CMS-10142 Prescription Drug Bid Pricing Tool

WORKSHEET 1 - Rx BASE PERIOD EXPERIENCE

Page 1 of 8
PD-2016.Beta
OMB Approved # 0938-0944

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

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

2016

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

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

N/A

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-$309
$310-$2,849
$2,850-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 CY2016.
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 (2/28/2015)

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:

2016

4. Contract Yr:
5. Org. Name:

10. PD Region:
11. PD Benefit Type:

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

6. SNP:

N/A

12. SNP Type

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)

Other
Change

Total
Utilization
Change

Projected
Scripts/
1000

(o)

Components of Utilization Change
PMPM
Allowed

Trend in
Scripts/1000

Formulary
Change

Risk
Change

Induced
Utilization*

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

Covariance

0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000

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

$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)

(h)

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

(i)

(j)

(k)

Tot. Unit
Cost Chg

Projected
Unit
Cost

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

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

(o)

(p)

Credibility

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

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

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

(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

at 0.000

4. Total Basic Bid

(i)
Credibility

$0.00
$0.00
$0.00
$0.00
$0.00

VII. Percentage of Revenue

1. Claims (Allowable Cost Target):
2. Non-Benefit Expenses
3. Gain/(Loss):

(h)
Manual Rate
Expense

$0.00
$0.00
$0.00
$0.00

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:

2016

4. Contract Yr:
5. Org. Name:

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

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

6. SNP:

N/A

II. Projection Data

1. Projected Member Months:

2. Projected Avg Risk Score:

0

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.

$0
$1-$319
$320-$2,959
$2,960-Catastrophic
Above Catastrophic

6.

Subtotal

(e)

# of
Members

(f)

Member
Months

# of
Scripts

(g)

(h)

Projected
Allowed

Avg Amt
Allowed
PMPM

0

0

0

$0.00

Gap
PMPM

$0.00
$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

(n)

Federal
Reins. PMPM

$0.00

(o)

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

Federal
LICS
PMPM

$0.00

Allowed:
Plan Liability:

12. Total

$0.00

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

$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

a.

Overall Gain/(Loss) Margin Level

b.

Corporate Margin Requirement % of Rev.
Corporate Margin Basis

c.

(j)

Cost Sharing

$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.

(i)

CONTRACT

1. Claims (Allowable Cost Target):
2. Non-Benefit Expenses
3. Gain/(Loss):

(i)

(j)

At 0.000

At 1.00

$0.00
$0.00

$0.00
$0.00

4. Total Basic Bid

$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:

2016

4. Contract Yr:
5. Org. Name:

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

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

6. SNP:

N/A

II. Projection Data

1. Projected Member months

2. Projected Avg Risk Score

0

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):

0.000

At 1.00

$0.00
$0.00

$0.00
$0.00

4. Total Basic Bid

$0.00
$0.00

$0.00
$0.00

5. Federal Reinsurance
6. LIS

$0.00
$0.00

$0.00

IV: Development of Bid Components and Tests for Actuarial Equivalence
(e)

At 0.000

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

5. Federal Reinsurance
6. LIS

(g)

(i)

1. Total Members
2. Member Months

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00

$0.00

(l)
0
0

Amounts below
Initial Coverage Limit
<$2,960

Amounts in
Gap

Amounts above
Catastrophic Threshold

All
Amounts

Allowed PMPM

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

$0.00
$0.00

$0.00
$0.00

$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
$0.00

$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

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
$0.00

For Reinsurance
$0.00
$0.00

Test for Actuarial Equivalence
Effective coinsurance with alternative cost sharing = to effective coinsurance for standard cost sharing

18.

A=B
C=D
Coverage in the Gap

No
No
No

0.0%
0.0%

$0.00
$0.00

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

16.
17.

0.0% C
0.0% D

At 1.00

$0.00
$0.00

Inc Reins.
$0.00

WORKSHEET 5 - Rx ALTERNATIVE COVERAGE

Page 5 of 8

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

2016

4. Contract Yr:
5. Org. Name:

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

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

6. SNP:

N/A

II. Projection Data

1. Projected Member months

2. Projected Avg Risk Score

0

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

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

C

A

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

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

$0.00

$0.00

9. LIS
IV. Development of Bid Components
(d)

(f)

(g)

(i)

(k)

Part D Covered Drugs
Amounts <=ICL
for all members
0
0
0
0
0
0
0
0
0
Type of Deductible
Type of Gap Coverage
Alt Coverage Deductible Amount
Alternative Coverage ICL
Amounts below Initial Coverage Limit
Amts in Gap
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Members with
<$2,960

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

Allowed PMPM

4. Standard
5. Alternative

Members
>=$2,960

(m)

(o)

Amts above
Catastrophic

All
Members

(q)

0

0
0
0

0
0

Amts above Catastrophic

Total
PMPM

NonPart D
Covd

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

Deductible

6. Proposed Deductible
7. Value of $320 Deductible
8. Value of Proposed Deductible

E

$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
0.0% K

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

Allowed Subject to Coins.

9. Standard
10. Alternative
Coins. %

11. Standard
12. Alternative

0.0%
0.0%

0.0% H
0.0% I

Coins PMPM

13. Standard
14. Alternative

$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

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

Federal Reinsurance

15. Standard
16. Alternative
Minus Rebates

For Reinsurance

17. Standard
18. Alternative

$0.00

Minus Other Insurance

19. Standard
20. Alternative
Plus Part D as Secondary

21. Standard
22. Alternative
Net Cost of Benefit

23. Standard
24. Alternative

$0.00
$0.00

$0.00 F
$0.00 G

VI. Tests for Alternative Coverage:

1.
2.
3.
4.
5.

$0.00
$0.00

$0.00

VII. Development of Supplemental Premium:

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 <=$320 (E <=320)
Average Catastrophic cost sharing <= Std (I <= H)

Yes
Yes
Yes
Yes
Yes

6. Coverage in the Gap (K <= J)

Yes

VIII. Development of Induced Utilization Adjustment
At 0.000

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

$0.00
$0.00

At 1.00

$0.00

$0.00

$0.00

$0.00
$0.00

0.000

0.000

At 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

$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:

2016

4. Contract Yr:
5. Org. Name:

6. SNP:

II. Projections for Equivalence Tests

(f)

Population Not Exceeding $2,960 with Std Coverage
All Spending

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

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

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

(h)

(j)

(i)

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

N/A
(k)

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

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

09. Total

0

Population Exceeding $2,960 with Std Coverage
All Spending

10.
11.
12.
13.
14.
15.
16.
17.

Number of Scripts

0

Amounts Allocated Up to ICL (1)

Std Cost Sharing $

0

Number of Scripts

$0.00

Allowed $

$0.00

Cost Sharing $

$0.00

Number of Scripts

Allowed $

0
Std Cost Sharing $

Number of Scripts

$0.00
Allowed $

Cost Sharing $ (1)

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

27. Total

0

Amounts Allocated over Catastrophic Coverage

28.
29.
30.
31.
32.
33.
34.
35.

Allowed $

$0.00

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

18. Total

19.
20.
21.
22.
23.
24.
25.
26.

$0.00

$0.00

Number of Scripts

Allowed $

$0.00
Std Cost Sharing $

0
Number of Scripts

$0.00
Allowed $

$0.00
Cost Sharing $

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

36. Total

0

$0.00

Number of Scripts

Allowed $

-

37. Non-Part D Covered Drugs - All Spending

$0.00
Std Cost Sharing $

-

0
Number of Scripts

$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:

2016

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

6. SNP:

II. Spending in the Coverage Gap
Population Exceeding $2,960 with Std Coverage
Amounts Allocated between $2,960 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 $2,960 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 $2,960 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)

N/A

$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:
5. Org. Name:

2016

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

6. SNP:

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

N/A

II. 2016 Defined Standard Benefit Parameters

1. Deductible
2. Initial Coverage Limit
3. Out-of-pocket Limit

$320
$2,960
$4,700

III. Summary of Key Bid Elements

1. Standardized Part D Bid
2. National Average Monthly Bid Amount
3. Base Beneficiary Premium

V. Working Model Text Box

$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
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

$0.00
$0.00
$0.00
$0.00
1.0000
$0.00

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

$0.10

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