attachment-1-rfp-487-26.pdf

1.0 Financial Proposal - Admin Fees

CY2027 CY2028 CY2029 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

1.1.6 Other, please specify Select One

1.1.7 Other, please specify Select One

1.1.8 Other, please specify Select One

1.1.9 Other, please specify Select One

1.1.10 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).

Confirmation that services included with the proposed Administrative Fee:

If not, Indicate the proposed fee amount

Fee Basis Comments

Table 2: Administrative Service

1.2.1 Account Management Team Select One Select One

1.2.2 Dedicated Customer Service Team Select One Select One

1.2.3 Toll Free Phone Lines Select One Select One

1.2.4 Formulary Administration/Management Select One Select One

1.2.5 Retail Pharmacy Network Management Select One Select One

1.2.6 Retail Pharmacy Network Audit Recovery Fees Select One Select One

1.2.7 Pharmacy Directories and other member materials Select One Select One

1.2.8 Standard Reports Select One Select One

1.2.9 Ad Hoc Reports Select One Select One

1.2.10 ePrescribing Administration Fees Select One Select One

1.2.11 Paper Claim Administration Fees Select One Select One

1.2.12 Monthly Data Feeds to the State or Designee(s) Select One Select One

1.2.13 Prospective/Concurrent DUR Select One Select One

1.2.14 Electronic Utilization Mangement Edits (ST/QL/PA) Select One Select One

1.2.15 Postage for all member communications Select One Select One 1.2.16

Shipping and Handling of Temperature Sensitive Products/ Prescriptions that require special handling or alternative shipping methods

Select One Select One

1.2.17 ID Cards (Including new and replacement ID cards) Select One Select One

1.2.18 Annual EOB Statements Select One Select One

1.2.19 Retro Termination Letters Select One Select One

1.2.20 Drug Notification Letters Select One Select One

1.2.21 COB Claims Processing Select One Select One

1.2.22 Medicaid/Medicare Subrogation Claims Select One Select One

1.2.23 Compound Drug Claims - Electronic claim edits Select One Select One

1.2.24 Fraud Waste and Abuse - Electronic claim edits Select One Select One

1.2.25 Opioid - Electronic claim edits Select One Select One

1.2.26 Vaccine claim processing fee (seasonal flu, COVID-19, etc) Select One Select One

1.2.27 Vaccination - Provider Administration Fee Select One Select One

1.2.28 Any fees associated with compliance with federal, state, and local regulations Select One Select One

1.2.29 Other, please specify Select One Select One

1.2.30 Other, please specify Select One Select One

1.2.31 Other, please specify Select One Select One

1.2.32 Other, please specify Select One Select One

1.2.33 Other, please specify Select One Select One

Table 3: Clinical Services

1.3.1 Prior Authorization - 1st Level Review (non-clinical) Select One Select One

1.3.2 Prior Authorization - 2nd Level Review (clinician) Select One Select One

1.3.3 Prior Authorization - 3rd Level Review (external) Select One Select One

1.3.4 Standard 1st level appeals processing Select One Select One

1.3.5 Standard 2nd level appeals processing (Medical Director) Select One Select One

1.3.6 Urgent appeals processing Select One Select One

1.3.7 Dose Optimization Program Select One Select One

1.3.8 Custom System Overrides Select One Select One

1.3.9 Fraud Waste and Abuse - Enhanced Intervention Program Select One Select One

1.3.10 Opioid - Enhanced Intervention Program Select One Select One

1.3.11 Retrospective DUR Select One Select One

1.3.12 Other, please specify Select One Select One

1.3.13 Other, please specify Select One Select One

1.3.14 Other, please specify Select One Select One

1.3.15 Other, please specify Select One Select One

1.3.16 Other, please specify Select One Select One

Table 4: Other Services

1.4.1 Retiree Drugs Subsidy (RDS) Services, if applicable Select One Select One

1.4.2 Specialty Copay Assistance Programs, including True Accumulation

Program Select One Select One

1.4.3 Other, please specify Select One Select One

1.4.4 Other, please specify Select One Select One

1.4.5 Other, please specify Select One Select One

1.4.6 Other, please specify Select One Select One

1.4.7 Other, please specify Select One Select One

Directions: Complete the tables below by confirming whether the listed services are included in your proposed Base Administrative and/or Base Clinical Fee or are available at an additional cost. All services covered under the base administration or claims processing fee should be listed. However, some services may be offered as optional at an additional cost to the plan sponsor.

For example, separate fees for providing paper EOBs, appeals, or programs requiring clinical intervention may be excluded from the base fees. These additional fees, regardless of whether offered bundled or a la carte, should be clearly identified along with the associated cost per unit.

All Contract Years (CY2027 - CY2029)

2.0 Financial Proposal - Pricing Guarantees

Notes: 1. Brand Pricing must include both single source and multi-source brands

2. Generic Pricing must include single-source generics

3. Bids must be 100% pass rebate through quotes as a % of Total AWP Cost for all Brand Scripts by channel

Complete Table 3 by providing your proposed allowance(s) for implementation costs, pharmacy audits and pharmacy consulting services.

Complete Table 4 by providing your GDR guarantee(s) by channel and plan year.

2.1 Retail 30, Retail90 and Mail Order Pharmacy for Non-Specialty Drugs

Name of proposed Broad Retail Network:

Name of proposed Exclusive Specialty Pharmacy:

Name of proposed Formulary:

CY2027 CY2028 CY2029 Comments Table 2.1(a): Retail30 Network Pricing - Transparent (pass-through)

Brand Generic

Brand Generic

2.1(a).3 Minimum Rebate guarantees as a % of Total Retail30 Brand AWP

CY2027 CY2028 CY2029 Comments Table 2.1(b): Retail90 Network Pricing - Transparent (pass-through)

Brand Generic

Brand Generic

2.1(b).3 Minimum Rebate guarantees as a % of Total Retail90 Brand AWP

CY2027 CY2028 CY2029 Comments Table 2.1(c): Mail Order Pricing - Acquisition Cost Plus Pricing w/underlying discount guarantees

Brand Generic

Brand Generic

2.1(c).3 Minimum Rebate guarantees as a % of Total Mail Order Brand AWP

Response a.) Non-Specialty Drugs - Exclusive Mail Order

2.2 Exclusive Specialty Pharmacy

CY2027 CY2028 CY2029 Comments Table 2.2: Specialty Drug Pricing - Acquisition Cost Plus Pricing w/underlying discount guarantees

Brand Generic New-to-Market Drugs Limited Distribution / Exclusive Distribution Drugs Low-WAC Biosimilars High-WAC Biosimilars

Brand Generic New-to-Market Drugs Limited Distribution / Exclusive Distribution Drugs Low-WAC Biosimilars High-WAC Biosimilars

2.2.3 Minimum Rebate guarantees as a % of Total Specialty AWP

Response 2.2.4 a.) Specialty Drugs - Exclusive Specialty Pharmacy

CY2027 CY2028 CY2029 Comments

Table 3: Allowances (PEPM, PMPM or flat dollar amounts)

2.3.1 Implementation allowance Select One

2.3.2 Pre- or post-implementation Audit Select One

2.3.3 Annual Claims/Rebate Audit Select One

2.3.4 General Pharmacy Program Management allowance Select One

2.3.5 Invoice Credit Select One

CY2027 CY2028 CY2029 Comments

Table 4: Generic Dispensing Rate (GDR) Guarantee

2.4.1 Retail 30

2.4.2 Mail Order

2.4.3 Specialty

2.1(a).2

Confirm the methodology that you are using as the basis for your Acquisition Cost Plus model (e.g., % of AWP, % of WAC, % of WAC by GPI-14, etc.):

In this scenario, Bidders should assume an exclusive PBM specialty arrangment for all specialty drugs.

2.2.1 Maximum Dispensing Fee Guarantee Per Script

2.2.2 Discount Guarantee

Discount Guarantee

Directions:The State is interested in transparent (pass-through) for retail network and Acquisition Cost Plus pricing with underlying discount guarantees, by channel and drug type

In this scenario, Bidders should assume an exclusive mail order arrangment for non-specialty drugs.

Note:

Retail (non-speciaty) should be quoted on a 1-31 day supply basis Mail Order (non-specialty) should be quoted on a 1-90 day supply basis. Note: the State does not currently allow for 90 day fills at Retail, but would like to understand how it could potentially be cost effective for the State?

Under the State's current plan design, specialty drugs are only available via the PBM's specialty pharmacy only and are limited to a 30 day supply

Confirm the methodology that you are using as the basis for your Mail Order Acquisition Cost Plus model (e.g., % of AWP, % of WAC, % of WAC by GPI-14, etc.):

Maximum Dispensing Fee Guarantee Per Script

Discount Guarantee

2.1(c).4

2.1(b).1

2.1(c).2

2.1(b).1 Maximum Dispensing Fee Guarantee Per Script

2.1(b).2 Discount Guarantee

Maximum Dispensing Fee Guarantee Per Script2.1(a).1

3.0 Specialty Drug List

11-Digit NDC Product Name Therapeutic Class Drug Type Limited Distribution

Drug (Y/N) Biosimilar Drug

(Y/N) New-to-Market

(Y/N) Guaranteed Discount %

Basis for Discount %

Maximum Dispensing Fee ($)

Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One

Directions: Provide your proposed drug list for all specialty pharmaceuticals, including biosimilars plus Limited Distribution Drugs that the PBM has access as well as those that the PBM does not have access, that your company dispenses and distributes to providers and patients for your proposed specialty pharmacy program. Your pricing must include adequate supplies of ancillaries such as needles, swabs, syringes, and containers.

4.0 Financial Proposal - Estimated Costs

CY2027 CY2028 CY2029

Enrollment Number of Members

SCRIPT COUNT

Retail 30

Generic Brand - included in rebate g'tees Brand - excluded from rebate g'tees Sub-total 0 0 0

Mail Order Generic Brand - included in rebate g'tees Brand - excluded from rebate g'tees Sub-total 0 0 0

Specialty Generic Brand - included in rebate g'tees Brand - excluded from rebate g'tees Sub-total 0 0 0

Total Script Count 0 0 0

AWP

Retail 30

Generic Brand Sub-total $0 $0 $0

Mail Order Generic Brand Sub-total $0 $0 $0

Specialty Generic Brand Sub-total $0 $0 $0

Total AWP $0 $0 $0

INGREDIENT COST

Retail 30

Generic Brand Sub-total $0 $0 $0

Mail Order Generic Brand Sub-total $0 $0 $0

Specialty Generic Brand Sub-total $0 $0 $0

Total Ingredient Cost $0 $0 $0

DISPENSING FEES

Retail 30

Generic Brand Sub-total $0 $0 $0

Mail Order Generic Brand Sub-total $0 $0 $0

Specialty Generic Brand Sub-total $0 $0 $0

Total Dispensing Fees $0 $0 $0

REBATES

Retail 30 Retail 90 Mail Order Specialty Total Rebates $0 $0 $0

OTHER COSTS

Administrative Fees Clinical Fees Other Fees Total Fees $0 $0 $0

SUMMARY

Ingredient Cost + Dispensing Fees $0 $0 $0 Administrative fees $0 $0 $0 less Rebates $0 $0 $0 less Member Cost Share Net Plan Cost $0 $0 $0

Directions: Provide the Bidder's estimated costs based on the proposed formulary and pricing for each contract year (e.g., CY2027, CY2028 and CY2029 separately). Your projections should include the projected ingredient cost, dispensing fees, administrative fees, member cost share and rebates. INCLUDE ALL CLAIMS IN YOUR PROJECTIONS, INCLUDING THOSE THAT MAY BE EXCLUDED FROM PRICING GUARANTEES. Member cost share estimates should be based on the plan design(s) currently in place.

5.0 Financial Proposal - Exclusions

11-Digit NDC Product Name Specialty Indicator Rx Count AWP Ingredient Cost Rx Count AWP Ingredient Cost Rx Count AWP Ingredient Cost Guarantee Exclusion Category

Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One

Retail 30 Pharmacies Mail Order Pharmacy Specialty Pharmacy

Directions: Using the States's detailed claim-by-claim prescription drug data, provide an exhibit with NDCs identifying the State's applicable non-specialty and specialty drug claims that are excluded (except for DAW 5 - House Generics that should be entered on TAB06_House Generics) from drug pricing guarantees. Provide separately for drugs dispensed at participating Retail 30 pharmacies, Mail Order pharmacy and at the PBM's Specialty Pharmacy.

6.0 DAW 5 "House Generics"

11-Digit NDC Product Name Therapeutic Class

Directions: Provide the list of drug products for which will be processed with a DAW 5 and excluded from pricing and/or rebate guarantees at the PBM's exclusive mail order and specialty pharmacies

7.0 Rebate Credit Products

11-Digit NDC Product Name Therapeutic Class 2027 2028 2029

Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One

Directions: Provide the list of drug products for which rebate credit will apply, if applicable

8.0 Financial Proposal - PMPM Pricing Guarantees

Name of proposed Broad Retail Network:

Name of proposed Exclusive Specialty Pharmacy:

Name of proposed Formulary:

CY2027 CY2028 CY2029

Table 1a: Acquisition Cost Rate Development 8.1(a).1 PMPM Ingredient Cost

8.1(a).2 PMPM Dispensing Fee

8.1(a).3 PMPM Base Administration Fee (guaranteed)

8.1(a).4 PMPM Administration Fees - All Other

8.1(a).5 PMPM Rebates (100% pass-through)

8.1(a).6 Annual Maximum PMPM Cost Guarantee $0.00 $0.00 $0.00

Confirmation Deviation or Explanation 8.1(a).7

Select One

8.1(a).8

8.1(a).9 a.) Retail b.) Mail Order c.) Specialty Mail Order

8.1(a).10

8.1(a).11

8.1(a).12 Please provide your proposed guaranteed quarterly rebate payment on a PMPM basis.

Confirm that the Bidder's Annual Maximum PMPM Cost shown in line 8.1(a).6 above includes assumes all claims experience will be included in the guarantee. The only exclusion permitted will be Cellular/Gene Therapy claims.

If the Bidder is not able to provide PMPM guarantees for CY2028 and/or CY2029 at this time, please provide your guaranteed maximum annual PMPM trend rate.

Confirm the methodology that you are using as the basis for your Acquisition Cost Plus model (e.g., NADAC, % of AWP, % of WAC, % of WAC by GPI-14, etc.):

Please provide an itemized list of the services included in line 8.1(a).4 above. Note that per unit costs for these services should be outlined in TAB1_Admin Fees.

Provide an itemized list of clinical programs that are required based on your guaranteed PMPM above.

Directions: The State is interested in an Acquisition Cost Plus financial guarantee arrangement . As such, Bidders are to propose an annual maximum cost guarantee on a PMPM basis by plan year in Tables 1a and 1b below. PMPM cost will be calculated as the sum of total allowed claim cost (e.g., ingredient cost, dispensing fees, administration fees) and admin fees, less rebates divided by member months.

Administration fees include all fees paid by the plan sponsor in monthly administrative fee invoices, including but not limited to prior authorizations, appeals, vaccine program fees, etc). For the purposes of this guarantee, the PBM should assume all claims experience will be included in the guarantee.