YOUR
LOGOYour Brand Benefits
Plan Stack Report
Report STK-SD-V2-0417
Status: Approved and locked
Approved by J. Owner, Main officer
SAMPLE
Employer groupSample District
Stack version2
Plan yearSample plan year
FundingSelf-funded
Enrolled employees412
Monthly total$394,634.20
Annualized$4,735,610.40
Effective PEPM$957.85
Enrollment by coverage tier
| Tier | Enrolled | Monthly rate | Monthly premium |
|---|
| Employee only | 248 | $520.00 | $128,960.00 |
| Employee + spouse | 61 | $1,080.00 | $65,880.00 |
| Employee + children | 54 | $960.00 | $51,840.00 |
| Family | 49 | $1,540.00 | $75,460.00 |
| Total | 412 | | $322,140.00 |
Plan components
| Category | Component | Method | Rate | Monthly |
|---|
| Medical plan | Plan design 1, PPO | Tier-rated | By tier | $322,140.00 |
| Administrator | TPA option A | Per employee per month | $32.00 | $13,184.00 |
| Pharmacy | PBM option C Included with TPA A | Bundled | $0.00 | $0.00 |
| Network | Network A, national | Per employee per month | $12.00 | $4,944.00 |
| Stop-loss | Specific stop-loss | Per employee per month | $78.00 | $32,136.00 |
| Stop-loss | Aggregate stop-loss | Per employee per month | $6.00 | $2,472.00 |
| Care management | Care management programRate override from $5.00, reason logged | Per employee per month | $4.50 | $1,854.00 |
| Credits | PBM rebate pass-through | Credit per employee per month | -$5.00 | -$2,060.00 |
Stop-loss terms
| Specific deductible | $50,000 per individual |
| Aggregate corridor | 125% of expected claims |
| Contract basis | 12/12 |
| Lasers | 1 disclosed, detail held by underwriter |
| Rate cap on renewal | None |
Compensation schedule
| Recipient | Type | Basis | Monthly | Est. annual |
|---|
| Sales rep A | Direct | $25.00 per employee per month | $10,300.00 | $123,600.00 |
| Sales rep B | Indirect | 3% of plan premium | $9,664.20 | $115,970.40 |
| Compensation on termination | None | Not applicable | $0.00 | $0.00 |
Plan premium$322,140.00
Vendor and administrative fees$54,590.00
Commissions$19,964.20
Credits and rebates-$2,060.00
Monthly total$394,634.20
One-time costs$0.00
Annualized$4,735,610.40
Changes from approved version 1
| Change | Monthly impact |
|---|
| Added Sales rep B, 3% of premium | +$9,664.20 |
| Changed TPA option B to TPA option A | +$1,442.00 |
| Changed PBM option A to PBM option C, included with TPA A | -$3,296.00 |
| Added aggregate stop-loss | +$2,472.00 |
| Added PBM rebate credit | -$2,060.00 |
| Net change, version 1 ($386,412.00) to version 2 | +$8,222.20 |
Approval record
| 09:12:04 | Stack version 2 created from approved version 1 by R. Alvarez, Internal officer |
| 09:26:52 | Rate override logged on care management, $5.00 to $4.50, reason "two-year term" |
| 09:40:09 | Submitted for approval by R. Alvarez |
| 14:03:33 | Approved and locked by J. Owner, Main officer |
| 14:03:35 | Report issued and delivered to plan sponsor |
R. AlvarezInternal officer, submitted
J. OwnerMain officer, approved and locked