CMS-R-262 CY 2016 MTMP – Fees Page Mockups

The Plan Benefit Package (PBP) and Formulary Submission for Advantage (MA) Plans and Prescription Drug Plans (PDPs) (CMS-R-262)

Appendix_C_MTMP_Fees Page Mockup 09082014

CY2016 Plan Benefit Package (PBP) Software and Formulary Submission (CMS-R-262)

OMB: 0938-0763

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0763 can be found here:
Document [pdf]
Download: pdf | pdf
CY 2016 MTMP – Fees Page Mockups
The edit/EditPageF.asp (Fees) page will be displayed in accordance with the scenarios described below –
1. If only PBM is selected under the Outside Personnel for the Provider of MTM Services on the
edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for PBM)
[ ] Fees are covered as part of the services of the global PBM contract without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources PBM
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - PBM
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service
Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

2. If only Disease Management vendor is selected under the Outside Personnel for the Provider of
MTM Services on the edit/EditPageE.asp (Resources) page.

FU Associate Ltd
9/8/2014
1|P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

Fees [Only appears if Outside personnel selected in Resources]
(Select one for Disease Management vendor)
[ ] Fees are covered as part of the services of the Disease Management vendor contract without being
priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Disease Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Disease Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service
Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

3. If only Medication Therapy Management vendor is selected under the Outside Personnel for the
Provider of MTM Services on the edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for Medication Therapy Management vendor)
[ ] Fees are covered as part of the services of the Medication Therapy Management vendor contract
without being priced out separately
OR

FU Associate Ltd
9/8/2014
2|P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Medication Therapy Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Medication Therapy Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

4. If any or combination of other vendor options - Local pharmacists, Long Term Care (LTC) Consultant
Pharmacists, Hospital Pharmacists, Physician, Registered Nurse, Licensed Practical Nurse, Nurse
Practitioner, Physician's Assistant, Pharmacy intern under the direct supervision of a pharmacist
and Pharmacy technician is selected under the Outside Personnel for the Provider of MTM Services
on the edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for Other vendor(s))
[ ] Fees are covered as part of the services of the Other vendor(s) contract without being priced out
separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Other vendor(s)
OR

FU Associate Ltd
9/8/2014
3|P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - Other
vendor(s) 1
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

5. If only PBM and Disease Management vendor are selected under the Outside Personnel for the
Provider of MTM Services on the edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for PBM)
[ ] Fees are covered as part of the services of the global PBM contract without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources PBM
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - PBM
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
1

This option is grayed-out, and not available for selection.

FU Associate Ltd
9/8/2014
4|P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00

Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*

(Select one for Disease Management vendor)
[ ] Fees are covered as part of the services of the Disease Management vendor contract without being
priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Disease Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Disease Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service
Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

6. If only PBM and Medication Therapy Management vendor are selected under the Outside Personnel
for the Provider of MTM Services on the edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
FU Associate Ltd
9/8/2014
5|P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

(Select one for PBM)
[ ] Fees are covered as part of the services of the global PBM contract without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources PBM
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - PBM
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Medication Therapy Management vendor)
[ ] Fees are covered as part of the services of the Medication Therapy Management vendor contract
without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Medication Therapy Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Medication Therapy Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
FU Associate Ltd
9/8/2014
6|P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

Per hour
Per minute
Per claim
Other:

7. If only Disease Management vendor and Medication Therapy Management vendor are selected
under the Outside Personnel for the Provider of MTM Services on the edit/EditPageE.asp
(Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for Disease Management vendor)
[ ] Fees are covered as part of the services of the Disease Management vendor contract without being
priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Disease Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Disease Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Medication Therapy Management vendor)
[ ] Fees are covered as part of the services of the Medication Therapy Management vendor contract
without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Medication Therapy Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Medication Therapy Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
FU Associate Ltd
9/8/2014
7|P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00

Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*

*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

8. If only PBM, Disease Management vendor and Medication Therapy Management vendor are
selected under the Outside Personnel for the Provider of MTM Services on the edit/EditPageE.asp
(Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for PBM)
[ ] Fees are covered as part of the services of the global PBM contract without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources PBM
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - PBM
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
FU Associate Ltd
9/8/2014
8|P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

(Select one for Disease Management vendor)
[ ] Fees are covered as part of the services of the Disease Management vendor contract without being
priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Disease Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Disease Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Medication Therapy Management vendor)
[ ] Fees are covered as part of the services of the Medication Therapy Management vendor contract
without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Medication Therapy Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Medication Therapy Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
FU Associate Ltd
9/8/2014
9|P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

Per member
Per month
Per hour
Per minute
Per claim
Other:

9. If only PBM and any or combination of other vendor options - Local pharmacists, Long Term Care
(LTC) Consultant Pharmacists, Hospital Pharmacists, Physician, Registered Nurse, Licensed
Practical Nurse, Nurse Practitioner, Physician's Assistant, Pharmacy intern under the direct
supervision of a pharmacist and Pharmacy technician is selected under the Outside Personnel for
the Provider of MTM Services on the edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for PBM)
[ ] Fees are covered as part of the services of the global PBM contract without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources PBM
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - PBM
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Other vendor(s))
[ ] Fees are covered as part of the services of the Other vendor(s) contract without being priced out
separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Other vendor(s)
OR

FU Associate Ltd
9/8/2014
10 | P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - Other
vendor(s) 2
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

10. If only Disease Management vendor and any or combination of other vendor options - Local
pharmacists, Long Term Care (LTC) Consultant Pharmacists, Hospital Pharmacists, Physician,
Registered Nurse, Licensed Practical Nurse, Nurse Practitioner, Physician's Assistant, Pharmacy
intern under the direct supervision of a pharmacist and Pharmacy technician is selected under the
Outside Personnel for the Provider of MTM Services on the edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for Disease Management vendor)
[ ] Fees are covered as part of the services of the Disease Management vendor contract without being
priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Disease Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Disease Management vendor
2

This option is grayed-out, and not available for selection.

FU Associate Ltd
9/8/2014
11 | P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Other vendor(s))
[ ] Fees are covered as part of the services of the Other vendor(s) contract without being priced out
separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Other vendor(s)
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - Other
vendor(s)3
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

3

This option is grayed-out, and not available for selection.

FU Associate Ltd
9/8/2014
12 | P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

11. If only Medication Therapy Management vendor and any or combination of other vendor options Local pharmacists, Long Term Care (LTC) Consultant Pharmacists, Hospital Pharmacists, Physician,
Registered Nurse, Licensed Practical Nurse, Nurse Practitioner, Physician's Assistant, Pharmacy
intern under the direct supervision of a pharmacist and Pharmacy technician is selected under the
Outside Personnel for the Provider of MTM Services on the edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for Medication Therapy Management vendor)
[ ] Fees are covered as part of the services of the Medication Therapy Management vendor contract
without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Medication Therapy Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Medication Therapy Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Other vendor(s))
[ ] Fees are covered as part of the services of the Other vendor(s) contract without being priced out
separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Other vendor(s)
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - Other
vendor(s)4
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
4

This option is grayed-out, and not available for selection.

FU Associate Ltd
9/8/2014
13 | P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00

Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*

*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

12. If only PBM, Disease Management vendor and any or combination of other vendor options - Local
pharmacists, Long Term Care (LTC) Consultant Pharmacists, Hospital Pharmacists, Physician,
Registered Nurse, Licensed Practical Nurse, Nurse Practitioner, Physician's Assistant, Pharmacy
intern under the direct supervision of a pharmacist and Pharmacy technician is selected under the
Outside Personnel for the Provider of MTM Services on the edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for PBM)
[ ] Fees are covered as part of the services of the global PBM contract without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources PBM
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - PBM
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
FU Associate Ltd
9/8/2014
14 | P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

$00000.00
$00000.00
$00000.00

Use drop Down Options*
Use drop Down Options*
Use drop Down Options*

(Select one for Disease Management vendor)
[ ] Fees are covered as part of the services of the Disease Management vendor contract without being
priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Disease Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Disease Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Other vendor(s))
[ ] Fees are covered as part of the services of the Other vendor(s) contract without being priced out
separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Other vendor(s)
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - Other
vendor(s)5
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
5

This option is grayed-out, and not available for selection.

FU Associate Ltd
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CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

$00000.00

Use drop Down Options*

*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

13. If only PBM, Medication Therapy Management vendor and any or combination of other vendor
options - Local pharmacists, Long Term Care (LTC) Consultant Pharmacists, Hospital Pharmacists,
Physician, Registered Nurse, Licensed Practical Nurse, Nurse Practitioner, Physician's Assistant,
Pharmacy intern under the direct supervision of a pharmacist and Pharmacy technician is selected
under the Outside Personnel for the Provider of MTM Services on the edit/EditPageE.asp
(Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for PBM)
[ ] Fees are covered as part of the services of the global PBM contract without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources PBM
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - PBM
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Medication Therapy Management vendor)
[ ] Fees are covered as part of the services of the Medication Therapy Management vendor contract
without being priced out separately
OR
FU Associate Ltd
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[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Medication Therapy Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Medication Therapy Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Other vendor(s))
[ ] Fees are covered as part of the services of the Other vendor(s) contract without being priced out
separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Other vendor(s)
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - Other
vendor(s)6
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
6

This option is grayed-out, and not available for selection.

FU Associate Ltd
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CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

Per hour
Per minute
Per claim
Other:

14. If only Disease Management vendor, Medication Therapy Management vendor and any or
combination of other vendor options - Local pharmacists, Long Term Care (LTC) Consultant
Pharmacists, Hospital Pharmacists, Physician, Registered Nurse, Licensed Practical Nurse, Nurse
Practitioner, Physician's Assistant, Pharmacy intern under the direct supervision of a pharmacist
and Pharmacy technician is selected under the Outside Personnel for the Provider of MTM Services
on the edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for Disease Management vendor)
[ ] Fees are covered as part of the services of the Disease Management vendor contract without being
priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Disease Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Disease Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Medication Therapy Management vendor)
[ ] Fees are covered as part of the services of the Medication Therapy Management vendor contract
without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Medication Therapy Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Medication Therapy Management vendor
FU Associate Ltd
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If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Other vendor(s))
[ ] Fees are covered as part of the services of the Other vendor(s) contract without being priced out
separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Other vendor(s)
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - Other
vendor(s)7
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

7

This option is grayed-out, and not available for selection.

FU Associate Ltd
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CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

15. If PBM, Disease Management vendor, Medication Therapy Management vendor and any or
combination of other vendor options - Local pharmacists, Long Term Care (LTC) Consultant
Pharmacists, Hospital Pharmacists, Physician, Registered Nurse, Licensed Practical Nurse, Nurse
Practitioner, Physician's Assistant, Pharmacy intern under the direct supervision of a pharmacist
and Pharmacy technician is selected under the Outside Personnel for the Provider of MTM Services
on the edit/EditPageE.asp (Resources) page.
Fees [Only appears if Outside personnel selected in Resources]
(Select one for PBM)
[ ] Fees are covered as part of the services of the global PBM contract without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources PBM
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - PBM
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Disease Management vendor)
[ ] Fees are covered as part of the services of the Disease Management vendor contract without being
priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Disease Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Disease Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
FU Associate Ltd
9/8/2014
20 | P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

$00000.00
$00000.00
$00000.00
$00000.00
$00000.00
$00000.00

Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*

(Select one for Medication Therapy Management vendor)
[ ] Fees are covered as part of the services of the Medication Therapy Management vendor contract
without being priced out separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Medication Therapy Management vendor
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources Medication Therapy Management vendor
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
(Select one for Other vendor(s))
[ ] Fees are covered as part of the services of the Other vendor(s) contract without being priced out
separately
OR
[ ] Fees priced out separately - Associates one fee table with all selected Outside Personnel Resources Other vendor(s)
OR
[ ] Fees priced out separately - Associates a fee table for each selected Outside Personnel Resources - Other
vendor(s)8
If fees priced out separately, complete the information for one or more Specific fee, Billing Method, and/or
Description:
Specific fee
Billing Method
Description (optional)
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
$00000.00
Use drop Down Options*
8

This option is grayed-out, and not available for selection.

FU Associate Ltd
9/8/2014
21 | P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING

$00000.00
$00000.00
$00000.00
$00000.00

Use drop Down Options*
Use drop Down Options*
Use drop Down Options*
Use drop Down Options*

*Use Drop Down Options:
Flat rate per service Capitated rate
Per member
Per member
Per month
Per hour
Per minute
Per claim
Other:

FU Associate Ltd
9/8/2014
22 | P a g e
CMS SENSITIVE INFORMATION – REQUIRE SPECIAL HANDLING
File Type	application/pdf
Author	Felix Yow
File Modified	2014-12-11
File Created	2014-12-11