36C25620Q0078-006.docx

VA256-17Q-0277

APPENDIX B – PAST PERFORMANCE FORM

Pharmacy Benefits Management Services, VHSO, Fayetteville, AR CBOC’s This document must be completed and submitted with the Request for Quote (RFQ). A minimum of three references are required. The reference shall be of the same type or similar services required, same size and magnitude as services required here.

1. Contractor: ____________________________________________________ Address: _____________________________________________________________ Point of Contact: ______________________________________________________ Phone Number: ______________________________________________________ Email Address: _______________________________________________________ Contract Number: ____________________________________________________ Type Services: _______________________________________________________ Size/magnitude contract: _______________________________________________

2. Contractor: ____________________________________________________ Address: _____________________________________________________________ Point of Contact: ______________________________________________________ Phone Number: ______________________________________________________ Email Address: _______________________________________________________ Contract Number: ____________________________________________________ Type Services: _______________________________________________________ Size/magnitude contract: _______________________________________________

3. Contractor: ____________________________________________________ Address: _____________________________________________________________ Point of Contact: ______________________________________________________ Phone Number: ______________________________________________________ Email Address: _______________________________________________________ Contract Number: ____________________________________________________ Type Services: _______________________________________________________ Size/magnitude contract: _______________________________________________