RFP APPENDIX L - FORMULARY DISRUPTION RESULTS.xlsx
XLSX spreadsheet 26 KB Posted
- Attached to
- 1451-25-R-RFQF-00002
- Solicitation number
- 3140004002
- Issued by
- Pike County, Mississippi
About this file
This file is a formulary disruption results spreadsheet template that appears to be part of RFP Appendix L, though the specific jurisdiction or agency is not indicated. The spreadsheet contains six tabs for tracking different types of drug formulary changes: non-maintenance and maintenance drugs moving between tier 2 (brand formulary) and tier 3 (brand non-formulary), as well as excluded drugs for both maintenance and non-maintenance categories. Each tab requires data entry for drug names, prescription counts, member counts, disease indications, GPI codes, dosage forms, and formulary alternatives.
The template is designed to analyze the impact of formulary changes on members, specifically excluding drugs affected by Affordable Care Act mandates. The spreadsheet requires users to identify the client name, formulary name, type of formulary (open, open with exclusions, or exclusionary), and provide definitions for maintenance versus non-maintenance medications. All tabs include automatic totaling functions for prescription and member counts, though the example shown contains no actual data entries.
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Text version
Non-Maintenance 2T to 3T Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include non-maintenance medications on this tab.
* 2T = second tier/brand formulary products; 3T = third tier/brand non-formulary products.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | |||||||
| Formulary Name: | |||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | |||||||
| Definition of maintenance vs non-maintenance medications: | |||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) | Formulary alternative |
Total 0 0
Maintenance 2T to 3T Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include maintenance medications on this tab.
* 2T = second tier/brand formulary products; 3T = third tier/brand non-formulary products.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Formulary Name: | |||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | |||||||
| Definition of maintenance vs non-maintenance medications: | |||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) | Formulary alternative |
Total 0 0
Non-Maintenance 3T to 2T Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include non-maintenance medications on this tab.
* 2T = second tier/brand formulary products; 3T = third tier/brand non-formulary products.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | 0 | 0 | 0 | 0 | 0 | 0 |
| Formulary Name: | ||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | ||||||
| Definition of maintenance vs non-maintenance medications: | ||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) |
Total 0 0
Maintenance 3T to 2 T Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include maintenance medications on this tab.
* 2T = second tier/brand formulary products; 3T = third tier/brand non-formulary products.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | 0 | 0 | 0 | 0 | 0 | 0 |
| Formulary Name: | ||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | ||||||
| Definition of maintenance vs non-maintenance medications: | ||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) |
Total 0 0
Exclusions - Non-Maintenance Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include non-maintenance medications on this tab.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Formulary Name: | |||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | |||||||
| Definition of maintenance vs non-maintenance medications: | |||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) | Formulary alternative |
Total 0 0
Exclusions - Maintenance Drugs Instructions:
* Exclude drugs impacted by Affordable Care Act mandates, if applicable.
* Only include maintenance medications on this tab.
* Please complete all light blue shaded cells in this document; add additional rows if necessary.
* PLEASE DO NOT REMOVE ANY COLUMNS OR TABS WITHIN THIS WORKBOOK.
* PLEASE ONLY USE THIS FORMAT FOR DISRUPTION SUBMISSIONS.
| Client Name: | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Formulary Name: | |||||||
| Type of Formulary (i.e. Open, Open with exclusions, Exclusionary, etc.): | |||||||
| Definition of maintenance vs non-maintenance medications: | |||||||
| Rank | Drug Name | Rx Count | Cardholder / Member Count | Condition / Disease Indication | GPI | Dosage Form (e.g., tablet, capsule, injection, testing equipment, gel, etc.) | Formulary alternative |
Total 0 0
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