41NHA-S3992 - PEBP - Attachment 4.6.1. - Cost Schedule.xlsx
XLSX spreadsheet 1 MB Posted
- Attached to
- Nevada State Pharmacy Benefit Manager
- Solicitation number
- 41NHA-S3992
- Issued by
- Nevada
About this file
This is a cost schedule attachment for a Request for Proposal (RFP) issued by the Nevada Health Authority (NVHA) Public Employee Benefit Program (PEBP) for Pharmacy Benefit Management (PBM) services. The RFP was released on October 22, 2026, with electronic submissions due by December 29, 2026, at 2:00 P.M. Pacific Standard Time. The contract period spans six years beginning July 1, 2028, through June 30, 2034, with optional add-on years available through June 30, 2036. The PBM services encompass core retail pharmacy services, specialty pharmacy, mail pharmacy, rebate administration, and network management across multiple drug classifications including brand and generic drugs at retail 30-day and 90-day supplies, specialty drugs, and long-dose dispensing (LDD) specialty drugs at retail locations.
Proposers must submit a single Excel workbook containing detailed cost proposals organized by service category (Core PBM Services, Specialty and Mail Pharmacy, Rebate Administration, and Disruption). All contractor compensation and margin must be disclosed as administrative fees on the designated administrative fees tab, with no additional fees payable outside those explicitly disclosed. Contractors must provide guaranteed dispensing fees and discounts off Average Wholesale Price (AWP) by drug classification for each plan year, minimum rebate guarantees at the Generic Product Identifier (GPI-14) level, and compliance with the Nationally Averaged Drug Acquisition Cost (NADAC) adjudication guarantees. The cost schedule includes tabs for retail network pricing, specialty and mail pharmacy pricing, rebate administration, pricing exclusions, network and formulary disruption analysis, and geographic access analysis. NVHA has emphasized that all responses must remain within the provided workbook format without modifications, and no supplemental documents, terms, or conditions will be accepted or reviewed as part of the evaluation process.
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Caveats & Limitations Caveats and Limitations
This file has been prepared for the specific purpose of providing Nevada Health Authority (NVHA) with information regarding the Pharmacy Benefit Manager (PBM) request for proposal (RFP). This information may not be appropriate and should not be used for any other purpose.
This draft includes Milliman standard PBM procurement language intended as a baseline for NVHA review. NVHA should review and customize these requirements to align with its sourcing strategy, business requirements, operational expectations, legal and procurement standards, and final RFP evaluation priorities. Inclusion of any requirement should not be interpreted as final NVHA approval of the requirement, scope, wording, or Contractor expectation.
This file has been prepared solely for the internal business use of NVHA. No portion of this file may be provided to any other party without Milliman’s prior written consent. Milliman does not intend to benefit, or create a legal duty to, any third-party recipient of its work, even if we permit the distribution of our work product to such third party.
Cover
41NHA-S3992 - REQUEST FOR PROPOSAL
Pharmacy Benefit Management (PBM) Services
| Nevada Health Authority Public Employee Benefit Program |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
INFORMATION BEING PRESENTED BY CONTRACTOR IN THIS RFP WORKBOOK IS SUBJECT TO THE TERMS AND CONDITIONS OF THE CONFIDENTIALITY AGREEMENT BETWEEN NVHA AND THE CONTRACTOR, WHICH THE CONTRACTOR MUST HAVE COMPLETED AND RETURNED TO NVHA PRIOR TO RECEIPT OF THE RFP. THE USE OF INFORMATION PROVIDED BY CONTRACTOR IN RESPONSE TO THIS RFP WORKBOOK OR ANY OTHER REQUEST MADE BY EITHER NVHA OR MILLIMAN OR ITS AFFILIATES ON BEHALF OF NVHA IN CONNECTION WITH THIS RFP WILL BE GOVERNED SOLELY BY THE TERMS AND CONDITIONS OF THAT CONFIDENTIALITY AGREEMENT AND, FOR AVOIDANCE OF DOUBT, WILL NOT BE SUBJECT TO ANY OTHER CONFIDENTIALITY AGREEMENT WHICH MAY EXIST BETWEEN CONTRACTOR AND MILLIMAN OR ITS AFFILIATES.
NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY THE CLIENT IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS.
This document is proprietary and confidential and cannot be copied or reproduced without prior written permission of NVHA.
Confidentiality Notice: This Request for Proposal including any attachments is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited.
Instructions
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY |
| NVHA IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
Instructions for Completion
All cost proposals should include a title page:
| The title Page shall include the following: | |
| A. Cost Proposal for: | Pharmacy Benefit Manager |
B. RFP: 41NHA-S3992
| C. Proposer Information: | Name: |
| Address: |
D. Proposal Opening Date: 12/29/26
E. Proposal Opening Time: 2:00 P.M.
Additional instructions
1. Cost Proposal Structure. Tabs are grouped by area of focus: ORange = Core PBM Services including Retail; Blue = Specialty and Mail Pharmacy; Teal = Rebate Administration; Yellow = Disruption. Please see the table below for important details regarding each tab, and read all instructions provided on each tab before responding.
2. Response Requirements: Proposers shall provide one (1) Excel Cost Proposal file. In this file, proposer shall complete every shaded input cell. Do not leave a required cell blank, do not enter "TBD" and do not overwrite any NVHA-supplied value, header, or formula.
3. General Requirements
a. Completed cost proposal shall be returned in the exact format of this cost proposal excel file. Contractor shall not add, delete, rename, reorder, or hide any tab. Do not insert or delete rows or columns. Do not alter any formula.
b. Contractor's response shall be contained entirely in this workbook. Attachments, cover letters, and standard-form terms will not be reviewed or considered part of the response unless explicitly requested.
c. All Contractor compensation and margin must be disclosed as an Administrative Fee on [Admin + Adtl Fees]. Any fee not disclosed on this tab is not payable at any time during the Contract term.
d. Capitalized terms carry the meanings on the Definitions section of the SOW. In the event of a conflict between this workbook and any other document, this workbook will govern.
e. Guarantees are stated by Plan Year. Plan Year 1 begins 1 July 2028.
| Tab | Scope and Coverage | Contractor Action Required |
| Cover | Identifies the RFP, release date, and response deadline. | Reference only. No response required. |
| Instructions | Explains how to complete the workbook and provides the tab index. | Read before completing any other tab. |
| Cost Schedule Summary Tab | Summary of projected admin fees, ingredient costs, dispensing fees, and rebates associated with proposal. | Complete the table using projections completed in the related tabs. |
| Admin + Adtl Fees | Base Administrative Fees, the schedule of every other fee, and the compensation attestations. | Enter a Base Administrative Fee. For every service, confirm inclusion in the base administrative fee or quote the fee. Complete the attestations. |
| Retail Network Pricing | Retail network composition, minimum AWP discount and maximum dispensing fee guarantees by drug classification for Plan Years 1–6, and the NADAC adjudication guarantee. | Complete the discount and dispensing fee tables and the Retail adjudication guarantee. |
| Pricing Exclusions | Identifies the Claims, products, or circumstances excluded from pricing guarantees. | Confirm each listed inclusion or exclusion and disclose any additional pricing exclusions. |
| Compounds and Vaccines | Pricing treatment for Compound Drugs and vaccines. | Complete all pricing fields. |
| Spec AAC+ Fee Schedule | NDC-11 level Actual Acquisition Cost per Billing Unit and dispensing fee guarantees for specialty, with escalators. | Populate the schedule with every NDC Contractor will dispense at specialty. Indicate LDD access for each. Rates for products not listed default to the AWP discount guarantees in [Spec AAC+ Pricing Terms] |
| Spec AAC+ Pricing Terms | Specialty pricing — illustrative AWP discount estimates and default and new-to-market AWP discount guarantees. | Complete all pricing fields. |
| Mail AAC+ Fee Schedule | NDC-11 level Actual Acquisition Cost per Billing Unit and dispensing fee guarantees for mail, with Plan Year 2-6 escalators. | Populate the schedule with every NDC Contractor will dispense at mail. State the billing unit for each. Rates for products not listed default to the AWP discount guarantees in [Mail AAC+ Pricing Terms] |
| Mail AAC+ Pricing Terms | Mail pricing — illustrative AWP discount estimates and default and new-to-market AWP discount guarantees. | Complete all pricing fields. |
| Projections Template | Projected net cost by Component and Plan Year. | Complete all fields and state the assumptions used on the tab. |
| Rebate GPI14 Level | Drug-level minimum rebate guarantees as a percentage of WAC at GPI-14, Plan Years 1–6. | Populate the schedule at GPI-14. Guarantees must be supported by detail sufficient for NVHA to validate performance independently. |
| Rebate Guarantee Exclusions | Claim types excluded from rebate guarantee calculations, for both Scenarios. | Confirm inclusion or exclusion for every Claim type, and add any further exclusion Contractor applies. |
| Manufacturer Questions | Manufacturer contracting, GPO, rebate aggregator, and Affiliate relationships. | Answer every question in full. |
| Rebate Projections | Projected rebate value by Plan Year. | Complete all fields and state the assumptions used on the tab. |
| Formulary Disruption | Summary of formulary disruption under proposed formulary. | Populate all requested fields. See instructions on tab for additional details. |
| Network Disruption | Summary of network disruption under proposed network. | For network disruption, compare current and proposed pharmacy network status and report claim counts and unique member counts. Member counts across rows are not additive. The network analyzed must match the network arrangements included in the applicable financial proposal. Use the claims, member, pharmacy, and supporting files provided by NVHA. Do not exclude claims or members unless specifically instructed. |
| Geo-Access | Summary of geo-access under proposed network. | Populate all geo-access fields. For geo access, use driving distance and the access standards specified in the workbook. Apply a consistent methodology to classify members as Urban, Suburban, or Rural. Provide all requested supporting detail, including excluded members, impacted pharmacies, ZIP codes where standards are not met, and the geo-analysis methodology and assumptions. |
| WAC Reductions & Biosim | Informational, provides lists of drugs with list price reductions and recent biosimilar launches that should be accounted for in financial offer. | Reference only. No response required. |
Cost Schedule Summary Tab
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY |
| NVHA IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
Summary of Projected Costs
Please use this tab to summarize the total costs and fees associated with your proposal. Items 1 and 2 should match the values in [Admin + Adtl Fees]. Items 3 and 4 should match the values in tab [Pricing Projections]. Item 5 should match the values in tab [Rebate Projections].
| Full 6-Year Contract Period | Optional Add-On Plan Years | ||||||
| ITEM # | PROJECT DELIVERABLES | Plan Year 1 | |||||
| 07/01/28 - 06/30/29 | Plan Year 2 | ||||||
| 07/01/29 - 06/30/30 | Plan Year 3 | ||||||
| 07/01/30 - 06/30/31 | Plan Year 4 7/1/2031 - 6/30/2032 | Plan Year 5 7/1/2032 - 6/30/2033 | Plan Year 6 - 1st Half 7/1/2033 - 12/31/2033 | TOTAL COST | Plan Year 6 - 2nd Half 1/1/2034 - 6/30/2034 | Year 7 | |
| 7/1/2034 - 6/30/2035 | Year 8 |
7/1/2035 - 6/30/2036
| 1 | Base Services Administrative Fees | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 2 | Optional Administrative Fees | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 3 | Ingredient Costs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 4 | Dispensing Fees | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 5 | Rebates | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Base Contract Totals (excl. optional administrative fees) | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
| Base Contract Totals (incl. optional administrative fees) | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Admin + Adtl Fees
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY |
| NVHA IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
| Commercial Fees |
| Instructions: This tab captures all Contractor compensation. Under NVHA's desired Pricing Model, the Base Administrative Fee is the only source of Contractor revenue, margin, and profit. Please complete the tables below, including providing a list of services included and excluded from the Base Administrative Fee as well as the charges for these services in your response that are not included in the base administrative fee or not referenced below. All services included in your Base Administrative Fee shall be flagged as 'Yes' in column D below and do not require completion of columns E:G. Any services not included in your Base Administrative Fee shall be flagged as 'No' in column D below, and columns E:G shall be completed. Disclosure is absolute. Any fee, charge, or compensation not disclosed on this tab is not payable at any time during the Contract term, regardless of when the underlying service is requested or performed. |
| Plan Years 1 through 6 | Optional Add-On Plan Years | ||||||||||
| Experience Period 2025/2026 | 7/1/2027 - 6/30/2028 | 7/1/2028 - 6/30/2029 | 7/1/2029 - 6/30/2030 | 7/1/2030 - 6/30/2031 | 7/1/2031 - 6/30/2032 | 7/1/2032 - 6/30/2033 | 7/1/2033 - 12/31/2033 | 1/1/2034 - 6/30/2034 | 7/1/2034 - 6/30/2035 | 7/1/2035 - 6/30/2036 | |
| Total Average Membership | |||||||||||
| Projected Base Admin Fee | |||||||||||
| Projected Admin Fee for Ad Hoc/Optional Services |
Administrative Fees Plan Year 1 Plan Year 2 Plan Year 3 Plan Year 4 Plan Year 5 Plan Year 6 - First Half Plan Year 6 - Second Half Optional Year 7 Optional Year 8 Basis for Fee / Credit, e.g., per paid claim or per member per month
| Base Administrative Fee | PMPM |
| Administrative Fee for Ad Hoc/Optional Services | PMPM |
| Core Administrative Activities | Included in Base Administrative Fee | Basis | Fee | Comments |
| Claims Processing Services | Yes | Enter Basis | Enter Fee | |
| • Eligibility management and verification | Yes | Enter Basis | Enter Fee | |
| • Online electronic claims processing/administration | Yes | Enter Basis | Enter Fee | |
| • Data retention | Yes | Enter Basis | Enter Fee | |
| • Data transfer with external vendors (daily / real time) | Yes | Enter Basis | Enter Fee | |
| Accumulator Management | Yes | Enter Basis | Enter Fee | |
| • Accumulator for deductibles and out of pocket maximums – real-time | Yes | Enter Basis | Enter Fee | |
| • bi-directional accumulator (e.g., deductible, MOOP) data exchange | Yes | Enter Basis | Enter Fee | |
| Real-Time Audit System – filters 100 percent of claims before payment | Yes | Enter Basis | Enter Fee | |
| ePrescribing | Yes | Enter Basis | Enter Fee | |
| • ePrescribing Implementation | Yes | Enter Basis | Enter Fee | |
| • ePrescribing on-going | Yes | Enter Basis | Enter Fee | |
| • Coordination of benefits | Yes | Enter Basis | Enter Fee | |
| • Direct member reimbursement claims processing | Yes | Enter Basis | Enter Fee | |
| Termination and Transition Services, including File Transfers | Yes | Enter Basis | Enter Fee | |
| • Claims history | Yes | Enter Basis | Enter Fee | |
| • Prior Authorization files | Yes | Enter Basis | Enter Fee | |
| • Open Refill Transfer (ORT) files | Yes | Enter Basis | Enter Fee | |
| • Claims run-out up to 12 months | Yes | Enter Basis | Enter Fee | |
| Pharmacy Network Services | Yes | Enter Basis | Enter Fee | |
| • Administration of the Pharmacy Network | Yes | Enter Basis | Enter Fee | |
| • Pharmacy Help Desk – available 24 hours a day, seven days a week | Yes | Enter Basis | Enter Fee | |
| Vendor Coordination | Yes | Enter Basis | Enter Fee | |
| • Coordinate with Rebate vendor | Yes | Enter Basis | Enter Fee | |
| • Coordinate with Specialty fulfillment vendor | Yes | Enter Basis | Enter Fee | |
| • Coordinate with GLP-1 vendor | Yes | Enter Basis | Enter Fee | |
| Implementation Services | Yes | Enter Basis | Enter Fee | |
| Benefit Plan Administration | Yes | Enter Basis | Enter Fee | |
| • Initial benefit design set-up for each Plan / group | Yes | Enter Basis | Enter Fee | |
| • Ongoing administration of each benefit Plan / group | Yes | Enter Basis | Enter Fee | |
| Member Services | Yes | Enter Basis | Enter Fee | |
| • Toll-free Member Services Help Desk - available 24 hours a day, seven days a week, 365 days a year | Yes | Enter Basis | Enter Fee | |
| • Member Website and mobile app | Yes | Enter Basis | Enter Fee | |
| Real Time Benefit Check | Yes | Enter Basis | Enter Fee | |
| Client Services | Yes | Enter Basis | Enter Fee | |
| •Designated Client Management Team | Yes | Enter Basis | Enter Fee | |
| • Implementation support | Yes | Enter Basis | Enter Fee | |
| • Standard Reporting Packages | Yes | Enter Basis | Enter Fee | |
| Account Management Services | Yes | Enter Basis | Enter Fee | |
| • Dedicated Account Team | Yes | Enter Basis | Enter Fee | |
| • Quarterly analysis of program utilization and impact of plan design/managed care interventions | Yes | Enter Basis | Enter Fee | |
| Member Communications | Yes | Enter Basis | Enter Fee | |
| • Welcome Booklet with ID cards; Postage, shipping and handling cost are pass through | Yes | Enter Basis | Enter Fee | |
| Online Client Access to PBM Systems with Unlimited Client Licenses | Yes | Enter Basis | Enter Fee | |
| • Prior Authorization Tool | Yes | Enter Basis | Enter Fee | |
| • Standard Claims Reporting Tool | Yes | Enter Basis | Enter Fee | |
| • Custom Reporting Tool | Yes | Enter Basis | Enter Fee | |
| • Eligibility Management | Yes | Enter Basis | Enter Fee | |
| Ad Hoc Reporting from PBM | Yes | Enter Basis | Enter Fee | |
| Online Client Access to Member Eligibility | Yes | Enter Basis | Enter Fee | |
| • Verifying, entering, and updating member eligibility | Yes | Enter Basis | Enter Fee | |
| • Viewing member claims history | Yes | Enter Basis | Enter Fee | |
| Pharmacy Call Center | Yes | Enter Basis | Enter Fee | |
| • Dedicated Plan phone number | Yes | Enter Basis | Enter Fee | |
| • Dedicated Plan representatives | Yes | Enter Basis | Enter Fee | |
| Online Client Website Access | Yes | Enter Basis | Enter Fee | |
| • Access to general and plan-specific information | Yes | Enter Basis | Enter Fee | |
| • Setup and training for up to five users | Yes | Enter Basis | Enter Fee | |
| • Client Website access | Yes | Enter Basis | Enter Fee | |
| − Pharmacy locator, refill Home Delivery Pharmacy, claims history | Yes | Enter Basis | Enter Fee | |
| − Health, wellness and disease education | Yes | Enter Basis | Enter Fee | |
| Home Delivery/Mail Service and Specialty Pharmacy | Yes | Enter Basis | Enter Fee | |
| • Standard postage included | Yes | Enter Basis | Enter Fee | |
| • Member directed Home Delivery express shipments | Yes | Enter Basis | Enter Fee | |
| Retail Pharmacy Audit Administration, onsite and desktop | Yes | Enter Basis | Enter Fee | |
| Audit Support Services | Yes | Enter Basis | Enter Fee | |
| Basic Fraud, Waste, and Abuse | Yes | Enter Basis | Enter Fee | |
| Enhanced Fraud, Waste, and Abuse | Yes | Enter Basis | Enter Fee | |
| Clinical Services | Yes | Enter Basis | Enter Fee | |
| • Concurrent Drug Utilization Review (CDUR) Standard | Yes | Enter Basis | Enter Fee | |
| • Concurrent Drug Utilization Review (CDUR) Enhanced | Yes | Enter Basis | Enter Fee | |
| • Concurrent Drug Utilization Review (CDUR) Custom | Yes | Enter Basis | Enter Fee | |
| • Retrospective Drug Utilization Review (RDUR) Standard | Yes | Enter Basis | Enter Fee | |
| • Retrospective Drug Utilization Review (RDUR) Enhanced | Yes | Enter Basis | Enter Fee | |
| • Retrospective Drug Utilization Review (RDUR) Custom | Yes | Enter Basis | Enter Fee | |
| • Administration of Formularies (ingestion of formulary file, administration) | Yes | Enter Basis | Enter Fee | |
| • Administration of standard Utilization Management programs | Yes | Enter Basis | Enter Fee | |
| • Administration of custom Utilization Management programs | Yes | Enter Basis | Enter Fee | |
| • Implementation of custom prior authorization criteria | Yes | Enter Basis | Enter Fee | |
| Delegated Utilization Management | Yes | Enter Basis | Enter Fee | |
| • Prior Authorization Administration | Yes | Enter Basis | Enter Fee | |
| • Step Therapy Administration | Yes | Enter Basis | Enter Fee | |
| • Quantity Limit Administration | Yes | Enter Basis | Enter Fee | |
| • Prior Authorization Administrative Overrides | Yes | Enter Basis | Enter Fee | |
| • Prior Authorization Clinical Overrides | Yes | Enter Basis | Enter Fee | |
| • Electronic Prior Authorization (ePA) | Yes | Enter Basis | Enter Fee | |
| • Level 1 Appeals / Initial Determinations | Yes | Enter Basis | Enter Fee | |
| • Appeals requiring a physician | Yes | Enter Basis | Enter Fee | |
| • Level 2 Appeals | Yes | Enter Basis | Enter Fee | |
| • External Appeals - Independent Review Organization (IRO) | Yes | Enter Basis | Enter Fee | |
| • Medication Therapy Management | Yes | Enter Basis | Enter Fee | |
| • Opioid Risk Management Solution | Yes | Enter Basis | Enter Fee | |
| Medical Drug Management | Yes | Enter Basis | Enter Fee | |
| • Medical Drug Policy Administration / Review | Yes | Enter Basis | Enter Fee | |
| • Medical Drug Policy Appeals | Yes | Enter Basis | Enter Fee | |
| • Site of Care Administration | Yes | Enter Basis | Enter Fee | |
| • Oncology Pathway Program Administration | Yes | Enter Basis | Enter Fee | |
| Subrogation claims (e.g., Medicaid) | Yes | Enter Basis | Enter Fee | |
| ID cards - subsequent mailings, replacements, or additional | Yes | Enter Basis | Enter Fee | |
| Explanation of Benefits (EOB) production and mailing | Yes | Enter Basis | Enter Fee | |
| Custom Mailings | Yes | Enter Basis | Enter Fee | |
| Point of Sale Rebate (funding by PBM) | Yes | Enter Basis | Enter Fee | |
| Point of Sale Rebate (funding by Plan) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee | |
| Other Fees (Please detail) | Yes | Enter Basis | Enter Fee |
Retail Network Pricing
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY |
| NVHA IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
| Retail Network Pricing |
Please provide Contractor's discounted AWP pricing offer for retail claims using the lower of logic previously described. The only source of revenue earned by Contractor should come from the base administrative fee listed on the Fees & Credits tab listed in column C.
Contractor will guarantee the dispensing fee at a component level in columns C:K.
Contractor will guarantee the discount off AWP at a component level in columns M:U.
In addition to the discount off AWP and dispensing fee guarantees, we expect Contractors to guarantee the percentage of retail claims that will adjudicate at or below a fixed percentage above NADAC.
| Retail Network Guarantees | |||||||||||||||||||
| Channel | Plan Year 1 Dispensing Fee Guarantee | Plan Year 2 Dispensing Fee Guarantee | Plan Year 3 Dispensing Fee Guarantee | Plan Year 4 Dispensing Fee Guarantee | Plan Year 5 Dispensing Fee Guarantee | Plan Year 6 First Half Dispensing Fee Guarantee | Plan Year 6 Second Half Dispensing Fee Guarantee | Optional Year 7 Dispensing Fee Guarantee | Optional Year 8 Dispensing Fee Guarantee | Basis of fee | Plan Year 1 Discount off AWP Guarantee | Plan Year 2 Discount off AWP Guarantee | Plan Year 3 Discount off AWP Guarantee | Plan Year 4 Discount off AWP Guarantee | Plan Year 5 Discount off AWP Guarantee | Plan Year 6 First Half Discount off AWP Guarantee | Plan Year 6 Second Half Discount off AWP Guarantee | Optional Year 7 Discount off AWP Guarantee | Optional Year 8 Discount off AWP Guarantee |
| Retail 30 - Non Specialty | |||||||||||||||||||
| Retail 30 Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $ per claim / % of AWP | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Retail 30 Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $ per claim / % of AWP | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Retail 90 - Non Specialty | |||||||||||||||||||
| Retail 90 Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $ per claim / % of AWP | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Retail 90 Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $ per claim / % of AWP | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Retail Brand Specialty - Non-LDD | |||||||||||||||||||
| Retail Brand Specialty Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $ per claim / % of AWP | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Retail Generic Specialty Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $ per claim / % of AWP | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| LDD at Retail | |||||||||||||||||||
| Retail Brand LDD Specialty Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $ per claim / % of AWP | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Retail Generic LDD Specialty Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $ per claim / % of AWP | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Retail Adjudication Guarantee | |||||||||||||||||||
| Channel | % of Retail Claims Guaranteed | Guaranteed % Threshold Above NADAC | Summary Statement | ||||||||||||||||
| Retail 30 - Non Specialty | |||||||||||||||||||
| Retail 30 Brand | 100.00% | 0.00% | Contractor agrees that 100% of Retail 30 Brand claims adjudicate at or below NADAC + 0% | ||||||||||||||||
| Retail 30 Generic | 100.00% | 0.00% | Contractor agrees that 100% of Retail 30 Generic claims adjudicate at or below NADAC + 0% | ||||||||||||||||
| Retail 90 - Non Specialty | |||||||||||||||||||
| Retail 90 Brand | 100.00% | 0.00% | Contractor agrees that 100% of Retail 90 Brand claims adjudicate at or below NADAC + 0% | ||||||||||||||||
| Retail 90 Generic | 100.00% | 0.00% | Contractor agrees that 100% of Retail 90 Generic claims adjudicate at or below NADAC + 0% | ||||||||||||||||
| Retail Specialty - Non-LDD | |||||||||||||||||||
| Brand Specialty Drugs | 100.00% | 0.00% | Contractor agrees that 100% of Brand Specialty Drugs claims adjudicate at or below NADAC + 0% | ||||||||||||||||
| Generic Specialty Drugs | 100.00% | 0.00% | Contractor agrees that 100% of Generic Specialty Drugs claims adjudicate at or below NADAC + 0% | ||||||||||||||||
| LDD at Retail | |||||||||||||||||||
| Brand LDD Specialty Drugs | 100.00% | 0.00% | Contractor agrees that 100% of Brand LDD Specialty Drugs claims adjudicate at or below NADAC + 0% | ||||||||||||||||
| Generic LDD Specialty Drugs | 100.00% | 0.00% | Contractor agrees that 100% of Generic LDD Specialty Drugs claims adjudicate at or below NADAC + 0% |
Pricing Exclusions
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY |
| NVHA IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
Pricing Exclusions
| Please indicate whether each category of claims is included or excluded from Network Discount / Dispensing Fee Guarantees by selecting an option from the drop downs in the table below. | ||||
| For any category of claims not explicitly outlined, please manually enter any and all remaining exclusions from Vendor's guarantees. | ||||
| Vendor agrees that any category of claim not marked on this tab as "Excluded from Guarantee" or manually input in the "Other" row will be included in Vendor's guarantees. | ||||
| Category of Claims | Commercial | Definition | Identification Logic using Objective Qualifiers | |
| Network Discount | Dispensing Fee | |||
| Claims with 100% member cost share | Select One | Select One | ||
| Claims that receives a discount through the 340B program, as indicated by the dispensing pharmacy or 340B third party administrator (e.g., submission clarification code of 20, ancillary file from dispensing pharmacy) | Select One | Select One | ||
| Claims processed at a contract pharmacy, as identified by a “340B Status” of 37 in NCPDP DataQ database, with or without proof or a 340B program drug discount | Select One | Select One | ||
| Claim processed at a contract pharmacy, as identified by the HRSA-published list of contract pharmacies, with or without proof or a 340B program drug discount | Select One | Select One | ||
| Claims processed at a pharmacy owned by a covered entity that serves both eligible and non-eligible patients, as identified by a “340B Status” of 38 in NCPDP DataQ database, with or without proof or a 340B program drug discount | Select One | Select One | ||
| Claims processed at a pharmacy owned by a covered entity that serves only eligible patients, as identified by a “340B Status” of 39 in NCPDP DataQ database, with or without proof or a 340B program drug discount | Select One | Select One | ||
| Authorized Generic Claims | Select One | Select One | ||
| Biosimilar Claims | Select One | Select One | ||
| Claims approved via formulary / medical / coverage exception process | Select One | Select One | ||
| Claims for devices without a prescription component | Select One | Select One | ||
| Claims greater than 180 days old | Select One | Select One | ||
| Claims with <90 day supply at mail | Select One | Select One | ||
| Claims with Ancillary Charges | Select One | Select One | ||
| Claims with Invalid Information | Select One | Select One | ||
| Compound Claims | Select One | Select One | ||
| Coordination of Benefits (COB) claims where client is the primary payer | Select One | Select One | ||
| Coordination of Benefits (COB) claims where client is the secondary payer | Select One | Select One | ||
| Cosmetic drugs (e.g. hair, skin) Claims | Select One | Select One | ||
| DAW 0 Claims | Select One | Select One | ||
| DAW 1 Claims | Select One | Select One | ||
| DAW 2 Claims | Select One | Select One | ||
| DAW 3 Claims | Select One | Select One | ||
| DAW 4 Claims | Select One | Select One | ||
| DAW 5 Claims | Select One | Select One | ||
| DAW 6 Claims | Select One | Select One | ||
| DAW 7 Claims | Select One | Select One | ||
| DAW 8 Claims | Select One | Select One | ||
| DAW 9 Claims | Select One | Select One | ||
| Discount Card Claims | Select One | Select One | ||
| Claims for drugs subject to patent litigation | Select One | Select One | ||
| Emergency Use Authorization (EUA) claims (while drugs are in the program) | Select One | Select One | ||
| Home Infusion Claims | Select One | Select One | ||
| Claims filled at Indian Tribal Pharmacies | Select One | Select One | ||
| Claims filled at on-site pharmacies or in-house pharmacies | Select One | Select One | ||
| Limited distribution drugs or exclusive distribution drugs (with PBM access) | Select One | Select One | ||
| Limited distribution drugs or exclusive distribution drugs (without PBM access) | Select One | Select One | ||
| Claims filled at Long Term Care (LTC) Pharmacies | Select One | Select One | ||
| MAC list drugs (drugs priced via maximum allowable cost list) | Select One | Select One | ||
| Maximum Fair Price Drugs (negotiated under Inflation Reduction Act) | Select One | Select One | ||
| Medicaid Managed Care Claims | Select One | Select One | ||
| Claims filled at military / veteran's administration (VA) pharmacies | Select One | Select One | ||
| Claims with Missing / Invalid Medispan data | Select One | Select One | ||
| Multi-Source Brands Claims | Select One | Select One | ||
| New to Market Claims | Select One | Select One | ||
| No Bill / No Remit Claims | Select One | Select One | ||
| Not Covered / Non-Formulary Claims | Select One | Select One | ||
| Claims filled at client owned and operated pharmacies | Select One | Select One | ||
| Claims filled at Out of Network Pharmacies | Select One | Select One | ||
| OTC insulins, diabetic test strips, and diabetic testing supplies | Select One | Select One | ||
| OTC - All other OTCs that are not insulin, diabetic test strips, and diabetic testing supplies | Select One | Select One | ||
| Paper / direct member reimbursement Claims | Select One | Select One | ||
| Pharmaceutical Incentive Claims | Select One | Select One | ||
| Pharmacies subject to region specific pricing | Select One | Select One | ||
| Pharmacies that do not meet PBM Standards | Select One | Select One | ||
| Pharmacies with client direct agreement | Select One | Select One | ||
| Claims filled at Prison Pharmacies | Select One | Select One | ||
| Claims with Repackaged NDCs | Select One | Select One | ||
| Claims filled at Rural Pharmacies | Select One | Select One | ||
| Subrogation Claims | Select One | Select One | ||
| Supplies and devices (e.g. implantable / wearable glucose meters but NOT including insulin and diabetic test strips) | Select One | Select One | ||
| Test Kits for COVID | Select One | Select One | ||
| Test Kits for non-COVID | Select One | Select One | ||
| Usual and customary (U&C) Claims | Select One | Select One | ||
| Vaccines, vaccine products, and/or vaccine administration Claims for COVID | Select One | Select One | ||
| Vaccines - For all other vaccines, vaccine products, and/or vaccine administration claims that are not COVID related | Select One | Select One | ||
| Zero balance due (ZBD) Claims | Select One | Select One | ||
| Other (please list) | Select One | Select One | ||
| Other (please list) | Select One | Select One | ||
| Other (please list) | Select One | Select One | ||
| Other (please list) | Select One | Select One | ||
| Other (please list) | Select One | Select One | ||
| Other (please list) | Select One | Select One |
Compounds and Vaccines
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY |
| NVHA IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
| Compound Pricing |
Please complete the table below reflecting reimbursement to pharmacies for compounding services. There are no additional fees or costs paid to Contractor for processing of Compound Claims.
| Level of Effort Code | Examples | Discount (AWP Minus) | LOE Fee (Admin Fee paid to Network Pharmacy) | Comments |
| 11 (Straightforward) | Magic Mouthwash, GI cocktails | Enter Discount | Enter Fee | |
| 12 (Low Complexity) | Two ingredient capsule/suppository; transdermal gel. | Enter Discount | Enter Fee | |
| 13 (Moderate Complexity) | Three or less ingredient cream/ointment/gel; three-ingredient capsule/suppository; two or less ingredient troche; non-complex suspension; tablet triturate. | Enter Discount | Enter Fee | |
| 14 (High Complexity) | Topical-containing controlled substance; three or more ingredient troche; four or more ingredient | Enter Discount | Enter Fee | |
| 15 (Sterile) | Sterile Compounds - must be compounded in a compliant environment and are dispensed as sterile finished preparation | Enter Discount | Enter Fee | |
| Vaccine Pricing |
Please complete the table below reflecting reimbursement to pharmacies for vaccination services. There are no additional fees or costs paid to Vendor for processing of Vaccine Claims.
| Vaccine | Discount (AWP Minus) | LOE Fee (Admin Fee paid to Network Pharmacy) | Comments |
| Influenza | Enter Discount | Enter Fee | |
| COVID-19 | Enter Discount | Enter Fee | |
| Pneumonia | Enter Discount | Enter Fee | |
| HPV | Enter Discount | Enter Fee | |
| Shinges/Zoster | Enter Discount | Enter Fee | |
| All Others (Tdap, HepA, HepB, MMR, etc.) | Enter Discount | Enter Fee |
Spec AAC+ Fee Schedule
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY THE |
| NVHA IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
| Specialty Fee Schedule - AAC+ |
| Please complete the table below for each 11-digit NDC and provide Contractor's guaranteed Actual Acquisition Cost (AAC) per unit and applicable Dispensing Fee per Unit for Specialty Pharmacy. |
| Complete all requested drug classification, therapy class, LDD, and Contractor access fields. For Plan and Optional Years 2 through 8, provide the guaranteed percentage change, if any, to the Plan Year 1 AAC per unit. |
| AAC must be provided at the individual drug level in accordance with AAC definition and applicable Pricing Terms of this RFP. |
| Contractor may add additional NDCs only for LDDs it has access to in the table below. Any LDDs Contractor does not have ability to dispense must be marked as such. |
| Any drugs not listed below will be subject to the default AWP discount guarantees on tab [Specialty AAC+ Pricing Terms] |
| Inputs | |
| Data Validation | |
| Drug Classification: | |
| Specialty Brand | |
| Specialty Generic | |
| Contractor Specialty Pharmacy has access? | Yes |
| No |
| 11 Digit NDC | Drug Name | ||||||||||||||||||||||||||
| (Brand Name if Brand Drug, Generic Name if Generic Drug) | Drug Classification | ||||||||||||||||||||||||||
| Brand / Generic | Therapy Class | LDD Yes / No | Actual Acquisition Cost Price per Unit (Year 1) | Actual Acquisition Price Estimate per Unit (Year 2) Escalator % | Actual Acquisition Price Estimate per Unit (Year 3) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 4) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 5) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 6 first half) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 6 second half) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 7) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 8) Escalator % | Actual Acquisition Cost Dispensing Fee (Year 1) | Actual Acquisition Dispense Fee Estimate per Unit (Year 2) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 3) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 4) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 5) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 6 first half) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 6 second half) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 7) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 8) Escalator % | Per Diem or other Fees | Per Diem or other Fees (describe) | |||||
| Vendor to complete | Vendor to complete | Vendor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete |
Spec AAC+ Pricing Terms
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY THE |
| NVHA IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
| Specialty Acquisition Cost Pricing |
Please provide Contractor's estimated discounts off of AWP based on the acquisition cost pricing offer for specialty claims. The only source of revenue earned by Contractor should come from the base administrative fee. Please provide Contractor's AWP discount guarantee for new-to-market (NTM) drugs and other drugs not found on the specialty pricing list in tab [Spec AAC+ Fee Schedule] (default).
| Drug Type | Year 1 Overall Estimated Discount off AWP | Year 2 Overall Estimated Discount off AWP | Year 3 Overall Estimated Discount off AWP | Year 4 Overall Estimated Discount off AWP | Year 5 Overall Estimated Discount off AWP | Year 6 First Half Overall Estimated Discount off AWP | Year 6 Second Half Overall Estimated Discount off AWP | Year 7 Overall Estimated Discount off AWP | Year 8 Overall Estimated Discount off AWP |
| Brand PBM Specialty Drugs | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Generic PBM Specialty Drugs | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Brand PBM Specialty LDD | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Generic PBM Specialty LDD | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Drug Type | Year 1 Overall Guaranteed Discount off AWP | Year 2 Overall Guaranteed Discount off AWP | Year 3 Overall Guaranteed Discount off AWP | Year 4 Overall Guaranteed Discount off AWP | Year 5 Overall Guaranteed Discount off AWP | Year 6 First Half Overall Guaranteed Discount off AWP | Year 6 Second Half Overall Guaranteed Discount off AWP | Year 7 Overall Guaranteed Discount off AWP | Year 8 Overall Guaranteed Discount off AWP |
| Brand NTM PBM Specialty Drugs | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Generic NTM PBM Specialty Drugs | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Brand PBM Specialty Default | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Generic PBM Specialty Default | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
Mail AAC+ Fee Schedule
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY THE |
| NVHA IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
| Mail Order - AAC+ Pricing |
| NVHA prefers an Actual Acquisition Cost (AAC) methodology for Mail Order Pharmacy pricing where Contractor owns or controls the dispensing operation and can substantiate AAC. If Contractor cannot support AAC, Contractor must identify the reason and quote its best available transparent pass-through, cost-plus, or other methodology, fully disclosing the underlying acquisition or subcontractor economics, all fees and markups, and any margin retained between the underlying cost and the amount charged to NVHA. |
| Mail drugs are guaranteed both at the individual drug level, and in aggregate at the end of each Plan Year (i.e., generic, brand) |
| Any drugs not listed below will be subject to the default AWP discount guarantees on tab [Mail AAC+ Pricing Terms] |
| Inputs |
| Data Validation |
| Drug Classification: |
| 11 Digit NDC | Drug Name | |||||||||||||||||||||||||
| (Brand Name if Brand Drug, Generic Name if Generic Drug) | Drug Classification | |||||||||||||||||||||||||
| Brand / Generic | Therapy Class | Actual Acquisition Cost Price per Unit (Year 1) | Actual Acquisition Price Estimate per Unit (Year 2) Escalator % | Actual Acquisition Price Estimate per Unit (Year 3) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 4) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 5) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 6 first half) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 6 second half) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 7) Escalator % | Actual Acquisition PriceEstimate per Unit (Year 8) Escalator % | Actual Acquisition Cost Dispensing Fee (Year 1) | Actual Acquisition Dispense Fee Estimate per Unit (Year 2) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 3) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 4) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 5) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 6 first half) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 6 second half) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 7) Escalator % | Actual Acquisition Dispense Fee Estimate per Unit (Year 8) Escalator % | Per Diem or other Fees | Per Diem or other Fees (describe) | |||||
| Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete | Contractor to complete |
Mail AAC+ Pricing Terms
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: 10/22/2026 |
| Electronic Submission Due By: 12/29/2026 @ 2:00 P.M. P.S.T. |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY THE |
| CLIENT IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
| Mail Order Acquisition Cost Pricing |
| Please provide Contractor's estimated discounts off of AWP based on the acquisition cost plus pricing offer for specialty claims. The only source of revenue earned by Contractor should come from the base administrative fee plus the dispensing fees listed in Columns C:E. |
| Please provide Contractor's AWP discount guarantee for new-to-market (NTM) non-specialty drugs and other drugs not found on the pricing list in tab [Mail AAC+ Fee Schedule] (default). |
| Drug Type | Year 1 Overall Estimated Discount off AWP | Year 2 Overall Estimated Discount off AWP | Year 3 Overall Estimated Discount off AWP | Year 4 Overall Estimated Discount off AWP | Year 5 Overall Estimated Discount off AWP | Year 6 First Half Overall Estimated Discount off AWP | Year 6 Second Half Overall Estimated Discount off AWP | Year 7 Overall Estimated Discount off AWP | Year 8 Overall Estimated Discount off AWP |
| Brand Drugs | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Generic Drugs | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Drug Type | Year 1 Overall Guaranteed Discount off AWP | Year 2 Overall Guaranteed Discount off AWP | Year 3 Overall Guaranteed Discount off AWP | Year 4 Overall Guaranteed Discount off AWP | Year 5 Overall Guaranteed Discount off AWP | Year 6 First Half Overall Guaranteed Discount off AWP | Year 6 Second Half Overall Guaranteed Discount off AWP | Year 7 Overall Guaranteed Discount off AWP | Year 8 Overall Guaranteed Discount off AWP |
| Brand NTM Drugs | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Generic NTM Drugs | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Brand PBM Mail Default | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
| Generic PBM Mail Default | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% | 0.00% |
Pricing Projections
| 41NHA-S3992 - Pharmacy Benefit Management (PBM) Services Request for Proposal |
| Release Date: Month Date, 2026 |
| Electronic Submission Due By: Month Date, 2026 @ time |
| Nevada Health Authority Public Employee Benefit Program |
| NOTICE: ANY AND ALL INFORMATION BEING PRESENTED BY YOUR ORGANIZATION MUST BE CONTAINED WITHIN THIS RFP WORKBOOK. ONLY ADDITIONAL DOCUMENTS REQUESTED BY |
| NVHA IN THIS RFP WILL BE ACCEPTED. NO ADDITIONAL DOCUMENTS, TERMS OR CONDITIONS WILL BE ACCEPTED OR REVIEWED AS PART OF THIS EVALUATION PROCESS. |
Financial Projections Template
| Instructions: | |||||||||||
| Please complete the following chart with the assumptions you used to underwrite this opportunity. | |||||||||||
| Average Membership in 2025 - <X> | |||||||||||
| Contractor Self-Reported Projection Assumptions | |||||||||||
| Plan Years 1 through 6 | Optional Add-On Plan Years | ||||||||||
| 2025/2026 | 7/1/2027 - 6/30/2028 | 7/1/2028 - 6/30/2029 | 7/1/2029 - 6/30/2030 | 7/1/2030 - 6/30/2031 | 7/1/2031 - 6/30/2032 | 7/1/2032 - 6/30/2033 | 7/1/2033 - 12/31/2033 | 1/1/2034 - 6/30/2034 | 7/1/2034 - 6/30/2035 | 7/1/2035 - 6/30/2036 | |
| Total Average Membership |
| PROJECTED SCRIPT COUNTS | |||||||||||
| Total Scripts | 2025/2026 | 7/1/2027 - 6/30/2028 | 7/1/2028 - 6/30/2029 | 7/1/2029 - 6/30/2030 | 7/1/2030 - 6/30/2031 | 7/1/2031 - 6/30/2032 | 7/1/2032 - 6/30/2033 | 7/1/2033 - 12/31/2033 | 1/1/2034 - 6/30/2034 | 7/1/2034 - 6/30/2035 | 7/1/2035 - 6/30/2036 |
| Retail 30 Brand | |||||||||||
| Retail 30 Generic | |||||||||||
| Retail 90 Brand | |||||||||||
| Retail 90 Generic | |||||||||||
| Retail Specialty Brand | |||||||||||
| Retail Specialty Generic | |||||||||||
| Retail LDD Brand | |||||||||||
| Retail LDD Generic | |||||||||||
| PBM Specialty Brand | |||||||||||
| PBM Specialty Generic | |||||||||||
| PBM Specialty LDD Brand | |||||||||||
| PBM Specialty LDD Generic | |||||||||||
| Mail Brand | |||||||||||
| Mail Generic | |||||||||||
| Other (describe) | |||||||||||
| Total Scripts | |||||||||||
| Scripts Eligible for Discount Guarantees | 2025/2026 | 7/1/2027 - 6/30/2028 | 7/1/2028 - 6/30/2029 | 7/1/2029 - 6/30/2030 | 7/1/2030 - 6/30/2031 | 7/1/2031 - 6/30/2032 | 7/1/2032 - 6/30/2033 | 7/1/2033 - 12/31/2033 | 1/1/2034 - 6/30/2034 | 7/1/2034 - 6/30/2035 | 7/1/2035 - 6/30/2036 |
| Retail 30 Brand | |||||||||||
| Retail 30 Generic | |||||||||||
| Retail 90 Brand | |||||||||||
| Retail 90 Generic | |||||||||||
| Retail Specialty Brand | |||||||||||
| Retail Specialty Generic | |||||||||||
| Retail LDD Brand | |||||||||||
| Retail LDD Generic | |||||||||||
| PBM Specialty Brand | |||||||||||
| PBM Specialty Generic | |||||||||||
| PBM Specialty LDD Brand | |||||||||||
| PBM Specialty LDD Generic | |||||||||||
| Mail Brand | |||||||||||
| Mail Generic | |||||||||||
| Other (describe) | |||||||||||
| Total Scripts Eligible for Discount Guarantees |
| Scripts Eligible for Dispensing Fee Guarantees | 2025/2026 | 7/1/2027 - 6/30/2028 | 7/1/2028 - 6/30/2029 | 7/1/2029 - 6/30/2030 | 7/1/2030 - 6/30/2031 | 7/1/2031 - 6/30/2032 | 7/1/2032 - 6/30/2033 | 7/1/2033 - 12/31/2033 | 1/1/2034 - 6/30/2034 | 7/1/2034 - 6/30/2035 | 7/1/2035 - 6/30/2036 |
| Retail 30 Brand | |||||||||||
| Retail 30 Generic | |||||||||||
| Retail 90 Brand | |||||||||||
| Retail 90 Generic | |||||||||||
| Retail Specialty Brand | |||||||||||
| Retail Specialty Generic | |||||||||||
| Retail LDD Brand | |||||||||||
| Retail LDD Generic | |||||||||||
| PBM Specialty Brand | |||||||||||
| PBM Specialty Generic | |||||||||||
| PBM Specialty LDD Brand | |||||||||||
| PBM Specialty LDD Generic | |||||||||||
| Mail Brand | |||||||||||
| Mail Generic | |||||||||||
| Other (describe) | |||||||||||
| Total Scripts Eligible for Dispensing Fee Guarantees |
| PROJECTED COSTS | |||||||||||
| Average Wholesale Price | 2025/2026 | 7/1/2027 - 6/30/2028 | 7/1/2028 - 6/30/2029 | 7/1/2029 - 6/30/2030 | 7/1/2030 - 6/30/2031 | 7/1/2031 - 6/30/2032 | 7/1/2032 - 6/30/2033 | 7/1/2033 - 12/31/2033 | 1/1/2034 - 6/30/2034 | 7/1/2034 - 6/30/2035 | 7/1/2035 - 6/30/2036 |
| Retail 30 Brand | |||||||||||
| Retail 30 Generic | |||||||||||
| Retail 90 Brand | |||||||||||
| Retail 90 Generic | |||||||||||
| Retail Specialty Brand | |||||||||||
| Retail Specialty Generic | |||||||||||
| Retail LDD Brand | |||||||||||
| Retail LDD Generic | |||||||||||
| PBM Specialty Brand | |||||||||||
| PBM Specialty Generic | |||||||||||
| PBM Specialty LDD Brand | |||||||||||
| PBM Specialty LDD Generic | |||||||||||
| Mail Brand | |||||||||||
| Mail Generic | |||||||||||
| Other (describe) |
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File details come from the government source that posted it. Updated .