Att 7 - Submittal Form I Network Disruption Analysis.xlsx

XLSX spreadsheet 2 MB Posted Oct 16, 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 · Oct 17, 2025

This document is a Network Disruption Analysis Submittal Form for a pharmacy benefits contract, consisting of three separate tables for Active Employee, Non-EGWP Retiree, and EGWP with Wrap plans. The form requires detailed documentation of potential pharmacy network changes, specifically tracking the number of retail pharmacies that would be out-of-network or in-network under a proposed new pharmacy network configuration. The analysis aims to quantify the potential disruption to members by measuring the number of distinct members and prescriptions that would be affected by network changes across different plan types.

The submittal form is designed for a comprehensive network analysis, requesting bidders to complete detailed tables that show the current pharmacy utilization and potential impact of network modifications. Each table requires reporting on out-of-network and in-network pharmacies, including the number of currently utilized pharmacies, distinct members using those pharmacies, and the total number of prescriptions adjudicated. Bidders are instructed to use claims data provided upon submission of confidentiality forms to populate these tables, with the goal of transparently demonstrating the potential member impact of proposed pharmacy network changes across different plan structures.

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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
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Amd Four RFP 2025-0200-0177 02-101-25 PBM Services.pdf	PDF	Dec 3, 2025
Amd Three Att 10 - Submittal Form L - Cost Proposal Version 2.xlsx	XLSX spreadsheet	Dec 3, 2025
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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
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Att 8 - Submittal Form J Formulary 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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Network Disrupt_Employee

Submittal Form I - Network Disruption Analysis
Network Disruption– Active Employee Plan
Table 1 - Summary
Offeror must complete the following retail network disruption table based on the offeror's proposed Retail 30 and the Retail 90 network using the Claims File that will be provided upon the submission of the ITP and NDA forms as detailed in RFP Section 3.18 Nondisclosure and Confidentiality. Results to be included are the number of members that will be required to change the utilized retail pharmacy as well as the number of prescriptions associated with the retail pharmacy change. Use the claims data for the Active Employee plan(s) to populate this table.
Retail 30 Pharmacy: Broad
Retail 90 Pharmacy: Broad
Type of Change	Retail 30 Network	Retail 90 Network
Out-of-Network Retail Pharmacies
Number of currently utilized retail pharmacies that are NOT part of the proposed network and are eligible to solicit
Number of distinct members that are using those retail pharmacies that are NOT part of the proposed network and are eligible to solicit
Number of prescriptions that adjudicated via those Retail pharmacies that are NOT part of the proposed network and are eligible to solicit
In-Network Retail Pharmacies
Number of currently utilized retail pharmacies that are part of the proposed network
Number of distinct members that are using those retail pharmacies that are part of the proposed network
Number of prescriptions that adjudicated via those retail pharmacies that are part of the proposed network
Table 2 - Detailed Disruption Results
Offeror must complete the table below by listing each distinct retail pharmacy along with the number of distinct patients who filled a script at the retail pharmacy and the number of prescriptions dispensed based on the day's supply dispensed. Then indicate whether or not the retail pharmacy is in-network or out-of-network based on the offeror's proposed network. Use the claims data for the Active Employee plan(s) to populate this table.
NPI	Name of Retail Pharmacy	Address of Pharmacy	City	State	ZIP	Number of Distinct Members	Number of Scripts	Number of Distinct Members	Number of Scripts	Retail 30 Network	Retail 90 Network
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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 Oct 17, 2025.