Exhibit_3_Financial_Questionnaire-Price_Sheet.xlsx
XLSX spreadsheet 11 MB Posted
- Attached to
- RFP for Pharmacy Benefit Manager
- Solicitation number
- EV00000953
- Issued by
- Oklahoma
About this file
This is a Financial Questionnaire and Price Sheet for a Pharmacy Benefit Manager (PBM) Request for Proposal (RFP) issued by the Oklahoma Health Care Authority's Employees Group Insurance Division (EGID) through the Office of Management and Enterprise Services Central Purchasing division. The RFP seeks PBM services including pharmacy claims adjudication, customer service, reporting, and related services for two populations: Commercial (103,266 employees; 158,044 members for CY 2025) and EGWP (28,615 members for CY 2025). The proposal requires vendors to provide comprehensive pricing on a post-AWP rollback basis with guaranteed minimum discounts, maximum dispensing fees, and full pass-through of manufacturer payments across multiple dispensing channels including Retail-30, Retail-90, Mail Order, Mail at Retail, and Specialty pharmacies. The contract term is three years with options to extend to years four and five, with all financial proposals remaining valid for an additional six months should the effective date be delayed. EGID retains the option to extend the contract for an additional two years under existing terms.
Vendors must complete extensive pricing worksheets addressing discount guarantees, dispensing fees, administrative fees, manufacturer payments, PMPM guarantees, specialty drug pricing, clinical program guarantees, rebate credits, and preferred biosimilar arrangements across four different formulary scenarios with varying exclusion levels. The financial proposal must be EGID-specific rather than book-of-business averages and must guarantee all pricing components including adjudication formulas for the full contract period. Pricing must include reconciliation provisions with dollar-for-dollar guarantees where surpluses in one component cannot offset shortfalls in another, and vendors must pass through 100% of manufacturer payments, rebates, data fees, and inflation protection payments to EGID. The RFP requires vendors to offer implementation allowances, annual audit allowances of $250,000, pharmacy management funds, and market check allowances. Clinical programs must have no shared savings with explicit, capped administrative fees, and utilization management programs must demonstrate positive ROI throughout the contract term. Material pricing change provisions allow adjustments only for specific circumstances including AWP changes, membership fluctuations exceeding 25%, formulary changes, unexpected generic introductions, and changes in law, with EGID having 45 days to review and determine acceptability of any requested changes.
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| Exhibit_6_Current_Plan_Designs.xlsx | XLSX spreadsheet | |
| Exhibit_1_Bidder_Reference_Worksheet.docx | DOCX document | |
| Exhibit_2_ThirdPartySupplierInfo.xlsx | XLSX spreadsheet | |
| Agency_Bidder_Instructions.pdf | ||
| Pre-Proposal_Conference_Agenda.docx | DOCX document | |
| Exhibit_7_-_Deviation_Explanations.xlsx | XLSX spreadsheet | |
| Exhibit_8_-_OHCA_EGID_Standard_Business_Associate_Agreement.docx | DOCX document | |
| Exhibit_9_-_Additional_Services_Cost_Proposal.docx | DOCX document | |
| 4_Attachment_C_EGID_Agency_Terms.docx | DOCX document | |
| 5_Attachment_D_IT_Terms.docx | DOCX document | |
| omes-form-cp004.docx | DOCX document | |
| Exhibit_5_Formulary___Network_Disruption.xlsx | XLSX spreadsheet | |
| OMESformCP076.pdf | ||
| Exhibit_4_Performance_Guarantees.xlsx | XLSX spreadsheet | |
| Q_A_Amendment_1.docx | DOCX document | |
| Exhibit_10_-_SB_1447_Certification.docx | DOCX document | |
| 3_Attachment_B_State_Terms.docx | DOCX document | |
| Attachment_A.pdf |
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Overview
| Commercial | EGWP | ||
| Total Members | 103,266 employees; 158,044 members (CY 2025) | Total Members | 28,615 members (CY 2025) |
| Pricing | Transparent & Pass-through and/or Per Member Per Month (PMPM) | Pricing | Transparent & Pass-through and/or Per Member Per Month (PMPM) |
| Retail-30 Network | Broad network | Retail-30 Network | Broad network |
| Retail-90 benefit | Broad network | Retail-90 benefit | Broad network |
| Specialty Benefit | Open Specialty | Specialty Benefit | Open Specialty |
| HIV, Transplant and PCSK9 drugs are all considered specialty. | HIV, Transplant and PCSK9 drugs are all considered specialty. |
| Formulary | With exclusions - requesting four different exclusionary formulary scenarios assuming most to least number of exclusions (see Rx-Pricing, MFP Comm tab for more details) | Formulary | With exclusions |
| Weight Loss | Not Covered | Weight Loss | Not Covered |
| Clinical (the following are in place/utilized today): | - Generic Only Preventive Drug List |
- Concurrent (POS) / Retrospective Drug Utilization Review
- Step Therapy, Quantity Limit and Prior Authorization edits
- Integrated Fraud, Waste & Abuse
- Dose Optimization
- Drug Savings Review
- Dose Optimization
- Specialty Starter Fill
- Enhanced SGM
- Opioid Management
- Drug Exclusion Plan Design
- Compound Drug Strategy Clinical (the following are in place/utilized today): - Concurrent (POS) / Retrospective Drug Utilization Review
- Step Therapy, Quantity Limit and Prior Authorization edits
- Integrated Fraud, Waste & Abuse
- Drug Savings Review
- Opioid Management
- Compound Drug Strategy
Explanation
| Request for PBM Proposal (RFP) for EGID |
| Explanation |
| This worksheet should be used to provide additional explanations for any questions for which a "See Explanation" response |
| was given. Explanations must be numbered to correspond to the question to which they pertain and they must be brief. |
Please Note: Any deviations outlined within the table below must be duplicated within the separate "Exhibit 7 - Deviation Explanations" Workbook.
| The State of Oklahoma has no responsibility to search, interpret, or cross-reference alternative terms, modifications, or revisions to performance guarantees outside Exhibit 4 or Exhibit 7. Any attempts to do so including but not limited to incorporating other documents or terms by reference, regardless of placement, wording, or intent will be treated as non-responsive and will not be considered |
| State the number of questions you addressed with further explanation: |
Sheet Name Question # Explanation
Financial
| Request for PBM Proposal (RFP) for EGID |
| Financial Questionnaire/Price Sheet |
To Vendor: Use Column F to provide a brief explanation. However if the length of the explanation is greater than 50 characters including spaces, you must use the "Explanation" worksheet to provide your detail explanation. Please note, your explanations must be limited to 400 characters or less
| Financial Questionnaire - Pricing Guarantees | Format Type | Response | Explanation |
| General | |||
| In the "RX-Pricing" worksheets included in this Excel workbook, you will quote on a post-AWP rollback basis, with guaranteed minimum discounts and maximum dispensing fees at Retail 30, Retail 90, Mail at Retail, Mail Order, and Specialty and a full pass through of Manufacturer Payments. The "Mail at Retail" option listed below refers to mail pricing at certain retail pharmacies for an 83-90 day supply with the same copay/coinsurance as Mail Order. Pricing worksheets requesting your organization's pricing are provided in this workbook. |
Only the responses in the designated response areas will be incorporated into the final agreement.
| 1. | The "RX-Pricing Exclusions" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 2. | The "RX-Pricing, Discounts & Dispensing Fees" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 3. | The "RX-Pricing Other Costs" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 4. | The "RX-Pricing MFP" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 5. | The "RX-Pricing PMPM Guarantee" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 6. | The "RX-Pricing PMPM Exclusions" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 7. | The "RX-Pricing Specialty Drugs" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 8. | The "RX-Pricing Credits" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 9. | The "RX-Pricing Preferred Biosimilars" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 10. | The "RX-Pricing Rebate Credit" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 11. | The "RX-Pricing, Clinical Programs" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 12. | The "RX-Pricing, State Mandated Reimbursement" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 13. | The "RX-Pricing Projections" Worksheet has been completed for each population (Commercial & EGWP): | Yes / No Explain | ||
| 14. | You will provide a current and complete list of Specialty Drugs using your most current available pricing. Your list will identify if each drug is a Brand/Generic, New to Market, Biosimilar, and Limited Distribution Drug, even if your firm does not have access to them. Please provide the list in the "RX-Pricing Spec" Worksheet for each population. | Fully Agree / Partial Agree / Disagree | ||
| 15. | In the "RX-Pricing" tabs, the percentage discounts you enter represent the guaranteed minimum annual ("Effective") AWP Discounts. | Fully Agree / Partial Agree / Disagree | ||
| 16. | In the "RX-Pricing" tabs, the Dispensing Fees you enter at a Retail Pharmacy represent the guaranteed maximum average annual Dispensing Fees. The Dispensing Fees you enter at Mail Order Pharmacy and Specialty Pharmacy represent the guaranteed Dispensing Fee for each paid claim. | Fully Agree / Partial Agree / Disagree | ||
| 17. | In the "RX-Pricing" tabs, the Manufacturer Payments you enter represent the guaranteed minimum Manufacturer Payments per dispensing channel. | Fully Agree / Partial Agree / Disagree | ||
| 18. | Please provide the effective date of your proposal. | Date | ||
| 19. | Confirm, your organization's financial proposal is for a period of three (3) years with the option to extend to years 4 and 5. The Proposer’s financial proposals must be valid for an additional six months should the effective date of the plan be delayed. EGID at its own discretion will have the option to extend the terms of this RFP for an additional two (2) years. All terms and conditions of the existing contract at the time of extension, including price, will be applicable. | Fully Agree / Partial Agree / Disagree | ||
| Material Pricing Changes | Format Type | Response | Explanation | |
| In the event one or more of the following occurs, you will have the right, upon notice, to request an equitable adjustment to the rates and guarantees in the respective "RX-Pricing" worksheets, solely as necessary to return the deal to its contracted economic position as of the effective date of such event: | ||||
| 20. | A change in the Pricing Source’s method for calculating AWP, including if AWP ceases to be published or otherwise becomes unavailable or PBM becomes required to change the Pricing Source from Medi-Span to another party, if such change has or upon becoming effective will have a material adverse impact on the benefits, costs or economics for PBM or EGID hat arise from or relate to this Agreement; | Fully Agree / Partial Agree / Disagree | ||
| 21. | A greater than a twenty-five percent (25%) change in EGID’s average plan Membership (measured on a rolling twelve month basis); | Fully Agree / Partial Agree / Disagree | ||
| 22. | EGID elects to use on-site clinics or pharmacies to dispense prescription drugs to Members and such use materially reduces Rebates and/or the number of Claims submitted to PBM; | Fully Agree / Partial Agree / Disagree | ||
| 23. | Unexpected industry changes, limited to: Unexpected Generic Drug introductions, unexpected OTC introductions and/or unexpected FDA recalls or market withdrawals. |
| Unexpectedly means the movement of a top 100 Brand Drug (measured as top 100 GPI-10 associated with single source Brand Drugs in your book of business by AWP) to off-patent more than six (6) months prior to its established patent expiration date or where Generic Drugs or over-the-counter substitutes for a top 100 Brand Drug become available more than six (6) months prior to the Brand Drug’s patent expiration date; | Fully Agree / Partial Agree / Disagree | |
| 24. | EGID-initiated change to benefit design or formulary that impacts PBMs ability to meet Rebate Guarantees. Such a EGID-initiated change is limited to changes to pharmacy benefit program, plan design, or formulary alignment. Adding, deleting, or modifying Member choice or incentives to enroll in pharmacy benefit options (e.g. CDHP, Exchanges, Medicare Part D plans). |
| In the event a modification to pricing guarantees is necessary, the parties will mutually agree on an appropriate adjustment which shall be equivalent to the impact of the change, such agreement not to be unreasonably withheld; | Fully Agree / Partial Agree / Disagree | ||||
| 25. | A change in law as pertains to payment of Rebates by pharmaceutical manufacturers; | Fully Agree / Partial Agree / Disagree | |||
| 26. | A change in any federal or state laws or regulations that causes any aspect of the Services to become unnecessary or necessary at a lower level of effort on the part of PBM and EGID determines to eliminate or reduce PBM obligations under this Agreement with respect to such services to address such change in law, if the elimination or a reduction in scope of such aspect of the services would result in a material reduction in PBM’s cost of performance under this Agreement. | Fully Agree / Partial Agree / Disagree | |||
| 27. | Should any of the above occur, you will provide the request to EGID along with the reason for the change, an EGID-specific analysis of the financial impact and any Member impact. EGID will have forty-five (45) days to review and determine if the change is reasonably acceptable. If EGID, in good faith, determines that the change is not reasonably acceptable, except as required by law, it will not occur during the term of the contract. | Fully Agree / Partial Agree / Disagree | |||
| 28. | For the avoidance of doubt, changes in AWP inflation rates, differences between underwriting projections and actual performance (other than covered in above items), drug mix shifts due to any dynamics other than those listed above, and pharmaceutical manufacturer merger and acquisition activity shall not constitute a Material Change. | Fully Agree / Partial Agree / Disagree | |||
| 29. | Except as explicitly set forth herein, pricing and financial guarantees will only change on an annual basis with the explicit written approval of EGID. | Fully Agree / Partial Agree / Disagree | |||
| Pricing Requirements | Format Type | Response | Explanation | ||
| 30. | All applicable financial terms (including but not limited to adjudication formulas, AWP discounts, dispensing fees, administrative and clinical program fees, Manufacturer Payments, specialty discounts, and specialty dispensing fees) submitted by you will be guaranteed as specified for the full contract period and incorporated into the contract. | Fully Agree / Partial Agree / Disagree | |||
| 31. | The financial terms you propose are EGID-specific, and not book of business averages. | Fully Agree / Partial Agree / Disagree | |||
| 32. | The financial guarantees you propose do NOT require EGID to make any plan design changes or implement any programs that are different from the current plan design(s). | Fully Agree / Partial Agree / Disagree | |||
| 33. | You will provide reporting to validate compliance with each and every financial guarantee, and such reporting must tie to your standard management reports. This includes separate Manufacturer Payment reports where prescription counts by dispensing channel and drug type must tie out to management reports. | Fully Agree / Partial Agree / Disagree | |||
| 34. | Your proposed pricing guarantees (i.e. discounts, dispensing fees, admin fees, Manufacturer Payments) will not be based on any minimum individual or aggregate days' supply at Retail, Mail Order, or Specialty Pharmacy (not including Retail 90 or "Mail at Retail" programs). | Fully Agree / Partial Agree / Disagree | |||
| 35. | With the exception of Specialty Drugs, each dispensing Channel's Guaranteed Minimum Manufacturer Payment are on a per Brand Drug Claim basis (i.e., not per rebateable Claim or per Formulary Claim). No adjustment will be made based on the actual average Days' Supply or any other adjustments such as a required Member Cost Share percentage or Plan share percentage. | Fully Agree / Partial Agree / Disagree | |||
| 36. | Rebate guarantees take into consideration anticipated movement of Brand Drugs to Generic Drugs throughout the term of the Agreement. | Fully Agree / Partial Agree / Disagree | |||
| 37. | For Specialty Drugs, the Guaranteed Minimum Manufacturer Payment will be based on a thirty (30) day supply Adjusted claim count. Rebate guarantees take into consideration anticipated movement of Brand Drugs to Generic Drugs throughout the term of the Agreement. | Fully Agree / Partial Agree / Disagree | |||
| 38. | Your quoted dispensing fees per claim are based on paid claims only, NOT claims that are reversed or rejected. | Fully Agree / Partial Agree / Disagree | |||
| 39. | U&C priced claims at Retail will NOT be assessed a Dispensing Fee. | Fully Agree / Partial Agree / Disagree | |||
| 40. | Retail claims priced using the U&C price (or submitted price, etc.) will be NOT be included in the guaranteed maximum dispensing fee per claim. | Fully Agree / Partial Agree / Disagree | |||
| 41. | The dispensing fee per claim listed for Mail Order, if any, is not an average but the guaranteed maximum amount that will apply per paid claim. | Fully Agree / Partial Agree / Disagree | |||
| 42. | Adjudication for Retail Pharmacy Claims: For each claim processed and dispensed to a member through a retail pharmacy, EGID shall pay PBM the Total Claim Cost less the member cost share plus any applicable administrative fees. The Total Claim Cost is defined to be the lowest of: |
i. The AWP minus the Brand Drug discount + Dispensing Fee + sales tax (Brand Drugs);
ii. The AWP minus the non-MAC discount + Dispensing Fee + sales tax (Generic Drugs);
iii. MAC + Dispensing Fee + sales tax; or,
| iv. The dispensing pharmacy’s U&C + sales tax. | Fully Agree / Partial Agree / Disagree | |
| 43. | Adjudication for Mail Order Pharmacy Claims: For each Claim processed and dispensed to a member through a mail order pharmacy, EGID shall pay PBM the Total Claim Cost less the member cost share plus any applicable administrative fees. The Total Claim Cost is defined to be the lowest of: |
i. The AWP minus the Brand Drug discount + Dispensing Fee + sales tax (Brand Drugs);
ii. The AWP minus the non-MAC discount + Dispensing Fee + sales tax (Generic Drugs); or,
| iii. MAC + Dispensing Fee + sales tax. | Fully Agree / Partial Agree / Disagree | |
| 44. | Member Cost Share: At the point of sale, Members will pay the lowest of: |
i. The Total Claim Cost as defined by dispensing channel above; or,
| ii. The applicable copayment as defined by the benefit plan. | Fully Agree / Partial Agree / Disagree | ||
| 45. | Confirm you will adjudicate multi-ingredient Compound Drug claims using the NCPDP D.0 standard. | Fully Agree / Partial Agree / Disagree | |
| 46. | For any Compound Drug claims submitted for reimbursement under the pharmacy benefit plan, you will require submission of the NDC for each individual ingredient in the Compound Drug to verify that the claim has been submitted in accordance with contractual and NCPDP standards. | Fully Agree / Partial Agree / Disagree | |
| 47. | You will collect the following elements for each Compound Drug claim from every pharmacy submitting a claim for a Compound Drug: |
1. Compound Indicator
2. NDC, Quantity, Submitted ingredient cost for each individual component in the recipe
3. Total Quantity and the total Usual & Customary price
| 4. Level of Effort value | Fully Agree / Partial Agree / Disagree | |
| 48. | Adjudication logic for each NDC in the Compound Drug claim recipe will be processed at the lowest of: |
i. The AWP minus the Brand Drug discount;
ii. The AWP minus the non-MAC discount;
iii. MAC (if applicable); or,
iv. The dispensing pharmacy’s submitted price.
| The lowest adjudicated price for each ingredient in the Compound Drug claim recipe will be combined to create a Total Compound Drug Claim Cost | Fully Agree / Partial Agree / Disagree | |
| 49. | EGID will reimburse you for each Compound Drug claim at the lowest of: |
i. The Total Compound Drug Claim Cost;
| ii. The pharmacy submitted Total Usual & Customary price; | Fully Agree / Partial Agree / Disagree | |||||
| 50. | As a standard practice, you will review each and every Compound Drug claim greater than $200 and complete an audit of the recipe when claims appear aberrant. | Fully Agree / Partial Agree / Disagree | ||||
| 51. | You will review all pharmacies that submitted a Compound Drug claim quarterly to be measured against peer groups to control for fraud, waste and abuse. | Fully Agree / Partial Agree / Disagree | ||||
| 52. | You cannot reclassify an existing specialty drug as non-specialty or non-specialty drug as specialty without mutual agreement between PBM and EGID, with justification. | Fully Agree / Partial Agree / Disagree | ||||
| 53. | Pricing for Specialty Drugs (excluding New to Market Limited Distribution Specialty Drugs) added to the list on or after 1/1/28 shall be equal to or greater than the respective brand or generic specialty Overall Effective Discount (OED) guarantee. | Fully Agree / Partial Agree / Disagree | ||||
| 54. | New to Market Limited Distribution Specialty Drugs may be defaulted to an initial rate for the first sixty (60) calendar days. After sixty (60) calendar days of acquiring access to a Limited Distribution Specialty Drug, you will renegotiate the price on the specialty drug list with EGID to a market competitive rate. | Fully Agree / Partial Agree / Disagree | ||||
| 55. | Split fills for specialty products will not be assessed two (2) dispensing fees. | Fully Agree / Partial Agree / Disagree | ||||
| 56. | Confirm your proposal (pricing discount guarantees, rebate guarantees, etc.) factors the impacts due to specialty biosimilars coming to the market and will not be adjusted further due to biosimilar impact. | Fully Agree / Partial Agree / Disagree | ||||
| 57. | Confirm your proposal (pricing discount guarantees, rebate guarantees, etc.) factors the impacts of the availability of rebates for all products that have experience a Wholesale Acquisition Cost (WAC) decrease before your submission (e.g., insulin products/other drugs impacted by the Inflation Reduction Act) and will not be adjusted further due to availability of rebates. | Fully Agree / Partial Agree / Disagree | ||||
| 58. | Confirm your proposal (pricing discount guarantees, rebate guarantees, etc.) factors the impacts of the availability of rebates for all products impacted by 2026 and 2027 Maximum Fair Price (MFP) updates and will not be adjusted further due to availability of rebates. Please ensure your response in the "Exclusions" or "Excl" tabs reflect this. | Fully Agree / Partial Agree / Disagree | ||||
| 59. | Would impacts due to the availability of rebates for all products impacted by MFP updates in 2028 and beyond result in changes minimum rebate guarantees? What process would PBM follow to remedy this? Please ensure your response in the "Exclusions" or "Excl" tabs reflect this. | Fully Agree / Partial Agree / Disagree | ||||
| Reconciliation of Discount and Dispensing Fee Guarantees | Format Type | Response | Explanation | |||
| 60. | All pricing discounts and dispensing fees guarantees will be reconciled on an individual component basis in each delivery channel comparing actual discounts and dispensing fees achieved with guaranteed discounts and dispensing fees. The reconciliation will be guaranteed dollar for dollar, meaning that a surplus in one pricing component will not be allowed to make up for a shortfall in another component within or across delivery channels. | Fully Agree / Partial Agree / Disagree | ||||
| 61. | You will calculate the achieved discounts with the following formula: [1-(total discounted AWP ingredient cost *excluding dispensing fees and penalties due to DAW claims and prior to application of copayments* of applicable prescription drug claims for the measurement period divided by total undiscounted AWP ingredient cost (both amounts will be calculated as of the date of adjudication) for the measurement/guarantee period)]. Discounted ingredient cost will always be the lowest of the AWP discount, MAC or U&C adjudication methodology. | Fully Agree / Partial Agree / Disagree | ||||
| 62. | You will measure and report quarterly the discount and dispensing fee performance for each delivery channel against the guaranteed discount and dispensing fee guarantees. | Fully Agree / Partial Agree / Disagree | ||||
| 63. | You will pay/credit EGID 100% of any shortfall for the brand, generic, specialty discount guarantees within ninety (90) calendar days from the close of each annual reconciliation period (with EGID retaining 100% of any additional savings achieved above each minimum guarantee and below each maximum guarantee). | Fully Agree / Partial Agree / Disagree | ||||
| 64. | If the reconciliation of any guaranteed discounts or dispensing fees result in a shortfall owed to EGID, you will not use Zero Balance Due claims, savings associated with any drug utilization review and/or step therapy programs (including brands to generics), DAW penalty amounts if the penalty applies to the member or make any other additional adjustments to offset the shortfall amount. | Fully Agree / Partial Agree / Disagree | ||||
| 65. | Brand Discount Guarantees. You will include all Brand Drugs in the brand drug discount guarantees. Brand drugs shall include single-source and multi-source brand drugs. You will not include any Generic Drugs (including but not limited to Single-Source Generics, House Generics, new to market generics, patent litigation generics, Authorized Generics and limited supply generics) in the brand discount guarantee nor reclassify any generics to adjudicate at the brand discount. | Fully Agree / Partial Agree / Disagree | ||||
| 66. | Generic Discount Guarantees. You will include all generics (including but not limited to generic drugs with an approved ANDA, Authorized Generics, House Generics, multi-source generics, generics subject to MAC pricing, new to market generics, Single-Source Generics, generics involved in patent litigation, and limited supply generics) in the overall generic discount and will not reclassify any Generics to adjudicate at the Brand Drug discount. You will not include any multi-source brand claims where a DAW penalty is assessed in the generic discount calculation. | Fully Agree / Partial Agree / Disagree | ||||
| 67. | Specialty Brand Discount Guarantees. You will include all Specialty Brand Drugs dispensed through your preferred Specialty Pharmacy (including but not limited to Biosimilars, new to market Specialty Drugs, Exclusive/Limited Distribution Specialty Drugs) in the Overall Effective Discount (OED). You will not include any specialty generic drugs in the OED calculation. | Fully Agree / Partial Agree / Disagree | ||||
| 68. | Specialty Generic Discount Guarantees. You will include all Specialty Generic Drugs dispensed through your preferred Specialty Pharmacy (including but not limited to Biosimilars, new to market Specialty Drugs, Exclusive/Limited Distribution Specialty Drugs) in the Overall Effective Discount (OED). You will not include any specialty Brand Drugs in the OED calculation. | Fully Agree / Partial Agree / Disagree | ||||
| 69. | In addition, your proposed specialty pricing will include varying ingredient cost discounts by Specialty Drug. The ingredient cost discount proposed for each specialty drug shall be guaranteed and you will adjudicate specialty claims filled in your preferred specialty pharmacy using the lesser of MAC or the "locked-in" drug discount. | Fully Agree / Partial Agree / Disagree | ||||
| 70. | You agree to include all Specialty Drugs dispensed at a Retail Pharmacy in the reconciliation of the non-specialty Retail 30 minimum Brand and Generic discount and dispensing fee guarantees in the "Rx-Pricing" Worksheet. | Fully Agree / Partial Agree / Disagree | ||||
| 71. | All Zero Balance Due claims (regardless of the delivery channel) will be reconciled at the adjudicated ingredient cost discount and will not be counted as AWP – 100%. EGID shall not be billed for any Zero Balance Due claims. | Fully Agree / Partial Agree / Disagree | ||||
| 72. | a. | Calculation of the Guaranteed Price shall only exclude the following types of claims: |
a. Compounds, bulk chemicals, powders;
b. Coordination of Benefit (CoB) claims;
c. Subrogation claims
d. Prescriptions filled at VA Hospitals
e. Claims processed at 340b pricing
f. EGID-Owned Pharmacy claims if pharmacy is not a Participating Pharmacy
| g. Out of Network Paper claims | Fully Agree / Partial Agree / Disagree | |||||
| b. | For the avoidance of doubt, all Claims not specifically outlined above or the 'RX-Pricing, Exclusions' as excluded will be included in the Guaranteed Price for purposes of discount and Dispensing Fee reconciliation. | Fully Agree / Partial Agree / Disagree | ||||
| 73. | Your will not pass on future increases in postage/mailing fees for your Mail Order Pharmacy and your preferred Specialty Pharmacy to EGID during the contract term. | Fully Agree / Partial Agree / Disagree | ||||
| 74. | You will adjudicate non-MAC generics with a discount that is higher than the minimum guaranteed discount for Brand Drugs in the same channel. Please specify your Non-MAC discount and dispensing fee guarantees in the "Rx-Pricing" worksheet. | Fully Agree / Partial Agree / Disagree | ||||
| 75. | Regardless as to whether an Agreement has been executed by a EGID, Vendor will measure, report, reconcile and pay any discount, dispensing fee shortfall as well as minimum guaranteed manufacturer payments in accordance with the terms specified below. | Fully Agree / Partial Agree / Disagree | ||||
| Reconciliation and Payment of Manufacturer Payment Guarantees | Format Type | Response | Explanation | |||
| 76. | Your offer will include Guaranteed Minimum Manufacturer Payments on a per Brand Drug paid prescription at Retail 30, Retail 90, "Mail at Retail"/Mail Order and Specialty Brand Claim basis | Fully Agree / Partial Agree / Disagree | ||||
| 77. | You will disclose all sources of Manufacturer Payments and Other Pharmaceutical Manufacturer Revenue. | Fully Agree / Partial Agree / Disagree | ||||
| 78. | Your proposed Guaranteed Minimum Manufacturer Payments are guaranteed minimums for the term of the agreement. | Fully Agree / Partial Agree / Disagree | ||||
| 79. | Your firm represents and warrants that it will not enter into any agreement with a pharmaceutical manufacturer for Manufacturer Payments with the impact to reduce or otherwise circumvent monies received from pharmaceutical manufacturers as being considered Manufacturer Payments. Furthermore, you will not require EGID to enroll in programs to receive Manufacturer Payments. | Fully Agree / Partial Agree / Disagree | ||||
| 80. | PBM agrees to pay EGID an amount greater of The Guaranteed Minimum Manufacturer Payment or 100% share of Manufacturer Payments received by PBM or PBM Affiliates. | Fully Agree / Partial Agree / Disagree | ||||
| 81. | a. | Calculation of the Guaranteed Minimum Manufacturer Payments shall only exclude the following types of Claims: |
a. Member submitted claims older than 180 days;
b. 100% Member Cost Share Program Claims
c. Subrogation claims
d. Claims processed at 340b pricing
| e. Vaccines in cases where the purchase price includes both the ingredient cost and the cost to administer the vaccine. | Fully Agree / Partial Agree / Disagree | |||||
| b. | For the avoidance of doubt, all Claims not specifically outlined above or within the 'RX-Pricing, Exclusions' worksheet as excluded will be included in the Rebate Guarantees and the Annual Rebate Guarantee Amount for purposes of reconciliation. Furthermore, EGID shall nevertheless receive the total amount of Manufacturer Payments received by PBM, if any, earned on the noted exclusions above or on the 'RX-Pricing, Exclusions' tab. | Fully Agree / Partial Agree / Disagree | ||||
| Please confirm the following: | ||||||
| 82. | You agree to pass-through 100% of Inflation Protection Payments to EGID | Fully Agree / Partial Agree / Disagree | ||||
| 83. | You agree to pass-through 100% of Manufacturer Administrative Fees to EGID | Fully Agree / Partial Agree / Disagree | ||||
| 84. | You agree to pass-through 100% of Rebates to EGID | Fully Agree / Partial Agree / Disagree | ||||
| 85. | You agree to pass-through 100% of Data Fees to EGID | Fully Agree / Partial Agree / Disagree | ||||
| 86. | You will provide an annual reconciliation of the 100% pass-through of Manufacturer Payments and the Guaranteed Minimum Manufacturer Payments. | Fully Agree / Partial Agree / Disagree | ||||
| 87. | The inclusion of copay assistance dollars, patient assistance funds and coupons in the measurement of Guaranteed Minimum Manufacturer Payment is not acceptable. Confirm that any monies collected from these programs are not included in the calculation of Manufacturer Payments and the Guaranteed Minimum Manufacturer Payment. | Fully Agree / Partial Agree / Disagree | ||||
| 88. | You will report and pay Guaranteed Minimum Manufacturer Payment amounts to EGID on a quarterly basis within sixty (60) calendar days after the end of the quarter, regardless of when the Manufacturer Payments are invoiced or collected. | Fully Agree / Partial Agree / Disagree | ||||
| 89. | At year end, you will reconcile the Manufacturer Payment pass-through percent against the Guaranteed Minimum Manufacturer Payments and provide documentation of your calculation and the result to EGID within one hundred twenty (120) calendar days from the end of each contract year. | Fully Agree / Partial Agree / Disagree | ||||
| 90. | You will pay any resulting credit to EGID automatically within one hundred fifty (120) calendar days after the end of each contract year without written request. | Fully Agree / Partial Agree / Disagree | ||||
| 91. | Any residual Manufacturer Payments received by PBM or PBM Affiliates, after initial invoice period, in excess of the Guaranteed Minimum Manufacturer Payments will be paid to EGID with PBM’s next payment cycle until Manufacturer Payments are no longer received by PBM or PBM Affiliates for EGID’s Claims utilization. | Fully Agree / Partial Agree / Disagree | ||||
| Credits/Allowances | Format Type | Response | Explanation | |||
| Please confirm your willingness to offer individual funds for the following: | ||||||
| 92. | You agree to provide an implementation allowance to assist in the onboarding of EGID including but not limited to: set-up charges, file charges, data feed exchange charges, eligibility charges etc. | Fully Agree / Partial Agree / Disagree | ||||
| 93. | Payment of the implementation allowance to EGID does not require EGID to submit receipts for reimbursable services; instead, the payment will be provided automatically sixty (60) calendar days after implementation. | Fully Agree / Partial Agree / Disagree | ||||
| 94. | An additional implementation support credit and implementation audit credit will be provided, if EGID increases membership during the contract term. | Fully Agree / Partial Agree / Disagree | ||||
| 95. | You agree to directly fund an annual audit allowance of $250,000 per year for EGID. | Fully Agree / Partial Agree / Disagree | ||||
| 96. | In addition to the allowances listed above, you agree to provide a separate Pharmacy Management Fund allowance to cover any additional costs incurred by EGID either directly through you or external costs related to the administration of the prescription drug program. | Fully Agree / Partial Agree / Disagree | ||||
| For sake of clarity, however not limited to, please confirm the willingness of the PMF to pay for the following: | ||||||
| 97. | Market Check | Fully Agree / Partial Agree / Disagree | ||||
| 98. | Audits (Benefit, Financial, Manufacturer Payment, Clinical, FWA etc.) | Fully Agree / Partial Agree / Disagree | ||||
| 99. | Clinical Programs and Utilization Management Fees (PAs, QL, Step Therapy) | Fully Agree / Partial Agree / Disagree | ||||
| 100. | Carve-out Fees (ex. third party file feeds/data exchanges) if applicable. | Fully Agree / Partial Agree / Disagree | ||||
| 93. | Procurement/Marketing Costs associated with this RFP | Fully Agree / Partial Agree / Disagree | ||||
| 94. | Health Initiatives (ex. Wellness credits) | Fully Agree / Partial Agree / Disagree | ||||
| 95. | Costs associated with a third party Health Benefits Administration Team. | Fully Agree / Partial Agree / Disagree | ||||
| 96. | You agree that any unused portion of the Pharmacy Management Fund in one period will carry over to the subsequent plan year. | Fully Agree / Partial Agree / Disagree | ||||
| Clinical Programs - Savings & Reporting | Format Type | Response | Explanation | |||
| 97. | You agree that clinical programs included in your financial proposal will have no shared savings, including Patient Assistance/Copay Card Programs. All fees will be explicit, capped and charged as an administrative fee on a monthly basis. | Fully Agree / Partial Agree / Disagree | ||||
| 98. | All proposed clinical programs will be guaranteed dollar-for-dollar, and EGID will receive 100% of any/all savings achieved in excess of any minimum guaranteed savings within ninety (90) calendar days from the end of each contract year. | Fully Agree / Partial Agree / Disagree | ||||
| 99. | All proposed utilization management programs will have a positive ROI for the entire time period they are in place. | Fully Agree / Partial Agree / Disagree | ||||
| 100. | You will provide the methodology for calculating ROI prior to the start of the program and will not change methodology during the life of the program without prior EGID consent. | Fully Agree / Partial Agree / Disagree | ||||
| 101. | Any savings achieved in excess from one clinical program will not be used to subsidize shortfalls in savings resulting from any other clinical program in any contract year. | Fully Agree / Partial Agree / Disagree | ||||
| 102. | You will exclude savings from Concurrent DUR and administrative edits, including but not limited to “refill too soon”, from any clinical savings guarantee. | Fully Agree / Partial Agree / Disagree | ||||
| 103. | You will provide quarterly performance reporting (activity and savings/outcomes) for EGID for all clinical programs, including fraud, waste, and abuse, within thirty (30) calendar days from the close of each quarter. | Fully Agree / Partial Agree / Disagree | ||||
| 104. | The reporting must clearly outline the performance of each individual clinical edit separately in addition to summary level reporting. | Fully Agree / Partial Agree / Disagree | ||||
| 105. | Savings assumptions must be based on EGID-specific utilization and not on book of business measures. | Fully Agree / Partial Agree / Disagree | ||||
| 106. | Savings reported will be direct savings associated with the pharmacy benefit and will not include any inferred medical savings. | Fully Agree / Partial Agree / Disagree | ||||
| 107. | You will provide a fixed fee per letter, if any, to provide and mail communications pieces to participants to help them lower costs (e.g., switching to generics, mail, etc.). | Fully Agree / Partial Agree / Disagree |
DropDown
| Included | Yes | Fully Agree | Yes | Complete | Wholly Owned | Confirmed | At least quarterly | Monthly | PM |
| Excluded | No | Partial Agree | No, Explain | Not Complete | Outsourced | Not Confirmed | At least semi-annually | Quarterly | PE |
| Included Channel Agnostic | Disagree | At least annually | Semi-Annually | PEPM | |||||
| Excluded Channel Agnostic | Other, specify | Annually | PMPM | ||||||
| Other, Explain |
RX-Pricing, Exclusions Comm
| Request for PBM Proposal (RFP) for EGID |
| RX-Pricing, Exclusions |
To Vendor: Use Columns E-G to provide a response as to whether the claim type listed in Column C is "INCLUDED" in the respective discount, dispensing fee, Manufacturer Payment guarantee. However if the length of the explanation is greater than 50 characters including spaces, you must use the "Explanation" worksheet to provide your detail explanation. Please note, your explanations must be limited to 400 characters or less
| Claim Exclusions | Response | Explanation | |||||
| Please confirm this exhibit will be included in the final contract. | Confirm | ||||||
| You understand that deviations from the Suggested Included/Excluded Guidelines in Columns H & I will result in adjustments to your financial offering. | Confirm | ||||||
| For the avoidance of doubt, all Claims not specifically outlined in the 'RX-Pricing, Exclusions' as excluded will be included in the Guaranteed Price for purposes of Discount and Dispensing Fee reconciliation. | Fully Agree / Disagree | ||||||
| For the avoidance of doubt, all Claims not specifically outlined as excluded will be included in the Manufacturer Payment Guarantees for purposes of reconciliation. Furthermore, Client shall receive the any Manufacturer Payment dollars received by PBM on any exclusions listed. | Fully Agree / Disagree | ||||||
| Please confirm the impact of HIV PrEP utilization has been accounted for in the proposed rebate guarantees. | Confirm | ||||||
| Claim Inclusion/Exclusion of Specific Claim Types | |||||||
| (THIS EXHIBIT WILL BE INCLUDED IN THE FINAL CONTRACT) | Discount and Dispensing Fee Guarantees | Manufacturer Payment Guarantees | |||||
| Format Type | Response | Response | Explanation | ||||
| 1. | Claims pursuant to a 100% Member Copayment Plan (see column J for clarification) | Included / Excluded, Explain | |||||
| 2. | 100% Member Paid Claims, Zero Plan Paid Claims (see column J for clarification) | Included / Excluded, Explain | |||||
| 3. | Anti-Nausea Drugs | Included / Excluded, Explain | |||||
| 4. | Authorized and Approved COVID-19 treatment Claims | Included / Excluded, Explain | |||||
| 5. | Biosimilar Drugs (Non-Specialty) | Included / Excluded, Explain | |||||
| 6. | Biosimilar Drugs (Specialty Drugs) | Included / Excluded, Explain | |||||
| 7. | Bulk Chemicals | Included / Excluded, Explain | |||||
| 8. | Claims approved by formulary exception | Included / Excluded, Explain | |||||
| 9. | Claims from Entities Eligible for Federal Supply Schedule Prices | Included / Excluded, Explain | |||||
| 10. | Claims older than 180 days | Included / Excluded, Explain | |||||
| 11. | 340B Claims | Included / Excluded, Explain | |||||
| 12. | Compound Drug Claims | Included / Excluded, Explain | |||||
| 13. | Coordination of Benefit (COB) / Secondary Payer | Included / Excluded, Explain | |||||
| 14. | Copay Assistance Program CLAIMS | Included / Excluded, Explain | |||||
| 15. | Copay Assistance Program DOLLARS | Included / Excluded, Explain | |||||
| 16. | Copay Maximizer Program CLAIMS | Included / Excluded, Explain | |||||
| 17. | Copay Maximizer Program DOLLARS | Included / Excluded, Explain | |||||
| 18. | COVID-19 Vaccines and administration | Included / Excluded, Explain | |||||
| 19. | COVID-19 test kits | Included / Excluded, Explain | |||||
| 20. | Discount Card Claims | Included / Excluded, Explain | |||||
| 21. | Dispense as Written (DAW) CLAIMS | Included / Excluded, Explain | |||||
| 22. | Dispense as Written (DAW) DOLLARS | Included / Excluded, Explain | |||||
| 23. | Diabetic Supplies (Meters, Strips, Syringes etc.) | Included / Excluded, Explain | |||||
| 24. | Exclusive/Limited Distribution Specialty Drugs for which you do not have access | Included / Excluded, Explain | |||||
| 25. | Exclusive/Limited Distribution Specialty Drugs that your specialty pharmacy has access | Included / Excluded, Explain | |||||
| 26. | Exclusive/Limited Distribution Specialty Drugs that only your specialty pharmacy has access | Included / Excluded, Explain | |||||
| 27. | Exclusive/Limited Distribution Specialty Drugs that are New to Market (NTM) | Included / Excluded, Explain | |||||
| 28. | Generic Specialty Drugs | Included / Excluded, Explain | |||||
| 29. | Hepatitis B Drugs | Included / Excluded, Explain | |||||
| 30. | Hepatitis C Drugs | Included / Excluded, Explain | |||||
| 31. | HIV Drugs | Included / Excluded, Explain | |||||
| 32. | Home Infusion Pharmacy or HIF | Included / Excluded, Explain | |||||
| 33. | Indian Health Services, Tribal or Urban Indian Health or I/T/U | Included / Excluded, Explain | |||||
| 34. | Insulin | Included / Excluded, Explain | |||||
| 35. | Long Term Care Pharmacy or LTC | Included / Excluded, Explain | |||||
| 36. | Low List Price Brand Drugs | Included / Excluded, Explain | |||||
| 37. | Maximum Fair Price Drugs (2026 MFPs) | Included / Excluded, Explain | |||||
| 38. | Maximum Fair Price Drugs (2027 MFPs) | Included / Excluded, Explain | |||||
| 39. | Maximum Fair Price Drugs (2028 MFPs) | Included / Excluded, Explain | |||||
| 40. | Maximum Fair Price Drugs (2029+ MFPs) | Included / Excluded, Explain | |||||
| 41. | Military Pharmacy | Included / Excluded, Explain | |||||
| 42. | Missing / Invalid Medi-Span data | Included / Excluded, Explain | |||||
| 43. | Most Favored Nation States | Included / Excluded, Explain | |||||
| 44. | Multi-Source Brand (MSB) Claims | Included / Excluded, Explain | |||||
| 45. | New to Market (NTM) Specialty Drugs | Included / Excluded, Explain | |||||
| 46. | No Bill, No Remit | Included / Excluded, Explain | |||||
| 47. | Non-Preferred Brand Drug Claims | Included / Excluded, Explain | |||||
| 48. | Onsite Pharmacy Utilization | Included / Excluded, Explain | |||||
| 49. | Out of Network Claims | Included / Excluded, Explain | |||||
| 50. | Over-the-Counter (OTC) Claims | Included / Excluded, Explain | |||||
| 51. | Paper or Member Submitted Claims | Included / Excluded, Explain | |||||
| 52. | PCSK-9 Inhibitor Claims | Included / Excluded, Explain | |||||
| 53. | Pharmacies subject to Region-specific Pricing | Included / Excluded, Explain | |||||
| 54. | Pharmacies that Do Not Meet your Discount or Credential standards | Included / Excluded, Explain | |||||
| 55. | Powders | Included / Excluded, Explain | |||||
| 56. | Repackaged National Drug Code (NDC) Claims | Included / Excluded, Explain | |||||
| 57. | Rural Pharmacies | Included / Excluded, Explain | |||||
| 58. | State mandated pharmacy reimbursement claims | Included / Excluded, Explain | |||||
| 59. | Subrogation Claims | Included / Excluded, Explain | |||||
| 60. | Transplant Drugs | Included / Excluded, Explain | |||||
| 61. | Usual and Customary (U&C) | Included / Excluded, Explain | |||||
| 62. | Vaccines (Seasonal, Non-Seasonal, Pandemic) | Included / Excluded, Explain | |||||
| 63. | Veteran Affairs Pharmacy or VA | Included / Excluded, Explain | |||||
| 64. | Weight Loss Drugs | Included / Excluded, Explain | |||||
| 65. |
RX-Pricing, Disc & DF Comm
| Request for PBM Proposal (RFP) for EGID |
| RX-Pricing, Discounts, Dispensing Fees, Administrative Fees |
Instructions: Please complete every cell on this worksheet. For retail, please propose pricing for your broadest retail network. Your financial offer MUST COMPLY with all Bidding Requirements and requirements in the Financial Questionnaire. Your pricing offer must be on a post-AWP rollback basis. All proposed terms are guaranteed including adjudication formulas.
| Identification Data |
| Vendor Name |
| ADMINISTRATIVE FEES | |||||
| Base Contract Term | Optional Contract Term | ||||
| Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | |
| Per Retail 30 Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Retail 90 Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Mail Order Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per LTC Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Indian Health, Tribal Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Home Infusion Pharmacy Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Territory Pharmacy Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Specialty Drug at Retail Pharmacy Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Specialty Drug at Specialty Pharmacy Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Vaccine Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Member Submit Paid Claim | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Onsite Claims (if applicable) | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Per Member Per Month (if applicable) | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Vaccine Administration Fees | |||||
| Base Contract Term | Optional Contract Term | ||||
| Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | |
| Seasonal | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| Non-Seasonal (including Pandemic) | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| RETAIL 30 (INCLUDING SPECIALTY FROM NON-PREFERRED SPECIALTY VENDORS) | |||||
| Rx with Day Supply of 1-83 | |||||
| Base Contract Term | Optional Contract Term | ||||
| Proposed Network Name | |||||
| Number of Pharmacies Nationwide | |||||
| Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | |
| Minimum AWP Discount Guarantees | |||||
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Drug Non-MAC Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Average Dispensing Fee per Paid Claim | |||||
| All Brands | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| All Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| RETAIL 90 (INCLUDING SPECIALTY FROM NON-PREFERRED SPECIALTY VENDORS) | |||||
| Rx with Day Supply +84 Days | |||||
| Base Contract Term | Optional Contract Term | ||||
| Proposed Network Name | |||||
| Number of Pharmacies Nationwide | |||||
| Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | |
| Minimum AWP Discount Guarantees | |||||
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Drug Non-MAC Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Maximum Dispensing Fee per Paid Claim | |||||
| All Brands | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| All Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| MAIL AT RETAIL (EXCLUDING SPECIALTY) | |||||
| Rx with Day Supply +84 Days | |||||
| Base Contract Term | Optional Contract Term | ||||
| Proposed Network Name | |||||
| Anchor Chains in Mail at Retail Network | |||||
| Number of Pharmacies Nationwide | |||||
| Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | |
| Minimum AWP Discount Guarantees | |||||
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Drug Non-MAC Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Maximum Dispensing Fee per Paid Claim | |||||
| All Brands | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| All Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| MAIL ORDER (EXCLUDING SPECIALTY DRUGS DISPENSED THROUGH YOUR PREFERRED SPECIALTY PHARMACY) | |||||
| Base Contract Term | Optional Contract Term | ||||
| Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | |
| Minimum AWP Discount Guarantees | |||||
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Drug Non-MAC Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Maximum Dispensing Fee per Paid Claim | |||||
| All Brands | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| All Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
| SPECIALTY DRUGS FILLED THROUGH NON-PREFERRED SPECIALTY VENDORS | |||||
| Base Contract Term | Optional Contract Term | ||||
| Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | |
| Open Network: | |||||
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Drug Non-MAC Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Exclusive Network: | |||||
| Brand Drug Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Effective Rate (MAC+Non-MAC) Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Generic Drug Non-MAC Discount Guarantee | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount | Insert AWP discount |
| Maximum Dispensing Fee per Paid Claim (Open and Exclusive) | |||||
| All Brands and Generics | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt | Insert Guaranteed Amt |
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