CMS-10142 Worksheets: Prescription Drug Bid Pricing Tool

WORKSHEET 1 - Rx BASE PERIOD EXPERIENCE Page 1 of 7 PD-2026.1 I. General Information OMB Approved # 0938-0944 (Expires: 3/31/2027)

1. Contract Number:

4. Contract Yr:

2026

7. Plan Name:

10. VBID-D:

N

12. PD Region:

2. Plan ID: 3. Segment ID:

5. Org. Name: 6. SNP:

8. Plan Type: 9. Enrollee Type:

13. PD Benefit Type:

11. ESRD-SNP:

N

14. SNP Type:

N/A

II. Base Period Background Information

1. Time Period Definition 2a. Total Member Months

0

5. Mapping Contr-Plan-Seg ID Member Months Contr-Plan-Seg ID Member Months

Incurred from: Incurred to: Paid through:

2b. LIS Member Months 3a. Risk Score 3b. LIS Risk Score

0.0000

3c. NLI Risk Score

4. Completion Factor

III. Part D Claims Experience

(d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n)

Total Count in Interval

Cumulative

Adjustments to Reflect Pt. D Coverage

Claim Interval

# of Members

Member Months

Total Number of Scripts

Total Allowed Dollars

Average Allowed Amount per Member

Average Paid Amount per Member

Average Cost Sharing per Member

Supplemental C.S. Reduc. per Member

Reimb for LIS per Member

Reimb for Fed Reins. per Member

Net Plan Responsibility per Member

1. $0 2. $1-$544 3. $545-Catastrophic * 4. Above Catastrophic * 5. Subtotal

$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

$0.00

$0.00

6. PMPM Values

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

7. Minus Rebates

$0.00

$0.00

8. Plus Part D as Secondary 9. Minus Manufacturer Discount

$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

$0.00 $0.00

13. Net PMPM on Supplemental Drugs

$0.00

$0.00

* See Instructions for Completing the Prescription Drug Plan BPT for CY2026.

IV. PMPM Non-Benefit Expenses VII. PMPM Income Statement Summary (m) (g)

1. Premium Revenue 2. LIS Reimb.

$0.00 $0.00

3. Fed Reins. 4. Allocated Buy-Down*

$0.00

5. Total Revenue

$0.00

6. Pharmacy Claims 7. Non-Benefit Expenses

$0.00

$0.00

8. Total Expenses 9. Gain/(Loss) Margin Including Buy-Down

$0.00 $0.00

Total

1. Sales and Marketing 2. Direct Administration 3. Indirect Administration 4. Net Cost of Private Reinsurance 5. Uncollected Cost Sharing Payments M3P

V. PMPM Premium Revenue (e) (f) (g)

Basic

Supplemental

Total

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

$0.00

$0.00

$0.00

4. Total Premium

$0.00

$0.00

$0.00

* MA rebate dollars to buy-down Part D premium (not true revenue)

Total Non-LI Brand Discount Amount

VI. IRA Part D Drug Experience (e) (f) (g) VIII. DIR #10 Experience (k)

Total Number of Scripts

Total Allowed Dollars

Total Cost Sharing

1. Maximum Fair Price Drugs

Total Dollars

1. DIR #10

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

WORKSHEET 2 - Rx PDP PROJECTION OF ALLOWED/ NON-BENEFIT Page 2 of 7 I. General Information

1. Contract Number: 4. Contract Yr: 2026 7. Plan Name: 10. VBID-D: N 12. PD Region: 2. Plan ID: 5. Org. Name: 8. Plan Type: 13. PD Benefit Type: 3. Segment ID: 6. SNP: 9. Enrollee Type: 11. ESRD-SNP: N 14. SNP Type: N/A

II. Utilization for Covered Part D Drugs

(e)

(f)

(g)

(h)

(i)

(j)

(k)

(l)

(m) (n) (o)

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 10. Total Retail 11. Total Mail Order 12. Total Generic 13. Total Brand (Preferred and Non-Preferred) 14. Total Specialty 15. Total

Base Period

Components of Utilization Change

Projected Scripts/ 1000

Covariance

# of Scripts/ 1000

Allowed per Script

PMPM Allowed

Trend in Scripts/1000

Formulary Change

Risk Change

Induced Utilization*

Other Change

Total Utilization Change

$0.00 $0.00 $0.00 $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 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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 $0.00 $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

0.000 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 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000

*Adjustment to remove impact of induced utilization due to supplemental coverage III. Cost for Covered Part D Drugs IV. Projected Allowed PMPM (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) (o) (p)

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 10. Total Retail 11. Total Mail Order 12. Total Generic 13. Total Brand (Preferred and Non-Preferred) 14. Total Specialty 15. Total

Components of Unit Cost Change

Projected Unit Cost

Projected Allowed PMPM

Manual Util/ 1000

Manual Unit Cost

Manual Rate PMPM

Credibility

Blended Allowed PMPM

Inflation Trend

Discount Change

Formulary Change

Other Change

Tot. Unit Cost Chg

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 $0.00 $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 $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 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000

0 $0.00 $0.00 0% $0.00 0 $0.00 $0.00 0% $0.00 0 $0.00 $0.00 0% $0.00 0 $0.00 $0.00 0% $0.00 0 $0.00 $0.00 0% $0.00 0 $0.00 $0.00 0% $0.00

CMS Guideline Credibility

0%

V. PMPM Non-Benefit Expenses and Gain/(Loss) Margin (e) VI. Percentage of Revenue (j) VII. Related Party (n)

Projected Expenses

at 0.000

Projected PMPM

1. Sales and Marketing 2. Direct Administration 3. Indirect Administration 4. Net Cost of Private Reinsurance 5. Uncollected Cost Sharing Payments M3P

1. Claims (Allowable Cost Target) $0.00 2. Non-Benefit Expenses $0.00 3. Gain/(Loss) Margin $0.00 4. Total Bid $0.00 5. Percentage of Revenue a. Claims (Allowable Cost Target) 0.0% b. Non-Benefit Expenses 0.0% c. Gain/(Loss) Margin 0.0%

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

VIII. DIR #10 Projection (n)

Projected PMPM

6. Total Non-Benefit Expenses $0.00 7. Basic Non-Benefit Expenses $0.00 8. Supplemental Non-Benefit Expenses $0.00 9. Basic Gain/(Loss) Margin $0.00 10. Supplemental Gain/(Loss) Margin $0.00

1. DIR #10

11. Total Gain/(Loss) Margin

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:

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

2026

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

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

N N

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

II. Projection Data

1. Projected Total Member Months: 0 2. Projected Avg Risk Score: 1a. Projected LIS Member Months: 2a. Projected LIS Risk Score: 1b. Projected NLI Member Months: 0 2b. Projected NLI Risk Score:

0.000

III. Part D Covered Drug Claims (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) (o)

Claim Interval

# of Members

Member Months

# of Scripts

Projected Allowed

Avg Amt Allowed PMPM

Cost Sharing

PMPM Deductible

Other Cost Sharing PMPM

Federal Reins. PMPM

Plan Liability PMPM

Federal LICS PMPM

1. $0 2. $1-$589 3. $590-Catastrophic 4. Above Catastrophic

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

5. Subtotal 6. Minus Rebates 7. Plus Part D as Secondary 8. Minus Manufacturer Discount 9. Total

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 $0.00 $0.00

$0.00 $0.00

IV. IRA Part D Drug Projection (d) (e) (f) V. Defined Standard Coverage Bid Development (k) (l)

Total Number of Scripts

Total Allowed Dollars

Total Cost Sharing

1. Maximum Fair Price Drugs

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

At 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

WORKSHEET 4 - Rx STANDARD COVERAGE WITH ACTUARIALLY EQUIVALENT COST SHARING I. General Information

Page 4 of 7

1. Contract Number: 4. Contract Yr: 2026 7. Plan Name: 10. VBID-D: N 12. PD Region: 2. Plan ID: 5. Org. Name: 8. Plan Type: 13. PD Benefit Type: 3. Segment ID: 6. SNP: 9. Enrollee Type: 11. ESRD-SNP: N 14. SNP Type: N/A

II. Projection Data

1. Projected Member Months

0

2. Projected Avg Risk Score

0.000

III. Development of Bid for Standard Coverage V. Std. Cov. Bid Development with Actuarially Equivalent C. S.

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

At 0.000

$0.00 $0.00 $0.00 $0.00

At 1.00 $0.00 $0.00 $0.00 $0.00

5. Net Federal Reinsurance 6. LIS

$0.00 $0.00

$0.00

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

At 0.000 $0.00 $0.00 $0.00 $0.00

At 1.00

$0.00 $0.00 $0.00 $0.00

5. Net Federal Reinsurance

$0.00

$0.00

6. Gross Federal Reinsurance 7. LIS

$0.00

1. Total Members 2. Member Months

0 0

Amounts below

Amounts above

Row

Catastrophic Threshold

Catastrophic Threshold

Subtotal

Allowed PMPM

3. Standard

$0.00

$0.00

$0.00

4. Standard with Act. Equiv. Cost Sharing

$0.00

$0.00

$0.00

5. Value of Deductible

$0.00

$0.00

$0.00

Allowed Subject to Coins.

6. Standard

$0.00

$0.00

$0.00

7. Standard with Act. Equiv. Sharing

$0.00

$0.00

$0.00

Coins. %

8. Standard

25.0% A

0.0%

0.0%

9. Standard with Act. Equiv. Sharing

0.0% B

0.0%

0.0%

Coins PMPM

10. Standard

$0.00

$0.00

$0.00

11. Standard with Act. Equiv. Sharing

$0.00

$0.00

$0.00

Net Cost of Benefit

12. Standard

$0.00

$0.00

$0.00

13. Standard with Act. Equiv. Sharing

$0.00

$0.00

$0.00

Rebates

For Reinsurance

Inc Reins.

14. Standard

$0.00

$0.00

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

WORKSHEET 5 - Rx ALTERNATIVE COVERAGE

Page 5 of 7

I. General Information

1. Contract Number: 4. Contract Yr: 2. Plan ID: 5. Org. Name: 3. Segment ID: 6. SNP:

2026

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

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

N N

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

N/A

II. Projection Data

1. Projected Member Months 0

2. Projected Avg Risk Score

0.000

III. Development of Bid for Standard Coverage V. Development of Actuarial Equivalence Test

1. Claims 2. Non-Benefit Expenses 3. Gain/(Loss) Margin

At 0.000 $0.00 $0.00 $0.00

C

At 1.00 $0.00 $0.00 $0.00

4. Total Basic Bid 5. Federal Reinsurance

$0.00 $0.00

$0.00 $0.00

6. Total Coverage

$0.00

A

$0.00

7. LIS

$0.00

1. Part D Covered Drugs 2. Non-Benefit Expenses 3. Gain/(Loss) Margin 4. Federal Reinsurance

At 0.000 $0.00 $0.00 $0.00 $0.00

D

At 1.00

$0.00 $0.00 $0.00 $0.00

5. Total Part D Covered 6. Non-Part D Covered Drugs

$0.00 $0.00

B

$0.00

7. Total Plan Coverage

$0.00

8. Total Basic Bid

$0.00

$0.00

9. LIS

IV. Development of Bid Components

(d) (f)

(g) (i) (m)

(o) (q)

Part D Covered Drugs

Members with Members Amounts <=CAT Amts above All <=CAT >CAT for all members Catastrophic Members

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

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Allowed PMPM 4. Standard 5. Alternative Deductible 6. Value of $590 Deductible 7. Value of Proposed Deductible Allowed Subject to Coins. 8. Standard 9. Alternative Coins. % 10. Standard 11. Alternative Coins PMPM 12. Standard 13. Alternative Federal Reinsurance 14. Standard 15. Alternative Minus Rebates 16. Standard 17. Alternative Plus Part D as Secondary 18. Standard 19. Alternative Net Cost of Benefit 20. Standard 21. Alternative

Type of Deductible Alt Coverage Deductible Amount

E Row

Non- Part D Covd

Amounts below Catastrophic Threshold Amts above Catastrophic Subtotal

$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% 25.0% 0.0% 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 For Reinsurance Inc Reins.

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 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 F $0.00 $0.00 $0.00 $0.00 $0.00 G $0.00 $0.00 $0.00

$0.00 $0.00

VI. Tests for Alternative Coverage VIII. Development of Induced Utilization Adjustment

VII. Development of Supplemental Premium

1. Total Coverage >= Std Coverage (B>=A) Yes 2. Unsubsidized Value >= Unsub Value for Std Covg (1=yes and D>=C) Yes 3. Average Cost at Catastrophic >= Std (G >=F) Yes 4. Deductible <=$590 (E <=590) Yes

At 0.000 1. Part D Covered Drugs $0.00 2. Non Part D Covered Drugs $0.00 3. Less Basic Covered $0.00

4. Supplemental Coverage $0.00 5. Reduction in Reinsurance $0.00 6. Additional Non-Benefit Expenses $0.00 7. Additional Gain/(Loss) Margin $0.00

8. Supplemental Premium $0.00

1. Claims for Standard

At 0.000 $0.00

At 1.00 $0.00

2. Impact of Alternative Utilization on Standard

$0.00

3. Allowable Cost Target for Alternative 4. Induced Utilization Adjustment

$0.00 0.000

$0.00 0.000

WORKSHEET 6 - Rx SCRIPT PROJECTIONS FOR DEFINED STANDARD, ACTUARIALLY EQUIVALENT OR ALTERNATIVE COVERAGE Page 6 of 7 I. General Information

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

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

2026

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

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

N N

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

II. Projections for Equivalence Tests

(f)

(g)

(h)

(i)

(j)

(k)

Population Not Exceeding the Catastrophic Threshold

Defined Standard Coverage

Actuarially Equivalent or Alternative Benefits

Lines 1-8 exclude Insulins/Vaccines and exclude claims subject to deductible 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

Number of Scripts

Allowed $

Std Cost Sharing $

Number of Scripts

Allowed $

Cost Sharing $

0

$0.00

$0.00

0

$0.00

$0.00

12. Claims Subject to Deductible

13. Manufacturer Discount

Population Exceeding the Catastrophic Threshold Lines 14-21 exclude Insulins/Vaccines and exclude claims subject to deductible 14. Retail Generic 15. Retail Preferred Brand 16. Retail Non-Preferred Brand 17. Retail Specialty 18. Mail Order Generic 19. Mail Order Preferred Brand 20. Mail Order Non-Preferred Brand 21. Mail Order Specialty 22. Insulins 23. Vaccines 24. Total

Number of Scripts

Allowed $

Std Cost Sharing $

Number of Scripts

Allowed $

Cost Sharing $

0

$0.00

0

$0.00

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. Retail Generic 28. Retail Preferred Brand 29. Retail Non-Preferred Brand 30. Retail Specialty 31. Mail Order Generic 32. Mail Order Preferred Brand 33. Mail Order Non-Preferred Brand 34. Mail Order Specialty 35. Insulins 36. Vaccines 37. Total

Number of Scripts

Allowed $

Std Cost Sharing $

Number of Scripts

Allowed $

Cost Sharing $

0

$0.00

$0.00

0

$0.00

$0.00

38. Manufacturer Discount

$0.00

Total Amounts Allocated Over the Catastrophic Threshold (All Populations) 39. All Spending Over Catastrophic Threshold 40. Manufacturer Discount

Number of Scripts

Allowed $

Std Cost Sharing $

Number of Scripts

Allowed $

Cost Sharing $

0

$0.00

41. Non-Part D Covered Drugs - All Spending

Subsidy for Selected Drugs

Defined Standard Total Dollars Alternative Total Dollars

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:

2026

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

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

N N

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

II. 2026 Defined Standard Benefit Parameters

1. Deductible $590 2. Out-of-pocket Limit $2,000

III. Summary of Key Bid Elements V. Working Model Text Box

1. Standardized Part D Bid $0.00

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

2. National Average Monthly Bid Amount 3. Base Beneficiary Premium

4. Maximum Base Beneficiary Premium (106% of Prior Contract Year) $38.98 Basic Part D Premium (prior to A/B rebate allocation) 5. Unrounded $0.00 6. Rounded $0.00 Supplemental Part D Premium (prior to A/B rebate allocation) 7. Unrounded $0.00 8. Rounded $0.00 9. Prospective federal reinsurance (non-standardized) $0.00 10. Prospective low-income cost sharing subsidy (non-standardized) $0.00 11. Target amount adjustment (allowed costs as a ratio of bid) 1.0000 12. Manufacturer Discount Amount (exclusive of Selected Drug Subsidy) $0.00 13. Selected Drug Subsidy Amount $0.00 14. Round Part D premiums to nearest (Rounding Rule) $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