Attachment 16b-GIC Financial Proposal-EGWP_for COMMBUYS.xlsx
XLSX spreadsheet 4 MB Posted
- Solicitation number
- BD-26-1049-GIC00-07GIC-130036
- Issued by
- Massachusetts
About this file
This is a financial proposal template document for Pharmacy Benefit Manager (PBM) services submitted to the Massachusetts Group Insurance Commission (GIC) for their Employer Group Waiver Plan (EGWP) program. The document outlines comprehensive pricing and financial terms for pharmacy benefit management covering approximately 124,278 covered members based on experience period data from January 1 to December 31, 2025. The contract is scheduled to commence July 1, 2027, with potential continuation through July 1, 2029, contingent on proposal acceptance. The RFP response instructions require bidders to populate detailed pricing proposal sections including discount guarantees, dispensing fees, rebate structures, administrative fees, and clinical fees across multiple pharmacy channels (retail 30-day, retail 90-day, mail-at-retail, specialty retail, mail order, and specialty pharmacy). Bidders must provide formulary lists, specialty drug designations, pricing detail reconciliation tied to historical claims data totaling $1.828 billion in undiscounted AWP across 3.3 million prescription claims, and projections for years 2027-2029.
The incumbent vendor, CVS Health (SilverScript), currently administers the EGWP program under a closed formulary (Bronze, Copper, or Platinum template) with open specialty networks and broad retail and mail-order networks delivering 90-day supplies for specialty medications. The proposal structure employs a PMPM (per-member-per-month) rebate guarantee sharing arrangement with no point-of-sale rebates; GLP-1 weight loss drugs are planned to be excluded from coverage by 2027. Bidders must confirm adherence to current arrangement parameters or provide detailed deviation explanations and alternative pricing methodologies. The document specifies reservation of rights provisions, requiring that financial impact thresholds exceed 10 percent of total contract value before adjustment consideration, with vendor communication of intent within 90 days and mutual agreement required for modifications. Financial guarantees include specific rebate credits for products experiencing significant WAC reductions or biosimilar introductions, such as Humira and Stelara biosimilars, with baseline rebate maintenance subject to pre-agreed inflationary adjustments. Administrative support includes requested one-time pharmacy credits of $225,000 ($150,000 implementation support plus $75,000 pre/post-implementation audit) and an ongoing allowance of $1,000,000 for pharmacy plan administration, with the vendor required to clarify whether these credits are embedded in pricing or charged separately.
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Text version
Contents, Instructions Client: Massachusetts GIC - EGWP Bidding Vendor Name: PBM B
Any information provided in this document will supersede that found in supplemental documents should they conflict. ?
| Table of Contents | |
| Pricing Response | |
| 1a) | Proposal Overview |
| 1b) | Pricing Terms |
| 1c) | Pharmacy Credits |
| 1d) | PMPM Guarantees (only populate if applicable) |
| 1e) | Alternative Trend Guarantees (only populate if applicable) |
| Financial Questionnaire | |
| 2a) | Definitions |
| 2b) | Discount & Rebate Guarantees |
| 2c) | Rebate Credits |
| 2d) | Reservation of Rights (ROR) |
| RFP Exhibits | |
| 3a) | Data Summary |
| 3b) | Pricing Detail |
| 3c) | Specialty List |
| 3d) | Non-Spec LDD List |
| 3e) | Projections |
| 3f) | Formulary |
| 3g) | Network Disruption |
| 3h) | Preventive Drug List |
| GeoAccess | |
| 4a) | Zip Codes |
| 4b) | R30 GeoAccess |
| 4c) | R90 GeoAccess |
Instructions
Unless directed otherwise within the tab, populate all light yellow input cells in all tabs.
If bidder is providing a proposal that does not have discount guarantees, per brand/claim rebate guarantees or PMPM rebate guarantees, in lieu of completing the Pricing Terms tab, please complete the PMPM Guarantee tab or the Alternative Trend Guarantee tab (if applicable) and provide a supplemental document that details methodology and proposal offer.
Pricing Detail (3b) is a critical input. When providing this, please ensure that total AWP and scripts tie exactly to what was provided.
1a) Proposal Overview
| Client: | Massachusetts GIC - EGWP | Bidding Vendor Name: | PBM B | |
| Contents | ||||
| Proposal Terms |
The parameters of the current arrangement are outlined in column C. The request is that your bid matches these parameters. Please provide confirmation of this in Column D. If there are deviations, please provide an explanation in column E.
| Current Arrangement Setup | Bidding Vendor Confirmation | Comments | ||
| Incumbent PBM | SilverScript | |||
| Effective Date | 7/1/27 | Note: Start date may be 7/1/2027 or 1/1/2028. | ||
| Formulary Type (With/Without exclusions) | With | ? | Note CVS has clarified "This is not an open formulary. SilverScript EGWP formularies come in three general templates: Platinum, Copper, Bronze (they are all closed formularies, listed in order of amount of Med D drugs covered – Bronze is broadest)." | |
| Specialty (Open/Exclusive) | Open | ? | ||
| R30 Network (Broad/Narrow) | Broad | ? | ||
| R90 Network (Broad/Narrow) | Broad | ? | ||
| Specialty Days' Supply (30 days, 90 days) | 90 | ? | ||
| Rebate Sharing Arrangement | PMPM | ? | Note: a PMPM rebate guarantee structure is currently in place, but alternative rebate guarantee structures (such as per brand script) may be proposed. | |
| Point of Sale Rebates (Yes/No) | No | ? | ||
| GLP-1 Weight Loss Drugs Covered (Yes/No) | Currently excluded from Primary, Covered in Wrap, however, GIC plans for these products to be excluded in 2027. | ? | Note: bids may assume the weight loss products are not covered in 2027 | |
| Weight Loss management program | PA on wrap | ? | ||
| Diabetic management program (Yes/No) | No | ? |
1b) Pricing Terms
| Client: | Massachusetts GIC - EGWP | Bidding Vendor: | PBM B | |
| Contents | ||||
| Pricing Terms | ||||
| Instructions | If bid contains minimum discount and/or rebate guarantees, please complete all cells below as it pertains to your proposed pricing terms. | |||
| Note: "Domestic Pharmacy" includes onsite pharmacies, inhouse pharmacies, and client owned pharmacies. | ||||
| Vendor Comments, if any |
| AWP Discount | Dispensing Fee Per Rx | Guaranteed (Y/N) | Comment, if any | ||||||
| DISCOUNTS AND DISPENSING FEES | 7/1/27 | 7/1/28 | 7/1/29 | 7/1/27 | 7/1/28 | 7/1/29 | |||
| Retail-30 Network, Non-specialty | Brand | % | % | % | ? | ||||
| Generic | % |
Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
| If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee | ? | |||||
| Retail-90 Network, Non-specialty | Brand | % | % | % | ? | |
| (subject to pricing other than retail or mail, if applicable) | Generic | % |
Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
| If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee | ? | |||||
| Mail at Retail network, Non-specialty | Brand | % | % | % | ? | |
| (subject to standard mail pricing and cost share, if applicable) | Generic | % |
Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
| If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee | ? | |||||
| Retail Specialty | Brand | % | % | % | ? | |
| Generic | % |
Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
| If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee | ? | |||||
| Mail Order (non-specialty) | Brand | % | % | % | ? | |
| Generic | % |
Grace Dilello: If a flat AWP discount is applied to all mail order generic drugs, enter the contracted mail order generic discount
If MAC pricing is used at mail order, and there is No Guaranteed aggregate annual AWP discount, then enter the expected AWP discount (including all MAC'd Mail Order Generics and all Non-MAC'd Mail Order Generics)
If MAC pricing is used at mail order, and there is a Guaranteed aggregate annual mail order generic discount (including all MAC'd Mail Order Generics and all Non-MAC'd Mail Order Generics) then enter such discount guarantee % Grace Dilello: If a flat AWP discount is applied to all mail order generic drugs, enter the contracted mail order generic discount
If MAC pricing is used at mail order, and there is No Guaranteed aggregate annual AWP discount, then enter the expected AWP discount (including all MAC'd Mail Order Generics and all Non-MAC'd Mail Order Generics)
If MAC pricing is used at mail order, and there is a Guaranteed aggregate annual mail order generic discount (including all MAC'd Mail Order Generics and all Non-MAC'd Mail Order Generics) then enter such discount guarantee % Grace Dilello: If a flat AWP discount is applied to all mail order generic drugs, enter the contracted mail order generic discount
If MAC pricing is used at mail order, and there is No Guaranteed aggregate annual AWP discount, then enter the expected AWP discount (including all MAC'd Mail Order Generics and all Non-MAC'd Mail Order Generics)
| If MAC pricing is used at mail order, and there is a Guaranteed aggregate annual mail order generic discount (including all MAC'd Mail Order Generics and all Non-MAC'd Mail Order Generics) then enter such discount guarantee | ? | |||||
| Specialty Pharmacy (mail) | Brand | % | % | % | ? | |
| Generic | % | % | % | ? | ||
| Limited Distribution Drugs | 30-Day, Non-Specialty Brand | % | % | % | ? | |
| (only need to complete this section if LDD have a separate discount guarantee) | 30-Day, Non-Specialty Generic | % | % | % | ? | |
| 90-Day, Non-Specialty Brand | % | % | % | ? | ||
| 90-Day, Non-Specialty Generic | % | % | % | ? | ||
| Retail Specialty Brand | % | % | % | ? | ||
| Retail Specialty Generic | % | % | % | ? | ||
| Mail Specialty Brand | % | % | % | ? | ||
| Mail Specialty Generic | % | % | % | ? | ||
| Domestic Pharmacy: 30-Day, non-specialty | 30-Day, non-specialty Brand | % | % | % | ? | |
| (only need to complete this section if Domestic Pharmacy claims are excluded from the above Retail network pricing guarantees) | 30-Day, non-specialty Generic | % |
Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
| If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee | ? | ||||
| 90-Day, non-specialty Brand | % | % | % | ? | |
| 90-Day, non-specialty Generic | % |
Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
| If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee | ? | ||||
| 30-Day, Specialty Brand | % | % | % | ? | |
| 30-Day, Specialty Generic | % |
Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
| If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee | ? | ||||
| 90-Day, Specialty Brand | % | % | % | ? | |
| 90-Day, Specialty Generic | % |
Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee % Grace Dilello: If there is No Guaranteed aggregate annual retail generic discount, then enter the expected AWP discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics)
| If there is a Guaranteed aggregate annual retail generic discount (including all MAC'd Retail Generics and all Non-MAC'd Retail Generics) then enter such discount guarantee | ? | |||||||
| Rebate Guarantees | Rebate Guarantee requires what Day Supply | 7/1/27 | 7/1/28 | 7/1/29 | ||||
| Guaranteed rebate amounts paid/credited to client | (min 30, min 90, up to 30, up to 90, 84+, clinical DS) | Guaranteed Amount | Guaranteed Amount | Guaranteed Amount | Basis | Comments | ||
| Retail-30 Network (non-specialty) | ? | $ | $ | $ | ? | |||
| Retail-90 Network (non-specialty) | ? | $ | $ | $ | ? | |||
| Mail at Retail network (non-specialty) | ? | $ | $ | $ | ? | |||
| Retail (specialty) | ? | $ | $ | $ | ? | |||
| Mail Order | ? | $ | $ | $ | ? | |||
| Specialty Pharmacy (mail) | ? | $ | $ | $ | ? | |||
| Domestic Pharmacy (non-specialty, 30 day) | ? | $ | $ | $ | ? | |||
| Domestic Pharmacy (non-specialty, 90 day) | ? | $ | $ | $ | ? | |||
| Domestic Pharmacy (specialty) | ? | $ | $ | $ | ? | |||
| If an additional set of rebate guarantees applies that differs from rebates above, then provide here. | ||||||||
| For example, rebates with 2-tier plan design, rebates with a weight management program, etc. | Rebate Guarantee requires what Day Supply | Guaranteed Amount | Guaranteed Amount | Guaranteed Amount | Basis | Comments | ||
| Retail-30 Network (non-specialty) | ? | $ | $ | $ | ? | |||
| Retail-90 Network (non-specialty) | ? | $ | $ | $ | ? | |||
| Mail at Retail network (non-specialty) | ? | $ | $ | $ | ? | |||
| Retail (specialty) | ? | $ | $ | $ | ? | |||
| Mail Order | ? | $ | $ | $ | ? | |||
| Specialty Pharmacy (mail) | ? | $ | $ | $ | ? | |||
| Domestic Pharmacy (non-specialty, 30 day) | ? | $ | $ | $ | ? | |||
| Domestic Pharmacy (non-specialty, 90 day) | ? | $ | $ | $ | ? | |||
| Domestic Pharmacy (specialty) | ? | $ | $ | $ | ? | |||
| Guaranteed rebate PEPM/PMPM amounts paid/credited to client (if applicable) | Rebate Guarantee requires what Day Supply | Guaranteed Amount | Guaranteed Amount | Guaranteed Amount | Basis | Comments | ||
| Rebate PEPM or PMPM guarantee for all channels and plan designs | N/A | $ | $ | $ | ? | |||
| ADMINISTRATIVE FEES | 7/1/27 | 7/1/28 | 7/1/29 | Basis | Comment, if any | |||
| Retail Network claims (non-specialty and specialty) | ? | |||||||
| Mail Order claims | ? | |||||||
| Specialty Pharmacy claims | ? | |||||||
| Base Administrative fee (PEPM or PMPM) | ? | |||||||
| Domestic Pharmacy (340b claims) | ? | |||||||
| Domestic Pharmacy (non-340b claims) | ? | |||||||
| Paper, member submitted claims | ? | |||||||
| Weight Loss management fee (if quote assumes enrollment in program) | ? | |||||||
| Diabetic program management fee (if quote assumes enrollment in program) | ? | |||||||
| CDH (HRA/HSA) plan administration | ? | |||||||
| Non-CDH plans, data integration of combined medical and Rx plan deductible and/or OOP max | ? | |||||||
| Point of Sale Rebates | ? | |||||||
| Termination Fee | ? | |||||||
| Transition Fees if Client Moves Rx to Another Vendor: | ? | |||||||
| Increase to Medical ASO Fee | ? | |||||||
| Fee for ongoing data integration between Rx and Medical Plan | ? | |||||||
| Vaccine Administration Fee | ? | |||||||
| Vaccine Program Fee | ? | |||||||
| For any additional program or admin fees, please list below. Examples include: State mandated pass-through pricing fees, e-prescribing, Data Feeds to third parties, Medicare, RDS and/or EGWP administration and reporting, Fee to provide data history files, etc. | ||||||||
| ? | ||||||||
| ? | ||||||||
| ? | ||||||||
| Clinical Fees | 7/1/27 | 7/1/28 | 7/1/29 | Basis | Comments | |||
| Utilization Management/Prior Authorization (Non-Specialty) | $ | $ | $ | ? | ||||
| Utilization Management/Prior Authorization (Specialty) | $ | $ | $ | ? | ||||
| Appeals - Level 1 | $ | $ | $ | ? | ||||
| Appeals - Level 2 | $ | $ | $ | ? | ||||
| Appeals - External | $ | $ | $ | ? | ||||
| Formulary Exceptions | $ | $ | $ | ? | ||||
| Clinical Management Program (Bundle) Fee | $ | $ | $ | ? | ||||
| Discount and Rebate Guarantee Exclusions | ||||||||
| Note if any of the following categories are excluded from minimum discount and rebate guarantees: | Discount Guarantees | Rebate Guarantees | Comments | |||||
| 340B: All Claims with Submission Clarification Code = 20 | ? | ? | ||||||
| 340B: All Claims dispensed by a pharmacy with 340B Status Code = 39 (per NCPDP DataQ database) | ? | ? | ||||||
| 340B: All Claims dispensed by a pharmacy with 340B Status Code = 38 (per NCPDP DataQ database) | ? | ? | ||||||
| Biosimilar products | ? | ? | ||||||
| Claims approved by formulary exception | ? | ? | ||||||
| Claims from non-participating pharmacies | ? | ? | ||||||
| DAW5 claims (House Generics) | ? | ? | ||||||
| Domestic Pharmacy Claims | ? | ? | ||||||
| LDD: existing Exclusive and Limited Distribution Drugs | ? | ? | ||||||
| LDD: new to market Exclusive and Limited Distribution Drugs | ? | ? | ||||||
| Multi-source Brand (MSB) drugs | ? | ? | ||||||
| New to market Specialty drugs | ? | ? | ||||||
| Non-Drug Claims (If excluded, please define in the Comments section) | ? | ? | ||||||
| OTC products - Diabetic (Test Strips, Insulin, and CGMs) | ? | ? | ||||||
| OTC products - Non-Diabetic (clarify below if necessary) | ? | ? | ||||||
| U&C claims | ? | ? | ||||||
| Vaccines | ? | ? | ||||||
| Vaccine administration claims | ? | ? | ||||||
| Zero paid claims (i.e., member pays 100% and the Plan pays zero) | ? | ? | ||||||
| Provide the contract language for the proposal's discount guarantee and rebate guarantee exclusions. | ||||||||
| Specify any/all other terms upon which the above guarantees are contingent. | ||||||||
| REBATES | Response | Comments | ||||||
| What is the name of the formulary drug list? | ||||||||
| Does the formulary have drug exclusions? | ? | |||||||
| What is the days' supply limit associated with the proposed Specialty rebate guarantees? |
(30 DS limit, 90 DS limit, clinical DS is used, other please specify)
| For financial reconciliation purposes, how will Dupixent be categorized for rebate guarantees for the duration of the contract? | ? |
| For financial reconciliation purposes, how will HIV Prep (Descovy, Apretude) be categorized for rebate guarantees for the duration of the contract? | ? |
| For financial reconciliation purposes, how will all other HIV drugs be categorized for rebate guarantees for the duration of the contract? | ? |
| For financial reconciliation purposes, how will Cystic Fibrosis drugs (Trikafta etc.) be categorized for rebate guarantees for the duration of the contract? | ? |
| For financial reconciliation purposes, how will PCSK9 products be categorized for rebate guarantees for the duration of the contract? | ? |
| For financial reconciliation purposes, how will Hepatitis C products be categorized for rebate guarantees for the duration of the contract? | ? |
| Which method below best describes how Rebates are shared? |
(a) Vendor pays/credits the client the greater of 100% of actual rebate earnings or the specified rebate guarantees provided above.
(b) Vendor pays/credits the client the greater of 100% of actual rebate earnings, the specified rebate guarantees provided above, or the specified PEPM/PMPM rebate amount provided above.
(c) Vendor pays/credits the specified rebate guarantees provided above and does not share the client's actual rebates.
(d) POS rebates – rebates are shared at the point of sale (i.e., either a set rebate per rebateable claim or drug-specific rebates)
(e) Vendor pays/credits the client a specified percentage of actual rebate earnings (provide percentage in comments section)
(f) Client does not receive direct rebate payments; instead, rebates are used to offset/lower the medical ASO fees (provide amount in comments section)
| (g) Rebate reinvestment – client does not receive direct rebate payments; instead, rebates are passed through via deeper AWP discounts | ? | |||
| Does the Rebate definition include Manufacturer Administrative Fees (MAF) and/or is 100% of MAF passed through to the client? | ? | |||
| Does the Rebate definition include price protection and/or are price protection payments passed through to the client? | ? | |||
| Does the Rebate definition include monies received from pharma from performance/outcome based programs? | ? | |||
| Humira Biosimilar Strategy | Response | Comments | ||
| Identify which situation applies, based on the formulary that was proposed for this bid, as of the contract effective date. |
(a) Humira will be the preferred product on the formulary.
(b) Humira will be co-preferred with Humira biosimilar products as of the contract effective date.
(c) Humira is excluded from the formulary, and a Low WAC biosimilar product is preferred.
(d) Humira is excluded from the formulary, and a High WAC biosimilar product is preferred.
(e) Humira is excluded from the formulary, and Low & High WAC biosimilar products are preferred.
| (f) Other – please explain in the comments section | ? | ||||
| Low WAC Biosimilars | High WAC Biosimilars | Brand Humira | |||
| What are the names and co-pay tiers of the Humira biosimilars covered on the formulary, if applicable | |||||
| What percentage of claims do you assume will be Low WAC biosimilars/ High WAC biosimilars/ Humira in underwriting? | |||||
| Note: total should add to 100% | % | % | % | ||
| What is the AWP reduction as a percentage of Humira (1- Biosimilar AWP/ Humira AWP) for these Low WAC and/or High WAC biosimilars? | % | % | N/A | ||
| When were the changes to the Humira biosimilar strategy implemented in the quoted formulary? | |||||
| If this change is planned in future, when will it be effective? | |||||
| Stelara Biosimilar Strategy | Response | Comments | |||
| Identify which situation applies, based on the formulary that was proposed for this bid, as of the contract effective date. |
(a) Stelara will be the preferred product on the formulary.
(b) Stelara will be co-preferred with Stelara biosimilar products as of the contract effective date.
(c) Stelara is excluded from the formulary, and a Low WAC biosimilar product is preferred.
(d) Stelara is excluded from the formulary, and a High WAC biosimilar product is preferred.
(e) Stelara is excluded from the formulary, and Low & High WAC biosimilar products are preferred.
| (f) Other – please explain in the space provided to the right | ? | ||||
| Low WAC Biosimilars | High WAC Biosimilars | Brand Stelara | |||
| What are the names and co-pay tiers of the Stelara biosimilars covered on the formulary, if applicable | |||||
| What percentage of claims do you assume will be Low WAC biosimilars/ High WAC biosimilars/ Stelara in underwriting? | |||||
| Note: total should add to 100% | % | % | % | ||
| What is the AWP reduction as a percentage of Stelara (1- Biosimilar AWP/ Stelara AWP) for these Low WAC and/or High WAC biosimilars? | % | % | N/A | ||
| When were the changes to the Stelara biosimilar strategy implemented in the quoted formulary? | |||||
| If this change is planned in future, when will it be effective? | |||||
| Pricing Arrangement | Response | Comments | |||
| Which of the following best describes your proposed Retail-30 Network pricing arrangement? |
(a) Traditional, "spread" pricing with fixed discount guarantees
(b) Pass-through of contracted rates; no guaranteed discounts or dispensing fees
(c) Pass-through of contracted rates, with guaranteed minimum discounts/maximum dispensing fees
| (d) Rebate reinvestment | ? | |
| Which of the following best describes your proposed Retail-90 pricing arrangement? |
(a) Not applicable. 90 day supply (DS) is not allowed at retail
(b) 90 DS allowed at any retail network pharmacy at the standard retail pricing terms
(c) 90 DS allowed at any retail network pharmacy; pricing better than standard retail but not as good as mail
(d) 90 DS allowed at certain retail network pharmacies at the standard retail pricing terms
(e) 90 DS allowed at certain retail network pharmacies; pricing better than standard retail but not as good as mail
| (f) 90 DS can be filled at certain retail network pharmacies at the standard mail pricing terms (Mail at Retail Network) | ? | |
| Which of the following best describes your proposed Mail Order pricing arrangement? |
(a) Fixed guarantees – traditional spread pricing
(b) No discount or dispensing fee guarantees
(c) Rebate reinvestment
| (d) Pass-through of acquisition cost with minimum discount/higher dispensing fee guarantees | ? | |
| Which of the following best describes your proposed Specialty Channel pricing arrangement? |
(a) Fixed guarantees – traditional spread pricing
(b) No discount or dispensing fee guarantees
(c) Rebate reinvestment
| (d) Pass-through of acquisition cost with minimum discount/higher dispensing fee guarantees | ? | |
| Which of the following best describes your proposed Domestic Pharmacy pricing arrangement? |
(a) Not applicable; Client doesn't have any Domestic Pharmacies
(b) Domestic Pharmacy claims are included in the standard retail-30 and retail-90 network discount and dispensing fee guarantees
(c) Pass-through of the Domestic Pharmacy's contracted network rates; no guaranteed discounts or dispensing fees
(d) Domestic Pharmacy actual acquisition costs are passed through directly to the Plan
| (e) Plan pays based on other AWP discounts and dispensing fees set by the Domestic Pharmacy | ? | |||
| Will Domestic Pharmacy claims be "no bill no pay" (a.k.a., "no bill no remit", "claim suppression")? | ? | |||
| Additional pricing information | Response | Comments | ||
| Name of Retail-30 Network | ||||
| Describe the Retail-30 network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | ||||
| Name of Retail-90 Network | ||||
| Describe the Retail-90 network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | ||||
| What is the days' supply requirement associated with the above Retail-90 Network discounts & dispensing fees (e.g., 84+) | ||||
| What is the minimum days' supply to receive the above Mail Order discounts & dispensing fees (e.g., no minimum, minimum 84 DS, average DS >=84) | ||||
| If minimum days' supply applies at Mail Order, approximately what percent of all Mail Order claims were less than the minimum? | % | |||
| Does the above pricing reflect a lockout or refill limits on Specialty drugs dispensed by Retail pharmacies? | ? | |||
| If there is a limit on the number of Specialty drugs dispensed by Retail pharmacies, how many retail fills are allowed? | ||||
| Are House Generics treated as Brand Claims for purposes of AWP discount guarantees? | ? | |||
| Provide your contractual definition of "Generic" applicable to AWP discount guarantees. | ||||
| Provide your contractual definition of "Brand" applicable to AWP discount guarantees. | ||||
| Provide your contractual definition of "Brand" applicable to minimum rebate guarantees. | ||||
| If quote assumes enrollment in weight loss management program, which of the following applies? |
(a) Seamless PA - not requiring physician attestation
(b) PA to label - aligns approval strictly to FDA-approved indications with physician attestation
(c) Any restrictions to the BMI or comorbidity requirements that differ from FDA indications
(d) Other restrictions such as limited prescriber network, documentation or lifestyle check-ins ?
1c) Pharmacy Credits
| Client: | Massachusetts GIC - EGWP | Bidding Vendor: | PBM B | |
| Contents | ||||
| Pharmacy Credits | ||||
| Instructions | Please complete all cells below as it pertains to your proposal. | |||
| Vendor Comments, if any | ||||
| Winning Vendor agrees to provide client with the following credits: | Requested Amount | Response | Basis (PEPM, PMPM, Annual, one-time, etc.) | |
| Implementation Support | $150,000 | One-time | ||
| Pre/Post Implementation Audit | $75,000 | One-time | ||
| Ongoing Allowance for pharmacy plan administration and/or support services (including market check) | $1,000,000 | One-time |
Are the credits embedded into your proposal or is an additional fee charged in order to provide these credits?
1d) PMPM Guarantee
| Client: | Massachusetts GIC - EGWP | Bidding Vendor: | PBM B | ||||
| Contents | |||||||
| PMPM Guarantees (only populate if applicable) | |||||||
| Instructions | If applicable, please complete all cells below as it pertains to your proposal. If vendor doesn't agree, provide detailed explanation. | ||||||
| In addition, you may provide a supplemental document that details methodology and proposal offer. | |||||||
| Vendor Comments, if any | |||||||
| PMPM Guarantee | Response | ||||||
| Vendor to provide proposed PMPM guarantee for Year 1 based on current claims and utilization assumptions. | |||||||
| Vendor confirms that the PMPM guarantee includes all pharmacy claims, including retail, mail and specialty. | |||||||
| Disclose if there are any claim types or circumstances that would be excluded from the PMPM guarantee. | |||||||
| Vendor assumes full dollar-for-dollar financial risk if actual net PMPM costs exceed the PMPM guarantee at reconciliation. Disclose if there is a limited amount at risk. | |||||||
| Vendor confirms that the PMPM guarantee serves as a ceiling rather than a target. Any cost savings realized below the guaranteed PMPM amount will not be eligible for shared savings or retention by the bidder. | |||||||
| Vendor to describe the methodology used to calculate the PMPM guarantee, including (1) data sources utilized, (2) calculation and criteria for any exclusions such as high-cost drugs or new drug introductions and (3) any adjustments made for plan design or enrollment changes. | |||||||
| Vendor to list any circumstances under which the PMPM guarantee may be adjusted during the active contract year or after the contract year ends. | |||||||
| Vendor to describe methodology and process for setting financial guarantees which will be reconciled for years 2 and 3. | |||||||
| Vendor to confirm that annual PMPM guarantees will be established no later than 45 days prior to the start of each contract year based upon the agreed methodology. | |||||||
| Outline the reconciliation or true-up process, including how overperformance is calculated and reimbursed and if it is capped. Include clear and measurable definitions for any exclusions if they are not described measurably above. | |||||||
| Vendor to confirm whether PMPM guarantee is contingent upon client implementing a copay maximizer program. If yes, vendor to confirm whether savings for the copay maximizer program are built into the offer, and whether those savings are net of fees. | |||||||
| Vendor to confirm that PMPM guarantee is based on gross cost (meaning that it is not reduced by member cost share). | |||||||
| ADMINISTRATIVE FEES & CLINICAL FEES | Fee is included in PMPM Guarantee? | 7/1/27 | 7/1/28 | 7/1/29 | Basis | Comment, if any | |
| List fees which apply and indicate whether they are included in PMPM guarantee | ? | $ | $ | $ | ? | ||
| ? | $ | $ | $ | ? | |||
| ? | $ | $ | $ | ? | |||
| ? | $ | $ | $ | ? | |||
| ? | $ | $ | $ | ? | |||
| ? | $ | $ | $ | ? |
1e)Alternative Trend Guarantee
| Client: | Massachusetts GIC - EGWP | Bidding Vendor: | PBM B | |
| Contents | ||||
| Alternative Trend Guarantee (only populate if applicable) | ||||
| Instructions | If applicable, please complete all cells below as it pertains to your proposal. | |||
| Please provide a supplemental document that details methodology and proposal offer. | ||||
| Vendor Comments, if any | ||||
| Trend Guarantee | Response | |||
| Describe any alternative, innovative, or nonstandard financial guarantees or performance commitments your organization is proposing specifically for Client that is not covered elsewhere in this RFP. All guarantees described in this section should be expressed in terms of total pharmacy cost (plan-paid and member-paid amounts) unless otherwise specified. | ||||
| Confirm that the guarantee applies to total pharmacy cost (plan + member share). If not, specify the basis. | ||||
| Define the metric(s) or measure(s) used to evaluate performance (e.g., trend reduction, adherence improvement, acquisition cost alignment). | ||||
| Specify the measurement period and settlement frequency (e.g., quarterly, annually). | ||||
| Describe any assumptions, exclusions, or client participation requirements associated with this guarantee. | ||||
| Outline the reconciliation or true-up process, including how underperformance is calculated and reimbursed. | ||||
| Indicate whether this guarantee is standard, optional, or available only under specific pricing models. |
| ADMINISTRATIVE FEES & CLINICAL FEES | Fee is included in PMPM Guarantee? | 7/1/27 | 7/1/28 | 7/1/29 | Basis | Comment, if any |
| List fees which apply and indicate whether they are included in PMPM guarantee | ? | $ | $ | $ | ? | |
| ? | $ | $ | $ | ? | ||
| ? | $ | $ | $ | ? | ||
| ? | $ | $ | $ | ? | ||
| ? | $ | $ | $ | ? | ||
| ? | $ | $ | $ | ? |
2a) Definitions
| Client: | Massachusetts GIC - EGWP | Bidding Vendor: | PBM B | |
| Contents | ||||
| Definitions | Response | If No, please explain | ||
| “340B Claim” means a Claim identified by the submission of “20” in any of the Submission Clarification Code fields and/or a Claim submitted by pharmacy owned by a covered entity, as defined in Section 340B(a)(4) of the Public Health Services Act, whose 340B status is coded as “39” in the NCPDP DataQ database. | ? | |||
| "AWP" means the average wholesale price of the Covered Product on the date dispensed, as set forth in the current price list in recognized sources such as MediSpan's Master Drug Database (MDDB®) file, if available, or following notice to Client, any other nationally recognized reporting service of pharmaceutical prices as utilized by Vendors as a pricing source for prescription drug pricing. Such AWP is for the 11-digit NDC of the actual package size used to fulfill the quantity dispensed, as submitted by the dispensing pharmacy (retail, mail order, and specialty pharmacy) on the date dispensed. | ? | |||
| Vendor agrees the definition of "Biosimilar products" is non-insulin FDA-approved biologic products that are highly similar to and have no clinically meaningful differences in terms of safety, purity, potency, and efficacy from its respective FDA-approved biological reference product. | ? | |||
| "Brand Drug" shall mean a Covered Product that is defined by MediSpan Multi-Source Code of “M”, "N", or "O". | ? | |||
| “Claim” means any electronic or paper request for payment or reimbursement arising from retail participating pharmacies, mail order pharmacies and specialty pharmacies, providing Covered Products to a Plan Participant processed under this Agreement in accordance with Client’ Plan. “Covered Products” as referenced herein, shall also include products that are approved to be covered through the Vendor's review processes (e.g., PA or medical exception process) or through the appeals process (including external appeals). | ? | |||
| "Compound Drug" means a prescription that meets the following criteria: two or more solid, semi-solid, or liquid ingredients, at least one of which is a Covered Product, that are weighed or measured then prepared according to the prescriber's order. | ? | |||
| “Cost Share” means the amount which a Member is required to pay for a Covered Product in accordance with the Plan, which may be a deductible, a percentage of the prescription price, a fixed amount and/or other charge or penalty. | ? | |||
| "Covered Drug" or "Covered Product" means a prescription drug, over-the-counter medication, and other service, supply or device that is covered under the terms and conditions set forth in the description of Client’ Plan. | ? | |||
| "Vendor's formulary/PDL" is a tool that identifies a drug as preferred or not preferred and doesn't exclude drugs from coverage as part of its formulary/PDL administration. | ? | |||
| "Generic Drug" shall mean a Covered Product that is defined by MediSpan Multi-Source Code of “Y”. | ? | |||
| "House Generic" shall mean a Multi-Source Brand Drug that has DAW (Dispense-As-Written) = 5. | ? | |||
| "Limited Distribution Drugs" or "LDD" means specialty products available through a limited number (15) of pharmacy providers due to exclusive or preferred vendor arrangements with pharmaceutical manufacturers and to which Vendor's Specialty Pharmacy does not have access. | ? | |||
| "MAC" or "Maximum Allowable Cost" means a list of off-patent drugs subject to maximum allowable cost payment schedules developed or selected by Vendor. The payment schedules specify the maximum unit ingredient cost payable by Client for drugs on the MAC list . | ? | |||
| “Manufacturer Administrative Fees” means the administrative fees received directly or indirectly by Vendor from pharmaceutical companies for administrative services rendered in contracting for Rebates and administering Rebate contracts, regardless of involvement by a group purchasing organization. | ? | |||
| “Member” or “Plan Participant” means each individual identified by Client to be eligible for prescription drug benefits under the Plan, as set forth in Client’ eligibility file or otherwise communicated by Client. | ? | |||
| “Multi-Source” means a legend drug or over-the-counter (OTC) drug that is manufactured by more than one labeler. | ? | |||
| “New to market” specialty drugs are products that meet the Specialty Drugs definition, that are newly introduced for sale by pharmaceutical manufacturers and made available for dispensing at pharmacies, that aren't included on Client's current Specialty Drug Price List. Once a drug meeting the criteria outlined above is approved for coverage by the P&T committee, it will be considered a Specialty Drug and no longer considered “new to market”. | ? | |||
| “Over the Counter Product” or “OTC” shall mean products with Medispan Rx OTC indicator value of “O” or “P”. | ? | |||
| “Participating Pharmacy” means a licensed retail pharmacy that participates in a retail network established by Vendor, used by Client’ Members under this Agreement. | ? | |||
| “Plan” means the self-funded pharmacy benefit plan(s), sponsored or administered by Client. | ? | |||
| "Rebates" mean all compensation or remuneration received directly or indirectly from a pharmaceutical manufacturer, attributable to the purchase and/or utilization of covered products by an eligible Participant; including such compensation or remuneration received by Vendor's subcontractor, affiliate, rebate aggregator or GPO arrangement. Compensation includes but is not limited to, discounts; credits; rebates, regardless of how categorized; fees; educational grants received from manufacturers in relation to the provision of utilization data to manufacturers for rebating, marketing, and related purposes; market share incentives; commissions; data fees; and price inflation protection payments. | ? | |||
| “Single-Source Generic” means products that are generic products available from only one generic labeler. | ? | |||
| “Specialty Drug” means drugs that are not insulin/insulin product and meet a minimum of four (4) or more of the following characteristics: |
• produced through DNA technology or biological processes;
• target chronic or complex disease;
• route of administration could be inhaled, infused, oral, or injected;
• unique handling, distribution and/or administration requirements;
• are only available via limited distribution model to Specialty Pharmacy provider(s), per manufacturer requirements; and
| • require a customized medication management program that includes medication use review, patient training, coordination of care and adherence management for successful use such that more frequent monitoring and training may be required. | ? | ||
| “Specialty Pharmacy” means one or more duly licensed pharmacies specified by Vendor, where prescriptions for Specialty Products are dispensed and delivered to Members via the mail. This classification as a Specialty Pharmacy is regardless of NCPDP's retail vs mail designation. | ? | ||
| “Usual and Customary” or “U&C” means a Participating Pharmacy's usual selling price (or sale price, if any) if the product were not eligible for coverage under Client’ Plan. | ? | ||
| "Specialty Drug Price List” means the list of products which identifies the reimbursement rates applicable under this Agreement which is maintained and updated by Vendor from time to time as new products come to market. Any changes to Client's Specialty Drug Price List after the contract Effective Date will meet the following specifications: | |||
| (a) Unless there is a change to the specialty distribution or labeling due to regulatory or manufacturer requirement, Vendor will not add any drugs to Client's Specialty Drug Price List that were previously available in the market and delivered through mail order and/or retail (i.e., non-specialty) prior to the start of the contract between Client and the Vendor. | ? | ||
| (b) Only newly FDA-approved and launched drugs, and drugs not on the market as of the contract effective date may be considered for addition to Client's Specialty Drug Price List after this date. | ? | ||
| (c) Vendor confirms that pricing for Specialty Drugs added to the list on or after the start of the contract shall be competitive in the marketplace and considered on an individual drug and/or therapeutic category basis, and shall not automatically apply a default rate/priceto a minimum discount. | ? | ||
| (d) Vendor shall not reclassify a Specialty or LDD medication already in the market during the contract year. Any reclassification needs to be effective at the beginning of the next contract year and Vendor will provide client a 180-day notice of the change. | ? |
2b)Discount & Rebate Guarantees
| Client: | Massachusetts GIC - EGWP | Bidding Vendor: | PBM B | |
| Contents | ||||
| Discount Reconciliation | Response | If No, please explain | ||
| Each component of Vendor's financial proposal (AWP discount guarantees, dispensing rate guarantees, and GDR guarantees) will be measured, reconciled and guaranteed on an individual component basis. There will be no cross subsidization within a distribution channel (Brand and Generic) or among distribution channels (Retail 30, Retail 90, Retail Specialty, Mail Order, and Specialty). That is, shortfalls in one guarantee may not be offset by overage in any other guarantee. | ? | |||
| Vendor agrees that all Limited Distribution Drugs will be reconciled within the appropriate delivery channel guarantees. That is, LDDs will not have a separate discount guarantee. | ? | |||
| All Specialty Drugs dispensed through a mail order facility will be reconciled against the aggregate Specialty Pharmacy AWP discount guarantees. Vendor will not classify certain mail order facilities as “Retail” specialty pharmacies. | ? | |||
| Vendor's proprietary brand/generic drug algorithm(s) will not be used to classify Claims as "Brand" or "Generic" for purposes of reconciling Client's AWP discount guarantees. | ? | |||
| Discount Guarantee | Response | If No, please explain | ||
| AWP discount guarantees will not be subject to day supply proration or adjustment. | ? | |||
| AWP discount guarantees will exclude the value of rebates, manufacturer coupons, and monies associated with copay assistance programs. | ? | |||
| The calculation of all proposed AWP discount guarantees (Retail Brand, Retail Generic, Mail Brand, Mail Generic, and Specialty Pharmacy) will include zero pay claims (Claims where the Member paid the full cost and the Plan pays zero) based on the actual adjudicated Ingredient Cost; the AWP discount for zero pay claims will not be included at a 100% discount. | ? | |||
| Any dollars associated with manufacturer coupons, copay assistance programs and/or copay accumulator programs will not be treated in any way as discounts on Claim costs. These dollars will be tracked separately and will never be used to reconcile guaranteed discounts, rebates, or dispensing fees. | ? | |||
| If Client requests a "Mail at Retail" Network, any Mail Order guarantees will also apply to non-Specialty Drug Claims filled at Vendor's "Mail at Retail" Network. | ? | |||
| If Vendor manages mail and specialty distribution, Vendor will apply any mail order pricing guarantees to non-specialty claims dispensed from Vendor's specialty mail pharmacy. | ? | |||
| Vendor will provide an overall effective discount guarantee for specialty medications, as well as individual drug-level minimum discount guarantees. At no point during the contract will the Vendor decrease the specialty drug-level minimum guarantees. | ? | |||
| Vendor agrees that all drugs on the specialty drug list that are filled at a PBM-owned pharmacy (including those LDD that the PBM has access to dispensing) will be included in the Specialty OED. | ? | |||
| Vendor will provide guaranteed AWP discounts, dispensing fees, administrative fees, and rebate guarantees for Specialty Drug Claims filled at Vendor's Specialty Pharmacy will apply , regardless of the days' supply. Vendor will not apply any retail pricing guarantees (AWP discounts, dispensing fees, administrative fees or rebate guarantees) to any Specialty Drug Claims filled at Specialty Pharmacy). | ? | |||
| Rebates | Response | Comment, if No | ||
| House Generic will be treated as a Brand Claim for purposes of Vendor's Per Brand Claim Rebate Guarantees. | ? | |||
| Minimum Per Brand Claim Rebate Guarantees will apply to Specialty Drugs based on channel/network that dispensed the Specialty Drug (Retail vs Specialty Pharmacy). | ? |
2c)Rebate Credits
| Client: | Massachusetts GIC - EGWP | Bidding Vendor: | PBM B | |
| Contents |
Covered Products List
| Fill out Column C for each product listed. |
| Rebate Credit = Rebate guarantees MAY be adjusted at the time of reconciliation to account for lost rebates associated with list price reductions or biosimilar utilization; the adjustment has NOT been accounted for in underwriting. |
| No Rebate Credit = Rebate guarantees MAY NOT be adjusted at the time of reconciliation to account for lost rebates associated with list price reductions or biosimilar utilization; the adjustment has already been accounted for in underwriting. |
| HUMIRA BIOSIMILARS | ? |
| STELARA BIOSIMILARS | ? |
| WEGOVY | ? |
| OZEMPIC | ? |
| RYBELSUS | ? |
| ELIQUIS | ? |
| FARXIGA | ? |
| FIASP | ? |
| GLYXAMBI | ? |
| HUMALOG U-200 KWIKPEN | ? |
| IMBRUVICA | ? |
| INSULIN GLARGINE U-300 | ? |
| JARDIANCE | ? |
| LINZESS | ? |
| LYUMJEV | ? |
| SYNJARDY | ? |
| SYNJARDY XR | ? |
| TRESIBA | ? |
| TRIJARDY XR | ? |
| XELJANZ | ? |
| List any additional products not mentioned above where a rebate credit applies |
| Rebate Credit Language | Response | If No, please explain |
| Vendor may only apply rebate credit to products that have either experienced a decrease in WAC greater than 25% or have had a biosimilar released with WAC at least 25% lower than the originator product. | ? | |
| Vendor agrees, that with the exception of products listed above, rebate credit may not be claimed for products that experienced a pricing event before 1/1/2026. | ? | |
| For any individual covered product, rebate credit may not exceed the difference between the Baseline Rebate and the actual earned Rebates on either, as applicable, the Low WAC Biosimilar or the rebateable product that has experienced a WAC decrease. |
| In this context, Baseline Rebate will be either the rebate available for the product prior to its WAC reduction (subject to a pre-agreed-upon inflationary factor) or the rebate available for the original product for which there is a biosimilar. | ? | |
| Vendor will maintain a list of products eligible for rebate credit and provide sixty (60) days’ advance notice of the addition of any Covered Product to this list. | ? | |
| In Audit, Vendor will share data necessary to validate rebate credit calculations. | ? | |
| Vendor will NOT apply Rebate Credit value for Claims that are NCPDP 340B pharmacy type 39 or submission clarification code 20. | ? |
2d) ROR
| Client: | Massachusetts GIC - EGWP | Bidding Vendor: | PBM B | |
| Contents |
| Requirement | Response | If No, please explain deviation in proposed reservation of rights. |
| Vendor agrees that reservation of rights provisions will only be invoked if the financial impact of the marketplace event exceeds 10% of the total contract value. | ? | |
| For any one market event, vendor must communicate intent to exercise reservation of rights within 90 days of the market event. | ? | |
| Vendor agrees that any adjustments will be equitable to the actual financial effect of the event, accounting for the start date of the impact of the market event. | ? | |
| Vendor agrees that any modifications to the agreement shall be mutually agreed upon by both the Vendor and the Client prior to implementation. If the Vendor and Client are unable to reach an agreement, Client will have the right to terminate the agreement for convenience without any penalties, termination fees, damages, Vendor rebate retention, or repayment obligations related to pharmacy credits. | ? | |
| Vendor will permit an independent audit to verify the accuracy and legitimacy of the marketplace event’s impact, as well as any related financial amendments or modifications. | ? |
3a) Data Summary
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