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 Pinellas County Board of County Commissioners in connection with RFP 26-0408 for PBM services. The spreadsheet template is designed to document proposed formulary changes across multiple drug tier categories, including maintenance and non-maintenance medications moving between second tier (2T) and third tier (3T) formulary status, as well as medications being added to or removed from formulary exclusions. The form requires vendors to populate light blue shaded cells with detailed information for each affected drug, including rank, drug name, prescription count, cardholder/member count, condition/disease indication, Generic Product Identifier (GPI), dosage form, and formulary alternatives. The document contains separate tabs for 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 medications, with instructions to exclude drugs impacted by Affordable Care Act mandates and to maintain the prescribed workbook format without removing columns or tabs.
The form is structured as a submission tool for the competitive RFP process where proposing PBM vendors must document any formulary modifications they propose to implement for Pinellas County's approximately 3,200 eligible employees. Vendors are required to use this standardized Excel format exclusively for disruption submissions and must provide complete information in the specified columns for all proposed formulary changes. The document does not specify pricing information, contract terms, or evaluation criteria within the form itself, but instead serves as a data collection instrument to support vendor proposals and allow the County to assess the scope and impact of formulary changes proposed by competing bidders during the PBM services procurement process.
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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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