CMS-10142 Worksheets: Prescription Drug Bid Pricing Tool

WORKSHEET 1 - Rx BASE PERIOD EXPERIENCE Page 1 of 7 PD-2027.1 I. General Information OMB Approved # 0938-0944 (Expires: 3/31/2027)
1. Contract Number:											4. Contract Yr:					2027								7. Plan Name:																		10. BAL-D:																11. PD Region:
2. Plan ID: 3. Segment ID:											5. Org. Name: 6. SNP:													8. Plan Type: 9. Enrollee Type:																		12. PD Benefit Type: 13. SNP Type:
																																																														N/A
II. Base Period Background Information
1. Time Period Definition 2a. Total Member Months																																						0				5. Mapping Contr-Plan-Seg ID Member Months Contr-Plan-Seg ID Member Months
Incurred from: Incurred to: Paid through:											2b. LIS Member Months 3a. Risk Score 3b. LIS Risk Score
																																						0.0000
											3c. NLI Risk Score
4. Completion Factor
III. Part D Claims Experience
(d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n)
					Total Count in Interval											Cumulative
																																														Adjustments to Reflect Pt. D Coverage
Claim Interval					# of Members						Member Months					Total Number of Scripts								Total Allowed Dollars							Average Allowed Amount per Member							Average Paid Amount per Member				Average Cost Sharing per Member				Supplemental C.S. Reduc. per Member						Reimb for LIS per Member						Reimb for Fed Reins. per Member				Net Plan Responsibility per Member
1. $0 2. $1-$589 3. $590-Catastrophic * 4. Above Catastrophic * 5. Subtotal																															$0.00																															$0.00
																															$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						$0.00				$0.00
6. PMPM Values																													$0.00									$0.00								$0.00						$0.00						$0.00				$0.00
7. Minus Rebates																															$0.00																															$0.00
8. Plus Part D as Secondary																															$0.00																															$0.00
9. Net Average Paid Amount PMPM $0.00 $0.00 $0.00 $0.00																																																														$0.00
10. Non-covered Supplemental Drugs 11. Rebates on Supplemental Drugs																															$0.00 $0.00
12. Net PMPM on Supplemental Drugs																																						$0.00																								$0.00
* See Instructions for Completing the Prescription Drug Plan BPT for CY2027.
IV. PMPM Non-Benefit Expenses VII. PMPM Income Statement Summary (m)
																																						1. Premium Revenue 2. LIS Reimb.																				$0.00 $0.00
(g)
Total
1. Sales and Marketing 2. Direct Administration 3. Indirect Administration 4. Net Cost of Private Reinsurance 5. Uncollected Cost Sharing Payments M3P																																						3. Fed Reins. 4. Allocated Buy-Down*																				$0.00
																																						5. Total Revenue																				$0.00
																																						6. Pharmacy Claims 7. Non-Benefit Expenses																				$0.00
6. Total Non-Benefit Expenses $0.00																																																										$0.00
																																						8. Total Expenses 9. Gain/(Loss) Margin Including Buy-Down																				$0.00 $0.00
V. PMPM Premium Revenue (e) (f) (g)
											Basic					Supplemental								Total
																																						* MA rebate dollars to buy-down Part D premium (not true revenue)
1. CMS Part D Payment 2. LI Premium Subsidy 3. Member Premium																								$0.00
																								$0.00
																								$0.00																		Manufacturer Discount Amount
4. Total Premium
VI. IRA Part D Drug Experience (e) (f) (g) VIII. DIR #10 Experience (k)
											Total Number of Scripts					Total Allowed Dollars								Total Cost Sharing														Total Dollars
																																						1. DIR #10
1. Maximum Fair Price Drugs
PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0944. The time required to complete this information collection is estimated to average 30 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
CMS - 10142
WORKSHEET 2 - Rx PDP PROJECTION OF ALLOWED/ NON-BENEFIT Page 2 of 7 I. General Information
1. Contract Number: 4. Contract Yr: 2. Plan ID: 5. Org. Name: 3. Segment ID: 6. SNP:																								2027						7. Plan Name: 8. Plan Type: 9. Enrollee Type:														10. BAL-D:										11. PD Region: 12. PD Benefit Type: 13. SNP Type: N/A
II. Utilization for Covered Part D Drugs (e)																										(f)				(g) (h)											(i)			(j)					(k)					(l) (m) (n)															(o)
															Base Period																						Components of Utilization Change
															# of																																											Total					Projected
															Scripts/									Allowed						PMPM							Trend in				Formulary			Risk					Induced					Other				Utilization					Scripts/
Type of Script															1000									per Script						Allowed							Scripts/1000				Change			Change					Utilization*					Change				Change					1000						Covariance
1. Retail Generic																														$0.00																												0.000					0						0.000
2. Retail Preferred Brand																														$0.00																												0.000					0						0.000
3. Retail Non-Preferred Brand																														$0.00																												0.000					0						0.000
4. Retail Specialty																														$0.00																												0.000					0						0.000
5. Mail Order Generic																														$0.00																												0.000					0						0.000
6. Mail Order Preferred Brand																														$0.00																												0.000					0						0.000
7. Mail Order Non-Preferred Brand																														$0.00																												0.000					0						0.000
8. Mail Order Specialty																														$0.00																												0.000					0						0.000
9. Maximum Fair Price Drugs																														$0.00																												0.000					0						0.000
10. Total Retail																					0							$0.00		$0.00							0.000						0.000				0.000		0.000					0.000				0.000					0						0.000
11. Total Mail Order																					0							$0.00		$0.00							0.000						0.000				0.000		0.000					0.000				0.000					0						0.000
12. Total Generic																					0							$0.00		$0.00							0.000						0.000				0.000		0.000					0.000				0.000					0						0.000
13. Total Brand (Preferred and Non-Preferred)																					0							$0.00		$0.00							0.000						0.000				0.000		0.000					0.000				0.000					0						0.000
14. Total Specialty																					0							$0.00		$0.00							0.000						0.000				0.000		0.000					0.000				0.000					0						0.000
15. Total																					0							$0.00		$0.00							0.000						0.000				0.000		0.000					0.000				0.000					0						0.000
*Adjustment to remove impact of induced utilization due to supplemental coverage III. Cost for Covered Part D Drugs (e)																										(f)				(g) (h)											(i)			(j)					(k)					IV. Projected Allowed PMPM (l) (m) (n)															(o)		(p)
															Components of Unit Cost Change																													Projected Unit Cost					Projected Allowed PMPM					Manual Util/ 1000				Manual Unit Cost					Manual Rate PMPM						Credibility		Blended Allowed PMPM
															Inflation Trend									Discount Change						Formulary Change							Other Change				Tot. Unit Cost Chg
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 9. Maximum Fair Price Drugs 10. Total Retail 11. Total Mail Order																																									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 $0.00 $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 $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 $0.00 0 $0.00													$0.00 $0.00			0% 0%	$0.00 $0.00
12. Total Generic 13. Total Brand (Preferred and Non-Preferred) 14. 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 $0.00 0 $0.00 0 $0.00													$0.00 $0.00 $0.00			0% 0% 0%	$0.00 $0.00 $0.00
15. Total																					0.000							0.000		0.000 0.000													0.000	$0.00					$0.00					0 $0.00													$0.00			0%	$0.00
CMS Guideline Credibility																																																																0%
V. PMPM Non-Benefit Expenses and Gain/(Loss) Margin (e)																														VI. Percentage of Revenue														(j)										VII. Related Party (n)
Projected Expenses																																												at 0.000										Projected PMPM
1. Sales and Marketing 2. Direct Administration 3. Indirect Administration 4. Net Cost of Private Reinsurance 5. Uncollected Cost Sharing Payments M3P																														1. Claims (Allowable Cost Target) 2. Non-Benefit Expenses 3. Gain/(Loss) Margin 4. Total Bid 5. Percentage of Revenue a. Claims (Allowable Cost Target) b. Non-Benefit Expenses c. Gain/(Loss) Margin																	$0.00 $0.00 $0.00 $0.00 0.0% 0.0% 0.0%							1. Related-Party Allowed Cost 2. Related-Party Non-Benefit Expense
																																																	VIII. DIR #10 Projection (n)
																																																						Projected PMPM
6. Total Non-Benefit Expenses 7. Basic Non-Benefit Expenses 8. Supplemental Non-Benefit Expenses 9. Basic Gain/(Loss) Margin 10. Supplemental Gain/(Loss) Margin																					$0.00 $0.00 $0.00 $0.00 $0.00
																																																						1. DIR #10
11. Total Gain/(Loss) Margin
WORKSHEET 3 - Rx CONTRACT PERIOD PROJECTION FOR DEFINED STANDARD COVERAGE Page 3 of 7
I. General Information
1. Contract Number: 2. Plan ID: 3. Segment ID:												4. Contract Yr: 5. Org. Name: 6. SNP:													2027					7. Plan Name: 8. Plan Type: 9. Enrollee Type:																						10. BAL-D:					11. PD Region: 12. PD Benefit Type: 13. SNP Type: N/A
II. Projection Data
1. Projected Total Member Months:												0					2. Projected Avg Risk Score:																							0.000
1a. Projected LIS Member Months: 1b. Projected NLI Member Months:												0					2a. Projected LIS Risk Score: 2b. Projected NLI Risk Score:
III. Part D Covered Drug Claims (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) (o)
Claim Interval											# of Members					Member Months										# of Scripts							Projected Allowed							Avg Amt Allowed PMPM					Cost Sharing													PMPM Deductible			Other Cost Sharing PMPM					Federal Reins. PMPM				Plan Liability PMPM		Federal LICS PMPM
1. $0 2. $1-$589 3. $590-Catastrophic 4. Above Catastrophic																																							$0.00																														$0.00
																																								$0.00					$0.00																									$0.00
																																								$0.00					$0.00																									$0.00
																																								$0.00					$0.00																									$0.00
5. Subtotal 0 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6. Minus Rebates $0.00 $0.00 7. Plus Part D as Secondary $0.00 $0.00 8. Minus Manufacturer Discount $0.00 9. Total $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
IV. IRA Part D Drug Projection (d) (e) (f) V. Defined Standard Coverage Bid Development (k) (l)
											Total Number of Scripts					Total Allowed Dollars										Total Cost Sharing
1. Maximum Fair Price Drugs
1. Claims (Allowable Cost Target) 2. Non-Benefit Expenses 3. Gain/(Loss) Margin 4. Total Basic Bid 5. Federal Reinsurance								At 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
WORKSHEET 4 - Rx STANDARD COVERAGE WITH ACTUARIALLY EQUIVALENT COST SHARING
I. General Information																																																											Page 4 of 7
1. Contract Number: 2. Plan ID: 3. Segment ID:						4. Contract Yr: 5. Org. Name: 6. SNP:												2027			7. Plan Name: 8. Plan Type: 9. Enrollee Type:																	10. BAL-D:												11. PD Region: 12. PD Benefit Type: 13. SNP Type:									N/A
II. Projection Data
1. Projected Member Months															0						2. Projected Avg Risk Score																								0.000
III. Development of Bid for Standard Coverage V. Std. Cov. Bid Development with Actuarially Equivalent C. S.
1. Claims (Allowable Cost Target) 2. Non-Benefit Expenses 3. Gain/(Loss) Margin 4. Total Basic Bid										At 0.000					$0.00 $0.00 $0.00 $0.00			At 1.00 $0.00 $0.00 $0.00 $0.00
5. Net Federal Reinsurance 6. LIS															$0.00 $0.00			$0.00
1. Claims (Allowable Cost Target) 2. Non-Benefit Expenses 3. Gain/(Loss) Margin 4. Total Basic Bid																At 0.000 $0.00 $0.00 $0.00 $0.00							At 1.00										$0.00 $0.00 $0.00 $0.00
5. Net Federal Reinsurance																$0.00																	$0.00
6. Gross Federal Reinsurance 7. LIS																							$0.00
1. Total Members 2. Member Months																																																0 0
Amounts below																																		Amounts above														Row
Catastrophic Threshold																																		Catastrophic Threshold														Subtotal
Allowed PMPM
3. Standard																					$0.00													$0.00														$0.00
4. Standard with Act. Equiv. Cost Sharing																					$0.00													$0.00														$0.00
5. Value of Deductible																					$0.00													$0.00														$0.00
Allowed Subject to Coins.
6. Standard																					$0.00													$0.00														$0.00
7. Standard with Act. Equiv. Sharing																					$0.00													$0.00														$0.00
Coins. %
8. Standard																					25.0% A													0.0%														0.0%
9. Standard with Act. Equiv. Sharing																					0.0% B													0.0%														0.0%
Coins PMPM
10. Standard																					$0.00													$0.00														$0.00
11. Standard with Act. Equiv. Sharing																					$0.00													$0.00														$0.00
Net Cost of Benefit
12. Standard																					$0.00													$0.00														$0.00
13. Standard with Act. Equiv. Sharing																					$0.00													$0.00														$0.00
Rebates																																		For Reinsurance														Inc Reins.
14. Standard																																		$0.00														$0.00
15. Standard with Act. Equiv. Sharing
Test for Actuarial Equivalence
Effective coinsurance with alternative cost sharing = to effective coinsurance for standard cost sharing
16. A=B										No
WORKSHEET 5 - Rx ALTERNATIVE COVERAGE																																																									Page 5 of 7
I. General Information
1. Contract Number: 4. Contract Yr: 2. Plan ID: 5. Org. Name: 3. Segment ID: 6. SNP:												2027										7. Plan Name: 8. Plan Type: 9. Enrollee Type:																	10. BAL-D:												11. PD Region: 12. PD Benefit Type: 13. SNP Type:						N/A
II. Projection Data
1. Projected Member Months 0																						2. Projected Avg Risk Score																	0.000
III. Development of Bid for Standard Coverage																																							V. Development of Actuarial Equivalence Test
1. Claims 2. Non-Benefit Expenses 3. Gain/(Loss) Margin									At 0.000 $0.00 $0.00 $0.00			C	At 1.00 $0.00 $0.00 $0.00
4. Total Basic Bid 5. Federal Reinsurance									$0.00 $0.00				$0.00 $0.00
6. Total Coverage									$0.00			A	$0.00
7. LIS									$0.00
1. Part D Covered Drugs 2. Non-Benefit Expenses 3. Gain/(Loss) Margin 4. Federal Reinsurance										At 0.000 $0.00 $0.00 $0.00 $0.00				D		At 1.00								$0.00 $0.00 $0.00 $0.00
5. Total Part D Covered 6. Non-Part D Covered Drugs										$0.00 $0.00				B										$0.00
7. Total Plan Coverage										$0.00
8. Total Basic Bid										$0.00														$0.00
9. LIS
IV. Development of Bid Components												(d) (f) (g) (i) (m)																																												(o) (q)
								Part D Covered Drugs
Members Members Amounts <=CAT Amts above All <=CAT >CAT for all members Catastrophic Members
1. Population not Meeting Deductible 2. Population Meeting Deductible 3. Member Months								0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Allowed PMPM 4. Standard 5. Alternative Deductible 6. Value of $590 Deductible 7. Value of Proposed Deductible Allowed Subject to Coins. 8. Standard 9. Alternative Coins. % 10. Standard 11. Alternative Coins PMPM 12. Standard 13. Alternative Federal Reinsurance 14. Standard 15. Alternative Minus Rebates 16. Standard 17. Alternative Plus Part D as Secondary 18. Standard 19. Alternative Net Cost of Benefit 20. Standard 21. Alternative								Type of Deductible Alt Coverage Deductible Amount																													E Row																						Non- Part D Covd
								Amounts below Catastrophic Threshold Amts above Catastrophic Subtotal
								$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 $0.00 $0.00 25.0% 25.0% 0.0% 0.0% 0.0% 0.0% 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 For Reinsurance Inc Reins.																																																			$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 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 F $0.00 $0.00 $0.00 $0.00 $0.00 G $0.00 $0.00 $0.00																																																			$0.00 $0.00
VI. Tests for Alternative Coverage VIII. Development of Induced Utilization Adjustment																																VII. Development of Supplemental Premium
1. Total Coverage >= Std Coverage (B>=A) Yes 2. Unsubsidized Value >= Unsub Value for Std Covg (1=yes and D>=C) Yes 3. Average Cost at Catastrophic >= Std (G >=F) Yes 4. Deductible <=$590 (E <=590) Yes
At 0.000 1. Part D Covered Drugs $0.00 2. Non Part D Covered Drugs $0.00 3. Less Basic Covered $0.00
4. Supplemental Coverage $0.00 5. Reduction in Reinsurance $0.00 6. Additional Non-Benefit Expenses $0.00 7. Additional Gain/(Loss) Margin $0.00
8. Supplemental Premium $0.00
1. Claims for Standard														At 0.000 $0.00							At 1.00 $0.00
2. Impact of Alternative Utilization on Standard																					$0.00
3. Allowable Cost Target for Alternative 4. Induced Utilization Adjustment														$0.00 0.000							$0.00 0.000
WORKSHEET 6 - Rx SCRIPT PROJECTIONS FOR DEFINED STANDARD, ACTUARIALLY EQUIVALENT OR ALTERNATIVE COVERAGE Page 6 of 7 I. General Information
1. Contract Number:												4. Contract Yr:																							2027						7. Plan Name:											10. BAL-D:								11. PD Region:
2. Plan ID: 3. Segment ID:												5. Org. Name: 6. SNP:																													8. Plan Type: 9. Enrollee Type:																			12. PD Benefit Type: 13. SNP Type:											N/A
II. Projections for Equivalence Tests (f) (g) (h) (i) (j) (k)
Population Not Exceeding the Catastrophic Threshold																																			Defined Standard Coverage																				Actuarially Equivalent or Alternative Benefits
Lines 1-8 exclude Insulins/Vaccines and exclude claims subject to deductible 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 9. Insulins 10. Vaccines 11. Total																																			Number of Scripts							Allowed $					Std Cost Sharing $								Number of Scripts					Allowed $							Cost Sharing $
																																									0					$0.00	$0.00													0				$0.00			$0.00
12. Claims Subject to Deductible
13. Manufacturer Discount
Population Exceeding the Catastrophic Threshold Lines 14-21 exclude Insulins/Vaccines and exclude claims subject to deductible 14. Retail Generic 15. Retail Preferred Brand 16. Retail Non-Preferred Brand 17. Retail Specialty 18. Mail Order Generic 19. Mail Order Preferred Brand 20. Mail Order Non-Preferred Brand 21. Mail Order Specialty 22. Insulins 23. Vaccines 24. Total																																			Number of Scripts							Allowed $					Std Cost Sharing $								Number of Scripts					Allowed $							Cost Sharing $
																																									0					$0.00	$0.00													0				$0.00			$0.00
25. Claims Subject to Deductible
26. Manufacturer Discount
Amounts Allocated up to Catastrophic Threshold (Lines 27-34 exclude Insulins/Vaccines and claims subject to deductible) 27. Retail Generic 28. Retail Preferred Brand 29. Retail Non-Preferred Brand 30. Retail Specialty 31. Mail Order Generic 32. Mail Order Preferred Brand 33. Mail Order Non-Preferred Brand 34. Mail Order Specialty 35. Insulins 36. Vaccines 37. Total																																			Number of Scripts							Allowed $					Std Cost Sharing $								Number of Scripts					Allowed $							Cost Sharing $
																																									0					$0.00	$0.00													0				$0.00			$0.00
38. Manufacturer Discount																																									$0.00
Total Amounts Allocated Over the Catastrophic Threshold (All Populations) 39. All Spending Over Catastrophic Threshold 40. Manufacturer Discount																																			Number of Scripts							Allowed $					Std Cost Sharing $								Number of Scripts					Allowed $							Cost Sharing $
																																			0							$0.00
41. Non-Part D Covered Drugs - All Spending
Subsidy for Selected Drugs
Defined Standard Total Dollars Alternative Total Dollars
WORKSHEET 7 - SUMMARY OF KEY BID ELEMENTS Page 7 of 7
I. General Information
1. Contract Number: 2. Plan ID: 3. Segment ID:												4. Contract Yr: 5. Org. Name: 6. SNP:								2027					7. Plan Name: 8. Plan Type: 9. Enrollee Type:											10. BAL-D:																	11. PD Region: 12. PD Benefit Type: 13. SNP Type: N/A
II. 2027 Defined Standard Benefit Parameters
1. Deductible $615 2. Out-of-pocket Limit $2,100
III. Summary of Key Bid Elements V. Working Model Text Box
1. Standardized Part D Bid $0.00																																														This section can be used at the discretion of the Plan sponsor. The contents are NOT uploaded in the bid submission.
2. National Average Monthly Bid Amount 3. Base Beneficiary Premium
Basic Part D Premium (prior to A/B rebate allocation) 4. Unrounded $0.00 5. Rounded $0.00 Supplemental Part D Premium (prior to A/B rebate allocation) 6. Unrounded $0.00 7. Rounded $0.00 8. Prospective Federal Reinsurance (non-standardized) $0.00 9. Prospective Low-Income Cost Sharing Subsidy (non-standardized) $0.00 10. Target Amount Adjustment (allowed costs as a ratio of bid) 1.0000 11. Manufacturer Discount Amount (exclusive of Selected Drug Subsidy) $0.00 12. Selected Drug Subsidy Amount $0.00 13. Round Part D Premiums to Nearest (Rounding Rule) $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