CMS-10142 Worksheets: Prescription Drug Bid Pricing Tool

WORKSHEET 1 - Rx BASE PERIOD EXPERIENCE

Page 1 of 7
PD-2025.1
OMB Approved # 0938-0944 (Expires: 8/31/2025)

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

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

2025

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

10. VBID-D:

N

11. ESRD-SNP:

N

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

15. PMM:
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
3a. Risk Score
3b. LIS Risk Score

0 5. Mapping

Contr-Plan-Seg ID

Member Months

Contr-Plan-Seg ID

Member Months

(k)

(l)

(m)

(n)

0.0000

3c. NLI Risk Score

4. Completion Factor

III. Part D Claims Experience
(d)

(e)

(f)

(g)

(h)

(i)

(j)

Total Count in Interval

Claim
Interval

1.
2.
3.
4.
5.

6.
7.
8.
9.

# of
Members

$0
$1-$504
$505-Catastrophic *
Above Catastrophic *
Subtotal

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

0

0

$0.00

PMPM Values
Minus Rebates
Plus Part D as Secondary
Minus Manufacturer Discount

$0.00
$0.00
$0.00

$0.00

$0.00

$0.00

10. Net Average Paid Amount PMPM

$0.00
$0.00
$0.00
$0.00
$0.00

11. Non-covered Supplemental Drugs
12. Rebates on Supplemental Drugs
13. 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
$0.00
$0.00
$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

VII. PMPM Income Statement Summary

1.
2.
3.
4.

(g)
Total

1.
2.
3.
4.
5.

Sales and Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Uncollected Cost Sharing Payments M3P

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

$0.00
(e)

(f)

(g)

Basic

Supplemental

Total

1. CMS Part D Payment
2. LI Premium Subsidy
3. Member Premium

$0.00

4. Total Premium
VI. IRA Part D Drug Experience

$0.00

$0.00

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

(e)

(f)

(g)

Total
Allowed
Dollars

Total
Cost Sharing

$0.00
$0.00

6. Pharmacy Claims
7. Non-Benefit Expenses

$0.00
$0.00
$0.00

8. Total Expenses

* MA rebate dollars to buy-down Part D premium (not true revenue)
Total Non-LI Brand Discount Amount

1. Insulins
2. Vaccines
3. Maximum Fair Price Drugs

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

Total
Number of
Scripts

(m)

5. Total Revenue

9. Gain/(Loss) Including Buy-Down
$0.00
$0.00

$0.00
$0.00

$0.00

* See Instructions for Completing the Prescription Drug Plan BPT for CY2025.
IV. PMPM Non-Benefit Expenses

Net Plan
Responsibility
per Member

$0.00

N

WORKSHEET 2 - Rx PDP PROJECTION OF ALLOWED/ NON-BENEFIT

Page 2 of 7

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

2025

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

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

10. VBID-D:

N

11. ESRD-SNP:

N

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

N

15. PMM:

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
9. Maximum Fair Price Drugs

# 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
$0.00

Covariance

0.000
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

10. Total Retail
11. 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
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000

12. Total Generic
13. Total Brand (Preferred and Non-Preferred)
14. 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

15. 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)

(g)

(h)

Components of Unit Cost Change
Discount
Formulary
Other
Change
Change
Change

Inflation
Trend

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
9. Maximum Fair Price Drugs

(i)

(j)

(k)

Tot. Unit
Cost Chg

Projected
Unit
Cost

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

10. Total Retail
11. Total Mail Order

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
0.000

12. Total Generic
13. Total Brand (Preferred and Non-Preferred)
14. 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

15. Total

0.000

0.000

0.000

0.000

0.000

$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
Uncollected Cost Sharing Payments M3P

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

6. Total Non-Benefit Expenses

$0.00

7. Basic Non-Benefit Expenses
8. Supplemental Non-Benefit Expenses

$0.00
$0.00

9. Basic Gain/(Loss)
10. Supplemental Gain/(Loss)
11. Total Gain/(Loss)

$0.00
$0.00

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

(j)

IV. Projected Allowed PMPM
(l)
(m)
Manual
Util/
1000

(n)

Manual
Unit
Cost

Manual
Rate
PMPM

$0.00
$0.00

0.0%
0.0%

0.0%

(p)

0%
0%

Blended
Allowed
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

Credibility

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

0
0
0

$0.00
$0.00
$0.00

$0.00
$0.00
$0.00

0%
0%
0%

$0.00
$0.00
$0.00

$0.00

0

$0.00
$0.00
CMS Guideline Credibility

0%
0%

$0.00

VII. Related Party

at 0.000
$0.00
$0.00

(o)

Projected
PMPM
1. Related-Party Allowed Cost
2. Related-Party Non-Benefit Expense

WORKSHEET 3 - Rx CONTRACT PERIOD PROJECTION FOR DEFINED STANDARD COVERAGE

Page 3 of 7

I. General Information

1. Contract Number:
2. Plan ID:
3. Segment ID:

2025

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

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

10. VBID-D:

N

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

11. ESRD-SNP: N

15. PMM:

N/A

II. Projection Data
1. Projected Total Member Months:
1a. Projected LIS Member Months:
1b. Projected NLI Member Months:

2. Projected Avg Risk Score:
2a. Projected LIS Risk Score:
2b. Projected NLI Risk Score:

0
0

0.000

III. Part D Covered Drug Claims
(d)
Claim
Interval

1.
2.
3.
4.

$0
$1-$544
$545-Catastrophic
Above Catastrophic

5.

Subtotal

(e)

# of
Members

(f)

Member
Months

# of
Scripts

(g)

(h)

Projected
Allowed

Avg Amt
Allowed
PMPM

(i)

$0.00
$0.00
$0.00
$0.00
0

0

0

$0.00

$0.00

6. Minus Rebates

$0.00

7. Plus Part D as Secondary

$0.00

(j)

Cost Sharing
$0.00
$0.00
$0.00
$0.00

(k)

(l)

PMPM
Deductible

Other
Cost Sharing
PMPM

$0.00

(m)

$0.00

(n)

Federal
Reins. PMPM

$0.00

$0.00

Insulins
Vaccines
Maximum Fair Price Drugs

$0.00

$0.00

$0.00

9. Total

1.
2.
3.

Plan Liability
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00

$0.00

8. Minus Manufacturer Discount

IV. IRA Part D Drug Projection

(o)
Federal
LICS
PMPM

$0.00

(e)

(d)
Total

Total

Number of
Scripts

Allowed
Dollars
0
0

(f)
Total

$0.00

$0.00

V. Defined Standard Coverage Bid Development
(k)

Cost Sharing

$0.00
$0.00

$0.00

$0.00

At 0.000

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

$0.00

(l)
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

N

WORKSHEET 4 - Rx STANDARD COVERAGE WITH ACTUARIALLY EQUIVALENT COST SHARING
Page 4 of 7
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:

2025

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

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

N

10. VBID-D:

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

11. ESRD-SNP: N

15. PMM:

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

At 0.000

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)

(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
Catastrophic Threshold

Amounts above
Catastrophic Threshold

Row
Subtotal

Allowed PMPM

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

$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

0.0%
0.0%

0.0%
0.0%

$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

Inc Reins.
$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

$0.00

Rebates
14. Standard
15. Standard with Act. Equiv. Sharing
Test for Actuarial Equivalence
Effective coinsurance with alternative cost sharing = to effective coinsurance for standard cost sharing
16.

A=B

No

$0.00

N

WORKSHEET 5 - Rx ALTERNATIVE COVERAGE

Page 5 of 7

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

2025

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

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

10. VBID-D:

N

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

11. ESRD-SNP: N

15. PMM: N

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

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)

(f)

(g)

Members with
<=CAT

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

Allowed PMPM

Members
>CAT

(i)
Part D Covered Drugs
Amounts <=CAT
for all members
0
0
0

0
0
0
0
0
0
Type of Deductible
Alt Coverage Deductible Amount
Amounts below Catastrophic Threshold

4. Standard
5. Alternative

(m)

(o)

(q)

Amts above
Catastrophic

All
Members

0

0
0
0

0
0

E
Amts above Catastrophic

Row
Subtotal

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
$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%

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
$0.00

Inc Reins.
$0.00

$0.00

$0.00

$0.00

$0.00

$0.00
$0.00

$0.00

$0.00
$0.00

Deductible

6. Value of $545 Deductible
7. Value of Proposed Deductible
Allowed Subject to Coins.

8. Standard
9. Alternative
Coins. %

10. Standard
11. Alternative

0.0%
0.0%

Coins PMPM

12. Standard
13. Alternative
Federal Reinsurance

14. Standard
15. Alternative

$0.00
For Reinsurance
$0.00

Minus Rebates

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

$0.00

VII. Development of Supplemental Premium

Yes
Yes
Yes
Yes

1. Total Coverage >= Std Coverage (B>=A)
2. Unsubsidized value >= Unsub Value for Std Covg (1=yes and D>=C)
3. Average Cost at Catastrophic >= Std (G >=F)

4. Deductible <=$545 (E <=545)

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

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:

4. Contract Yr:
5. Org. Name:

Page 6 of 7

2025

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

6. SNP:

II. Projections for Equivalence Tests
Population Not Exceeding the Catastrophic Threshold
Lines 1-8 exclude Insulins/Vaccines and exclude claims subject to deductible

(f)

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

10. VBID-D:

N

11. ESRD-SNP:

N

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

(j)

(i)

(k)

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

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
9. Insulins
10. Vaccines
11. Total
12. Claims Subject to Deductible

0

$0.00

$0.00

0

$0.00

$0.00

13. Manufacturer Discount
Population Exceeding the Catastrophic Threshold
Lines 14-21 exclude Insulins/Vaccines and exclude claims subject to deductible

14.
15.
16.
17.
18.
19.
20.
21.
22.
23.

Number of Scripts

24. Total
25. Claims Subject to Deductible
26. Manufacturer Discount
Amounts Allocated up to Catastrophic Threshold (Lines 27-34 exclude Insulins/Vaccines and claims subject to deductible)

27.
28.
29.
30.
31.
32.
33.
34.

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
Insulins
Vaccines
0

Number of Scripts

$0.00

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

35. Insulins
36. Vaccines
37. Total
38. Manufacturer Discount
Amounts Allocated Over the Catastrophic Threshold

0

42. Subsidy for Selected Drugs - All Spending

$0.00

0

$0.00

$0.00
Number of Scripts

39. All Spending Over Catastrophic Threshold
40. Manufacturer Discount
41. Non-Part D Covered Drugs - All Spending

$0.00
Allowed $

0

-

Std Cost Sharing $
$0.00

-

$0.00

$0.00
Number of Scripts

Allowed $
0

-

Cost Sharing $
$0.00

15. PMM:

N/A

N

WORKSHEET 7 - SUMMARY OF KEY BID ELEMENTS

Page 7 of 7

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

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

2025

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

10. VBID-D:

N

11. ESRD-SNP:

N

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

II. 2025 Defined Standard Benefit Parameters

1. Deductible
2. Out-of-pocket Limit

$545
$2,000

III. Summary of Key Bid Elements

1. Standardized Part D Bid
2. National Average Monthly Bid Amount
3. Base Beneficiary Premium
4. Maximum Base Beneficiary Premium (106% of Prior Contract Year)
Basic Part D Premium (prior to A/B rebate allocation)
5. Unrounded
6. Rounded
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. Manufacturer Discount Amount
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

V. Working Model Text Box

$0.00

$36.78
$0.00
$0.00

$0.00
$0.00
$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.

15. PMM: N