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36C25620Q0078 P09 Attachment 2 Price Calculation Document 10-29-2019.docx
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36C256-20-Q-0074
| Attachment 2. | Dated October 28, 2019 | |
| FACTOR 3 TOTAL EVALUATED PRICE CALCULATION DOCUMENT |
Instructions As Described in the Evaluation Criteria (FAR 52.212-2 Evaluation – Commercial Items) Factor 4 Price shall be evaluated based on the offeror’s Proposed Discounts and Dispensing Fees and calculated based on the sample set of prescription data found in the worksheet and the calculation formula identified below. The sample consists of the top 6 Name Brand and top 10 Generic drugs that have been prescribed in the last 12 months by the CBOC’s. The numbers identified in Column’s A, B, and C are based on the approximate numbers for the drugs ordered over the past 12 months. Offerors are required to fill in the proposed % discount rate for “II” (corresponding to CLINS 0001AB AND 0002AB). The proposed % discount will not change for the period of performance you are quoting. When you fill in your Dispensing fee for IV (corresponding to CLINS 0001AC AND 0002AC) the dispensing fee will not change for the period of performance you are quoting. You are required to fill in the proposed values and calculate the Total Cost per item and the Total Evaluated Price for your offer for all items and performance periods. This calculation table is for price evaluation purposes only and does not reflect the actual prescriptions or quantities or associated costs that will be ordered under the resultant contract.
Formula Instructions:
Step 1. Multiply II (column B AWP per Tablet) times III CLIN (generic Prescription: Discount from AWP).
Step 2. Multiply IV (column C total scripts) times V CLIN (Dispensing Fee per prescription).
Step 3. Multiply I Column A (Approx. Tablets for previous 12 Mo.) times total of Step 3. for total cost per drug.
Step 4. Add total of Step 1 and Step 2. Step 4 is your total cost of Drug.
| SAMPLE: |
| I |
| II |
| III |
| Step 1. |
| IV |
| V |
| Step 2. |
| Step 3. |
| Step 4. |
| Generic |
| Column A |
Per Tablet(s) Column B
AWP
Per Tablet
CLIN
0001AB
Generic Prescription Discount from AWP.
| Multiply II times III |
| Column |
C
Total Scripts
CLIN 0001AC
Dispensing fee per prescription Multiply IV times V
| Multiply I (Column A) times Step 1. |
| Add total of Step 2. And Step 3. |
Total Cost per Drug
AZITHROMYCIN 250mg
7.79
.4
$3.116
$0.75
$337.5
$ 7,790.00
$ 8127.50
Factor 4 Price
Base Period
| NAME BRAND DRUG |
| Tablet(s) Per |
AWP
Per Tablet
Total Scripts
| I |
| II |
| III |
| Step 1. |
| IV |
| V |
| Step 2. |
| Step 3. |
| Step 4. |
| Column A |
| Column B |
| CLIN |
0001AA
Name Brand Prescription Discount from AWP.
| Multiply II times III |
| Column |
C
CLIN 0001AC
Dispensing fee per prescription Multiply IV times V
| Multiply I (Column A) times Step 1. |
| Add total of Step 2. And Step 3. |
Total Cost per Drug
COMBIVENT AEROSOL 20-100 INHALER
325.75
| 2 |
| ELIQUIS TABLET 2.5MG |
6.12
LANTUS INSULIN 100U/ML VIAL
253.48
| 4 |
| LEVEMIR INSULIN VIAL |
274.38
PROAIR HFA INHALER
| 125 |
| 54.08 |
| 6 |
| SYMBICORT AEROSOL 160-4.5 |
| 100 |
| 297.02 |
| GENERIC DRUG |
| Tablet(s) Per |
AWP
Total
| I |
| II |
| III |
| Step 1. |
| IV |
| V |
| Step 2. |
| Step 3. |
| Step 4. |
| Column A |
| Column B |
| CLIN |
0001AB
Generic Prescription Discount from AWP.
| Multiply II times III |
| Column |
C
CLIN 0001AC
Dispensing fee per prescription Multiply IV times V
| Multiply I (Column A) times Step 1. |
| Add total of Step 2. And Step 3. |
AZITHROMYCIN 250mg
7.79
HYDROCODONE 10mg/ACETAMINOPHEN 325mg
15000
0.93
| 13 |
| PREDNISONE 5MG |
| 12250 |
| 0.50 |
| $________ |
| $_______ |
| 300 |
| $________ |
| $_______ |
| $_________ |
| $____________ |
SULFAMETHOXAZOLE 800MG/TRIMETHO 160MG
1.15
LEVOFLOXACIN 500MG
20.00
AMOXICILLIN 875MG/CLAVULANATE 125MG
4.90
| CYCLOBENZABRINE 10MG |
| 3500 |
| 1.09 |
TRAMADOL HCL 50MG
0.83
AMOXICILLIN 500MG
0.38
DOXYCYCLINE MONOHYDRATE 100MG
11250
2.37
| Sub Total |
| Base Period: |
| $_________ |
Optional Period 1
| NAME BRAND DRUG |
| Tablet(s) Per |
AWP
Total
| I |
| II |
| III |
| Step 1. |
| IV |
| V |
| Step 2. |
| Step 3. |
| Step 4. |
| Column A |
| Column B |
| CLIN |
0001AA
Name Brand Prescription Discount from AWP.
| Multiply II times III |
| Column |
C
CLIN 0001AC
Dispensing fee per prescription Multiply IV times V
| Multiply I (Column A) times Step 1. |
| Add total of Step 2. And Step 3. |
COMBIVENT AEROSOL 20-100 INHALER
325.75
| 2 |
| ELIQUIS TABLET 2.5MG |
6.12
LANTUS INSULIN 100U/ML VIAL
253.48
| 4 |
| LEVEMIR INSULIN VIAL |
274.38
PROAIR HFA INHALER
| 125 |
| 54.08 |
| 6 |
| SYMBICORT AEROSOL 160-4.5 |
| 100 |
| 297.02 |
| GENERIC DRUG |
| Tablet(s) Per |
AWP
Total
| I |
| II |
| III |
| Step 1. |
| IV |
| V |
| Step 2. |
| Step 3. |
| Step 4. |
| Column A |
| Column B |
| CLIN |
0001AB
Generic Prescription Discount from AWP.
| Multiply II times III |
| Column |
C
CLIN 0001AC
Dispensing fee per prescription Multiply IV times V
| Multiply I (Column A) times Step 1. |
| Add total of Step 2. And Step 3. |
Total Cost per Drug
AZITHROMYCIN 250mg
7.79
| 12 |
| HYDROCODONE 10mg/ACETAMINOPHEN |
325mg
15000
0.93
PREDNISONE 5MG
12250
0.50
| 14 |
| SULFAMETHOXAZOLE 800MG/TRIMETHO 160MG |
1.15
LEVOFLOXACIN 500MG
20.00
AMOXICILLIN 875MG/CLAVULANATE 125MG
4.90
| 17 |
| CYCLOBENZABRINE 10MG |
| 3500 |
| 1.09 |
TRAMADOL HCL 50MG
0.83
AMOXICILLIN 500MG
0.38
| 20 |
| DOXYCYCLINE MONOHYDRATE 100MG |
11250
2.37
| Sub Total |
| Opt Period 1: |
| $_________ |
GRAND
TOTAL
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