Attachment_D_-_26-0321-P_PBM_Formulary_Disruption_Request.xlsx
XLSX spreadsheet 30 KB Posted
- Attached to
- 26-0408-RFP Pharmacy Benefit Manager Services
- Solicitation number
- 26-0408-REQ
- Issued by
- Pinellas County, Florida
About this file
This is a Pharmacy Benefit Manager (PBM) Formulary Disruption Request form submitted by the Pinellas County Board of County Commissioners in Florida. The document serves as a template for identifying and categorizing medications that require formulary placement changes as part of the county's PBM services contract. The form is structured to capture maintenance and non-maintenance medications across multiple tier transitions, including movements from second tier (2T) to third tier (3T), third tier to second tier, and exclusions. For each drug submission, the county must provide the drug name, prescription count, cardholder/member count, condition or disease indication, generic product identifier (GPI), dosage form, and formulary alternatives. The form explicitly instructs that only medications not impacted by Affordable Care Act mandates should be included, and that submitters must complete all required fields with additional rows added as necessary.
The document contains multiple blank tabs designated for different medication categories with zero populated data, indicating this is a template being prepared for the county's upcoming PBM services transition scheduled for January 1, 2027. Critical instructions prohibit removal of any columns or tabs within the workbook and restrict submissions to this specific format only. The form requires the user to define the formulary type (such as Open, Open with exclusions, or Exclusionary) and provide definitions distinguishing maintenance versus non-maintenance medications, which have not yet been populated. This disruption request process appears designed to facilitate a smooth transition to new PBM services for approximately 3,200 eligible county employees by documenting any formulary changes needed from the current or prior plan.
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Text version
Maintenance 1T to 2T Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include maintenance medications on this tab.
* 2T = second tier/brand formulary products; 3T = third tier/brand non-formulary products.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | Pinellas County Board of County Commissioners | ||||||
| Formulary Name: | |||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | |||||||
| Definition of maintenance vs non-maintenance medications: | |||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) | Formulary alternative |
Total 0 0
Non-Maintenance 2T to 3T Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include non-maintenance medications on this tab.
* 2T = second tier/brand formulary products; 3T = third tier/brand non-formulary products.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | Pinellas County Board of County Commissioners | ||||||
| Formulary Name: | |||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | |||||||
| Definition of maintenance vs non-maintenance medications: | |||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) | Formulary alternative |
Total 0 0
Maintenance 2T to 3T Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include maintenance medications on this tab.
* 2T = second tier/brand formulary products; 3T = third tier/brand non-formulary products.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | Pinellas County Board of County Commissioners | 0 | 0 | 0 | 0 | 0 | 0 |
| Formulary Name: | |||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | |||||||
| Definition of maintenance vs non-maintenance medications: | |||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) | Formulary alternative |
Total 0 0
Non-Maintenance 3T to 2T Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include non-maintenance medications on this tab.
* 2T = second tier/brand formulary products; 3T = third tier/brand non-formulary products.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | Pinellas County Board of County Commissioners | 0 | 0 | 0 | 0 | 0 |
| Formulary Name: | ||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | ||||||
| Definition of maintenance vs non-maintenance medications: | ||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) |
Total 0 0
Maintenance 3T to 2 T Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include maintenance medications on this tab.
* 2T = second tier/brand formulary products; 3T = third tier/brand non-formulary products.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | Pinellas County Board of County Commissioners | 0 | 0 | 0 | 0 | 0 |
| Formulary Name: | ||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | ||||||
| Definition of maintenance vs non-maintenance medications: | ||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) |
Total 0 0
Exclusions - Non-Maintenance Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include non-maintenance medications on this tab.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | Pinellas County Board of County Commissioners | 0 | 0 | 0 | 0 | 0 | 0 |
| Formulary Name: | |||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | |||||||
| Definition of maintenance vs non-maintenance medications: | |||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) | Formulary alternative |
Total 0 0
Exclusions - Maintenance Drugs Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include maintenance medications on this tab.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | Pinellas County Board of County Commissioners | 0 | 0 | 0 | 0 | 0 | 0 |
| Formulary Name: | |||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | |||||||
| Definition of maintenance vs non-maintenance medications: | |||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) | Formulary alternative |
Total 0 0
File details come from the government source that posted it. Updated .