122436 O5 - Cost Sheet.xlsx
XLSX spreadsheet 111 KB Posted
- Solicitation number
- 122436 O5
- Issued by
- Blaine County, Nebraska
About this file
This is a Cost Sheet for Solicitation Number 122436 O5, focused on Pharmacy Benefit Management (PBM) Services for a self-funded population. The document covers a three-year initial contract term with two additional option years, targeting a consistent estimated enrollment of 28,386 members throughout the contract period. The cost sheet requires bidders to provide per member per month (PMPM) fees for standard pharmacy services, including comprehensive administrative functions such as toll-free phone lines, data feeds, drug utilization review, reporting, appeals processing, formulary management, prior authorization, fraud prevention, and member communication services.
The pricing structure demands guaranteed Administrative Services Only (ASO) fees for the entire contract duration, with detailed pricing guarantees for pharmacy network pricing across retail, mail, and specialty medication channels. The document requires bidders to specify AWP (Average Wholesale Price) discounts for brand and generic medications, dispensing fees, and rebate percentages. Bidders must provide transparent pricing for non-specialty and specialty medications, including minimum per-brand claim rebate guarantees. The cost sheet allows for optional additional services and requires credits/allowances to be specified, with the understanding that any ancillary services not explicitly identified are assumed to be included in the base ASO fee.
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Text version
Pharmacy Admin Fees
| COST SHEET | |
| SOLICITATION NUMBER 122436 O5 | Bidder: |
| Pharmacy Benefit Management Services Fees | |
| Financial Proposal Work Sheet: Enter the per Member per Month (PMPM) fees for Section I - Standard Services below for the plan designs currently in place. |
Fees on any other basis, (i.e., as a percentage of claims, on a per claim basis or a combination) will NOT be considered. The ASO Fees are to be guaranteed for the three (3) year contract period. Any ancillary service relating to the administration of the health plan not specifically identified in bidder’s proposal is assumed to be included in the ASO fee. All services covered under the fee should be listed. IF THE FEE STRUCTURE IS DIFFERENT BY PLAN, COMPLETE THIS SCHEDULE FOR EACH PLAN AND LABEL EACH SCHEDULE ACCORDINGLY. Enrollment figures represent estimated counts.
| Initial Contract Term | 1st Option Year | 2nd Option Year | |||
| Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | |
| Section I - Pharmacy Benefit Management Services Fees | Estimated |
Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees
| Number of Enrolled Members => | 28,386 | 28,386 | 28,386 | 28,386 | 28,386 | |
| PBM Fees per Member per Month (PMPM) | ||||||
| Pharmacy Benefit Management and Administration Fee | ||||||
| Toll Free Phone Lines | ||||||
| Monthly Data Feeds to Fund or Designee(s) | ||||||
| Prospective /Concurrent/Retro DUR | ||||||
| Standard Reports | ||||||
| Ad Hoc Reports | ||||||
| COB Program | ||||||
| First Level Appeals | ||||||
| Second Level Appeals | ||||||
| Urgent Appeals | ||||||
| Formulary and Rebate Administration | ||||||
| Prior Authorization Program | ||||||
| Fraud and Abuse Program | ||||||
| Step Therapy Program | ||||||
| Quantity Limitations | ||||||
| Dose Optimization | ||||||
| Medication Management | ||||||
| Custom System Overrides | ||||||
| Manual Claim Processing | ||||||
| Annual EOB Statements | ||||||
| Retro Termination Letters | ||||||
| Member-submit Claims | ||||||
| Drug Notification Letters | ||||||
| Member Formulary Guides | ||||||
| Member ID Cards | ||||||
| Member Mailing Postage | ||||||
| Enrollment Packet Mailing | ||||||
| Audit Recovery Fees | ||||||
| E-Prescribing | ||||||
| Vaccine Services | ||||||
| Section I - Standard Services MONTHLY TOTAL | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Initial Contract Term | 1st Option Year | 2nd Option Year | ||||
| Section II - Credits/Allowances | Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | |
| Indicate your willingness to offer the listed credits/allowances ("Y/N"). If "Y", then indicate the annual dollar amount of the credit/allowance for each plan year. | Self-Funded Population | Self-Funded Population | Self-Funded Population | Self-Funded Population | Self-Funded Population | |
| Description | Y/N | 28,386 | 28,386 | 28,386 | 28,386 | 28,386 |
| One-time Implementation Credit | ||||||
| General Pharmacy Program Management - including communication expenses, clinical programs, consulting fees or be used as a credit against claim invoices. | ||||||
| Other . . . |
Section II - Credits/Allowances ANNUAL TOTAL $0.00 $0.00 $0.00 $0.00 $0.00
| Initial Contract Term | 1st Option Year | 2nd Option Year | |||||
| Section III - Additional and/or Optional Programs/Services | Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | ||
| List and describe any additional and/or optional services proposed, the associated administration charges, and the average expected monthly total for each service. Add lines, as needed to accommodate all fees. | |||||||
| Note: This section will not count toward Evaluation Scoring. | Self-Funded Population | Self-Funded Population | Self-Funded Population | Self-Funded Population | Self-Funded Population | ||
| Service Description | Service Fee and Structure | ||||||
| (PSPM, PMPM, X% of Savings, etc.) | Estimated Monthly Total | Estimated Monthly Total | Estimated Monthly Total | Estimated Monthly Total | Estimated Monthly Total |
Section III - Additional/Optional Services MONTHLY TOTAL $0.00 $0.00 $0.00 $0.00 $0.00
PBM Pricing Guarantees
| COST SHEET | |
| SOLICITATION NUMBER 122436 O5 | Bidder: |
| PBM Pricing Guarantees |
Prescription Drug Pricing and Rebates:
AWP Reimbursement Basis—Complete the following table using the drug reimbursement that your organization is willing to guarantee, on a dollar-for-dollar basis, for each year of the contract. Columns marked "AWP Discount” are to be completed using a discount from 100% AWP and dispensing fee logic. All guarantees must be based on the AWP unit cost dispensed at the point of sale, and post September 26, 2009 AWP rollback, including usual & customary and zero-balance claims prior to the impact of member cost sharing. Generic discount guarantee must include all single-source as well as multi-source generic drugs.
The aggregate brand discount guarantee for specialty drugs should include biosimilar specialty drugs. In addition to the aggregate specialty drug discount and rebate guarantees, please provide separately a list of all specialty drugs and their individual discount guarantees.
Specialty drug pricing must be based on an open (non-exclusive) basis.
| Self-Funded Population | |||
| Pharmacy Network | |||
| Guaranteed Pricing for Non-Specialty Medications | |||
| Channel | Retail | Retail | |
| Day Supply (DS) | </=30 DS | 31 - 90 DS | >0 DS |
| AWP Discount for All Brands | |||
| Year 1 | |||
| Year 2 | |||
| Year 3 | |||
| Year 4 | |||
| Year 5 | |||
| AWP Discount for All Generics Including Single-Source | |||
| Year 1 | |||
| Year 2 | |||
| Year 3 | |||
| Year 4 | |||
| Year 5 | |||
| Dispensing Fee/Rx | |||
| Year 1 | |||
| Year 2 | |||
| Year 3 | |||
| Year 4 | |||
| Year 5 |
| Specialty Pharmacy | |||
| Guarantee Pricing for Specialty Medications | |||
| Channel | Retail | Retail | |
| Day Supply (DS) | </=30 DS | 31 - 90 DS | >0 DS |
| AWP Discount for All Brands | |||
| Year 1 | |||
| Year 2 | |||
| Year 3 | |||
| Year 4 | |||
| Year 5 | |||
| AWP Discount for All Generics | |||
| Year 1 | |||
| Year 2 | |||
| Year 3 | |||
| Year 4 | |||
| Year 5 | |||
| Dispensing Fee/Rx | |||
| Year 1 | |||
| Year 2 | |||
| Year 3 | |||
| Year 4 | |||
| Year 5 | |||
| Rebates & Other Manufacturer Revenue | |||
| %-Share | 100% | ||
| Guaranteed Minimum Per Brand Claim Rebate Guarantees | |||
| Non-Specialty Medications | |||
| Year 1 | |||
| Year 2 | |||
| Year 3 | |||
| Year 4 | |||
| Year 5 | |||
| Specialty Medications | |||
| Year 1 | |||
| Year 2 | |||
| Year 3 | |||
| Year 4 | |||
| Year 5 |
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