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["ListYes_No",null,"Select one"]
[null,null,"Yes"]
[null,null,"No"]
[]
["List_GEOMap",null,"Select one"]
[null,null,"Zip Code Dispersion"]
[null,null,"Center of Zip Code"]
[null,null,"Geo-coding (Employee Zip Code address)"]
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["ListYesNo",null,"Select one"]
[null,null,"Yes"]
[null,null,"No - See Section A-15: Deviations"]
[]
["ListYesNowithCost",null,"Select one"]
[null,null,"Yes, at no additional cost to the State"]
[null,null,"Yes, at an additional cost to the State described below"]
[null,null,"Not offered"]
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["List_Agree",null,"Select one"]
[null,null,"Agree"]
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["List_Offered",null,"Select one"]
[null,null,"Offered"]
[null,null,"Not offered"]
[]
["List_Complete",null,"Select one"]
[null,null,"Completed"]
[null,null,"Not completed"]
[]
["List_Attached",null,"Select one"]
[null,null,"Attached"]
[null,null,"Not attached"]
[]
["ListCorpTaxStatus",null,"Select one"]
[null,null,"For profit"]
[null,null,"Not for profit"]
[]
["List_NCQA_Accreditation",null,"Select one"]
[null,null,"Accredited"]
[null,null,"Accredation Not Requested"]
[null,null,"Appealed by Plan"]
[null,null,"Denied"]
[null,null,"Full"]
[null,null,"In Process"]
[null,null,"One year"]
[null,null,"Provisional"]
[]
["List_JCAHO_Accreditation",null,"Select one"]
[null,null,"Accreditation Denied"]
[null,null,"Accreditation not requested"]
[null,null,"Accreditation with Commendation"]
[null,null,"Accreditation with Full standards of Compliance"]
[null,null,"Accreditation with Requirements for Improvement"]
[null,null,"Conditional Accreditation"]
[null,null,"Preliminary Denial of  Accreditation"]
[null,null,"Provisional Accreditation"]
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["List_URAC_Accreditation",null,"Select one"]
[null,null,"Accreditation Denied"]
[null,null,"Accreditation in Proceess"]
[null,null,"Accreditation Not Required"]
[null,null,"Accreditation Voluntarily Withdrawn"]
[null,null,"Conditional Accreditation"]
[null,null,"Corrective Action"]
[null,null,"Full Accreditation"]
[null,null,"Provisional Accreditation"]
[]
["List_Designated",null,"Select one"]
[null,null,"Dedicated staff"]
[null,null,"Designated staff"]
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["List_L14_Q3",null,"Select one"]
[null,null,"Confirmed"]
[null,null,"Not confirmed"]
[]
["List_L14_Q12",null,"Select one"]
[null,null,"0 - 5%"]
[null,null,"6 - 10%"]
[null,null,"Higher than 10%"]
[]
["List_L14_Q16",null,"Select one"]
[null,null,"Yes, a decrease in the network size"]
[null,null,"Yes, an increase in the network size"]
[null,null,"No material change in the network size"]
[]
["List_L14_Q20",null,"Select one"]
[null,null,"Reviewed or verified"]
[null,null,"Not reviewed or verified"]
[]
["List_L14_Q27",null,"Select one"]
[null,null,"Annually"]
[null,null,"Once every two years"]
[null,null,"Other"]
[]
["List_L14_Q32",null,"Select one"]
[null,null,"Less than 3 years"]
[null,null,"3 - 5 years"]
[null,null,"6 or more years"]
[]
["List_L14_Q37",null,"Select one"]
[null,null,"Global Capitation"]
[null,null,"Per Diem"]
[null,null,"Discounted Fee for Service"]
[null,null,"Other"]
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["List_L14_Q44",null,"Select one"]
[null,null,"Less than 5%"]
[null,null,"5 - 10%"]
[null,null,"10 - 15%"]
[null,null,"More than 15%"]
[]
["List_L14_Q47",null,"Select one"]
[null,null,"Less than 2 weeks"]
[null,null,"2 - 4 weeks"]
[null,null,"More than 4 weeks"]
[]
["List_L14_Q58",null,"Select one"]
[null,null,"Pay and pursue"]
[null,null,"Pursue and Pay"]
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["List_L14_Q67",null,"Select one"]
[null,null,"Yes, both in-network and out-of-network"]
[null,null,"Yes, out-of-network only"]
[null,null,"No"]
[]
["List_L14_Q73",null,"Select one"]
[null,null,"Quarterly"]
[null,null,"Annually"]
[null,null,"Other"]
[]
["List_L14_Q74",null,"Select one"]
[null,null,"Less than 1%"]
[null,null,"1 - 2%"]
[null,null,"3 - 5%"]
[null,null,"5 - 10%"]
[null,null,"More than 10%"]
[]
["List_L14_Q86",null,"Select one"]
[null,null,"Less than 5%"]
[null,null,"5 - 10%"]
[null,null,"10 - 15%"]
[null,null,"More than 15%"]
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["List_L14_Q108",null,"Select one"]
[null,null,"Less than 5%"]
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[null,null,"10 - 15%"]
[null,null,"More than 15%"]
[]
["List_L14_Q115",null,"Select one"]
[null,null,"24 hour delay"]
[null,null,"48 hour delay"]
[null,null,"Greater than 48 hour delay"]
[]
["List_L14_Q77",null,"Select one"]
[null,null,"Automated process"]
[null,null,"Manual process"]
[]
["List_L14_Q126",null,"Select one"]
[null,null,"Automatically tracked only"]
[null,null,"Automatically tracked with reporting capabilities"]
[null,null,"Not tracked or reported by the system"]
[]
["List_Exp_Dev",null,"Select one"]
[null,null,"Explanation"]
[]
["List_RxVolume",null,"Select one"]
[null,null,"Increase"]
[null,null,"Decrease"]
[null,null,"No change"]
[]
["List_Confirm",null,"Select one"]
[null,null,"Confirmed"]
[null,null,"Not confirmed"]
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["List_Formulary",null,"Select one"]
[null,null,"Preferred Brand"]
[null,null,"Non-Preferred Brand"]
[null,null,"Generic"]

{"sheet":"Intro","index":1,"n_rows":15,"n_cols":1,"rows_kept":15,"cut":false,"hidden":false,"merged":[]}
[]
[]
[]
[]
[]
[]
["South Carolina Public Employee Benefit Authority"]
["Insurance Benefits"]
["202 Arbor Lake Drive"]
["Columbia, South Carolina 29223"]
[]
[]
[]
["Pharmacy Benefit Management Services"]
["Offeror's Financial Proposal Response"]

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[]
[]
[]
["Request for Proposal for Pharmacy Benefit Management Services"]
["Tab A-10: Financial Proposal"]
[]
["Representations made by the Offeror in this Proposal become contractual obligations that must be met during the contract term."]
[]
["Instructions: Please complete the financial exhibit below in its entirety.  It is South Carolina Public Employee Benefit Authority's (PEBA) intent to conduct as fair and equitable analysis as possible, and for that reason the information requested is very detailed.\n\nThe Financial Proposal is based on the current program in which the PBM will pass-through 100% of all costs and pharmaceutical manufacturer revenue to PEBA for all participants.  For those participants who opt-out of EGWP and into the Commercial Plan, PEBA will continue to utilize the Retiree Drug Subsidy program. All PEBA pharmacy benefits will be provided on a self-funded basis. "]
["The EGWP Plan will provide pharmacy benefits for all Medicare primary participants covered by the State Health Plan.\n\nThe Commercial Plan will provide pharmacy coverage for all non-Medicare participants in the State Health Plan, MUSC Health Plan, and all Medicare Primary participants who have opted out of the EGWP Plan."]
["The administrative fees, dispensing fees and rebates must be provided in accordance with the instructions found in Part 5 of the RFP, Information for Offerors to Submit, 5.2 Business Proposal, Offeror’s Financial Proposal Response for Tab A-10."]
["In Table I below, all-inclusive administrative fees must be provided on a per member per month, or PMPM, basis.  Fees shall be quoted separately for the Commercial Plan, EGWP and Medicare Part B Coordination.  The administrative fees must include the cost associated with providing PEBA with all the required services described in Part 3, Scope of Work,  of the RFP. The administrative fees must also include the cost associated with any additional clinical and/or administrative programs the Offeror chooses to include (per Part 3 Scope of Work, Section A Pricing and Cost Containment, Item 10.bbb).  These additional programs must be listed in the cover letter of the Offeror's Financial Proposal.  No additional supplemental pricing information (i.e. optional programs, deviations or caveats to the specifications of the RFP) shall be submitted in the Offeror's response to the RFP. "]
["In Table II below, please provide the requested pricing information for participants enrolled in the EGWP plan.\n\nIn Table III below, please provide the requested pricing information for participants not enrolled in the EGWP plan.\n"]
[]
[null,"Table I"]
[null,"Administrative Fees (PMPM)",null,null,null,null,null,"1/1/26 - 12/31/26","1/1/27 - 12/31/27"]
[null,"1.","Commercial Plan Administrative Fee (per member per month)"]
[null,"2.","EGWP Administrative Fee (per member per month)"]
[null,"3.","Medicare Part B Coordination Solution"]
[]
[null,"Table II"]
[null,"EGWP Plan",null,null,null,null,null,"1/1/26 - 12/31/26","1/1/27 - 12/31/27"]
[null,"DISPENSING FEES (Per Script)"]
[null,"1.","Home Delivery"]
[null,null,"a.)","Brand "]
[null,null,"b.)","Generic"]
[null,"2.","Specialty (Contractor affiliated pharmacy)"]
[null,null,"a.)","Brand "]
[null,null,"b.)","Generic"]
[null,"3.","Specialty (Non-Contractor affiliated pharmacy)"]
[null,null,"a.)","Brand "]
[null,null,"b.)","Generic"]
[null,"Trend Guarantee"]
[null,"4.","Guaranteed Net PMPM"]
[]
[null,"Table III"]
[null,"Commercial Plan",null,null,null,null,null,"1/1/26 - 12/31/26","1/1/27 - 12/31/27"]
[null,"DISPENSING FEES (Per Script)"]
[null,"1.","Home Delivery"]
[null,null,"a.)","Brand "]
[null,null,"b.)","Generic"]
[null,"2.","Specialty (Contractor affiliated pharmacy)"]
[null,null,"a.)","Brand "]
[null,null,"b.)","Generic"]
[null,"3.","Specialty (Non-Contractor affiliated pharmacy)"]
[null,null,"a.)","Brand "]
[null,null,"b.)","Generic"]
[null,"Trend Guarantee"]
[null,"4.","Guaranteed Net PMPM"]
[]
[]
[null,"I hereby certify that the fixed, single, all-inclusive PMPM administrative fees offered in Table I above  include the costs associated with providing PEBA with all required services described in the Pharmacy Benefit Management Services RFP, including but not limited to Part III, Scope of Work, Sections A through M.  Furthermore, the pricing guarantees offered in Table II, Table III and Table IV above have been developed in accordance to the specifications described in the RFP, including but not limited to Part V: Information for Offerors to Submit, Section B: Financial Proposal, sub-section 2., and shall remain unchanged, subject to the Change Order provision of the RFP, for the initial two (2) year term of the contract."]
[]
[]
[null,"Offeror Name"]
[]
[null,"Printed Name of Authorized Representative"]
[]
[null,"Signature Authorized Representative"]
[]
[null,"Date"]