8. Attachment G - Cost Proposal.xlsx

XLSX spreadsheet 58 KB Posted Jun 3, 2025

Attached to: RFP No. DMS-2425-312 MAPD
Solicitation number: RFP-12976
Issued by: Leon County, Florida

About this file

Written by GovTribe AI · Jun 9, 2025

This is a Cost Proposal attachment (Attachment G) for a Medicare Advantage Prescription Drug (MA-PD) Benefits Request for Proposal (RFP No. DMS-24/25-312) issued by the Florida Department of Management Services. The solicitation requests respondents to submit proposed monthly premiums for either PPO or HMO Medicare Advantage plans, with coverage for the 2026 calendar year. Respondents must provide premium rates for three coverage tiers: Tier I (Benchmark Plan with $500 annual out-of-pocket maximum), Tier II (Moderate Coverage Plan with $1,000 annual out-of-pocket maximum), and Tier III (High Cost-Share Plan with $2,000 annual out-of-pocket maximum). The proposal requires detailed coverage information across all U.S. states and all Florida counties, with respondents having the option to provide nationwide or county-specific coverage.

The pricing is strictly regulated, with monthly premiums not exceeding $430 per member per month, and respondents must list their 2025 Medicare Advantage and Part D Star Rating. The proposal requires comprehensive service details including copayments for various medical services, prescription drugs, and healthcare interventions across different tiers. Respondents' quoted premium rates are guaranteed maximum rates for the first contract year, with potential rate adjustments allowed in subsequent years. By May 1 of each year, respondents can submit a premium rate validation to the Department if rate changes are requested, which must be supported by documentation submitted to CMS demonstrating the need for rate adjustments.

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File	Type	Posted
6. Attachment E - Reporting and Deliverables.pdf	PDF	Jun 3, 2025
11. Attachment J - PUR 7801.docx	DOCX document	Jun 3, 2025
4. Attachment C - Covered Benefits and Services.pdf	PDF	Jun 3, 2025
9. Attachment H - Data Use Agreement.pdf	PDF	Jun 3, 2025
1. DMS-2425-312_MAPD RFP (1).pdf	PDF	Jun 3, 2025
11. Attachment J - PUR 7801.docx	DOCX document	Jun 3, 2025
13. Attachment L - Business-Assoc-Agreement.pdf	PDF	Jun 3, 2025
12. Attachment K - Draft Contract.pdf	PDF	Jun 3, 2025
6. Attachment E - Reporting and Deliverables.pdf	PDF	Jun 3, 2025
9. Attachment H - Data Use Agreement.pdf	PDF	Jun 3, 2025
13. Attachment L - Business-Assoc-Agreement.pdf	PDF	Jun 3, 2025
2. Attachment A - Administrative Requirements.pdf	PDF	Jun 3, 2025
4. Attachment C - Covered Benefits and Services.pdf	PDF	Jun 3, 2025
9. Attachment H - Data Use Agreement.pdf	PDF	Jun 3, 2025
12. Attachment K - Draft Contract.pdf	PDF	Jun 3, 2025
13. Attachment L - Business-Assoc-Agreement.pdf	PDF	Jun 3, 2025
2. Attachment A - Administrative Requirements.pdf	PDF	Jun 3, 2025
6. Attachment E - Reporting and Deliverables.pdf	PDF	Jun 3, 2025
8. Attachment G - Cost Proposal.xlsx	XLSX spreadsheet	Jun 3, 2025
Addendum No. 1.pdf	PDF	Jun 3, 2025
2. Revised Attachment A - Administrative Requirements.pdf	PDF	Jun 3, 2025
DMS-2425-312 Q&A.pdf	PDF	Jun 3, 2025
13. Attachment L - Business-Assoc-Agreement.pdf	PDF	Jun 3, 2025
7. Attachment F - Technical Reply.xlsx	XLSX spreadsheet	Jun 3, 2025
Addendum No. 1.pdf	PDF	Jun 3, 2025
DMS-2425-312 Q&A.pdf	PDF	Jun 3, 2025
1. DMS-2425-312_MAPD RFP (1).pdf	PDF	Jun 3, 2025
11. Attachment J - PUR 7801.docx	DOCX document	Jun 3, 2025
12. Attachment K - Draft Contract.pdf	PDF	Jun 3, 2025
7. Attachment F - Technical Reply.xlsx	XLSX spreadsheet	Jun 3, 2025
1. DMS-2425-312_MAPD RFP (1).pdf	PDF	Jun 3, 2025
3. Attachment B - Performance Guarantees.pdf	PDF	Jun 3, 2025
5. Attachment D - Enrollment File Layout and Schedule.pdf	PDF	Jun 3, 2025
12. Attachment K - Draft Contract.pdf	PDF	Jun 3, 2025
3. Attachment B - Performance Guarantees.pdf	PDF	Jun 3, 2025
5. Attachment D - Enrollment File Layout and Schedule.pdf	PDF	Jun 3, 2025
6. Attachment E - Reporting and Deliverables.pdf	PDF	Jun 3, 2025
8. Revised Attachment G - Cost Proposal.xlsx	XLSX spreadsheet	Jun 3, 2025
Addendum No. 1.pdf	PDF	Jun 3, 2025
Addendum No. 2.pdf	PDF	Jun 3, 2025
4. Attachment C - Covered Benefits and Services.pdf	PDF	Jun 3, 2025
8. Revised Attachment G - Cost Proposal.xlsx	XLSX spreadsheet	Jun 3, 2025
3. Attachment B - Performance Guarantees.pdf	PDF	Jun 3, 2025
5. Attachment D - Enrollment File Layout and Schedule.pdf	PDF	Jun 3, 2025
7. Attachment F - Technical Reply.xlsx	XLSX spreadsheet	Jun 3, 2025
4. Attachment C - Covered Benefits and Services.pdf	PDF	Jun 3, 2025
7. Attachment F - Technical Reply.xlsx	XLSX spreadsheet	Jun 3, 2025
9. Attachment H - Data Use Agreement.pdf	PDF	Jun 3, 2025
1. DMS-2425-312_MAPD RFP (1).pdf	PDF	Jun 3, 2025
11. Attachment J - PUR 7801.docx	DOCX document	Jun 3, 2025

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G-1 Instructions

ATTACHMENT G-1: INSTRUCTIONS FOR COST PROPOSAL

RFP No.: DMS-24/25-312

MEDICARE ADVANTAGE PRESCRIPTION DRUG (MA-PD) BENEFITS

Instructions: Respondent should read this tab for information to supplement the instructions in Attachment G-2 through G-4.

1. The Department is requesting Cost Proposals for Medicare Advantage and Prescription Drug (MA-PD) Plans. Each Respondent must submit proposed premiums for at least one (1) plan type, PPO or HMO.

2. Respondent must provide a corresponding proposed monthly premium amount for each Tier (I, II, and III), in accordance with the instructions outlined in Tab G-2 and Tab G-3.

3. Proposed monthly premium rates cannot exceed $430.00 Per Month Per Member. The average for each tab will be rounded to the second decimal.

4. Respondent must provide their 2025 Medicare Advantage and Part D Star Rating in the Star Rating field highlighted in yellow in Tab G-2 and Tab G-3.

Attachments:

Attachment G-2 - PPO Nationwide Coverage: Provide a list of ZIP codes and cities, organized by state, for any areas where network access is not available.

Attachment G-3 - HMO Florida County Coverage: HMO Respondents must indicate each Florida county where they propose to provide services OR indicate they propose to provide services in all Florida counties.

Attachment G-4 - Services by Tiers: Indicate plan type, PPO or HMO. Provide the Copayment dollar amount for each Covered Service for each tier.

The coverage tiers are defined as follows:

Tier I - Benchmark Plan: Includes a $500 annual medical out-of-pocket maximum and is intended to offer the highest level of coverage and cost protection. This tier should closely resemble the current MA-PD plans offered by the Program.

Tier II - Moderate Coverage Plan: Includes a $1,000 annual medical out-of-pocket maximum. This tier is designed to balance monthly premium costs with moderate out-of-pocket exposure for Members.

Tier III - High Cost-Share Plan: Includes a $2,000 annual medical out-of-pocket maximum and is structured to provide lower monthly premiums in exchange for higher Member cost-sharing responsibilities.

RFP No. DMS-24/25-&K000000312&K01+000 Attachment G-1: Instructions for Financial Proposal &P of &N

G-2 PPO Coverage

ATTACHMENT G-2: NATIONWIDE MEMBERS

RFP No.: DMS-24/25-312

MEDICARE ADVANTAGE PRESCRIPTION DRUG (MA-PD) BENEFITS NATIONWIDE
	Instructions for Completing G-2 -PPO Coverage Tab:
	1. Provide a list of zip codes and cities by state for any areas where provider network access is NOT available .
	2. Provide Respondent's proposed calendar year 2026 monthly premium MA-PD rates by Tiers for eligible State of Florida Group Insurance Plan Members, Per Month Per Member (PMPM). The premium rates shall be uniform across all counties in which Respondent plans to offer its proposed MA-PD plan. Respondent can only provide one proposed monthly premium rate regardless of cities proposed.
	3. The premium for Tier I, II, and II will be averaged into one premium.
	a. The Respondent's quoted premium rates are guaranteed maximum rates for year one (1) of the Contract. No other fees or charges may be added to the Contract after award, nor will the Respondent be compensated for more than applicable monthly premiums by coverage tier (Tier I, II, and III).

b. For all subsequent years: By May 1 of each calendar year for the subsequent Contract year (beginning January 1), the Respondent shall prepare a premium rate validation, as submitted to CMS, (i.e. a demonstration of the need for rate adjustments) and submit to the Department if a premium rate change is requested.

4. Respondent is required to list their 2025 Medicare Advantage and Part D Star Rating in the Star Rating field highlighted in yellow.

		State	Zip Code	City	Tier I Premium Rate
PMPM	Tier II Premium Rate
PMPM	Tier III Premium Rate
PMPM	Average of Premiums
		AK
		AK
		AK			Star Rating	Star Rating Score	0
		AK
		AK
		AL
		AL
		AL
		AL
		AL
		AR
		AR
		AR
		AR
		AR
		AZ
		AZ
		AZ
		AZ
		AZ
		CA
		CA
		CA
		CA
		CA
		CO
		CO
		CO
		CO
		CO
		CT
		CT
		CT
		CT
		CT
		DC
		DC
		DC
		DC
		DC
		DE
		DE
		DE
		DE
		DE
		GA
		GA
		GA
		GA
		GA
		HI
		HI
		HI
		HI
		IA
		IA
		IA
		IA
		IA
		ID
		ID
		ID
		ID
		ID
		IL
		IL
		IL
		IL
		IL
		IN
		IN
		IN
		IN
		IN
		KS
		KS
		KS
		KS
		KS
		KY
		KY
		KY
		KY
		KY
		LA
		LA
		LA
		LA
		LA
		MA
		MA
		MA
		MA
		MA
		MD
		MD
		MD
		MD
		MD
		ME
		ME
		ME
		ME
		ME
		MI
		MI
		MI
		MI
		MI
		MN
		MN
		MN
		MN
		MN
		MO
		MO
		MO
		MO
		MO
		MS
		MS
		MS
		MS
		MS
		MT
		MT
		MT
		MT
		MT
		NC
		NC
		NC
		NC
		NC
		ND
		ND
		ND
		ND
		ND
		NE
		NE
		NH
		NH
		NH
		NH
		NH
		NJ
		NJ
		NJ
		NJ
		NJ
		NM
		NM
		NM
		NM
		NM
		NV
		NV
		NV
		NV
		NV
		NY
		NY
		NY
		NY
		NY
		OH
		OH
		OH
		OH
		OH
		OK
		OK
		OK
		OK
		OK
		OR
		OR
		OR
		OR
		OR
		PA
		PA
		PA
		PA
		PA
		PR
		PR
		PR
		PR
		RI
		RI
		RI
		RI
		RI
		SD
		SD
		SD
		SD
		SD
		TN
		TN
		TN
		TN
		TN
		TN
		TN
		TN
		TN
		TN
		TX
		TX
		TX
		TX
		TX
		UT
		UT
		UT
		UT
		UT
		VA
		VA
		VA
		VA
		VA
		VT
		VT
		VT
		VT
		VT
		WA
		WA
		WA
		WA
		WA
		WI
		WI
		WI
		WI
		WI
		WV
		WV
		WV
		WV
		WV
		WY
		WY
		WY
		WY
		WY

RFP No.: DMS-24/25-312 Attachment G-2: PPO Coverage &P of &N

G-3 HMO Coverage ATTACHMENT G-3: HMO Coverage RFP No.: DMS-24/25-312

MEDICARE ADVANTAGE PRESCRIPTION DRUG (MA-PD) HMO PREMIUMS

Respondents must select ONE (1) of the following options to indicate how they are proposing a financial reply for this tab:
	Option one (1): Enter "Confirmed" in cell B5 if Respondent is proposing MA-PD coverage in all Florida counties. Please enter the premium rate for Tier I, II, and III that will apply to all counties in row 9. Respondent does not need to select "Yes" for each county in column C of Table 1 below.
	Option two (2): Enter "Confirmed" in cell B6 if Respondent is proposing MA-PD coverage in some, but not all Florida counties. In counties the Respondent will offer coverage, Respondent must confirm by selecting "Yes" from the corresponding drop down box. Please enter the premium rate for Tier I, II, and III for those counties in row 9.
Instructions for Completing G-3 - HMO Coverage Tab:
1. In the table below, provide Respondent's proposed calendar year 2026 monthly premium MA-PD rates by Tiers for eligible State of Florida Group Insurance Plan Members, Per Month Per Member (PMPM). The premium rates shall be uniform across all counties in which Respondent plans to offer its proposed MA-PD plan. Respondent can only provide one proposed monthly premium rate regardless of counties selected.
a. The premium for Tier I, II, and II will be averaged into one premium in the Average of Premiums field.
b. The Respondent's quoted premium rates are guaranteed maximum rates for year one (1) of the Contract. No other fees or charges may be added to the Contract after award, nor will the Respondent be compensated for more than applicable monthly premiums by coverage tier (Tier I, II, and III).
c. For all subsequent years: By May 1 of each calendar year for the subsequent Contract year (beginning January 1), the Respondent shall prepare a premium rate validation, as submitted to CMS, (i.e. a demonstration of the need for rate adjustments) and submit to the Department if a premium rate change is requested.
2. Respondent is required to list their 2025 Medicare Advantage and Part D Star Rating in the Star Rating field highlighted in yellow.

		County	If Respondent entered "Confirmed" in cell B6, please select "Yes" for each county in which the Respondent will offer proposed plan.	Tier I Premium Rate
PMPM	Tier II Premium Rate
PMPM	Tier III Premium Rate

PMPM

		Premium Rates
Alachua County	Select One
Baker County	Select One	Average of Premiums
Bay County	Select One
Bradford County	Select One	Star Rating	Star Rating Score	0
Brevard County	Select One
Broward County	Select One
Calhoun County	Select One
Charlotte County	Select One
Citrus County	Select One
Clay County	Select One
Collier County	Select One
Columbia County	Select One
DeSoto County	Select One
Dixie County	Select One
Duval County	Select One
Escambia County	Select One
Flagler County	Select One
Franklin County	Select One
Gadsden County	Select One
Gilchrist County	Select One
Glades County	Select One
Gulf County	Select One
Hamilton County	Select One
Hardee County	Select One
Hendry County	Select One
Hernando County	Select One
Highlands County	Select One
Hillsborough County	Select One
Holmes County	Select One
Indian River County	Select One
Jackson County	Select One
Jefferson County	Select One
Lafayette County	Select One
Lake County	Select One
Lee County	Select One
Leon County	Select One
Levy County	Select One
Liberty County	Select One
Madison County	Select One
Manatee County	Select One
Marion County	Select One
Martin County	Select One
Miami-Dade County	Select One
Monroe County	Select One
Nassau County	Select One
Okaloosa County	Select One
Okeechobee County	Select One
Orange County	Select One
Osceola County	Select One
Palm Beach County	Select One
Pasco County	Select One
Pinellas County	Select One
Polk County	Select One
Putnam County	Select One
Santa Rosa County	Select One
Sarasota County	Select One
Seminole County	Select One
St. Johns County	Select One
St. Lucie County	Select One
Sumter County	Select One
Suwannee County	Select One
Taylor County	Select One
Union County	Select One
Volusia County	Select One
Wakulla County	Select One
Walton County	Select One
Washington County	Select One

Attachment G-3: HMO Coverage &P of &N

G-4 Services by Tiers ATTACHMENT G-4: Services by Tiers RFP No.: DMS-24/25-312

MEDICARE ADVANTAGE PRESCRIPTION DRUG (MA-PD) PREMIUMS

Instructions for Completing G-4 -Services by Tiers Tab:

1. In B13, Respondent must notate if the Cost Proposal is for HMO or PPO.

2. Review the required services in the 'Covered Service' column.

3. In the 'Copayment' columns, enter the copayment amount associated with the Covered Service for the proposed plan.

a. Use standard U.S. currency (e.g., $20) for the dollar amounts.

b. Respondents are required to enter an amount in every yellow highlighted cell for columns E, F, and G.

4. Respondents must not delete or modify any cell in the table.

Plan Type: HMO or PPO? Tier I Out-of-Pocket Maximum $500 Tier II Out-of-Pocket Maximum $1000 Tier III Out-of-Pocket Maximum $2000

			Copayment	Copayment	Copayment
Category	Covered Service	Unit	Dollars $	Dollars $	Dollars $
Physician Services	Primary Care Office Visit	Per Visit	$ - 0	$ - 0	$ - 0
Physician Services	Primary Care Office Telehealth	Per Visit
Physician Services	Specialty Care Office Visit	Per Visit
Physician Services	Specialty Care Office Telehealth	Per Visit
Physician Services	Urgent Care - Office Visit	Per Visit
Physician Services	Urgent Care - Telehealth	Per Visit
Preventive & Alternative Care	Preventive Services	Per Visit
Preventive & Alternative Care	Chiropractic Care	Per Visit
Mental Health	Outpatient Mental Health / Substance Use Disorder	Per Visit
Medical Services	Outpatient Procedures and Other Medical Care	Per Visit
Hospital Services	Inpatient Hospital Care (Room & Board)	Per Day
Hospital Services	Outpatient Procedures in Hospital	Per Occurrence
Hospital Services	Mental Health Inpatient Hospital Care	Per Admission / Per Day
Emergency Services	Emergency Room Visit	Per Visit
Emergency Services	Ambulance Service	Per Transport
Other Services	Home Health Services	Per Occurrence
Other Services	Hospice Care	Per Occurrence
Other Services	Skilled Nursing Facility	Per Confinement
Other Services	Ambulatory Surgical Center	Per Occurrence
Equipment & Devices	Durable Medical Equipment	Per Device / Per Appliance
Equipment & Devices	Orthotic/Prosthetic Devices	Per Device / Per Appliance
Diagnostics	Imaging (MRI, PET, CT, etc.)	Per Visit
Diagnostics	Lab Services	Per Visit
Rehabilitation	Physical/Occupational/Speech Therapy	Per Visit
Rehabilitation	Cardiac Rehab	Per Admission / Per Day
Rehabilitation	Pulmonary Rehab	Per Admission / Per Day
Supplies & Drugs	Diabetic Testing Supplies	Per Fill
Prescription Drugs	Tier 1 Generic Drugs (30 Day Suppy)	Per Fill
Prescription Drugs	Tier 1 Generic Drugs (60 Day Supply)	Per Fill
Prescription Drugs	Tier 1 Generic Drugs (90 Day Supply)	Per Fill
Prescription Drugs	Tier 2 Preferred Brand Drugs (30 Day Suppy)	Per Fill
Prescription Drugs	Tier 2 Preferred Brand Drugs (60 Day Suppy)	Per Fill
Prescription Drugs	Tier 2 Preferred Brand Drugs (90 Day Supply)	Per Fill
Prescription Drugs	Tier 3 Non-Preferred Brand Drugs (30 Day Supply)	Per Fill
Prescription Drugs	Tier 3 Non-Preferred Brand Drugs (60 Day Supply)	Per Fill
Prescription Drugs	Tier 3 Non-Preferred Brand Drugs (90 Day Supply)	Per Fill
Prescription Drugs	Tier 4 Specialty Drugs (30 Day Supply)	Per Fill
Prescription Drugs	Tier 4 Specialty Drugs (60 Day Supply)	Per Fill
Prescription Drugs	Tier 4 Specialty Drugs (90 Day Supply)	Per Fill
Prescription Drugs	Tier 5 Additional Specialty Tier (30 Day Supply)	Per Fill
Prescription Drugs	Tier 5 Additional Specialty Tier (60 Day Supply)	Per Fill
Prescription Drugs	Tier 5 Additional Specialty Tier (90 Day Supply)	Per Fill
Prescription Drugs	Tier 6 Select Care / Preventive Drugs (30 Day Supply)	Per Fill
Prescription Drugs	Tier 6 Select Care / Preventive Drugs (60 Day Supply)	Per Fill
Prescription Drugs	Tier 6 Select Care / Preventive Drugs (90 Day Supply)	Per Fill
		Average Total Per Tier:	$ - 0	$ - 0	$ - 0

Average of Tier I,II,III: $ - 0

Attachment G-4: Services by Tiers &P of &N

File details come from the government source that posted it. Updated Jun 9, 2025.