Addendum_HCPS_Attachment_E_Rx_Financials_12.1.25.xlsx
XLSX spreadsheet 702 KB Posted
- Attached to
- Medical/Rx
- Solicitation number
- 25598-RFP-DST
- Issued by
- Hillsborough County, Florida
About this file
Addendum to Hillsborough County Public Schools Medical/Rx RFP
This addendum document provides detailed financial questionnaire templates for pharmacy benefit management (PBM) vendors responding to Hillsborough County Public Schools' (HCPS) Request for Proposals (RFP 25598-DST) for prescription drug services effective January 1, 2027. The addendum outlines mandatory submission requirements across multiple Excel worksheets covering retail network disruption reporting, geographic access analysis, formulary disruption assessment, pricing structures, specialty drug listings, clinical program offerings, and rebate credit eligibility. Vendors must complete all sections comprehensively, including three-year financial projections (Year 1-3), network specifications, discount guarantees on a post-AWP rollback basis, dispensing fees, administrative fees by claim type, and manufacturer payment minimums. The document specifies detailed parameters for network access standards, requiring vendors to demonstrate that members have access to at least two pharmacies within five miles using driving distance measurements. All proposed terms are guaranteed, and vendors must provide officer certification confirming the accuracy and completeness of their financial submissions.
The pricing requirements mandate separate financial offers for multiple pharmacy channels including retail 30-day supplies, retail 90-day supplies, mail order, mail-at-retail, long-term care, home infusion, Indian Health Services, territory pharmacies, and specialty drugs through both preferred and non-preferred specialty vendors. Vendors must specify whether claims are included or excluded from discount guarantees and manufacturer payment guarantees across 68 distinct claim types, with detailed guidance provided regarding ACA medications, biosimilars, 340B claims, compound drugs, coordinated benefits, copay assistance programs, diabetes supplies, hepatitis and HIV drugs, insulins, Maximum Fair Price drugs, specialty pharmaceuticals, vaccines, and weight loss medications. The addendum requires completion of clinical program offerings, other cost services, state-mandated reimbursement provisions, and projected financial spend components, with all pricing assumptions transparently documented. Vendors must also identify limited distribution drugs, preferred biosimilar products eligible for rebate credits, and provide comprehensive assumptions regarding membership, prescription volumes per member per year, channel utilization percentages, average AWP per prescription by drug type and channel, and generic utilization rates to support underwriting analysis.
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Text version
Rx Retail Network Disruption
| The School Board of Hillsborough County, FL |
| Retail Network Disruption |
Instructions: We've included the below parameters but please also provide your standard reporting for your retail network disruption report. Please use the detailed Rx data provided in the zipped folder: HCPS_Detailed Rx Data.zip
| Participating Pharmacy | |||||||
| NABP or NCPDP # | Pharmacy Chain | Pharmacy Name | Pharmacy Address | Pharmacy City | Pharmacy State | Pharmacy Zip Code | Yes/No |
Rx Retail 90 Network Distruptio
| The School Board of Hillsborough County, FL |
| Retail 90 Day Network Disruption |
Instructions: We've included the below parameters but please also provide your standard reporting for your standard retail 90 network disruption report using the detailed Rx data provided in the zipped folder: HCPS_Detailed Rx Data.zip
| Participating Pharmacy | |||||||
| NABP or NCPDP # | Pharmacy Chain | Pharmacy Name | Pharmacy Address | Pharmacy City | Pharmacy State | Pharmacy Zip Code | Yes/No |
Geo Access-Rx
| The School Board of Hillsborough County, FL |
| Geo-Access - Rx |
Instructions: Please prepare “Geo-Access” reports using the parameters in the tables below, based on the data in the census workbook. Note that it is important that you follow the exact parameters. Please also provide information on those zip codes where the access standard is not met.
| 1. | Network #1: Broadest Retail Network: | ||
| Access Standard: 2 Pharmacies within 5 Miles | Mileage Standard Measured in Driving Distance | ||
| a. | Total number of network pharmacies within access standard | ||
| b. | Number of Employees on census file | ||
| c. | Number of Employees with access to at least two (2) network pharmacies within 5 miles | ||
| d. | Number of Employees without access to at least two (2) network pharmacies within 5 miles (Line B-C) | ||
| e. | Number of Employees without access because no pharmacy exists within access standard | ||
| f. | Number of Employees without access because a pharmacy exists but is not in the proposed network (Line D-E) |
| 1. | Network #2: Retail 90 Network: | ||
| Access Standard: 2 Pharmacies within 5 Miles | Measured in Driving Distance | ||
| a. | Total number of network pharmacies within access standard | ||
| b. | Number of Employees on census file | ||
| c. | Number of Employees with access to at least two (2) network pharmacies within 5 miles | ||
| d. | Number of Employees without access to at least two (2) network pharmacies within 5 miles (Line B-C) | ||
| e. | Number of Employees without access because no pharmacy exists within access standard | ||
| f. | Number of Employees without access because a pharmacy exists but is not in the proposed network (Line D-E) |
&"Arial Narrow,Regular" Request for Prescription Drug Proposal &P
Rx Formulary Disruption
| The School Board of Hillsborough County, FL |
| Formulary Disruption |
Instructions: We've included the below parameters but please also provide your standard reporting for your standard exclusions based formulary disruption report using the detailed Rx data provided in the zipped folder: HCPS_Detailed Rx Data.zip
| Utilization Rank | ||||
| (highest utilization measured by number of claims listed first) | NDC 11 | Drug Name | Therapeutic Class | Formulary Status as of January 1, 2026 |
| (Formulary, Non-Formulary, Excluded) | Tier as of |
January 1, 2026
| (1, 2, 3, 4, or Not Covered) | Specialty |
| (Y/N) | Additional Comments/Notes |
(ex. ACA Medication, Preventive List Drug, Generic Now Available)
RX-Pricing, Credits
| The School Board of Hillsborough County, FL |
| RX-Pricing, Credits and Allowances |
| Proprietary & Confidential |
| Instructions: Please complete every cell on this worksheet. Your financial offer MUST COMPLY with all Bidding Requirements and requirements in the Financial Questionnaire. All proposed terms are guaranteed. |
| Aon Identification Data |
| Vendor Name |
Line of Business Commercial Credits
| Include relevant basis (e.g., PMPM, PMPY, Annual etc.) | Base Contract Term | ||
| Year 1 | Year 2 | Year 3 | |
| Annual Audit Allowance | |||
| Annual Market Check Allowance | |||
| Implementation Credit/Allowance | |||
| Pre-implementation Audit Credit | |||
| Pharmacy Management Fund (PMF) | |||
| Other Credit | |||
| Total Value ($) |
DropDown
| Included | Yes | Fully Agree | Yes | Complete | Wholly Owned | Confirmed | At least quarterly | Monthly | PMPY | Admin Fees |
| Excluded | No | Partial Agree | No, Explain | Not Complete | Outsourced | Not Confirmed | At least semi-annually | Quarterly | PEPY | Select |
| Included Channel Agnostic | Disagree | At least annually | Semi-Annually | PEPM | Per Rx | |||||
| Excluded Channel Agnostic | Other, specify | Annually | PMPM | PEPM | ||||||
| Other, Explain | Total | PMPM | ||||||||
| Per Rx & PEPM | ||||||||||
| Per Rx & PMPM |
RX-Pricing, Discount & DF
| The School Board of Hillsborough County, FL |
| RX-Pricing, Discounts, Dispensing Fees, Administrative Fees |
| Proprietary & Confidential |
| Instructions: Please complete every cell on this worksheet. For retail, please propose pricing for your broadest retail network. Your financial offer MUST COMPLY with all Bidding Requirements and requirements in the Financial Questionnaire. Your pricing offer must be on a post-AWP rollback basis. All proposed terms are guaranteed including adjudication formulas. |
| Aon Identification Data |
| Vendor Name |
| ADMINISTRATIVE FEES | |||
| Base Contract Term | |||
| Year 1 | Year 2 | Year 3 | |
| Administrative Fee Basis | Select | Select | Select |
| Per Retail 30 Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Retail 90 Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Mail Order Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per LTC Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Indian Health, Tribal Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Home Infusion Pharmacy Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Territory Pharmacy Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Specialty Drug at Retail Pharmacy Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Specialty Drug at Specialty Pharmacy Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Vaccine Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Member Submit Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Onsite Claims (if applicable) | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Member Per Month (if applicable) | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Vaccine Seasonal | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Vaccine Non-Seasonal (including Pandemic) | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| RETAIL 30 (INCLUDING SPECIALTY FROM NON-PREFERRED SPECIALTY VENDORS) | |||
| Rx with Day Supply of 1-83 | |||
| Base Contract Term | |||
| Proposed Network Name | |||
| Number of Pharmacies Nationwide | |||
| Year 1 | Year 2 | Year 3 | |
| Minimum AWP Discount Guarantees |
With Integrated Discount Card Program
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Minimum AWP Discount Guarantees |
Without Integrated Discount Card Program
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Average Dispensing Fee per Paid Claim | |||
| All Brands | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| All Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| RETAIL 90 (INCLUDING SPECIALTY FROM NON-PREFERRED SPECIALTY VENDORS) | |||
| Rx with Day Supply +84 Days | |||
| Base Contract Term | |||
| Proposed Network Name | |||
| Number of Pharmacies Nationwide | |||
| Year 1 | Year 2 | Year 3 | |
| Minimum AWP Discount Guarantees |
With Integrated Discount Card Program
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Minimum AWP Discount Guarantees |
Without Integrated Discount Card Program
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Maximum Dispensing Fee per Paid Claim | |||
| All Brands | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| All Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| MAIL AT RETAIL (EXCLUDING SPECIALTY) | |||
| Rx with Day Supply +84 Days | |||
| Base Contract Term | |||
| Proposed Network Name | |||
| Anchor Chains in Mail at Retail Network | |||
| Number of Pharmacies Nationwide | |||
| Year 1 | Year 2 | Year 3 | |
| Minimum AWP Discount Guarantees | |||
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Maximum Dispensing Fee per Paid Claim | |||
| All Brands | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| All Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| MAIL ORDER (EXCLUDING SPECIALTY DRUGS DISPENSED THROUGH YOUR PREFERRED SPECIALTY PHARMACY) | |||
| Base Contract Term | |||
| Year 1 | Year 2 | Year 3 | |
| Minimum AWP Discount Guarantees | |||
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Maximum Dispensing Fee per Paid Claim | |||
| All Brands | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| All Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| SPECIALTY DRUGS FILLED THROUGH NON-PREFERRED SPECIALTY VENDORS | |||
| Base Contract Term | |||
| Year 1 | Year 2 | Year 3 | |
| Open Network: | |||
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Exclusive Network: | |||
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Maximum Dispensing Fee per Paid Claim (Open and Exclusive) | |||
| All Brands and Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| SPECIALTY DRUGS FILLED THROUGH YOUR PREFERRED SPECIALTY VENDOR | |||
| Base Contract Term | |||
| Year 1 | Year 2 | Year 3 | |
| Open Network: | |||
| Minimum AWP Discount Guarantee: All Brands | Insert Guaranteed Discount for all brands at Specialty | Insert Guaranteed Discount for all brands at Specialty | Insert Guaranteed Discount for all brands at Specialty |
| Minimum AWP Discount Guarantee: All Generics | Insert Guaranteed Discount for all generics at Specialty | Insert Guaranteed Discount for all generics at Specialty | Insert Guaranteed Discount for all generics at Specialty |
| Exclusive Network: | |||
| Minimum AWP Discount Guarantee: All Brands | Insert Guaranteed Discount for all brands at Specialty | Insert Guaranteed Discount for all brands at Specialty | Insert Guaranteed Discount for all brands at Specialty |
| Minimum AWP Discount Guarantee: All Generics | Insert Guaranteed Discount for all generics at Specialty | Insert Guaranteed Discount for all generics at Specialty | Insert Guaranteed Discount for all generics at Specialty |
| Maximum Dispensing Fee per Paid Claim (Open and Exclusive) | |||
| All Brands and Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Compound Drug Claims | |||
| Base Contract Term | |||
| Year 1 | Year 2 | Year 3 | |
| 11 - Single ingredient batched capsule; any combination of commercially available | Insert LOE Amt | Insert LOE Amt | Insert LOE Amt |
| 12 - Two or Three ingredient batched capsule; transdermal gel | Insert LOE Amt | Insert LOE Amt | Insert LOE Amt |
| 13 - Four or more ingredient batched capsule; three or less ingredient cream/ointment/gel: suppository; two or less ingredient capsule: noncomplex suspension; tablet triturate | Insert LOE Amt | Insert LOE Amt | Insert LOE Amt |
| 14 - Topical containing controlled ingredient; three or more ingredient troche; four or more ingredient capsule; complex suspensions (i.e. pediatric); custom capsule (includes rapid dissolution preparations); chemotherapy cream/ointment/gel; hormone therapy (capsules, troches, and suppositories). | Insert LOE Amt | Insert LOE Amt | Insert LOE Amt |
RX-Pricing, MFP
| The School Board of Hillsborough County, FL |
| RX-Pricing, Manufacturer Payment Bid |
| Proprietary & Confidential |
| Instructions: Please complete every cell on this worksheet. Your financial offer MUST COMPLY with all Bidding Requirements and requirements in the Financial Questionnaire. All proposed terms are guaranteed. |
| Aon Identification Data |
| Vendor Name |
BASED ON ALL PLAN DESIGNS WITHIN EXCLUSION FORMULARY Guaranteed Manufacturer Payment Amount Per Brand Rx
| Base Contract Term | |||
| Guaranteed Minimum Manufacturer Payment per Paid Claim | |||
| Name of Formulary Proposed | Please insert the name of the Formulary proposed | ||
| Number of Excluded Products on Formulary as of today | Please specify the number of excluded products on Formulary | ||
| Year 1 | Year 2 | Year 3 | |
| Per Member Per Month (PMPM) All Channels | Guaranteed Manufacturer Payment PMPM | Guaranteed Manufacturer Payment PMPM | Guaranteed Manufacturer Payment PMPM |
| Per Retail Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim |
| Per Retail 90 Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim |
| Per Mail Order and "Mail at Retail" Brand Claim (excluding Specialty) | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim |
| Per Retail Specialty Brand Claim (Non-preferred specialty vendor) | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim |
| Per Specialty Brand Claim (Preferred Specialty Pharmacy) | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim |
BASED ON ALL PLAN DESIGNS WITHIN OPEN FORMULARY Guaranteed Manufacturer Payment Amount Per Brand Rx
| Base Contract Term | |||
| Guaranteed Minimum Manufacturer Payment per Paid Claim | |||
| Name of Formulary Proposed | Please insert the name of the Formulary proposed | ||
| Number of Excluded Products on Formulary as of today | Please specify the number of excluded products on Formulary (If any) | ||
| Year 1 | Year 2 | Year 3 | |
| Per Member Per Month (PMPM) All Channels | Guaranteed Manufacturer Payment PMPM | Guaranteed Manufacturer Payment PMPM | Guaranteed Manufacturer Payment PMPM |
| Per Retail Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim |
| Per Retail 90 Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim |
| Per Mail Order and "Mail at Retail" Brand Claim (excluding Specialty) | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim |
| Per Retail Specialty Brand Claim (Non-preferred specialty vendor) | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim |
| Per Specialty Brand Claim (Preferred Specialty Pharmacy) | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim | Guaranteed Manufacturer Payment per Paid Brand Claim |
RX-Pricing, Specialty Drugs
| The School Board of Hillsborough County, FL |
| RX-Pricing, Specialty Drug List (Preferred Specialty Pharmacy/Mail) |
| Proprietary & Confidential |
| Aon Identification Data |
| Vendor Name |
| Instructions: Please provide your list in alphabetic order by therapeutic class description; within in each therapeutic class description, please list the drug names in alphabetical order. All columns must be completed for each product listed. | ||||||||||||||||||
| Discount is % off AWP on a post-rollback basis | ||||||||||||||||||
| Please use the GPI-4 Indicator for Therapeutic Class ID | Biosimilar | New to Market Specialty Drug | Limited Distribution | Is Your Preferred Specialty Pharmacy a Limited Distribution Vendor? | Specialty Retail (If not included in Non-Specialty Retail) | Open Network Guaranteed Terms | Exclusive Network Guaranteed Terms | |||||||||||
| NDC | Therapeutic Class ID GPI-4 | Therapeutic Class Description (GPI-4) | Generic Drug Identifier (e.g. GCN or full GPI) | Drug Name | Strength | Dosage Form | Brand/ Generic | Yes / No | Yes / No | Yes / No | Yes / No | Discount | Disp Fee | Discount | Disp Fee | Discount | Disp Fee |
RX-Pricing, Exclusions
| The School Board of Hillsborough County, FL |
| RX-Pricing, Exclusions |
| Proprietary & Confidential |
| To Vendor: Use Columns E-G to provide a response as to whether the claim type listed in Column C is "INCLUDED" in the respective discount, dispensing fee, and Manufacturer Payment guarantee. Please limit your explanations to 400 characters or less. |
| Claim Exclusions | Response | Explanation | ||||||||
| 1. | Please confirm this exhibit will be included in the final contract. | Confirm | ||||||||
| 2. | You understand that deviations from Aon's Suggested Included/Excluded Guidelines in Columns H & I will result in adjustments to your financial offering. | Confirm | ||||||||
| 3. | For the avoidance of doubt, all Claims not specifically outlined in the 'RX-Pricing, Exclusions' as excluded will be included in the Guaranteed Price for purposes of Discount and Dispensing Fee reconciliation. | Fully Agree / Disagree | ||||||||
| 4. | For the avoidance of doubt, all Claims not specifically outlined as excluded will be included in the Manufacturer Payment Guarantees for purposes of reconciliation. Furthermore, Client shall receive the any Manufacturer Payment dollars received by PBM on any exclusions listed. | Fully Agree / Disagree | ||||||||
| Claim Inclusion/Exclusion of Specific Claim Types | Discount Guarantees | Guaranteed Minimum Manufacturer Payment | Explanation | Aon's Suggested | ||||||
| Discount Guarantees | Aon's Suggested Manufactuerer Payments | Aon's Explanation/Ask | ||||||||
| Please confirm if the following claims are included in the Guaranteed Price and/or Guaranteed Minimum Manufacturer Payment | ||||||||||
| 5. | Claims pursuant to a 100% Member Copayment Plan (see column J for clarification) | Included / Excluded, Explain | Included | Included | This Inclusion/Exclusion line item only refers to Plan Designs that require Members Pay 100% of all claim costs. (This should apply in extremely rare circumstances) | |||||
| 6. | 100% Member Paid Claims, Zero Plan Paid Claims (see column J for clarification) | Included / Excluded, Explain | Included | Included | This Inclusion/Exclusion line item includes all Claims where the Member pays the Total Claim Cost and the Plan pays zero. | |||||
| 7. | Anti-Nausea Drugs | Included / Excluded, Explain | Included | Included | ||||||
| 8. | Authorized and Approved COVID-19 treatment Claims | Included / Excluded, Explain | Included | Included | ||||||
| 9. | Biosimilar Drugs (Non-Specialty) | Included / Excluded, Explain | Included | Included | ||||||
| 10. | Biosimilar Drugs (Specialty Drugs) | Included / Excluded, Explain | Included | Included | ||||||
| 11. | Bulk Chemicals | Included / Excluded, Explain | Included | Included | ||||||
| 12. | Claims approved by formulary exception | Included / Excluded, Explain | Included | Included | ||||||
| 13. | Claims from Entities Eligible for Federal Supply Schedule Prices | Included / Excluded, Explain | Included | Included | ||||||
| 14. | Claims older than 180 days | Included / Excluded, Explain | Included | Included | ||||||
| 15. | 340B Claims | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 16. | Compound Drug Claims | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 17. | Coordination of Benefit (COB) / Secondary Payer | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 18. | Copay Assistance Program CLAIMS | Included / Excluded, Explain | Included | Included | ||||||
| 19. | Copay Assistance Program DOLLARS | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 20. | Copay Maximizer Program CLAIMS | Included / Excluded, Explain | Included | Included | ||||||
| 21. | Copay Maximizer Program DOLLARS | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 22. | COVID-19 Vaccines and administration | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 23. | COVID-19 test kits | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 24. | Discount Card Claims | Included / Excluded, Explain | Included | Included | ||||||
| 25. | Dispense as Written (DAW) CLAIMS | Included / Excluded, Explain | Included | Included | ||||||
| 26. | Dispense as Written (DAW) DOLLARS | Included / Excluded, Explain | Excluded | Excluded | This Inclusion/Exclusion line item refers to Penalty Dollars from DAW programs being counted either as part of the discount guarantee or the manufacturer payment guarantee. | |||||
| 27. | Diabetic Supplies (Meters, Strips, Syringes etc.) | Included / Excluded, Explain | Included | Included | ||||||
| 28. | Exclusive/Limited Distribution Specialty Drugs for which you do not have access | Included / Excluded, Explain | Included | Included | ||||||
| 29. | Exclusive/Limited Distribution Specialty Drugs that your specialty pharmacy has access | Included / Excluded, Explain | Included | Included | ||||||
| 30. | Exclusive/Limited Distribution Specialty Drugs that only your specialty pharmacy has access | Included / Excluded, Explain | Included | Included | ||||||
| 31. | Exclusive/Limited Distribution Specialty Drugs that are New to Market (NTM) | Included / Excluded, Explain | Included | Included | ||||||
| 32. | Generic Specialty Drugs | Included / Excluded, Explain | Included | Excluded | ||||||
| 33. | Hepatitis B Drugs | Included / Excluded, Explain | Included | Included | ||||||
| 34. | Hepatitis C Drugs | Included / Excluded, Explain | Included | Included | ||||||
| 35. | HIV Drugs | Included / Excluded, Explain | Included | Included | ||||||
| 36. | Home Infusion Pharmacy or HIF | Included / Excluded, Explain | Included | Included | ||||||
| 37. | Indian Health Services, Tribal or Urban Indian Health or I/T/U | Included / Excluded, Explain | Included | Included | ||||||
| 38. | Insulin | Included / Excluded, Explain | Included | Included | ||||||
| 39. | Long Term Care Pharmacy or LTC | Included / Excluded, Explain | Included | Included | ||||||
| 40. | Low List Price Brand Drugs | Included / Excluded, Explain | Included | Included | ||||||
| 41. | Maximum Fair Price Drugs (2026 MFPs) | Included / Excluded, Explain | Included | Included | ||||||
| 42. | Maximum Fair Price Drugs (2027 MFPs) | Included / Excluded, Explain | Included | Included | ||||||
| 43. | Maximum Fair Price Drugs (2028 MFPs) | Included / Excluded, Explain | Included | Included | ||||||
| 44. | Maximum Fair Price Drugs (2029+ MFPs) | Included / Excluded, Explain | Included | Included | ||||||
| 45. | Military Pharmacy | Included / Excluded, Explain | Included | Included | ||||||
| 46. | Missing / Invalid Medi-Span data | Included / Excluded, Explain | Included | Included | ||||||
| 47. | Most Favored Nation States | Included / Excluded, Explain | Included | Included | ||||||
| 48. | Multi-Source Brand (MSB) Claims | Included / Excluded, Explain | Included | Included | ||||||
| 49. | New to Market (NTM) Specialty Drugs | Included / Excluded, Explain | Included | Included | ||||||
| 50. | No Bill, No Remit | Included / Excluded, Explain | Excluded | Included | ||||||
| 51. | Non-Preferred Brand Drug Claims | Included / Excluded, Explain | Included | Included | ||||||
| 52. | Onsite Pharmacy Utilization | Included / Excluded, Explain | Subject to Client | Included | ||||||
| 53. | Out of Network Claims | Included / Excluded, Explain | Excluded | Included | If Excluded from Guarantees, provide a list of these pharmacies. | |||||
| 54. | Over-the-Counter (OTC) Claims | Included / Excluded, Explain | Included | Included | ||||||
| 55. | Paper or Member Submitted Claims | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 56. | PCSK-9 Inhibitor Claims | Included / Excluded, Explain | Included | Included | ||||||
| 57. | Pharmacies subject to Region-specific Pricing | Included / Excluded, Explain | Excluded | Included | If Excluded from Guarantees, provide a list of these pharmacies. | |||||
| 58. | Pharmacies that Do Not Meet your Discount or Credential standards | Included / Excluded, Explain | Excluded | Included | If Excluded from Guarantees, provide a list of these pharmacies. | |||||
| 59. | Powders | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 60. | Repackaged National Drug Code (NDC) Claims | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 61. | Rural Pharmacies | Included / Excluded, Explain | Included | Included | If Excluded from Guarantees, provide a list of these pharmacies. | |||||
| 62. | State mandated pharmacy reimbursement claims | Included / Excluded, Explain | Excluded | Included | ||||||
| 63. | Subrogation Claims | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 64. | Transplant Drugs | Included / Excluded, Explain | Included | Included | ||||||
| 65. | Usual and Customary (U&C) | Included / Excluded, Explain | Included | Included | ||||||
| 66. | Vaccines (Seasonal, Non-Seasonal, Pandemic) | Included / Excluded, Explain | Excluded | Excluded | ||||||
| 67. | Veteran Affairs Pharmacy or VA | Included / Excluded, Explain | Included | Included | ||||||
| 68. | Weight Loss Drugs | Included / Excluded, Explain | Included | Included |
RX-Pricing, Other Costs
| The School Board of Hillsborough County, FL |
| RX-Pricing, Other Costs |
| Proprietary & Confidential |
| Instructions: Please complete every cell on this worksheet. Your financial offer MUST COMPLY with all Bidding Requirements and requirements in the Financial Questionnaire. All proposed terms are guaranteed. Please indicate the charges/fees associated with the following types of programs (include charges for basic, enhanced, and optional programs). If charges vary depending on drug class, put a range in the corresponding cell, (ex.: $0.05-$0.08 PMPM). For clinical programs, please provide any relevant product/program names and corresponding ROI. |
| Aon Identification Data |
| Vendor Name |
Other Costs
| Category | Services | Required/Optional | Fee | Fee Basis | Notes and ROI (if applicable) |
| Member Communication/Services | Annual communications (benefit change announcements) | ||||
| Member Communication/Services | Explanation of benefits (EOBs) production and distribution | ||||
| Member Communication/Services | Member call center | ||||
| Member Communication/Services | Marketing material | ||||
| Member Communication/Services | Postage for member notification letters | ||||
| Member Communication/Services | Transition fill letter to member and provider - standard | ||||
| Member Communication/Services | Transition fill letter to member and provider - custom | ||||
| Member Communication/Services | Enrollment application and eligibility management services | ||||
| Member Communication/Services | Enrollment kit and communication material | ||||
| Member Communication/Services | Enrollment materials (mail order materials, internet-based member services communication, welcome letters) | ||||
| Member Communication/Services | Replacement ID cards | ||||
| Member Communication/Services | Targeted communications - standard (member formulary/network disruption, benefit changes, generic drug promotion, etc.) | ||||
| Member Communication/Services | Targeted communications - custom (member formulary/network disruption, benefit changes, generic drug promotion, etc.) |
| Administrative/Reporting | Member Submitted Paper Claim Processing |
| Administrative/Reporting | Point of Sale (POS) Rebate Administration |
| Administrative/Reporting | Postage for mail claims |
| Administrative/Reporting | Standard COB administration |
| Administrative/Reporting | Client Portal Access to systems for claims and utilization |
| Administrative/Reporting | Client Portal Access to systems for eligibility |
| Administrative/Reporting | Client Portal Access to systems for prior authorizations |
| Administrative/Reporting | Reporting and analytical services: Ad hoc analytical services |
| Administrative/Reporting | Reporting and analytical services: Customized reporting |
| Administrative/Reporting | Reporting and analytical services: Standard reporting |
| Administrative/Reporting | Interactive/online ad hoc user report creation and queries |
| Administrative/Reporting | Data feed sharing and accumulators |
| Administrative/Reporting | Ongoing file feeds to other vendors |
| Administrative/Reporting | E-prescribing services |
| Administrative/Reporting | CMS-required letter management |
| Administrative/Reporting | Government enrollment material and facilitation |
| Administrative/Reporting | Mandated government reporting (e.g. RxDC, et al) |
| Post-Termination Services | Account team support |
| Post-Termination Services | All CMS regulatory support functions (e.g. PDE, Data Validation, DIR, and other CMS audits and requirements) to enable Client to meet all CMS deadlines, reporting, and data requirements |
| Post-Termination Services | Audit support |
| Post-Termination Services | Claims files (pharmacy claim detail, prior authorizations, accumulators, etc.) |
| Post-Termination Services | Client reporting portal access |
| Post-Termination Services | Eligibility processing |
| Post-Termination Services | Explanation of benefits |
| Post-Termination Services | Financial reports |
| Post-Termination Services | Open refill files (mail order and specialty) |
| Post-Termination Services | Run-out claims processing |
| List all other non-clinical program costs/fees | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other | |
| Other |
RX-Pricing, Preferred Bios
| The School Board of Hillsborough County, FL |
| RX-Pricing, Preferred Biosimilars |
| Proprietary & Confidential |
| Instructions: Please complete the chart below including ALL preferred biosimilars aligned to your formulary proposed. If multiple formularies have been proposed, complete for each formulary. |
| Aon Identification Data |
| Vendor Name |
| Complete list of preferred biosimilar products | ||||||||
| Proposed Formulary Name | Biosimilar Drug Name | Biosimilar NDC-11 - list all NDCs for preferred biosimilar | Formulary Status (Preferred/Non-Preferred) | Originator Product Drug Name | Originator Product NDC | Originator Product Excluded from Formulary (Y/N) | % Underwritten Shift to Biosimilar | Eligible for Rebate Credit (Y/N) |
x
RX-Pricing, Rebate Credit
| The School Board of Hillsborough County, FL |
| RX-Pricing, Rebate Credit Eligible Products |
| Proprietary & Confidential |
| Instructions: Please complete the list below with all products that will be eligible for a rebate credit aligned to your offer |
| Aon Identification Data |
| Vendor Name |
| Complete list of products that will be Rebate Credit eligible | ||
| Drug Name | NDC-11 | Biosimilar Product (Y/N)? |
RX-Pricing, LDD
| The School Board of Hillsborough County, FL |
| RX-Pricing, Limited Distribution Drugs |
| Proprietary & Confidential |
| Instructions: Please complete this tab with all Limited Distribution Drugs (specialty and non-specialty) |
| Aon Identification Data |
| Vendor Name |
| Complete list of Limited Distribution Drugs | ||||
| NDC-11 | Product Name | Specialty Drug Indicator | ||
| (Y/N) | Brand Generic Indicator (B/G) | Is Your Preferred Specialty Pharmacy a Limited Distribution Pharmacy? (Y/N) |
x
RX-Pricing, Clinical Programs
| The School Board of Hillsborough County, FL |
| RX-Pricing, Clinical/UM Programs |
| Proprietary & Confidential |
| Instructions: Please complete the table below to capture the various programs. Insert additional rows at the bottom as needed. |
| Aon Identification Data |
| Vendor Name |
| Program Name | Description | Required/Optional | Offered on a bundled or undbundled basis | Year 1 Fee | Year 2 Fee | Year 3 Fee | Fee Basis (Included, PMPM, per review, etc) | Year 1 Guaranteed Savings | Year 2 Guaranteed Savings | Year 3 Guaranteed Savings | Guaranteed Savings Basis (PMPM, per review, etc) | How is Guaranteed Savings calculated? | ||
| Preventive Drug List | Tier 3 | |||||||||||||
| Generic Only List | ||||||||||||||
| Generic and Brand List | ||||||||||||||
| Brand Only List | ||||||||||||||
| Is customization allowed? | ||||||||||||||
| What is the member cost structure after bypassing the deductible | ||||||||||||||
| Tier 1 or Brand for Generic Strategy | ||||||||||||||
| Is this mandatory as part of offer? | ||||||||||||||
| Is customization allowed? | ||||||||||||||
| What medications are included in the program | ||||||||||||||
| DUR | ||||||||||||||
| Concurrent Drug Utilization Review (cDUR) | ||||||||||||||
| Retrospective Drug Utilization Review (rDUR) | ||||||||||||||
| Safety programs (i.e … ) | ||||||||||||||
| Utilization Management | ||||||||||||||
| Prior Authorization | ||||||||||||||
| Quantity Limits | ||||||||||||||
| Step Therapy: generic first | ||||||||||||||
| Step Therapy: generic or preferred brand first | ||||||||||||||
| Step Therapy: preferred brand first | ||||||||||||||
| Duration of Therapy Limits | ||||||||||||||
| Dose Optimization | ||||||||||||||
| Drug exclusions (other than formulary exclusions) | ||||||||||||||
| Starter Fill/Split Fill Program | ||||||||||||||
| Therapeutic Duplications | ||||||||||||||
| Other | ||||||||||||||
| Custom Formulary and UM | ||||||||||||||
| Custom Prior Authorization Program | ||||||||||||||
| Custom Quantity Limits | ||||||||||||||
| Custom Step Therapy Program | ||||||||||||||
| Custom formulary services and management | ||||||||||||||
| Value-based contracting programs | ||||||||||||||
| Clinical Programs | ||||||||||||||
| Fraud, Waste and Abuse (Standard) | ||||||||||||||
| Fraud, Waste and Abuse (Enhanced) | ||||||||||||||
| Overutilization monitoring system | ||||||||||||||
| Targeted specialty pharmacy services | ||||||||||||||
| High cost claimant analysis | ||||||||||||||
| Opioid Management | ||||||||||||||
| Medical Channel Management | ||||||||||||||
| Adherence | ||||||||||||||
| Gaps in Care/Adherence | ||||||||||||||
| Pharmacogenomics | ||||||||||||||
| Compound Drug Management Strategy | ||||||||||||||
| Patient Assistance Programs | ||||||||||||||
| Value based arrangements | ||||||||||||||
| Disease Management | ||||||||||||||
| Care Engines | ||||||||||||||
| High Cost Low Value Drug List | ||||||||||||||
| Generic incentive programs | ||||||||||||||
| Physician intervention and academic detailing | ||||||||||||||
| Other: | ||||||||||||||
| Copay Assistance | ||||||||||||||
| Copay Assistance Program (Non-Specialty) | ||||||||||||||
| Copay Assistance Program (Specialty) | ||||||||||||||
| Copay Maximizer Program (Non-Speciality) | ||||||||||||||
| Copay Maximizer Program (Speciality) | ||||||||||||||
| Patient Assistance Program (Non-Speciality) | ||||||||||||||
| Patient Assistance Program (Speciality) | ||||||||||||||
| Accumulation Adjustment Offering | ||||||||||||||
| What is the member's cost share? | ||||||||||||||
| Does the program include HIV and Transplant drugs? | ||||||||||||||
| Is there a penalty if members do not enroll? If so, please explain. | ||||||||||||||
| DAW | ||||||||||||||
| DAW 1 or 2 or Both | ||||||||||||||
| Other | ||||||||||||||
| Non-FDA Approved Medication Management | ||||||||||||||
| Medically Administered Drugs | ||||||||||||||
| Gene and Cellular | ||||||||||||||
| Compound Management | ||||||||||||||
| VA Claims | ||||||||||||||
| Subrogation | ||||||||||||||
| COB Claims | ||||||||||||||
| Coverage of Testing Supplies (Diabetes, Covid, BP monitors, Peek Flow) | ||||||||||||||
| Additional Point Solution Vendors | ||||||||||||||
| Other: | ||||||||||||||
| PA/Appeals | ||||||||||||||
| Administrative/technical PA reviews/overrides | ||||||||||||||
| Clinical prior authorization review | ||||||||||||||
| First level Appeals | ||||||||||||||
| Second Level Appeal | ||||||||||||||
| External Reviews by IRO | ||||||||||||||
| Formulary Exceptions | ||||||||||||||
| Physician-specific review | ||||||||||||||
| Redeterminations, Appeals and Grievances management | ||||||||||||||
| Other: | ||||||||||||||
| Admin Fees | ||||||||||||||
| Program Administrave Fee | ||||||||||||||
| Influenza Administrative Fee | ||||||||||||||
| Covid19 Administrive Fee | ||||||||||||||
| All other Administravive Fee | ||||||||||||||
| Weight Loss | ||||||||||||||
| Is weight loss a covered benefit | ||||||||||||||
| Please provide clinical criteria for weight loss drugs and list any additional relevant clinical/nutrition/wellness program enhancements | ||||||||||||||
| List all other clinical program costs/fees |
Rx-Pricing, State Mandated Reim
| The School Board of Hillsborough County, FL |
| RX-Pricing, State Mandated Reimbursement |
| Proprietary & Confidential |
| Instructions: Only complete this tab if any claims within the provided data are impacted by a state mandated reimbursement. If the state mandated reimbursement methodology applies to all pharmacies within the state, fill out columns D-F on a single row (pharmacy name and pharmacy NPI do not need to be identified in this scenario). If the state mandated reimbursement methodology within a specific state varies by pharmacy type (e.g. independent vs chain), columns B-F must be completed for each pharmacy within that state. |
| Aon Identification Data |
| Vendor Name |
| Pharmacy List | ||||
| Pharmacy Name | Pharmacy NPI | State | Detailed Adjudication Logic (e.g. NADAC) | Mandated Dispensing Fee (per Rx) |
Rx-Pricing, PMPM Exclusions
| The School Board of Hillsborough County, FL |
| RX-Pricing, State Mandated Reimbursement |
| Proprietary & Confidential |
| Instructions: Only complete this list of a PMPM offer has been given. Use Columns B-F below to identify all NDCs that are excluded as part of your PMPM offer. For these products that are excluded, fill out the columns below that indicate if these products will be guaranteed at a Discount + Dispensing Fee Guarantee or a Cost/Unit + Dispensing Fee Guarantee. If these products do not come with a cost guarantee, please do not fill out the columns and indicate that there is no guarantee in Column G. |
| Aon Identification Data |
| Vendor Name |
| NDC | Discount Guarantee | Cost/Unit Guarantee | Dispensing Fee Guarantee | Projected Costs in Year 1 | ||
| (Trended costs based on provided claims) | PBM Comments |
RX-Pricing, Projections
| The School Board of Hillsborough County, FL |
| RX-Pricing, Projections |
| Proprietary & Confidential |
| Instructions: Please complete every cell on this worksheet. Your offer MUST COMPLY with all Bidding Requirements and requirements in the Financial Questionnaire and reflect the pricing inputs in the Rx, Pricing Sections of this workbook. |
| Aon Identification Data |
| Vendor Name |
| Calculation | Spend Component | Year 1 | Year 2 | Year 3 | |||||||
| Base Contract Term | |||||||||||
| Total AWP | [Insert Response] | [Insert Response] | [Insert Response] | ||||||||
| Total Claim Count | [Insert Response] | [Insert Response] | [Insert Response] | ||||||||
| Excluded AWP from Pricing Guarantees | [Insert Response] | [Insert Response] | [Insert Response] | ||||||||
| Excluded Claim Counts from Pricing Guarantees | [Insert Response] | [Insert Response] | [Insert Response] | ||||||||
| 1 | Ingredient Costs | [Insert Response] | [Insert Response] | [Insert Response] | |||||||
| 2 | Dispensing Fees | [Insert Response] | [Insert Response] | [Insert Response] | |||||||
| 3 (1+2) | Projected Costs | [Insert Response] | [Insert Response] | [Insert Response] | |||||||
| 4 | Administrative Fees | [Insert Response] | [Insert Response] | [Insert Response] | |||||||
| 5 | Clinical Program Fees | [Insert Response] | [Insert Response] | [Insert Response] | |||||||
| 6 | Total Manufacturer Payments (guarantees) | [Insert Response] | [Insert Response] | [Insert Response] | |||||||
| 7 (3+4+5-6) | Total Gross Cost Net of Rebate | [Insert Response] | [Insert Response] | [Insert Response] | |||||||
| Year 1 | Year 2 | Year 3 | |||||||||
| Total # of Brand Claims | Estimated # of Brand claims that will be eligible for the per brand rebate guarantee | Estimated total minimum guaranteed rebates | Total # of Brand Claims | Estimated # of Brand claims that will be eligible for the per brand rebate guarantee | Estimated total minimum guaranteed rebates | Total # of Brand Claims | Estimated # of Brand claims that will be eligible for the per brand rebate guarantee | Estimated total minimum guaranteed rebates | |||
| Retail 30 Network | |||||||||||
| Retail 90 Network | |||||||||||
| Mail Order | |||||||||||
| Non Preferred Specialty | |||||||||||
| Preferred Specialty | |||||||||||
| Total | |||||||||||
| Provide the financial assumptions that PBM is using to underwrite the proposed offer. If different assumptions were used for different Formularies or Lines of Business, please duplicate this table and label each rendition to correspond to each Formulary/LOB. | |||||||||||
| Component | Year 1 | Year 2 | Year 3 | ||||||||
| # of Members (Lives) | |||||||||||
| # of Rxs PMPY (Total Annual Claims / Members) | |||||||||||
| Channel Utilization Percentage (Total Channel Rxs / Total all Rxs) | |||||||||||
| Retail Pharmacy (1-83 Days) | |||||||||||
| Retail Pharmacy (+84 Days) | |||||||||||
| LTC Pharmacies | |||||||||||
| Other non-traditional Pharmacies | |||||||||||
| Mail Order Pharmacy | |||||||||||
| Specialty Drugs dispensed at Non-Preferred Specialty Pharmacy Network | |||||||||||
| Specialty Drugs dispensed at Preferred Specialty Pharmacy Network | |||||||||||
| Average AWP per Rx (Total Drug Type AWP / Total Drug Type Rxs) | |||||||||||
| Retail Pharmacy | |||||||||||
| (1-83 Days) | Brand Drugs | ||||||||||
| Generic Drugs | |||||||||||
| Retail Pharmacy | |||||||||||
| (+84 Days) | Brand Drugs | ||||||||||
| Generic Drugs | |||||||||||
| LTC Claims | Brand Drugs | ||||||||||
| Generic Drugs | |||||||||||
| Other non-traditional Pharmacies | Brand Drugs | ||||||||||
| Generic Drugs | |||||||||||
| Mail Order Pharmacy | Brand Drugs | ||||||||||
| Generic Drugs | |||||||||||
| Specialty Drugs dispensed at Non-Preferred Specialty Pharmacy Network | Brand Drugs | ||||||||||
| Generic Drugs | |||||||||||
| Specialty Drugs dispensed at Preferred Specialty Pharmacy Network | Brand Drugs | ||||||||||
| Generic Drugs | |||||||||||
| Generic Utilization Percentage (Total Channel Generic Rxs / Total Channel Rxs) | |||||||||||
| Retail Pharmacy (1-83 Days) | |||||||||||
| Retail Pharmacy (+84 Days) | |||||||||||
| LTC Pharmacies | |||||||||||
| Other non-traditional Pharmacies | |||||||||||
| Mail Order Pharmacy | |||||||||||
| Specialty Drugs dispensed at Non-Preferred Specialty Pharmacy Network | |||||||||||
| Specialty Drugs dispensed at Preferred Specialty Pharmacy Network | |||||||||||
| Projected Utilization (Total Brand Rxs in Category / Total Brand Rxs) | |||||||||||
| 340B Claims | |||||||||||
| Limited Distribution Drugs | |||||||||||
| Over-the-Counter Drugs | |||||||||||
| GLP-1s - Diabetes Management | |||||||||||
| GLP-1s - Weight Loss | |||||||||||
| Claims approved by formulary exception (Total Channel Rxs / Total All Rxs |
Officer Statement
| The School Board of Hillsborough County, FL |
| Officer Certification |
| Proprietary & Confidential |
| Please have an Officer review and sign this worksheet to confirm the information is valid. |
| Please include the completed form with your proposal. |
| OFFICER'S STATEMENT |
| PBM Vendor Legal Name |
| PBM Vendor Marketing Name |
| Street Address |
| City |
| State |
| Zip |
| Phone Number |
| Fax Number |
| Web Address |
| Name of Officer completing statement |
| Title of Officer completing statement |
| Phone Number of Officer completing statement |
| Email Address of Officer completing statement |
I certify that our response to this Request for Proposal is complete and accurate to the best of my knowledge and contains no material omissions or misstatements. I acknowledge that Client will rely upon the information included in our response to make decisions concerning the pharmacy benefit management services that are offered to their employees.
Officer's Signature
Date Signed image1.png
File details come from the government source that posted it. Updated .