PBIRX - Pharmacy Benefit Intermediary

Download a hardcopy version of this form to fill out and mail, or submit this form for more immediate attention.

Broker/Consultant Information

Name

Address

Line 2

City, State, Zip

Telephone

Fax

Contact

Proposal Due Date

Commission Requested

Client Information

Name

Address

Line 2

City, State, Zip

Telephone

Fax

Contact

Effective Date

Nature of Business

Type of Program Requested

Guaranteed Rate

Structured Payment
(Self-Insured with Stop-Loss)

ASO

Discount Card

Current Plan

Fully Insured or ASO

Annual/Monthly Cap (S/F$) (PEPM/PMPM)

Current Vendor/Contract Expiration Date

Annual Deductible (Calendar or Fiscal Year) (S/F$)(PEPM/PMPM)

More than one plan design per location?
(If yes, click here and attach plan)

DAW (Dispense as Written) Program

Medical Carrier

Mandatory or Voluntary Generic

Office Visit Copay (< or > $10)

Dependent Age

Date Limitation

Student Age

Date Limitation

Wellness Plan?

Formulary (Three-Tiered/Closed)*

Mandatory Mail After One or Two Refills

Employer Contribution Percent

Employee

Dependent

Retiree

Other

*Closed participant pays full cost of non-preferred drugs

Claims Experience

Click here and attach claims experience for at least the most recent 12 months available along with the associated census for the experience periods. Note the date and nature of any benefit design or co-pay change that may have occurred during the experience period. If claim experience is not available, note reason and in its place furnish a detailed census including date of birth and coverage type for each eligible employee and dependent counts. (When claim history is not available in addition to detailed census we also require, detailed plan design information, and existing and/or renewal rate information in order to furnish a rate quotation.)

Copay Options*

Retail

	Current	Option 1	Option 2
Generic
Brand
Brand Non-Formulary

Mail

	Current	Option 1	Option 2
Generic
Brand
Brand Non-Formulary

Days Supply Limitations and Refill Limits**

Network:

Mail:

*Indicate any unique co-payment structure for specific medications, i.e. 20% injectables; 100% lifestyle drugs
** i.e. network: 30 days; 34 days >100doses; mail: 60, 90, 180 days

Plan Coverage Options*

Drugs Covered	Current	Option 1	Option 2
Oral Contraceptives
Diabetic Supplies
Fertility
Smoking Deterrents
Weight Loss
Growth Hormones
Vitamins
Aids Medications
Injectables
Erectile Dysfunction
Cosmetic Medications (Retin-A, Hair Loss)
Other**
Specialty Injectible Drug Program
Include a copy of current Plan design booklet (Drug Include/Exclude List) *Include any limitations of specific drugs and/or drugs requiring prior authorization

Employee Census*

Active Employees	Current Census	Current Rates	Renewal Rates
Single
Parent + Child
Husband + Wife
Family
Retiree Coverage? If yes, please complete table
	Retiree Census	Current Rates	Renewal Rates
Single
Parent + Child
Husband + Wife
Family
*Click here to attach a census data to include: DOB, Gender, Dependent coverage category

Miscellaneous Information

Reason case is out for bid

Other vendors bidding

Would you like PBIRx to develop RFP?

Additional information

This document is proprietary and confidential to PBIRx. This document has been delivered to the recipient solely for the purpose of permitting the recipient to evaluate a potential relationship with PBIRx. All other uses are prohibited.

Do you have questions about the services offered at PBIRx?

Please contact us at info@pbirx.com or fill out a form online to request a quote.