Schedule B Pricing Wisconsin.xlsx
XLSX spreadsheet 36 KB Posted
- Attached to
- Mail Order Incontinence Supplies and Services
- Solicitation number
- RFP 171 210000000821 2
- Issued by
- Michigan
About this file
This is a pricing schedule (Schedule B) for Request for Proposal No. 210000000821 issued by the State of Michigan for the Wisconsin Department of Health Services to procure mail order incontinence supplies and services. The contract encompasses 53 line items across multiple product categories including insertion trays, catheters, external collection devices, anchoring devices, briefs, pull-on undergarments, liners, underpads, and related supplies. Estimated annual quantities vary significantly by item, ranging from 1 unit to over 4.5 million units for disposable liners and shields. The pricing schedule provides three contract term options: a 3-year base contract term, a 4-year base contract term, and a 5-year base contract term. Bidders must submit detailed unit costs and total bid amounts for each line item across all selected contract terms, with costs including all delivery, set-up fees, and handling charges.
Contractors are required to submit pricing in a modifiable format such as Microsoft Excel or Word, with failure to complete the schedule potentially resulting in proposal disqualification. Price proposals must be independently determined without consultation with competing contractors. The pricing schedule references specific brand and manufacturer equivalents for most items, with notes indicating that Wisconsin currently does not cover certain HCPCS codes and is seeking to establish contractual maximum fees and identify specific brands through this procurement. The document specifies that the state is not obligated to purchase minimum quantities and that estimated annual quantities are based on prior purchases. Contractors are encouraged to offer quick payment discount terms, and estimated internal transition costs for contractor changes are $125,000.
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Other files
| File | Type | Posted |
|---|---|---|
| Schedule A Statement of Work.docx | DOCX document | |
| Schedule C WI Prod & Ben Usage.xlsx | XLSX spreadsheet | |
| DIS RFP Statistics for Q & A - WISCONSIN.pdf | ||
| Schedule B Pricing Michigan.xlsx | XLSX spreadsheet | |
| WI Contract for Goods Template.docx | DOCX document | |
| Schedule C MI Prod & Ben Usage.xlsx | XLSX spreadsheet | |
| Standard Contract Terms MI.docx | DOCX document | |
| RFP 210000000821 Questions and Answers - 2-12-21.pdf | ||
| DIS RFP Statistics for Q & A - MICHIGAN.pdf | ||
| Schedule D WI BAA with Contract.pdf | ||
| Schedule D MDHHS BAA.pdf | ||
| RFP 210000000821 Amendment No. 1.pdf | ||
| RFP No. 210000000821 Prop Inst-CT Form-Vendor Questions Wksht.docx | DOCX document |
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STATE OF MICHIGAN
Request For Proposal No. 210000000821 Mail Order Incontinence Supplies and Services Wisconsin Department of Health service
SCHEDULE B
PRICING
1. The Contractor must provide a pricing schedule for the proposed Contract Activities using the table as included in this Schedule B. The pricing schedule should be submitted in a modifiable format (e.g.. Microsoft Word or Excel); however, you may also submit an additional pricing schedule in a non-modifiable format (e.g., PDF). Failure to complete the pricing schedule as requested may result in disqualification of your proposal.
2. Price proposals must include all costs, including but not limited to, any one-time or set-up charges, fees, and potential costs that Contractor may charge the State (e.g., shipping and handling, per piece pricing, and palletizing).
3. The Contractor is encouraged to offer quick payment terms. The number of days must not include processing time for payment to be received by the Contractor's financial institution.
Quick payment terms: ________ % discount off invoice if paid within ________ days after receipt of invoice.
4. By submitting its proposal, the Contractor certifies that the prices were arrived at independently, and without consultation, communication, or agreement with any other Contractor.
5. The State is not obligated to purchase in any specific quantity. Quantities specified if any, are estimates based on prior purchases. Exact quantities to be purchased are unknown, however the Contractor will be required to furnish all such materials and services as may be ordered during the contract period.
6. Costs of delivery, including emergency deliveries, must be included in the unit price of each Product. The Contractor must not charge the State or the Beneficiary any additional charge for delivery.
Schedule B Pricing WI
| Schedule B - Pricing for Selected Incontinence Supplies - Wisconsin Department of Health Services | ||||||||||||||
| 3 Year Base Contract Term | 4 Year Base Contract Term | 5 Year Base Contract Term | ||||||||||||
| Item No. | Unit | HCPC Code | Description | Monthly Quantity Limit (PA Required Over Qty Limit) | Estimated Annual Quantity | Unit Cost Per Item | Total Bid Amount | Unit Cost Per Item | Total Bid Amount | Unit Cost Per Item | Total Bid Amount | Referenced Brands/Manufacturers | Exact Matches Proposed | Proposed Alternate Product Details |
| 1 | EA | A4310 | Insertion tray without drainage bag and without catheter (accessories only) | 2 | 3,005 | $0.00 | $0.00 | $0.00 | AMSINO AS880 10 cc, AMSINO AS890 30 cc, Bard 802010, Bard 802030. | |||||
| 2 | EA | A4311 | Insertion tray without drainage bag with indwelling catheter, foley type, two-way latex with coating, (Teflon, silicone, silicone elastomer or hydrophilic, etc.) | 2 | 11 | $0.00 | $0.00 | $0.00 | Bard 800 Series | |||||
| 3 | EA | A4312 | Insertion tray without drainage bag with indwelling catheter, foley type, two-way, all silicone | 2 | 9 | $0.00 | $0.00 | $0.00 | Bard 720000 Series | |||||
| 4 | EA | A4314 | Insertion tray with drainage bag with indwelling catheter, foley type, two-way latex w/coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.) | 2 | 180 | $0.00 | $0.00 | $0.00 | Bard 802016, Bard 802018 | |||||
| 5 | EA | A4315 | Insertion tray with drainage bag, with indwelling catheter, foley type, two-way, all silicone | 2 | 42 | $0.00 | $0.00 | $0.00 | Covidien 6900 Series, Covidien 6950, Bard 897214, Bard 897216, Bard 897218. | |||||
| 6 | EA | A4320 | Irrigation tray with bulb or piston syringe, any purpose | 30 | 1,292 | $0.00 | $0.00 | $0.00 | AMSINO AS130 (Bulb), AMSINO AS136 (Piston), Covidien 67803. | |||||
| 7 | EA | A4322 | Irrigation syringe, bulb or piston, each | 30 | 1,323 | $0.00 | $0.00 | $0.00 | Amsino AS011 (Bulb), Bard 750379. | |||||
| 8 | EA | A4349 | Male external catheter with or without adhesive strip, disposable, each | 96 | 24,940 | $0.00 | $0.00 | $0.00 | Coloplast 5000 Series, Coloplast 7200 Series, Coloplast 8000 Series. | |||||
| 9 | EA | A4326** | Male external catheter, specialty type, e.g., inflatable, faceplate, etc. each | 2 | 105 | $0.00 | $0.00 | $0.00 | ||||||
| 10 | EA | A4328** | Female external urinary collection device; pouch, each | 12 | 1 | $0.00 | $0.00 | $0.00 | ||||||
| 11 | EA | A4330 | Perianal fecal collection pouch with adhesive, each | Not a covered HCPCS code | N/A | |||||||||
| 12 | EA | A4331 | Extension drainage tubing, any type, any length, with urinary leg bag or urostomy pouch, each | 4 | 1,892 | $0.00 | $0.00 | $0.00 | Coloplast 475, AMSINO AS311. | |||||
| 13 | EA | A4333 | Urinary catheter anchoring device, adhesive skin attachment | 4 | 1,237 | $0.00 | $0.00 | $0.00 | M.C. Johnson 5445-2, M.C. Johnson 5445-3. | |||||
| 14 | EA | A4334 | Urinary catheter anchoring device, leg strap | 6 | 377 | $0.00 | $0.00 | $0.00 | Covidien 8887600149 | |||||
| 15 | EA | T4523-U1* | Belted/Unbelted Undergarment WO Sides | 150 | 23,994 | $0.00 | $0.00 | $0.00 | Select Belt Less PBE 2078, Select Belted PBE 2650, Tranquility Belted Undergarment PBE 2150, Covidien Belted Undergarment MD-171B10, Absorbent Products 11530 | |||||
| 16 | EA | A4338 | Indwelling catheter, foley type, two-way latex w/coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.) each | 2 | 1,549 | $0.00 | $0.00 | $0.00 | AMSINO AS4000 Series, Bard 12361 12A123630A Series, Teleflex 180705120-180705280 Series, Telefex 180730140-180730280 Series. | |||||
| 17 | EA | A4340 | Indwelling catheter, specialty type, e.g. Coude, mushroom, wing, etc., each | 5 | 573 | $0.00 | $0.00 | $0.00 | Covidien 20512C-20524 Series, Teleflex 318112-918124 Series, Coloplast AA6308-AA6310 Series, Coloplast AA6312-AA6324 Series. | |||||
| 18 | EA | A4344 | Indwelling catheter, foley type, two-way, all silicone, each | 5 | 2,027 | $0.00 | $0.00 | $0.00 | Coloplast AA61XX Series, Coloplast AA6CXX Series, AMSINO AS40000 Series, Bard 806316-806324 Series, Bard 806514-806524 Series, Bard 165808-165824 Series, Teleflex 170605120-170605260 Series | |||||
| 19 | EA | A4351 | Intermittent urinary catheter, straight tip, each | 200 | 443,978 | $0.00 | $0.00 | $0.00 | Coloplast 110 Series, Coloplast 200 Series, Coloplast 300 Series, Coloplast 400 Series, AMSINO AS861000 Series, COV400608 8FR, COV400610 10FR, COV400612 12FR, COV400614 14FR, COV400616 16FR, COV400618 18FR, COV8887660903 14FR 6", Coviden KN8888492025, Coviden KN8888492033, CovidenKN8888492041, Coviden KN8888492058, Bard 802408-802422 Series. | |||||
| 20 | EA | A4351-U4 | Intermittent urinary catheter, straight tip, each | Wisconsin Medicaid reimburses A4351 across the lifespan | N/A | |||||||||
| 21 | EA | A4352 | Intermittent urinary catheter, coude (curved) tip, each | 150 | 86,994 | $0.00 | $0.00 | $0.00 | Coloplast 600 Series, Coloplast 800 Series, Bard 423710-423718. | |||||
| 22 | EA | A4352-U4 | Intermittent urinary catheter, coude (curved) tip, each | Wisconsin Medicaid reimburses A4352 without modifier across the lifespan | N/A | |||||||||
| 23 | EA | A4357 | Bedside drainage bag, day or night, with or without anti-reflux device, with or w/o tube, each | 3 | 3,880 | $0.00 | $0.00 | $0.00 | Bard 802001 AMSINO AS332 | |||||
| 24 | EA | A4358 | Urinary leg bag, vinyl, with or w/o tube, each | 10 | 3,974 | $0.00 | $0.00 | $0.00 | Amsino AS306Nm Amsino AS307N, Bard 4A4174. | |||||
| 25 | EA | A4402 | Lubricant | Covered outside of this contract | N/A | |||||||||
| 26 | EA | T4521 | Adult size brief / diaper small, each | 300 | 955,955 | $0.00 | $0.00 | $0.00 | Select PBE 2620, Tranquility Full Fit PBE 2120, Attends BRBX10, Hook & Loop Covidien 63062, Tena Specialty Brief SCA 66100, First Quality Brief PV-011, KN66032 Small Wings Choice Plus Quilted. | |||||
| 27 | EA | T4522 | Adult size brief / diaper medium, each | 300 | 1,258,040 | $0.00 | $0.00 | $0.00 | Select Full fit PBE 2624, Hook & Loop Covidien 63063, Attends BRB20, Tena Ultra Brief Med SCA 67200, FQ Per-Fit Breathable PF-012/1, KN66033 Med Wings Choice Plus Quilted, Wings Choice Adult Brief Medium Covidien KN60043DP, SCA67320, 32-44". | |||||
| 28 | EA | T4523 | Adult size brief / diaper large, each | 300 | 836,154 | $0.00 | $0.00 | $0.00 | Select Full Fit PBE 2634, Hook & Loop Covidien 63064, Attends BR30, Attends BRB30, Tena Ultra Brief Large SCA68122, FQ Per-Fit Breathable PF-013/1, KN66034 Large Wings Choice Plus Quilted, Wings Choice Adult Brief Large Covidien KN60044DP, SCA67330, 40-56". | |||||
| 29 | EA | T4524 | Adult size brief / diaper x-large, each | 300 | 317,998 | $0.00 | $0.00 | $0.00 | Select Full Fit PBE 2635, Hook & Loop Covidien 63065, Attends BR40, Attends BRB40, FQ Per-Fit Breathable PF-014/1, KN66035 X-Large Wings Choice Plus Quilted, Wings Choice Adult Brief XLG Covidien KN60045DP, SCA67340, 52-62". | |||||
| 30 | EA | T4525 | Adult size pull on small, each | 150 | 526,236 | $0.00 | $0.00 | $0.00 | Select Sm PBE 2604,Attends 7 PaperPak APP0710, First Quality PV-511. | |||||
| 31 | EA | T4526 | Adult size pull on medium, each | 150 | 1,498,765 | $0.00 | $0.00 | $0.00 | Select Med PBE 2605, Sure Care Protective Underwear Covidien 1605, Attends 7 APP0720, Tena Plus SCA, 72241, First Quality PF-512, First Quality PFM-512, First Qualify PFW-512. | |||||
| 32 | EA | T4527 | Adult size pull on large, each | 150 | 1,232,822 | $0.00 | $0.00 | $0.00 | Select Lg, PBE 2606, Sure Care Protective Underwear Covidien 1615, Attends 7 PaperPak APP0730, Tena Plus SCA 72340, FQ Per-Fit PF-513, First Quality PFM-513, First Quality PFW-513. | |||||
| 33 | EA | T4528 | Adult size pull on x-large each | 150 | 925,458 | $0.00 | $0.00 | $0.00 | Select XLG PBE 2607, Sure Care Protective Underwear, Covidien 1625, Attends 7 PaperPak APP0740, Tena Plus SCA 772419, FA Per-Fit PF-514, First Quality PFM-514, First Quality PFW-514. | |||||
| 34 | EA | T4529 | Pediatric size brief / diaper small / medium, each | 300 | 3,912 | $0.00 | $0.00 | $0.00 | Curity Ultra Fits Covidien 80018, Curity Utra Fits Covidien 80028, Huggies 43088 (size 1), Huggies 43091 (size 2), Huggies 43094 (size 3), Luvs Baby Diapers PNG341417 (size 2), Luvs Baby Diapers 238793 (size 3), First Quality CR2001. Cuties TM Baby Diaper-Size 2, 12-18 lbs., First Quality CR3001, Cuties TM Baby Diaper-Size 3, 16-28 lbs. | |||||
| 35 | EA | T4530 | Pediatric size brief / diaper large, each | 300 | 220,624 | $0.00 | $0.00 | $0.00 | Curity Ultra Fits Covidien 80038CF, Curity Ultra Fits Covidien 80048, Huggies 43085 (Size 5), Huggies 43084 (Size 4), Luvs Baby Diapers 238800 (Size 4), Luve Baby Diapers 239055 (Size 5), First Quality CR4001, Cuties TM Baby Diaper-Size 4, 22-37 lbs., First Quality CR5001, Cuties TM Baby Diaper-Size 5, 27+ lbs. | |||||
| 36 | EA | T4531 | Pediatric size pull on small/medium, each | 150 | 14,368 | $0.00 | $0.00 | $0.00 | Run Around MD Boy, Covidien 70063B, Run Around, Md. Girl Covidien 70063G, Huggies 43138 Youth Pull On Brief 2T-3T Boys, Huggies 43136 Youth Pull On Briefs 2T-3T Girls, Curity Sleeppants Covidien 70073, First Quality CR7007 Trn Pants Girl 2T-3T, Attends CMF-B2, Attends CMF-G2. | |||||
| 37 | EA | T4532 | Pediatric size pull on large, each | 150 | 60,954 | $0.00 | $0.00 | $0.00 | Run Around Lg. Boy, Covidien 70064B, Run Around Lg. Girl Covidien 70064 GC, Huggies Youth Pull On Briefs 43139 3T-4T Boys, Huggies 43137 3T-4T Girls, First Quality CR8007 Cutie Trn Pants Boy 3T-4T, First Quality CR8008 Trn Pants Girl 3T-4T, Attends CMF-B3, Attends CMF-G3. | |||||
| 38 | EA | T4533 | Youth size brief / diaper, each | 300 | 1,759,151 | $0.00 | $0.00 | $0.00 | Tranquility PBE 2166, Curity Ultra Fits Covidien 80058, Huggies 43095 (Size 6), Luvs Baby Diapers 238772 (Size 6), First Quality CR 6001, Cuties TM Baby Diaper-Size 6, 35+ lbs., Attends BRBY 20"-28", Attends CMF-7. | |||||
| 39 | EA | T4534 | Youth size pull on, each | 150 | 1,709,822 | $0.00 | $0.00 | $0.00 | Select Extra Small Brief PBE 2603, RunAround X-Lg. Boy Covidien 70065B, Run Around X-Lg Girl Covidien 70065G, Huggies Pull-Up 434135 4T-5T Boy, Huggies Pull-Up 43116 4T-5T Girl, Curity Sleeppants Covidien 70074, Sleep Overs Youth Underwear SLP05301, Sleep Over Youth Underwear SLP5302, 65-125 lbs., First Quality CR9007 Trn Pants Boy 4T-5T, First Quality CR9008 Trn Girl 4T-5T, Attends CMF-B4, Attends CMF-G4. | |||||
| 40 | EA | T4535 | Disposable liner / shield / pad, each | 300 | 4,513,175 | $0.00 | $0.00 | $0.00 | Booster Pad PBE 2760, Select Shield PBE 2648, Booster Pad PBE 2072, Tranquility Super Plus Trimshield PBE 2083, Dignity ThinSerts Humanicare 30054, Humanicare Dignity Natural Liner HC26955, HC26954, Humanicare Stackable Pad HC30053, Humanicare Dignity Plus Super Liner HC30071, Humanicare Dignity Plus Liner HC30074, Humanicare Spartan Liners HC40340, Attends Shaped Pad LP0500, Serenity extra pads(mod) SCA 48900, FQ Prevail Pantiliner PV-926, FZ Prevail Day Time Liner PL-100/1 and Attends LP0600, Prevail Bladder Control Pad extra BC-012, Absorten Products Company 19244 Booster Liner, First Quality PQPPv-915/1, Prevail Extra Plus Liner BC-013, First Quality PQPPV923/1, Presto ILS21500 Absorbent Liner, Absorbent Products APC57244, Absorbent Products APC 46250. | |||||
| 41 | EA | T4536 | Reusable washable underwear any size, each | 10 | 1,449 | $0.00 | $0.00 | $0.00 | Covidien KN705A Small/Med., Covidien KN706A Large/X-Large, Covidien KN707A XX-Large/XXX-Large. | |||||
| 42 | EA | T4541 | Disposable underpads (e.g., Chux’s), large 23 x 36 | 200 | 3,876,801 | $0.00 | $0.00 | $0.00 | Covidien 1093DP, 7176, 2675, Griffin Medical 1836. | |||||
| 43 | EA | T4542 | Disposable underpads (e.g., Chux’s), small 17 x 24 | 200 | 30,100 | $0.00 | $0.00 | $0.00 | PaperPak UFS170, Griffin Medical Underpad 17x24 #2504. | |||||
| 44 | EA | T4543 | Bariatric adult size brief / diaper xx-large, each | 300 | 129,480 | $0.00 | $0.00 | $0.00 | Whitestone 43790, Prevail Breathable Bariatric Brief, 63”-94” PV-094, Attends DD60, Principle Business Enterpries 2190. | |||||
| 45 | EA | A4649 | Misc. Supply | Covered outside of this contract | Prior Authorization Always Required | No Reference, prior authorization supply | ||||||||
| 46 | EA | A5112** | Urinary leg bag; latex | 1 | 26 | $0.00 | $0.00 | $0.00 | ||||||
| 47 | EA | A5120 | Skin barrier, wipes, 50/box (antiseptic), per wipe | Covered outside of this contract | N/A | |||||||||
| 48 | EA | S5199 | Personal Care Products / Wipes/Adult/Baby, per wipe | Not a covered HCPCS code | N/A | |||||||||
| 49 | EA | A6250** | Skin sealants, protectants, moisturizers, ointment, any type, any size | 2 | 36,480 | $0.00 | $0.00 | $0.00 | ||||||
| 50 | EA | A4520 | Diaper/Incontinent pant, reusable/washable | Not a covered HCPCS code | N/A | |||||||||
| 51 | EA | A4354** | Insertion Tray with Drainage Bag | 3 | 136 | $0.00 | $0.00 | $0.00 | ||||||
| 52 | EA | A4353** | Intermittent Urinary Catheter with Insertion Supplies | 150 | 160,454 | $0.00 | $0.00 | $0.00 | ||||||
| 53 | EA | T4544 | Adult pull on, X-large; New coder per Medicare requirement | 150 | 334,488 | $0.00 | $0.00 | $0.00 | PAPAUB24060, Presto FQPV-517, First Quality, COV 1560P, Covidien, Principle Business Enterprises PBE2608. | |||||
| Subtotal Items 1-53: | $0.00 | $0.00 | $0.00 | |||||||||||
| GRAND TOTAL BID AMOUNT: | $0.00 | $0.00 | $0.00 | |||||||||||
| (Subtotal x 3, 4 and 5 years) | ||||||||||||||
| Notes: | ||||||||||||||
| 1. If the estimated annual quantity specified is "0", a quantity of "1" is in the formula found in Columns "H, J & L -Total Bid Amount" to calculate your total bid amount for the item. | ||||||||||||||
| 2. Do not enter a unit cost per item or total bid amount for line item no. 45 Misc. Supply. | ||||||||||||||
| 3. If transition to a new Contractor is required, WI DHS estimated internal transition costs are $125,000.00. | ||||||||||||||
| * Wisconsin covers Belted/Unbelted Undergarment WO Sides with HCPCS Code T4523-U1 | ||||||||||||||
| ** Wisconsin currently does not cover these HCPCS codes under the current contract. Wisconsin currently sets a max fee and vendors supply products represented by the HCPCS. The estimated quantity is based on current utlization. There is no references brand/manufacturers to share as Wisconsin currnetly does not currently limit brand or manufacturer or record product brand or manufacturer dispensed. Wisconsn is looking to this contract to identify contractual max fee and brands. |
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