CMS-10142 Prescription Drug: Worksheet 1

WORKSHEET 1 - Rx BASE PERIOD EXPERIENCE

Page 1 of 8
PD-2018.1
OMB Approved # 0938-0944 (Expires : TBD)

I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:

4. Contract Yr:
5. Org. Name:
6. SNP:

2018

7. Plan Name:
8. Plan Type:
9. Enrollee Type:

10. VBID:
11. MTM:

N
N

12. PD Region:
13. PD Benefit Type:
14. SNP Type:

N/A

II. Base Period Background Information
1. Time Period Definition
Incurred from:
Incurred to:
Paid through:
6. Briefly describe the source of the base period experience data:

2a. Total Member Months
2b. LIS Member Months
3. Risk Score
4. Completion Factor

0 5. Mapping

Contr-Plan-Seg ID

Member Months

Contr-Plan-Seg ID

Member Months

(k)

(l)

(m)

(n)

III. Part D Claims Experience
(d)

(e)

(f)

(g)

(h)

(i)

(j)

Total Count in Interval
Allowed
Claim
Interval
1.
2.
3.
4.
5.
6.

$0
$1-$359
$360-$3,309
$3,310-Catastrophic *
Above Catastrophic *
Subtotal

7.

% OON

8.
9.
10.
11.

# of
Members

Cumulative
Total
Number of
Scripts

Member
Months

0

0

Total
Allowed
Dollars

0

Average
Allowed Amount
per Member

$0.00

PMPM Values
Minus Rebates
Plus Part D as Secondary
Net Average Paid Amount PMPM

Average
Paid Amount
per Member

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

Average
Cost Sharing
per Member

$0.00

$0.00

$0.00

$0.00
$0.00
$0.00
$0.00

12. Non-covered Supplemental Drugs
13. Rebates on Supplemental Drugs
14. Net PMPM on Supplemental Drugs

Adjustments to Reflect Pt. D Coverage
Supplemental
Reimb for
Reimb
C.S. Reduc.
LIS
for Fed Reins.
per Member
per Member
per Member

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00
$0.00
$0.00

VI. PMPM Income Statement Summary
(g)
Total

1.
2.
3.
4.
5.

Sales and Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Insurer Fees

6. Total Non-Benefit Expenses

$0.00

(m)

1. Premium Revenue

$0.00

2.
3.
4.
5.

$0.00
$0.00

LIS Reimb.
Fed Reins.
Allocated Buy-Down*
Total Revenue

6. Pharmacy Claims
7. Non-Benefit Expenses
8. Total Expenses

$0.00
$0.00
$0.00
$0.00

V. PMPM Premium Revenue
(e)

(f)

(g)

Basic

Supplemental

Total

9. Gain/(Loss) Including Buy-Down

1. CMS Part D Payment
2. LI Premium Subsidy

$0.00
$0.00

3. Member Premium

$0.00

4. Member Penalty Premium
5. Total Premium

$0.00
$0.00

CMS - 10142 (2/29/2016)

$0.00

$0.00

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

$0.00
$0.00
$0.00
$0.00

$0.00

* See Instructions for Completing the Prescription Drug Plan BPT for CY2018.
IV. PMPM Non-Benefit Expenses

Net Plan
Responsibility
per Member

* MA rebate dollars to buy-down Part D premium (not true revenue)
Total Non-LI Brand Discount Amount

$0.00

WORKSHEET 2 - Rx PDP PROJECTION OF ALLOWED/ NON-BENEFIT

Page 2 of 8

I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:

4. Contract Yr:
5. Org. Name:
6. SNP:

2018

7. Plan Name:
8. Plan Type:
9. Enrollee Type:

10. VBID:
11. MTM:

N
N

12. PD Region:
13. PD Benefit Type:
14. SNP Type:

N/A

II. Utilization for Covered Part D Drugs
(e)

(f)

(g)

(h)

(i)

Base Period

Type of Script
1. Retail Generic
2. Retail Preferred Brand
3. Retail Non-Preferred Brand
4. Retail Specialty
5. Mail Order Generic
6. Mail Order Preferred Brand
7. Mail Order Non-Preferred Brand
8. Mail Order Specialty

# of
Scripts/
1000

Allowed
per Script

(j)

(k)

(l)

(m)

(n)

(o)

Components of Utilization Change
PMPM
Allowed
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

Trend in
Scripts/1000

Formulary
Change

Risk
Change

Induced
Utilization*

Total
Utilization
Change
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000

Other
Change

Projected
Scripts/
1000
0
0
0
0
0
0
0
0

Covariance
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000

9. Total Retail
10. Total Mail Order

0
0

$0.00
$0.00

$0.00
$0.00

0.000
0.000

0.000
0.000

0.000
0.000

0.000
0.000

0.000
0.000

0.000
0.000

0
0

0.000
0.000

11. Total Generic
12. Total Brand (Preferred and Non-Preferred)
13. Total Specialty

0
0
0

$0.00
$0.00
$0.00

$0.00
$0.00
$0.00

0.000
0.000
0.000

0.000
0.000
0.000

0.000
0.000
0.000

0.000
0.000
0.000

0.000
0.000
0.000

0.000
0.000
0.000

0
0
0

0.000
0.000
0.000

14. Total
0
$0.00
*Adjustment to remove impact of induced utilization due to supplemental coverage

$0.00

0.000

0.000

0.000

0.000

0.000

0.000

0

0.000

III. Cost for Covered Part D Drugs
(e)

(f)

(h)

(i)

Components of Unit Cost Change
Discount
Formulary
Other
Change
Change
Change

Inflation
Trend
1.
2.
3.
4.
5.
6.
7.
8.

(g)

Retail Generic
Retail Preferred Brand
Retail Non-Preferred Brand
Retail Specialty
Mail Order Generic
Mail Order Preferred Brand
Mail Order Non-Preferred Brand
Mail Order Specialty

(j)

(k)

Tot. Unit
Cost Chg
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000

Projected
Unit
Cost
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

Projected
Allowed
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

IV. Projected Allowed PMPM
(l)
(m)
Manual
Util/
1000

Manual
Unit
Cost

(n)
Manual
Rate
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

(o)

(p)

Credibility

Blended
Allowed
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

9. Total Retail
10. Total Mail Order

0.000
0.000

0.000
0.000

0.000
0.000

0.000
0.000

0.000
0.000

$0.00
$0.00

$0.00
$0.00

0
0

$0.00
$0.00

$0.00
$0.00

0%
0%

$0.00
$0.00

11. Total Generic
12. Total Brand (Preferred and Non-Preferred)
13. Total Specialty

0.000
0.000
0.000

0.000
0.000
0.000

0.000
0.000
0.000

0.000
0.000
0.000

0.000
0.000
0.000

$0.00
$0.00
$0.00

$0.00
$0.00
$0.00

0
0
0

$0.00
$0.00
$0.00

$0.00
$0.00
$0.00

0%
0%
0%

$0.00
$0.00
$0.00

14. Total

0.000

0.000

0.000

0.000

0.000

$0.00

$0.00

0

$0.00
$0.00
CMS Guideline Credibility

0%
0%

$0.00

V. PMPM Non-Benefit Expenses

(e)

VI. Percentage of Revenue

Projected Expenses
1.
2.
3.
4.
5.

Sales and Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Insurer Fees

6. Total Non-Benefit Expenses

$0.00

(j)

VII. Development of Manual Rate

1. Claims (Allowable Cost Target):
2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid

at 0.000
$0.00
$0.00
$0.00
$0.00

5. Percentage of Revenue
a. Claims (Allowable Cost Target):

0.0%

b. Non-Benefit Expenses
c. Gain/(Loss):

0.0%
0.0%

1. Describe the source/year and assumptions used in the
development of the manual rate.

WORKSHEET 3 - Rx CONTRACT PERIOD PROJECTION FOR DEFINED STANDARD COVERAGE

Page 3 of 8

I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:

4. Contract Yr:
5. Org. Name:
6. SNP:

2018

7. Plan Name:
8. Plan Type:
9. Enrollee Type:

10. VBID:
11. MTM:

N
N

12. PD Region:
13. PD Benefit Type:
14. SNP Type:

N/A

II. Projection Data
1. Projected Member Months:

0

2. Projected Avg Risk Score:

3. Projected LIS Member Months:
4. Projected non-LIS Member Months:

0

III. Part D Covered Drug Claims
(d)

1.
2.
3.
4.
5.
6.

Allowed
Claim
Interval
$0
$1-$399
$400-$3,699
$3,700-Catastrophic
Above Catastrophic
Subtotal

(e)

# of
Members

(f)

Member
Months

0

(g)

# of
Scripts

0

(h)

Projected
Allowed

0

$0.00

7. Minus Rebates
8. Minus Other Insurance
9. Plus Part D as Secondary
10. Projected % OON Included above:
11.
12. Total

(i)

Avg Amt
Allowed
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

(j)

Cost Sharing
$0.00
$0.00
$0.00
$0.00
$0.00

PMPM
Deductible

$0.00

(m)

$0.00

(n)

Federal
Reins. PMPM

$0.00

(o)

Plan Liability
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

$0.00

$0.00
$0.00
$0.00

$0.00

$0.00

Federal
LICS
PMPM

$0.00

Allowed:
Plan Liability:
$0.00

$0.00

$0.00

$0.00

V. Defined Standard Coverage Bid Development
(i)

1.
2.
3.

Basic Non-Benefit Expenses
Supplemental Non-Benefit Expenses
Total Non-Benefit Expenses

$0.00
$0.00
$0.00

4.
5.
6.

Basic Gain/(Loss)
Supplemental Gain/(Loss)
Total Gain/(Loss)

$0.00
$0.00

10. Is this bid part of a valid product pairing?
11.. Bids in Product Pairing

$0.00

(l)
Other
Cost Sharing
PMPM

$0.00
$0.00
$0.00

IV. Non-Benefit Expenses and Gain/(Loss)

7. Overall Gain/(Loss) Margin Level
8. Corporate Margin Requirement % of Rev.
9.. Corporate Margin Basis

Gap
PMPM

(k)

(j)

At 0.000
1. Claims (Allowable Cost Target):
2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid

$0.00
$0.00
$0.00
$0.00

At 1.00
$0.00
$0.00
$0.00
$0.00

5. Federal Reinsurance:

$0.00

$0.00

$0.00

$0.00

$0.00

WORKSHEET 4 - Rx STANDARD COVERAGE WITH ACTUARIALLY EQUIVALENT COST SHARING
Page 4 of 8
I.
1.
2.
3.

General Information
Contract Number:
Plan ID:
Segment ID:

4. Contract Yr:
5. Org. Name:
6. SNP:

2018

7. Plan Name:
8. Plan Type:
9. Enrollee Type:

10. VBID: N
11. MTM: N

12. PD Region:
13. PD Benefit Type:
14. SNP Type:

N/A

II. Projection Data
1. Projected Member months

0

2. Projected Avg Risk Score

III. Development of Bid for Standard Coverage

V. Std. Cov. Bid Development with Actuarially Equivalent C. S.

At 0.000
1. Claims (Allowable Cost Target)
2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid
5. Federal Reinsurance
6. LIS

0.000

At 1.00
$0.00
$0.00
$0.00
$0.00
$0.00

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

IV: Development of Bid Components and Tests for Actuarial Equivalence
(e)

1. Claims (Allowable Cost Target)
2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid
5. Federal Reinsurance
6. LIS

(g)

(i)

At 0.000
$0.00
$0.00
$0.00
$0.00
$0.00

(l)

1. Total Members
2. Member Months

0
0
Amounts below
Initial Coverage Limit
<$3,700

Amounts in
Gap

Amounts above
Catastrophic Threshold

All
Amounts

Allowed PMPM
3. Standard
4. Standard with Act. Equiv. Cost Sharing

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

5. Value of Deductible

$0.00

$0.00

$0.00

$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

0.0%
0.0%

0.0% C
0.0% D

0.0%
0.0%

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

Allowed Subject to Coins.
6. Standard
7. Standard with Act. Equiv. Sharing
Coins. %
8. Standard
9. Standard with Act. Equiv. Sharing
Coins PMPM
10. Standard
11. Standard with Act. Equiv. Sharing

25.0% A
0.0% B

Net Cost of Benefit
12. Standard
13. Standard with Act. Equiv. Sharing
Rebates
14. Standard
15. Standard with Act. Equiv. Sharing

For Reinsurance
$0.00
$0.00

Test for Actuarial Equivalence
Effective coinsurance with alternative cost sharing = to effective coinsurance for standard cost sharing
16.
17.
18.

A=B
C=D
Coverage in the Gap

No
No
No

Inc Reins.
$0.00

At 1.00
$0.00
$0.00
$0.00
$0.00
$0.00

WORKSHEET 5 - Rx ALTERNATIVE COVERAGE

Page 5 of 8

I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:

4. Contract Yr:
5. Org. Name:
6. SNP:

2018

7. Plan Name:
8. Plan Type:
9. Enrollee Type:

10. VBID:
11. MTM:

N
N

12. PD Region:
13. PD Benefit Type:
14. SNP Type:

N/A

II. Projection Data
1. Projected Member months

0

2. Projected Avg Risk Score

III. Development of Bid for Standard Coverage
1. Claims
2. Non-Benefit Expenses
3. Gain/(Loss)
4. Total Basic Bid
5. Federal Reinsurance
6. Total Coverage
7. LIS

0.000

V. Development of Actuarial Equivalence Test

At 0.000
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

C

A

At 1.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

At 0.000
$0.00 D
$0.00
$0.00
$0.00
$0.00 B
$0.00
$0.00

1. Part D Covered Drugs
2. Non-Benefit Expenses
3. Gain/(Loss)
4. Federal Reinsurance
5. Total Part D Covered
6. Non-Part D Covered Drugs
7. Total Plan Coverage
8. Total Basic Bid
9. LIS

At 1.00
$0.00
$0.00
$0.00
$0.00
$0.00

$0.00

$0.00

IV. Development of Bid Components
(d)

(f)

(o)

Amts above
Catastrophic

(q)

All
Members
0
0
0

0
0
0

Amts above Catastrophic
$0.00
$0.00

Total
PMPM
$0.00
$0.00

NonPart D
Covd
$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

25.0%
0.0%

25.0%
0.0%

0.0%
0.0%

100.0% J
0.0% K

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

0.0% H
0.0% I
$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00
Inc Reins.
$0.00

$0.00
$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00 F
$0.00 G

$0.00
$0.00

$0.00
$0.00

0.0%
0.0%

$0.00
$0.00

For Reinsurance

VII. Development of Supplemental Premium:
Yes
Yes
Yes
Yes
Yes
Yes

VIII. Development of Induced Utilization Adjustment

2. Impact of Alternative Utilization on Standard
3. Allowable Cost Target for Alternative
4. Induced Utilization Adjustment

(m)

$0.00

Total Coverage >= Std Coverage (B>=A)
Unsubsidized value>= Unsub Value for Std Covg(1=yes and D>=C)
Average Cost at Initial Covg Limit >= Std (G >=F)
Deductible <=$400 (E <=400)
Average Catastrophic cost sharing <= Std (I <= H)
Coverage in the Gap (K <= J)

1. Claims for Standard

(k)

E

VI. Tests for Alternative Coverage:
1.
2.
3.
4.
5.
6.

(i)

Part D Covered Drugs
Members with
Members
Amounts <=ICL
<$3,700
>=$3,700
for all members
0
0
0
0
0
0
0
0
0
Type of Deductible
Type of Gap Coverage
Alt Coverage Deductible Amount
Alternative Coverage ICL
Amounts below Initial Coverage Limit
Amts in Gap
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

1. Population not Meeting Deductible
2. Population Meeting Deductible
3. Member Months

Allowed PMPM
4. Standard
5. Alternative
Deductible
6. Proposed Deductible
7. Value of $400 Deductible
8. Value of Proposed Deductible
Allowed Subject to Coins.
9. Standard
10. Alternative
Coins. %
11. Standard
12. Alternative
Coins PMPM
13. Standard
14. Alternative
Federal Reinsurance
15. Standard
16. Alternative
Minus Rebates
17. Standard
18. Alternative
Minus Other Insurance
19. Standard
20. Alternative
Plus Part D as Secondary
21. Standard
22. Alternative
Net Cost of Benefit
23. Standard
24. Alternative

(g)

1. Part D Covered Drugs
2. Non Part D Covered Drugs
3. Less Basic Covered
4. Supplemental Coverage
5. Reduction in Reinsurance
6. Additional Non-Benefit Expenses

At 0.000
$0.00

At 1.00
$0.00

$0.00
0.000

$0.00
$0.00
0.000

7. Additional Gain/(Loss)
8. Supplemental Premium

At 0.000
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

$0.00

WORKSHEET 6 - Rx SCRIPT PROJECTIONS FOR DEFINED STANDARD, ACTUARIALLY EQUIVALENT OR ALTERNATIVE COVERAGE
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:

4. Contract Yr:
5. Org. Name:
6. SNP:

2018

II. Projections for Equivalence Tests
Population Not Exceeding $3,700 with Std Coverage
All Spending
1. Retail Generic
2. Retail Preferred Brand
3. Retail Non-Preferred Brand
4. Retail Specialty
5. Mail Order Generic
6. Mail Order Preferred Brand
7. Mail Order Non-Preferred Brand
8. Mail Order Specialty

7. Plan Name:
8. Plan Type:
9. Enrollee Type:

10. VBID:
11. MTM:

(f)

(g)
(h)
Defined Standard Coverage
Number of Scripts
Allowed $
Std Cost Sharing $

09. Total

0

Population Exceeding $3,700 with Std Coverage
All Spending
10. Retail Generic
11. Retail Preferred Brand
12. Retail Non-Preferred Brand
13. Retail Specialty
14. Mail Order Generic
15. Mail Order Preferred Brand
16. Mail Order Non-Preferred Brand
17. Mail Order Specialty

$0.00

Number of Scripts

18. Total

Allowed $

0

Amounts Allocated Up to ICL (1)
19. Retail Generic
20. Retail Preferred Brand
21. Retail Non-Preferred Brand
22. Retail Specialty
23. Mail Order Generic
24. Mail Order Preferred Brand
25. Mail Order Non-Preferred Brand
26. Mail Order Specialty

Allowed $

0

Amounts Allocated over Catastrophic Coverage
28. Retail Generic
29. Retail Preferred Brand
30. Retail Non-Preferred Brand
31. Retail Specialty
32. Mail Order Generic
33. Mail Order Preferred Brand
34. Mail Order Non-Preferred Brand
35. Mail Order Specialty

Number of Scripts

36. Total

Allowed $

0

0

Number of Scripts

Allowed $
-

$0.00

Allowed $

Number of Scripts

$0.00
Std Cost Sharing $

$0.00

Number of Scripts
-

37. Non-Part D Covered Drugs - All Spending

(j)
(k)
Actuarially Equivalent or Alternative Benefits
Number of Scripts
Allowed $
Cost Sharing $

0
Std Cost Sharing $

$0.00

12. PD Region:
13. PD Benefit Type:
14. SNP Type:

(i)

$0.00

Number of Scripts

27. Total

N
N

$0.00

Std Cost Sharing $

Page 6 of 8

Std Cost Sharing $
-

$0.00

0

$0.00

Cost Sharing $ (1)

$0.00
Allowed $

0
Number of Scripts

Cost Sharing $

Allowed $

Number of Scripts

$0.00

$0.00
Cost Sharing $

$0.00
Allowed $

$0.00
Cost Sharing $

(1) - The cost sharing for the section labeled "Amounts Up to ICL" should include non-uniform deductibles and/or reduced ICL levels.

NETWORK PRICING

GENERIC
% discount off AWP

RETAIL
MAIL

Dispensing Fee

BRAND
% discount off AWP

SPECIALTY
Dispensing Fee

% discount off AWP

Dispensing Fee

N/A

WORKSHEET 6A - COVERAGE IN THE GAP
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:

Page 7 of 8
4. Contract Yr:
5. Org. Name:

2018

6. SNP:

II. Spending in the Coverage Gap
Population Exceeding $3,700 with Std Coverage
Amounts Allocated between $3,700 and Catastrophic
1. Retail Generic
2. Retail Preferred Brand
3. Retail Non-Preferred Brand
4. Retail Specialty Generic
5. Retail Specialty Brand
6. Mail Order Generic
7. Mail Order Preferred Brand
8. Mail Order Non-Preferred Brand
9. Mail Order Specialty Generic
10. Mail Order Specialty Brand

10. VBID:
11. MTM:

7. Plan Name:
8. Plan Type:
9. Enrollee Type:
(f)

(g)
(h)
Defined Standard Coverage
Number of Scripts
Allowed $
Std Cost Sharing $
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00

11. Total

0

$0.00

N
N

12. PD Region:
13. PD Benefit Type:
14. SNP Type:

(j)

(i)

(k)

Actuarially Equivalent or Alternative Benefits
Number of Scripts
Allowed $
Cost Sharing $
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00
0
$0.00
$0.00

$0.00

0

$0.00

$0.00

Low Income Population Amounts Allocated between $3,700 and Catastrophic
Number of Scripts
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.

Allowed $

Std Cost Sharing $

Number of Scripts

Allowed $

Cost Sharing $

Retail Generic
Retail Preferred Brand
Retail Non-Preferred Brand
Retail Specialty Generic
Retail Specialty Brand
Mail Order Generic
Mail Order Preferred Brand
Mail Order Non-Preferred Brand
Mail Order Specialty Generic
Mail Order Specialty Brand

22. Total

0

$0.00

$0.00

0

$0.00

$0.00

Non-Low Income Population Amounts Allocated between $3,700 and Catastrophic
Number of Scripts
23. Retail Generic
24. Retail Preferred Brand
25. Retail Non-Preferred Brand
26. Retail Specialty Generic
27. Retail Specialty Brand
28. Mail Order Generic
29. Mail Order Preferred Brand
30. Mail Order Non-Preferred Brand
31. Mail Order Specialty Generic
32. Mail Order Specialty Brand
33. Total

Non-LI Generics in Gap PMPM
Non-LI Brand Discount Amt PMPM

Allowed $

0

$0.00
$0.00

Std Cost Sharing $

$0.00

$0.00

Number of Scripts

Allowed $

0

Cost Sharing $

$0.00

$0.00

N/A

WORKSHEET 7 - SUMMARY OF KEY BID ELEMENTS

Page 8 of 8

I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:

4. Contract Yr:
5. Org. Name:
6. SNP:

2018

7. Plan Name:
8. Plan Type:
9. Enrollee Type:

10. VBID:
11. MTM:

N
N

12. PD Region:
13. PD Benefit Type:
14. SNP Type:
N/A

II. 2018 Defined Standard Benefit Parameters
1. Deductible
2. Initial Coverage Limit
3. Out-of-pocket Limit

$400
$3,700
$4,950

III. Summary of Key Bid Elements
1. Standardized Part D Bid
2. National Average Monthly Bid Amount

V. Working Model Text Box
$0.00

This section can be used at the discretion of the Plan sponsor.
The contents are NOT uploaded in the bid submission.

3. Base Beneficiary Premium
Basic Part D Premium (prior to A/B rebate allocation)
4. Unrounded
5. Rounded

$0.00
$0.00

Supplemental Part D Premium (prior to A/B rebate allocation)
6. Unrounded
7. Rounded

$0.00
$0.00

8. Prospective federal reinsurance (non-standardized)
9. Prospective low-income cost sharing subsidy (non-standardized)
10.Target amount adjustment (allowed costs as a ratio of bid)
11. Prospective brand discount amount
Rounding Rule
12. Round Part D premiums to nearest

$0.00
$0.00
1.0000
$0.00
$0.10

IV. Part D Bid Pricing Tool Contacts
Plan Bid Contact
Name
Phone
Email
Part D Certifying Actuary
Name and Credentials
Phone
Email
Part D Additional BPT Actuarial Contact
Name
Phone
Email
Date Prepared

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