1.0 Formulary Disruption

1.1 Summary of PBM Disruption Analysis

Claims Dispensed between 9/1/2025 and 12/31/2025 Total number of members covered: 26,145 Non-Specialty formulary: Broad Formulary with Standard Exclusions Specialty formulary: Broad Formulary with Standard Exclusions

Enter the name of your proposed formulary, which serves as the basis of your disruption analysis:

Summary

Type of Change Number of Distinct Members Impacted

% of Total Members Number of Scripts Impacted % of Total Scripts (including all brands and generics)

Non-Specialty No change Positive (higher-cost tier to lower-cost tier) Negative (lower-cost tier to higher-cost tier) Moving from Covered to Not Covered/Excluded Specialty No change Positive (higher-cost tier to lower-cost tier) Negative (lower-cost tier to higher-cost tier) Moving from Covered to Not Covered/Excluded Overall No change Positive (higher-cost tier to lower-cost tier) Negative (lower-cost tier to higher-cost tier) Moving from Covered to Not Covered/Excluded Note: Each distinct member of the population may be impacted positively, negatively or not at all. Therefore, the number of members impacted in the table above are not additive.

1.2 Detailed Disruption Results

Proposed Formulary

NDC Drug Name Therapeutic Class Number of Distinct

Patients Number of Scripts

Maintenance Drug Indicator

Specialty Indicator Brand/Generic Indicator Tier

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Directions: Complete the following formulary disruption tables based on your proposed formulary. Your analysis should be based on the most recent four (4) months in the commercial plan's claims data that will be provided upon the submission of the “Intent to Propose” Form. Results to be included are the number of members that will require a change as well as the number of prescriptions associated with the formulary change.

Directions: Complete the table below by listing each drug utilized in the most recent four (4) months of the commercial plan's claims data by NDC, the number of distinct patients for which the drug was dispensed and the total number of prescriptions filled. For each NDC, use the drop-down options provided to indicate if the drug is a maintenance medication, specialty or non-specialty with respect to your proposed formulary, brand or generic status and the tier that the drug will be considered for the purposes of calculating member cost share.

2.0 Network Disruption

2.1 Summary of PBM Disruption Analysis

Name of Broad Retail 30 Pharmacy:

Type of Change Retail 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

2.2 Detailed Disruption Results

Proposed Retail Network

NPI Name of Retail Pharmacy Address of Pharmacy City State ZIP Pharmacy Type Number of Distinct

Members Number of Scripts Retail 30 Network

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Directions: Complete the following retail network disruption table based on your proposed Retail pharmacy network and on the claims data. 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.

Directions: Complete the table below by listing each distinct retail pharmacy included in the data set provided with the RFP 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 your proposed network.

3.0 Clinical Programs List

Name of Program Description of Program Member Impact Cost & Cost Basis ROI (X:Y) Projected Cost/Savings ($000s) Required/Optional

Program?

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Directions: Provide a complete list of your clinical programs with pricing and projected savings associated with each program and highlight those programs recommended for the State. Describe the type of impact members will face for each of these programs.