Amd Three Att 10 - Submittal Form L - Cost Proposal Version 2.xlsx

XLSX spreadsheet 111 KB Posted Dec 3, 2025

Attached to: Notice of Cancellation RFP 2025-0200-0177 / 02-101-25 Pharmacy Benefit Manager Services
Solicitation number: 2025-0200-0177 / 02-101-25
Issued by: Alaska

About this file

Written by GovTribe AI · Dec 4, 2025

This file is a cost proposal submittal form for Pharmacy Benefit Manager (PBM) services to the State of Alaska's Department of Administration, Division of Retirement and Benefits, specifically for AlaskaCare health plans covering active employees, non-EGWP retirees, and EGWP participants with wrap coverage. The PBM services encompass comprehensive pharmacy network management, claims processing, clinical programs, formulary management, and Medicare Part D compliance across three distinct plan types. The contract term runs from January 1, 2027, through December 31, 2029, with up to eight optional one-year renewals. A six-month implementation period precedes the contract effective date. Proposals are due by December 15, 2025, at 11:00 AM Alaska Time, with the final deadline for questions on November 10, 2025. The State of Alaska plans to cover approximately 86,900 members across all plans, with annual prescription volumes exceeding 1.6 million claims and total drug costs around $992 million.

The cost proposal form requires offerors to provide detailed pricing guarantees, including administrative fees, AWP discounts, dispensing fees, rebate guarantees, and trend guarantees for each contract year on a per-member, per-prescription, or flat-dollar basis. All pricing must be guaranteed from January 1, 2027, through December 31, 2029, with renewal pricing based on 2029 rates unless renegotiated. Offerors must also submit performance guarantee amounts at risk for both implementation and ongoing annual service, pricing exclusions by drug NDC for each pharmacy channel, and financial projections including ingredient costs, dispensing fees, administrative fees, rebates, and member cost-sharing. The current incumbent contractor is Optum Rx. The estimated budget ranges from $65 million to $85 million, with proposals exceeding $100 million considered non-responsive. The State requires a 100% pass-through of rebates for all three plans and mandates comprehensive performance metrics measured quarterly or annually on a plan-specific basis, including standards for claims accuracy, system downtime, member satisfaction, issue resolution, and account management responsiveness.

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Other files

File	Type	Posted
Amd Six RFP 2025-0200-0177 02-101-25 PBM Services.pdf	PDF	Aug 14, 2026
Notice of Cancellation RFP#2025-0200-0177-02-101-25 Pharmacy Benefit Manager (PBM) Services.pdf	PDF	Aug 14, 2026
Amd Five RFP 2025-0200-0177 02-101-25 PBM Services.pdf	PDF	Dec 10, 2025
Amd Three RFP 2025-0200-0177 02-101-25 PBM Services.pdf	PDF	Dec 3, 2025
Amd Four RFP 2025-0200-0177 02-101-25 PBM Services.pdf	PDF	Dec 3, 2025
Amd Two RFP 2025-0200-0177 02-101-25 PBM Services.pdf	PDF	Nov 24, 2025
Amd One RFP 2025-0200-0177 02-101-25 PBM Services.pdf	PDF	Nov 4, 2025
Att 1 - Submittal Form A Offeror Information and Certifications.docx	DOCX document	Oct 16, 2025
Att 4 - Submittal Form G (Part 1 of 2) - Contractual Reqs.xlsx	XLSX spreadsheet	Oct 16, 2025
Att 3 - Submittal Form F Mandatory Requirements.xlsx	XLSX spreadsheet	Oct 16, 2025
Att 12 - Submittal Form M (Part 2 of 2) - Financial Requirements Narrative Response Form.docx	DOCX document	Oct 16, 2025
Att 17 - HIPPA Business Associate Agreement.docx	DOCX document	Oct 16, 2025
Att 16 - Intent to Propose Form (ITP).xlsx	XLSX spreadsheet	Oct 16, 2025
Att 11 - Submittal Form M (Part 1 of 2) - Financial Requirements.xlsx	XLSX spreadsheet	Oct 16, 2025
Att 10 - Submittal Form L - Cost Proposal.xlsx	XLSX spreadsheet	Oct 16, 2025
Att 9 - Submittal Form K Subcontractors.xlsx	XLSX spreadsheet	Oct 16, 2025
Att 14 - Client Reference Form.docx	DOCX document	Oct 16, 2025
Att 6 - Submittal Form H GeoAccess Analysis.xlsx	XLSX spreadsheet	Oct 16, 2025
Att 5 - Submittal Form G (Part 2 of 2) - Contractual Reqs Narrative Response Form.docx	DOCX document	Oct 16, 2025
Att 2 - Submittal Forms B-E.docx	DOCX document	Oct 16, 2025
RFP 2025-0200-0177 02-101-25 PBM Services.pdf	PDF	Oct 16, 2025
Att 8 - Submittal Form J Formulary Disruption Analysis.xlsx	XLSX spreadsheet	Oct 16, 2025
Att 7 - Submittal Form I Network Disruption Analysis.xlsx	XLSX spreadsheet	Oct 16, 2025
Att 13 - Standard Agreement Form & Appx A-D.pdf	PDF	Oct 16, 2025
Att 15 - Non-Disclosure Agreement (NDA).docx	DOCX document	Oct 16, 2025

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1) Perf Guar_Employee

Submittal Form L - Cost Proposal

Performance Guarantees - Active Employee Plan

	All guarantees shall be set and measured quarterly (or annually, if applicable), and must be measured on a Plan-specific basis. Measurement of performance guarantees may be based on internal self-reporting, subject to independent audit. For each performance guarantee, offeror must confirm they agree to each requested Implementation and Ongoing Service Performance Guarantees. Indicate the measurement criteria (Book of Business or Plan Specific) and the timing for the criteria measurement and payments (quarterly and/or annually). In addition, the offeror may provide other guarantees designated to differentiate the PBM's program.
	All PBM fees must be guaranteed from January 1, 2027, through December 31, 2029. The pricing for the final year of the initial contract term, January 1, 2029, through December 31, 2029, will apply to all subsequent optional one-year renewals exercised by the State, unless updated pricing terms are negotiated by the State and executed via the contract amendment process.
	Offerors are required to complete this submittal form by suppling responses to all rows included on 15 spreadsheet tabs.
	Question			Response
	11.0	Offeror must indicate the Total Amount at Risk (per Member dollar amount or flat dollar amount) the offeror is proposing to AlaskaCare for Implementation Performance Guarantees.		Select One
	12.0	Offeror must indicate the Total Annual Amount at Risk (per Member dollar amount or flat dollar amount) per contract year the offeror is proposing to AlaskaCare for Ongoing Annual Service Performance Guarantees.		Select One
	13.0	Offeror must confirm the proposed penalties will not be the sole and exclusive remedy available to AlaskaCare for such failure and that the offeror shall pay any amount owed to AlaskaCare and/or its members if the offeror fails to properly administer claims in addition to the missed performance guarantee metric.		Select One
	14.0	Offeror must confirm AlaskaCare may determine the weighting from 0% to 30% for each of the offeror's proposed Performance Guarantees prior to the start of each contractual year as long as the total amount equals to 100%.		Select One
	15.0	Offeror must confirm they shall provide separate non-financial performance guarantees for the Retail 90 prescriptions filled at one retail chain or include them with the non-financial performance guarantees for the proposed Retail 30 network.		Select One
	16.0	Offeror must confirm that if the implementation time period is less than 90 days, implementation guarantees will still apply.		Select One
	17.0	Offeror must confirm that if the implementation time period is less than 90 days, first quarter performance guarantees shall still be tracked, reported, and results shall be included in the annual calculations.		Select One
			Requested Standard	Willingness to Comply	Indicate the PBM’s Proposed Standard if Different from Requested Standard	Measurement Criteria
(BOB or Client specific)	Timing of Measurement and Payments (Quarterly or Annually)
	Implementation Performance Guarantees
	18.0	Clean Implementation	There will be 0.0% systems errors, 0.0% ID card delays, and AlaskaCare will have access to 100.0% of the tools prior to effective date.	Select One		Select One	Select One
	19.0	Implementation Timeline	Implementation team shall be assigned and introduced to AlaskaCare at least six (6) months in advance of effective date and 100.0% of key milestones will be achieved.	Select One		Select One	Select One
	110.0	Implementation Team	Implementation team members will not change and shall be responsible for the accurate installation of all administrative, clinical and financial parameters for AlaskaCare's program.	Select One		Select One	Select One
	111.0	Implementation Satisfaction Scorecard	AlaskaCare will be at least 90.0% satisfied with the implementation process. The satisfaction scorecard shall be completed following the implementation process.	Select One		Select One	Select One
	Ongoing Performance Guaranteed
	Payment Accuracy & System Performance
	112.0	Protected Health Information	PBM guarantees no incidents in violation of HIPAA Security Rules, which results in a transmission of electronic PHI for AlaskaCare's covered members. This is measured and reported on a quarterly basis and on a Plan-specific basis.	Select One		Select One	Select One
	113.0	Plan Administration Accuracy	100.0% of all claims will adjudicate based on the plan design set up. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	114.0	Financial accuracy (electronic and paper claims)	Percentage of claim payments made without error relative to the total dollars paid will be at least 99.5%. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	115.0	Mail Service Non-Financial Accuracy	The mail service pharmacy shall guarantee dispensing accuracy of at least 99.996% (correct member name, correct member address, correct drug, correct dosage form, and correct strength). This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	116.0	Home Delivery Accuracy	At least 99.996% of home delivery and specialty pharmacy prescriptions dispensed with no errors.	Select One		Select One	Select One
	117.0	System Downtime	At least 99.5% access to its systems by all the retail pharmacies in PBM's network 24 hours a day, 7 days a week, 365 days a year. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	118.0	Invoicing Errors	All invoicing errors will be credited back to AlaskaCare by next billing cycle or PBM will pay interest. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	119.0	Claims Eligibility Data	Eligibility loads not to exceed 24-hours after receipt. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	120.0	Eligibility Data Error Reporting	Eligibility file error reporting on all clean eligibility file updates will be provided to AlaskaCare within one business day after receipt. Eligibility file error reporting on all eligibility file updates will be provided to AlaskaCare within two business days after receipt. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	121.0	Eligibility Processing Accuracy	100% of usable, error-free program eligibility files received by the PBM shal be loaded without error. This is measured and reported on a contract year basis and on a plan-specific basis.	Select One		Select One	Select One
	122.0	Eligibility Error Rate Audits	Error rate identified through quarterly audits shall not exceed, on an average basis, 2%. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	123.0	Retail Pharmacy Audit	100% of participating retail pharmacies shall be subject to automated review audits and 20% of participating pharmacies will be subject to further investigation (e.g., desk audits, on-site audits, etc.) as a result of the automated review audits. The PBM shall perform daily review audits of claims that pay over $1,000. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	124.0	Pharmacy Audit Resolution	48 hours after receipt of findings. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	125.0	Retail Pharmacy Turnover	Less than 5% of retail pharmacies will leave the retail network. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	126.0	Network Pharmacy Geographic Access	PBM agrees that at least 95% of members, based on Plan-supplied eligibility, shall have access to a network pharmacy within a five-mile radius of the member's residence in the PBMs Network Program, if there is an existing pharmacy within that radius. The PBM agrees to cure within 90 days, if the percent drops below the above stated percentages. This is measured and reported on an annual basis and on a plan-specific basis.	Select One		Select One	Select One
	127.0	Claims Detail File	All claims detail files sent to external vendors will be provided within eight days of request or scheduled delivery date. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	Account Management
	128.0	Contracting Cooperation	Response to recommended contract language changes within 10 business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	129.0	Client Approval of Member Communications	100% of all member communications will be approved by AlaskaCare - exceptions for drug recalls and urgent patient safety communications. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	130.0	Online Reporting Data Availability	Online reporting data will be available within an annual average of fifteen business days after the billing cycle that contains the last day of the month. This is measured and reported on annual basis and on a plan-specific basis.	Select One		Select One	Select One
	131.0	Delivery of Standard Reports	PBM shall deliver all standard reports to AlaskaCare within 30 days of end of reporting quarter. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	132.0	Accuracy of Standard Reports	All standard reports provided will be 100% accurate. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	133.0	PBM Account Team's Performance	PBM's account team's performance for each contract year will receive an average of three or better on a scale of 1 to 5 (5 being the best based on a range of performance criteria agreed to between AlaskaCare and the PBM at the beginning of such contract year) from AlaskaCare's benefits staff. This is measured and reported on an annual basis and on a plan-specific basis.	Select One		Select One	Select One
	134.0	Account Management Turnover	Account team members will remain constant for at least the first 18 months of the contract period, unless a change in account management staff is requested by AlaskaCare. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	135.0	Account Management Reporting	Account Manager will provide a monthly status report that highlights outstanding open issues and will be available to meet with AlaskaCare on a monthly basis to discuss the status report. This is measured and reported on a contract year and plan-specific basis.	Select One		Select One	Select One
	136.0	Account Management Client Meetings	During first quarter after the effective date, the PBM shall be available to meet with AlaskaCare on a minimum of a monthly basis and thereafter on a minimum of a quarterly basis. This is measured and reported on a contract year and plan specific basis.	Select One		Select One	Select One
	137.0	Account Management Responsiveness/ Initial Issue Resolution – The Plan Staff Involvement / Escalation	PBM will resolve all issues, including member issues that required the involvement of AlaskaCare's staff due to incorrect or incomplete information being provided by the PBM, within two business days. If not resolved within 48 hours, a penalty will be applied per case, up to an annual maximum. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	138.0	Account Management Responsiveness/ Final Issue Resolution – The Plan Staff Involvement / Escalation	PBM will ultimately resolve 100.0% of issues brought up by AlaskaCare within 14 business days. If not, a $5,000 penalty will be applied per case, up to the total annual maximum. AlaskaCare may allocate 0% to 100% of the total dollars at risk for this Ongoing Performance Guarantee. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	Member Services
	139.0	Mail Turnaround – Prescriptions not requiring intervention	100% of prescriptions shall be dispensed within two business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	140.0	Mail Turnaround – Prescriptions requiring intervention	100% of prescriptions will be dispensed within three business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	141.0	Paper Claims Turnaround	95% of prescriptions reimbursed within average of 10 business days and 100% within average of 14 business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	142.0	ID Cards Mailing	98% of all ID cards are sent within five business days of receipt of eligibility. 100% mailed within 10 business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	143.0	Replacement ID Card Mailing	Standard replacement ID cards will be produced within an annual average of five business days of the request. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	144.0	Mailing Member Materials	All applicable member materials (for example, mail order forms) will be mailed at least 10 days prior to the effective date and will be 100% accurate (provided that eligibility file was received at least 30 days prior to the effective date). This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	145.0	Phone Average Speed of Answer	100% of calls to the plan-specific toll-free line shall be answered within 20 seconds (excluding IVR). This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	146.0	Telephone Blockage Rate/ Busy Signal	Blockage rate will be 1% or less. Blockage is defined as a caller receiving a busy signal. Measured at a book of business level.	Select One		Select One	Select One
	147.0	Phone Abandonment Rate	All calls to the plan-specific toll-free line shall be answered with an abandonment rate of 2.5% or less. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	148.0	Written Inquiry Answer Time	95% of inquiries responded to in five business days - 100% in 20 business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	149.0	Member Satisfaction Survey	PBM must agrees to conduct a Member Satisfaction Survey for each contract year and that the satisfaction rate will be 92% or greater. A penalty of $100,000 per contract year may be assessed against the PBM for failure to meet this standard. “Member Satisfaction Rate” means (i) the number of Eligible Persons responding to PBM annual standard Patient Satisfaction Survey as being satisfied with the overall performance under the Integrated Program divided by (ii) the number of Eligible Persons responding to such annual Patient Satisfaction Survey; the Plan must provide timely approvals and responses, and a minimum of 20% of surveys must be returned for the performance standard to be applicable. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	150.0	Issue Resolution: Verbal Inquiries	PBM must resolve 99% of all telephone issues at the first point of contact (the number of telephone inquiries completely resolved at the time of initial contact divided by the total number of calls). This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One
	151.0	Issue Resolution: Written Inquiries	PBM must resolve 98% of all written inquiries within 10 business days of receipt of inquiry. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One		Select One	Select One

2) FinProp_ASO Fees_Employee

Submittal Form L - Cost Proposal
ASO Fees - Active Employee Plan
Offeror must complete the table below by confirming whether the following items are included in the offeror's proposed administrative fee or are available at an additional cost. All services covered under the base administration fee should be listed. However, some services may be offered as optional or ancillary and be covered by separate add-on fees. For example, separate fees for providing EOBs, COB, appeals, integration with potential HDHP plans and subrogation or for providing duplicate ID cards can be offered and excluded from the base fees. These fees must be listed separately as an option.
		Confirmation that services included with the proposed Administrative Fee:	If not, Indicate the proposed fee amount	Fee Basis
Table 1: Administrative Service
11.0	Toll-Free Phone Lines	Select One		Select One
12.0	Monthly Data Feeds to AlaskaCare or Designee(s)	Select One		Select One
13.0	Prospective/Concurrent DUR	Select One		Select One
14.0	Standard Reports	Select One		Select One
15.0	Ad Hoc Reports	Select One		Select One
16.0	COB Program	Select One		Select One
17.0	Utilization Management Fees	Select One		Select One
18.0	Mandatory Mail Program	Select One		Select One
19.0	Dose Optimization Program	Select One		Select One
110.0	Prior Authorization Program	Select One		Select One
111.0	Step Therapy Program	Select One		Select One
112.0	Quantity Limitations	Select One		Select One
113.0	Overrides	Select One		Select One
114.0	Custom System Overrides	Select One		Select One
115.0	Standard 1st level appeals processing	Select One		Select One
116.0	Standard 2nd level appeals processing	Select One		Select One
117.0	Urgent appeals processing	Select One		Select One
118.0	Appeal Services for Utilization Management, formulary and benefit reviews	Select One		Select One
119.0	Urgent Appeal Service for Utilization Management, formulary and benefit reviews	Select One		Select One
120.0	Annual EOB Statements	Select One		Select One
121.0	Retro Termination Letters	Select One		Select One
122.0	Group Coding	Select One		Select One
123.0	Drug Notification Letters	Select One		Select One
124.0	Formulary Administration/Management	Select One		Select One
125.0	ID Cards (Including new and replacement ID cards)	Select One		Select One
126.0	Pharmacy Directories and other member materials	Select One		Select One
127.0	Retail Pharmacy Network Audit Recovery Fees	Select One		Select One
128.0	Compound Drug Management	Select One		Select One
129.0	Fraud Waste and Abuse Program	Select One		Select One
130.0	Opioid Management Program	Select One		Select One
131.0	Medicaid/Medicare Subrogation Claims	Select One		Select One
132.0	Paper Claims	Select One		Select One
133.0	Retrospective DUR	Select One		Select One
134.0	ePrescribing Fees	Select One		Select One
135.0	Influenza Vaccination Program – Administration Fee	Select One		Select One
136.0	Non-Influenza Vaccination Program – Administration Fee	Select One		Select One
137.0	COVID-19 Vaccination Program – Administration Fee	Select One		Select One
138.0	Postage, shipping and handling costs	Select One		Select One
139.0	Other, please specify	Select One		Select One

3) FinProp_Guarantees_Employee

Submittal Form L - Cost Proposal

Pricing Guarantees - Active Employee Plan

Offeror must complete Table 1 below with the offeror's proposed administrative fees for each year of the initial contract term and the fee basis by which each fee will be charged on the monthly administrative fee invoice. Note that any per prescription fees must be based on prescriptions that are actually dispensed (not adjustments, errors or reversals). In the additional space provided, list any additional fees that will be charged over and above the base administration fee, the proposed fee by plan year and the fee basis (e.g. prior authorization, clinical program(s), etc).

All fees listed in the Cost Proposal must be guaranteed from January 1, 2027 through December 31, 2029. The pricing for the final year of the initial contract term, January 1, 2029 through December 31, 2029, will apply to all subsequent optional one-year renewals exercised by the State of Alaska unless updated pricing terms are negotiated by the State of Alaska.

Complete Tables 2-6 with the offeror's proposed pricing guarantees with the AWP discounts, dispensing fees and rebates that the offeror is willing to guarantee on a dollar-for-dollar basis for each year of the initial contract term. Rows marked "AWP Discount” are to be completed using a discount from 100% AWP and dispensing fee logic. All discount guarantees must be based on the AWP unit cost dispensed and post September 26, 2009 AWP rollback.

Offeror must complete Table 7 by providing their proposed allowance(s) for implementation costs, pharmacy audits and pharmacy consulting services.

Offeror must complete Table 8 by providing their GDR guarantee(s) by channel and plan year.

Offeror must complete Table 9 by providing their proposed PMPY claim cost trend guarantee on an overall basis by plan year.

Offeror must complete Table 10 by confirming the pricing guarantee category that will be used for each drug type for the purposes of guarantee reconciliation.

Name of proposed Retail 30 Network:
Name of proposed Retail 90 Network:
Name of proposed Exclusive Specialty Pharmacy:
Name of proposed formulary:
Confirm that pricing reflects the requested non-specialty network, Broad Formulary with Exclusions				Select One
Confirm that pricing reflects the requested Specialty network				Select One
		January 1, 2027 - December 31, 2027	January 1, 2028 - December 31, 2028	January 1, 2029 - December 31, 2029	Fee Basis
Table 1: Administration Fees (Dollar Amount per Unit)
1.1.1	Base Administration Fee				Select One
1.1.2	Base Clinical Program Fee				Select One
1.1.3	Other, please specify				Select One
1.1.4	Other, please specify				Select One
1.1.5	Other, please specify				Select One
*Note that any per prescription fees must be based on prescriptions that are actually dispensed (not adjustments, errors, or reversals).
		January 1, 2027 - December 31, 2027	January 1, 2028 - December 31, 2028	January 1, 2029 - December 31, 2029	Comments
Table 2: Retail 30 Pharmacy Pricing (1-30 days supply)
1.2.1	Minimum AWP Discount
	Generic
	Brand
1.2.2	Maximum Dispensing Fee per Script
	Generic
	Brand
1.2.3	Minimum Rebate Guarantee per Brand Script
Table 3: Retail 90 Pharmacy Pricing (31-90 days supply)
1.3.1	Minimum AWP Discount
	Generic
	Brand
1.3.2	Maximum Dispensing Fee per Script
	Generic
	Brand
1.3.3	Minimum Rebate Guarantee per Brand Script
Table 4: Mail Order Pharmacy Pricing (1-90 days supply)
1.4.1	Minimum AWP Discount
	Generic
	Brand
1.4.2	Maximum Dispensing Fee per Script
	Generic
	Brand
1.4.3	Minimum Rebate Guarantee per Brand Script
Table 5: Specialty at Retail Pricing (1-30 days supply)
1.5.10	Minimum AWP Discount
	Generic
	Brand
	New-to-Market Drugs
	Limited Distribution/Exclusive Distribution Drugs
	Low-WAC Biosimilar
	High WAC Biosimilar
1.5.11	Maximum Dispensing Fee per Script
	Generic
	Brand
	New-to-Market Drugs
	Limited Distribution/Exclusive Distribution Drugs
	Low-WAC Biosimilar
	High WAC Biosimilar
1.5.12	Minimum Rebate Guarantee per Script
	Brand
	New-to-Market Drugs
	Limited Distribution/Exclusive Distribution Drugs
	Low-WAC Biosimilar
	High WAC Biosimilar
Table 6: Exclusive Specialty Pharmacy Pricing (1-90 days supply)
1.6.1	Minimum AWP Discount
	Generic
	Brand
	New-to-Market Drugs
	Limited Distribution/Exclusive Distribution Drugs
	Low-WAC Biosimilar
	High WAC Biosimilar
1.6.2	Maximum Dispensing Fee per Script
	Generic
	Brand
	New-to-Market Drugs
	Limited Distribution/Exclusive Distribution Drugs
	Low-WAC Biosimilar
	High WAC Biosimilar
1.6.3	Minimum Rebate Guarantee per Script
	Brand
	New-to-Market Drugs
	Limited Distribution/Exclusive Distribution Drugs
	Low-WAC Biosimilar
	High WAC Biosimilar
Table 7: Allowances (PEPM, PMPM or flat dollar amounts)
1.7.1	Implementation allowance				Select One
1.7.2	General Pharmacy Program Management allowance (funds to be available for use for activities including but not limited to pre- or post-implementation audits, claims and/or rebate audits, Rx Market Checks, and/or pharmacy benefits consulting fees)				Select One
1.7.3	Other, please specify.				Select One
Table 8: Generic Dispensing Rate (GDR) Guarantee
1.8.1	Retail 30
1.8.2	Retail 90
1.8.3	Mail Order
Table 9: Trend Guarantee (PMPY plan cost net of rebates and member cost share)
1.9.1	Overall Trend
			Pricing Guarantee Bucket Deviations						Guarantee Requirements
		Confirmation of Guarantee Requirements	Member Cost Share Adjudication	AWP Discounts	Dispensing Fees	Rebates	Comments	Member Cost Share Adjudication	AWP Discounts	Dispensing Fees	Rebates
Table 10: Pricing Guarantee Category
NON-SPECIALTY (RETAIL OR MAIL)
1.10.1	Single-source generics (SSG)	Select One	Select One	Select One	Select One	Select One		Generic	Generic	Generic	--
1.10.2	Multi-source generics (MSG)	Select One	Select One	Select One	Select One	Select One		Generic	Generic	Generic	--
1.10.3	Single-source brands (SSB)	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.4	Multi-source brands (MSB)	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.5	Brand with DAW 0	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.6	Brand with DAW 1	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.7	Brand with DAW 2	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.8	Brand with DAW 3	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.9	Brand with DAW 4	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.10	Brand with DAW 5/House Generics	Select One	Select One	Select One	Select One	Select One		Generic	Generic	Generic	Brand
1.10.11	Brand with DAW 6	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.12	Brand with DAW 7	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.13	Brand with DAW 8	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.14	Brand with DAW 9	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.15	Authorized Generics/Sole source Generics	Select One	Select One	Select One	Select One	Select One		Generic	Generic	Generic	--
1.10.16	U&C Generic	Select One	Select One	Select One	Select One	Select One		Generic	Generic	Generic	--
1.10.17	U&C Brand	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.18	OTC Generic	Select One	Select One	Select One	Select One	Select One		Generic	Generic	Generic	--
1.10.19	OTC Brand	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.20	Non-formulary brand approved by exception	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
1.10.21	New-to-Market (NTM)	Select One	Select One	Select One	Select One	Select One		Brand	Brand	Brand	Brand
SPECIALTY at RETAIL
1.10.22	Limited Distribution/Exclusive Distribution Drugs	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
1.10.23	Low-WAC Biosimilar	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
1.10.24	High WAC Biosimilar	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
1.10.25	New-to-Market (NTM)	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
1.10.26	PCSK-9	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
1.10.27	Hepatitus B	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
SPECIALTY at MAIL
1.10.28	Limited Distribution/Exclusive Distribution Drugs	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
1.10.29	Low-WAC Biosimilar	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
1.10.30	High WAC Biosimilar	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
1.10.31	New-to-Market (NTM)	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
1.10.32	PCSK-9	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand
1.10.33	Hepatitus B	Select One	Select One	Select One	Select One	Select One		Specialty	Specialty OED Guarantee	Specialty OED Guarantee	Specialty Brand

4)Financial Exclusions_Employee

Submittal Form L - Cost Proposal

Exclusions - Active Employee Plan

Using AlaskaCare's detailed claim-by-claim prescription drug data, provide an exhibit with NDCs identifying AlaskaCare's applicable non-specialty and specialty drug claims that are excluded from the offeror's drug pricing guarantees. Offeror must provide separately for drugs dispensed at participating Retail 30 pharmacies, Retail 90 pharmacies, Mail Order pharmacy, and at the offeror's Specialty Pharmacy.

Retail 30 Pharmacies

Retail 90 Pharmacies

Mail Order Pharmacy

Specialty Pharmacy

11-Digit NDC

Product Name

Specialty Indicator

Rx Count

AWP

Ingredient Cost

Rx Count

AWP

Ingredient Cost

Rx Count

AWP

Ingredient Cost

Rx Count

AWP

Ingredient Cost

Select One

5) Financial Proj_Employee

Submittal Form L - Cost Proposal

Projection - Active Employee Plan

Offeror must provide the offeror's projected costs based on the proposed formulary and pricing for each year of the initial contract term. The offerors projections must include the projected ingredient cost, dispensing fees, administrative fees, member cost share and rebates. Member cost share estimates should be based on the plan design(s) currently in place for the Commercial Plan(s). Note that the savings as a result of the proposed Copay Assistance Program/ Variable Copay Solutions Program should be shown separately in the Summary table below. Note: This exhibit will be used to validate the financial projections provided by the offeror.
	January 1, 2027 - December 31, 2027	January 1, 2028 - December 31, 2028	January 1, 2029 - December 31, 2029
Enrollment
Number of Members
SCRIPT COUNT
Generic
Brand
Brand - rebate eligible
Brand - not rebate eligible
Total Script Count	0	0	0
AWP
Retail 30
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Retail 90
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Mail Order
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Specialty
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Total AWP	$0.00	$0.00	$0.00

INGREDIENT COST
Retail 30
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Retail 90
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Mail Order
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Specialty
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Total Ingredient Cost	$0.00	$0.00	$0.00
DISPENSING FEES
Retail 30
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Retail 90
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Mail Order
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Specialty
Generic
Brand
Sub-total	$0.00	$0.00	$0.00
Total Dispensing Fees	$0.00	$0.00	$0.00
REBATES
Retail 30
Retail 90
Mail Order
Specialty
Total Rebates	$0.00	$0.00	$0.00

OTHER COSTS
Administrative Fees
Clinical Fees
Other Fees
Total Fees	$0.00	$0.00	$0.00

SUMMARY
Ingredient Cost + Dispensing Fees	$0	$0	$0
Administrative fees	$0	$0	$0
less Rebates	$0	$0	$0
less Member Cost Share
less Copay Assistance Program Savings
Net Plan Cost	$0	$0	$0

6) Perf Guar_NonEGWP

Submittal Form L - Cost Proposal
Performance Guarantees - Non-EGWP Retiree Plan
All guarantees shall be set and measured quarterly (or annually, if applicable), and must be measured on a plan-specific basis. Measurement of performance guarantees may be based on internal self-reporting, subject to independent audit. For each performance guarantee, offeror must confirm they agree to each requested Implementation and Ongoing Service Performance Guarantee. Indicate the measurement criteria (Book of Business or Plan Specific) and the timing for the criteria measurement and payments (quarterly and/or annually). In addition, the offeror may provide other guarantees designated to differentiate the offeror's program.
Question		Response
11.0	Indicate the Total Amount at Risk (per Member dollar amount or flat dollar amount) you are proposing to AlaskaCare for Implementation Performance Guarantees.	Select One
12.0	Indicate the Total Annual Amount at Risk (per Member dollar amount or flat dollar amount) per contract year you are proposing to AlaskaCare for Ongoing Annual Service Performance Guarantees.	Select One
13.0	Confirm the proposed penalties will not be the sole and exclusive remedy available to AlaskaCare for such failure. Confirm the PBM shall pay any amount owed to AlaskaCare and/or its members if the PBM fails to properly administer claims in addition to the missed performance guarantee metric.	Select One
14.0	Confirm AlaskaCare may determine the weighting from 0% to 30% for each of the proposed Performance Guarantees prior to the start of each contractual year as long as the total amount equals to 100%.	Select One
15.0	Confirm the PBM shall provide separate non-financial performance guarantees for the Retail 90 prescriptions filled at one retail chain or include them with the non-financial performance guarantees for the proposed Retail 30 network.	Select One
16.0	Confirm that if the implementation time period is less than 90 days, implementation guarantees shall still apply.	Select One
17.0	Confirm that if the implementation time period is less than 90 days, first quarter performance guarantees shall still be tracked, reported, and results shall be included in the annual calculations.	Select One

			Requested Standard	Willingness to Comply	Indicate the PBM’s Proposed Standard if Different from Requested Standard	Measurement Criteria
(BOB or Client specific)	Timing of Measurement and Payments (Quarterly or Annually)
	Implementation Performance Guarantees
	18.0	Clean Implementation	There will be 0.0% systems errors, 0.0% ID card delays, and AlaskaCare will have access to 100.0% of the tools prior to effective date.	Select One		Select One	Select One
	19.0	Implementation Timeline	Implementation team shall be assigned and introduced to AlaskaCare at least six months in advance of effective date and 100.0% of key milestones shall be achieved.	Select One		Select One	Select One
	110.0	Implementation Team	Implementation team members shall not change and shall be responsible for the accurate installation of all administrative, clinical and financial parameters for AlaskaCare's program.	Select One		Select One	Select One
	111.0	Implementation Satisfaction Scorecard	AlaskaCare will be at least 90.0% satisfied with the implementation process. The satisfaction scorecard shall be completed following the implementation process.	Select One		Select One	Select One

Ongoing Performance Guaranteed
Payment Accuracy & System Performance
112.0	Protected Health Information	PBM guarantees no incidents in violation of HIPAA Security Rules, which results in a transmission of electronic PHI for AlaskaCare's covered members. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
113.0	Plan Administration Accuracy	100.0% of all claims will adjudicate based on the plan design set up. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
114.0	Financial accuracy (electronic and paper claims)	Percentage of claim payments made without error relative to the total dollars paid shall be at least 99.5%. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
115.0	Mail Service Non-Financial Accuracy	The mail service pharmacy shall guarantee dispensing accuracy of at least 99.996% (correct member name, correct member address, correct drug, correct dosage form, and correct strength). This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
116.0	Home Delivery Accuracy	At least 99.996% of home delivery and specialty pharmacy prescriptions dispensed with no errors.	Select One	Select One	Select One
117.0	System Downtime	At least 99.5% access to its systems by all the retail pharmacies in PBM's network 24 hours a day, 7 days a week, 365 days a year. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
118.0	Invoicing Errors	All invoicing errors shall be credited back to AlaskaCare by next billing cycle or PBM shall pay interest. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
119.0	Claims Eligibility Data	Eligibility loads not to exceed 24-hours after receipt. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
120.0	Eligibility Data Error Reporting	Eligibility file error reporting on all clean eligibility file updates shall be provided to AlaskaCare within one business day after receipt. Eligibility file error reporting on all eligibility file updates shall be provided to AlaskaCare within two business days after receipt. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
121.0	Eligibility Processing Accuracy	100% of usable, error-free program eligibility files received by the PBM shall be loaded without error. This is measured and reported on a contract year basis and on a plan-specific basis.	Select One	Select One	Select One
122.0	Eligibility Error Rate Audits	Error rate identified through quarterly audits shall not exceed, on an average basis, 2%. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
123.0	Retail Pharmacy Audit	100% of participating retail pharmacies shall be subject to automated review audits and 20% of participating pharmacies shall be subject to further investigation (e.g., desk audits, on-site audits, etc.) as a result of the automated review audits. The PBM shall perform daily review audits of claims that pay over $1,000. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
124.0	Pharmacy Audit Resolution	48 hours after receipt of findings. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
125.0	Retail Pharmacy Turnover	Less than 5% of retail pharmacies shall leave the retail network. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
126.0	Network Pharmacy Geographic Access	PBM agrees that at least 95% of members, based on plan-supplied eligibility, will have access to a network pharmacy within a five-mile radius of the member's residence in the PBMs Network Program, if there is an existing pharmacy within that radius. The PBM agrees to cure within 90 days, if the percent drops below the above stated percentages. This is measured and reported on an annual basis and on a plan-specific basis.	Select One	Select One	Select One
127.0	Claims Detail File	All claims detail files sent to external vendors shall be provided within eight days of request or scheduled delivery date. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
Account Management
128.0	Contracting Cooperation	Response to recommended contract language changes within 10 business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
129.0	Client Approval of Member Communications	100% of all member communications shall be approved by AlaskaCare - exceptions for drug recalls and urgent patient safety communications. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
130.0	Online Reporting Data Availability	Online reporting data shall be available within an annual average of fifteen business days after the billing cycle that contains the last day of the month. This is measured and reported on annual basis and on a plan-specific basis.	Select One	Select One	Select One
131.0	Delivery of Standard Reports	PBM shall deliver all standard reports to AlaskaCare within 30 days of end of reporting quarter. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
132.0	Accuracy of Standard Reports	All standard reports provided shall be 100% accurate. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
133.0	PBM Account Team's Performance	PBM account team's performance for each contract year shall receive an average of three or better on a scale of 1 to 5 (5 being the best based on a range of performance criteria agreed to between AlaskaCare and the PBM at the beginning of such contract year) from AlaskaCare's benefits staff. This is measured and reported on an annual basis and on a plan-specific basis.	Select One	Select One	Select One
134.0	Account Management Turnover	Account team members shall remain constant for at least the first 18 months of the contract period, unless a change in account management staff is requested by AlaskaCare. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
135.0	Account Management Reporting	The Account Manager shall provide a monthly status report that highlights outstanding open issues and shall be available to meet with AlaskaCare on a monthly basis to discuss the status report. This is measured and reported on a contract year and plan-specific basis.	Select One	Select One	Select One
136.0	Account Management Client Meetings	During first quarter after the effective date, the PBM shall be available to meet with AlaskaCare on a minimum of a monthly basis and thereafter on a minimum of a quarterly basis. This is measured and reported on a contract year and plan specific basis.	Select One	Select One	Select One
137.0	Account Management Responsiveness/ Initial Issue Resolution – The Plan Staff Involvement / Escalation	PBM shall resolve all issues, including member issues that required the involvement of AlaskaCare's staff due to incorrect or incomplete information being provided by the PBM, within two business days. If not resolved within 48 hours, a penalty shall be applied per case, up to an annual maximum. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
138.0	Account Management Responsiveness/ Final Issue Resolution – The Plan Staff Involvement / Escalation	PBM shall ultimately resolve 100.0% of issues brought up by AlaskaCare within 14 business days. If not, a $5,000 penalty will be applied per case, up to the total annual maximum. AlaskaCare may allocate 0% to 100% of the total dollars at risk for this Ongoing Performance Guarantee. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
Member Services
139.0	Mail Turnaround – Prescriptions not requiring intervention	100% of prescriptions shall be dispensed within two business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
140.0	Mail Turnaround – Prescriptions requiring intervention	100% of prescriptions will be dispensed within three business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
141.0	Paper Claims Turnaround	95% of prescriptions reimbursed within average of 10 business days and 100% within average of 14 business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One
142.0	ID Cards Mailing	98% of all ID cards are sent within five business days of receipt of eligibility. 100% mailed within 10 business days. This is measured and reported on a quarterly basis and on a plan-specific basis.	Select One	Select One	Select One

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Dec 4, 2025.