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pdfWORKSHEET 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-2010.1
OMB Approved # 0938-0944
2010
7. Plan Name:
8. Plan Type:
9. Enrollee Type:
II. Base Period Background Information
1. Time Period Definition
Incurred from:
Incurred to:
Paid through:
7. Briefly describe the source of the base period experience data:
10. PD Region:
11. PD Benefit Type:
12. Payment Demo Type:
2a. Total Member Months
2b. LIS Member Months
3. Risk Score
4. Completion Factor
5. Network Pricing
6. Mapping
Contract-Plan ID Member Months
Contract-Plan ID
Member Months
(m)
(n)
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-$275
$276-$2,510
$2,511-$5,726
$5,727+
Subtotal
% OON
Member
Months
0
(f)
(g)
(h)
(i)
(j)
Cumulative
Total
Number of
Scripts
Total
Allowed
Dollars
Average
Allowed Amount
per Member
Average
Paid Amount
per Member
Average
Cost Sharing
per Member
0
0
$0.00
PMPM Values
Minus Rebates
Plus Part D as Secondary
Net Average Paid Amount PMPM
Non-covered Supplemental Drugs
Rebates on Supplemental Drugs
Net PMPM on Supplemental Drugs
$0.00
IV. PMPM Non-Benefit Expenses
(e)
Basic
1.
2.
3.
4.
5.
Sales and Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Total Non-Benefit Expenses
(f)
Supplemental
$0.00
(g)
Total
$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
(k)
(l)
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
VI. PMPM Income Statement Summary
1. Premium Revenue
2. LIS Reimb.
3. Fed Reins.
4. Allocated Buy-Down*
5. Total Revenue
6. Pharmacy Claims
7. Non-Benefit Expenses
8. Total Expenses
Net Plan
Responsibility
per Member
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(m)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
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
$0.00
$0.00
(g)
Total
9. Gain/(Loss) Including Buy-Down
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
* MA rebate dollars to buy-down Part D premium (not true revenue)
CMS - 10142 (03/2011)
CY2010 PD BPT - PRA.xls
12/17/2008
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
2010
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)
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
# of
Scripts/
1000
Allowed
per Script
(g)
(h)
PMPM
Allowed
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(i)
(j)
(k)
Components of Utilization Change
Trend in
Scripts/1000
Formulary
Change
Risk
Change
Induced
Utilization*
(l)
(m)
(n)
Total
Utilization
Change
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
Other
Change
(o)
Projected
Scripts/
1000
0
0
0
0
0
0
0
0
??
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
Tot. Unit
Cost Chg
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
(j)
Projected
Unit
Cost
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(k)
Projected
Allowed
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
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)
IV. Projected Allowed PMPM
(l)
(m)
Manual
Manual
Util/
Unit
1000
Cost
(n)
(o)
Manual
Rate
PMPM
Credibility
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(p)
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
1.
2.
3.
4.
5.
Sales and Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Total Non-Benefit Expenses
CY2010 PD BPT - PRA.xls
(e)
Base Period
$0.00
$0.00
$0.00
$0.00
$0.00
(f)
(g)
Trend
Contract Period
$0.00
$0.00
$0.00
$0.00
$0.00
(h)
Manual Rate
Expense
(i)
Credibility
(j)
Blended
Expense
$0.00
$0.00
$0.00
$0.00
$0.00
VI. Development of Manual Rate
1. Describe the source/year and assumptions used in the
development of the manual rate.
12/17/2008
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:
4. Network Pricing:
2010
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-$294
$295-$2,699
$2,700-$6,153
$6,154+
Subtotal
(d)
(e)
(f)
(g)
# of
Members
Member
Months
# of
Scripts
Projected
Allowed
0
0
0
$0.00
(h)
Avg Amt
Allowed
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7. Minus Rebates
8. Minus Other Insurance
9. Plus Part D as Secondary
10. Projected % OON Included above:
11.
12. Total
(j)
(k)
Cost Sharing
Gap
PMPM
PMPM
Deductible
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(l)
Other
Cost Sharing
PMPM
$0.00
$0.00
$0.00
$0.00
(m)
(n)
Federal
Reins. PMPM
$0.00
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
(o)
Federal
LIS
PMPM
$0.00
Allowed:
Plan Liability:
$0.00
IV. Non-Benefit Expenses and Gain/(Loss)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
V. Defined Standard Coverage Bid Development
(d)
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
CY2010 PD BPT - PRA.xls
(i)
1. Claims (Allowable Cost Target):
2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid
(i)
At 0.000
$0.00
$0.00
$0.00
$0.00
(j)
At 1.00
$0.00
$0.00
$0.00
$0.00
5. Federal Reinsurance:
$0.00
$0.00
12/17/2008
WORKSHEET 4 - Rx STANDARD COVERAGE WITH ACTUARIALLY EQUIVALENT COST SHARING
Page 4 of 7
I. General Information
1. Contract Numbe
2. Plan ID:
3. Segment:
4. Contract Yr:
5. Org. Name:
6. SNP:
II. Projection Data
1. Projected Member months
III. Development of Bid for Standard Coverage
At 0.000
1. Claims (Allowable Cost Target)
2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid
5. Federal Reinsurance
6. LIS
2010
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
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)
Amounts below
Initial Coverage Limit
<$2,700
1. Total Members
2. Member Months
0.000
V. Std. Cov. Bid Development with Actuarially Equivalent C. S.
At 0.000
At 1.00
1. Claims (Allowable Cost Target)
$0.00
$0.00
2. Non-Benefit Expenses
$0.00
$0.00
3. Gain/(Loss):
$0.00
$0.00
4. Total Basic Bid
$0.00
$0.00
5. Federal Reinsurance
$0.00
$0.00
6. LIS
(h)
Amounts above
Catastrophic Threshold
>=$6,154
(k)
All
Amounts
0
0
Allowed PMPM
3. Standard
4. Standard with Act. Equiv. Cost Sharing
$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
0.0% 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
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
Inc Reins.
$0.00
Test for Actuarial Equivalence
Effective coinsurance with alternative cost sharing = to effective coinsurance for standard cost sharing
16.
17.
CY2010 PD BPT - PRA.xls
A=B
C=D
No
No
12/17/2008
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
2010
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
0.000
V. Development of Actuarial Equivalence Test
III. Development of Bid for Standard Coverage
At 0.000
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
1. Claims
2. Non-Benefit Expenses
3. Gain/(Loss)
4. Total Basic Bid
5. Federal Reinsurance
6. Total Coverage
7. LIS
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
$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
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 $295 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
<$2,700
Members
>=$2,700
Amounts <=ICL
for all members
0
0
0
0
0
0
Type of Deductible
Alternative Coverage ICL
Amounts below Initial Coverage Limit
$0.00
$0.00
$0.00
$0.00
(o)
All
Members
0
0
0
0
0
0
(q)
0
0
0
Type of Gap Coverage
$0.00
$0.00
Amts in Gap
$0.00
Amts above
Catastrophic
$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
$0.00
25.0%
0.0%
25.0%
0.0%
0.0%
0.0%
100.0%
$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
$0.00
VII. Development of Supplemental Premium:
Yes
Yes
Yes
Yes
Yes
VIII. Development of Induced Utilization Adjustment
CY2010 PD BPT - PRA.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 <=$295 (E <=295)
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 0.000
$0.00
$0.00
0.000
At 1.00
$0.00
$0.00
$0.00
0.000
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 0.000
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
12/17/2008
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:
2010
II. Projections for Equivalence Tests
Population Not Exceeding $2,700 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. PD Region:
11. PD Benefit Type:
12. Payment Demo Type:
(f)
(g)
(h)
Defined Standard Coverage
Number of Scripts
Allowed $
Std Cost Sharing $
09. Total
0
Population Exceeding $2,700 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
27. Total
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
Allowed $
0
0
Std Cost Sharing $
Number of Scripts
Std Cost Sharing $
Number of Scripts
$0.00
Std Cost Sharing $
Allowed $
-
$0.00
Allowed $
0
$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 $
$0.00
$0.00
Number of Scripts
36. Total
(i)
$0.00
Number of Scripts
Page 6 of 7
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
Dispensing Fee
BRAND
% discount off AWP
SPECIALTY
Dispensing Fee
% discount off AWP
Dispensing Fee
RETAIL
MAIL
CY2010 PD BPT - PRA.xls
12/17/2008
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: 2010
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. 2010 Defined Standard Benefit Parameters
1. Deductible
$295
2. Initial Coverage Limit
$2,700
3. Out-of-pocket Limit
$4,350
III. Summary of Key Bid Elements
1. Standardized Part D Bid
2. National Average Monthly Bid Amount
3. Base Beneficiary Premium
$0.00
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)
Rounding Rule
11. Round Part D premiums to nearest
V. Working Model Text Box
This section can be used at the discretion of the Plan sponsor. The contents
are NOT uploaded in the bid submission.
$0.00
$0.00
1.0000
$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 Contact
Name
Phone
Email
Date Prepared
CY2010 PD BPT - PRA.xls
12/17/2008
| File Type | application/pdf |
| Author | CMS |
| File Modified | 2008-12-17 |
| File Created | 2008-12-17 |