ࡱ> GF `\pSally Griffith-Onnen Ba==L;u08X@"1Arial1Arial1Arial1Arial1 Arial1Arial1Arial1Calibri1Arial1$Arial1Arial1Calibri1Calibri1Calibri1Calibri1 Calibri1Calibri"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_) 00000000000 "$"#,##0.00"Yes";"Yes";"No""True";"True";"False""On";"On";"Off"],[$ -2]\ #,##0.00_);[Red]\([$ -2]\ #,##0.00\)                + ) , *     ! ! !           x@ @ 2 |@ @ 2 x@@ 2 |@ * | * x@ @ *  h@ @  l@ @ !x@ @ !|@ @ q!|@ !!|@ q!|@ @ )x@ @ !!|@ @ q!|@ @   !  a*"@ @ *  a""@ @ *  Q""@ @ *     !   !!|@ @ !|@ @  h  l !x !| q!| !!| !!| q!| !| Q  ( )x ( (   ! ! "x@@* "x @* "<@ "  "   Normal_Sheet1`%"Formula and Tier Descriptions%T8Offer Contingencies StatementPOffer spreadsheet  ; "fNf8@ZR3 A@@  A;Manufacturer NameFORMULA (1 or 2)Offer Contingencies  Offer Comment Bidder NameBidder Phone No. Bidder EmailSSDC DME Special RebateCAll offer submission rates and offers need to be submitted per unitExample: A box of 100 strips that has an AWP/WAC rate listed per box needs to be divided by 100 to get to the individual strip unit price~If WAC rates are not published you MUST include the AWP calculation used to calculate the WAC rate used for the bid submission>This should be added under the comment section upon submissionyThis section should also be filled out to convey any offer related information that you would like the States to consider\The AWP and WAC rates submitted need to reflect 2010 Quarter 1 (1/1/2010 - 3/31/2010) rates. WAC (1Q2010) AWP (1Q2010)XSpreadsheets that have rates listed other than 2010 Q1 will be returned for rate update.Comments Field:dSubmitting an offer indicates agreement to the Offer contingency Statement section of this worksheetsSubmitting an offer indicates your agreement that this offer can be extended to all SSDC pool participating states Offer Submission Terms:In addition to the information above the comments field should be used to include procurement options for any Free Meter offers5. Nonpayment of rebates means the failure to pay any rebates to an SSDC Pool State for the calendar year in which the offer was due. Confirm Offer^The SSDC Pool States guarantees that any and all Offers submitted will be treated accordingly:@By submitting this offer you confirm that, regarding your offer:Tier One%WAC or GNP Offer RateCalculated Offer unit amountTier Two Tier Three Tier FourIncomplete spreadsheets will be returned and will not be consider for state review unless a completed spreadsheet is returned before the deadline.Offer submission guidelines=2. I affirm and certify the accuracy of the values displayed.6. I agree that an agreement with a State shall be reduced to writing with said State consistent with the contract terms that have been published by said State.NDC/HRIProduct DescriptionABy submitting this offer, you confirm that, regarding your offer:>1. I have reviewed the values in all data cells for accuracy. D3. I am authorized to make all offers presented in this submission. 4. I agree that all offers are made with the understanding that the individual terms and conditions of the SSDC member states Diabetic Special Rebate Agreements (SRAs) apply.5. I agree that any agreement with a SSDC Pool State shall be governed by the law of said State and that any legal action may only be brought and maintained in the courts of said State as identified here: Iowa- Polk County District Court for the State of Iowa, Des Moines, Iowa, or in the United States District Court for the Southern District of Iowa, Central Division, Des Moines, Iowa, wherever jurisdiction is appropriate.3Maine-Maine Superior Court, Kennebec County, Maine.GOregon  Oregon Circuit Court of Marion County for the State of Oregon.3Utah- Third District Court, Salt Lake County, Utah.=Vermont- Vermont Superior Court, Washington County, Vermont. YWyoming- Wyoming District Court for the First Judicial District, Laramie County, Wyoming.West Virginia- Circuit Court of Kanawha County, Charleston, West Virginia or United States District Court for the Southern District of West Virginia, Charleston, West Virginia. ]7. I agree to keep the unit rebate amount confidential in accordance with the contract terms.>1. SSDC Member State populations will be limited to Medicaid. 2. Except as otherwise may be required to be disclosed by law or judicial process, offers will be held confidential, whether accepted or not. 3. Offers accepted by SSDC Pool States as of the close of negotiations are binding between the Offerer and an SSDC Pool State once approved by said State's Drug Committee and/or said State's Medicaid Director. rb. Fifty thousand ($50,000.00) dollars in aggregate as to any SSDC Pool State at the time that the offer was due. 6. All offers are made with the understanding that the individual terms and conditions of the SSDC member states Diabetic Special Rebate Agreements apply. k7. The unit rebate amount is confidential and will only be disclosed in accordance with the contract terms.4. Offers that are received from Manufacturers that are currently not in good standing due to either nonpayment or substantial underpayment of rebates (basic/CMS or special shall not be considered. An underpayment of rebates is substantial if it exceeds the lower of either: la. Ten (10%) percent of any quarter's basic/CMS or special rebates invoiced amount by any SSDC Pool State orB4 d<)  9 cc  ]3  dMbP?_*+%M\\Augprint\DC_Ricoh_C6000 odXX0CourierHelvetica 0XdQTYRPJL,WIN2000,PCL6C,2.0.0.0,COLOR@PJL SET GUISTARTJOB=1 @PJL SET GSPJLFILE= @PJL SET GUIENDJOB=1 dddd߀_ XjC:\WINDOWS\SYSTEM32\SPOOL\DRIVERS\W32X86\3\RIC66BA.XPIK2@P@7 U o "dXX??c@U*(  f  c $\2 A@` ]`\2  (<Formula 1: Percentage of WAC. Formula for State Special Rebate calculation: WAC * % of WAC = State Special Rebate Amount per unit Formula 2: Guaranteed Net Price. Formula for State Special Rebate calculation: WAC - Guaranteed Net Price = State Special Rebate Amount per unit <(D D8ll  s *2  A@ K K]`2  g(<h Tiers (Preferred Brand Levels) Preferred Brand Levels, referred to as Tiers in this offer spreadsheet, represent how the State will use an offer in a given tier. A description of each Tier level is provided below. Level 1 one exclusive product. Level 2 two co-preferred products Level 3 three co-preferred products Level 4 four or more preferred products<(  gg>@)))7ggD  7*IBM|O  dMbP?_*+%M\\Augprint\DC_Ricoh_C6000 odXX0CourierHelvetica 0XdQTYRPJL,WIN2000,PCL6C,2.0.0.0,COLOR@PJL SET GUISTARTJOB=1 @PJL SET GSPJLFILE= @PJL SET GUIENDJOB=1 dddd߀_ XjC:\WINDOWS\SYSTEM32\SPOOL\DRIVERS\W32X86\3\RIC66BA.XPIK2@P@7 U o "dXX??c@U7,,,,,, , , ,  ,,,,,,,,,,,,,   M3 M4 M5 M9 N: N6 M M7 M8   L& M' M" M( M) M* N+ N, N- N. N/ N0 N1Dl   ,!,"#$%&'()*+,-./0123456 M# !M2%2 >@  7ggD  &`hi  dMbP?_*+%!&CCONFIDENTIAL AND PROPRIETARYM\\Augprint\DC_Ricoh_C6000 odXX0CourierHelvetica 0XdQTYRPJL,WIN2000,PCL6C,2.0.0.0,COLOR@PJL SET GUISTARTJOB=1 @PJL SET GSPJLFILE= @PJL SET GUIENDJOB=1 dddd߀_ XjC:\WINDOWS\SYSTEM32\SPOOL\DRIVERS\W32X86\3\RIC66BA.XPIK2@P@7 U o "GXX??U} I}  } } I } I } I } m } $ } } $ } $ } } $ } I%H} $ &J @ ;@ @     6; 3 QR 4   5G OP O P  O P  O P ! "$ !% ! ! # $ % $  %  $  %  $  % &$'())*)+,-*<0=/.$'())*)-,-*<0=/.$'())*)-/-*<0=/.$ '())*)-/-*<0=/.$ '())*)-/-*<0=/.$ '())*)+,-*<0=/.$ '())*)-,-*<0=/.$ '())*)-/-*<0=/.$'())*)-/-*<0=/.$'())*)-/-*<0=/.$'())*)-,-*<0=/.$'())*)-/-*<0=/.$'())*)-/-*<0=/.$'())*)-/-*<0=/.$>?@@A@BCBADEFCI 6 78787878J 1   S!SSSSSSS 1 1111 2 1 11<&`(((((((((((((((*&  !"#1$% 2 !1 "2 #9#:;:;:;:;K $ %2 d*>@<d  2   7,NDCNDC should be 11 digits-Please enter the 11 digit NDC for the product-Please enter an 11 digit NDC for the product.ggD Oh+'0HPd  shmartinSally Griffith-OnnenMicrosoft Excel@Ğr@q@E՜.+,0d PXt | !GHS Data Management Formula and Tier DescriptionsOffer Contingencies StatementOffer spreadsheet'Offer spreadsheet'!Print_Area  Worksheets Named Ranges  !"#$%&'()*+,-./012345789:;<=?@ABCDERoot Entry FWorkbookBkSummaryInformation(6DocumentSummaryInformation8>