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

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

Z0001

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Provider of MTM Services:
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In-house staff
Outside personnel
PBM
Name of PBM:
Name of PBM:
Name of PBM:
Name of PBM:
Name of PBM:
Disease Management vendor
Medication Therapy Management vendor
Name of
vendor:
In-house Pharmacists
Local Pharmacists
Physician
Registered Nurse
Licensed Practical Nurse
Nurse Practitioner
Physician's Assistant
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Name of
vendor:

Name of
vendor:

Name of
vendor:
Name of
vendor:
Name of
vendor:
Local pharmacists
Long Term Care (LTC) Consultant Pharmacists
Hospital Pharmacists
Physician
Registered Nurse
Licensed Practical Nurse
Nurse Practitioner
Physician's Assistant
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Qualified Provider of Interactive, Person-to-Person CMR with written summaries:
Select all options that apply
Local Pharmacist
Long Term Care (LTC) Consultant Pharmacist
Plan Sponsor Pharmacist
Plan Benefit Manager (PBM) Pharmacist
MTM Vendor Local Pharmacist
MTM Vendor In-house Pharmacist
Hospital Pharmacist
Physician
Registered Nurse
Licensed Practical Nurse
Nurse Practitioner
Physician's Assistant

Other
Other
Other
Other
Other
Other
Other
Other
Other
Other

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For each “Name of Vendor” under the MTM Vendor and or “Name of
PBM” under the PBM is checked, the sub-elements – In-house
Pharmacists, Local Pharmacists, Physician, Registered Nurse, Licensed
Practical Nurse, Nurse Practitioner, Physician’s Assistant and 10 Other
fields will be displayed.