The file's text, extracted by GovTribe without its formatting.
Cover Page
CONFIDENTIAL & PROPRIETARY
| Request for Proposal for |
| PHARMACY BENEFIT MANGEMENT SERVICES |
| Solicitation Number: ARFP PEI2500000002 |
COST PROPOSAL (Pricing Workbook)
West Virginia Public Employees Insurance Agency
RFP Release Date: May 23, 2025 ID#AAABiq4exCE tc={B52BAED1-7943-4234-93A8-50EF5EDE5EFD} (2025-04-30 14:54:39) [Threaded comment]
Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924
Comment:
Dates will be updated throughout once ready to release.
| RFP Due Date: | July 11, 2025 |
| Effective Date: | July 1, 2026 |
| CONFIDENTIALITY NOTICE |
| This Request for Proposal and the information contained herein is confidential. No part of this Request for Proposal may be reproduced or shared with anyone outside of your organization without prior written consent. |
Pass-Through Pricing Template
| CONFIDENTIAL & PROPRIETARY | | | |
| COMPLETION OF PASS THROUGH AND PMPM TABS REQUIRED FOR RFP SUBMISSION | | | |
| PASS-THROUGH PRICING TEMPLATE | Year 1 | Year 2 | Year 3 |
| | 07/01/2026 - | | |
| 06/30/2027 | 07/01/2027 - 06/30/2028 | 07/01/2028 - 06/30/2029 | | |
| * If pricing is based on NADAC or other source, please provide your AWP equivalent. | | | |
| RETAIL 1-83 (NON-SPECIALTY) | | | |
| Guaranteed minimum overall brand discount off AWP | | | |
| Guaranteed minimum overall generic discount off AWP | | | |
| Guaranteed maximum dispensing fee per brand claim |
| Guaranteed maximum dispensing fee per generic claim |
West Virginia Domiciled Pharmacies NADAC + $10.49 NADAC + $10.49 NADAC + $10.49
| RETAIL 84+ (NON-SPECIALTY) |
| Guaranteed minimum overall brand discount off AWP |
| Guaranteed minimum overall generic discount off AWP |
| Guaranteed maximum dispensing fee per brand claim |
| Guaranteed maximum dispensing fee per generic claim |
West Virginia Domiciled Pharmacies NADAC + $10.49 NADAC + $10.49 NADAC + $10.49
| MAIL ORDER - ALL DAYS' SUPPLY (NON-SPECIALTY) |
| Guaranteed minimum overall brand discount off AWP |
| Guaranteed minimum overall generic discount off AWP |
| Guaranteed maximum dispensing fee per brand claim |
| Guaranteed maximum dispensing fee per generic claim |
| OPEN SPECIALTY 1-30 DAYS' SUPPLY |
| Guaranteed minimum overall brand discount off AWP |
| Guaranteed minimum overall generic discount off AWP |
| Guaranteed maximum dispensing fee per brand claim |
| Guaranteed maximum dispensing fee per generic claim |
West Virginia Domiciled Pharmacies NADAC + $10.49 NADAC + $10.49 NADAC + $10.49
PREFERRED SPECIALTY 1-30 DAYS' SUPPLY
(Note: Preferred specialty should be compliant with legislation)
| Guaranteed minimum overall brand discount off AWP |
| Guaranteed minimum overall generic discount off AWP |
| Guaranteed maximum dispensing fee per brand claim |
| Guaranteed maximum dispensing fee per generic claim |
| West Virginia Domiciled Pharmacies | NADAC + $10.49 | NADAC + $10.49 | NADAC + $10.49 |
| PBM Specialty Pharmacy | NADAC + $10.49 | NADAC + $10.49 | NADAC + $10.49 |
LIMITED/EXCLUSIVE DISTRIBUTION DRUGS
ID#AAABiq4exCA tc={D1ED2938-798F-4395-B5DE-0670FA5CE518} (2025-04-30 14:54:39) [Threaded comment]
Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924
Comment:
Preference would be to include in specialty guarantees.
| Are limited distribution drugs considered specialty? |
| Confirm limited distribution drugs will be included in the pricing and rebate guarantees? |
| Guaranteed minimum overall brand discount off AWP |
| Guaranteed minimum overall generic discount off AWP |
| Guaranteed maximum dispensing fee per claim |
| Please confirm you will comply with reimbursement to West Virginia domiciled pharmacies at NADAC + $10.49. | | | |
| Please confirm you will provide reimbursement at PBM specialty pharmacies at NADAC + $10.49. Note: Currently PBM Specialty is NADAC + $10.49. | | | |
| If you do not agree to the days' supply limits listed above, please provide days' supply limits by channel and outline the discounts/dispensing fees/rebates that claims outside of the provided range are to receive. | Days Supply | Proposed Days Supply | Proposed Financials |
(Discount, Fees, Rebate)
| Retail 1-83 |
| Retail 84+ |
| Mail Order (All Days) |
| Open Specialty 1-30 |
| Preferred Specialty 1-30 |
| What is your default pricing for any new drugs being added to the specialty drug list? Include the AWP discount and any fees that will apply. If days' supply has impact or differentiates discounts, please outline clearly. | |
| Please state any applicable dispensing fees charged for LTC, Home Infusion, Compound, VA, and ITU claims. | |
PMPM Pricing Template
| | CONFIDENTIAL & PROPRIETARY | | | |
| | COMPLETION OF PASS THROUGH AND PMPM TABS REQUIRED FOR RFP SUBMISSION | | | |
| | | Year 1 | Year 2 | Year 3 |
| | PMPM Guarantee | 07/01/2026 - | | |
| 06/30/2027 | 07/01/2027 - | | | | |
| 06/30/2028 | 07/01/2028 - | | | | |
06/30/2029
| | PMPM Guarantee Guidelines: | |
| | PMPM Guarantee Guidelines: | CONFIRM/ |
| DO NOT CONFIRM | ADDITIONAL INFORMATION, IF NOT CONFIRMING | | |
| | It is expected that the PMPM guarantee includes all drugs and channels except for NEW catastrophic claims as noted below. | |
| | It is expected that your PMPM guarantee utilizes your formulary that is most closely aligned to WVPEIA's current formulary (formulary with exclusions). | |
| | Your PMPM guarantee should only assume current programs as being in place (i.e. SaveOn) | |
| | Your PMPM guarantee does NOT require additional clinical or other programs to be implemented. | |
| | Your PMPM guarantee only excludes NEW catastrophic claims (claims over $30,000/claim) that are not currently in the claims data. | |
| - Adjunctive Specialty List |
| - Cost Watch List |
| - Active Management List |
Independent Review Organization Carve-Out
Trademark Codes
| CONFIDENTIAL & PROPRIETARY |
| Definitions - Trademark Code Classification |
| If your PBM's brand and generic definitions include reference to the MediSpan Trademark Code, you are required to complete the classification table below. | | |
| *For PBMs using these codes, your specific classification must be confirmed. | | |
| | Please complete based on your classification, responding with "Brand" or "Generic" |
| Multi-Source Code | Brand Name Code* | PBM Classification |
| M,N | T | |
| O | T | |
| O | B, G | |
| Y | T | |
| Y | B, G | |
| M,N | G | |
| M,N | B | |
Specialty Pricing
| CONFIDENTIAL & PROPRIETARY |
| SPECIALTY PHARMACY PRICING |
| Provide a detailed list of all products currently treated as Specialty, Limited Distribution (LDD), and Biosimilar Drugs by NDC 11 with the applicable discounts. Identify differences in pricing for Preferred versus Open plans. Please provide as Attachment in Excel format. |
| SPECIALTY, LIMITED DISTRIBUTION DRUG, AND BIOSIMILAR PRICING LIST | | | | | | | | |
| Drug Name | NDC-11 | Indication | Brand/Generic Indicator | Formulary Status | AWP Discount - Open | AWP Discount - Preferred | Limited Distribution (Yes/No) | Biosimilar (Yes/No) |
Rebates
| CONFIDENTIAL & PROPRIETARY |
| REBATES |
| Rebates guarantees should be based on a minimum per brand claim. Deviations that require an average 30 or 90 days supply must be documented below. |
| 1. Please complete the tables below to include the following formulary that best aligns with WV PEIA's current formulary. |
| 2. List any exclusion(s) to your rebate guarantees and provide non-trended rebate estimates. |
| PROVIDE FORMULARY NAME (WITH EXCLUSIONS): | |
| 3 TIER BRAND | |
| Year | Retail |
| (1-83 Days' Supply) | Retail | |
| (84+ Days' Supply) | Mail Order | |
| (All Days' Supply) | Open Specialty | |
| (1-30 Days' Supply) | Preferred Specialty | |
(1-30 Days' Supply)
| 7/1/2026-6/30/2027 |
| 7/1/2027-6/30/2028 |
| 7/1/2028-6/30/2029 |
| REBATE ESTIMATE | | |
| Please provide your non-trended rebate estimate(s) for each year of the agreement. | | |
| Formulary Name | Contract Year | Non-Trended Rebate Estimate |
| 7/1/2026-6/30/2027 | |
| 7/1/2027-6/30/2028 | |
| 7/1/2028-6/30/2029 | |
| Additional Rebate Questions: | |
| Estimated Biosimilar Rebate Credit (Clawback) 2026 | $ |
| Estimated AMPCap Rebate Credit (Clawback) 2026 | $ |
Biosimilars
| CONFIDENTIAL & PROPRIETARY |
| BIOSIMILARS |
| Please outline your biosimilar formulary and conversion strategy. |
| Please outline your projected conversion rate to biosimilars with your strategy. |
| Please complete the table below based on your pricing and rebates for the utilization within the RFP specific claims file. | | |
| # of Rxs | Average Gross |
Cost/Rx (based on your discounted costs and dispensing fees) Total Gross Cost
| (based on your discounted costs and dispensing fees) | Total Projected (non-trended) rebates |
| (based on your expected rebates net of credits or clawbacks) | Total Net Cost |
(Gross less rebates)
| Humira |
| Biosimilar(s) for Humira |
| Stelara |
| Biosimilar(s) for Stelara |
Discount & Rebate Exclusion
| CONFIDENTIAL & PROPRIETARY |
| DISCOUNT AND REBATE EXCLUSIONS FOR PASS THROUGH PRICING GUARANTEES |
| DISCOUNT AND DISPENSING FEE GUARANTEE EXCLUSIONS |
| Select if the following claim types are excluded or included from discount and dispensing fee guarantees. |
| Note: All other claim categories are expected to be included in the guarantees. |
| Paper or Member Submitted |
| Compound Products |
| COB or Secondary Payor |
| Subrogation Claims |
| Claims Dispensed from an on-site or WV PEIA owned pharmacy |
| Vaccines |
| State or government mandated pharmacy reimbursement claims |
Silent exclusions are prohibited. All exclusions from guarantees have been provided.
| REBATE EXCLUSIONS |
| Select if the following claim types are excluded or included from rebate guarantees. |
| Note: All other claim categories are expected to be included in the guarantees. |
| Paper or Member Submitted |
| Compound Products |
| COB or Secondary Payor |
| Subrogation Claims |
| Vaccines |
Silent exclusions are prohibited. All exclusions from guarantees have been provided.
| Provide the following related to the rebate guarantee offer utilizing the claims data provided: | |
| Number of claims by channel (i.e. Mail Brand) that qualify for a rebate guarantee. | Days Supply |
| Retail 1-83: |
| Retail 84+: |
| Mail Order (All Days): |
| Open Specialty 1-30 |
| Preferred Specialty 1-30: |
| Number of claims excluded from the rebate guarantees with the applicable exclusion reason. | |
Cost Containment Savings
| CONFIDENTIAL & PROPRIETARY |
| COST CONTAINMENT STRATEGIES |
| Please complete the following table relative to each of your proposed cost containment strategy(ies). |
| SPECIALTY MANUFACTURER ASSISTANCE PROGRAM |
| Name of PBM's Manufacturer Assistance Program: |
| Analysis Timeframe: |
| Estimated Net Savings ($): |
| Estimated Rebate Impact ($) (if applicable): |
| Would you be willing to guarantee the projected savings? If so, please provide details on your guarantee. |
| Annualized Impacted Script Count: |
| Annualized Unique NDC Count: |
| Program Fees: |
| Confirm the program fees are factored into estimated net savings? |
| Plan Design Changes/Requirements: |
| OTHER PROPOSED PROGRAMS & SAVINGS | | | | | |
| Program Type | Maximum Savings ($) | Conversion Rate (%)* | Conversion Rate Savings ($) | Estimated Rebate Impact ($) | Estimated Net Savings ($) |
| Manufacturer Assistance/Copay Card | | | | | |
| Patient Assistance Program/Alternative Funding | | | | | |
| Diabetes Management | | | | | |
| GLP-1 Management | | | | | |
| Other | | | | | |
| use additional lines as necessary | | | | | |
* expected conversion rate based on experience
| Confirm your programs include a true out of pocket accumulator? |
| Please provide details. |
| OTHER COST CONTAINMENT STRATEGIES |
Adminstrative Fees
| CONFIDENTIAL & PROPRIETARY | | | |
| ADMINISTRATIVE FEES | Year 1 | Year 2 | Year 3 |
| | 07/01/2026 - | | |
| 06/30/2027 | 07/01/2027 - | | | |
| 06/30/2028 | 07/01/2028 - | | | |
06/30/2029 All Inclusive PMPM Admin Fee $ $ $
| SERVICE | CONFIRM INCLUDED IN ADMIN FEE | IF NOT INCLUDED IN ALL-INCLUSIVE ADMIN FEE, NOTE FEES HERE |
| ID Cards (NOTE: PEIA's TPA handles currently. Provide a cost if PBM is ever required to support) | | |
| Standard 2nd Level Appeals Processing (NOTE: PEIA handles currently. Provide a cost if PBM is ever required to support). | | |
| Clinical Prior Authorization and Standard 1st Level Appeals for Non- Specialty (Note: PEIA does not require, but may need support - need to know cost if support is needed). | | |
| Independent Review Organization Appeals (IRO) (Note: PEIA does not require, but may need support - need to know cost if support is needed). | | |
| Clinical Prior Authorization Specialty, Tier Exceptions and Formulary Exceptions | | |
| Standard 1st Level Appeals Processing and Determination - Specialty, Tier Exceptions and Formulary Exceptions | | |
| Urgent Appeals Processing | | |
| On-line standard Reporting | | |
| Ad-Hoc Reporting | | |
| Administrative Prior Authorizations | | |
| Member Portal | | |
| Client Portal | | |
| DUR Programs | | |
| Dedicated Account Services and Account Management | | |
| Implementation/Transition Assistance | | |
| Customer Satisfaction Survey | | |
| Dedicated Member Services and Call Center | | |
| Plan Specific Internet Website | | |
| Member Enrollment Packages ("packet") | | |
| Network Management | | |
| Eligibility Administration | | |
| Electronic Claims Processing | | |
| Mail Services Claims Integration | | |
| Specialty Pharmacy Claims Integration | | |
| Claim Forms | | |
| Vaccine Services | | |
| Paper Claims | | |
| E-Prescribing | | |
| Electronic Prior Authorizations | | |
| Toll Free Phone Lines for Participants, Pharmacies, and Providers | | |
| Electronic Data Transfer to Data Warehouse and to third party vendors, TPA, TruData, etc. | | |
| Data Integration with Health Plan Administrator | | |
| Data Integration with WV University School of Pharmacy Rational Drug Therapy Program | | |
| Prospective/Concurrent/Retro DUR | | |
| Standard Reports and Data Management | | |
| Access to Web-based Reporting | | |
| COB Program | | |
| Medicaid Subrogation Claims | | |
| Medicare Seconday Payer Claims | | |
| Dose Optimization Program | | |
| Prior Authorization Program | | |
| Step Therapy Program | | |
| Quantity Limitations | | |
| Custom System Overrides | | |
| Annual EOB Statements | | |
| Retro Termination Letters | | |
| Drug Notification Letters to Member and Provider | | |
| Formulary Administration/Management | | |
| Access to Pharmacy Directories and Other Member Materials (Note: Must provide PEIA specific full formulary, PDL, MDL, Preventive Drug List, spec drug list, diabetes waived copay list, medical specialty inj PA list, others if necessary to PEIA for website) | | |
| Online Formulary/Preferred Drug Listings Customized | | |
| Participant Online Access | | |
| Dedicated Clinical Service Team | | |
| Disease Management Program Support | | |
| Abuse/Fraud Program Development and Management | | |
| Rebate Management/Administration | | |
| Data Processing | | |
| Systems Maintenance | | |
| HIPAA Compliance | | |
| Actuarial, Underwriting, and Consulting Services | | |
| Printing and Mailing Costs Related to Pharmacy Benefits | | |
| Overrides | | |
| Audit Recovery Fees | | |
| Contracting | | |
| Compound Drug Management | | |
| Corporate and Other Overhead | | |
| Taxes | | |
| add'l lines if needed | | |
| add'l lines if needed | | |
Credits & Allowances
| CONFIDENTIAL & PROPRIETARY | | | |
| CREDITS & ALLOWANCES | | | |
| Please outline any credits/allowances you are providing to the client as part of your overall offer. | | | |
| Amount | Frequency* | Details |
| Implementation Credit | | | |
| Pharmacy Management Allowance | | | |
| Audit Allowance | | | |
| Other | | | |
| * monthly, annually, PEPM, PMPM, etc. | | | |
Formulary Disruption
| CONFIDENTIAL & PROPRIETARY | |
| FORMULARY DISRUPTION | |
| Please fill out the provided summary template for proposed formulary(ies), including formulary name and type (open/closed). | |
| Completion of this tab is a requirement of the RFP. The full detailed formulary impact analysis should be included as an attachment. | |
| Please use most recent 4 months of data based on maintenance medications only. |
| PBM Formulary Name: |
| Formulary Type: |
| Moving to Non-Formulary (Negative Disruption) |
| # of Utilizers Impacted |
| % of Utilizers Impacted |
| # of Rxs Impacted |
| % of Rxs Impacted |
| Moving to Excluded |
| # of Utilizers Impacted |
| % of Utilizers Impacted |
| # of Rxs Impacted |
| % of Rxs Impacted |
Network Disruption
| CONFIDENTIAL & PROPRIETARY |
| NETWORK DISRUPTION |
| Please provide your Network Disruption including the number of impacted pharmacies, utilizers and Rxs in the provided attachment format. Additionally, complete the Network Disruption summary below. |
| ATTACHMENT FORMAT | | | | |
| Pharmacy ID (NABP/NCPDP) | Pharmacy Name | Rx Count | Member Count | In Network (Yes/No) |
NETWORK DISRUPTION SUMMARY
| | Total # of Pharmacies Impacted | Total # of |
| Rxs Impacted | Total # of Utilizers Impacted | | |
| | Total % of Pharmacies Impacted | Total % of |
| Rxs Impacted | Total % of Utilizers Impacted | | |
image1.png image2.png