Total Revenue Disclosure Statement_Blank.xlsx

TRDS

Health Plan Vendor Name:

Disclosure type: Retrospective (Actual) / Prospective (Estimated) Retrospective

Employer Group Name:

Effective Period: Start End

Plan Name(s) For Which Disclosure Applies:

Enrolled subscribers:

Average Contract Size:

This statement is intended to capture the full and complete variable revenue as pertaining to this group's relationship with you, the carrier. The carrier represents that the information provided below reflects an accurate and complete picture of all revenue sources.

Note that members with Medicare coverage should be captured on a separate statements vs. actives.

For purposes of this disclosure:

• Variable Fees represent amounts charged by programs where fees are dependent on the level of savings.

• Other Fees will capture revenue outside of variable fees which are not part of fixed fees captured separately (see below for more details).

As you complete this Revenue Disclosure, please be mindful of the following expectations.

• Actuals should be completed if you are the current carrier for this employer and are asked to complete a retrospective lookback of variable fees. Estimates should be provided for non-incumbents in RFP situations, and for prospective requests for current employer groups.

• For new business opportunities, estimates of variable fees should reflect best estimates based on information available from the client and your book of business. There is an understanding that these fees will vary from actual experience.

• Should terms vary by plan, please complete a Total Revenue Disclosure for each of the client’s plans (for all coverages included in the fees - e.g. medical and behavioral)

• This Revenue Disclosure contemplates the medical plan only (e.g. PBM, dental, and other coverages are outside of this scope). All revenue generated at either your company or your parent level (as applicable), as well as amounts paid to a 3rd party who is charged with administering programs is required to be disclosed herein.

• The 'Other' category is intended to capture any items that are part of your Total Revenue but fall outside named categories, such as specialty drug rebates coming through the medical plan.

• Pass through of claims expenses can be excluded unless carrier will retain a portion of these revenues. However, if there are fees, charges, or other mechanisms that represent an incremental net revenue (or possibility thereof), such disclosure is required. An example of this might be any spread pricing, such as what you the carrier charges the client on a capitated basis (higher) as compared to what then gets paid to providers.

• If there are sources of revenue that you are unable or unwilling to disclose, please detail below the nature of the revenue stream and the reason for not disclosing. The client has the right to audit any and all of the components of this disclosure.

• We ask that an authorized representative of the company attest to accuracy of the statement on the signature line below the grid.

Please provide for each program that falls within category

Please provide for each program that falls within category

(e.g. Bill Review, Audits, etc.)

Please provide for each program that falls within category

Please provide for each program that falls within category

Total Capped Rate Offered (PEPM, across all revenue sources - both fixed + variable) (if applicable)

3. For programs where you are estimating a range of variable fees, please explain how you calculate client-specific estimates. This response can include but is not limited to how you leverage book of business information, client-specific information like demographics, geography, claims experience, etc. among other factors that play into your calculations.

4. Please describe any other Variable Fee programs not specified above or circumstances where any of the above disclosure does not apply.

Name:

Title:

Signature:

Date:

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