by
Williamson County, San Antonio City, Texas

View the file

Other files

File Type Posted
4-PD 1.1 Attachment C- Subcontracting.docx DOCX document
15-PD 1.1 Attachment E- Pharmacy Vendor Response Workbook.xlsx XLSX spreadsheet
3-PD 1.1 Attachment B- Reference Sheet.docx DOCX document
1-PD 1.0 RFP 26-008 Health and Pharmacy Benefits.pdf PDF
2-PD 1.1 Attachment A- Proposal Submittal Form.docx DOCX document
7-PD 1.1 Attachment H- UHC Choice Summary Plan Description.pdf PDF
10-PD 1.1 Attachment K- City of RR Plan Design CH+ PS1 Rx Plan Summary.pdf PDF
14-PD 1.1 Attachment D- Medical Vendor Response Workbook.xlsx XLSX spreadsheet
13-PD 1.2 Terms-and-Conditions November 2021.pdf PDF
6-PD 1.1 Attachment G- City of Round Rock 2026 Benefits Guide.pdf PDF
9-PD 1.1 Attachment J- City of RR Plan Design CH EP1 Rx Plan Summary.pdf PDF
12-PD 1.2 CORR Insurance 08 2024.pdf PDF
8-PD 1.1 Attachment I- UHC Choice Plus Summary Plan Description.pdf PDF
5-PD 1.1 Attachment F- Pharmacy Claims Repricing Worksheet.xlsx XLSX spreadsheet
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Sheet2

Filled DateDays Supply CountNational Drug CodeDrug NameDrug TypeDrug Strength DescriptionBrand/GenericIndividual IDNABP NumberPharmacy NamePharmacy National Provider Identification NumberPharmacy Dispenser TypeCustomer Segment NumberBenefit Structure One CodeBenefit Structure Two CodeQuantity CountPharmacy Drug OTC CodeSubmitted Charge Amount
4/17/25282143380TRULICITYW0.75MG/0.5Brand19608673364533178WALMART PHARMACY 10-548015684896231925175112R1184.63
6/10/25282143380TRULICITYW0.75MG/0.5Brand19608673364533178WALMART PHARMACY 10-548015684896231925175112R1184.63
5/13/25282143380TRULICITYW0.75MG/0.5Brand19608673364533178WALMART PHARMACY 10-548015684896231925175112R1184.63
11/13/25282143380TRULICITYW0.75MG/0.5Brand1087445314542622WALGREENS #1023214271362741925175772R1184.63
11/11/25282143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175772R1184.63
9/27/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
9/8/25282143480TRULICITYW1.5 MG/0.5Brand19608673364533178WALMART PHARMACY 10-548015684896231925175112R1184.63
9/20/25282143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175772R1184.63
5/3/25282143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175772R1184.63
3/17/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
8/14/25282143480TRULICITYW1.5 MG/0.5Brand19608673364533178WALMART PHARMACY 10-548015684896231925175112R1184.63
8/27/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
12/10/25282143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175772R1184.63
10/17/25282143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175772R1184.63
8/20/25282143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175772R1184.63
5/29/25282143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175772R1184.63
6/8/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
5/10/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
6/25/25282143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175772R1184.63
3/12/25842143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175776R3553.88
12/23/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
7/14/25282143480TRULICITYW1.5 MG/0.5Brand19608673364533178WALMART PHARMACY 10-548015684896231925175112R1184.63
1/20/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
3/12/25-842143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY1730298704192517577-6R-3553.88
10/24/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
11/23/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
4/8/25282143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175772R1184.63
4/13/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
7/7/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
8/1/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
2/16/25282143480TRULICITYW1.5 MG/0.5Brand19615672484520284HEB PHARMACY14675618861925175112R1184.63
7/23/25282143480TRULICITYW1.5 MG/0.5Brand412459574519320HEB PHARMACY17302987041925175772R1184.63
11/18/25282143480TRULICITYW1.5 MG/0.5Brand19608673364533178WALMART PHARMACY 10-548015684896231925175112R1184.63
3/18/25302143611EMGALITY PENW120 MG/MLBrand2290756245909594HEB PHARMACY11244603401925175771R890.03
8/19/25302143611EMGALITY PENW120 MG/MLBrand2290756245909594HEB PHARMACY11244603401925175331R890.03
4/20/25302143611EMGALITY PENW120 MG/MLBrand2290756245909594HEB PHARMACY11244603401925175331R890.03
5/19/25302143611EMGALITY PENW120 MG/MLBrand2290756245909594HEB PHARMACY11244603401925175331R890.03
6/24/25302143611EMGALITY PENW120 MG/MLBrand2290756245909594HEB PHARMACY11244603401925175331R890.03
10/24/25302143611EMGALITY PENW120 MG/MLBrand2290756244520284HEB PHARMACY14675618861925175331R890.03
3/3/25902143611EMGALITY PENW120 MG/MLBrand19630315244549094WALGREENS #1156615484249061925175113R2670.09
7/22/25302143611EMGALITY PENW120 MG/MLBrand2290756245909594HEB PHARMACY11244603401925175331R890.03
9/2/25902143611EMGALITY PENW120 MG/MLBrand19630315244549094WALGREENS #1156615484249061925175113R2670.09
9/27/25302143611EMGALITY PENW120 MG/MLBrand2290756244520284HEB PHARMACY14675618861925175331R890.03
11/17/25902143611EMGALITY PENW120 MG/MLBrand19630315244549094WALGREENS #1156615484249061925175113R2670.09
2/23/25302143611EMGALITY PENW120 MG/MLBrand2290756245909594HEB PHARMACY11244603401925175771R890.03
11/27/25302143611EMGALITY PENW120 MG/MLBrand2290756244520284HEB PHARMACY14675618861925175331R890.03
6/4/25902143611EMGALITY PENW120 MG/MLBrand19630315244549094WALGREENS #1156615484249061925175113R2670.09
1/23/25302143611EMGALITY PENW120 MG/MLBrand2290756245909594HEB PHARMACY11244603401925175771R890.03
5/11/25282145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
2/28/25-282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY1972612943192517577-2R-1295.72
6/1/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
12/15/25302145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
4/15/25282145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
11/17/25282145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
1/28/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
10/15/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
6/25/25-282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY1972612943192517577-2R-1295.72
6/25/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
9/28/25282145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
1/2/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1282.9
11/20/25282145780MOUNJAROW15MG/0.5MLBrand12342193894519320HEB PHARMACY17302987041925175112R1295.72
8/17/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
9/15/25282145780MOUNJAROW15MG/0.5MLBrand20285892714547468WALGREENS #1096110333957441925175772R1295.72
6/9/25282145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
10/25/25302145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
12/11/25282145780MOUNJAROW15MG/0.5MLBrand18314204554545161CVS PHARMACY #0011616494724321925175112R1295.72
9/15/25-282145780MOUNJAROW15MG/0.5MLBrand20285892714547468WALGREENS #109611033395744192517577-2R-1295.72
7/24/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
12/11/25-282145780MOUNJAROW15MG/0.5MLBrand18314204554545161CVS PHARMACY #001161649472432192517511-2R-1295.72
1/23/25302145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
9/15/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
7/31/25282145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
8/21/25282145780MOUNJAROW15MG/0.5MLBrand20285892714547468WALGREENS #1096110333957441925175772R1295.72
2/19/25282145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
3/18/25282145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
9/18/25282145780MOUNJAROW15MG/0.5MLBrand12342193894519320HEB PHARMACY17302987041925175112R1295.72
7/4/25282145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
12/8/25282145780MOUNJAROW15MG/0.5MLBrand12342193894519320HEB PHARMACY17302987041925175112R1295.72
11/10/25-282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY1972612943192517577-2R-1295.72
3/18/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
11/17/25282145780MOUNJAROW15MG/0.5MLBrand20285892714547468WALGREENS #1096110333957441925175772R1295.72
11/10/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
4/12/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
7/23/25282145780MOUNJAROW15MG/0.5MLBrand18314204554530982WALGREENS #731013967504511925175112R1295.72
9/19/25282145780MOUNJAROW15MG/0.5MLBrand20285892714547468WALGREENS #1096110333957441925175772R1295.72
10/20/25282145780MOUNJAROW15MG/0.5MLBrand12342193894519320HEB PHARMACY17302987041925175112R1295.72
11/20/25-282145780MOUNJAROW15MG/0.5MLBrand12342193894519320HEB PHARMACY1730298704192517511-2R-1295.72
7/29/25282145780MOUNJAROW15MG/0.5MLBrand20285892714547468WALGREENS #1096110333957441925175772R1295.72
10/16/25282145780MOUNJAROW15MG/0.5MLBrand20285892714547468WALGREENS #1096110333957441925175772R1295.72
2/28/25282145780MOUNJAROW15MG/0.5MLBrand5783868254569541HEB PHARMACY19726129431925175772R1295.72
12/30/25282145780MOUNJAROW15MG/0.5MLBrand19604496635919711RANDALLS PHARMACY #314517508305501925175772R1295.72
8/29/25282145780MOUNJAROW15MG/0.5MLBrand2782958534547569CVS PHARMACY #0669019323871491925175772R1295.72
6/25/25282145780MOUNJAROW15MG/0.5MLBrand20285892714547468WALGREENS #1096110333957441925175772R1295.72
12/16/25282145780MOUNJAROW15MG/0.5MLBrand20285892715900596CVS PHARMACY #0459912455438341925175772R1295.72
7/11/25282146080MOUNJAROW12.5MG/0.5Brand20210459905943192HEB PHARMACY #80410137544491925175772R1295.72
9/25/25282146080MOUNJAROW12.5MG/0.5Brand19647856114569541HEB PHARMACY19726129431925175112R1295.72
6/23/25282146080MOUNJAROW12.5MG/0.5Brand18314204554530982WALGREENS #731013967504511925175112R1295.72
12/15/25282146080MOUNJAROW12.5MG/0.5Brand19647856114569541HEB PHARMACY19726129431925175112R1295.72
10/18/25282146080MOUNJAROW12.5MG/0.5Brand19665069045909594HEB PHARMACY11244603401925175112R1295.72
12/18/25842146080MOUNJAROW12.5MG/0.5Brand790012354547468WALGREENS #1096110333957441925175776R3887.16
12/19/25282146080MOUNJAROW12.5MG/0.5Brand4291218534547569CVS PHARMACY #0669019323871491925175112R1295.72
1/2/25282146080MOUNJAROW12.5MG/0.5Brand908758245909811COSTCO PHARMACY #115218719269981925175772R1282.9
2/21/25282146080MOUNJAROW12.5MG/0.5Brand20210459905943192HEB PHARMACY #80410137544491925175772R1295.72
1/4/25282146080MOUNJAROW12.5MG/0.5Brand19665069045909594HEB PHARMACY11244603401925175112R1295.72
10/2/25282146080MOUNJAROW12.5MG/0.5Brand1697626234547468WALGREENS #1096110333957441925175772R1295.72
11/20/25842146080MOUNJAROW12.5MG/0.5Brand19252620305741372OPTUM PHARMACY 700, LLC17903402065925175776R4049.14
5/8/25282146080MOUNJAROW12.5MG/0.5Brand19647856114569541HEB PHARMACY19726129431925175112R1295.72
12/18/25842146080MOUNJAROW12.5MG/0.5Brand19635874815926716OPTUM PHARMACY 704, INC.11548936005925175776R4049.14
6/18/25282146080MOUNJAROW12.5MG/0.5Brand908758245909811COSTCO PHARMACY #115218719269981925175772R1295.72
6/24/25842146080MOUNJAROW12.5MG/0.5Brand19252620305926716OPTUM PHARMACY 704, INC.11548936005925175776R4049.14
1/20/25282146080MOUNJAROW12.5MG/0.5Brand20210459905943192HEB PHARMACY #80410137544491925175772R1295.72
12/29/25282146080MOUNJAROW12.5MG/0.5Brand1697626234547468WALGREENS #1096110333957441925175772R1295.72
7/1/25282146080MOUNJAROW12.5MG/0.5Brand19647856114569541HEB PHARMACY19726129431925175112R1295.72
10/23/25282146080MOUNJAROW12.5MG/0.5Brand908758245909811COSTCO PHARMACY #115218719269981925175772R1295.72
11/17/25282146080MOUNJAROW12.5MG/0.5Brand19665069045909594HEB PHARMACY11244603401925175112R1295.72
6/14/25282146080MOUNJAROW12.5MG/0.5Brand20210459905943192HEB PHARMACY #80410137544491925175772R1295.72
8/26/25842146080MOUNJAROW12.5MG/0.5Brand19252620305741372OPTUM PHARMACY 700, LLC17903402065925175776R4049.14
8/27/25282146080MOUNJAROW12.5MG/0.5Brand908758245909811COSTCO PHARMACY #115218719269981925175772R1295.72
5/30/25282146080MOUNJAROW12.5MG/0.5Brand20285892714547468WALGREENS #1096110333957441925175772R1295.72
4/5/25282146080MOUNJAROW12.5MG/0.5Brand19647856114516146SAMS PHARMACY12058533301925175112R1295.72
4/29/25282146080MOUNJAROW12.5MG/0.5Brand908758245909811COSTCO PHARMACY #115218719269981925175772R1295.72
8/15/25282146080MOUNJAROW12.5MG/0.5Brand12342193894519320HEB PHARMACY17302987041925175112R1295.72
10/29/25282146080MOUNJAROW12.5MG/0.5Brand4291218534547569CVS PHARMACY #0669019323871491925175112R1295.72
9/16/25282146080MOUNJAROW12.5MG/0.5Brand19665069045909594HEB PHARMACY11244603401925175112R1295.72
4/16/25282146080MOUNJAROW12.5MG/0.5Brand20210459905943192HEB PHARMACY #80410137544491925175772R1295.72
12/23/25282146080MOUNJAROW12.5MG/0.5Brand908758245909811COSTCO PHARMACY #115218719269981925175772R1295.72
3/8/25282146080MOUNJAROW12.5MG/0.5Brand19647856114516146SAMS PHARMACY12058533301925175112R1295.72
7/27/25282146080MOUNJAROW12.5MG/0.5Brand19647856114569541HEB PHARMACY19726129431925175112R1295.72
10/21/25282146080MOUNJAROW12.5MG/0.5Brand19647856114569541HEB PHARMACY19726129431925175112R1295.72
4/6/25842146080MOUNJAROW12.5MG/0.5Brand19252620305926716OPTUM PHARMACY 704, INC.11548936005925175776R4049.14
4/27/25842146080MOUNJAROW12.5MG/0.5Brand19635874815741372OPTUM PHARMACY 700, LLC17903402065925175776R4049.14
9/29/25282146080MOUNJAROW12.5MG/0.5Brand4291218534547569CVS PHARMACY #0669019323871491925175112R1295.72
5/23/25282146080MOUNJAROW12.5MG/0.5Brand19665069045909594HEB PHARMACY11244603401925175112R1295.72
4/1/25282146080MOUNJAROW12.5MG/0.5Brand19665069045909594HEB PHARMACY11244603401925175112R1295.72
7/19/25282146080MOUNJAROW12.5MG/0.5Brand19665069045909594HEB PHARMACY11244603401925175112R1295.72
11/18/25282146080MOUNJAROW12.5MG/0.5Brand19647856114569541HEB PHARMACY19726129431925175112R1295.72
11/13/25282146080MOUNJAROW12.5MG/0.5Brand19604496635919711RANDALLS PHARMACY #314517508305501925175772R1295.72
10/5/25282146080MOUNJAROW12.5MG/0.5Brand20210459905943192HEB PHARMACY #80410137544491925175772R1295.72
6/22/25282146080MOUNJAROW12.5MG/0.5Brand19665069045909594HEB PHARMACY11244603401925175112R1295.72
2/8/25282146080MOUNJAROW12.5MG/0.5Brand19647856114516146SAMS PHARMACY12058533301925175112R1295.72
4/26/25282146080MOUNJAROW12.5MG/0.5Brand19665069045909594HEB PHARMACY11244603401925175112R1295.72
5/21/25282146080MOUNJAROW12.5MG/0.5Brand908758245909811COSTCO PHARMACY #115218719269981925175772R1295.72
7/30/25282146080MOUNJAROW12.5MG/0.5Brand908758245909811COSTCO PHARMACY #115218719269981925175772R1295.72
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