Attachment T_Pharmacy Pricing Terms.xlsx

35 KB Posted

Attached to
RFP for Medical & Pharmacy Benefits
Solicitation number
S-44300-00014758
Issued by
Marion County, Oregon

About this file

Written by GovTribe AI ·

This is a pharmacy pricing terms attachment for the Oregon Public Employees' Benefit Board (PEBB) Request for Proposal (RFP) for medical and pharmacy benefits services. The document establishes the detailed pricing framework that vendor respondents must complete to submit competitive proposals for pharmacy benefit management services. The pricing template requires vendors to specify AWP (Average Wholesale Price) discounts and dispensing fees for 2026, 2027, and 2028, differentiated by pharmacy channel (retail 30-day, retail 90-day, mail order, specialty pharmacy, and domestic pharmacy), formulary status (specialty and non-specialty), and drug classification (brand and generic). The RFP submission deadline is November 14, 2025, with all proposals submitted electronically through Proposal Technologies Network, Inc.'s platform on OregonBuys.

The pricing terms document requires vendors to provide guaranteed discount percentages, dispensing fees per prescription, and confirmation of pricing guarantees across multiple service categories and contract years. Additionally, vendors must specify administrative fees (per claim, per employee per month, per member per month, or per year basis), clinical service fees for utilization management and prior authorization, and comprehensive rebate guarantee structures for both formularies with and without drug exclusions. The attachment addresses rebate sharing methodologies, percentage allocations to the client, and exclusions from guarantees including 340B claims, biosimilar products, limited distribution drugs, and various other drug categories. Vendors must clarify their contractual definitions of generic and brand products, detail network pharmacy compositions and sizes, specify days' supply requirements for different channels, and confirm treatment of specialty drug dispensing restrictions. The document also requires disclosure of supplemental programs such as Brand Over Generic initiatives, house generic classifications, and pricing methodologies for unique claim categories such as U&C claims and MAC pricing.

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Pricing_Terms

1 Pricing

1.1
Response
1InstructionsPlease complete all cells below as it pertains to your proposed pricing terms. Please provide specialty discounts which differ between Brand and Generic, rather than a single Overall Effective Discount guarantee.
2Note: "Domestic Pharmacy" includes onsite pharmacies, inhouse pharmacies, and client owned pharmacies.
3Vendor Comments, if any(500 words.)
4
5AWP DiscountAWP DiscountAWP DiscountDispensing Fee Per RxDispensing Fee Per RxDispensing Fee Per RxGuaranteed
6DISCOUNTS AND DISPENSING FEES202620272028202620272028(Y/N)Comments
7Retail-30 Network, Non-specialtyBrand%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
8Generic%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
9Retail-90 Network, Non-specialtyBrand%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
10(subject to pricing other than retail or mail, if applicable)Generic%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
11Mail at Retail network, Non-specialtyBrand%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
12(subject to standard mail pricing and costshare, if applicable)Generic%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
13Retail SpecialtyBrand%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
14Generic%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
15Mail Order (non-specialty)Brand%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
16Generic%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
17Specialty Pharmacy (mail)Brand%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
18Generic%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
19Limited Distribution DrugsSpecialty Retail%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
20Specialty Mail%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
21All Channels%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
22Domestic Pharmacy30-Day, non-specialty Brand%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
23(only need to complete this section if Domestic Pharmacy claims are excluded from the above Retail network pricing guarantees)30-Day, non-specialty Generic%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
2490-Day, non-specialty Brand%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
2590-Day, non-specialty Generic%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
2630-Day, Specialty Brand%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
2730-Day, Specialty Generic%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
2890-Day, Specialty Brand%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
2990-Day, Specialty Generic%%%(Single, Pull-down list.

1: Yes,

2: No)(100 words.)
30ADMINISTRATIVE FEES202620272028BasisComments
31Retail Network claims (non-specialty and specialty)(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
32Mail Order claims(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
33Specialty Pharmacy claims(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
34Domestic Pharmacy (340b claims)(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
35Domestic Pharmacy (non-340b claims)(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
36Paper, member submitted claims(Single, Pull-down list.

1: per member submit claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
37CDH (HRA/HSA) plan administration(Single, Pull-down list.

1: per claim, 2: per CDH Employee per month, 3: per CDH Member per month,

4: per year)(100 words.)
38Non-CDH plans, data integration of combined medical and Rx plan deductible and/or OOP max(Single, Pull-down list.

1: per claim, 2: per non-CDH Employee per month, 3: per non-CDH Member per month,

4: per year)(100 words.)
39Point of Sale Rebates(Single, Pull-down list.

1: per claim, 2: per non-specialty claim, 3: PEPM, 4: PMPM,

5: per year)(100 words.)
40Transition Fees if Client Moves Rx to Another Vendor:(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
41Increase to Medical ASO Fee(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
42Fee for ongoing data integration between Rx and Medical Plan(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
43Vaccine Administration Fee(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
44Vaccine Program Fee(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
45All Other program or administrative fees, please list:(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM, 4: per year,

5: n/a)(100 words.)
46(e-prescribing, Data Feeds to third parties, Medicare(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: one time fee)(100 words.)
47RDS and/or EGWP administration and reporting,(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
48Fee to provide data history files, etc)(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
49Clinical Fees202620272028BasisComments
50Utilization Management/Prior Authorization (Non-Specialty)(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
51Utilization Management/Prior Authorization (Specialty)(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
52Appeals - Level 1(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
53Appeals - Level 2(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
54Appeals - External(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
55Formulary Exceptions(Single, Pull-down list.

1: per claim, 2: PEPM, 3: PMPM,

4: per year)(100 words.)
56REBATES
571) Rebate Guarantees for formularies WITH drug exclusionsRebate Guarantee requires what Day SupplyGuaranteed AmountGuaranteed AmountGuaranteed Amount
581a) Guaranteed rebate amounts paid/credited to client for 3-tier Incentive plan designs(min 30, min 90, up to 30, up to 90, 84+, clinical DS)202620272028BasisComments
59Retail-30 Network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
60Retail-90 Network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
61Mail at Retail network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
62Retail (specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
63Mail Order(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
64Specialty Pharmacy (mail)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
65Domestic Pharmacy (non-specialty, 30 day)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
66Domestic Pharmacy (non-specialty, 90 day)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
67Domestic Pharmacy (specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
681b) Guaranteed rebate amounts paid/credited to client for all other plan designsRebate Guarantee requires what Day SupplyGuaranteed AmountGuaranteed AmountGuaranteed AmountBasisComments
69Retail-30 Network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
70Retail-90 Network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
71Mail at Retail network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
72Retail (specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
73Mail Order(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
74Specialty Pharmacy (mail)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
75Domestic Pharmacy (non-specialty, 30 day)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
76Domestic Pharmacy (non-specialty, 90 day)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
77Domestic Pharmacy (specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
782) Rebate Guarantees for formularies WITHOUT drug exclusionsRebate Guarantee requires what Day SupplyGuaranteed AmountGuaranteed AmountGuaranteed Amount
792a) Guaranteed rebate amounts paid/credited to client for 3-tier Incentive plan designs(min 30, min 90, up to 30, up to 90, 84+, clinical DS)202620272028BasisComments
80Retail-30 Network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
81Retail-90 Network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
82Mail at Retail network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
83Retail (specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
84Mail Order(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
85Specialty Pharmacy (mail)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
86Domestic Pharmacy (non-specialty, 30 day)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
87Domestic Pharmacy (non-specialty, 90 day)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
88Domestic Pharmacy (specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
892b) Guaranteed rebate amounts paid/credited to client for all other plan designsRebate Guarantee requires what Day SupplyGuaranteed AmountGuaranteed AmountGuaranteed AmountBasisComments
90Retail-30 Network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
91Retail-90 Network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
92Mail at Retail network (non-specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
93Retail (specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
94Mail Order(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
95Specialty Pharmacy (mail)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
96Domestic Pharmacy (non-specialty, 30 day)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
97Domestic Pharmacy (non-specialty, 90 day)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
98Domestic Pharmacy (specialty)(Single, Pull-down list.

1: min 30, 2: min 90, 3: up to 30, 4: up to 90, 5: 84+, 6: clinical DS) (Single, Pull-down list.

1: per claim, 2: per Rx, 3: Per Brand claim, 4: Per Brand Rx, 5: per Formulary Brand claim, 6: per Formulary Brand Rx, 7: per Tier-2 claim, 8: per Tier-2 Rx, 9: per Tier-2 Brand claim, 10: per Tier-2 Brand Rx, 11: per Rebateable claim, 12: per Rebateable Rx, 13: PEPM,

14: PMPM)(100 words.)
993) Which method below best describes how Rebates are shared?(Single, Pull-down list.

1: a, 2: b, 3: c, 4: d, 5: e, 6: f, 7: g, 8: h) (Single, Pull-down list.

1: a, 2: b, 3: c, 4: d, 5: e, 6: f, 7: g, 8: h) (Single, Pull-down list.

1: a, 2: b, 3: c, 4: d, 5: e, 6: f, 7: g, 8: h)

100(a) Client does not receive direct rebate payments; instead, rebates are used to offset/lower the medical ASO fees
101(b) Rebate reinvestment – client does not receive direct rebate payments; instead, rebates are passed through via deeper AWP discounts
102(c) POS rebates – rebates are shared at the point of sale (i.e., either a set rebate per rebateable claim or drug-specific rebates)
103(d) The vendor pays/credits the client all or some portion of actual rebate earnings
104(e) Vendor guarantees to pay client a specified percentage of actual rebate earnings noted in question (6) below
105(f) Vendor guarantees to pay client a specified rebate amount "per claim" noted in (1) and (2) above
106(g) Vendor guarantees to pay client the greater of: (e) or (f)
107(h) Vendor guarantees to pay client the greater of: (e), (f) or a specified amount PEPM or PMPM
1084) If the answer to 3) above is (a), how much is the rebate offset/reduction to the medical ASO fee?(Single, Pull-down list.

1: PEPM,

2: PMPM)(100 words.)
1095) If the answer to 3) above is (h), what is the guaranteed rebate PEPM or PMPM?(Single, Pull-down list.

1: PEPM,

2: PMPM)(100 words.)
1106) If the answer to 3) above is (c), (d), (e), (g), or (h) what % of actual Rebates are shared with the plan?202620272028
111- Retail (non-specialty)%%%
112- Retail (specialty)%%%
113- Mail Order%%%
114- Specialty Pharmacy/mail%%%
115- Domestic Pharmacy (non-specialty)%%%
116- Domestic Pharmacy (specialty)%%%
117- 340B claims%%%
1187) Do the percentages noted in 6) above also apply to:202620272028
119- Manufacturer Administrative Fees (MAF); are MAF included in the % share noted in #6 above?(Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No) 120 - Price Protection Rebates; are Price Protection Rebates included in the % share noted in #6 above? (Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No) 121 - monies received from pharma from performance/outcome based programs; are such monies included in the % share noted in #6 above? (Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No)

1228a) What is the name of the formulary WITH drug exclusions, addressed in (1) above?(10 words.)(10 words.)(10 words.)
1238b) What is the name of the formulary WITHOUT drug exclusions, addressed in (2) above?(10 words.)(10 words.)(10 words.)
1249a) What criteria is used to determine which plans are eligible for the 3-tier Incentive rebate guarantees outlined in (1a) and (2a) above?(200 words.)
1259b) Which client plan(s) are eligible for the 3-tier Incentive rebate guarantees outlined in (1a) and (2a) above?(200 words.)(200 words.)(200 words.)
12610) Additional confirmation regarding above Rebate guarantees:202620272028
127The above Mail Order rebate guarantees apply to non-specialty drug claims filled at your mail order pharmacy, regardless of day supply.(Single, Pull-down list.

1: Confirmed, 2: Not Confirmed) (Single, Pull-down list.

1: Confirmed, 2: Not Confirmed) (Single, Pull-down list.

1: Confirmed, 2: Not Confirmed) 128 The above rebate guarantees are not subject to day supply proration or adjustment. (Single, Pull-down list.

1: Confirmed, 2: Not Confirmed) (Single, Pull-down list.

1: Confirmed, 2: Not Confirmed) (Single, Pull-down list.

1: Confirmed, 2: Not Confirmed) 129 Rebate Guarantees for all products depend on the channel/network that was used to dispense said product (retail-30, mail order, specialty pharmacy, etc.) (Single, Pull-down list.

1: Confirmed, 2: Not Confirmed) (Single, Pull-down list.

1: Confirmed, 2: Not Confirmed) (Single, Pull-down list.

1: Confirmed, 2: Not Confirmed)

13011) Note if any of the following categories are excluded from minimum REBATE Guarantees:202620272028
131340B: All Claims with Submission Clarification Code = 20(Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 132 340B: All Claims dispensed by a pharmacy with 340B Status Code = 39 (per NCPDP DataQ database) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 133 340B: All Claims dispensed by a pharmacy with 340B Status Code = 38 (per NCPDP DataQ database) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 134 Biosimilar products (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 135 Claims approved by formulary exception (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 136 DAW5 claims (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 137 LDD: existing Exclusive and Limited Distribution Drugs (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 138 LDD: new to market Exclusive and Limited Distribution Drugs (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 139 Multi-source Brand (MSB) drugs (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 140 New to market Specialty drugs (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 141 OTC products - Diabetic (Test Strips, Insulin, and CGMs) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 142 OTC products - Non-Diabetic (clarify below if necessary) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 143 U&C claims (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 144 Vaccines (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 145 Vaccine administration claims (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 146 Zero paid claims (i.e., member pays 100% and the Plan pays zero) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded)

14712) List all other exclusions applicable to the above Rebate guarantees, if any.(500 words.)(500 words.)(500 words.)
14813) Specify any/all other terms upon which the above Rebate guarantees are contingent and/or impact rebates paid to Client.(500 words.)(500 words.)(500 words.)
14914) Rebate Credit Language202620272028
15014a) Which years, if any, does Rebate Credit Language apply to this contract? If 'Yes' for any year, please answer 18b.(Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No)

15114b) Which of the following are not incorporated into the underwriting for this offer and thus will be included in the calculation of rebate credit?
152Insulin/Anti-Diabetic Products affected by removal of AMP-Cap(Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No) 153 Biosimilar products (Humira/Stelara/others) (Single, Pull-down list.

1: Humira, 2: Stelara, 3: Both, 4: Neither ) (Single, Pull-down list.

1: Humira, 2: Stelara, 3: Both, 4: Neither ) (Single, Pull-down list.

1: Humira, 2: Stelara, 3: Both, 4: Neither )

154Please list all product categories that are not incorporated into the underwriting for this offer and thus will be included in the calculation of rebate credit.(500 words.)(500 words.)(500 words.)
155Please list all product categories that are incorporated into the underwriting for this offer and thus will not be included in the calculation of rebate credit.(500 words.)(500 words.)(500 words.)
156Pricing Arrangement202620272028
157Which of the following best describes your proposed Retail-30 Network pricing arrangement?(Single, Pull-down list.

1: a, 2: b, 3: c, 4: d) (Single, Pull-down list.

1: a, 2: b, 3: c, 4: d) (Single, Pull-down list.

1: a, 2: b, 3: c, 4: d)

158(a) Traditional, "spread" pricing with fixed discount guarantees
159(b) Pass-through of contracted rates; no guaranteed discounts or dispensing fees
160(c) Pass-through of contracted rates, with guaranteed minimum discounts/maximum dispensing fees
161(d) Rebate reinvestment
162Which of the following best describes your proposed Retail-90 pricing arrangement?(Single, Pull-down list.

1: a, 2: b, 3: c, 4: d, 5: e, 6: f) (Single, Pull-down list.

1: a, 2: b, 3: c, 4: d, 5: e, 6: f) (Single, Pull-down list.

1: a, 2: b, 3: c, 4: d, 5: e, 6: f)

163(a) Not applicable. 90 day supply (DS) is not allowed at retail
164(b) 90 DS allowed at any retail network pharmacy at the standard retail pricing terms
165(c) 90 DS allowed at any retail network pharmacy; pricing better than standard retail but not as good as mail
166(d) 90 DS allowed at certain retail network pharmacies at the standard retail pricing terms
167(e) 90 DS allowed at certain retail network pharmacies; pricing better than standard retail but not as good as mail
168(f) 90 DS can be filled at certain retail network pharmacies at the standard mail pricing terms (Mail at Retail Network)
169Which of the following best describes your proposed Mail Order pricing arrangement?(Single, Pull-down list.

1: a, 2: b, 3: c, 4: d) (Single, Pull-down list.

1: a, 2: b, 3: c, 4: d) (Single, Pull-down list.

1: a, 2: b, 3: c, 4: d)

170(a) Fixed guarantees – traditional spread pricing
171(b) No discount or dispensing fee guarantees
172(c) Rebate reinvestment
173(d) Pass-through of acquisition cost with minimum discount/maximum dispensing fee guarantees
174Which of the following best describes your proposed Domestic Pharmacy pricing arrangement?(Single, Pull-down list.

1: a, 2: b, 3: c, 4: d, 5: e) (Single, Pull-down list.

1: a, 2: b, 3: c, 4: d, 5: e) (Single, Pull-down list.

1: a, 2: b, 3: c, 4: d, 5: e)

175(a) Not applicable; Client doesn't have any Domestic Pharmacies
176(b) Domestic Pharmacy claims are included in the standard retail-30 and retail-90 network discount and dispensing fee guarantees
177(c) Pass-through of the Domestic Pharmacy's contracted network rates; no guaranteed discounts or dispensing fees
178(d) Domestic Pharmacy actual acquisition costs are passed through directly to the Plan
179(e) Plan pays based on other AWP discounts and dispensing fees set by the Domestic Pharmacy
180Will Domestic Pharmacy claims be "no bill no pay" (a.k.a., "no bill no remit", "claim suppression")?(Single, Pull-down list.

1: yes, 2: no, 3: n/a, 4: don’t know) (Single, Pull-down list.

1: yes, 2: no, 3: n/a, 4: don’t know) (Single, Pull-down list.

1: yes, 2: no, 3: n/a, 4: don’t know)

181Additional pricing information202620272028
182Name of Retail-30 Network(10 words.)(10 words.)(10 words.)
183Name of Retail-90 Network(10 words.)(10 words.)(10 words.)
184Name of Mail at Retail network(10 words.)(10 words.)(10 words.)
185Estimated number of pharmacies included in the Retail-30 Network(Integer.)(Integer.)(Integer.)
186Estimated number of pharmacies included in Retail-90 Network, if applicable(Integer.)(Integer.)(Integer.)
187Estimated number of pharmacies included in Mail at Retail network, if applicable(Integer.)(Integer.)(Integer.)
188Major retail pharmacy chains excluded from the Retail-30 Network, if any(100 words.)(100 words.)(100 words.)
189Describe the pharmacies included in your proposed Retail-90 Network, if applicable(100 words.)(100 words.)(100 words.)
190Describe the pharmacies included in your proposed Mail at Retail network, if applicable(100 words.)(100 words.)(100 words.)
191What is the days' supply requirement associated with the above Retail-90 Network discounts & dispensing fees (e.g., 84+)(50 words.)(50 words.)(50 words.)
192What is the days' supply requirement associated with the above Mail at Retail network discounts & dispensing fees (e.g., 84+)(50 words.)(50 words.)(50 words.)
193What is the minimum days' supply to receive the above Mail Order discounts & dispensing fees (e.g., no minimum, minimum 84 DS, average DS >=84)(50 words.)(50 words.)(50 words.)
194If minimum days' supply applies at Mail Order, approximately what percent of all Mail Order claims were less than the minimum?%%%
195At Retail, do members pay the lowest of (a) discounted price, (b) member copay and (c) U&C/sale price?(Single, Pull-down list.

1: Yes, 2: No. EEs pay Lower of copay & U&C/sale-price, 3: No. EEs pay Lower of discounted price & member copay) (Single, Pull-down list.

1: Yes, 2: No. EEs pay Lower of copay & U&C/sale-price, 3: No. EEs pay Lower of discounted price & member copay) (Single, Pull-down list.

1: Yes, 2: No. EEs pay Lower of copay & U&C/sale-price, 3: No. EEs pay Lower of discounted price & member copay) 196 Is MAC pricing used at Mail Order? (Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No) (Single, Pull-down list.

1: Yes, 2: No) 197 Does the above pricing reflect a lockout or refill limits on Specialty drugs dispensed by Retail pharmacies? (Single, Pull-down list.

1: Open, unrestricted, 2: Refill Limits apply, 3: Exclusive, Retail Lockout) (Single, Pull-down list.

1: Open, unrestricted, 2: Refill Limits apply, 3: Exclusive, Retail Lockout) (Single, Pull-down list.

1: Open, unrestricted, 2: Refill Limits apply, 3: Exclusive, Retail Lockout)

198If there is a limit on the number of Specialty drugs dispensed by Retail pharmacies, how many retail fills are allowed?(Integer.)(Integer.)(Integer.)
199Provide your contractual definition of "Generic" applicable to AWP discount guarantees.(100 words.)(100 words.)(100 words.)
200Provide your contractual definition of "Brand" applicable to AWP discount guarantees.(100 words.)(100 words.)(100 words.)
201Provide your contractual definition of "Brand" applicable to minimum rebate guarantees.(100 words.)(100 words.)(100 words.)
202Is a Brand Over Generic program used?(100 words.)(100 words.)(100 words.)
203Are Brand products in your Brand Over Generic program included in your Brand or Generic discount guarantees?(Single, Pull-down list.

1: Brand, 2: Generic, 3: n/a) (Single, Pull-down list.

1: Brand, 2: Generic, 3: n/a) (Single, Pull-down list.

1: Brand, 2: Generic, 3: n/a) 204 Are Brand products in your Brand Over Generic program included in your minimum Rebate guarantees? (Single, Pull-down list.

1: Yes, 2: No, 3: n/a) (Single, Pull-down list.

1: Yes, 2: No, 3: n/a) (Single, Pull-down list.

1: Yes, 2: No, 3: n/a) 205 How are single-source generics defined (e.g., products available from one generic manufacturer, two generic manufacturers, etc.)? (Single, Pull-down list.

1: One Generic Manufacturer, 2: Two Generic Manufacturers, 3: Three or More Generic Manufacturers) (Single, Pull-down list.

1: One Generic Manufacturer, 2: Two Generic Manufacturers, 3: Three or More Generic Manufacturers) (Single, Pull-down list.

1: One Generic Manufacturer, 2: Two Generic Manufacturers, 3: Three or More Generic Manufacturers) 206 Are single-source generics (SSG) included in the above Brand or Generic discounts? (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither) (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither) (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither) 207 Are multi-source brand (MSB) drugs included in the above Brand or Generic discounts? (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither) (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither) (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither) 208 Are U&C claims included in the above Retail Brand discounts? (Single, Pull-down list.

1: U&C claims are included in the above discounts, 2: U&C included in adjudication logic, but U&C claims are excluded from above discounts, 3: U&C pricing isn't used) (Single, Pull-down list.

1: U&C claims are included in the above discounts, 2: U&C included in adjudication logic, but U&C claims are excluded from above discounts, 3: U&C pricing isn't used) (Single, Pull-down list.

1: U&C claims are included in the above discounts, 2: U&C included in adjudication logic, but U&C claims are excluded from above discounts, 3: U&C pricing isn't used) 209 Are U&C claims included in the above Retail Generic discounts? (Single, Pull-down list.

1: U&C claims are included in the above discounts, 2: U&C included in adjudication logic, but U&C claims are excluded from above discounts, 3: U&C pricing isn't used) (Single, Pull-down list.

1: U&C claims are included in the above discounts, 2: U&C included in adjudication logic, but U&C claims are excluded from above discounts, 3: U&C pricing isn't used) (Single, Pull-down list.

1: U&C claims are included in the above discounts, 2: U&C included in adjudication logic, but U&C claims are excluded from above discounts, 3: U&C pricing isn't used) 210 Are House Generics included in the above Retail Brand or Generic discount guarantees? (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither, 4: n/a (don't use House Generics)) (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither, 4: n/a (don't use House Generics)) (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither, 4: n/a (don't use House Generics)) 211 Are House Generics included in the above Mail Brand or Generic discount guarantees? (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither, 4: n/a (don't use House Generics)) (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither, 4: n/a (don't use House Generics)) (Single, Pull-down list.

1: Brand, 2: Generic, 3: Neither, 4: n/a (don't use House Generics)) 212 Are House Generics included in the above Specialty Pharmacy discount guarantees? (Single, Pull-down list.

1: Yes, 2: No, 3: n/a (don't use House Generics)) (Single, Pull-down list.

1: Yes, 2: No, 3: n/a (don't use House Generics)) (Single, Pull-down list.

1: Yes, 2: No, 3: n/a (don't use House Generics))

213Note if any of the following categories are excluded from the above AWP DISCOUNT guarantees:202620272028
214340B: All Claims with Submission Clarification Code = 20(Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 215 340B: All Claims dispensed by a pharmacy with 340B Status Code = 39 (per NCPDP DataQ database) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 216 340B: All Claims dispensed by a pharmacy with 340B Status Code = 38 (per NCPDP DataQ database) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 217 Biosimilar products (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 218 Claims approved by formulary exception (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 219 LDD: existing Exclusive and Limited Distribution Drugs (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 220 LDD: new to market Exclusive and Limited Distribution Drugs (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 221 Multi-source Brand (MSB) drugs (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 222 New to market Specialty drugs (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 223 OTC products - Diabetic (Test Strips, Insulin, and CGMs) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 224 OTC products - Non-Diabetic (clarify below if necessary) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 225 Vaccines (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 226 Vaccine administration claims (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) 227 Zero paid claims (i.e., member pays 100% and the Plan pays zero) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded) (Single, Pull-down list.

1: Included, 2: Excluded)

228List all other exclusions applicable to the above AWP discount guarantees, if any(500 words.)(500 words.)(500 words.)
229Please provide any additional clarification regarding the above AWP discounts(500 words.)(500 words.)(500 words.)

&"Arial,Regular"&10PEBB Medical & Pharmacy Benefit RFP OregonBuys Bid No. S-44300-00014758 &"Arial,Regular"&10Attachment T Pharmacy Pricing Terms

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