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 in response to RFP 26-0408 for Pharmacy Benefit Manager Services. The document is a standardized Excel workbook template designed to capture formulary disruption data across multiple drug tier transition categories, including maintenance and non-maintenance medications transitioning between second tier (2T) and third tier (3T) formulary products, as well as exclusions from the formulary. The form requires respondents to complete light blue shaded cells with detailed information for each affected drug, including rank, drug name, prescription count, cardholder/member count, condition or disease indication, Generic Product Identifier (GPI), dosage form, and available formulary alternatives. The template is divided into six distinct tabs organized by medication type and formulary tier movement: 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. Instructions explicitly state that drugs impacted by Affordable Care Act mandates should be excluded, columns and tabs within the workbook should not be removed, and only this specified format should be used for disruption submissions.
The document serves as a critical component of the PBM procurement process, enabling Pinellas County to evaluate how potential vendors plan to manage formulary changes and drug tier adjustments for the approximately 3,200 eligible county employees. Respondents must clearly distinguish between maintenance and non-maintenance medications and define their own criteria for this distinction within each tab. The form allows vendors to document both upward tier movements (drugs moving to higher cost-sharing tiers) and downward movements (drugs moving to lower cost-sharing tiers), as well as formulary exclusions, providing the County with transparency regarding potential disruptions to employee pharmacy benefits under each proposed PBM's management. This submission requirement directly supports the County's evaluation of clinical management capabilities and member access considerations as outlined in the broader RFP evaluation criteria.
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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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