CY2013 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262

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CY 2014 MTMP - Enter/Edit
Contract(s):

Z0001

Fees
For the Fees priced out separately option, provide additional information.
Fees are covered as part of the services of the global PBM or vendor contract without
being priced out separately
Fees priced out separately – Associates one fee table with all PBMs/MTMs
Fees priced out separately – Associates a fee table for each PBM/MTM

PBM

Name of PBM
vendor:

Test PBM 1

Complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee

Billing Method

$
$
$
$
$
$
$
$
$
$
Medication Therapy Management vendor
Name of MTM
Test MTM 1
vendor:

Description
(optional)

Complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
$
$
$
$
$
$
$
$
$
$

Billing Method

Description
(optional)

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Select Contract Year

1. If “Fees priced out separately Associates one fee table with all PBMs/MTMs” is
selected, a fee table will be displayed.
2. If “Fees priced out separately – Associates a fee table for each PBM/MTM” is
selected, each name of the PBM/MTM entered in the Resources page will be
auto-populated with a fee table.