Exhibit A-14 - PBM Questionnaire.xlsx
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- Attached to
- Medical, Dental, Vision Insurance Services
- Solicitation number
- 2604-002
- Issued by
- Travis County, Austin City, Texas
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INTERNAL
| DO NOT USE THIS SECTION | CM Instructions: | ||||||||
| Sent out for Bid or Pre-Negotiation Project | Bid / Renewal | Fill out Blue and Orange | |||||||
| PBM for Pre-Negotiation Project | SAMPLE PBM | ||||||||
| DO NOT USE THIS SECTION | |||||||||
| PBM renewal is requested from | RENEWAL PBM | ||||||||
| ALWAYS FILL OUT | Analyst Instructions: | ||||||||
| Group Legal Name | Central Health System | Analyst toggle formulary disruption to correct type in Internal tab | |||||||
| Title of This Document | Exhibit A-14 PBM Questionnaire.xlsx | Add all NDCs from last 6 months to Formulary Disruption | |||||||
| Is this a renewal request ONLY or a bid situation? | Bid Situation | (Always Bid Situation for now) | -Ensure Formulary Disruption TYPE is toggled to the correct version in cell D20 on this tab | ||||||
| Are we using a pre-negotiated contract for 9-10? | No | (Always no for now) | Add all brand OR specialty NDCs to tabs 8a and 8b | ||||||
| Is this a PATH group? | No | Hide Internal | |||||||
| If not PATH, confirm Data Lake should be included | Yes | Lock down tabs (Tabs SHOULD be already set up to protect with the below specifications, but check) | "Select unlocked" ONLY for tabs 1b, 9, 10, RecTemplate | ||||||
| Are we requesting PMF? | No | "Selected unlocked" and "Select locked" for rest of tabs (2-8b) | |||||||
| If requesting, amount of PMF | |||||||||
| Lock down WORKBOOK | |||||||||
| FILL OUT FOR RFP BID REQUESTS ONLY | |||||||||
| Fees/Credits | Formulary Disruption TYPE: Tier or P/NP | Tier Level | Analyst responsible for toggle | ||||||
| Email 1 (Typically RD, if only providing 1 email use this) | Required | ||||||||
| Email 2 (Typically CM) | Leave blank if you don't want a second individual receiving intent to bid emails | ||||||||
| Implementation Credit Amount | $10,000 | RD Emails | |||||||
| Implementation Credit Due Date | Q1 2027 | Generated automatically, check results | Karen.Springstead@MarshMMA.com | ||||||
| SPD Credit Amount | $7,500 | Employees | RFP Fee | Imp Cred | SPD Cred | PMF | Eric.Nedelkoff@MarshMMA.com | ||
| Client or Prospect | Client | < 500 | $2,000 | $2,000 | $5,000 | N/A | Scott.Hyland@MarshMMA.com | ||
| Group Information | Current Renewal Date | 1/1/27 | 500 - 999 | $5,000 | $5,000 | $5,000 | N/A | Ken.Rose@MarshMMA.com | |
| Current Medical Carrier/TPA | Aetna | 1,000 - 2,499 | $10,000 | $10,000 | $5,000 | $10,000 | David.Heaton@MarshMMA.com | ||
| Current PBM | Aetna/CVS | 2,500 - 4,999 | $25,000 | $25,000 | $5,000 | $25,000 | Myong.Shipman@MarshMMA.com | ||
| Currently Carved-Out or Carved-In? | Carved-In | 5,000 - 9,999 | $50,000 | $50,000 | $5,000 | $50,000 | Chris.Hollman@MarshMMA.com | ||
| Current Formulary Name | Aetna Standard Formulary | 10,000+ | Custom | Custom | Custom | Custom | Apryl.Sawey@MarshMMA.com | ||
| Current Formulary Administration | Managed | Rick.Kelly@MarshMMA.com | |||||||
| Current Plan Design(s) | PPO, HDHP | Sherri.Eaddy@MarshMMA.com | |||||||
| ERISA Status (ERISA or Non-ERISA) | Non-ERISA | Brandon.Crosby@MarshMMA.com | |||||||
| Healthcare Reform Status | Non-Grandfathered | Jeremy.Meyer@MarshMMA.com | |||||||
| Plan State HQ | Texas | ||||||||
| Industry | Health Care | ||||||||
| Total Enrolled Employees | 2,000 | ||||||||
| Total Member Count | 3,399 |
| Extra Notes on this Client you want to pull forward to tab 1b: | CM Emails | |
| Leave blank if no extra notes are needed | Sherri.Eaddy@MarshMMA.com | |
| Adrienne.Calcote@MarshMMA.com | ||
| Lisa.b.Richard@Marshmma.com | ||
| Taylor.Kirkhart@MarshMMA.com | ||
| Julia.Hernandez@MarshMMA.com | ||
| Emilie.Nelson@MarshMMA.com |
TOC
| Tab Number | Tab Description & Link |
| 1b | Key Confirmations, RFP Fee, Credit Requests |
| 2 | Discounts, Dispensing Fees, Rebates |
| 3 | Fees and Credits |
| 4 | Formulary Disruption |
| 5 | Network Disruption |
| 6 | Biosimilars |
| 7 | AMP Cap |
| 8a | Brand Drug Strategy Details |
| 8b | Program Details |
| 9 | Contract Terms Part 1 |
| 10 | Contract Terms Part 2 |
Named Ranges
| Drop Down Named Ranges - All Start with "DD" | Named Cell Log for Macro Extraction | |||||
| Confirmed | Internal Tab | |||||
| Not Confirmed | INT.ClientName | Client Name | ||||
| INT.Renewal_OR_BidSituation | Indicates if renewal request only or bid exercise | |||||
| Yes | INT.Tier_Or_PNP | Indicates type of formulary disruption for bid exercise | ||||
| No | INT.RDEmail | RD Email | ||||
| INT.CMEmail | CM Email | |||||
| Specialty | INT.RFP_Fee_Amount | Amount of RFP fee requested in bid exercise | ||||
| Non-Specialty | INT.RFP_Fee_Due | Requested due date RFP fee | ||||
| INT.Impl_Cred_Amount | Amount of implementation credit requested | |||||
| Preferred | INT.Impl_Credit_Date | Requested due date of implementation credit | ||||
| Non-Preferred | INT.SPD_Credit_Amount | Amount of SPD related credit requested | ||||
| INT.Client_Prospect | Client or prospect | |||||
| In-House | INT.Bid_Eff_Date | Effective date of bid requested - bid exercise only | ||||
| External Vendor | INT.MedCarrier_TPA | Current medical carrier or TPA | ||||
| INT.IncumbentPBMForBid | Incumbent PBM for bid | |||||
| Yes | INT.CarveIn_CarveOut | If group is currently carved-in or out | ||||
| No, not offering this program | INT.Form_Type | Formulary type | ||||
| No, the program cost is included in the base PBM administrative fee | INT.Form_Admin | Formulary administration | ||||
| No, the cost of the program is included in the cost of the sourced drugs.For clarity, do not select this if you are charging a shared savings fee. | INT.PlanDesigns | Summary of current plan designs | ||||
| INT.ERISA | ERISA or Non-ERISA | |||||
| Shared Savings Percentage: | ||||||
| Estimated lost rebate value not included in calculation of savings | INT.Healthcare_Reform | Grandfathered or Non-Grandfathered | ||||
| Shared Savings Percentage: | ||||||
| Estimated lost rebate value included in calculation of savings | INT.Plan_State_HQ | Plan headquarter state | ||||
| PEPM | INT.Industry | Industry | ||||
| PMPM | INT.Enrollment_BidSituation | Enrollment provided by MMA RxS in bid exercise | ||||
| Per Claim | INT.Membership_BidSituation | Membership provided by MMA RxS in bid exercise | ||||
| Flat | INT.PreNegORBidMode | Template being used for pre-negotiation project or seeking client specific bid or renewal - helps generate PBM name throughout template | ||||
| Other | INT.PBMForPreNeg | PBM Name if using template for pre-negotiation project | ||||
| INT.PreNeg8_10 | If we are sending out bid/renewal request with pre-negotiated terms filled out on Tabs 8-10 | |||||
| Brand | INT.Path | If group is with PATH (for data lake inclusion) | ||||
| Generic | INT.DataLakeIncl | Available to turn off data lake inclusion for reasons other than PATH | ||||
| N/A - Not Offering Rebate Guarantees | INT.DocTitle | Document title when not using template for pre-negotiated terms | ||||
| INT.PMFRequested | Yes/No if we are requesting PMF (applies for either renewal or RFP) | |||||
| Specialty | INT.PMFAmountRequested | Amount of PMF requested in either renewal or RFP | ||||
| Non-Specialty | INT.RenewalPBM | PBM renewal is requested from | ||||
| N/A - Not Offering Rebate Guarantees | ||||||
| Tab 1a: Renewal Confirmation | ||||||
| LDD | Tab1a.All_Info | Flexible range returning all questions and answers from PBM providing renewal | Formula: OFFSET('1a'!$B$8,0,0,LOOKUP(2,1/('1a'!$B:$B<>""),ROW('1a'!$B:$B))-MATCH(TRUE, INDEX(('1a'!$B:$B<>""), 0), 0)+1,4) | |||
| Non-LDD | Tab1a.Enrollment_Renewal | Enrollment provided by PBM for renewal request | ||||
| LDDs are not Excluded from Rebates | Tab1a.Membership_Renewal | Membership provided by PBM for renewal request | ||||
| N/A - Not Offering Rebate Guarantees | ||||||
| Tab 1b: Bid Info | ||||||
| < 30 Days | Tab1b.All_Info | Flexible range returning all questions and answers from bidding PBM | Formula: =OFFSET('1b'!$B$11,0,0,LOOKUP(2,1/('1b'!$B:$B<>""),ROW('1b'!$B:$B))-MATCH(TRUE, INDEX(('1b'!$B:$B<>""), 0), 0)+1,4) | |||
| 30 Days | Tab 1b.BiddingPBMID | Bidding PBM Cell only within All_Info | ||||
| 60 Days | Tab 2: Financials | |||||
| 90 Days | Tab2.QuoteInfo.Labels | Summary info about quote - LABELS | ||||
| Other | Tab2.QuoteInfo.Labels | Summary info about quote - VALUES | ||||
| Tab2.AreExternalVendorsIncl | Yes / No for if external vendors are included | |||||
| Component-by-component: An overperformance in a channel guarantee cannot be used to offset an underperformance in any other channel guarantee. | Tab2.ListVendorsIncluded | Table of vendors included in proposal | ||||
| With offsetting within channels: An overperformance in a channel guarantee can by used to offset underperformances in certain other channel guarantees. |
| E.g. An overperformance in the Retail Brand Discount guarantee can offset a shortfall in the Retail Generic Discount guarantee, but cannot offset a shortfall in the Mail Generic Discount guarantee. If this option is selected, please provide a complete description of guarantee offsetting allowed within the contract. | Tab2.RebateQsLabels | Structure of rebate offer - LABELS | ||||
| In aggregate: An overperformance in a channel guarantee can be used to offset underperformances in any other channel guarantee. | Tab2.RebateQsValues | Structure of rebate offer - VALUES | ||||
| Other | Tab2.RebatesChannelLabels | Channel labels for rebate offer | ||||
| Tab2.RebatesEligibleRxs | PBM eligible scripts by channel | |||||
| Component-by-component: An overperformance in a channel guarantee cannot be used to offset an underperformance in any other channel guarantee. | Tab2.RebatesGuaranteed | Value of minimum guarantees by channel | ||||
| In aggregate: An overperformance in a channel guarantee can be used to offset underperformances in any other channel guarantee. | Tab2.RebatesPBMCalcTotals | Total rebates by channel calculated by PBM | ||||
| Other | Tab2.RebatesEstPassThrough | PBM estimated rebate passed through in total by channel | ||||
| Tab2.DiscountStructureLabels | Structure of discount offer - LABELS | |||||
| 3 Months | Tab2.DiscountStructureValues | Structure of discount offer - VALUES | ||||
| 6 Months | Tab2.DiscDispChannelLabels | Channel labels for discount & disp fee offer | ||||
| > 6 Months | Tab2.DiscDispRates1 | Values of guaranteed (or estimated) discounts & disp fee by channel | ||||
| Other | Tab2.DiscDispRates2 | Values of estimated pass through discounts if pass through with guarantees | ||||
| Biosimilars are considered to be specialty brand claims for purposes of rebate guarantees | ||||||
| Biosimilars are excluded from all rebate guarantees | Tab 3: Fees & Credits | |||||
| Tab3.FeeLabels | Requested fees - LABELS | |||||
| Included in Minimum Channel Guarantees | Tab3.FeeBasis | Requested fees - BASIS | ||||
| Excluded from Minimum Channel Guarantees | Tab3.FeeAmounts | Requested fees - VALUES | ||||
| Bid does not include Minimum Channel Guarantees | Tab3.FeeBasisIfOther | Requested fees - BASIS IF OTHER | ||||
| Tab3.FeeOtherInfo | Other info collected on requested fees | |||||
| Included in Minimum Per-Script Channel Guarantees | Tab3.CreditsLabels | Requested credits - LABELS | ||||
| Excluded from Minimum Per-Script Channel Guarantees | Tab3.CreditBasis | Requested credits - BASIS | ||||
| Bid does not include Minimum Per-Script Channel Guarantees | Tab3.CreditsAmounts | Requested credits - VALUES | ||||
| Tab3.CreditBasisIfOther | Requested credits - BASIS IF OTHER | |||||
| The minimum rebate guarantee varies for Specialty Mail and Specialty Retail claims and will be broken out as such on the Financials tab | Tab3.CreditsOtherInfo | Other info collected on requested credits | ||||
| Aggregate specialty rebate guarantee applies to both Specialty Mail and Specialty Retail Claims | ||||||
| Specialty Retail claims are excluded from rebate guarantees | Tab 4: Formulary Disruption | |||||
| Specialty Retail claims earn the non-specialty rebate guarantees | Tab4.FormDisSum | Formulary disruption summary table | ||||
| Tab4.FormDisDetail | Full grid of NDC-11 level detail on formulary disruption | Formula: OFFSET('4'!$B$22,0,0,COUNTA('4'!$B$22:$B$200001),9) | ||||
| LDDs are not subject to any discount guarantee | ||||||
| LDDs are included in the specialty discount guarantees | Tab 5: Network Disruption | |||||
| LDDs are included in their own separate "LDD Discount Guarantee" | Tab5.NetworkDisSum | Network disruption summary table | ||||
| Tab5.NetworkDisDetail | Full grid of pharmacies excluded from PBM network | Formula: OFFSET('5'!$B$19,0,0,COUNTA('5'!$B$19:$B$219142),8) | ||||
| Confirmed | ||||||
| The minimum rebate guarantees will be trued up to the value of the earned rebates received from pharma, but no upfront rebate credit will be provided on employer's invoices. | Tab 6: Biosimilar Details | |||||
| The minimum rebate guarantees represent the full rebate offer and no true up will be provided. | Tab6.HumiraQuestions | Questions on Humira formulary status | ||||
| Tab6.HumiraAnswers | Responses on Humira formulary status | |||||
| Confirmed | Tab6.HumiraChangesExpected | If PBM expects changes to Humira formulary status | ||||
| Not Confirmed, but agree to proposed terms for making updates and sharing lists with MMA Rx Solutions | Tab6.HumiraNDCLevel | Humira biosimilars formulary & NDC mix expectations | Formula: =OFFSET('6'!$C$35,0,0,COUNTA('6'!$C$35:$C$200001),3) | |||
| Not Confirmed | Tab6.StelaraQuestions | Questions on Stelara formulary status | ||||
| Tab6.StelaraAnswers | Responses on Stelara formulary status | |||||
| Q4 2025 | Tab6.StelaraChangesExpected | If PBM expects changes to Stelara formulary status | ||||
| Q1 2026 | Tab6.StelaraNDCLevel | Stelara biosimilars formulary & NDC mix expectations | Formula: =OFFSET('6'!$J$35,0,0,COUNTA('6'!$J$35:$J$200001),3) | |||
| Q2 2026 | ||||||
| Q3 2026 | Tab 7: AMP Cap | |||||
| Q4 2026 | Tab7.AMPCapGrid | AMP Cap NDCs impacted and PBM rebate strategy | Formula: OFFSET('7'!$B$9,0,0,COUNTA('7'!$B$9:$B$203069),4) | |||
| Q1 2027 | ||||||
| Q2 2027 | Tab 8a: Brand Drug Strategy | |||||
| Q3 2027 | Tab8a.BDS_Detail | Returns table of bucketing for rebate purposes by NDC | Formula: OFFSET('8a'!$B$8,0,0,COUNTA('8a'!$B$8:$B$286827),6) | |||
| Q4 2027 | ||||||
| Q1 2028 | Tab 8b: Brand Drug Strategy (RFP) | |||||
| Q2 2028 | Tab8b.AltFundSum | Summary of programs offered, fees, HDHP strategy | ||||
| Q3 2028 | Tab8b.AltFund_Detail | Returns table of programs and bucketing for rebate purposes by NDC | Formula: OFFSET('8b'!$B$21,0,0,COUNTA('8b'!$B$21:$B$287361),6) | |||
| Q4 2028 | ||||||
| Tab 9: Contract Structure Part I | ||||||
| Renewal Request Only | Tab9.A.EnshrinedASA | Confirmation that PBM will enshrine our RFP in client ASA | ||||
| Bid Situation | Tab9.B.ContractTerm | 12 month term, termination penalties | ||||
| Tab9.C.GteeStructure | Structure of discount & rebate guarantees | |||||
| Managed with Exclusions | Tab9.D.ContractRevisions | Rights to revise terms | ||||
| Open Formulary | ||||||
| Tab 10: Contract Structure Part II | ||||||
| Minimum Guarantees Only | Tab10.A.ReconciliationTerms | Discount and rebate reconciliation terms | ||||
| Pass Through Rebates Only - 100% | Tab10.B.Definitions | Confirmation of key definitions | ||||
| Pass Through Rebates Only - Other % | Tab10.C.PricingConsiderations | Confirmation of key pricing considerations | ||||
| Greater of Minimum Guarantees and 100% of Earned Rebates | Tab10.D.DiscExcl | Discount exclusions | ||||
| Greater of Minimum Guarantees and Other % of Earned Rebates | Tab10.E.RebateExcl | Rebate exclusions | ||||
| Greater of Minimum Guarantees, 100% of Earned Rebates, and Upfront Rebate Credit | ||||||
| Greater of Minimum Guarantees, Other % of Earned Rebates, and Upfront Rebate Credit | ||||||
| Minimum Guarantees AND Separate Upfront Rebate Credit | ||||||
| Other, please provide details | ||||||
| Estimates | ||||||
| Guarantees | ||||||
| Aggregate Specialty Rebate Guarantee | ||||||
| Specialty Retail and Specialty Mail | ||||||
| Specialty Mail Only, Specialty Retail Claims Earn Non-Specialty Guarantee | ||||||
| Spread Pricing | ||||||
| Pass Through Pricing with No Discount Guarantees | ||||||
| Pass Through Pricing with Discount Guarantees | ||||||
| Brands | ||||||
| Generics | ||||||
| Aggregate Dispensing Fee Guarantee | ||||||
| Separate Guarantees for Brand and Generic | ||||||
| Aggregate Specialty Dispensing Fee Guarantee | ||||||
| Specialty Retail and Specialty Mail Dispensing Fees | ||||||
| Specialty Mail Dispensing Fee Only, No Guarantee for Specialty Retail Dispensing Fees | ||||||
| Specialty Mail Dispensing Fee Only, Specialty Retail Claims Subject to Non-Specialty Dispensing Fee Guarantees | ||||||
| No Specialty Dispensing Fee Guarantees are Offered | ||||||
| Aggregate Specialty Discount Guarantee | ||||||
| Specialty Brand and Specialty Generic Discount Guarantees | ||||||
| Specialty Retail and Specialty Mail Discount Guarantees | ||||||
| Specialty Mail Brand, Specialty Mail Generic, Specialty Retail Brand, Specialty Retail Generic | ||||||
| No Specialty Discount Guarantees are Offered | ||||||
| Specialty Retail Claims are Included in the Applicable Specialty Discount Guarantee Outlined Below | ||||||
| Specialty Retail Claims are Included in the Applicable Retail (Non-Specialty) Discount Guarantee Outlined Below | ||||||
| Specialty Retail Claims are Excluded from all Discount Guarantees | ||||||
| LDDs are Included in the Applicable Specialty Discount Guarantee Outlined Below | ||||||
| Separate LDD Discount Guarantee | ||||||
| No Guarantee is Available on LDDs | ||||||
| PMPM | ||||||
| PEPM | ||||||
| Per Script | ||||||
| Per PA Review | ||||||
| Flat Amount | ||||||
| Per Script in Specific States | ||||||
| Other | ||||||
| Included in Pharmacy Admin Fee | ||||||
| Included in Clinical Fee / UM Fee | ||||||
| PMPM | ||||||
| PEPM | ||||||
| Per Script | ||||||
| Per PA Review | ||||||
| Flat Amount | ||||||
| Per Script in Specific States | ||||||
| Other | ||||||
| We do not charge a state-based fee | ||||||
| Included in Pharmacy Admin Fee | ||||||
| Included in Clinical Fee / UM Fee | ||||||
| PMPM | ||||||
| PEPM | ||||||
| Per Script | ||||||
| Per PA Review | ||||||
| Flat Amount | ||||||
| Per Script in Specific States | ||||||
| Other | ||||||
| In addition to minimum rebate guarantee offer | ||||||
| True up to greater of: 1) upfront rebate credit and 2) minimum rebate guarantees and/or earned rebate value | ||||||
| Full amount credited to group's invoice | ||||||
| Reimbursement for expenses reported | ||||||
| 1 | ||||||
| 2 | ||||||
| 3 | ||||||
| 4 | ||||||
| 5 | ||||||
| Excluded | ||||||
| Preferred | ||||||
| Non-Preferred | ||||||
| Excluded | ||||||
| Yes | ||||||
| No, not offering this program | ||||||
| No, the program cost is included in the base PBM administrative fee | ||||||
| No, the cost of the program is included in the cost of the sourced drugs. For clarity, do not select this if you are charging a shared savings fee. | ||||||
| Shared Savings Percentage: Estimated lost rebate value not included in calculation of savings | ||||||
| Shared Savings Percentage: Estimated lost rebate value included in calculation of savings | ||||||
| PEPM | ||||||
| PMPM | ||||||
| Per Claim | ||||||
| Flat | ||||||
| Other | ||||||
| Tier Level | ||||||
| Preferred / Non-Preferred | ||||||
| 3. For purposes of the New Formulary Tier column, please use the following guidelines: | ||||||
| a. Excluded NDCs should be non-covered drugs with no path to fill outside of medical necessity | ||||||
| b. Please note that this column only takes the numerical values 1-5 and 'Excluded'. To avoid errors, if you are pasting values into this column, please ensure that these are the only values being pasted | ||||||
| 3. For purposes of the New Formulary Status column, please use the following guidelines: | ||||||
| a. Non-Preferred NDCs should be covered benefits that may have higher member copays, coinsurance factors, etc., | ||||||
| b. Excluded NDCs should be non-covered drugs with no path to fill outside of medical necessity, | ||||||
| c. Please note that this column only takes the values 'Preferred', 'Non-Preferred', and 'Excluded'. To avoid errors, if you are pasting values into this column, please ensure that these are the only values being pasted | ||||||
| Pharmacy Only | ||||||
| Pharmacy and Medical | ||||||
| PEPM | ||||||
| PMPM | ||||||
| Incumbent PBM | ||||||
| Not the Incumbent PBM | ||||||
| All Humira biosimilars are considered brand for purposes of discount guarantees | ||||||
| All Humira biosimilars are considered generic for purposes of discount guarantees | ||||||
| Response to the brand / generic definition item above applies to Humira biosimilars for purposes of discount guarantees | ||||||
| Other | ||||||
| Humira biosimilars are eligible for the discount & dispensing fee guarantees | ||||||
| Humira biosimilars are excluded from the discount & dispensing fee guarantees | ||||||
| Other | ||||||
| All Humira biosimilars are considered specialty for purposes of discount guarantees | ||||||
| All Humira biosimilars are considered non-specialty for purposes of discount guarantees | ||||||
| Other | ||||||
| All Stelara biosimilars are considered brand for purposes of discount guarantees | ||||||
| All Stelara biosimilars are considered generic for purposes of discount guarantees | ||||||
| Response to the brand / generic definition item above applies to Stelara biosimilars for purposes of discount guarantees | ||||||
| Other | ||||||
| Stelara biosimilars are eligible for the discount & dispensing fee guarantees | ||||||
| Stelara biosimilars are excluded from the discount & dispensing fee guarantees | ||||||
| Other | ||||||
| All Stelara biosimilars are considered specialty for purposes of discount guarantees | ||||||
| All Stelara biosimilars are considered non-specialty for purposes of discount guarantees | ||||||
| Other | ||||||
| All Humira biosimilars are considered brand for purposes of minimum rebate guarantees | ||||||
| All Humira biosimilars are considered generic for purposes of minimum rebate guarantees | ||||||
| Response to the brand / generic definition item above applies to Humira biosimilars for purposes of minimum rebate guarantees | ||||||
| Other | ||||||
| Humira biosimilars are eligible for the minimum rebate guarantees | ||||||
| Humira biosimilars are excluded from the minimum rebate guarantees | ||||||
| Other | ||||||
| All Humira biosimilars are considered specialty for purposes of minimum rebate guarantees | ||||||
| All Humira biosimilars are considered non-specialty for purposes of minimum rebate guarantees | ||||||
| Other | ||||||
| All Stelara biosimilars are considered brand for purposes of minimum rebate guarantees | ||||||
| All Stelara biosimilars are considered generic for purposes of minimum rebate guarantees | ||||||
| Response to the brand / generic definition item above applies to Stelara biosimilars for purposes of minimum rebate guarantees | ||||||
| Other | ||||||
| Stelara biosimilars are eligible for the minimum rebate guarantees | ||||||
| Stelara biosimilars are excluded from the minimum rebate guarantees | ||||||
| Other | ||||||
| All Stelara biosimilars are considered specialty for purposes of minimum rebate guarantees | ||||||
| All Stelara biosimilars are considered non-specialty for purposes of minimum rebate guarantees | ||||||
| Other | ||||||
| Offering a discount guarantee on new to market drugs | ||||||
| Not offering a discount guarantee on new to market drugs | ||||||
| All HIV drugs are considered specialty for discount and dispensing fee purposes | ||||||
| All HIV drugs except HIV PreP products (Truvada, Descovy, Apretude) are considered specialty for discount and dispensing fee purposes | ||||||
| All HIV drugs are considered non-specialty for discount and dispensing fee purposes | ||||||
| All HIV drugs are considered specialty for minimum rebate guarantee purposes | ||||||
| All HIV drugs except HIV PreP products (Truvada, Descovy, Apretude) are considered specialty for minimum rebate guarantee purposes | ||||||
| All HIV drugs are considered non-specialty for minimum rebate guarantee purposes | ||||||
| Confirmed - no rebate crediting on Humira biosimilars | ||||||
| Not Confirmed | ||||||
| Confirmed - no rebate crediting on Stelara biosimilars | ||||||
| Not Confirmed | ||||||
| Confirmed - no rebate crediting on AMP Cap drugs with price reductions effective in 2024 | ||||||
| Not Confirmed | ||||||
| Confirmed - no rebate crediting on AMP Cap drugs with price reductions effective in 2025 | ||||||
| Not Confirmed | ||||||
| Confirmed - no rebate crediting on AMP Cap drugs with price reductions effective in 2026 | ||||||
| Not Confirmed | ||||||
| This bid does not include any PMPM guarantee, trend guarantee, savings guarantee, or similar financial guarantee related to total cost during the contract period. | ||||||
| This bid includes a PMPM guarantee, trend guarantee, savings guarantee, or similar guarantee related to total cost during the contract period. The provided discount, dispensing fee, and rebate guarantees are guaranteed and reconcilable regardless of whether the PMPM guarantee is met. | ||||||
| This bid includes an optional PMPM guarantee, trend guarantee, savings guarantee, or similar guarantee related to total cost during the contract period. Opting into this guarantee will result in some or all discount, dispensing fee, and/or rebate guarantees being altered, reduced, removed, or no longer being reconcilable in the case that the optional PMPM guarantee, trend guarantee, savings guarantee, or similar guarantee related to total cost during the contract period is achieved. | ||||||
| This bid includes a PMPM guarantee, trend guarantee, savings guarantee, or similar guarantee related to total plan during the contract period. Some or all of the provided discount, dispensing fee, and/or rebate guarantees are no longer guaranteed and reconcilable if the PMPM guarantee, trend guarantee, savings guarantee, or similar is achieved. | ||||||
| Bid / Renewal | ||||||
| Pre-Negotiation Project | ||||||
| Confirmed | ||||||
| Not Confirmed | ||||||
| N/A - I am a medical carrier / TPA. | ||||||
| All employers, regardless of number of employees, are permitted | ||||||
| > 500 | ||||||
| > 1,000 | ||||||
| Other | ||||||
| We produce a fully prepared SPD for pharmacy benefits for each client | ||||||
| We do not produce a fully prepared SPD, but agree to the credit and associated terms | ||||||
| We do not produce a fully prepared SPD, and do not agree to the credit and associated terms | ||||||
| Pay cost share dictated by benefit design | ||||||
| Members always pay $0 | ||||||
| Plan sponsor choice | ||||||
| Mandatory | ||||||
| Optional | ||||||
| Plan sponsor choice | ||||||
| All employers, regardless of number of employees, are permitted | ||||||
| > 500 | ||||||
| > 1,000 | ||||||
| N/A - carve-out PBM | ||||||
| Other | ||||||
| Confirmed | ||||||
| Not Confirmed - upfront rebate credit is calculated on a PEPM basis | ||||||
| Not Confirmed - upfront rebate credit is calculated on a flat total monthly credit basis | ||||||
| Not Confirmed - no upfront credit will be provided | ||||||
| Other | ||||||
| Retail | ||||||
| Specialty | ||||||
| Shared Savings Percentage | ||||||
| PEPM | ||||||
| PMPM | ||||||
| Per Claim | ||||||
| Flat | ||||||
| Other | ||||||
| Confirmed | ||||||
| Not Confirmed - Specialty Retail Claims are Ineligible for Rebate Guarantees | ||||||
| Not Confirmed - Specialty Retail Claims are Eligible for Non-Specialty Rebate Guarantees | ||||||
| Specialty Retail Claims earn their own separate Specialty Retail Rebate Guarantee | ||||||
| Other |
1a
| Client Identification (1 of 6) | |||
| Please indicate the name of the employer for whom this proposal is prepared. | 1000 | Central Health System | |
| . | |||
| PBM Identification (2 of 6) | |||
| Please indicate the name of the PBM filling out the response in the grey box. | 1001 | RENEWAL PBM | |
| . | |||
| Confirmation of Effective Date (3 of 6) | |||
| Please confirm the date the proposal will go into effect. | 1002 | Please Complete all Questions | |
| . | |||
| Current Enrollment & Membership Counts (4 of 6) | |||
| Please provide the total enrolled employees at the time of this bid. | 1003 | Please Complete all Questions | |
| Please provide the total members at the time of this bid. | 1004 | Please Complete all Questions | |
| . | |||
| MMA Rx Solutions Pre-Negotiated Contract Terms Agreement (5 of 6) | |||
| N/A, Please continue to the next section | 1005 |
| . | |
| Pharmacy Management Fund (6 of 6) | |
| N/A | 1007 |
1b
| Bidding PBM Identification (1 of 7) | Information Provided by MMA Rx Solutions | |||
| Please indicate the name of the PBM filling out the response in the grey box. | 1008 | Please Complete all Questions | ||
| Group Legal Name | Central Health System | |||
| MMA Rx Solutions Pre-Negotiated Contract Terms Agreement (2 of 7) | Client or Prospect | Client | ||
| N/A, Please continue to the next section | 1009 | Current Renewal Date | 1/1/27 | |
| Current Medical Carrier/TPA | Aetna | |||
| Carrier / TPA Relationship (3 of 7) | Current PBM | Aetna/CVS | ||
| Please confirm if you currently work with this group's medical carrier / TPA: Aetna. | 1010 | Please Complete all Questions | Currently Carved-Out or Carved-In? | Carved-In |
| Current Formulary Type | Aetna Standard Formulary | |||
| Current Formulary Administration | Managed | |||
| Implementation Credit (4 of 7) | Current Plan Design(s) | PPO, HDHP | ||
| By agreeing to provide a proposal for services, the winning PBM agrees to credit Employer the following: Implementation Credit of $10,000 applied to Employer in Q1 2027 to cover the costs on any implementation, employee communication, and time of internal resources. | 1013 | Please Complete all Questions | ERISA Status (ERISA or Non-ERISA) | Non-ERISA |
| Healthcare Reform Status | Non-Grandfathered | |||
| Plan State HQ | Texas | |||
| Industry | Health Care | |||
| Total Enrolled Employees | 2,000 | |||
| Client SPD (5 of 7) | Total Member Count | 3,399 | ||
| Will you produce a client-specific SPD? | 1015 | Please Complete all Questions |
Please confirm you will provide a NEW client a credit of $7,500 for outside counsel to produce a compliant SPD. 1016 Please Complete all Questions
Please confirm you will provide the necessary information to outside counsel to support the production of a compliant SPD. 1017 Please Complete all Questions
| Carve-Out Fee (6 of 7) | ||
| Please confirm if you are bidding on both the medical & pharmacy benefits. | 1018 | Please Complete all Questions |
Please provide the carve-out fee (i.e. increase to medical admin fee) that applies if the employer elects to use a separate PBM for pharmacy benefits. 1019 Please Complete all Questions
Please provide the basis for the carve-out fee above. 1020 Please Complete all Questions
Please confirm the carve-out fee does not vary based on the selected PBM (i.e. client election of a non-preferred PBM 1019 Please Complete all Questions
If not confirmed, please provide details on the levels of carve-out fee and which carve-out fee PBMs apply to each. 1019 Please Complete all Questions
| Transition Fees (7 of 7) | ||
| Please confirm if you are the incumbent PBM. | 1021 | Please Complete all Questions |
In case of PBM transition, please confirm the fee per ORTF. 1022 Please Complete all Questions
In case of PBM transition, please confirm the fee per claims history file. 1023 Please Complete all Questions
In case of PBM transition, please confirm the fee per open prior authorization file. 1024 Please Complete all Questions
| January 1, 2027 |
| Central Health System |
Instructions
| This tab is intended to collect information about the structure of your financial offer for discounts and rebates. Please complete in its entirety. | |
| Grey | cells are requested to be completed |
| Orange | cells contain drop downs. Depending on the question, these drop downs may generate requests for additional information or information in a different format. |
Quote Information
| Subscribers | 2,000 |
| Customers | 3,399 |
| Date Range used in the analysis | |
| Total number of scripts used in the analysis | |
| Proposed Effective Date | January 1, 2027 |
| Name of Formulary Quoted | |
| Formulary Description |
Inclusion of External Vendors
Are there any external vendors included in your proposal?
| Vendor Name | Vendor Role | ||
| If yes, please list the vendors along with their role in the pharmacy benefit | 1 | ||
| 2 | |||
| 3 | |||
| 4 |
Rebate Offer:
Please Provide Rebate Eligible Script Counts Prior to the Impact of Alternative Funding Programs such as PAP/Importation, Per Script Guarantees Should Assume the Implementation of Alternative Funding Programs Included in the Proposal Alternative Funding Programs should be outlined on Tab 8b (if requested)
| Overall Rebate Structure Quoted: |
| Structure for Specialty Rebates: |
| Scripts Eligible for Minimum Guarantees based on the File Provided | Minimum Guaranteed Rebates | Calculated Rebate Dollars | ||
| Non-Specialty | ||||
| Guarantee Retail Brand Per Script | $0 | |||
| Guarantee Retail 90 Brand Per Script | $0 | |||
| Guarantee Mail Brand Per Script | $0 |
| Specialty | ||
| Guarantee Specialty Retail Per Script | $0 |
Discount and Dispensing Fee Offer
Description of Retail 30 day network quoted. Address the number of pharmacies in your network, pharmacy restrictions, and major chains inclusions and exclusions.
Description of Retail 90 day network quoted. Address the number of pharmacies in your network, pharmacy restrictions, major chains inclusions and exclusions, requirements to fill maintenance drugs at specific retail pharmacies for 90 day supply.
Description of Mail network quoted. Address pharmacy restrictions for filling via mail, any requirements to fill maintenance drugs at Mail and grace fill allowances, as applicable.
Description of Specialty arrangement quoted (i.e., Exclusive Specialty, Open Specialty) Address pharmacy restrictions and grace fill allowances, as applicable.
| Single Source Generics are Reconciled with Brands or Generics: |
| Pricing Structure Offered: |
| Retail 30 Dispensing Fee Structure: |
| Retail 90 Dispensing Fee Structure: |
| Specialty Dispensing Fee Structure: |
| Specialty Discount Structure: |
| Confirm Eligibility of Specialty Retail Claims: |
| LDD Discount Structure: |
| New to Market Drug Guarantee Structure: |
Guaranteed Discounts & Dispensing Fees NOTE: If not honoring Rx Solutions 1 year deal request, please enter year 1 ONLY in this section
| Retail 30 day Network | ||
| Retail Brand Discount | AWP - | |
| Retail Generic Discount | AWP - | |
| Retail Dispensing Fee Brand | Per Script | |
| Retail Dispensing Fee Generic | Per Script |
| Retail 90 day Network | ||
| Retail 90 Brand Discount | AWP - | |
| Retail 90 Generic Discount | AWP - | |
| Retail 90 Dispensing Fee Brand | Per Script | |
| Retail 90 Dispensing Fee Generic | Per Script |
| Mail Home Delivery | ||
| Mail Home Delivery Brand Discount | AWP - | |
| Mail Home Delivery Generic Discount | AWP - | |
| Mail Home Delivery Dispensing Fee | Per Script |
| Specialty | ||
| Fill out Orange Drop Down | AWP - | |
| Fill out Orange Drop Down | AWP - | |
| Fill out Orange Drop Down | AWP - | |
| Fill out Orange Drop Down | AWP - | |
| Specialty Mail Dispensing Fee Guarantee | Per Script |
Limited Distribution Drugs
New to Market Drugs
| January 1, 2027 |
| Central Health System |
Instructions
| This tab is intended to collect information about the structure of your proposed fees and credits. Please complete in its entirety. | |
| Grey | cells are requested to be completed |
| Orange | cells contain drop downs. Depending on the question, these drop downs may generate requests for additional information or information in a different format. |
Fees Please Provide ALL fees in the grid below.
Fee Basis Fee Amount Fee Basis if 'Other' Other Information Requested
Pharmacy Administrative Fee
Clinical Fee/UM Package Fee
Prior Authorization Fee Please complete the PA fee information with specific amount and basis. If not provided, we assume a $2.50 per script fee.
Fee for Claims Filled in Certain States Per Script in Specific States Please complete the state assessment fee information.
OTHER FEES BELOW
Fee 1
Fee 2
Fee 3
Credits
Credit Basis Credit Amount Credit Basis if 'Other' Other Information Requested
Upfront Rebate Credit
Implementation Credit
| Pharmacy Management Fund |
| ERROR:#REF! |
OTHER CREDITS BELOW
Credit 1
Credit 2
Credit 3
Formulary Disruption
| Instructions: |
| 1. Please limit the disruption analysis to the most recent 6 months of claims. |
| 2. In addition to the Formulary Disruption Summary Table, please fill out the Detail Exhibit for all NDCs. |
| 3. For purposes of the New Formulary Tier column, please use the following guidelines: |
a. Excluded NDCs should be non-covered drugs with no path to fill outside of medical necessity
b. Please note that this column only takes the numerical values 1-5 and 'Excluded'. To avoid errors, if you are pasting values into this column, please ensure that these are the only values being pasted
| 4. Please provide formulary alternatives to all scripts with negative disruption on an NDC basis. A representative NDC may be used if needed (e.g. if the alternative is a generic with many available NDCs. Up to 3 formulary alternatives may be listed. |
| 5. Please provide all script counts on a net basis, accounting for the impact of reversals. |
| Formulary Disruption Summary Table | |||
| Period Examined | 8/16/25 | 2/15/26 | |
| Total Scripts Analyzed | |||
| Net Script Count | % of Total Scripts | ||
| Scripts with Positive Impact | ERROR:#DIV/0! | Positive Impact: Scripts moving to a lower formulary tier | |
| Scripts with Negative Impact | ERROR:#DIV/0! | Negative Impact: Scripts moving to a higher formulary tier | |
| Scripts Moving to Exclude | ERROR:#DIV/0! | ||
| Scripts with No Change | ERROR:#DIV/0! | ||
| Unique Member Count: Negative Impact | |||
| Unique Member Count: Moving to Exclude |
| Formulary Disruption Detail Exhibit | ||||||||||
| NDC | Drug Name | Current Formulary Tier | Net Script Count in Period Examined | Unique Member Count in Period Examined | New Formulary Tier* | Alternative Formulary Drug 1 | Alternative Formulary Drug 2 | Alternative Formulary Drug 3 | *Please note that this column only takes the values 1-5 and 'Excluded'. To avoid errors, if you are pasting values into this column, please ensure that these are the only values being pasted. | |
| 29300038905 | METFORMIN TAB 500MG ER | 1 | Please fill in chart completely | 1 | ||||||
| 81964022114 | AMOX/K CLAV TAB 875-125 | 1 | Please fill in chart completely | 1 | ||||||
| 55513012301 | TEZSPIRE INJ 210MG | 2 | Please fill in chart completely | 1 | ||||||
| 2150680 | MOUNJARO INJ 2.5/0.5 | 1 | Please fill in chart completely | 1 | ||||||
| 2150680 | MOUNJARO INJ 2.5/0.5 | 2 | Please fill in chart completely | 1 | ||||||
| 430042014 | LO LOESTRIN TAB 1-10-10 | 1 | Please fill in chart completely | 1 | ||||||
| 430042014 | LO LOESTRIN TAB 1-10-10 | 2 | Please fill in chart completely | 1 | ||||||
| 74210001 | SKYRIZI PEN INJ 150MG/ML | 1 | Please fill in chart completely | 1 | ||||||
| 74210001 | SKYRIZI PEN INJ 150MG/ML | 2 | Please fill in chart completely | 1 | ||||||
| 70954005920 | PREDNISONE TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 2147180 | MOUNJARO INJ 10MG/0.5 | 1 | Please fill in chart completely | 1 | ||||||
| 2147180 | MOUNJARO INJ 10MG/0.5 | 2 | Please fill in chart completely | 1 | ||||||
| 456120130 | LINZESS CAP 145MCG | 1 | Please fill in chart completely | 1 | ||||||
| 456120130 | LINZESS CAP 145MCG | 2 | Please fill in chart completely | 1 | ||||||
| 62332000131 | FAMOTIDINE TAB 20MG | 1 | Please fill in chart completely | 1 | ||||||
| 16714061205 | SERTRALINE TAB 50MG | 1 | Please fill in chart completely | 1 | ||||||
| 68180098103 | LISINOPRIL TAB 20MG | 1 | Please fill in chart completely | 1 | ||||||
| 43547037009 | VALSARTAN TAB 320MG | 1 | Please fill in chart completely | 1 | ||||||
| 69238207707 | PROPRANOLOL TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 27808023302 | DOXYCYCL HYC CAP 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 31722072890 | MONTELUKAST CHW 5MG | 1 | Please fill in chart completely | 1 | ||||||
| 3089421 | ELIQUIS TAB 5MG | 1 | Please fill in chart completely | 1 | ||||||
| 3089421 | ELIQUIS TAB 5MG | 2 | Please fill in chart completely | 1 | ||||||
| 2148480 | MOUNJARO INJ 7.5/0.5 | 1 | Please fill in chart completely | 1 | ||||||
| 2148480 | MOUNJARO INJ 7.5/0.5 | 2 | Please fill in chart completely | 1 | ||||||
| 169477212 | OZEMPIC INJ 8MG/3ML | 1 | Please fill in chart completely | 1 | ||||||
| 169477212 | OZEMPIC INJ 8MG/3ML | 2 | Please fill in chart completely | 1 | ||||||
| 68180096301 | ALBUTEROL AER HFA | 1 | Please fill in chart completely | 1 | ||||||
| 29300012510 | MELOXICAM TAB 15MG | 1 | Please fill in chart completely | 1 | ||||||
| 72888012005 | LABETALOL TAB 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 68382050010 | OMEPRAZOLE CAP 40MG | 1 | Please fill in chart completely | 1 | ||||||
| 70710135203 | VENLAFAXINE TAB 225MG ER | 1 | Please fill in chart completely | 1 | ||||||
| 57237000511 | FLUCONAZOLE TAB 150MG | 1 | Please fill in chart completely | 1 | ||||||
| 45802009735 | ESTRADIOL CRE 0.01% | 1 | Please fill in chart completely | 1 | ||||||
| 59762500901 | CLINDAMYCIN CRE 2% VAG | 1 | Please fill in chart completely | 1 | ||||||
| 23155084210 | METFORMIN TAB 850MG | 1 | Please fill in chart completely | 1 | ||||||
| 29300035510 | TRAMADOL HCL TAB 50MG | 1 | Please fill in chart completely | 1 | ||||||
| 69097084615 | CYCLOBENZAPR TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 69584085310 | SPIRONOLACT TAB 50MG | 1 | Please fill in chart completely | 1 | ||||||
| 31722070210 | LOSARTAN POT TAB 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 31722063231 | OSELTAMIVIR CAP 75MG | 1 | Please fill in chart completely | 1 | ||||||
| 54327099 | FLUTICASONE SPR 50MCG | 1 | Please fill in chart completely | 1 | ||||||
| 70710119003 | NORELGE/ETHI DIS 150/35 | 1 | Please fill in chart completely | 1 | ||||||
| 51672127501 | CLOTRIMAZOLE CRE 1% | 1 | Please fill in chart completely | 1 | ||||||
| 555097202 | AMPHET/DEXTR TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 64380044601 | APAP/CODEINE TAB 300-30MG | 1 | Please fill in chart completely | 1 | ||||||
| 64380079901 | OSELTAMIVIR CAP 75MG | 1 | Please fill in chart completely | 1 | ||||||
| 68382013716 | LOSARTAN POT TAB 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 50228011410 | FLUOXETINE CAP 20MG | 1 | Please fill in chart completely | 1 | ||||||
| 2143611 | EMGALITY INJ 120MG/ML | 1 | Please fill in chart completely | 1 | ||||||
| 2143611 | EMGALITY INJ 120MG/ML | 2 | Please fill in chart completely | 1 | ||||||
| 2149580 | MOUNJARO INJ 5MG/0.5 | 1 | Please fill in chart completely | 1 | ||||||
| 2149580 | MOUNJARO INJ 5MG/0.5 | 2 | Please fill in chart completely | 1 | ||||||
| 74709430 | QULIPTA TAB 60MG | 2 | Please fill in chart completely | 1 | ||||||
| 944270007 | GAMMAGARD INJ 30GM/300 | 3 | Please fill in chart completely | 1 | ||||||
| 42806071401 | BENZONATATE CAP 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 16714020030 | ONDANSETRON TAB 4MG ODT | 1 | Please fill in chart completely | 1 | ||||||
| 16571010501 | AMITRIPTYLIN TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 45963055550 | GABAPENTIN CAP 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 42192060716 | BROM/PSE/DM SYP 2/30/10 | 1 | Please fill in chart completely | 1 | ||||||
| 72888001205 | CYCLOBENZAPR TAB 5MG | 1 | Please fill in chart completely | 1 | ||||||
| 68462019005 | NAPROXEN TAB 500MG | 1 | Please fill in chart completely | 1 | ||||||
| 65862042005 | SMZ/TMP DS TAB 800-160 | 1 | Please fill in chart completely | 1 | ||||||
| 31722053705 | LEVETIRACETA TAB 500MG | 1 | Please fill in chart completely | 1 | ||||||
| 65862001005 | METFORMIN TAB 1000MG | 1 | Please fill in chart completely | 1 | ||||||
| 121103416 | HYDROXYZINE SYP 10MG/5ML | 1 | Please fill in chart completely | 1 | ||||||
| 60219170801 | PREDNISONE TAB 20MG | 1 | Please fill in chart completely | 1 | ||||||
| 115180301 | HYDROXYZ PAM CAP 25MG | 1 | Please fill in chart completely | 1 | ||||||
| 68180089473 | DROS/ETH EST TAB LEVOMEFO | 1 | Please fill in chart completely | 1 | ||||||
| 71930002643 | BROM/PSE/DM SYP | 1 | Please fill in chart completely | 1 | ||||||
| 68382091711 | METHYLPRED TAB 8MG | 1 | Please fill in chart completely | 1 | ||||||
| 93081001 | NORTRIPTYLIN CAP 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 61958200201 | DESCOVY TAB 200/25MG | 1 | Please fill in chart completely | 1 | ||||||
| 61958200201 | DESCOVY TAB 200/25MG | 2 | Please fill in chart completely | 1 | ||||||
| 16714040604 | LARIN FE TAB 1/20 | 1 | Please fill in chart completely | 1 | ||||||
| 69097014260 | ALBUTEROL AER HFA | 1 | Please fill in chart completely | 1 | ||||||
| 45802046564 | KETOCONAZOLE SHA 2% | 1 | Please fill in chart completely | 1 | ||||||
| 93314705 | CEPHALEXIN CAP 500MG | 1 | Please fill in chart completely | 1 | ||||||
| 33342009441 | RIZATRIPTAN TAB 10MG ODT | 1 | Please fill in chart completely | 1 | ||||||
| 310737220 | BUDES/FORMOT AER 80-4.5 | 1 | Please fill in chart completely | 1 | ||||||
| 42806071405 | BENZONATATE CAP 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 64380071207 | BENZONATATE CAP 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 68180035309 | SERTRALINE TAB 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 16714036504 | ELINEST TAB | 1 | Please fill in chart completely | 1 | ||||||
| 43386070083 | SODIUM/POTAS SOL MAGNESIU | 1 | Please fill in chart completely | 1 | ||||||
| 65162046550 | IBUPROFEN TAB 600MG | 1 | Please fill in chart completely | 1 | ||||||
| 51672129303 | CLOBETASOL SOL 0.05% | 1 | Please fill in chart completely | 1 | ||||||
| 50111064801 | FLUOXETINE CAP 20MG | 1 | Please fill in chart completely | 1 | ||||||
| 51672140700 | TRETINOIN CRE 0.025% | 1 | Please fill in chart completely | 1 | ||||||
| 70710113803 | FLUCONAZOLE TAB 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 29300039605 | AMLODIPINE TAB 2.5MG | 1 | Please fill in chart completely | 1 | ||||||
| 21922003601 | CLINDAMYCIN LOT 1% | 1 | Please fill in chart completely | 1 | ||||||
| 73302045601 | ELLA TAB 30MG | 3 | Please fill in chart completely | 1 | ||||||
| 60505083305 | AZELASTINE SPR 0.1% | 1 | Please fill in chart completely | 1 | ||||||
| 68382080505 | TRAZODONE TAB 50MG | 1 | Please fill in chart completely | 1 | ||||||
| 69238207701 | PROPRANOLOL TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 42806054701 | VITAMIN D CAP 1.25MG | 1 | Please fill in chart completely | 1 | ||||||
| 69238207901 | PROPRANOLOL TAB 40MG | 1 | Please fill in chart completely | 1 | ||||||
| 31722070530 | VALACYCLOVIR TAB 1GM | 1 | Please fill in chart completely | 1 | ||||||
| 187540004 | JUBLIA SOL 10% | 3 | Please fill in chart completely | 1 | ||||||
| 70700011985 | ESTARYLLA TAB 0.25-35 | 1 | Please fill in chart completely | 1 | ||||||
| 60219234801 | TRAMADOL HCL TAB 50MG | 1 | Please fill in chart completely | 1 | ||||||
| 65862044890 | VALACYCLOVIR TAB 500MG | 1 | Please fill in chart completely | 1 | ||||||
| 406012405 | HYDROCO/APAP TAB 7.5-325 | 1 | Please fill in chart completely | 1 | ||||||
| 555097302 | AMPHET/DEXTR TAB 20MG | 1 | Please fill in chart completely | 1 | ||||||
| 72205004411 | OSELTAMIVIR CAP 75MG | 1 | Please fill in chart completely | 1 | ||||||
| 69584061150 | METHOCARBAM TAB 500MG | 1 | Please fill in chart completely | 1 | ||||||
| 50742061510 | METOPROL SUC TAB 25MG ER | 1 | Please fill in chart completely | 1 | ||||||
| 64380080707 | IBUPROFEN TAB 800MG | 1 | Please fill in chart completely | 1 | ||||||
| 65862064163 | AZITHROMYCIN TAB 250MG | 1 | Please fill in chart completely | 1 | ||||||
| 548835202 | BAQSIMI TWO POW 3MG/DOSE | 2 | Please fill in chart completely | 1 | ||||||
| 31722071830 | ATOMOXETINE CAP 60MG | 1 | Please fill in chart completely | 1 | ||||||
| 169413013 | OZEMPIC INJ 4MG/3ML | 2 | Please fill in chart completely | 1 | ||||||
| 16714008211 | HYDROXYZ HCL TAB 25MG | 1 | Please fill in chart completely | 1 | ||||||
| 13668013610 | ESCITALOPRAM TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 65649040001 | PLENVU SOL | 3 | Please fill in chart completely | 1 | ||||||
| 2143480 | TRULICITY INJ 1.5/0.5 | 2 | Please fill in chart completely | 1 | ||||||
| 31722018901 | AMPHET/DEXTR CAP 25MG ER | 1 | Please fill in chart completely | 1 | ||||||
| 65862049001 | QUETIAPINE TAB 50MG | 1 | Please fill in chart completely | 1 | ||||||
| 51672407008 | CETIRIZINE SOL 1MG/ML | 1 | Please fill in chart completely | 1 | ||||||
| 13668042905 | PANTOPRAZOLE TAB 40MG | 1 | Please fill in chart completely | 1 | ||||||
| 43547042050 | LISINOP/HCTZ TAB 10-12.5 | 1 | Please fill in chart completely | 1 | ||||||
| 54074287 | ALBUTEROL AER HFA | 1 | Please fill in chart completely | 1 | ||||||
| 27241009810 | DULOXETINE CAP 30MG DR | 1 | Please fill in chart completely | 1 | ||||||
| 115169449 | EPINEPHRINE INJ 0.3MG | 1 | Please fill in chart completely | 1 | ||||||
| 50742050504 | SCOPOLAMINE DIS 1MG/3DAY | 1 | Please fill in chart completely | 1 | ||||||
| 8627007701 | DEXCOM G7 MIS SENSOR | 1 | Please fill in chart completely | 1 | ||||||
| 8627007701 | DEXCOM G7 MIS SENSOR | 2 | Please fill in chart completely | 1 | ||||||
| 93354143 | ESTRADIOL CRE 0.01% | 1 | Please fill in chart completely | 1 | ||||||
| 54032656 | FLUTIC/SALME AER 100/50 | 1 | Please fill in chart completely | 1 | ||||||
| 70700016201 | PROGESTERONE CAP 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 50111078751 | AZITHROMYCIN TAB 250MG | 1 | Please fill in chart completely | 1 | ||||||
| 70954005820 | PREDNISONE TAB 5MG | 1 | Please fill in chart completely | 1 | ||||||
| 68462022101 | LITHIUM CARB CAP 300MG | 1 | Please fill in chart completely | 1 | ||||||
| 64380078507 | PREDNISONE TAB 20MG | 1 | Please fill in chart completely | 1 | ||||||
| 713067831 | NYSTATIN CRE 100000 | 1 | Please fill in chart completely | 1 | ||||||
| 74003956 | ORILISSA TAB 200MG | 2 | Please fill in chart completely | 1 | ||||||
| 43547042210 | LISINOP/HCTZ TAB 20-25MG | 1 | Please fill in chart completely | 1 | ||||||
| 65162080810 | PROGESTERONE CAP 200MG | 1 | Please fill in chart completely | 1 | ||||||
| 16714061305 | SERTRALINE TAB 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 65862072130 | RABEPRAZOLE TAB 20MG | 1 | Please fill in chart completely | 1 | ||||||
| 13811070610 | METHYLPHENID TAB 18MG OSM | 1 | Please fill in chart completely | 1 | ||||||
| 16714029904 | AMOXICILLIN CAP 500MG | 1 | Please fill in chart completely | 1 | ||||||
| 55513013760 | OTEZLA TAB 30MG | 2 | Please fill in chart completely | 1 | ||||||
| 68180097103 | LEVOTHYROXIN TAB 125MCG | 1 | Please fill in chart completely | 1 | ||||||
| 72578000805 | METRONIDAZOL TAB 500MG | 1 | Please fill in chart completely | 1 | ||||||
| 67877051110 | ATORVASTATIN TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 62332025118 | AZITHROMYCIN TAB 250MG | 1 | Please fill in chart completely | 1 | ||||||
| 69097012805 | AMLODIPINE TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 58160084252 | BOOSTRIX INJ | 1 | Please fill in chart completely | 1 | ||||||
| 58160084252 | BOOSTRIX INJ | 3 | Please fill in chart completely | 1 | ||||||
| 62332000271 | FAMOTIDINE TAB 40MG | 1 | Please fill in chart completely | 1 | ||||||
| 378668910 | PANTOPRAZOLE TAB 40MG | 1 | Please fill in chart completely | 1 | ||||||
| 121088508 | PREDNISOLONE SOL 15MG/5ML | 1 | Please fill in chart completely | 1 | ||||||
| 70700016301 | PROGESTERONE CAP 200MG | 1 | Please fill in chart completely | 1 | ||||||
| 68382080701 | TRAZODONE TAB 150MG | 1 | Please fill in chart completely | 1 | ||||||
| 23155087810 | LISINOPRIL TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 527810737 | DEXMETHYLPHE CAP 10MG ER | 1 | Please fill in chart completely | 1 | ||||||
| 65862078490 | ESOMEPRA MAG CAP 40MG DR | 1 | Please fill in chart completely | 1 | ||||||
| 65862001705 | AMOXICILLIN CAP 500MG | 1 | Please fill in chart completely | 1 | ||||||
| 68462022001 | LITHIUM CARB CAP 150MG | 1 | Please fill in chart completely | 1 | ||||||
| 65162099508 | DOTTI DIS 0.075MG | 1 | Please fill in chart completely | 1 | ||||||
| 27241013909 | OSELTAMIVIR SUS 6MG/ML | 1 | Please fill in chart completely | 1 | ||||||
| 68462018022 | MUPIROCIN OIN 2% | 1 | Please fill in chart completely | 1 | ||||||
| 69238183207 | LEVOTHYROXIN TAB 75MCG | 1 | Please fill in chart completely | 1 | ||||||
| 57237023305 | SMZ/TMP DS TAB 800-160 | 1 | Please fill in chart completely | 1 | ||||||
| 228202750 | ALPRAZOLAM TAB 0.25MG | 1 | Please fill in chart completely | 1 | ||||||
| 65862044990 | VALACYCLOVIR TAB 1GM | 1 | Please fill in chart completely | 1 | ||||||
| 68645061090 | LISINOPRIL TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 59762500801 | MISOPROSTOL TAB 200MCG | 1 | Please fill in chart completely | 1 | ||||||
| 168014630 | HYDROCORT OIN 2.5% | 1 | Please fill in chart completely | 1 | ||||||
| 65862039110 | ONDANSETRON TAB 8MG ODT | 1 | Please fill in chart completely | 1 | ||||||
| 8508300021 | OMNIPOD 5 DX MIS POD G7G6 | 1 | Please fill in chart completely | 1 | ||||||
| 8508300021 | OMNIPOD 5 DX MIS POD G7G6 | 2 | Please fill in chart completely | 1 | ||||||
| 16571086250 | BUPROPION TAB 150MG XL | 1 | Please fill in chart completely | 1 | ||||||
| 65038028699 | AZSTARYS CAP 26.1-5.2 | 1 | Please fill in chart completely | 1 | ||||||
| 65038028699 | AZSTARYS CAP 26.1-5.2 | 2 | Please fill in chart completely | 1 | ||||||
| 59417010710 | VYVANSE CAP 70MG | 3 | Please fill in chart completely | 1 | ||||||
| 43547028011 | ESCITALOPRAM TAB 5MG | 1 | Please fill in chart completely | 1 | ||||||
| 72205026130 | VILAZODONE TAB 20MG | 1 | Please fill in chart completely | 1 | ||||||
| 21922001605 | CLOBETASOL CRE 0.05% | 1 | Please fill in chart completely | 1 | ||||||
| 24591502 | DUPIXENT INJ 300/2ML | 1 | Please fill in chart completely | 1 | ||||||
| 24591502 | DUPIXENT INJ 300/2ML | 2 | Please fill in chart completely | 1 | ||||||
| 68180035202 | SERTRALINE TAB 50MG | 1 | Please fill in chart completely | 1 | ||||||
| 228277911 | PROPRANOLOL CAP 80MG ER | 1 | Please fill in chart completely | 1 | ||||||
| 299382230 | ORACEA CAP 40MG | 2 | Please fill in chart completely | 1 | ||||||
| 65162068090 | PROMETHAZINE SOL DM | 1 | Please fill in chart completely | 1 | ||||||
| 27808015703 | ROSUVASTATIN TAB 20MG | 1 | Please fill in chart completely | 1 | ||||||
| 29300039710 | AMLODIPINE TAB 5MG | 1 | Please fill in chart completely | 1 | ||||||
| 228202910 | ALPRAZOLAM TAB 0.5MG | 1 | Please fill in chart completely | 1 | ||||||
| 42806042501 | BUPROPION TAB 150MG SR | 1 | Please fill in chart completely | 1 | ||||||
| 143988701 | AMOXICILLIN SUS 400/5ML | 1 | Please fill in chart completely | 1 | ||||||
| 69238115403 | EZETIMIBE TAB 10MG | 1 | Please fill in chart completely | 1 | ||||||
| 527466437 | LISDEXAMFETA CAP 40MG | 1 | Please fill in chart completely | 1 | ||||||
| 60505267109 | ATORVASTATIN TAB 80MG | 1 | Please fill in chart completely | 1 | ||||||
| 59651042801 | SPIRONOLACT TAB 100MG | 1 | Please fill in chart completely | 1 | ||||||
| 378335099 | ESTRADIOL DIS 0.05MG | 1 | Please fill in chart completely | 1 | ||||||
| 72511076002 | REPATHA SURE INJ 140MG/ML | 2 | Please fill in chart completely | 1 | ||||||
| 42806071505 | BENZONATATE CAP 200MG | 1 | Please fill in chart completely | 1 | ||||||
| 24979019801 | GUANFACINE TAB 1MG | 1 | Please fill in chart completely | 1 | ||||||
| 169750111 | NOVOLOG INJ 100/ML | 1 | Please fill in chart completely | 1 |
This is the start of the file's text. The full file is on GovTribe.
File details come from the government source that posted it. Updated .