ADMINISTRATION OF PRESCRIPTION DRUGS

1.0 Formulary Disruption
1.1 Summary of PBM Disruption Analysis
Directions: Complete the following formulary disruption tables based on your proposed formulary. Your analysis should be based on the most recent four (4) months in the commercial plan's claims data that will be provided upon the
submission of the "Intent to Propose" Form. Results to be included are the number of members that will require a change as well as the number of prescriptions associated with the formulary change.
Claims Dispensed between 9/1/2025 and 12/31/2025
Total number of members covered: 26,145
Non-Specialty formulary: Broad Formulary with Standard Exclusions
Specialty formulary: Broad Formulary with Standard Exclusions
Enter the name of your proposed formulary, which serves as the basis of your disruption analysis:
Summary
Type of Change M N e u m m b b e e r r s o I f m D p is a t c in te c d t % of Total Members Number of Scripts Impacted % a o l f l T b o ra ta n l d S s c a r n ip d t s g e (i n n e c r l i u c d s i ) ng
Non-Specialty
No change
Positive (higher-cost tier to lower-
cost tier)
Negative (lower-cost tier to higher-
cost tier)
Moving from Covered to Not
Covered/Excluded
Specialty
No change
Positive (higher-cost tier to lower-
cost tier)
Negative (lower-cost tier to higher-
cost tier)
Moving from Covered to Not
Covered/Excluded
Overall
No change
Positive (higher-cost tier to lower-
cost tier)
Negative (lower-cost tier to higher-
cost tier)
Moving from Covered to Not
Covered/Excluded
Note: Each distinct member of the population may be impacted positively, negatively or not at all. Therefore, the number of members impacted in the table above are not additive.
1.2 Detailed Disruption Results
Directions: Complete the table below by listing each drug utilized in the most recent four (4) months of the commercial plan's claims data by NDC, the number of distinct patients for which the drug was dispensed and the total number of
prescriptions filled. For each NDC, use the drop-down options provided to indicate if the drug is a maintenance medication, specialty or non-specialty with respect to your proposed formulary, brand or generic status and the tier that the drug
will be considered for the purposes of calculating member cost share.
Proposed Formulary
Number of Distinct Maintenance Drug
NDC Drug Name Therapeutic Class Patients Number of Scripts Indicator Specialty Indicator Brand/Generic Indicator Tier
Select One Select One Select One Select One
Select One Select One Select One Select One
Select One Select One Select One Select One
Select One Select One Select One Select One
Select One Select One Select One Select One
Select One Select One Select One Select One
Select One Select One Select One Select One
Select One Select One Select One Select One
Select One Select One Select One Select One
Select One Select One Select One Select One
Select One Select One Select One Select One

2.0 Network Disruption
2.1 Summary of PBM Disruption Analysis
Directions: Complete the following retail network disruption table based on your proposed Retail pharmacy network and on the claims data. Results to be included are the number of members that will be required to change the utilized retail
pharmacy as well as the number of prescriptions associated with the retail pharmacy change.
Name of Broad Retail 30 Pharmacy:
Type of Change Retail Network
Out-of-Network Retail Pharmacies
Number of currently utilized retail pharmacies that are
NOT part of the proposed network and are eligible to
solicit
Number of distinct members that are using those retail
pharmacies that are NOT part of the proposed network
and are eligible to solicit
Number of prescriptions that adjudicated via those
Retail pharmacies that are NOT part of the proposed
network and are eligible to solicit
In-Network Retail Pharmacies
Number of currently utilized retail pharmacies that are
part of the proposed network
Number of distinct members that are using those retail
pharmacies that are part of the proposed network
Number of prescriptions that adjudicated via those
retail pharmacies that are part of the proposed network
2.2 Detailed Disruption Results
Directions: Complete the table below by listing each distinct retail pharmacy included in the data set provided with the RFP along with the number of distinct patients who filled a script at the retail pharmacy and the number of prescriptions
dispensed based on the day's supply dispensed. Then indicate whether or not the retail pharmacy is in-network or out-of-network based on your proposed network.
Proposed Retail Network
NPI Name of Retail Pharmacy Address of Pharmacy City State ZIP Pharmacy Type Num M be e r m o b f D er i s stinct Number of Scripts Retail 30 Network
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One
Select One Select One

3.0 Clinical Programs List
Directions: Provide a complete list of your clinical programs with pricing and projected savings associated with each program and highlight those programs recommended for the State. Describe the type of impact members will face for each of these programs.
Required/Optional
Name of Program Description of Program Member Impact Cost & Cost Basis ROI (X:Y) Projected Cost/Savings ($000s)
Program?
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
Select One
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