Attestation Agreement

User Roles:

AC

Actuarial Attestation for the Gross and Net Value Tests if no Benefit options are combined

I hereby attest to the following:

I am a qualified actuary and a member of the American Academy of Actuaries. I am familiar with the requirements for, and am qualified to prepare, a Retiree Drug Subsidy (RDS) Actuarial Attestation.

The actuarial Gross Value of each of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the actuarial Gross Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D eligible individuals who are participants and beneficiaries of the Plan Sponsor's plan for the subject plan year.

I have determined that each of the Benefit Option(s) listed in this Plan Sponsor Application meet the Gross Value Test requirements of 42 C.F.R. §423 884(d), including the relevant actuarial guidelines issued by CMS, and the data and assumptions used in the development of this attestation are reasonable and are based on generally accepted actuarial principles, including the appropriate actuarial standards of practice.

Each Benefit Option individually meets the Net Value test as set forth at 42 C.F.R. §423.884(d).

The actuarial Net Value of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the actuarial Net Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D eligible individuals who are participants and beneficiaries of the Plan Sponsor's Plan for the subject plan year.

The Net Value of the Plan Sponsor's prescription drug coverage was determined using a methodology consistent with the requirements set forth at 42 C.F.R. §423.884(d)(5) and all relevant actuarial guidelines issued by CMS, and the data and assumptions used in the development of this attestation are reasonable and are based on generally accepted actuarial principles, including the appropriate actuarial standards of practice.

I understand and acknowledge that the information being provided in this attestation is being used to obtain Federal funds.

I agree to maintain and make available reports, working documents and other records as required under 42 C.F.R. 423.§888(d). This includes information about data and/or assumptions I may have relied upon.

I certify that this attestation is true and accurate to the best of my knowledge and belief.

Actuarial Attestation for the Gross and Net Value Tests if Benefit Options are combined

I hereby attest to the following:

I am a qualified actuary and a member of the American Academy of Actuaries. I am familiar with the requirements for, and am qualified to prepare, a Retiree Drug Subsidy (RDS) actuarial attestation.

The actuarial Gross Value of each of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the actuarial Gross Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D eligible individuals who are participants and beneficiaries of the Plan Sponsor's plan for the subject plan year.

I have determined that each of the Benefit Option(s) listed in this Plan Sponsor Application meet the Gross Value Test requirements of 42 C.F.R. §423 884(d), including the relevant actuarial guidelines issued by CMS, and the data and assumptions used in the development of this attestation are reasonable and are based on generally accepted actuarial principles, including the appropriate actuarial standards of practice.

Two or more Benefit Options have been combined in order to meet the Net Value test as set forth at 42 C.F.R. 423.§884(d), and each option not so combined individually meets the Net Value test as set forth in 42 C.F.R. §884(d).

The actuarial Net Value of the Benefit Option(s) listed in this Plan Sponsor Application is at least equal to the actuarial Net Value of the defined standard prescription drug coverage under Medicare Part D for the Medicare Part D eligible individuals who are participants and beneficiaries of the Plan Sponsor's Plan for the subject plan year.

The Net Value of the Plan Sponsor's prescription drug coverage was determined using a methodology consistent with the requirements set forth at 42 C.F.R. §423.884(d)(5) and all relevant actuarial guidelines issued by CMS, and the data and assumptions used in the development of this attestation are reasonable and are based on generally accepted actuarial principles, including the appropriate actuarial standards of practice.

I understand and acknowledge that the information being provided in this attestation is being used to obtain Federal funds.

I agree to maintain and make available reports, working documents and other records as required under 42 C.F.R. 423.§888(d). This includes information about data and/or assumptions I may have relied upon.