CMS-10142 Bid Pricing Tool (BPT) for Prescription Drug Plans (PDP)

WORKSHEET 1 - Rx BASE PERIOD EXPERIENCE

Page 1 of 8
PD-2015.Beta
OMB Approved # 0938-0944

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

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

2015

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

10. PD Region:
11. PD Benefit Type:
12. SNP Type

Chronic or Disabling

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

Contract-Plan ID Member Months

Contract-Plan ID

Member Months

(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-$324
$325-$2,969
$2,970-Catastrophic *
Above Catastrophic *
Subtotal

7.

% OON

# of
Members

(k)

(l)

Cumulative
Total
Number of
Scripts

Member
Months

Total
Allowed
Dollars

Average
Allowed Amount
per Member

Average
Paid Amount
per Member

Average
Cost Sharing
per Member

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

0

0

$0.00

8. PMPM Values
9. Minus Rebates
10. Plus Part D as Secondary

$0.00
$0.00
$0.00
$0.00

$0.00

$0.00

$0.00

$0.00

$0.00
$0.00
$0.00
$0.00

11. Net Average Paid Amount PMPM

12. Non-covered Supplemental Drugs
13. Rebates on Supplemental Drugs

$0.00

$0.00

$0.00

14. Net PMPM on Supplemental Drugs

$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 CY2015.
VI. PMPM Income Statement Summary

1.
2.
3.
4.

(g)
Total

1.
2.
3.
4.
5.

Sales and Marketing
Direct Administration
Indirect Administration

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

(m)
$0.00
$0.00
$0.00

5. Total Revenue

$0.00

6. Pharmacy Claims
7. Non-Benefit Expenses

$0.00
$0.00
$0.00

Net Cost of Private Reinsurance

Insurer Fees

6. Total Non-Benefit Expenses

$0.00

8. Total Expenses

V. PMPM Premium Revenue

1.
2.
3.
4.

(e)

(f)

(g)

Basic

Supplemental

Total

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

5. Total Premium
CMS - 10142 (5/31/2014)

9. Gain/(Loss) Including Buy-Down
$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

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:

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

2015

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

10. PD Region:
11. PD Benefit Type:
12. SNP Type

Chronic or Disabling

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

1.
2.
3.
4.
5.

(e)

(f)

(g)

Base Period

Trend

Contract Period

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

6. Total Non-Benefit Expenses

(h)
Manual Rate
Expense

(i)
Credibility

(j)
Blended
Expense

$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

VII. Percentage of Revenue
at 0.000
1. Claims (Allowable Cost Target):

$0.00

2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid

$0.00
$0.00
$0.00

5. Percentage of Revenue
a. Claims (Allowable Cost Target):
b. Non-Benefit Expenses
c. Gain/(Loss):

0.0%
0.0%
0.0%

VI. Development of Manual Rate
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:

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

2015

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

10. PD Region:
11. PD Benefit Type:
12. SNP Type

Chronic or Disabling

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)
Allowed
Claim
Interval
1.
2.
3.
4.
5.
6.

(e)

# of
Members

$0
$1-$309
$310-$2,849
$2,850-Catastrophic
Above Catastrophic
Subtotal

(f)

Member
Months

0

# of
Scripts

0

0

(g)

(h)

Projected
Allowed

Avg Amt
Allowed
PMPM

$0.00

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

(j)

Cost Sharing

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

Gap
PMPM

$0.00
$0.00
$0.00
$0.00
$0.00

$0.00

(k)

(l)

PMPM
Deductible

Other
Cost Sharing
PMPM

$0.00

(m)

$0.00

$0.00
$0.00
$0.00

Federal
Reins. PMPM

$0.00

(n)

(o)

Plan Liability
PMPM

Federal
LICS
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

$0.00

Allowed:
Plan Liability:
$0.00

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

$0.00

$0.00

$0.00

V. Defined Standard Coverage Bid Development
(d)

(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

Overall Gain/(Loss) Margin Level

(i)

CONTRACT

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

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

2015

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

10. PD Region:
11. PD Benefit Type
12. SNP Type

Chronic or Disabling

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

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

IV: Development of Bid Components and Tests for Actuarial Equivalence
(e)
Amounts below
Initial Coverage Limit
<$2,850

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

(h)

(k)

Amounts above
Catastrophic Threshold

All
Amounts

1. Total Members
2. Member Months

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

25.0% A
0.0% B

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
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:

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

2015

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

10. PD Region:
11. PD Benefit Type:
12. SNP Type

Chronic or Disabling

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)

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 $310 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)

Members with
<$2,850

Members
>=$2,850

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

Amts in Gap
$0.00

(o)
All
Members
0
0
0

Amts above
Catastrophic
$0.00

(q)

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

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

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

$0.00
$0.00

(m)
Amts above
Catastrophic

$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 <=$310 (E <=310)
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
Amounts <=ICL
for all members
0
0
0
Type of Gap Coverage

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

Page 6 of 8

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

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

2015

II. Projections for Equivalence Tests

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

Population Not Exceeding $2,850 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

10. PD Region:
11. PD Benefit Type:
12. SNP Type

(g)

(h)

(i)

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

09. Total

0

Population Exceeding $2,850 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

Number of Scripts

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
36. Total

Number of Scripts

0
Allowed $

Number of Scripts

$0.00

Number of Scripts
-

Allowed $
-

Allowed $

Number of Scripts

$0.00
Std Cost Sharing $

Cost Sharing $ (1)

$0.00
Allowed $

0
Number of Scripts

Cost Sharing $

Allowed $

Number of Scripts

$0.00

$0.00

0

$0.00
Std Cost Sharing $
-

(k)

$0.00

0
Std Cost Sharing $

$0.00

0

37. Non-Part D Covered Drugs - All Spending

0

$0.00
Allowed $

(j)

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

$0.00

Std Cost Sharing $

Chronic or Disabling

$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

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:

2015

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

6. SNP:

II. Spending in the Coverage Gap
Population Exceeding $2,850 with Std Coverage
Amounts Allocated between $2,850 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

(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

Low Income Population Amounts Allocated between $2,850 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 $2,850 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
0

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

10. PD Region:
11. PD Benefit Type:
12. SNP Type

$0.00
$0.00

$0.00

Allowed $

$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 $

(j)

(i)

Chronic or Disabling

$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

Page 8 of 8

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

4. Contract Yr: 2015
5. Org. Name:
6. SNP:

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

10. PD Region:
11. PD Benefit Type:
12. SNP Type

Chronic or Disabling

II. 2015 Defined Standard Benefit Parameters
1. Deductible
2. Initial Coverage Limit
3. Out-of-pocket Limit

$310
$2,850
$4,550

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

V. Working Model Text Box
$0.00

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
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

$0.00
$0.00
1.0000
$0.00
$0.10

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