Form CMS-10142 PD BPT Screen Shots

WORKSHEET 1 - Rx BASE PERIOD EXPERIENCE
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment:

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

Page 1 of 7
PD-2008.1
OMB Approved # 0938-0944

2008

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

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:

10. PD Region
11. PD Benefit Type:
12. Payment Demo Type:

2. Member Months
3. Crediblity (Full, Partial, None)

4. Risk Score
5. Completion factor

III. Part D Claims Experience
(d)
(e)
Total Count in Interval
Allowed
Claim
Interval
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

# of
Members

$0
$1-$250
$251-$2,250
$2,251-$5,100
$5,100+
Subtotal
% OON

Member
Months

-

-

(f)

(g)

(h)

(i)

Total
Number of
Scripts

Total
Allowed
Dollars

Average
Allowed Amount
per Member

Average
Paid Amount
per Member

-

$

-

PMPM Values
Minus PMPM Rebates
Plus PMPM Value of Part D as Secondary
PMPM Net Expenses
PMPM Non-covered Supplemental Drugs
PMPM Rebates on Supplemental Drugs
Net PMPM on Supplemental Drugs

(e)
Basic
Sales and Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Total Non-Benefit Expenses

-

(f)
Supplemental

(g)
Total
$

$

-

$

-

-

$

(k)

Average
Cost Sharing
per Member

(l)

(m)

(n)

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

Net Plan
Responsibility
per Member
$

$

-

$

$0.00
$0.00
$0.00
-

$

-

$0.00

IV. PMPM Non-Benefit Expenses

1.
2.
3.
4.
5.

$
$
$
$
$
$

(j)
Cumulative

$

-

$

-

$

-

$

-

$

-

$0.00

$0.00

$0.00

$

$0.00

$0.00

$0.00

$

-

$

-

VI. PMPM Income Statement Summary
1. Premium Revenue
2. LIS Reimb.
3. Fed Reins.
4. Allocated Buy-Down*
5. Total Revenue

(m)
$

$0.00
$0.00

$

-

$

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

$

-

9. Gain/(Loss) Including Buy-Down

$

-

V. PMPM Premium Revenue
(e)
Basic
1.
2.
3.
4.
5.

CMS Part D Payment
LI Premium Subsidy
Member Premium
Member Penalty Premium
Total Premium

(f)
Supplemental

(g)
Total
$

$

-

$

-

$

-

* MA rebate dollars to buy-down Part D premium (not true revenue)

CMS - 10142 (03/2009)
CY2008 PD BPT.xls

5/16/2007

WORKSHEET 2 - Rx PDP PROJECTION OF ALLOWED/ NON-BENEFIT
I. General Information
1. Contract Num
2. Plan ID:
3. Segment:

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

Page 2 of 7

2008

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

10. PD Region:
11. PD Benefit Type:
12. Payment Demo Type:

II. Utilization for Covered Part D Drugs
(e)
# of
Scripts/
1000

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

(f)
Base Period

(g)

(h)

(i)
(j)
(k)
Components of Utilization Change

Allowed
per Script

PMPM
Allowed

Trend in
Scripts/1000

Formulary
Change

Risk
Change

Induced
Utilization*

(l)

Other
Change

-

(m)

(n)

Total
Utilization
Change
-

Projected
Scripts/
1000
-

9. Total Retail
10. Total Mail Order

-

-

-

-

-

-

-

-

-

-

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

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

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

$

III. Cost for Covered Part D Drugs
(e)

(f)
(g)
(h)
Components of Unit Cost Change
Discount
Formulary
Other
Change
Change
Change

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

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

(i)
Tot. Unit
Cost Chg
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000

(j)
Projected
Unit
Cost
-

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

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

-

14. Total

0.000

0.000

0.000

0.000

0.000 $

-

V. PMPM Non-Benefit Expenses

(e)
Base Period

1.
2.
3.
4.
5.

Sales and Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Total Non-Benefit Expenses

CY2008 PD BPT.xls

$

$

-

(f)

(g)

Trend

Contract Period
$
$
-

(h)
Manual Rate
Expense

(i)
Credibility

(k)
Projected
Allowed
PMPM
-

0.000
0.000

(j)
Blended
Expense
$
$
-

$

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

(n)
Manual
Rate
PMPM
-

(o)

Credibility

(p)
Blended
Allowed
PMPM
-

-

-

-

-

100%
100%

-

-

-

-

-

100%
100%
100%

-

-

-

-

100% $

-

$

-

$

VI. Development of Manual Rate
1. Describe the source/year and assumptions used in the
development of the manual rate.

5/16/2007

WORKSHEET 3 - Rx CONTRACT PERIOD PROJECTION FOR DEFINED STANDARD COVERAGE
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment:

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

II. Projection Data
1. Projected Member months:

2008

Page 3 of 7

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

0

10. PD Region:
11. PD Benefit Type:
12. Payment Demo Type:

2. Projected Avg Risk Score:

3. Projected LIS Member months:

III. Part D Covered Drug Claims

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

Allowed
Claim
Interval
$0
$1-$274
$275-$2,509
$2,510-$5,725
$5,726+
Subtotal

(d)

(e)

(f)

(g)

# of
Members

Member
Months

# of
Scripts

Projected
Allowed

(h)
Avg Amt
Allowed
PMPM
$

-

-

0 $

-

$

-

(i)

(j)

(k)

Cost Sharing

Gap
PMPM

PMPM
Deductible

(l)
Other
Cost Sharing
PMPM

(m)
Federal
Reins. PMPM

$

-

$

-

$

-

$

-

$

-

$

-

$

-

-

Allowed:
Plan Liability:
$

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

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

V. Defined Standard Coverage Bid Development
(d)

1.
2.
3.

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

$

4.
5.
6.

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

$

CY2008 PD BPT.xls

Plan Liability
PMPM
$0.00
$0.00
$
-

(o)
Federal
LIS
PMPM

$

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

(n)

-

(i)
At 0.0000
1. Claims (Allowable Cost Target):
2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid

5. Federal Reinsurance:

$

(j)
At 1.00

$

-

$

$

-

$

-

$

-

5/16/2007

WORKSHEET 4 - Rx STANDARD COVERAGE WITH ACTUARIALLY EQUIVALENT COST SHARING
Page 4 of 7
I. General Information
1. Contract Number
2. Plan ID:
3. Segment:

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

2008

II. Projection Data
1. Projected Member months

III. Development of Bid for Standard Coverage
At 0.0000
1. Claims (Allowable Cost Target) $
2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid
$
5. Federal Reinsurance
6. LIS

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

0

2. Projected Avg Risk Score

At 1.00
-

10. PD Region:
11. PD Benefit Type
12. Payment Demo Type

$

$

-

IV: Development of Bid Components and Tests for Actuarial Equivalence
(e)
Amounts below
Initial Coverage Limit
<$2,510
1. Total Members
2. Member Months

0.000

V. Std. Cov. Bid Development with Actuarially Equivalent C. S
At 0.0000
At 1.00
1. Claims (Allowable Cost Target)
$0.00
$0.00
2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid
$0.00 $
5. Federal Reinsurance
6. LIS

(h)
Amounts above
Catastrophic Threshold
>=$5,726

(k)
All
Amounts
-

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

$

-

$

-

$
$

-

5. Value of Deductible

$

-

$

-

$

-

$
$

-

$
$

-

$
$

-

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

25.0% A
0.0% B

0.0% C
0.0% D

0.0%
0.0%

$
$

-

$
$

-

$
$

-

$
$

-

$
$

-

$
$

-

Rebates
14. Standard
15. Standard with Act. Equiv. Sharing

For Reinsurance
$
$
-

Inc Reins.
$
-

Test for Actuarial Equivalence
Effective coinsurance with alternative cost sharing = to effective coinsurance for standard cost sharing
16.
17.
CY2008 PD BPT.xls

A=B
C=D

No
No
5/16/2007

WORKSHEET 5 - Rx ALTERNATIVE COVERAGE
I. General Information
1. Contract Number
2. Plan ID:
3. Segment:

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

II. Projection Data
1. Projected Member months

Page 5 of 7

2008

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

0

10. PD Region:
11. PD Benefit Type:
12. Payment Demo Type:

2. Projected Avg Risk Score

III. Development of Bid for Standard Coverage
At 0.0000
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 1.00
C

$

A

$

-

$

At 0.0000
$
$
$
-

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
D $

B $

-

$

-

IV. Development of Bid Components
(d)

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 $275 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

(f)

(g)

(i)

Members with
<$2,510
-

Members
>=$2,510
-

Amounts <=ICL
for all members
-

$
$

Amounts below Initial Coverage Limit
$
$
$
$

$

-

$
$

-

$
$

-

$
$

-

$
$

-

$
$

-

25.0%
0.0%
$
$

-

$
$

-

25.0%
0.0%
$
$

-

$
$

-

(o)
All
Members
-

0
Amts in
Gap
$
-

Amts above
Catastrophic
$
-

-

(q)

NonPart D
Covd

Total
PMPM
$
$

-

-

$
$

-

-

$
$

-

$
$

-

$
$

0.0%
0.0%
$
$

F $
G $

-

-

-

$
$

100.0%

$
$

$
$

-

-

$
$

0.0% H
0.0% I
$
$

-

0.0%
0.0%

$
$

-

$
$

-

$
$
For Reinsurance
$
$
-

$
$
Inc Reins.
$
-

-

$

-

$

-

$

-

$

-

$

-

$

-

$
$

-

$
$

-

$
$

-

-

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

VIII. Development of Induced Utilization Adjustment
At 0.0000

CY2008 PD BPT.xls

-

(m)
Amts above
Catastrophic

E

VI. Tests for Alternative Coverage:
1. Total Coverage >= Std Coverage (B>=A)
2. Unsubsidized value>= Unsub Value for Std Covg(1=yes and D>=C)
3. Average Cost at Initial Covg Limit >= Std (G >=F)
4. Deductible <=$275 (E <=275)
5. Average Catastrophic cost sharing <= Std (I <= H)

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

(k)
Part D Covered Drugs

$

-

$

-

At 1.00
$
$

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

At 0.0000
$
$
$
$

5/16/2007

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

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

II. Projections for Equivalence Tests
Population Not Exceeding $2,510 with Std Coverage
All Spending
1. Retail Generic
2. Retail Preferred Brand
3. Retail Non-Preferred Brand
4. Retail Specialty (2)
5. Mail Order Generic
6. Mail Order Preferred Brand
7. Mail Order Non-Preferred Brand
8. Mail Order Specialty (2)
09. Total
Population Exceeding $2,510 with Std Coverage
All Spending
10. Retail Generic
11. Retail Preferred Brand
12. Retail Non-Preferred Brand
13. Retail Specialty (2)
14. Mail Order Generic
15. Mail Order Preferred Brand
16. Mail Order Non-Preferred Brand
17. Mail Order Specialty (2)
18. Total
Amounts Allocated Up to ICL (1)
19. Retail Generic
20. Retail Preferred Brand
21. Retail Non-Preferred Brand
22. Retail Specialty (2)
23. Mail Order Generic
24. Mail Order Preferred Brand
25. Mail Order Non-Preferred Brand
26. Mail Order Specialty (2)
27. Total
Amounts Allocated over Catastrophic Coverage
28. Retail Generic
29. Retail Preferred Brand
30. Retail Non-Preferred Brand
31. Retail Specialty (2)
32. Mail Order Generic
33. Mail Order Preferred Brand
34. Mail Order Non-Preferred Brand
35. Mail Order Specialty (2)
36. Total

37. Non-Part D Covered Drugs - All Spending

2008

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

(f)

10. PD Region:
11. PD Benefit Type:
12. Payment Demo Type

(g)

(h)

(i)

$

Number of Scripts

-

Number of Scripts
-

-

Std Cost Sharing $

$

Std Cost Sharing $

$

-

$

Allowed $

-

-

Allowed $
-

$

(k)

-

Number of Scripts

-

$

Allowed $

$

-

Cost Sharing $

Allowed $

$

Number of Scripts

Std Cost Sharing $
-

$

Number of Scripts

Std Cost Sharing $

$

-

Number of Scripts

Allowed $

Number of Scripts

-

$

Allowed $

Number of Scripts

-

-

(j)

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

Defined Standard Coverage
Number of Scripts
Allowed $
Std Cost Sharing $

-

Page 6 of 7

Cost Sharing $ (1)

-

$

Allowed $

$

Allowed $

Cost Sharing $

$

Cost Sharing $

(1) - The cost sharing for the section labeled "Amounts Up to ICL" should include non-uniform deductibles and/or reduced ICL levels.
(2) - The Specialty tier is only used when the Plan places Specialty drugs on a separate tier in accordance with CMS guidelines.
CY2008 PD BPT.xls

5/16/2007

WORKSHEET 7 - SUMMARY OF KEY BID ELEMENTS
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment:

Page 7 of 7

4. Contract Yr: 2008
5. Org. Name:
6. SNP:

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

10. PD Region:
11. PD Benefit Type:
12. Payment Demo Type:

II. 2008 Defined Standard Benefit Parameters
1. Deductible
$275
2. Initial Coverage Limit
$2,510
3. Out-of-pocket Limit
$4,050
III. Summary of Key Bid Elements
1. Standardized Part D Bid
2. National Average Monthly Bid Amount
3. Base Beneficiary Premium

$

-

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

$
$

-

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

$
$

-

$
$

1.0000

$

0.10

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)
Rounding Rule
11. Round Part D premiums to nearest
IV. Part D Bid Pricing Tool Contacts
Plan Bid Contact
Name
Phone
Email
Part D Certifying Actuary
Name
Phone
Email
Date Prepared

CY2008 PD BPT.xls

5/16/2007