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pdfWORKSHEET 1 - Rx BASE PERIOD EXPERIENCE
Page 1 of 8
PD-2019.Beta
OMB Approved # 0938-0944 (Expires: TBD)
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Yr:
5. Org. Name:
6. SNP:
2019
7. Plan Name:
8. Plan Type:
9. Enrollee Type:
10. VBID:
11. MTM:
N
N
12. PD Region:
13. PD Benefit Type:
14. SNP Type:
N/A
II. Base Period Background Information
1. Time Period Definition
Incurred from:
Incurred to:
Paid through:
2a. Total Member Months
2b. LIS Member Months
3. Risk Score
4. Completion Factor
0 5. Mapping
Contr-Plan-Seg ID
Member Months
Contr-Plan-Seg ID
Member Months
(k)
(l)
(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-$399
$400-$3,699
$3,700-Catastrophic *
Above Catastrophic *
Subtotal
7.
% OON
# of
Members
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 CY2019.
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
(e)
(f)
(g)
Basic
Supplemental
Total
1. CMS Part D Payment
2. LI Premium Subsidy
3. Member Premium
4. Total Premium
CMS - 10142 (4/30/2017)
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
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 ID:
2019
4. Contract Yr:
5. Org. Name:
7. Plan Name:
8. Plan Type:
9. Enrollee Type:
6. SNP:
N
N
10. VBID:
11. MTM:
12. PD Region:
13. PD Benefit Type:
N/A
14. 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)
Inflation
Trend
1.
2.
3.
4.
5.
6.
7.
8.
(g)
(h)
Components of Unit Cost Change
Discount
Formulary
Other
Change
Change
Change
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)
Tot. Unit
Cost Chg
Projected
Unit
Cost
(k)
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
(e)
VI. Percentage of Revenue
Projected Expenses
1.
2.
3.
4.
5.
Sales and Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Insurer Fees
6. Total Non-Benefit Expenses
1. Claims (Allowable Cost Target):
2. Non-Benefit Expenses
3. Gain/(Loss):
4. Total Basic Bid
$0.00
5. Percentage of Revenue
a. Claims (Allowable Cost Target):
b. Non-Benefit Expenses
c. Gain/(Loss):
(j)
at 0.000
$0.00
$0.00
$0.00
$0.00
0.0%
0.0%
0.0%
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 ID:
2019
4. Contract Yr:
5. Org. Name:
7. Plan Name:
8. Plan Type:
9. Enrollee Type:
6. SNP:
N
N
10. VBID:
11. MTM:
12. PD Region:
13. PD Benefit Type:
14. SNP Type:
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-$404
$405-$3,749
$3,750-Catastrophic
Above Catastrophic
6.
Subtotal
(e)
# of
Members
(f)
Member
Months
# of
Scripts
(g)
(h)
Projected
Allowed
Avg Amt
Allowed
PMPM
(i)
0
0
$0.00
$0.00
8. Plus Part D as Secondary
$0.00
$0.00
IV. Non-Benefit Expenses and Gain/(Loss)
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
7.
Overall Gain/(Loss) Margin Level
10. Is this bid part of a valid product pairing?
11.. Bids in Product Pairing
(l)
PMPM
Deductible
Other
Cost Sharing
PMPM
$0.00
(m)
$0.00
(n)
Federal
Reins. PMPM
$0.00
$0.00
(o)
Plan Liability
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Federal
LICS
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
V. Defined Standard Coverage Bid Development
1.
2.
3.
Corporate Margin Requirement % of Rev.
9.. Corporate Margin Basis
$0.00
(k)
Allowed:
Plan Liability:
11. Total
8.
Gap
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
7. Minus Rebates
9. Projected % OON Included above:
10.
Cost Sharing
$0.00
$0.00
$0.00
$0.00
$0.00
0
(j)
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
$0.00
$0.00
WORKSHEET 4 - Rx STANDARD COVERAGE WITH ACTUARIALLY EQUIVALENT COST SHARING
Page 4 of 8
I.
1.
2.
3.
General Information
Contract Number:
Plan ID:
Segment ID:
2019
4. Contract Yr:
5. Org. Name:
10. VBID: N
11. MTM: N
7. Plan Name:
8. Plan Type:
9. Enrollee Type:
6. SNP:
12. PD Region:
13. PD Benefit Type:
14. SNP Type:
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)
At 1.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
(l)
1. Total Members
2. Member Months
0
0
Amounts below
Initial Coverage Limit
<$3,750
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
0.0%
0.0%
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
$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
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
WORKSHEET 5 - Rx ALTERNATIVE COVERAGE
Page 5 of 8
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
2019
4. Contract Yr:
5. Org. Name:
7. Plan Name:
8. Plan Type:
9. Enrollee Type:
6. SNP:
N
N
10. VBID:
11. MTM:
12. PD Region:
13. PD Benefit Type:
14. SNP Type:
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
At 0.000
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
0.000
V. Development of Actuarial Equivalence Test
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)
1. Population not Meeting Deductible
2. Population Meeting Deductible
3. Member Months
Allowed PMPM
4. Standard
5. Alternative
(f)
(g)
(i)
(k)
Part D Covered Drugs
Members with
Members
Amounts <=ICL
<$3,750
>=$3,750
for all members
0
0
0
0
0
0
0
0
0
Type of Deductible
Type of Gap Coverage
Alt Coverage Deductible Amount
E
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
(m)
(o)
(q)
Amts above
Catastrophic
All
Members
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. Value of $405 Deductible
7. Value of Proposed 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
$0.00
$0.00
$0.00
$0.00
Allowed Subject to Coins.
8. Standard
9. Alternative
$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
Coins. %
10. Standard
11. Alternative
0.0% H
0.0% I
0.0%
0.0%
Coins PMPM
12. Standard
13. 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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Federal Reinsurance
14. Standard
15. Alternative
Minus Rebates
For Reinsurance
16. Standard
17. Alternative
$0.00
Plus Part D as Secondary
18. Standard
19. Alternative
Net Cost of Benefit
20. Standard
21. 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
$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 <=$405 (E <=405)
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
Inc Reins.
$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
$0.00
$0.00
6. Additional Non-Benefit Expenses
7. Additional Gain/(Loss)
8. Supplemental Premium
$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
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
2019
4. Contract Yr:
5. Org. Name:
6. SNP:
II. Projections for Equivalence Tests
Population Not Exceeding $3,750 with Std Coverage
All Spending
1.
2.
3.
4.
5.
6.
7.
8.
7. Plan Name:
8. Plan Type:
9. Enrollee Type:
N
N
10. VBID:
11. MTM:
(f)
(g)
(h)
Defined Standard Coverage
Number of Scripts
Allowed $
Std Cost Sharing $
Page 6 of 8
12. PD Region:
13. PD Benefit Type:
14. SNP Type:
(j)
(i)
(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 $3,750 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
N/A
WORKSHEET 6A - COVERAGE IN THE GAP
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
Page 7 of 8
4. Contract Yr:
5. Org. Name:
2019
6. SNP:
II. Spending in the Coverage Gap
(f)
Population Exceeding $3,750 with Std Coverage
Amounts Allocated between $3,750 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
10. VBID:
11. MTM:
7. Plan Name:
8. Plan Type:
9. Enrollee Type:
(g)
(h)
0
$0.00
12. PD Region:
13. PD Benefit Type:
14. SNP Type:
(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
N
N
(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
0
$0.00
$0.00
Low Income Population Amounts Allocated between $3,750 and Catastrophic
Number of Scripts
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Allowed $
Std Cost Sharing $
Number of Scripts
Allowed $
Cost Sharing $
Retail Generic
Retail Preferred Brand
Retail Non-Preferred Brand
Retail Specialty Generic
Retail Specialty Brand
Mail Order Generic
Mail Order Preferred Brand
Mail Order Non-Preferred Brand
Mail Order Specialty Generic
Mail Order Specialty Brand
22. Total
0
$0.00
$0.00
0
$0.00
$0.00
Non-Low Income Population Amounts Allocated between $3,750 and Catastrophic
Number of Scripts
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
Allowed $
Std Cost Sharing $
Number of Scripts
Allowed $
Cost Sharing $
Retail Generic
Retail Preferred Brand
Retail Non-Preferred Brand
Retail Specialty Generic
Retail Specialty Brand
Mail Order Generic
Mail Order Preferred Brand
Mail Order Non-Preferred Brand
Mail Order Specialty Generic
Mail Order Specialty Brand
33. Total
Non-LI Generics in Gap PMPM
Non-LI Brand Discount Amt PMPM
0
$0.00
$0.00
$0.00
$0.00
0
$0.00
$0.00
N/A
WORKSHEET 7 - SUMMARY OF KEY BID ELEMENTS
Page 8 of 8
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Yr:
5. Org. Name:
6. SNP:
2019
7. Plan Name:
8. Plan Type:
9. Enrollee Type:
10. VBID:
11. MTM:
N
N
12. PD Region:
13. PD Benefit Type:
14. SNP Type:
N/A
II. 2019 Defined Standard Benefit Parameters
1. Deductible
2. Initial Coverage Limit
3. Out-of-pocket Limit
$405
$3,750
$5,000
III. Summary of Key Bid Elements
1.
2.
3.
4.
Standardized Part D Bid
National Average Monthly Bid Amount
Base Beneficiary Premium
MTM Performance Payment
V. Working Model Text Box
$0.00
This section can be used at the discretion of the Plan sponsor.
The contents are NOT uploaded in the bid submission.
Basic Part D Premium (prior to A/B rebate allocation)
5. Unrounded
6. Rounded
$0.00
$0.00
Supplemental Part D Premium (prior to A/B rebate allocation)
7. Unrounded
8. Rounded
$0.00
$0.00
9. Prospective federal reinsurance (non-standardized)
10. Prospective low-income cost sharing subsidy (non-standardized)
11. Target amount adjustment (allowed costs as a ratio of bid)
12. Prospective brand discount amount
$0.00
$0.00
1.0000
$0.00
Rounding Rule
13. Round Part D premiums to nearest
$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 Actuarial Contact
Name
Phone
Email
Date Prepared
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time required to complete this information collection is estimated to average 30 hours per response, including the time to review instructions,
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| File Type | application/pdf |
| File Title | CY 2019 PD BPT |
| Author | HHS/CMS |
| File Modified | 2017-12-27 |
| File Created | 2017-12-06 |