Exhibit_9_MAPD_Benefits_Summary.docx
DOCX document 51 KB Posted
- Attached to
- OEIBA Program Commercial HMO, MSP, and MAPD Plans State and local contract opportunity
- Solicitation number
- EV00000681
- Issued by
- Oklahoma County, Hobart City, Oklahoma
About this file
This document is an Exhibit 9 MAPD (Medicare Advantage Prescription Drug) Benefits Summary for a state or local employee insurance benefits program, detailing plan options for the 2026 plan year. The document provides comprehensive instructions for bidders to complete a benefits summary, requiring submission of either a standalone national MAPD plan or an MAPD plan in combination with other health plan types. Bidders must provide detailed information about their proposed Medicare Advantage plan, including service coverage across multiple healthcare categories such as hospitalization, outpatient services, professional services, therapy, diagnostic services, home health care, mental health care, and specialized treatments.
The document outlines specific requirements for pharmacy benefits, including copay structures, network pharmacy guidelines, and drug tier classifications. Bidders must demonstrate compliance with Medicare Modernization Act of 2003 requirements and provide a detailed breakdown of drug coverage, including 30-day and 90-day supply options across multiple drug tiers. The exhibit mandates that only one MAPD plan per supplier will be accepted for the 2026 plan year, and the benefits summary must be signed by the bidder's senior executive. Notably, current contract holders have the option to propose plan changes, which must be highlighted in bold text, while new bidders must provide a comprehensive current plan benefits overview.
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Text version
Exhibit 9 MAPD Benefits Summary [Supplier Name] Plan Year 2026
What type of MAPD plan is Bidder offering for this bid?
☐ MAPD in combination with a non-Medicare HMO ☐ MAPD in combination with an MSP and a non-Medicare HMO ☐ Standalone national MAPD
Instructions:
1. All plan design options must correspond to Exhibit 10 MAPD Premium Rate and LIS Quote.
2. All Part D pharmacy coverage descriptions and benefits listed must reflect compliance with CMS benefit guidance for MAPD plans and meet the Creditable Coverage definition.
3. List complete benefits when submitting “PY2026 No Plan Changes” and the “PY2026 With Proposed Plan Changes.”
4. Column “PY2026 No Plan Changes” is required for all Bidders and should list complete plan benefits unless the Supplier’s current MAPD plan is not an option for this solicitation.
a. For Bidders with current contracts with the OEIBA Program, this column should list the Supplier’s current plan benefits with no changes.
5. Only Bidders with current contracts have the option to also complete column “PY2026 with Proposed Plan Changes.”
a. This column should include all PY2025 plan benefits along with proposed plan changes for PY2026. Proposed plan changes must be in bold.
6. Benefit Summary must be from the member’s perspective.
7. No more than one (1) MAPD plan proposed by the Supplier will be accepted for PY2026.
8. MAPD Benefit Summary must be signed by the Bidder’s President, Chief Executive Officer or authorized representative.
Example
| Services |
| PY2026 |
No Plan Changes (Required for all Bidders)
PY2026
With Proposed Plan Changes (Optional only for current Suppliers)
In-Area Urgent Care Services
$10 copay for each visit
$15 copay for each visit
All Benefits Based on Medicare-covered Services
| SERVICES |
| PY2026 |
No Plan Changes (Required for all Bidders)
PY2026
With Proposed Plan Changes (Optional only for current Suppliers)
HOSPITALIZATION
Semi-private room (private if medically necessary) Nursing Services and medications All meals, including special diets Laboratory tests X-rays and other radiology services Inpatient physician and surgical services, including anesthesia Necessary medical supplies and appliances Blood and its administration Operating room, Special care units and rehabilitation services
ORGAN TRANSPLANTS AT A MEDICARE-APPROVED TRANSPLANT FACILITY
OUTPATIENT HOSPITAL SERVICES
Including outpatient surgical services in an ambulatory surgical center or outpatient hospital facility
RADIATION THERAPY
BLOOD
IN-AREA URGENT CARE SERVICES
OUT-OF-AREA URGENT CARE SERVICES
Urgently needed services worldwide (during a temporary absence from the service area)
EMERGENCY SERVICES
Emergency services needed worldwide
AMBULANCE SERVICES
Medically necessary
SKILLED NURSING FACILITY CARE
(Inpatient Services) Semi-private room Regular nursing services (except private-duty nurse) All meals, including special diets Physical, occupational, and speech therapy Drugs furnished by the facility Necessary medical equipment and supplies Blood and its administration Inpatient radiology and pathology Use of appliances such as a wheelchair
PROFESSIONAL SERVICES
Office Visits Consultation, diagnosis, and treatment by specialist Medical and surgical care Allergy tests and treatment (serum) Diagnostic tests and treatments Medical supplies including casts, dressings and splints
PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY SERVICES
X-RAY/DIAGNOSTIC RADIOLOGY SERVICES
Including annual mammography screening, if medically indicated.
LABORATORY SERVICES
PHYSICAL, SPEECH, AND OCCUPATIONAL THERAPY
HEARING EXAMINATIONS
CHIROPRACTIC
Limited to manual manipulation of the spine
PART-TIME OR INTERMITTENT SKILLED NURSING CARE
Home health aide in conjunction with skilled care Medical social services under direction of a physician Medical supplies (other than drugs) and equipment provided by the agency
DURABLE MEDICAL EQUIPMENT
DME and supplies, prosthetic devices, therapeutic shoes/inserts for severe diabetes
BARIATRIC SURGERY
CDC-RECOGNIZED DIABETES PREVENTION PROGRAM
TELEHEALTH/TELEMEDICINE/VIRTUAL VISITS
IMMUNIZATIONS
Includes flu injections and all Medicare-approved immunizations
PHYSICAL EXAM
Examination
WELL FEMALE EXAM
Examination Pap Smear
INPATIENT MENTAL HEALTH CARE
Inpatient services and supplies in a Medicare-approved psychiatric hospital.
OUTPATIENT MENTAL HEALTH CARE
Outpatient services of psychiatrist, psychologists and other mental health and substance abuse providers
ALCOHOL/DRUG TREATMENT
Inpatient Outpatient
PODIATRY CARE
Treatment of disease or injuries of the foot.
SELF-ADMINISTERED ORAL ANTI-CANCER DRUGS
Includes drugs as approved by Medicare or its generic equivalent
SELF-ADMINSTERED ERYTHROPOIETIN
Drug for dialysis patients
INJECTABLE DRUGS FOR OSTEOPOROSIS
Post-menopausal homebound women under physician’s supervision.
IMMUNOSUPPRESSIVE DRUGS
Includes Imuran, Sandimmune & any other FDA-approved outpatient immunosuppressive agent
OPTIONAL BENEFITS
Dental Health education Vision care Other (Please explain)
Pharmacy Copay Structure for Network Benefits
| General Information |
| PY2026 |
No Plan Changes (Required)
| Specify if there is a difference between retail and mail order, preferred retail or standard |
| PY2026 |
No Plan Changes (Optional)
Mandatory generic and formulary medications you get at a Network Pharmacy
Some drugs require prior authorization
Quantity limits apply to certain drugs
Only copays for covered drugs purchased at Network Pharmacies count toward out-of-pocket maximums
Pharmacy benefits must meet the minimum requirements for benefits as outlined in the Medicare Modernization Act of 2003
Pharmacy benefits must meet the minimum requirements for benefits as outlined in the Medicare Modernization Act of 2003
You will be notified before any changes are made to your plan's formulary.
CMS regulated changes to Part D coverage must be included in bold regardless of if Supplier is proposing plan changes.
30- Day Supply (Fill in type of drug for each tier. Example: generic drugs)
(Tier 1) ______Drugs
(Tier 2)
(Tier 3)
(Tier 4)
(Tier 5)
31- to 90-Day Supply (Fill in type of drug for each tier)
(Tier 1)
(Tier 2)
(Tier 3)
(Tier 4)
(Tier 5)
Catastrophic Coverage/Out-of-Pocket Maximum/Gap Coverage
Additional Notes
| ___________________ | __________________________ _____________ | ||
| Signature | Printed Name | Date |
Title Supplier Name (To be signed by the Supplier’s President, Chief Executive Officer or authorized representative.)
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