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 PBM Formulary Disruption Request form submitted by Pinellas County Board of County Commissioners for use in conjunction with RFP 26-0408 for Pharmacy Benefit Manager Services. The standardized Excel workbook template is designed to document formulary changes and disruptions across six submission categories: Maintenance 1T to 2T, Non-Maintenance 2T to 3T, Maintenance 2T to 3T, Non-Maintenance 3T to 2T, Maintenance 3T to 2T, Exclusions-Non-Maintenance, and Exclusions-Maintenance. Proposing vendors must complete all light blue shaded cells within the template, providing detailed information for each drug including rank, drug name, prescription count, cardholder/member count, condition/disease indication, GPI code, dosage form, and formulary alternatives. The form requires vendors to exclude drugs impacted by Affordable Care Act mandates and to clearly distinguish between maintenance and non-maintenance medications across tier levels (2T representing second tier/brand formulary products and 3T representing third tier/brand non-formulary products).
The document serves as a critical submission requirement for vendors responding to the County's RFP for PBM services covering approximately 3,200 eligible county employees with a five-year contract term beginning January 1, 2027. All proposers must utilize this specific format exclusively for formulary disruption submissions and retain the complete workbook structure without removing any columns or tabs. The form requires vendors to define the formulary type, establish definitions for maintenance versus non-maintenance medications specific to the County's plan design, and provide comprehensive data necessary for the County to evaluate formulary coverage impacts and potential member disruptions during the transition from the incumbent vendor, Express Scripts Inc., to the selected provider.
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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
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