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

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Contracts included with Submission
Contract Number

Contract Name

Z0001

Contract Example
Individuals that will be Notified of Submission

Contract
Number

Role

Name

Email

All

MTMP Submission

John Doe

[email protected]

Z0001

Medicare Compliance
Officer

Mary Hue

[email protected]

Targeting Criteria for Eligibility
in the MTMP
MTM Program offered to:

Multiple Chronic Diseases
Minimum number of chronic
diseases:
Chronic disease(s) that apply:
Multiple Covered Part D Drugs
Minimum number of Covered Part
D Drugs:
Type of Covered Part D Drugs that
apply:

Only enrollees who meet the specified targeting criteria
per CMS requirements

2
Any chronic disease applies

2
Chronic/maintenance drugs apply

Incurred Cost for Covered Part
D Drugs
Specific Threshold and Frequency
Incurred one-fourth of specified annual cost threshold in previous three months
Targeting
Frequency:
Data evaluated for targeting:

Daily
Drug claims

Enrollment/Disenrollment
Method of enrollment:

Opt-Out only

Interventions
Recipient of interventions:
Beneficiary
Prescriber
Specific beneficiary interventions:
Interactive, Person-to-Person, Comprehensive Medication Review, annual
Interactive, person-to-person or telehealth consultation
Face-to-face
Materials delivered to beneficiary after the interactive, person-to-person CMR
consultation
Individualized, written summary of CMR in CMS' standardized format
(includes beneficiary cover letter, medication action plan, and personal
medication list)
Delivery of individualized written summary of CMR in CMS' standardized format:
Mail
Targeted medication reviews, at least quarterly, with follow-up interventions when
necessary
Specific prescriber interventions:
Prescriber interventions to resolve medication-related problems or optimize therapy
Phone consultation
Description:
Test
Resources
Provider of MTM services:
Outside personnel
Medication Therapy Management vendor: Test Vendor 1
In-house Pharmacists
Medication Therapy Management vendor: Test Vendor 2
Local Pharmacists
Qualified Provider of Interactive, Person-to-Person CMR with written summaries:
Physician
Fees
Fees priced out separately
Test PBM Vendor 1
$12.00 Flat rate per service
$5.00 Capitated rate
Test MTM Vendor 2
$12.00 Flat rate per service
$5.00 Capitated rate
Outcomes Measured
Part D Reporting Requirements
Drug-drug interactions measure

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