122436 O5 - Cost Sheet.xlsx

Pharmacy Admin Fees

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.

Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees

Section II - Credits/Allowances ANNUAL TOTAL $0.00 $0.00 $0.00 $0.00 $0.00

Section III - Additional/Optional Services MONTHLY TOTAL $0.00 $0.00 $0.00 $0.00 $0.00

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.