Cms-10142 Pd-bpt

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

Page 1 of 8
PD-2014.2
OMB Approved # 0938-0944

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

2014

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:

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

0 5. 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-$320
$321-$2,930
$2,931-Catastrophic *
Above Catastrophic *
Subtotal
% OON

(f)

Total
Number of
Scripts

Member
Months

0

(g)

0

(h)

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
Non-covered Supplemental Drugs
Rebates on Supplemental Drugs
Net PMPM on Supplemental Drugs

(i)

$0.00

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

(j)
Cumulative

Average
Paid Amount
per Member

Average
Cost Sharing
per Member

$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

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

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

* See Instructions for Completing the Prescription Drug Plan BPT for CY2014.
IV. PMPM Non-Benefit Expenses
(e)
Basic
1.
2.
3.
4.

(f)
Supplemental

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

$0.00
$0.00
$0.00
$0.00

5. Total Non-Benefit Expenses
V. PMPM Premium Revenue

$0.00
(e)
Basic

1.
2.
3.
4.
5.

(g)
Total

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

CMS - 10142 (4/30/2013)

CY2014 draft part d bpt.xlsm

$0.00
(f)
Supplemental

$0.00

$0.00

$0.00
(g)
Total

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
9. Gain/(Loss) Including Buy-Down

$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
$0.00

* MA rebate dollars to buy-down Part D premium (not true revenue)
Total Non-LI Brand Discount Amount
a. NBE Quality Initiatives
b. Taxes and Fees
c. Insurer Fees (subset of Taxes and Fees)

12/06/2012

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

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

Page 2 of 8

2014

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

10. PD Region:
11. PD Benefit 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

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

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)
Manual
Rate
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

(o)

Credibility

(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.

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

(e)
Base Period
$0.00
$0.00
$0.00
$0.00

5. Total Non-Benefit Expenses

$0.00

VII. Percentage of Revenue
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

5. Percentage of Revenue
a. Claims (Allowable Cost Target):
b. Non-Benefit Expenses
c. Gain/(Loss):
CY2014 draft part d bpt.xlsm

0%
0%
0%

(f)

(g)

Trend

Contract Period
$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.

$0.00

6. NBE Quality Initiatives
7. Taxes and Fees
8. Insurer Fees (subset of Taxes and Fees)

d. Adjusted MLR*

0.0%

* Adjusted MLR is based on bid projection. Numerator includes
Quality Initiatives and denominator excludes Taxes and Fees.

12/06/2012

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:

2014

Page 3 of 8

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

0

10. PD Region:
11. PD Benefit Type:

2. Projected Avg Risk Score:

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

0

III. Part D Covered Drug Claims

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

Allowed
Claim
Interval
$0
$1-$324
$325-$2,969
$2,970-Catastrophic
Above Catastrophic
Subtotal

(d)

(e)

(f)

(g)

# of
Members

Member
Months

# of
Scripts

Projected
Allowed

0

0

0

$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

(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
LICS
PMPM

$0.00

Allowed:
Plan Liability:
$0.00

(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

CY2014 draft part d bpt.xlsm

(i)

$0.00
$0.00
$0.00

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

Overall Gain/(Loss) Margin Level

(h)
Avg Amt
Allowed
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

$0.00

$0.00

$0.00

V. Defined Standard Coverage Bid Development
(i)
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

(j)
At 1.00
$0.00
$0.00
$0.00
$0.00

5. Federal Reinsurance:

$0.00

$0.00

$0.00

$0.00

$0.00

CONTRACT

12/06/2012

WORKSHEET 4 - Rx STANDARD COVERAGE WITH ACTUARIALLY EQUIVALENT COST SHARING
Page 4 of 8
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

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

2014

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

0

10. PD Region:
11. PD Benefit 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
<$2,970
1. Total Members
2. Member Months

0.000

V. Std. Cov. Bid Development with Actuarially Equivalent C. S.
At 0.000
1. Claims (Allowable Cost Target)
$0.00
2. Non-Benefit Expenses
$0.00
3. Gain/(Loss):
$0.00
4. Total Basic Bid
$0.00
5. Federal Reinsurance
$0.00
6. LIS

(h)
Amounts above
Catastrophic Threshold

(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

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

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.
18.
CY2014 draft part d bpt.xlsm

A=B
C=D
Coverage in the Gap

No
No
No
12/06/2012

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 8

2014

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

0

10. PD Region:
11. PD Benefit Type:

2. Projected Avg Risk Score

III. Development of Bid for Standard Coverage
At 0.000
1. Claims
$0.00
2. Non-Benefit Expenses
$0.00
3. Gain/(Loss)
$0.00
4. Total Basic Bid
$0.00
5. Federal Reinsurance
$0.00
6. Total Coverage
$0.00
7. LIS
$0.00

0.000

V. Development of Actuarial Equivalence Test
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)

(f)

(g)

Members with
<$2,970

Allowed PMPM
4. Standard
5. Alternative
Deductible
6. Proposed Deductible
7. Value of $325 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

(o)

Amts above
Catastrophic

All
Members
0
0
0

Amts above
Catastrophic

Amts in Gap
$0.00

(q)

$0.00

0
0
0
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% J
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

$0.00

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

VIII. Development of Induced Utilization Adjustment

CY2014 draft part d bpt.xlsm

$0.00
$0.00

(m)

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 <=$325 (E <=325)
5. Average Catastrophic cost sharing <= Std (I <= H)
6. Coverage in the Gap (K <= J)

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
Amounts <=ICL
for all members
0
0
0
Type of Gap Coverage

Members
>=$2,970
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

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

(i)

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

12/06/2012

WORKSHEET 6 - Rx SCRIPT PROJECTIONS FOR DEFINED STANDARD, ACTUARIALLY EQUIVALENT OR ALTERNATIVE COVERAGE
I.
1.
2.
3.

General Information
Contract Number:
Plan ID:
Segment:

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

2014

II. Projections for Equivalence Tests
Population Not Exceeding $2,970 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:

(f)

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

09. Total

0

Population Exceeding $2,970 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

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

0

0
Std Cost Sharing $

$0.00

Number of Scripts

36. Total

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

$0.00

Std Cost Sharing $

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

(i)

$0.00

Number of Scripts

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

Dispensing Fee

BRAND
% discount off AWP

SPECIALTY
Dispensing Fee

% discount off AWP

Dispensing Fee

RETAIL
CY2014 draft part d bpt.xlsm

MAIL

12/06/2012

WORKSHEET 6A - COVERAGE IN THE GAP
I.
1.
2.
3.

General Information
Contract Number:
Plan ID:
Segment:

Page 7 of 8

4. Contract Yr:
5. Org. Name:

2014

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

6. SNP:

II. Spending in the Coverage Gap

(f)

Population Exceeding $2,970 with Std Coverage
Amounts Allocated between $2,970 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

(g)

(h)

0

Low Income Population Amounts Allocated between $2,970 and Catastrophic
Number of Scripts
12. Retail Generic
13. Retail Preferred Brand
14. Retail Non-Preferred Brand
15. Retail Specialty Generic
16. Retail Specialty Brand
17. Mail Order Generic
18. Mail Order Preferred Brand
19. Mail Order Non-Preferred Brand
20. Mail Order Specialty Generic
21. Mail Order Specialty Brand
22. Total

$0.00

Allowed $

0

Non-Low Income Population Amounts Allocated between $2,970 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

Allowed $

0

$0.00
$0.00

$0.00

0

Number of Scripts

$0.00

Std Cost Sharing $

$0.00

(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

Std Cost Sharing $

$0.00

(j)

(i)

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

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

10. PD Region:
11. PD Benefit Type:

$0.00

Allowed $

0

Number of Scripts

Cost Sharing $

$0.00

Allowed $

0

$0.00

$0.00

Cost Sharing $

$0.00

$0.00

WORKSHEET 7 - SUMMARY OF KEY BID ELEMENTS
I.
1.
2.
3.

General Information
Contract Number:
Plan ID:
Segment:

Page 8 of 8

4. Contract Yr: 2014
5. Org. Name:
6. SNP:

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

10. PD Region:
11. PD Benefit Type:

II. 2014 Defined Standard Benefit Parameters
1. Deductible
$325
2. Initial Coverage Limit
$2,970
3. Out-of-pocket Limit
$4,750
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)
11. Prospective brand discount amount
Rounding Rule
12. 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
$0.00
$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 Contact
Name
Phone
Email
Date Prepared

CY2014 draft part d bpt.xlsm

12/06/2012