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NATIONAL MAIL-ORDER COMPETITION

50 Percent Compliance Form

MANDATORY FORM: IF YOU ARE BIDDING IN THE NATIONAL MAIL-ORDER COMPETITION, YOU MUST MAIL THIS FORM IN TIME FOR THE COMPETITIVE BIDDING IMPLEMENTATION CONTRACTOR (CBIC) TO RECEIVE IT BY THE LAST DAY OF BIDDING. IF WE DO NOT RECEIVE YOUR FORM ON TIME, YOUR BID WILL BE REJECTED.

Why we need this form from you:

For the national mail-order competition, the law requires that the Centers for Medicare & Medicaid Services (CMS) reject bids from suppliers that do not demonstrate that their bid covers at least 50 percent, by volume, of all types of mail-order diabetic testing strips. You must demonstrate your compliance with the 50 percent rule by completing and mailing this form. In addition, the models you list on this form will be shown in the Supplier Directory on www.medicare.gov that beneficiaries and referral agents use to locate contract suppliers.

Directions:

From the list below, select ALL models of test strips (HCPCS code A4253) that you intend to furnish to Medicare beneficiaries if you win a contract. The test strip product is identified by the glucose monitor model with which it is used. The percent of market share for each model will populate in the corresponding column. The cumulative market share will be displayed in the “TOTAL” box at the bottom of the form. Once you reach the 50 percent threshold, please enter any additional models you intend to provide. It is very important to indicate ALL models you intend to provide as this information will be shown in the Supplier Directory. If the model is not on the pre-populated list, please select “Other” and enter the model information. Models that you enter in the “Other” field will get a combined market share and count 10 percent towards your total market share for compliance with the 50 percent rule. Once you have completed this form, print and mail it with the other required hardcopy documents to the CBIC. DO NOT make any changes to the printed form. If you need to revise or correct a form you have already printed, please complete a new form. If you are commonly owned or controlled with another bidding supplier, you should only submit ONE form for each bidder number. Keep a copy of your completed form for your files.

Business Information [*required]

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(Check upper left corner of any screen in DBidS for bidder number)

Compliance with the 50 Percent Rule
Bidder Product Offering
Remove Model Percent of Market Share

Add Product Information
TOTAL



If you have any questions about this form, please contact the CBIC customer service center at 877-577-5331.