Form CMS-10142 Worksheets: Prescription Drug Bid Pricing Tool

WORKSHEET 1 - Rx BASE PERIOD EXPERIENCE

Page 1 of 8
PD-2022.1
OMB Approved # 0938-0944 (Expires: 7/31/2023)

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

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

2022

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

10. VBID-D:
11. MTM:
12. ESRD-SNP:

N
N
N

13. PD Region:
14. PD Benefit Type:
15. SNP Type:

16. PMM:
17. SSM:
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-$414
$415-$3,819
$3,820-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 CY2022.
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
5. Total Premium

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

$0.00

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-0944. The time required to complete this information collection is estimated to average 30 hours
per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
CMS - 10142

$0.00
$0.00

$0.00

$0.00
$0.00
$0.00

IV. PMPM Non-Benefit Expenses

Net Plan
Responsibility
per Member

$0.00

N

N/A

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:

2022

4. Contract Yr:
5. Org. Name:

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

6. SNP:

10. VBID-D:
11. MTM:
12. ESRD-SNP:

N
N
N

13. PD Region:
14. PD Benefit Type:
15. SNP Type:

N
N/A

16. PMM:

17. SSM:
N/A

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.

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

5. 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:

2022

4. Contract Yr:
5. Org. Name:

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

6. SNP:

10. VBID-D:
11. MTM:

12. ESRD-SNP:

N
N
N

13. PD Region:
14. PD Benefit Type:
15. SNP Type:

16. PMM:

17. SSM:
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-$434
$435-$4,019
$4,020-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

N
N/A

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:

2021

4. Contract Yr:
5. Org. Name:

10. VBID-D:
N
11. MTM: N

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

6. SNP:

13. PD Region:
14. PD Benefit Type:
15. SNP Type:

12. ESRD-SNP:
N

16. PMM:

N

17. SSM:

N/A

N/A

II. Projection Data

1. Projected Member months

2. Projected Avg Risk Score

0

III. Development of Bid for Standard Coverage

0

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

0

(l)

1. Total Members
2. Member Months

0
0
Amounts below
Initial Coverage Limit
<$4,020

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

$0.00

WORKSHEET 5 - Rx ALTERNATIVE COVERAGE

Page 5 of 8

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

2022

4. Contract Yr:
5. Org. Name:

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

6. SNP:

N
N
N

10. VBID-D:
11. MTM:

12. ESRD-SNP:

13. PD Region:
14. PD Benefit Type:
15. SNP Type:

16. PMM: N

17. SSM:
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
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

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
<$4,130
>=$4,130
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 $445 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

$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.

8. Standard
9. Alternative
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

Inc Reins.
$0.00

$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

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 <=$445 (E <=445)
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

$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

N/A

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:

2021

4. Contract Yr:
5. Org. Name:

6. SNP:

II. Projections for Equivalence Tests

(f)

Population Not Exceeding $4,020 with Std Coverage
Lines 1-9 exclude claims subject to deductible

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

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

Page 6 of 8

N
N
N

10. VBID-D:
11. MTM:

12. ESRD-SNP:

(g)

(h)

(j)

(i)

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

13. PD Region:
14. PD Benefit Type:
15. SNP Type:

N

16. PMM:
17. SSM:

N/A

N/A

(k)

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

0
0

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

0

9. Total

0

$0.00

$0.00

0

$0.00

$0.00

0

0

0

0

0

10. Claims Subject to Deductible
Population Exceeding $4,020 with Std Coverage
Lines 11-18 exclude claims subject to deductible

11.
12.
13.
14.
15.
16.
17.
18.

Number of Scripts

Allowed $

Std Cost Sharing $

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

19. Total

0

$0.00

0

$0.00

0

20. Claims Subject to Deductible

-

Amounts Allocated Up to ICL (excluding claims subject to deductible)Number of Scripts

21.
22.
23.
24.
25.
26.
27.
28.

Std Cost Sharing $

Number of Scripts

Allowed $

0

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

29. Total

0

Amounts Allocated over Catastrophic Coverage

30.
31.
32.
33.
34.
35.
36.
37.

Allowed $

Number of Scripts

$0.00
Allowed $

$0.00
Std Cost Sharing $

0
Number of Scripts

$0.00
Allowed $

$0.00

0
Number of Scripts

$0.00
Allowed $

-

39. Non-Part D Covered Drugs - All Spending
NETWORK PRICING

Std Cost Sharing $

-

GENERIC
% discount off AWP

$0.00

0
Number of Scripts

0

0

$0.00
Allowed $

$0.00

0

0 (i)

0

0

Cost Sharing $

BRAND

Dispensing Fee

0

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

38. Total

0

% discount off AWP

SPECIALTY
Dispensing Fee

% discount off AWP

Dispensing Fee

RETAIL
MAIL

0

WORKSHEET 6A - COVERAGE IN THE GAP

Page 7 of 8

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

4. Contract Yr:
5. Org. Name:

2021

6. SNP:

II. Spending in the Coverage Gap

(f)

Population Exceeding $4,020 with Std Coverage
Amounts Allocated between $4,020 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-D:
11. MTM:
12. ESRD-SNP:

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

(h)

0

$0.00

13. PD Region:
14. PD Benefit Type:
15. 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
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 $4,020 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 $4,020 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

16. PMM: N
17. SSM: N/A
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:

2022

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

10. VBID-D:
11. MTM:

12. ESRD-SNP:

N
N
N

13. PD Region:
14. PD Benefit Type:
15. SNP Type:
N/A

II. 2022 Defined Standard Benefit Parameters

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

$445
$4,130
$6,550

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

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
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
$0.00
$0.00
1.0000
$0.00

Rounding Rule

13. 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 Actuarial 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.

16. PMM: N

17. SSM:

N/A