Attachment_C_-_Pharmacy_Drug_Plan_Formulary.xlsx

XLSX spreadsheet 24 KB Posted

Attached to
Medicare Supplemental Plans and Medicare Part D Employer Group Waiver Plans
Solicitation number
Y26-151
Issued by
Orange County, Orlando City, Florida

About this file

This is a Pharmacy Drug Plan Formulary attachment for Orange County, Florida's Medicare Supplemental Plans and Medicare Part D Employer Group Waiver Plans procurement (Y26-151). The formulary worksheet requires respondents to classify 100 pharmaceutical drugs across two plan tiers—Low Plan and High Plan—using four formulary categories: Generic, Preferred Brand, Non-Preferred Brand, and Specialty. The drugs listed represent a comprehensive range of therapeutic classes including biologics (HUMIRA, ENBREL, STELARA), specialty medications (POMALYST, GILENYA), diabetes treatments (HUMALOG, TRESIBA, OZEMPIC), cardiovascular drugs (ELIQUIS, XARELTO, ENTRESTO), and other chronic condition therapies. Sealed responses for the Medicare Supplemental and Part D plans were due by 4:00 pm EST on Thursday, May 7, 2026, and all submissions were required to be made electronically through the OpenGov e-Procurement Platform, with hand-delivery, mail, telephone, fax, and email submissions being prohibited.

The formulary worksheet does not specify pricing terms, co-payment structures, or out-of-pocket maximums within the attachment itself. The document appears to be a template requiring bidders to populate their specific formulary tier classifications based on their current formulary lists, indicating that pricing and benefit design details would likely be addressed in other sections of the solicitation. No incumbent information, set-asides, or funding amounts are documented in this formulary attachment, as it serves primarily as a technical specification tool for evaluating and comparing how each respondent's drug coverage aligns with the County's requirements for both Low and High plan options.

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Sheet1

Company Name:
INSTRUCTIONS: Complete the worksheet below by providing the specific formulary tier for each drug listed. Use your current formulary list . Use "Generic", "Preferred Brand" or "Non-Preferred Brand", "Specialty". Do not re-sort.
Low PlanHigh Plan
NDCDrug NameClassificationClassification
59572050221POMALYST CAP 2MG
57894006103STELARA INJ 90MG/ML
00078060715GILENYA CAP 0.5MG
58468021002AUBAGIO TAB 14MG
00074433902HUMIRA PEN INJ 40MG/0.8
00074379902HUMIRA KIT 40MG/0.8
58406043504ENBREL INJ 50MG/ML
00003089421ELIQUIS TAB 5MG
58468021004AUBAGIO TAB 14MG
61958200201DESCOVY TAB 200/25
00006027782JANUVIA TAB 100MG
62559052101INDERAL LA CAP 80MG
00002879959HUMALOG KWIK INJ 100/ML
00002143480TRULICITY INJ 1.5/0.5
00173088710TRELEGY AER ELLIPTA
00169266015TRESIBA FLEX INJ 100UNIT
00088221905LANTUS SOLOS INJ 100/ML
00051846233ANDROGEL GEL 1.62%
58406002104ENBREL INJ 50MG/ML
69865026501NUCYNTA ER TAB 250MG
00169255013TRESIBA FLEX INJ 200UNIT
50458057990XARELTO TAB 20MG
00006057561JANUMET TAB 50-500MG
00310621030FARXIGA TAB 10MG
64764017530DEXILANT CAP 60MG DR
00169406012VICTOZA INJ 18MG/3ML
69097091402OMEPRA/BICAR CAP 40-1100
00023916330RESTASIS EMU 0.05%
00078077720ENTRESTO TAB 49-51MG
50458014130INVOKANA TAB 300MG
67877049090EZETIMIBE TAB 10MG
00310654004BYDUREON BC INJ 2/0.85ML
45802075401TESTOSTERONE GEL 1.62%
61958100301RANEXA TAB 500MG
00002840001FORTEO SOL 600/2.4
00032301628CREON CAP 36000UNT
00024576105SOLIQUA INJ 100/33
00032122401CREON CAP 24000UNT
00597010061SPIRIVA SPR 2.5MCG
00006027754JANUVIA TAB 100MG
45802004475ACYCLOVIR CRE 5%
66869020490LIVALO TAB 2MG
00006027731JANUVIA TAB 100MG
00597016061SPIRIVA AER 1.25MCG
00456120130LINZESS CAP 145MCG
00169643810LEVEMIR INJ FLEXTOUC
00023320503LUMIGAN SOL 0.01%
00169406013VICTOZA INJ 18MG/3ML
00597015330JARDIANCE TAB 25MG
00009519101DETROL LA CAP 4MG
00006008131JANUMET XR TAB 100-1000
00078065920ENTRESTO TAB 24-26MG
50458057830XARELTO TAB 15MG
00024586903TOUJEO SOLO INJ 300IU/ML
00173085910BREO ELLIPTA INH 100-25
61958100401RANEXA TAB 1000MG
00186077760BRILINTA TAB 90MG
00006057782JANUMET TAB 50-1000
72733590102PRALUENT INJ 75MG/ML
00169413602OZEMPIC INJ 2/1.5ML
69865026002NUCYNTA ER TAB 200MG
00597036055PRADAXA CAP 150MG
50458057930XARELTO TAB 20MG
00002879759HUMALOG MIX INJ 75/25KWP
24510029160NUCYNTA ER TAB 250MG
00002771227HUMALOG KWIK INJ 200/ML
00024414260MULTAQ TAB 400MG
00069024430TOVIAZ TAB 8MG
65597011630TRIBENZOR40- TAB 5-25MG
00310075190CRESTOR TAB 10MG
00173069500ADVAIR DISKU AER 100/50
00023614230RAPAFLO CAP 8MG
00006057762JANUMET TAB 50-1000
65976010001ARESTIN MIS 1MG
00186037020SYMBICORT AER 160-4.5
50458058030XARELTO TAB 10MG
00597014030TRADJENTA TAB 5MG
00456122830NAMZARIC CAP 28-10MG
00310626060XIGDUO XR TAB 5-1000MG
00456112030VIIBRYD TAB 20MG
00002751001HUMALOG INJ 100/ML
00597014090TRADJENTA TAB 5MG
00078051205TEGRETOL-XR TAB 400MG
64764075030TRINTELLIX TAB 20MG
00173069600ADVAIR DISKU AER 250/50
00591292418TESTOSTERONE GEL 1.62%
49884000702ASA/DIPYRIDA CAP 25-200MG
00054033425CEVIMELINE CAP 30MG
58160082311SHINGRIX INJ 50MCG
00024590102PRALUENT INJ 75MG/ML
57664066383CARVEDILOL CAP 10MG ER
00173088210BREO ELLIPTA INH 200-25
00597028090SYNJARDY XR TAB 10-1000
00591352530LIDOCAINE PAD 5%
24208060203PROLENSA SOL 0.07%
00093301756TADALAFIL TAB 5MG
55513080060CORLANOR TAB 5MG
50458014030INVOKANA TAB 100MG
00597029578SYNJARDY XR TAB 25-1000
68180022301NIACIN ER TAB 1000MG

&"-,Bold"ATTACHMENT C

PHARMACY DRUG PLAN FORMULARY

File details come from the government source that posted it. Updated .