INSUI Sealed Proposal for: KERB COUNTY Medical Stop Loss, TPA Services, Life Insurance and AD&D __ CE MANAGEMENT SERVICES ORIGINAL HIGH PLAN $ 40.000 Specific Deductible Basis for Deductible: Incurred 15 months Paid 12 months. Number of Rates Monthly Premium Annual Premium Partici ants Specific Premium: Single 165 $95.06 $15,684.90 $188,218.80 Family 78 $216.09 $16,855.02 $202,260.24 Composite NIA N/A N/A N/A Aggregate Premium 243 $7.79 $1,892.97 $22,715.64 Composite Aggregate Attachment Pts. Single 165 $424.02 $69,963.30 $839,559.60 Family 78 $812.60 $63,382.80 $760,593.60 fir' HIGH PLAN $ 50,000 Specific Deductible Basis for Deductible: Incurred 15 months Paid 12 months. Number of Rates Monthly Premium Annual Premium Partici ants Specific Premium: Single 165 $77.28 $12,751.20 $153,014.40 Family 78 $178.96 $13,958.88 $167,506.56 Composite N/A NIA NIA NIA Aggregate Premium 243 $7.90 $1,919.70 $23,036.40 Composite Aggregate Attachment Pts. Single 165 $438.80 $72,402.00 $868,824.00 Family 78 $843.81 $65,817.18 $789,806.16 HIGH PLAN $ 60,000 Specific Deductible Basis for Deductible: Incurred 15 months Paid 12 months. Number of Rates Monthly Premium Annual Premium Partici ants Specific Premium: Single 165 $63.72 $10,513.80 $126,165.60 Family 78 $150.28 $11,721.84 $140,662.08 Composite NIA N/A N/A N/A Aggregate Premium 243 $7.91 $1,922.13 $23,065.56 Composite Aggregate Attachment Pts. Single 165 $450.09 $74,264.85 $891,178.20 Family 78 $867.80 $67,688.40 $812,260.80 ~ INSURANCE MANAGEMENT SERVICES SPECIFIC PREMIUM EMP ONLY EMP/CHILD EMP/SPOUSE EMP/FAMILY AGGREGATE PREMIUM AGGREGATE FACTORS EMP ONLY EMP/CHILD EMP/SPOUSE EMP/FAMILY ADMINISTRATION FEE* TYPE OF CONTRACT KERR COUNTY GROUP HEALTH INSURANCE 01/01/08 EFFECTIVE DATE MUTUAL OF MUTUAL OF MUTUAL OF MUTUAL OF OMAHA OMAHA OMAHA OMAHA CURRENT $40,000 $50,000 $60,000 $50,000 $95.06 $77.28 $63.72 $52.77 $216.09 $178.96 $150.28 $129.65 $216.09 $178.96 $150.28 $129.65 $216.09 $178.96 $150.28 $129.65 $7.79 $7.90 $7.91 $14.00 $424.02 $438.80 $450.09 $408.59 $812.60 $843.81 $867.80 $809.44 $812.60 $843.81 $867.80 $781.26 $812.60 $843.81 $867.80 $1,062.00 $34.75 $34.75 $34.75 $37.97 15/12 SPEC . 15/12 SPEC. 15/12 SPEC. 15/12 SPEC. 15/12 AGG . 15/12 AGG. 15/12 AGG. 15/12 AGG. ANNUALIZED COST (BASED ON CURRENT ENROLLMENT) AGGREGATE PREMIUM 243 $22,715.64 $23,036.40 $23,065.56 $40,824.00 SPECIFIC PREMIUM EMP ONLY 165 $188,218.80 $153,014.40 $126,165.60 $104,484.60 EMP/CHILD 31 $80,385.48 $66,573.12 $55,904.16 $48,229.80 EMP/SPOUSE 21 $54,454.68 $45,097.92 $37,870.56 $32,671.80 EMP/FAMILY 26 $67,420.08 $55,835.52 $46,887.36 $40,450.80 ADMINISTRATION FEE* 243 $101,331.00 $101,331.00 $101,331.00 $110,720.52 TOTAL FIXED COST $514,525.68 $444,888.36 $391,224.24 $377,381.52 ESTIMATED CLAIMS $1,280,122.56 $1,326,904.13 $1,362,751.20 $1,310,673.12 EST. ANNUAL LIAB. $1,794,648.24 $1,771,792.49 $1,753,975.44 $1,688,054.64 ATTACHMENT POINT $1,600,153.20 $1,658,630.16 $1,703,439.00 $1,638,341.40 MAX. PLAN LIAB. $2,114,678.88 $2,103,518.52 $2,094,663.24 $2,015,722.92 *Administration includes Medical, COBRA/HIPAA, Precert, PPO, Disease Management and HRA with debit card. Sun Life Financial's Life/AD&D rate is $0.333/$1,000 with an estimated annual cost of $18,342.36 based on a benefit of $20,000 per employee. Notes and Contingencies: err'' Insurance Management Services 1) A one-time Prescription Card deposit of $40 per employee is required at installation of group. At termination this deposit is refunded to the group. There is also a Prescription Card claim charge of $1.25 per claim processed. This is in addition to the above. 2) Administration Fee includes Pre-Admission Certification, Case Management, Concurrent Review and Discharge Planning. This is a capitated fee with no additional hourly fees applicable. 3) Administration Fee does not include printing of PPO directories. 4) Set-Up Fee is $1,000 plus actual vendor cost for employee booklets. 5) Quote assumes use of Texas True Choice Network with a PHCS wrap. A fee equal to 20% of the savings will be charged on claims incurred within the PHCS wrap area. Mutual of Omaha 1) Rates assume plan has utilization review, pre-certification and large case management. Terms of our proposal are subject to change if this assumption is incorrect. 2) Only full-time employees working a minimum of 30 hours per week or all eligible members meeting the hour bank requirements as state in the current plan are eligible for coverage. 3) A minimum of 75% participation is required if the plan is contributory and 100% if the plan is non-contributory. Those coverage under another employer-sponsored plan will not be included in the participation. However, if `fir'` quoting alongside and HMO plan, participation of 50% of the eligible employees are required whether they are in another employer-sponsored plan or not. 4) Specific and Aggregate include coverage for Medical and Rx. 5) Actively at work provision is waived for known disabled employees and dependents subject to underwriting approval. If not disclosed prior to the effective date, reimbursements will be limited to plan losses from employees "actively at work" and dependents "performing normal activities" as described in the Stop Loss contract. 6) Receipt of updated monthly paid claims, enrollment and shock loss information up to the month prior to the effective date, which may cause a revision of the proposed rates and factors. 7) Rates/factors will be finalized based on receipt and approval of the Select Risk Questionnaire not more than 30 days prior to the effective date disclosing: Claims paid, pending, pre-authorized, or not yet billed that are expected to exceed $20,000 or 50% of any specific deductible (if less), hospital confinements, and any participants who are currently disabled or absent from work due to illness or injury. 8) The minimum annual aggregate deductible is 100% of the Aggreate Factors multiplied by the 1st month's enrollment multiplied by 12. 9) A final census showing all eligible employees and all those participating on the effective date of the plan is required. We reserve the right to reevaluate our quote based on final enrollment. ~r 10) Our proposal assumes the current plan document includes Pre-existing conditiona limitations. If not, our standard Pre-existion conditions limitations will be included in our Stop loss contract. 11) The plan document must be received and approved by us within 30 days of the effective date of the plan. Our Terms assume Experimental services, U&C charges and Medical) Necessary services are addressed (and acceptable to Mutual of Omaha) in the Plan Document. If they are not addressed/acceptable, we will add our ~, standard language to the Stop Loss contract. Requests for reimbursement will not be processed until approval is received. Reimbursements for all individuals is dependent upon satisfaction of all Policy and Plan Document provisions, limitations, exclusions and eligibility requirements. 12) Expenses for on the job injuries and treatment of illness or injury resulting from war or any act of war, whether declared or undeclared, or while in the armed forces of any country or international organization will not be considered eligible. 13) The Stop Loss Coverage is based upon the terms and conditions outlined in the underlying plan document. However, if the terms of the stop loss policy differ from the underlying plan document, the terms of the stop loss policy will control. 14) This quote covers retirees and is based on Medicare being primary on retirees age 65 or older. The quote is subject to change if Medicare is not primary on these employees. 15) The maximum lifetime specific reimbursement is $1,000,000 less the specific deductible, and the maximum aggregate reimbursement is $1,000,000. 16) Specific run-in lis limited to the specific deductible. Specific run-in can be waived after receipt and approval of pended claim reports. 17) Continuation of In-Force benefits is assumed unless otherwise stated. 18) Any claim dollars, which exceed the specific level and are incurred prior to the effective date, or losses that should have been reimbursed by the prior Stop Loss carrier, will not be applied to the Aggregate Attachment `fir" Point. 19) This quote is based on the current participation between the two plan options. If final enrolled participation varies, we reserve the right to adjust our quote. 20) This quote is illustrative only, pending receipt of current shock /trigger information. 21) Quote is subject to review of any claims at or expected to be 50% or more of the current specific deductible and subject to review of any trigger diagnosis claims. 22) Quote is based on Texas True Choice Network and IMS. 23) Rates/factors will be finalized based on receipt and approval of a 50% specific deductible report (including anyone expected to exceed $20,000 or 50% of any specific deductible (if less), pending claim report, pre- certification report, large case management report(s), trigger/ICD-9 report (that takes into account the trigger/ ICD-9 diagnoses referred to in the Large Case Management section of the TPA Administrative Manual), hospital confinements during the past 30 days or expecteed to be within 90 days after the proposed effective date and any participants who are currently disabled (physically or mentally unable to perform all of the usual and customary duties and normal activities of an individual who is in good health) or absent from work due to illness or injury. This must be provided not more than 30 days prior to the effective date. 24) Need shock details (diagnosis, current /historical procedures, prognoses, hospital stays, ect) on the following individuals: 45211901 45227601 45230551 45240201 4529001 49394852 Underwriter: Brad Waldecker brad.waldecker@mutualofomaha.com Telephon (402)351-8358 Fax: Mutual of Omaha Mutual Of Omaha Plaza Omaha, NE 68175 To: Joe Clark Email: Company: Insurance Management Services, Inc. Date: 11 /12/2007 Re: Kerr County For more than 90 years Mutual of Omaha has provided individual financial services and group benefit services to its customers. With an A.M. Best rating of A (Excellent), we have earned a reputation worldwide as a solid, stable, customer-driven company. Mutual of Omaha would like to be your carrier of choice. The proposal for this case is attached for your review. We appreciate your consideration and look forward to being of service to you. Should you have any questions, please feel free to contact me. Benefit Summary Medical Plan Class 1 r aaefte Benefit Plan Type Directed PPO Network In-Network Out-Netwo Individual Calendar Year Deductible $1,000 $2,000 Family Calendar Year Deductible $3,000 $6,000 Coinsurance Percentage 90% 70% Maximum Coinsurance $10,000 $10,000 Family Coinsurance Limit 3.Ox 3.Ox Individual Out of Pocket Limit $2,000 $5,000 Family Out of Pocket Limit 6,000 15,000 Physician Office Visit Copay $30 N/A Plan Maximum $1,000,000 Utilization Review IMS Effective Date Group Name Producer Underwriter No. 01/01/2008 Kerr County Insurance Management Services, Inc. (Am Brad Waldecker 59945 Generated: 11/12/2007 09:27 Mutual of Omaha Mutual Of Omaha Plaza, Omaha, NE, 68175 Telephone: (402)351-8358 suing Carrier Mutual of Omaha Proposal No 59945 Underwriter Brad Waldecker Proposal Valid Thru Group Kerr County Effective 01/01/2008 Expiration 12/31/2008 SPECIFIC STOP LOSS COVERAGE Coverages Contract Type Annual Specific Deductible Maximum Lifetime Reimbursement Rate per Month (Enrollment) Single Family Estimated Annual Premium Rate(s) Includes Commissions of AGGREGATE STOP LOSS COVERAGE Coverages Contract Type Loss Limit per Individual Maximum Annual Reimbursement Rate per Month (Enrollment) Super Composite Estimated Annual Premium Rate(s) Includes Commissions of Monthly Aggregate Claim Factors (Enrollment) Medical Single Family SUMMARY OF COSTS Fixed Costs Monthly Specific Premium: Monthly Aggregate Premium: Total Fixed Monthly Premium: Variable Costs Monthly Attachment Point Annual Attachment Point Total Costs Expected Monthly Costs (Fixed plus Claim) Expected Annual Costs (Fixed plus Claim) Total Monthly Costs Total Annual Costs Specific Accommodation Organ Transplant Option 1 Option 2 Option 3 Medical, Rx Card Medical, Rx Card Medical, Rx Card 15/12 15/12 15/12 per Pers $ 40,000 per Pers $ 50,000 per Pers $ 60,000 $ 960,000 $ 950,000 $ 940,000 (165) $ 95.06 (165) $ 77.28 (165) $ 63.72 (78) $ 216.09 (78) $ 178.96 (78) $ 150.28 $ 390,479 $ 320,521 $ 266,828 15.00 % 15.00 % 15.00 Option 1 Option 2 Option 3 Medical, Rx Card Medical, Rx Card Medical, Rx Card 15/12 15/12 15/12 $ 40,000 $ 50,000 $ 60,000 $ 1,000,000 $ 1,000,000 $ 1,000,000 (243) $ 7.79 (243) $ 7.90 (243) $ 7.91 $ 22,716 $ 23,036 $ 23,066 15.00% 15.00% 15.00% (165) $ 424.02 (165) $ 438.80 (165) $ 450.09 (78) $ 812.60 (78) $ 843.81 (78) $ 867.80 Option 1 Option 2 Option 3 $ 32,540 $ 26,710 $ 22,236 $ 1,893 $ 1,920 $ 1,922 $ 34,433 $ 28,630 $ 24,158 $ 133,346 $ 138,219 $ 141,953 $ 1,600,153 $ 1,658,630 $ 1,703,439 $ 141,110 $ 139,205 $ 137,720 $ 1,693,317 $ 1,670,461 $ 1,652,645 $ 167,779 $ 166,849 $ 166,111 $ 2,013,348 $ 2,002,187 $ 1,993,333 Included in above rates. Included Included Included Rates and Factors are Subject to the Attached Conditions and Assumptions Effective Date Group Name Producer Underwriter No. 01/01/2008 Kerr County Insurance Management Services, Inc. (Am Brad Waldecker 59945 Generated: 11/12/2007 09:27 Proposal Conditions and Assumptions THIS DOCUMENT MAY CONTAIN PROTECTED HEALTH INFORMATION (PHI) AND SHOULD BE SHARED ONLY WITH 'NDIVIDUALS DESIGNATED TO VIEW SUCH INFORMATION PER HIAA REGULATIONS. • For more than 90 years, Mutual of Omaha has provided individual financial services and group benefit services to its customers. With an A.M. Best rating of A+ (Superior), we have earned a reputation worldwide as a solid, stable, customer-driven company. Mutual of Omaha would like to be your carrier of choice. For more information please visit our website @ www. mutualofomaha.com/brokers/products/stoploss/index. html • Stop Loss coverage is underwritten by United of Omaha. • Our rates assume your plan has utilization review, pre-certification and large case management. Terms of our proposal are subject to change if this assumption is incorrect. • The rates reflect a 12-month contract period. This proposal is valid only up to the proposed effective date. • Only full-time employees working a minimum of 30 hours per week or all eligible members meeting the hour bank requirements as stated in the current plan are eligible for coverage. • A minimum of 75% participation is required if the plan is contributory and 100% if the plan is non-contributory. Those covered under another employer-sponsored plan will not be included in the participation calculation. However, if quoting along-side an HMO plan, participation of 50% of the eligible employees are required whether they are in another employer-sponsored plan or not. • Actively at work provision is waived for known disabled employees and dependents subject to underwriting approval. If not disclosed prior to the effective date, reimbursements will be limited to plan losses from employees "actively at work" and dependents "performing normal activities" as described in the Stop Loss contract. • Receipt of updated monthly paid claims, enrollment and shock loss information up to the month prior to the effective date, which may cause a revision of the proposed rates and factors. ~+'' • Rates/factors will be finalized based on receipt and approval of the Select Risk Questionnaire not more than 30 days prior to the effective date disclosing: Claims paid, pending, pre-authorized, or not yet billed that are expected to exceed $20,000 or 50% of any specific deductible (if less), hospital confinements, and any participants who are currently disabled or absent from work due to illness or injury. • The minimum annual aggregate deductible is 100% of the Aggregate Factors multiplied by the 1st month's enrollment multiplied by 12. • A final census showing all eligible employees and all those participating on the effective date of the plan is required. We reserve the right to reevaluate our quote based on final enrollment. • Our proposal assumes the current plan document includes Pre-existing conditions limitations. If not, our standard Pre-existing conditions limitations will be included in our Stop Loss contract. • The plan document must be received and approved by us within 30 days of the effective date of the plan. Our Terms assume Experimental services, U&C charges and Medically Necessary services are addressed (and acceptable to Mutual of Omaha) in the Plan Document. If they are not addressed/acceptable, we will add our standard language to the Stop Loss contract. Requests for reimbursement will not be processed until approval is received. Reimbursements for all individuals is dependent upon satisfaction of all Policy and Plan Doc provisions, limitations, exclusions and eligibility requirements. • Expenses for on the job injuries and the treatment of illness or injury resulting from war or any act or war, whether declared or undeclared, or while in the armed forces of any country or international organization will not be considered eligible. • The Stop Loss Coverage is based upon the terms and conditions outlined in the underlying plan document. However, if the terms of the stop loss policy differ from the underlying plan document, the terms of the stop loss policy will control. ''`r~' Effective Date Group Name Producer 01!01/2008 Kerr County Insurance Management Services, Inc. (Am Underwriter No. Brad Waldecker 59945 Generated: 11/12/2007 09:27 Proposal Conditions and Assumptions • Any individual involved with the marketing of this proposal is required to be licensed and appointed by Mutual of Omaha. Contracts can not be issued nor commissions paid until such license/appointment is secured. Furthermore, pre-appointment is required in certain states prior to the marketing of the proposal. Adherence to the state requirements must be followed. • This quote covers retirees and is based on Medicare being primary on retirees age 65 or older. The quote is subject to change if Medicare is not primary on these retirees. • The maximum lifetime specific reimbursement is $1,000,000 less the specific deductible, and the maximum aggregate reimbursement is $1,000,000. • Specific run-in is limited to the specific deductible. Spec run-in can be waived after receipt and approval of pended claim reports. • Continuation of In-Force benefits is assumed unless otherwise stated. . Any claim dollars, which exceed the specific level and are incurred prior to the effective date, or losses that should have been reimbursed by the prior Stop Loss carrier, will not be applied to the Aggregate Attachment Point. . This quote is based on the current participation between plan options. If final enrolled participation varies, we reserve the right to adjust our quote. • Specific Terminal Liability is available for an additional fee of 5% of annual Specific premium. Aggregate Terminal Liability is available for an additional fee of $1.00 per/ee/mo. • Quote is subject to review of any claims at or expected to be 50% or more of the current specific deductible and subject to review of any trigger diagnosis claims. • Quote is based on PPO: TTC or PHCS UR: IMS . Rates/Factors will be finalized based on receipt and approval of a 50% specific deductible report(including anyone expected to exceed $20,000 or 50% of any specific deductible, if less), pending claim report, precertification report, large case management report(s), trigger/ICD-9 report(that takes into account the trigger/ICD-9 diagnoses referred to in the Large Case Management section of the TPA Administative Manual), hospital confinements during the past 30 days or expected to be within 90 days after the proposed effective date and any participants who are currently disabled(physically or mentally unable to perform all of the usual and customary duties and normal activates of an individual who is in good health) or absent from work due to illness or injury. This must be provided not more than 30 days prior to the effective date. • -Need shock details (diagnosis, current /historical procedures, prognoses, hospital stays, etc) on the following individuals: 45211901 45227601 45230551 45240201 4529001 49394852 ~rrr' Effective Date Group Name 01/01/2008 Kerr County Generated: 11/12/2007 09:27 Producer Underwriter No. Insurance Management Services, Inc. (Am Brad Waldecker 59945 ~,,,: INSURANCE MANAGEMENT SERVICES Managing Care for You Participating Employee Per Month $34. CLAIMS ADMINISTRATION Medical Included / HIPAA Administration I Included I PPO ACCESS & ADMINISTRATION Texas Tnae Choice Included PHCS 20% of savings PRESCRIPTION CARD PROGRAM Charge per claim processed $1.25 One-time Prescription Card deposit per employee $40.00 (Upon terminiation this deposit is refunded to the group) IMS MANAGED CARE, INC. Included IMS Managed Care provides Pre-Admission Certification, Case Management, Concurrent Review, and Discharge Planning. NON-NETWORK NEGOTIATED DISCOUNTS I Included) .IMS REPORTING SYSTEM Included Online Reports, Hard Copy Reports & AdHoc Reports (IMS May charge for complex report requests) SPRINTING OF EMPLOYEE BOOKLETS ~ Actual Vendor Cosh SPRINTING OF PPO DIRECTORIES ~ Not Included PRODUCTION OF GROUP ID CARDS I Included) INSURANCE MANAGEMENT SERVICES Managing Care for You CLAIMS ADMINISTRATION Dental $3.00 Vision $1.50 STD $0.50 FLE~CIBLE SPENDING ACCOUNT ADMINISTRATION (FSA) Per participating employee per month $5.00 Set-up Fee $500.00 HRA ADMINISTRATION (Health Reimbursement Arrangement) Included includes debit card HSA ADMINISTRATION (Health Savings Account) Per participating employee per month $5.00 DEBIT CARD FEATURE (Available with an FSA, HRA &HSA) Included DISEASE MANAGEMENT Per participating employee per month Included IMS Managed Care, tnc. currently targets the following diseases: Asthma, Diabetes, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure and Hypertension WELLNESS PROGRAM Per participating employee per month $2.50 Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD&D Health Reimbursement Arrangement Cafeteria Plan (IRS code 125) Adminish~ation Prescription Benefit Management PLEASE FILL IN THE FOLLOWING INFORMATION NEEDED AND SUBMIT WITH PROPOSAL. The undersigned proposer, by signing and executing this proposal, certifies and represents to Kerr County that proposer has not offered, conferred or agreed to confer any pecuniary benefit, as defined by (1.07 (a) (6) of the Texas Penal Code, or any other thing of value as consideration for the receipt of information or any special treatment of advantage relating to this proposal; the proposer also certifies and represents that the proposer has not offered, conferred or agreed! to confer any pecuniary benefit or other thing of value as consideration for the recipient's decision, opinion, recommendation, vote or other exercise of discretion concerning this proposal, the proposer certifies and represents that proposer has neither coerced nor attempted to influence the exercise of discretion by any officer, trustee, agent or employee of Kerr County concerning this proposal on the basis of any consideration not authorized by law; the proposer also certifies and represents that proposer has not received any information not available to other proposers so as to give the undersigned a preferential advantage with respect to this proposal; the proposer further certifies and represents that proposer has not violated any state, federal, or local law, regulation or ordinance relating to bribery, improper influence, collusion or the like and that proposer will not in the future offer, confer, or agree to confer any pecuniary benefit or other thing of value of any officer, trustee, agent or employee of Kerr County in return for the person having exercised their person's official discretion, power or duty with respect to this proposal; the proposer certifies and represents that it has not now and will not in the future offer, confer, or agree to confer a pecuniary benefit or other thing of value to any officer, trustee, agent, or employee of Kerr County in connection with information regarding this proposal, the submission of this proposal, the award of this proposal or the performance, delivery or sale pursuant to this proposal. The Proposer represents that he, his agent(s), nor any corporate employee has contacted any officer, trustee, elected County official or any other County employee with the intent to discuss, influence, or in any manner affect the outcome of the bid process. The proposer shall defend, indemnify, and hold harmless Kerr County, all of its officers, agents and employees from and against all claims, actions, suits, demands, proceeding, costs, damages, and liabilities, arising out of, connected with, or resulting from any acts or omissions of contractor or any agent, employee, subcontractor, or Supplier of contractor in the execution or performance of this RFP. I have read all of the specifications and general proposal requirements and do hereby certify that all items submitted meet specifications. COMPANY: Insurance Management Services AGENT NAME: P~D~k Sanders _ AGENT SIGNATURE: _ ~`'(_Jfll~1~e(~L ADDRESS: 731 N. Taylor CITY: Amarillo STATE: Texas ZIP CODE: 79107 TELEPHONE: 806-373-5944 FAX: 806-373-3121 FEDERALTIN#: 75-2355889 AND/OR SOCIAL SECURITY #: No Deviations. DEVIATIONS FROM SPECIFICATIONS IF ANY (Attach documents as necessary or state No Deviations): Kerr County Specific and Aggregate Stop Loss Insurance Third Parly Medical Claims Administration Group Term Life and AD&D Health Reimbursement Arrangement Cafeteria Plan (IRS code 125) Administration Prescription Benefit Management CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS Name Of Entity:Insurance Management Services The prospective participant certifies to the best of its knowledge and belief that it and its principals: a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency: b) Have not within a three year period preceding this proposal been convicted of had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State, Local) with commission of any of the offenses enumerated in paragraph (I) (b) of this certification; and d) Have not within a three year period preceding this application/proposal had one or more public transactions (Federal, State, Local) terminated for cause or default. I understand that a false statement on this certification may be grounds for rejection of this proposal or termination of the award. In addition, under 18 USC Section 1001, a false statement may result in a fine up to a $ 10,000.00 or imprisonment for up to five (5) years, or both. PATRICK SANDERS, V.P. OF MARKETING _ Name and Title of Authorization Representative (Typed) Signature of Authorized Representative Date: 11/12/07 I am unable to certify to the above statements. My explanation is attached. Conflict of Interest Questionnaire For Vendor or Other Person Doing Business with a Local Government Entity This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with a government entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7`h business day after the date the person becomes aware of the facts that require the statement to be filed. See section 176.006, Local Government Code. A person commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C Misdemeanor. 1. Name of person doing business with local government entity. 2. ^ Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which the activity described in Section 176.006(a) Local Government Code, is pending and not later than the 7°i business day afrer the originally filed questionnaire becomes incomplete or inaccurate.) 3. Describe each affiliation or business relationship with an employee or contractor of the local government entity who makes recommendations to a local government officer of the local government entity with respect to expenditure of money. 4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local government entity that is subject of this questionnaire. 5. Name of local government officer with whom filer has an affiliation or business relationship. (Complete this section only if the answer to A, B or C is YES) This section, item 5 including subparts A, B, C & D must be completed for each officer with whom the filer has affiliation or business relationship. Attach additional s as necessary. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of this questionnaire? ^ YES X NO B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction ofthe local government officer named in this section? ^ YES X NO C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves as an officer or director or holds an ownership position of 10% or-more? ^ YES X NO D. Describe each affiliation or business relationship. 6. Describe any other affiliation or business relationship that might cause a conflict of interest. 7. Signatures ~0~~~ 11/12/2007 Signature of person doing business with the Date Governmental entity Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD&D Health Reimbursement Arrangement Cafeteria Plan (IRS code 125) Administration Prescription Benefit Management Individual Stop Loss Insurance (ISL)/Aggregate Stop Loss Insurance (ASL) Request for Proposal Submission Form RFP ASSUMPTIONS: 1. Proposal is to be based on the duplication of the existing Plan of Benefits, unless otherwise specified, Any deviations must be clearly identified and explained. All proposals will be assumed to have been submitted without any deviations unless clearly noted. 2. Proposal is to be based on the provided census. 3. Contract effective date is to be January 1, 2008. All participants enrolled in the insurance plan as of December 31, 2007 are to be covered on a "no loss/no gain" basis. "No loss/no gain" for participants are to include credit/debit for accumulated deductible, coinsurance, and lifetime maximum benefits. 4. KERB COUNTY desires to receive proposals for a three (3) year period on one of the following basis: • Fixed price for the three (3) year period, or • Two annual renewal adjustments determined by formula at the time the contract is awarded, or • One (1) year contract with two annual renewal options for rate and premiums deemed to be favorable to KERB COUNTY. Renewal rates are to be provided to KERB COUNTY by October 1 (90 days prior to anniversary date). 5. KERB COUNTY will only consider stop loss insurance policies meeting the following: a Specific and Group Aggregate Policy on a 15/12; paid/12; 24/12 or paid /15 basis for Medical and Drug (Rx). We do not wish to see an aggregating specific. b. Medical and Drug (RX) Specific Coverage with $40,000; $50,000; $60,000 Stop loss. c. Medical and Drug Aggregate Coverage at 120% and 125% of expected claims d Final determination on all lasers, if any, including deductible amounts and conditional lasers should be clearly identified and provided with RFP response based on provided claims data e. Insurance Company Quotation Document with all terms clearly listed f.. Waive Actively at Work Provisions 6. Renewal rate must be received by KERR COUNTY at least 90 days prior to date of rate change. 7. Any estimated savings, performance or other guarantees should be specific, quantifiable and should include a method for validation. QUESTIONS: 1. Describe the business entity submitting the proposal: a. Insurance Company Name: b. Address: c. Contact Person: d. Telephone Number: e. Year Founded (Ins. Co): Mutual of Omaha Mutual of Omaha Plaza, Omaha NE 68175 Brad Waldecker 402 351-8358 1909 Page ~ 1 Kerr County Specific and Aggregate Stop Loss Insurance f. What percentage of overall business is Health related? June YTD 2007: 63% of the revenue for the Group Benetit Services division was health related. g. Managing Underwriter's Name: United of Omaha Life Insurance Company h. Year Founded (Managing Underwriter): 1926 i. Number of Years for Representing Insurance Company: n/a 2. Describe Financial Stability of Insurance Company offering stop loss coverage: a. Financial Rating Service Current Rating Prior Year Rating A.M. Best A+ A Standard & Poors AA- AA- Moody's Aa3 Aa3 b. Is Insurance Company authorized to do business in Texas? ~r' Yes. 3. Provide three (3) Texas client references (preferably public entities): Since we do not work directly with employergroups, references are not available. Please contact us to discuss. Company Name: Company Contact information: Name Phone Number Company Name: Company Contact information: Name Phone Number Company Name: Company Contact information: Name Phone Number Page ~ 2 4. Describe the business entity submitting the proposal: a. Name of Business Entity: Insurance Management Services b. Current Business Address: 731 N. Tavlor, Amarillo Texas, 79107 c. Mailing Address: P.O Box 15688 Amarillo Texas 79010.5 d Contact Person: Christina Smith e. Telephone Number: 806-373-5944 f. Type of Business Entity: w,,,Corporation XGeneral Partnership Sole Proprietorship Registered Limited Liability Partnership _ Limited Liability Company 5. a. Has the business entity been a defendant in any lawsuit in any state or federal court during the preceding five (5) years? X Yes No If yes, identify each lawsuit by party, case number, court, subject matter, and disposition: 1 Chad Brown vs Insurance Management Services, Civil Action No CV04-1289, US District Court, Western District of Louisiana, 2005. Plaintiff was a participant with one of the groups we administer. He was involved in a Motor Vehicle Accident that was not his fault, and suffered iniuries. Police at the scene and hospital tests proved that Mr. Brown was legally drunk at the time of his accident. While the accident was not his fault, we denied his claims due to the fact that by operating a vehicle while legally drunk he was in violation of the law at the time of his accident. This was a clear violation of the plan lan~ua~e. Summary iud~ment issued in our favor on Apri129, 2005. 2 The suit is Cause No. 7732-D in Tavlor County, Texas District Court and is titled: Sears Methodist Retirement System Inc. vs. United of Omaha Life Insurance Company and 1MS Marketing, Inc. d/b/a Insurance Management Services. The case has to do with the reinsurance denial of a run-out claim. It was filed October 14, 2005 and has been settled. b. Does the business entity have any claims filed against it which are unresolved and presently pending before any State of Texas Administrative agency? Yes X No If yes, please provide a full description of the charges 6. Financial Information: a. Has the business entity filed a voluntary or involuntary petition in bankruptcy, obtained an order for relief, or received a discharge on any debt under the U.S. Bankruptcy laws during the preceding seven (7) years? _ Yes X No If yes, please describe: b. Has any owner, member, or partner of the business entity filed a petition in bankruptcy, obtained an order for relief, or received a discharge on any debt under the U.S. Banl~uptcy laws during the preceding seven (7) years? Yes X No If yes, please describe: 7. Describe insurance coverage (include copy of Insurance Certificate): a. The business entity must provide satisfactory evidence of existing insurance coverage in the amount of $1,000,000.00 for Errors and Omissions or other fiduciary liability. If the business entity is selected to provide services it must provide evidence that such coverage will be in effect for the duration of the agreement. See Attachment "A" Errors & Omissions Certificate. 8. Describe ISL and ASL claim payment: a. Where will claims be paid? Omaha, NE b. What is the definition of "paid claim" to be eligible for reimbursement? We define a "Paid" claim as one that has been processed, provided adraft/check is delivered to the payee within _5 days after the day the claim was processed. c. Can KERR County's HR Director and consultant speak directly to claim examiner for questions related to payment of claim? X Yes No Comment: d. What is the normal processing time for ISL claim? Our time service goal is 10 days. e. What is normal processing time for ASL claim? Our time service goal is 10 days but is dependent on if an onsite audit is required. f. What expenses related to investigation of claim are eligible for reimbursement (e.g. hospital audit, medical records, etc) by the stop loss carrier? Hospital audits initiated by Mutual of Omaha, case management and negotiation fees. g. If KERR COUNTY has negotiated with providers, will these discounts be accepted, in lieu of doing a hospital or other audit? X Yes No h. Describe documentation needed for ISL claim reimbursement: Specific Claim Process Notify us as soon as possible of potential specific claims. As soon as paid claims for the contract period exceed the specific deductible, you must submit an initial request for reimbursement with the following: • Copies of all pertinent eligibility documentation (e.g., enrollment card, screen prints of history, COBRA payments, documentation) and verification of creditable coverage (how coverage is Page ~ 4 maintained while off work) • Results of other insurance, Medicare and subrogation investigation • Signed subrogation form and accident details, if applicable • Copies of care certifications (preauthorizations, hospital precertifications, etc.) • Copies of case management progress notes • Copies of all provider bills (refunds, benefit exceptions, overpayments) • Copies of EOBs • Claim history report • Proof of deductible and out of pocket Any subsequent claim filings must also include the following information: • Claim history report • Copies of care certification (preauthorizations, hospital preeertifications, etc.) • Copies of case management progress notes • Copies of all provider bills (refunds, exception payments, overpayments) • Copies of EOBs Describe Underwriting: a Will any claimants be excluded or assigned a higher deductible (lasered)? Yes X No If so, please describe: No, but still have to evaluate shocks and triggers thru October 2007 when available. Even if there is someone who would normally be lasered, we can always consider alternatives like an Aggregating Specific deductible, loading premium, etc vs. lasering. 10. Did you provide a Specimen Stop Loss Contract? Available on request Yes X No 11. Does your Stop Loss insurance contract have any exclusions or limitations that are more restrictive than those used in KERR County's booklet? Yes X No If so, please describe: Not that we are aware of, but we don't have the entire plan doc. 12. Are the active-at-work and disabled dependent provisions waived for the effective date of the contract? X Yes _ No 13. If Centers of Excellence are used for your transplant coverage, please provide specific information for facilities cost and procedures to be used: Please attach a schedule with complete information: Mutual of Omaha's Medical Specialty Network (MSN) includes providers that have contracted both directly and indirectly with Mutual of Omaha to provide organ or tissue transplants. The providers are leased through United Resource Network (URN). The MSN is an option for self-funded group health plans for which you provide administrative services and Mutual of Omaha provides stop loss coverage. Mutual of Omaha encourages you to use the MSN; however, the choice is yours. By using the MSN, your clients are assured that the facilities they are using are accredited, provide quality service, the best possible outcomes, and cost effectiveness. For all transplant cases, your Mutual of Omaha case manager will contact you about utilizing this network. Use of other networks with comparable facilities and contracted rates also is acceptable. 14. Please state any variations to the Request for Proposal Assumptions or other qualifications for your quote: None 15. After the ISL deductible is reached will the stop loss carrier pay claims directly to vendor or require Kerr County to pay claim and be reimbursed? No If reimbursed what is turnaround time? 45 days Page ~ 5 16. For what period of time are quoted rates guaranteed? 12 months 17. Is a longer rate guarantee available? Yes X No If so, please describe: 18. Are quoted rates net of agent commission? Yes X No If no, please describe: Rates include 15% commissions. 19. Do quoted rates include advance funding for: a. Specific Claims? X Yes No If no, additional cost to provide: b. Aggregate Claims? J Yes X No If no, additional cost to provide: No. Additional cost for advance on Aggregate is $1.50 /employee / mo. 20. Is the quote based on the services of a specific provider network? X Yes _ No 21. Please give rate differential to use the following networks: Specific Aggregate a. PHCS -6.0% -2.3% b. Healthsmart X9.0°/~ +2.0% c. BC/BS No data No data d. CNN No data No data e. Beechstreet +2.5% +1.2% f. Texas True Choice Quoted Quoted 21. The following rate exhibit may be used for rate submission however included with the CD or available by Internet is an Excel Spreadsheet titled, "Self Funded Quote Spreadsheet". Complete this spreadsheet as it will be used for bid analysis. Please see section entitled "Proposal". Page ~ 6 Kerr County Third Party Administration Questionnaire TPA Organization 1. Name, Address, City, State, Zip Code and Telephone Number of Firm. Insurance Management Services 731 N. Taylor Amarillo, TX 79107 Toll Free: 1-800-687-5944 Local: 806-373-5944 2. Is your firm owned or operated by a parent company? If yes, please identify the parent and its primary business. IMS is not owned nor operated by a parent company. 3. How long has your firm been in business? How long have you done claims administration? IMS has been in business for 24 years, we have been doing claims administration for 24 years as well. 4. Who are the principal officers in your firm? How long have they been in their positions? President -Joe C. Clark - 24 years; Vice President -Steve Willingham - 24 years; Vice President of Marketing -Patrick Sanders - 10 years; Director of Operations -Jay Mcllraith - 4 years 5. Is this a branch facility? If so, please identify the main office location. IMS is not a branch facility. 6. How many claim processors are Full Time employees in your firm? IMS currently has 8 full time claim processors. 6a. How many claim processors will be appointed to service this account? IMS will appoint one claims processor to service Kerr County. 6b. Of those approximately how many years of experience does each have with medical claims processing? Claim processor experience average is 10 years of service with IMS and 15 in the industry. 7. Do you have bilingual claims personnel available to plan participants who call your office for customer service and/or claims processing? Yes, we have l0 bilingual claims personnel available to plan participants who call to our customer services and/or claims processing. 8. How many clients do you perform claim administration services for? What is the average size? We serve 145 clients with an average of 186 employee lives, or 333 covered lives. 9. Do you carry Errors & Omissions coverage? Provide a copy of your current policy. Please see Attachment "A" for a copy of our current Errors & Omissions coverage. Page ~ 7 Claims Administration 1. What are your claim office performance standards for claim accuracy and turnaround time? Standard for claim accuracy: 98% Standard for turnaround time: 15 days. 2. What is your average turnaround time? Our average turnaround time is 7.17 days. 3. What is your current per day production minimum expected of your claims processor? The average caseload of claims paid per processor per day is 125-150. 4. What are your internal audit procedures? Every 100th claim and every claim over Specific are put on hold for the auditor to check. Each analyst has a different dollar-amount limit on the claims they pay. Any claim over this limit is put on hold for the auditor. In the case of a large claim we have questions about, the claim is sent to Managed Care for review first. If necessary, the claim is then forwarded to AIIMed (our Medical Consultant) for further review. 5. What edits and controls are used to avoid duplicate payments? An internal control file that matches date of service, provider, and type of service performed, flags duplicate charges. This file helps us eliminate duplicate claims before they are processed. 6. What safeguards exist to protect against claims abuse and fraud? Our Claims Edit System, Ingenix, is effective in fraud prevention. In addition, we are also offering to our clients at a percent of savings cost, HCI, an outside vendor specializing in fraud detection and overpayment abuse. 7. What program do you use to unbundle claims? The Claims Edit System (CF.S) from Ingenix is used to unbundle claims. 8. What coordination of benefits (COB) procedures do you follow? A section on the claim form asks if there is other insurance and if the spouse is employed. Once determined that other coverage is available, the additional coverage is logged into our claims paying system. Data elements stored include the insured's name, the name of the other carrier, and the policy number if it is available. The data is updated yearly by claim form. 9. What database do you use to determine Reasonable and Customary fee allowances? How frequently do you update your R&C screens? Ingenix MDR (standard of 60, 70, 75, 80, 85, 90, 95 percentile at the discretion of the employer); R&C information is updated semi-annually. 10. Describe your procedures for professional Medical claims review? All of our claims are processed through our electronic rules engine. This engine ensures that all necessary data is contained within the claim. For electronic claims, providers and participants listed on the claim are pushed through national terrorist watch databases. We are completely HIPAA compliant with regards to privacy and security. Page ~ 8 11. Explain your hospital bill audit procedures. We normally do not audit PPO hospital bills unless the bill looks excessive. With regard to Non-PPO hospital bills, we attempt to negotiate in lieu of an audit. 12. Describe your procedures for tracking and reporting excess claims? Claims Analysts watch billing procedures closely and meet to discuss questionable bills. Auto adjudication is turned off for those physicians with excessive billing errors or procedures. 13. Explain how you handle subrogation and third party disbursements? When one of our claims analysts reviews a claim and determines that there is a possible subrogation claim, subrogation papers are sent to the insured. We pend the claims until we receive signed subrogation paperwork. Once we have received signed subrogation paperwork, we will negotiate any settlement with the participant or their attorneys on behalf of the insured group. IMS follows up on settlements monthly. See Attachment "B" for Sample Subrogation letters. 14. List the excess carriers which you are approved with for claims administration? See attachment "C" for a list of our excess carriers. 15. Do you provide a toll free number for claim inquiries? If yes, what is the cost? IMS has a toll free number that is available Monday through Friday 8:30am.-_S:OOpm central. There is not an additional cost for this service. Our toll free number is I-800-687-5944. 16. What are your normal hours of operation to answer calls for claim inquiries? Our normal hours of operation are Monday through Friday 8:30-S:OOpm central time. 17. Describe your customer service process when an employee calls with a claim inquiry. Our customer service staff is well trained and are able to answer most questions with first-time call resolution. These representatives have access to all claim data and have the expertise to help immediately. If for some reason research is necessary, the question is turned over to the senior customer service representative or supervisor. 18. If you have a separate customer service unit, what are your standards for: Answer Time: Abandon Rate: Each Customer Service Representative is assigned to their own block of Groups to promote personable service. Calls are sent directly to the Customer Service Representative that is assigned to the group that the call is in regards. If the CTS representative is on the phone, the receptionist lets the caller know and gives them the option to speak to another CTS representative or leave a message for their CTS representative. 19. What submission rate has been assumed when calculating your fee? No, IMS does not use submission rate when determining fees. Fees are based on number of covered employees. 20. Does your fee assume a first year claim lag? If so, what is the cost to purchase mature claim year administration? No, our fee does not assume a first year claim lag. 21. Does your fee assume any excess loss carrier overrides? Yes, if applicable. Page ~ 9 Eligibility System 1. How is an insured's eligibility assigned and maintained? Most groups choose to enter their eligibility data electronically via the IMS website or through a data ~'' download. However, some groups do still send eligibility information in hard-copy form. The eligibility administrator manually enters the information when it is received in paper form from these groups. One eligibility administrator and four backup administrators are assigned to each employer group. The employer will deal with that eligibility administrator or one their group's backup administrators, who are responsible for assigning and maintaining all eligibility information for the group. 2. How often can eligibility information be updated? Eligibility is timely updated upon receipt. 3. Do you maintain information on each of the family members separately, as well as the employee? Yes, each individual family member is entered and maintained separately in the computer system. 4. What is your accuracy standard and turnaround time for loading new groups, updates, and changes? If the data is delivered to IMS in the requested electronic file layout, new groups, updates and changes will be loaded within two days of receipt. If the information is received in some other format, it could take longer. Once we have established the new format for a group, the data would be loaded on the day of receipt. Since information sent electronically from the group is loaded directly into the system, accuracy of 100% is maintained. System Capabilities 1. Is your claim processing system completely automated? Yes, claims administration is automated. Claims are received by EDI or by hard copy and then scanned in as an EDI document. The computer system initially checks provider and patient eligibility. The claim is then auto adjudicated through the claims system or manually checked by the claims examiner. All claims are scanned into the system and are available electronically and all hard copies are kept for seven years. The software used is GBAS. 2. Are there any significant manual activities required to process claims? We currently process all hospital bills manually. We have made a decision to continue to do this, as complete electronic processing of hospital bills would not serve our clients' best interests. 3. Describe your claims payment system, including hardware and software? Hardware: The claims system runs on a Digital / HP Alpha Server 4100. Software: GBAS version 7.80-03C. 4. Do you own or rent your claim payment system software? We own 85 licenses and the source code for the GBAS software. 5. How is a person's claim history tracked? It is tracked automatically through the claims paying system (GBAS) as claims are calculated. Page ~ 10 6. How many benefit components (IE -separate deductible, totals, lifetime benefits, etc.) can be maintained by the system? The system maintains: Deductibles- PPO, NonPPO, Integrated; Individual and Family "'fir Out of Pockets-PPO, NonPPO, Integrated; Individual and Family Lifetime Maximums for numerous benefits Annual Maximums-Individual and Family Basic Benefits Supplemental Accident maximums Copayments 7. Can the system track number of visits by procedure? Yes, number of visits by procedure is tracked in our system. 8. Can the system handle different benefit levels for PPOs? Yes, the system can handle different benefit levels for PPOs. 9. How many PPOs can the system handle for one client? At this point, we have clients with up to five PPOs. We are not aware of any system limitations in this area. 10. Can your system accept Electronic Data interchange claim submissions? Yes, our system can handle EDI claims. 11. What percentage of your claims is currently accepted on an electronic basis? 22% of claims are received via EDI. 85% of the remainder are received on paper then scanned and converted into an EDI file before it ever enters our system. Banking Arrangements 1. Do you require the use of a specific bank for claim accounts? If so, please provide the name, address, and phone number of the bank. An account will be set up for the client at their bank of choice, preferably atone of our local banks, or the employer may use one of their existing accounts. This account will be owned by the employer. 2. Is an initial claims deposit required to establish banking arrangements? No initial claims payment deposit is necessary. IMS opens accounts with zero balances. 3. Will you perform bank account reconciliations? Yes, IMS will perform bank account reconciliations for Kerr County at no additional cost. 4. Are there any additional costs to the banking? (LE.: -EFT charges, monthly charges, etc.) If the employer's bank of choice charges a monthly fee or wired funds fee, these charges will be passed along to the employer. IMS choice banks do not charge for the operations performed through IMS. 5. What is the cost of the check stock you provide? Check stock is provided at no additional charge. Page ~ 11 6. How many checks are provided in your cost assumptions? As stated in the question above there is no additional charge for checks. Utilization Review 1. What U.R. services are performed in-house? All UR services are performed in-house by IMS Managed Care, Inc. 2. What outside U.R. services do you use? How long have you used them? We do not utilize any outside UR services. Indicate which U.R. services you have assumed in your proposal? Pre Notification -Included Preadmission Review -Included Concurrent Review - On Site or Off Site -Included Retrospective Review -Included Large Case Management -Included Discharge Planning -Included Can you accommodate Pre-Notification for the following? Specialty Care referrals Home Health Care Ancillary Services Inpatient Surgical procedures Outpatient Surgical procedures Lab & X-ray procedures Inpatient Mental Health and Substance Abuse Outpatient Mental Health and Substance Abuse IMS can perform pre-notifications for all of the below benefits. Preferred Provider Organizations 1. Do you have capabilities to process PPO discounts in-house? Yes we have the capabilities to process PPO discounts in-house. 2. Which PPOs do you have access to processing in-house? We currently can process the following in-house: Texas True Choice, PHCS, OMNI Networks, Beech Street, First Health, Alliance, Health Partners of Kansas and Team Choice. We have the ability to reprice claims in- house for each of these PPOs. We also can submit claims for repricing to each of these electronically. 3. Can you install PPO discounts for direct contracts with providers? If so, what is the charge? Yes, IMS can install PPO discounts for Direct Contracts. There is no additional charge for this. 4. How many different PPOs do you interface with currently? Who are they? We currently send claims electronically to the following: Texas True Choice, PHCS, OMNI Networks, Beech Street, First Health, Alliance, Health Partners of Kansas, and Team Choice. Page ~ 12 5. Which PPOs are you currently using? (attach directory or website access) We currently use the following networks: Texas True Choice www.texastruechoice.com PHCS www.phcs.com ~/ OMNI Networks www.omni-networks.com Beech Street www.beechstreet.com First Health www.firsthealth.com Alliance www.nwtexashealthcare.com Health Partners of Kansas www.phpkc.com Team Choice www.team-choice.com Reporting 1. Provide a list of reports available in your standard reporting package. What is the cost of these reports? Please see attachment "D" for our Sample Report Package. 2. Can you generate customized reports? Are reports available through Internet? What is the charge? Yes, customized reports can be generated at no additional charge. 3. How are paid claims reported? Individuals receive EOBs (Explanations of Benefits). See Attachment "E" for a sample EOB. Groups receive numerous monthly claims reports. Please see Attachment "D" for more details regarding these monthly reports. 4. How does your firm report claims to Excess Loss carriers? We notify the Excess Loss carriers monthly of all participants that have reached 50% of the specific deductible. When a participant reaches the Specific limit, the Excess Loss carrier is notified. A report is sent to the Excess Loss carrier along with copies of all Explanations of Benefits (EOBs) and all checks that have been paid on that participant for the appropriate time period. 5. Can you report on PPO savings? Yes, IMS can report on PPO savings. Please see attachment "D" for our sample Network Discount Report. General L What is the cost for producing a plan document? Is it included in your cost assumptions? Yes, the cost for producing a plan document is included in the initial setup fee. 2. What is the cost for producing a Summary Plan Description? Is it included in your cost assumptions? Our Plan Document serves as the Summary Plan Description. As mentioned above, cost for producing the Plan Document is included in the initial setup fee. 3. What is the cost of having the Plan Document and SPDs changed due to regulatory changes? Is it included in your cost assumptions? The cost of having the Plan Document and SPDs changed due to regulatory changes is included in the administration fee. Page ~ 13 4. What is the cost of printing the S00 Summary Plan Descriptions for the plan participants? Is it included in your cost assumptions? We charge the actual vendor cost for printing Summary Plan Descriptions for the plan participants. S. What is the cost for printing 1000 ID cards? Is it included in your cost assumptions? The printing of ID cards is included in our administration fee. 6. What is the cost of Explanation of Benefits: Is it included in you cost assumptions? If so, how many do you assume? There is no additional cost for production of Explanations of Benefits to the provider and the insured each time a claim is processed. 7. Is there an initial set-up fee charged for the installation of our plan? Our standard set-up fee for a group is $1,000.00. 8. Please disclose any additional fees or expenses that are borne by the client including but not limited to any contractual reimbursements, capitated fees or other fees paid to the TPA, e.g. Rs reimbursements. Please see section entitled "Proposal" for fees and expenses. 9. Do you offer assistance in the administration of COBRA benefits? HIPPA Certificates? Please explain the type of assistance and/or administration duties you provide. Insurance Management Services does offer assistance in the administration of Cobra benefits and HIPAA certificates. These services are included in the administration fee. Cobra/HIPAA administration is a complex process, governed by constantly changing rules and regulations. Virtually all aspects of Cobra/HIPAA are extremely time-sensitive, so prompt and proper actions are critical. Insurance Management Services will: • Assume responsibility for all of your Cobra administrative procedures. • Provide monthly Cobra account reports upon request. • Send Cobra notification packets to qualified participants by certified mail. • Provide the qualified participant with a premium Cobra bill each month. • Send the Cobra premium payments to the appropriate providers monthly. • Mail qualified Cobra participant's notices of late premium payment. • Determine if there has been a "Qualifying Event". • If a qualifying event is verified during cobra continuation, the group is notified of this change. • Provide telephone support for Cobra/HIPAA participants and clients. • Send expiration notices to Cobra coverage participants. • Prepare and distribute HIPAA certificates of creditable coverage to participants and dependents. • Accept and investigate any certificates of creditable coverage presented to Insurance Management Services as proof of prior creditable coverage. HRA Questionnaire 1. Do you offer HRA administration in conjunction with your claims administration? Yes, IMS can offer HRA administration in conjunction with our claims administration. 2. How often do you reimburse a claimant for expenses incurred that are filed on a paper claim form? All HRA claims are paid the Wednesday following the receive date. 3. Do you provide a debit card for all participants? Page ~ 14 We offer a debit card for use with our HRA accounts, This card gives participants the ability to utilize their HRA benefits without having to submit a paper claim. The debit card requires a minimum of 20% of total annual elections at all times for those who elect the debit card feature. 4. Do you require the use of a specific banking institution? No, IMS does not require the use of a specific bank. 5. Is there a minimum funding requirement? If so what? The debit card requires a minimum of 20% of total annual elections at all times for those who elect the debit card feature. 6. Please describe your HRA administration in relationship to your medical claims administration. HRA administration is integrated with the medical claims system. 7. Identify all costs associated with your HRA administration package to include all costs and services provided. There is a $500.00 initial set-up fee for the HRA. The administration fee is X5.00 per participating employee per month. The debit card feature is included in the $5.00 monthly administration fee. 8. Do you include access to accounts via the Internet? At what additional cost if any? Yes, our website, www.imstpa.com, will give participants direct access to their HRA account and show them their claims filed, their remaining balances, and claim status. Prescription Benefit Manager Questionnaire Please fmd the current prescription drug plan design in the medical plan summary attachment. 1. Please describe your retail pharmacy network (number of independents and number of chains; are all chains in the network?) including its relationship to you (e.g. owned or leased). Designed to provide maximum geographic coverage at marketplace-competitive rates and fees, Caremark's comprehensive National Network consists of more than 62,000 stores in the mainland United States, Puerto Rico and the Virgin Islands. Caremark's National Network consists of 96% of all walk-in pharmacies located within the United States, thereby providing clients with maximum geographic coverage and offering their plan participants greater choice and maximum convenience. Additions to the existing network are made as new stores open, or at the request of the client or plan participants. Currently, there are 38,971 chain pharmacies and 24,473 independent pharmacies in Caremark's National Network. All major chains participate in Caremark's National Network. Caremark contracts directly with network pharmacies. Every participating pharmacy is bound contractually to provide services in compliance with the standards outlined in the Caremark Provider Agreement. 2. Please confirm that prescription drugs prescribed by any licensed health care provider, including dentists, will be covered by the pharmacy program. Caremark confirms. Caremark can exclude providers (pharmacies and/or prescribers) upon request in the benefit design. They do not have an automated way to exclude providers based upon new versus refill prescriptions. Once the provider is excluded on the benefit design, then they will be blocked for all claims. Caremark can manage this in a one-off process utilizing member level prior authorizations as long as the medications with refills are identified by the client. Caremark does honor and fill prescriptions written by nurse practitioners and physicians' assistants, when permitted by state laws. Page ~ 15 For example, Texas does not confer independent prescribing authority upon nurse practitioners (they must work under a supervising licensed physician). Therefore, Caremark is prohibited from legally filling and dispensing prescriptions signed by independent nurse practitioners. The pharmacy can fill the prescriptions only if the nurse practitioner has a supervising physician, but an independent nurse practitioner does not work under a supervising physician. As such, any prescriptions written by an independent nurse practitioner will be forwarded to one of their other mail service pharmacies, such as the one in Wilkes-Barre, since Pennsylvania law allows for the filling of prescriptions written by independent nurse practitioners. 3. Is the use of a formulary mandatory? Please attach a copy of the formulary for review. Yes. Caremark's Prescribing Guide places a strong clinical focus on better-managed pharmaceutical care. The information contained in this Guide is derived from the clinical literature and clinical practice. All drugs are reviewed and approved by their Pharmacy and Therapeutics (P&T) Committee. The Prescribing Guide will assist practitioners in selecting the most clinically appropriate and cost-effective drugs for their patients. Please see Attachment "F" for a copy of Caremark's Drug List. 4. Does the retail brand discount include savings from formulary, network spread, clinical savings, DUR savings? No. No monies from the above mentioned are applied to the retail brand discount. 5. Is the brand discount a hard discount? Caremark guarantees the brand discount, except under circumstances that are laid out in the contract, which is mutually negotiated by the parties. 6. Is the brand discount an average? Is it based on 11 digits NDC? Yes. The brand discount is an average. Caremark guarantees a fixed brand discount at retail. Caremark estimates the value of U&C at less than 1% across all claims. Retail claims are based on the i1-digit NDC code. Mail order claims are based on the 9-digit NDC number of the original medication. 7. Is the brand discount at mail order based on 100 units or actual acquisition NDC? Caremark purchases drugs in different package sizes based on a number of different and changing factors: the technology in their pharmacies, the demand for the item, sizes available from the manufacture, etc. For purposes of consistency, Caremark bills based on the AWP of the 100-count package size if available, and, if not, on that of the next nearest size. 8. Is the mail discount based on 11 digit NDC? The AWP used in adjudication of mail order claims is based on the 9-digit NDC number of the original medication. 9. Is pricing for retail brand and overall generic effective rate guaranteed? All pricing is guaranteed. 10. Your quote MUST include a traditional pricing model and a transparency full pass-thru model. Is the pricing guaranteed? Caremark's quote will include a traditional pricing model and a transparency full pass-thru model with pricing guaranteed for the three year term of the contract. 1 L What is the discount for specialty drugs? What is the dispensing fee? Is the specialty drug program apass-thru under a transparency model? Are supplies included in the pricing? Discount for Specialty drugs is AWP - 14%. The dispensing fee is -0- (zero). Page ~ 16 If the group requests that the specialty drug program be a pass-thru under a transparency model then IMS can do that. Yes, supplies are included in the pricing. 12. Please provide your definition of "generic". Also provide a definition of the generic included in the overall generic guarantee. A generic is a drug manufactured by a company that is not the innovator. Most generic drug names reflect the chemical name of the drug. For the most part, these drugs are less expensive, yet they have the same therapeutic value. Caremark will use the indicators of the Medi-Span Master Drug Database (MDDB) and its associated files as appropriate, as updated regularly by Medi-Span, or another nationally available reporting service of pharmaceutical drug information in determining the classification of drugs (e.g., legend vs. over-the-counter, brand vs. generic, single-source vs. multi-source) for purposes of this Agreement. 13. What quantity is an AWP based on for mail order? Caremark purchases drugs in different package sizes based on a number of different and changing factors: the technology in their pharmacies, the demand for the item, sizes available from the manufacture, etc. For purposes of consistency, Caremark bills based on the AWP of the 100-count package size if available, and, if not, on that of the next nearest size. 14. How are manufacturer rebates handled? Will KERB COUNTY share in the rebates? If so, what percentage? IMS will share 50% of the rebates payable to IMS for Kerr County. 15. Do rebates have a minimum guarantee per claim? Per brand? No, there is not a minimum guarantee per claim or per brand. Again, IMS will share 50% of the rebates payable to IMS for Kerr County. 16. Are rebates paid quarterly? If not, when? On average, clients receive rebate payments for rebatable claims 180 to 270 days from the time the prescriptions were dispensed. Typically, Caremark remits payment to their clients within 60 days of the beginning of each calendar quarter rebates received on their behalf by them during the prior calendar quarter, net of any service fees due to them. 17. Under transparency pricing model, are rebates a 100% pass thru of Gross? No. 18. Will coverage of OTC impact rebates? If so, how much? Caremark generally does not recommend coverage of OTC products. 19. Do rebates survive termination? When are they paid after termination? Yes, unless the client termination is in breach of the agreement. Caremark pays all such rebates pursuant to the terms of the agreements with the client. 20. Are rebates paid on specialty drugs? Yes, IMS will share 50% of the rebates payable to IMS for Kerr County. Page ~ 17 21. Do you contract directly with manufacturers for formulary rebates or do you use another PBM? If yes, who handles? We use CaremarkPCS Health, L.P., ("Caremark"), which is a wholly owned indirect subsidiary of CaremarkPCS, a subsidiary of Caremark Rx, L.L.C. whose parent company is CVS Caremark Corporation to contract with manufacturers for formulary rebates 22. Please describe how the drugs for the formulary are selected, and who is responsible for the selection. The Caremark drug list selection considers new drug approvals, generic competition, new research regarding current medications, pharmacoeconomic studies and data, improvement in plan participant compliance, improved clinical efficacy, etc. Considerations impacting the cost effectiveness of any medication include clinical efficacy (e.g., cure rate, impact on morbidity and/or mortality), improvement in surrogate markers (laboratory and other diagnostic tests), dosing frequency or duration, and potential improvements in plan participant compliance. Members of the National Pharmacy & Therapeutics (P&T) Committee provide Caremark with complete disclosure of all conflict-of-interest relationships on at least an annual basis. A member who has a relationship with a pharmaceutical manufacturer will recuse him/herself from voting on decisions involving that pharmaceutical manufacturer. The Caremark formulary process is developed and managed through the activities of the National P&T Committee and the P&T Subcommittee. These committees work together to achieve a rigorous formulary process and maintain the process in a coordinated manner. Objective and comprehensive reviews are presented to the Caremark National P&T Committee for discussion and action. Agents are added to the formulary based on their effectiveness, safety, and therapeutic role (e.g., treatmentlprevention) in the management of disease states. The P&T Committee thoroughly reviews individual drugs and drug classes, using principles defined by the evidence-based medical literature. The committee also considers national trends, client needs, and plan participant demographics. Medication Monographs Medication Monographs and Therapeutic Class Reviews are prepared by clinical pharmacists in the Clinical Formulary Department to support the Caremark P&T Committee functions. These monographs and therapeutic class reviews are prepared following a comprehensive review of the available clinical literature. Numerous references and information resources are used to assist in evaluation and review of the medications under consideration for formulary addition. These peer-reviewed resources -selected on the basis of their reputation among healthcare professionals as being accurate, reliable, current, comprehensive, and respected -are considered by many as representing an industry standard. The following criteria are included in each medication monograph and therapeutic class review. • Disease state background information • FDA review designation/category • FDA-approved indications • Mechanism(s) of action • Pharmacokinetics - Onset of action - Absorption/distribution - Metabolism/excretion - Duration of action/dosage regimen • Efficacy - a summary of evidence-based clinical studies • Warnings/Precautions • Adverse reaction profile • Significant drug interactions • Product availability • Dosage and administration Page ~ 18 • Approach to treatment • Formulary consideration • References. Other information that may be provided includes but is not limited to: • Drug pipeline information • Investigational or off-label use • Comparison of therapeutic alternatives • Pharmacoeconomic data • Comparisons with other forms of medication therapy currently being used • Compliance issues. Additional considerations and desirable features are provided in the following chart: ~ •. Safet The medication must be roven to be safe. Efficacy The medication must be roven to be effective. Desired Product Features Include: ^ Distinct new therapeutic or pharmacologic features that focus on, but are not limited to, age- ran a or breadth of FDA-ap roved indications ^ Better adverse-effects profile, includin lower frequenc and diminished severit ^ Fewer contraindications or precautions ^ Greater efficac as shown b well controlled comparative clinical trials ^ Improved or unique dosin schedule ^ Improved or unique dosa a form P&T Committee Guided by the expertise of Caremark's independent National Pharmacy & Therapeutics (P&T) Committee, Caremark recommends the most clinically appropriate, cost-effective prescription drugs and healthcare programs to optimize your healthcare investment and plan member outcomes. The P&T Committee is an independent body of 18 healthcare professionals and academicians recognized as national experts and leaders in their fields of specialty. A unique feature of the P&T Committee is the inclusion of a pharmacoeconomist whose input includes quality-of--life considerations, and a medical ethicist who provides unbiased feedback regarding the logic and appropriateness of P&T Committee decisions. With the complexity of today's medical field, input from this well-rounded group of specialists enables the P&T Committee to make sound, balanced decisions supporting your plan participants' healthcare. Financial or contract rebate considerations are not part of the P&T Committee's drug selection process. Caremark has established conflict-of-interest safeguards to uphold the integrity and independence of the Committee. Membership The Caremark P&T Committee is made up of actively practicing, geographically diverse medical professionals who are recognized by peers as leading thinkers and highly competent practitioners of the healthcare sciences. Committee members represent a diversity of medical disciplines; a majority of the specialties represented include disciplines that rely heavily upon drug therapies in their daily practice. On an as-needed basis, additional physician experts serve as consultants during topic discussions related to their areas of specialty. The voting committee members are not Caremark employees. None of Caremark's members are under contract with, or employed by, pharmaceutical manufacturers. Caremark's National P&T Committee meets face-to-face on a quarterly basis and, as needed, on an ad- hoc basis. The Caremark P&T Committee is composed of 18 independent healthcare professionals, Page ~ 19 including 1-1 physicians, 3 pharmacists and a medical ethicist. The 14 physicians represent the following specialties: • Allergy • Cardiology ~''' • Clinical Pharmacology • Endocrinology • Family Practice • Gastroenterology • Gerontology • Hematology/Oncology • Internal Medicine • Infectious Disease • Pediatrics • Pediatric/Adolescent Psychiatry • Pharmacoeconomics • Psychiatry. 23. Do you own your own mail service? If not, who do you sub-contract with and do you retain revenue? Yes. Caremark owns its full-service mail service pharmacies which offer operational efficiencies that optimize administrative processes and support more sophisticated levels of clinical and cost management. Their mail service program is administered through the same online, real-time claims processing system used by their retail pharmacies. This program offers clients tighter cost management controls, higher levels of clinical management, and a reduced administrative burden through such operational efficiencies as: • Drug utilization review edits applied consistently across all claims • Formulary control that provides enhanced management and cost control • Plan participant claims history profiles for more effective drug utilization review ~'' • Comprehensive data management • Stringent claims auditing procedures to support quality service levels. 24. Do you own your own Specialty Pharmacy? Or subcontract? If yes, who handles specialty pharmacy? Caremark provides our Specialty Pharmacy Services. 25. What is the average turnaround time for mail order pharmacy? Caremark's mail service pharmacy's typical turnaround time -from the time a prescription is received to the time it is filled and shipped to the plan participant - is an average of two business days for clean prescriptions and an average of five business days for exception orders. A clean prescription is defined as one for which a product is available in the pharmacy and for which the pharmacist is not required to contact the prescriber for clarification, consultation, or intervention before dispensing. An exception prescription is defined as one that is subject to clinical review, utilization review, accounts receivable review, or therapeutic interchange. Time in-house is monitored by astate-of--the-art scanning system that tracks each prescription throughout the dispensing process. A unique bar-code identifier is assigned to each order to provide constant monitoring for that prescription order. 26. Can mail order pharmacy be ordered on-line? Yes. In continuing their commitment to provide plan participants with convenient access to mail service, Caremark has developed Web-based mail service solutions. Participants can continue to use the Internet to order prescription refills or check the status of mail service prescriptions at any time. Caremark offers cobranding and single sign-on services to simplify access for plan participants. Page ~ 20 27. Does the PBM allow 90-day fills at retail in addition to mail order? If so, what contracted pharmacies participate? What is the discount to KERB COiJNTY fora 90-day network? What plan design is used? There are many reasons to encourage the filling of a 90-day supply at mail vs. retail. Some reasons include the following: • Mail service remains the most cost-effective and economical distribution channel for dispensing maintenance medications. • Retail providers cannot generally match mail service rates and fees. • When retail rates and fees do not match mail service, the plan sponsor has to increase the plan participants' cost share in order to "break even" on maintenance medications filled at retail. • If retail providers agree to "match" mail service rates, those rates generally only apply to the 84- to 90-day supply. • The retail provider is not motivated to dispense a 90-day supply when the reimbursement is more aggressive than the reimbursement for a lesser days' supply. Most prescriptions are written for a 30-day supply. Conversion to a 90-day fill would have to be driven by plan participant request or implementation of a hard reject for filling lesser quantities. • Unlike most retail providers offering 90-days supply, Caremark applies its mail service rates for all prescriptions submitted, regardless of the days' supply. • Retail providers generally do not stock adequate inventory for filling 90-day supplies of maintenance medications. "Partial fills" are common and can create additional inconveniences for the plan participant. • Mail service has proven to be more proficient at generic substitution and faster at new generic uptake. 28. Do you offer alternatives in the pharmacy program that can help control or reduce the plan costs? If so, please provide details and approximate savings for each feature. Pharmacy trend management is one of the key drivers of effective healthcare cost management. Caremark offers a wide array of service options that will improve your level of preferred and generic drug dispensing and optimize appropriate drug therapy. These services also encourage the efforts of physicians and plan participants in the use of cost-effective, clinically appropriate pharmacy care. Generics Caremark offers solutions in generic utilization supported by online information and resources that highlight the safety, quality, and value of generic medications. • Generic Uptake Program (GUP) -Provides real-time messaging/edits for multisource brands that encourage the use of generic alternatives. • Coupons (Plan Sponsored) -Promote generic drug use with mailed coupons for generic alternatives to multisource brands. • Count on Generics®-Educates plan participants on the safety, quality and value of generic drugs through print-ready communication materials. • Dispense as Written (DAW) 1 and 2 -Encourage the use of generic equivalents using cost-share strategies. Page ~ 21 Trend Management Caremark offers targeted clinical solutions to promote alternative therapies to high-cost prescription drugs. • Therapeutic interchange -These plan design solutions encourage plan participants to choose preferred over non-preferred brand drugs. • CustomCare Programs -These programs provide an overall analysis of ongoing pharmaceutical care to reduce inappropriate, inefficient, or medically unnecessary prescribing while offering clinically sound, case-by-case consultation. • Prior Authorization -Determines benefit coverage based on criteria selected by the client. • Step Therapy -Monitors and manages the optimal use of first-line therapies to help control drug costs. • Dose Optimization -Manages dosages based on therapeutic intent and clinical appropriateness to simplify drug therapy regimens. • Drug Limits -Ensure proper quantities and duration of therapy for select medications. • iBenefit -Caremark can provide an individualized report for each plan participant; it will include a summary of his/her claims history and encourage that plan participant to consider lower-cost drug alternatives by highlighting savings opportunities. Comprehensive Healthcare Management Caremark's integrated approach to managing drug spend focuses on healthcare solutions that work with prescribers, clients, and plan participants to ensure optimal use of drug therapies in accord with ~Irr+ evidence-based guidelines. This approach also ensures that plan participants are adhering to their prescribed therapies and are, therefore, less likely to suffer costly and unnecessary adverse events. Caremark can integrate plan participant-specific laboratory, medical, and prescription claims data to identify plan participants who are at increased risk for adverse events. Utilizing state-of--the-art technology and evidence-based clinical algorithms, Caremark targets at-risk individuals and engage their physicians with specific and actionable care suggestions. Fewer gaps in care result in low disruption to daily lives. For plan sponsors, healthcare savings are achieved by the prevention of adverse medical events. Caremark works with plan participants, physicians, and pharmacists to monitor the ongoing use of the medications as prescribed. Compliance and Persistency -Caremark offers a systematic approach to early identification and monitoring of high-risk clinical situations. They identify high-risk plan participants by running integrated drug data through specific clinical algorithms. The prescription profiles are then reviewed by clinical pharmacists for drug therapy adherence and other clinical issues. For each drug-related problem identified, the pharmacist provides the prescriber with therapy suggestions and clinically beneficial solutions. Refill Reminders - Caremark,com will a-mail refill reminder notices to plan participants for mail service prescriptions. Thus plan participants can access timely reminders at their convenience, at a location of their choosing. Page ~ 22 Safety Services Caremark employs a comprehensive approach to management of drug-safety issues that affect their clients' plan participants. Services include: / Real-time messaging to pharmacists to identify and prioritize safety issues / Online interactive tools to educate plan participants about possible drug safety issues / Real-time messaging and mailed information to physicians to highlight safety issues / Third-party industry data to establish and maintain safety guidelines. Following are highlights of the programs Caremark employs to address drug safety issues. Point-of-Service Drug Utilization Review Edits Caremark implements the following point-of-service DUR edits: • Drug-drug • Drug-allergy • Drug-age • Drug-gender • Therapeutic duplication. Plan Participant Safety Advisory Caremark implements the following participant safety advisories: • Drug Warnings • Drug Recalls • Drug Withdrawals. Plan Participant Safety and Quality Management (PPSQM) Program - In keeping with their dedication to safety and their efforts to ensure appropriate drug utilization, Caremark offers a program that seeks to identify potential misuse or overuse of controlled substances by plan participants. iScribe messaging -This Caremark proprietary and innovative ePrescribing service offering is a turnkey solution provided at the point-of--care that improves plan participant safety and controls drug costs. Via a handheld device, the physician receives information about potential drug interactions, formulary status, and lower-cost therapeutic alternatives. 29. Please explain your Drug Utilization Review process for these programs: a. Prospective b. Concurrent c. Retrospective Many components of the Caremark clinical solutions are designed to impact physician prescribing, when appropriate. Caremark's programs consistently provide physicians and plan participants with information that encourages cost-effective prescribing. A. Prospective programs are implemented at the point of prescribing. This is the most efficient point to affect prescription prescribing when indicated. It saves re-work, and significantly reduces the "hassle factor" for physicians. iBenefit report -This is an individualized report that can be provided to each plan participant; it includes a summary of his/her claims history and encourages consideration of lower-cost drug alternatives by highlighting savings opportunities. Page ~ 23 B. Caremark employs a comprehensive approach to detecting and preventing drug safety issues that can affect plan participants. Through their Drug Utilization Review (DUR) program, pre-dispensing DUR edit checks are performed on an online, retrl-time basis for both their mail and retail network pharmacies. ~` Caremark's pre-dispensing drug utilization activities are an integral component of their overall commitment to safety and quality. Caremark pharmacists identify potential drug interactions and/or duplicate therapies and discuss these potential problems with the prescribing physician(s), helping to ensure that the appropriate drug, in the amount prescribed, is delivered to your plan participants. All prescriptions are first checked for plan participant eligibility and plan design features. They are then compared against previous histories of prescriptions filled by the same pharmacy, by other participating retail network pharmacies, and by the mail service pharmacies. All drug conflicts are detected online when the prescription is entered into the computer system. If a conflict is identified, the pharmacist reviews the plan participant's history and may contact the prescribing physician prior to filling the prescription. Prescriptions remain active for conflict analysis for 125% of their days' supply. Claims that match data in the file are rejected; a message that tells the pharmacist the date of service, name, and quantity of the duplicate drug already dispensed. The pharmacist can then verify the information and make any appropriate changes. The pharmacist also can override the reject if, in his/her professional judgment, the prescription is appropriate. Drug Edits The following edit checks are samples of those completed online, in real time. An approval or rejection message is sent back to the pharmacist within 3 seconds of the time at which the pharmacist transmits the information to Caremark. Duplicate Drug Therapy Caremark examines each prescription submitted, checks that prescription against any other drugs in the same class, and rejects the prescription if duplicates occur. This edit protects the plan participant from potentially overmedicating, which could be life threatening. Too Early Refill This edit, driven by days' supply, prevents abuse, overmedication of the plan participant, or stockpiling of a medication -practices that are unsafe and are likely to prove expensive for the client. Clients can request different values for different days' supply, which allows for maximum flexibility and fewer false rejections. The usual parameters are as follows: 0-10 days' supply, 25% of the drug supply must have elapsed; 10-34 days' supply, 50% of the drug supply must have elapsed; and 34-100 days' supply, 75% of the drug supply must have elapsed before the prescription can be refilled. Caremark examines the claim prescription number, the date of service, and the days' supply. A claim transmitted before the allotted days' supply has been exhausted is rejected, and an appropriate message is displayed to the pharmacist providing the reason for the reject; the prescription number; and the drug, quantity, and date filled. The pharmacist can then verify the information and override the edit only if appropriate. Drug Dose Check/Low Dose Alert; Drug Dose Check/High Dose Alert Page ~ 24 Also referred to as the MIN/MAX dose edit, this edit checks each prescription submitted for incorrect dosage, or excessive or questionable daily dosage. An appropriate message is sent back to the pharmacist, indicating the usual dosage for the prescribed medication. If the dosage submitted exceeds the program parameters, the MIN/MAX dose edit is applied. This edit checks for excessive days' supply according to the recommended dosage, thus alerting the pharmacist to potential overuse of medications. Incorrect Dosage The daily dose is computed by dividing the quantity dispensed by the indicated days' supply. This value is then checked against an internal table maintained as part of the drug file. The table lists the appropriate dosage for each specific drug. If the prescribed dosage exceeds the recommended dosage in the table, a reject message is returned to the pharmacist. The pharmacist can then verify the information and make any necessary changes. The pharmacist also can override the reject, exercising professional responsibility if the dosage is actually correct according to the prescribing physician. Duplicate Prescription All prescriptions are checked for the same pharmacy, drug date, and prescription number to prevent duplicate billing. Thus, any excess payments to the pharmacy or to the plan participant are prevented. Drug-to-Drug Interaction Caremark examines all medications currently being taken by the plan participant against the new submittal, to determine the potential for adverse reactions (i.e., drug-to-drug interaction) when the new drug is used. ~rrr'' Three levels of severity are associated with this edit. The first level, "Advisory," indicates mild severity and the probability that the interaction will have little potential risk to the plan participant. In this situation, no message is sent but a record is made for reporting purposes. The second level, "Severe," sends a message alerting the pharmacist that the potential for a serious interaction exists. The third level, "Very Severe," entails a high risk of potential harm to the plan participant and sends a message rejecting the claim. Both the "Severe" and "Very Severe" responses provide messages to the pharmacist stating that the new prescription will interact with another medication the plan participant is currently taking. The message includes the name, strength, and quantity of the interacting medication. Drug-Age Caremark examines all medications the plan participant is currently taking, the new prescription, and the plan participant's age. They then determine whether the medication is appropriate for a plan participant of that age. Three levels of warning are associated with this edit: Advisory, Severe, and Very Severe. Override Codes All of the point-of-service drug utilization review processes enable the pharmacist to override an edit when s/he has reviewed the data with the plan participant and/or physician and has determined that the prescription is safe and effective to dispense. Both the plan and the pharmacy track these overrides. Page ~ 25 C. Caremark offers an innovative and flexible suite of clinical solutions that can be tailored to best meet Kerr County's specific goals. Their retrospective program offerings implement assessments of prescribing patterns for individual plan participants, according to pre-established standards. Their retrospective programs in combination with their concurrent and prospective solutions provide a holistic approach to achieving high-quality care with the most cost-effective medications. Caremark's retrospective drug therapy management includes: • CustomCare programs -Provide an overall analysis of ongoing pharmaceutical care to reduce inappropriate, inefficient, or medically unnecessary prescribing while offering clinically sound, case-by-case consultation. UR Pharmacy and URPIus Programs,- Provide an overall analysis of ongoing pharmaceutical care to encourage adherence to national prescribing guidelines and reduce inappropriate, inefficient, or medically unnecessary prescribing while offering clinically sound, case-by-case consultation. The goal of these programs is to avoid adverse medical events that can result increased total healthcare costs. UR Pharmacy utilizes pharmacy claims only, while URPIus utilizes integrated pharmacy and medical claims. 30. Please submit a sample of your standard reporting package. Attach samples of your standard reporting package that is included in your quote. Please note if your paid claims numbers are based on paid or incurred claims figures. Please see Attachment "G" for a sample of Caremark's Standard Reporting Package. 31. Include in your response a PPI report, a specialty drug report, and a net cost per day for mail or retail report w/ specialty and acute meds removed. Please see Attachment "H" for a sample of Caremark's Specialty Standard Reporting Offerings. 32. How do you propose getting members to look at alternative brands that have generics available and do your manufacturer contracts preclude you from providing this type of information to members? One of the easiest and most effective ways to control drug spend is to maximize generic utilization. Count on Generics'N' is a special Caremark initiative designed to increase generic dispensing and utilization through a comprehensive suite of activities that engage physicians, pharmacists, plan participants and plan sponsors through proactive communications, interventions, incentives, and education. Count on Generics has two main areas of focus: • Empower and educate plan participants about the safety, effectiveness, and cost savings of generic drugs. For example, Caremark's Count on Generics plan participant education toolkit provides valuable communication tools and techniques to reach plan participants in multiple ways - to educate and encourage them to use generics. • Provide new ways to maximize generic opportunities. Caremark will help increase your population's use of generic drugs and reduce your organization's prescription benefit costs. For example, one of your important overall plan benefit goals will be targeting how assertive your plan(s) should be in encouraging the use of generics. Caremark's capabilities and offerings provide a range of options, including but not limited to: - Plan participant and physician education programs - Automatic substitution of A-rated generic equivalent - Creative plan design and co-pay options - Brand interchange programs for a generic drug within or across therapeutic categories. Page ~ 26 The Caremark Count on Generics initiative is part of their standard offering at no additional cost, unless otherwise noted. Kerr County can count on Caremark to recommend and implement programs to optimize generics that will faithfully align with its overall goals. The Count on Generics campaign offers: An emphasis on promoting generic prescribing and utilization throughout all Caremark pharmacy benefit management services provided to Kerr County • A flexible selection of programs to meet client-specific needs • Plan participant and physician-specific targeting • Empowered consumer decision-making • Strong physician engagement to prescribe generics • Engagement of pharmacists to dispense generics at the point of service. The Caremark Count on Generics Initiative You can count on Caremark to encourage appropriate use of generics every step of the way: when a new generic launches, before the prescription is written, at the point of prescribing, when the prescription is being filled, and even after the prescription is filled. All of the following initiatives are available at no cost to plan sponsors: • When a new generic launches, Caremark is there to: - Obtain quality generic products in a timely fashion at the best possible price. - Alert plan participants taking the brand-name drug and proactively provide information regarding the associated benefits of receiving a newly available generic. - Ensure that Caremark pharmacies begin to substitute generics for brand-name drugs, as appropriate. • Before the prescription is written, Caremark works with plan sponsors to meet their goals and prepare plan participants for important decisions regarding generics. - Your Caremark account management team will work with you to design a pharmacy benefit plan to encourage generics according to your plan goals. Examples of plan design offerings that encourage generics are: ^ Multi-tiered co-pays: Plan participants are required to pay a higher amount for brand-name products than for generics, thus encouraging the plan participant to use generics from an economic point of view. ^ Differential Coinsurance: Plan participants are reimbursed at a higher rate for generic products. For example, plan participants are reimbursed 90/10 for generics and 80/20 for brand-name drugs, encouraging the plan participant to use generics from an economic point of view. ^ Physician Request: Plan participants are required to obtain physician authorization in order to receive brand-name dispensing when approved generic products are available. ^ Mandatory Generic Differential: Plan participants must accept generic products or pay the difference in price between the brand-name and generic drugs, in addition to the standard co-payment. Thus, the client would never be charged more than the generic price, even if the plan participant received the brand-name drug. ^ Mandatory Generic at Mail with Retail Differential: Client specifies that if the plan participant and/or physician do not permit generic substitution with a mail service Page ~ 27 prescription and an approved generic is available, the prescription will be returned to the plan participant. The plan participant may then obtain the prescription at a retail pharmacy, paying the difference in price between the brand-name medication and the generic plus the applicable co-payment. ^ Mandatory Generic at Mail without Retail Coverage: Client specifies that if the plan participant and/or physician do not permit generic substitution with a mail service prescription and an approved generic is available, the prescription will be returned to the plan participant and will not be covered at either mail or retail. - Caremark's Trend Management experts will utilize proprietary data to evaluate drug trends, plan participant compliance, and the impact of Kerr County's plan design on generic usage. - Caremark provides plan participants and physicians with drug lists that promote generics as a first line of prescribing and encourages plan participants to use the drug list in prescribing situations at each doctor visit. - Caremark offers a comprehensive online and Cll-ROM toolkit that includes plan participant education materials to help give plan participants the confidence to request and take generics. This kit contains full-color templates that clients can co-brand with their own logos, including: ^ Wall poster ^ Quarterly generic campaign stuffier ^ Payroll stuffer ^ Tri-fold brochure ^ Table tent card ^ Email messages ^ Newsletter articles. - Plan participants are encouraged to visit Caremark.com to complete a test claim, learn about generic availability and cost savings, and obtain educational resources. • At the point of prescribing, Caremark is there to help prescribers and plan participants make a decision for generics if appropriate, by: - Providing user-friendly drug lists to plan participants and physicians that encourage generics - Sending "Dear lloctor" letters to plan participants' doctors in order to educate the physicians on the importance of generic prescribing and how prescriptions should be written for the plan. - Analyzing physicians' generic prescribing patterns. Caremark may then send Physician Profiling mailings with peer comparisons that identify and recommend opportunities to prescribe generics. - Encouraging plan participants to ask for generics at their doctors' offices, by means of the educational materials noted above. • When a prescription is being filled, Caremark is there to ensure that generics are optimized appropriately at both mail and retail pharmacies: - Caremark ensures that the plan sponsor's plan design decisions to optimize generics are managed and adjudicated appropriately through its automated and fully integrated drug safety system. Page ~ 28 - Caremark's drug conflict interaction checking system automatically determines when abrand- name drug has a generic equivalent. The pharmacist will dispense the generic alternative, provided that the physician has not written "Dispense as Written" (DAW). - A retail generic uptake process provides point-of--sale messaging for new generic launches and other targeted generics, alerting the pharmacist of interchange opportunities for multisource brand drugs. - Under targeted mail interventions for therapeutic optimization (an enhanced clinical service at a reasonable fee), Dispense As Written (DAW) prescriptions for brand-name drugs are identified at Caremark's mail service pharmacy. A Caremark clinician telephones the prescribing physician in an attempt to convert the prescription to a generic substitute and to educate the physician about the value of generic drugs. The final decision about dispensing abrand-name drug or a generic substitute rests with the prescribing physician. - Caremark clinicians analyze and identify certain therapeutic categories that may include clinically similar drugs. If a drug does not have an A-rated generic alternative, Caremark will work with the prescriber to determine whether a generic within the same class may be clinically appropriate. This is accomplished prior to filling at Caremark's mail service. • After a prescription is filled for abrand-name drug when a generic is available, Caremark can provide programs (with the client's approval) to help guide the next decision toward one that favors a generic. This includes: - Retail DAW mailings: Caremark will identify retail brand-name prescriptions dispensed with a generic available. They will then send mailings to the physician or the plan participant according to who requested the prescription to be filled Dispense as Written (DAW). Mailings educate the recipient about the safety, efficacy, and value of generics and on actions they can take to have future prescriptions filled as generics. - Generic Therapeutic Interchange at retail: Caremark clinicians identify certain therapeutic categories that may include clinically similar drugs. If a drug does not have a generic alternative, Caremark will send communications to the physician to consider prescribing a generic within the same class for the next prescription. - Caremark can provide plan participants with reports that summarize their past prescription activity and indicate opportunities to save where generics may be available. -- Under Caremark's targeted interventions for therapeutic optimization (an enhanced clinical offering at a reasonable fee), if a therapy is changed for clinical reasons and a generic is available for the newly prescribed therapy, Caremark will recommend that the physician prescribe the generic. - Caremark recognizes that optimizing generics can make a significant difference in a plan sponsor's drug trend. In addition, plan participants can benefit from appropriate generic use according to their plan benefits. In short, generics are one of the fastest and most effective ways to reduce healthcare costs. While many decisions influence which specific drug might be used in any given situation, Kerr County can count on Caremark to optimize generics appropriately every step of the way and in accordance with its organization's goals. Page ~ 29 Generic Program Outcomes Outcomes include: • Mail service DAW calls/faxes to physicians: 35% conversion rate from multisource brands to generics • Retail DAW letters to physicians: 16.5% conversion rate from multisource brands to generics • Generic Uptake Program: 55% conversion rate from multisource brands to generics • Projected iScribe use: .8% to 1% increase in generic dispensing rate. 33. What financial advantage would KERR COUNTY gain if we limited the pharmacy network to several large chains? Could exceptions be made in outlying areas? Caremark is only offering their National Network at this time. 34. Is electronic billing available? Reports on line? Is an interactive website available? Can members compare pricing of drugs on line? Yes. The following options are available to clients for reimbursement to Caremark: • Wire Transfer -This is a method of electronic funds transfer whereby the client initiates a wire to Caremark's designated bank account. • Automated Clearing House (ACH) llebit -This is a method of electronic funds transfer whereby Caremark instructs their bank to debit the client's bank account for the amount due. These funds are then transferred to Caremark's bank account. This method is available on a regularly scheduled basis. • Automated Clearing House (ACH) Credit -This is a method of electronic funds transfer whereby the client initiates the ACH from its bank account to Caremark's designated account. • Payment By Check -The client generates a check on its bank account and sends the check to Caremark's designated lockbox. The client is informed of the amount due by invoice sent via first class mail, fax, or secured Internet image. Payment is made by check within 10 days of the date shown on the invoice. Claim deposits may be required to cover their cash exposure for disbursements made to the pharmacies. Payments by wire transfer, automatic clearing house (ACH), and electronic funds transfer (EFT) are due on the date shown on the invoice. Terms are 48 hours for claims. Caremark's financial services professionals will assist in the review of the various claim payment methods to determine the most appropriate method for Kerr County. Any financial security requirements will be determined by a review of Kerr County's audited financial statements. Online Reporting Caremark offers an online report viewing tool called OnDemand Reporting. OnDemand will help Kerr County manage plan performance by providing instant access to production reports online. In addition, this easy-to-use Internet-based application will enable Kerr County's staff to conveniently access production reports. Following are some of the benefits of Caremark's OnDemand Reporting system: • Convenient Internet access to documents • No delay in paper production and delivery • Ability for multiple users to view the same document, each using an assigned logon ID and password Page ~ 30 • Search capabilities that help the user find specific information Ability to zoom in on areas of the report for easier viewing • Full printing capabilities • Ability to copy pages to file • Ease of learning and use. In order to access documents that reside on Caremark's computer system through OnDemand Reporting, Kerr County will be assigned a valid logon ID and password. In the case of multiple users, each individual user will be required to have his or her own logon ID and password. Caremark will provide initial logon IDs and passwords to individuals specified by Kerr County. Caremark's Website Caremark's main Web site, www.caremark.com, is the portal through which clients, plan participants, clinicians, and investors can obtain detailed information about their organization and the services and programs they offer. The main entries of their corporate site include the following: Online Pharmacy Services for Plan Participants Prescriptions and Benefits Prescription and benefit information is personalized for users at the plan level. This means that plan participants who log onto the site are provided with accurate information specific to their plan, such as drug costs and formulary information. Plan participants are able to: • Order mail service refills online • Submit new mail service prescriptions online (expected to be available in 2007) • Request information on a new prescription • Check drug coverage and price, including therapeutic alternatives • View online drug list • View benefit information • Check order status • Check drug interactions (Gold Standard Multimedia) • Search drug information (Gold Standard Multimedia) • View 24-month drug history • Find a local pharmacy (client network-specific) and access maps/driving directions • Download forms (claim and order forms) • Access CaremarkDirect (purchase non-covered prescriptions through Caremark's Mail Service) • Gain a-mail access to Customer Care Center • View secured plan member messaging via the plan member's online Message Center • Read a-mail alerts regarding available refills, expiring refills, and shipped prescription refills • Set a-mail alerts • Access the Savings Center, an application that proactively identifies savings opportunities and messages the plan participant. By accessing the Web site, plan participants benefit from: • Enhanced personalization • Enhanced single sign-on • Service-based eAlerts with embedded savings messages • Integrated Health Record -This interactive tool pulls together self-reported data from plan participants with claims history and other inputs to provide a more comprehensive look at risk among the membership (fee based/pilot in 2007, delivery in 2008) Page ~ 31 • Medicine Cabinet -This tool, which will enable plan participants to keep track of all prescription and OTC medications, is combined with an interaction checker to help users ensure safety with their medications (expected delivery in 2008). Health and Drug Information Caremark offers plan participants a comprehensive health and wellness section on Caremark.com, including content produced in-house as well as content aggregated from best-in-class third-party vendors. This award-winning offering provides plan participants with valuable information to help them better manage their own health and conditions in addition to their medication regimens. In 2007, Caremark will begin weaving content throughout the site to provide users with access to critical information when they need it most, enabling plan members to: • Utilize 19 self-care centers and dozens more condition centers to find valuable information quickly • Access Caremark's "Ask A Pharmacist" interactive feature • Access hundreds of frequently asked questions • Access interactive tools, quizzes, animated guides, calculators, videos, and podcasts • Read 2,000 plus articles written by Caremark's award-winning editorial team • Read more than 30,000 health and welfare articles provided by best-in-class third-party vendors • Find answers in a comprehensive Drug Center that provides information on the safe use of medications, questions to ask your doctor, and understanding potential risks and side effects of medications. Plan Sponsors Client Care Access • Single sign on access • Client specific messaging • RxPipeline information. OnDemand Reports • Access standard client reports • Save and print reports • Search for information within the reports. Client Online Services • Manage plan participant eligibility maintenance - Coverage dates - Plan coverage - Plan participant demographics (date of birth, address, etc.) - Plan participant profile information. • Review prescription history in real time (financial and prescription detail) • Manage pre-authorization maintenance • Process test claims to predetermine benefits • View account balances (deductible, out-of-pocket, and maximum benefit accumulations) • Access explanation of benefits inquiry • Locate pharmacy • Manage Medicare benefits. Page ~ 32 Client Open Enrollment Site • Access co-branded Web site(s) that include a pharmacy locator, selected Caremark Drug List, and basic plan design information. Client Personalization • Access drug payment and coverage (client contribution and annual cost) • Access benefit summary with custom verbiage and link • View customized plan participant FAQ section • Access display of custom logos and customized messaging. Specialty Pharmacy Services • Access Condition Overview • Access condition-specific educational information • Access Caremark enrollment form • Access online refill capability • View treatment information • Access links to related health Web sites • Access specialty centers with health and wellness content related to specialty conditions. Investor Information • Access Caremark's Annual Report, letter to shareholders, or proxy notice • Learn about their executive management team • Request financial information -historical price lookup, cost basis information, earnings estimates • Link to other sites to obtain stock prices, read the latest news or press releases, or review Caremark's SEC filings • Sign up for automatic a-mail stock quotes, SEC filings, and news releases • View calendar of corporate events • Access frequently asked questions. Company Overview • View company history • View mission statement • View guiding principles • View executive leadership. Health Professionals • Access TrendsRx Alert • Access TrendsRx Drug Pipeline and News • Access TrendsRx Quarterly • Access Clinical Update • View Drug Lists • View Participating Pharmacy Administrative Manual • Access NCPDP Version 5.1 Payer Sheet. 35. Will the PBM provide assistance with developing a communication piece? Yes. Kerr County will receive assistance from Caremark's experienced Communication Specialists during implementation to determine the most appropriate and effective strategies for employer group Page ~ 33 and participant communications. Caremark offers Kerr County great flexibility in tailoring a participant communication plan to meet its objectives. As part of the implementation planning process, your account services team -including an Implementation Manager and a Communications Professional -will be available to discuss the various err" options. Their team approach will enable them to plan and design a comprehensive communications program, ensuring as smooth and seamless a transition to their company as possible. After implementation, continued support will be provided in evaluating the program's effectiveness over time. 36. Provide all materials used in marketing your product. Please see Attachment "I" for a sample Benefit Communications Booklet, and Attachment "J" for a Participant Brochure. 37. Do your administration fees include the following: a. Postage (in D below) Kerr County will be responsible for the postage required to mail materials directly to plan participants' homes. b. Claim forms Caremark confirms. Caremark provides standard claim forms (free of charge) online and in hard copy, to any participant when the need arises to file a paper claim. c. ID cards, (medical/rx combo cards?) Yes, our administration fee includes the ID cards for the participants. d. Mailing to participants homes Kerr County will be responsible for the postage required to mail materials directly to plan participants' homes. e. Participating provider directories Caremark confirms. A provider directory can be found on Caremark's website at www.caremark.com. f. Customer service representatives specific to KERB COUNTY. Caremark will designate a Customer Care Team to service Kerr County's plan participants. They will determine staffing for this team through the use of a staffing model that considers both prescription volume, as well as the complexity level of Kerr County's plan design(s). g. Mail order forms Caremark confirms. h. 1 - 800 number to call center Caremark confirms. Standard report packages Caremark confirms Page ~ 34 38. Does your plan currently offer on-line access to claims and eligibility information for employees? Is there a separate charge for this to the plan? Yes. Caremark's Client Online Services online system is an innovative Web-based system that enables plan sponsors to proactively manage pharmacy benefits, at an individual level, for their member ``r+' population. Users no longer have to send paper updates and changes to Caremark. Real-time additions and updates can be entered directly into the Client Online Services~~~ system and are effective immediately. The Web-enabled system can be accessed from any PC with an Internet connection and provides real-time data. This service is available for no additional cost. Because it provides ready access to such information, the Client Online Services"' online system helps plan sponsors better serve their plan participants. It also provides greater convenience, e.g., sponsors can handle exceptions promptly and accurately before the plan participant visits the pharmacy. With Client Online Services", users can perform the following functions: • Eligibility Inquiry -View current eligibility information. Eligibility Maintenance -Within this function, the user can: - Add new plan participantldependent for individual updates. - Extend coverage for plan participant/dependent individual updates. - Terminate coverage for plan participant/dependent individual updates. - Change coverage codes (family coverage to individual). - Change plan participant/dependent personal information (name, date of birth, etc.). • Plan Benefit Override (Pre-authorization) Maintenance -Override general plan design limitations for an individual such as days' supply limitations, co-payment amounts, or refill restrictions. • Plan Benefit Override (Pre authorization) Inquiry -View any plan design overrides for an individual. • Claims History -View all prescription transactions for plan participants and dependents, including denied claims. • Accumulated Balance Summary -View financial details such as paid claims history and accumulated summary, • Test Claims -Perform simulation claim adjudications to verify pharmacy benefit exceptions and coverage. NOTE: Caremark clients utilizing the Web-based Client Online Services° system are accountable for all revisions, additions, and terminations made under authorized Caremark User IDs. Records maintained via the Client Online Services° system will remain activeleligible until the record is either manually terminated or provided on an eligibility tape with termination date. 39. Will any revenue be paid to a third party administrator for services, fees, disease state management or other vendor services by the PBM? Will all compensation to third parties be disclosed? Is an implementation allowance paid to the payor? If so, how much per member or head of household? Caremark furnishes the core PBM services to be provided to Kerr County and does not have a strategic alliance or subcontract arrangement for such services. 40. Will you audit the pharmacy data? Specifically, as a payor, what independent source will audit claims? What are the fees associated with an independent audit? Caremark will allow the client or a mutually agreed upon independent third party to conduct an annual claims audit of Caremark data for the prior contract year upon no less than sixty (60) days prior written notice. Client acknowledges that as a part of the claims audit it shall not be entitled to audit: (i) Page ~ 35 documents that Caremark is barred from disclosing by applicable Law or pursuant to an obligation of confidentiality to a third party; and (ii) agreements with vendors, pharmaceutical manufacturers, or distributors, participating pharmacies or other providers of products or services to Caremark. Caremark will permit a mutually agreed upon independent third party to audit a reasonable sample of ~` records and contracts on behalf of client directly related to its specific rebate program once each 12- month period, following 60 days' prior written notice. Such audits, performed at client's expense, can include formulary and rebate provisions to the extent permitted by their contracts with manufacturers and will be limited to information necessary for validating the accuracy of the rebate amounts distributed by Caremark to client. Any mutually agreed upon third-party auditor engaged by the client shall execute a confidentiality agreement with Caremark in a form and substance acceptable to Caremark prior to conducting an audit. 41. Will you provide consultative modeling and forecasting annually? Caremark has a benefit modeling tool available that would aid Kerr County in designing and rating benefits. Modeling Tools Your experienced account services team will utilize advanced tools to provide plan recommendations, including benefit design and analysis support. The team will be fully supported by Caremark's plan. This level of support and their unique benefit design tools are unmatched by any other pharmacy benefit manager. Plan Design Model The Plan Design & Performance Model is a consultative tool that enables Caremark's sales personnel to measure the financial impact of various plan design changes and assess clients' plan performance. Through its automated data retrieval system, it provides quick answers to complex plan design questions. The model was designed with the intention of matching client goals with Caremark products and services. The Plan Design Model feature forecasts client-specific savings for individual - or combinations of - plan design changes for both retail and mail service claims. The Plan Performance Summary feature is a reporting tool that enables Caremark sales personnel to capture the client's key statistics and compare them to the client's previous performance or to Caremark's peer clients. Performed during the first quarter of the new plan year, the RxInsights''`' annual review is designed to assist clients in managing their prescription drug benefit. Caremark will provide a comprehensive analysis of Kerr County's plan performance that includes both financial and non-financial information. Their Rxlnsights"~ annual review will supply Kerr County with comparative information about their plan from year-to-year, as well as illustrate how the plan compares to industry trends. In addition to analyzing the data, the review will focus on the clinical aspects of the plan, thus providing Kerr County with a broad and extensive information base from which decisions regarding the program can be made. The Rxlnsights`~' annual review will provide significant support for Caremark's consultative approach to account management and will enable Kerr County to make fact-based plan design and new program decisions. Caremark's Account Management Team will make plan design recommendations based on the results of the RxInsights® annual review. Team members can also suggest programs or initiatives that focus on Page ~ 36 issues unique within Kerr County's plan, reduce overall healthcare spending, and improve health outcomes. In addition, individuals from Caremark's clinical support team, Trend Management Department, as well as from other areas within the company, may participate in the RxInsights® annual review with Kerr County to offer their expertise and analysis. 42. Will atrue-up of guarantees be performed annually? If so, when can KERB COUNTY expect payment of true-ups above guarantees under transparency model? In a traditional model, the pricing variability is eliminated by applying the guaranteed discounts at the point of sale. This model eliminates the back-end reconciliation and "true-ups" typically associated with the transparent contracts. PBMs generally offer more aggressive guarantees because incentives are more aligned around generics dispensing, and PBMs have the opportunity to be rewarded for over- performing on guarantees. In a transparent model, the actual pricing components are variable and require aback-end reconciliation and "true-up" to compare the actual performance against the guarantee. PBMs typically offer less aggressive guarantees with this model because they assume only downside risk. 43. Will the mail service provider provide to KERB COUNTY copies of their suppliers (wholesaler or manufacturer) invoices showing net invoice for medications? Acquisition cost at mail and specialty is Caremark's confidential and proprietary information and is not subject to disclosure. 44. Will your firm detail its total revenue from all sources for administering the KERB COUNTY pharmacy benefit plan and allow an independent audit by the KERB COUNTY? Caremark may receive fees or other compensation from pharmaceutical manufacturers for services rendered and property provided to pharmaceutical manufacturers including administrative fees not exceeding three (3) percent of the AWP of the products dispensed across Caremark's book of business. In addition, Caremark may receive concurrent or retrospective rebates or discounts from pharmaceutical manufacturers and distributors which are attributable to product purchases for prescriptions dispensed by its mail or specialty pharmacies, service provision, market share or other factors. These amounts are paid to Caremark for performing services on behalf of the pharmaceutical manufacturers and are not allocated in any way on aclient-specific basis. The term "rebates" does not include these fees, compensation, and discounts, which belong exclusively to Caremark. 45. The 3 fmalist will be required to make a presentation to KERR COUNTY and answer questions to fully explain the specifics of the program offered. Caremark confirms. 46. Will your firm contractually guarantee that the amount you reimburse to pharmacy providers is the exact same amount that is billed to the plan sponsor? For the traditional offer, the proposed retail rates do not necessarily reflect the pharmacy contracted rates, and Caremark may retain the difference. For the transparency offer, the amount billed to the client will be equal to the amount paid to the pharmacies. ATTACH A SAMPLE DRAFT OF THE PBM CONTRACT Not available at this time. Page ~ 37 Cafeteria Plan Administration 1. Name, address, city, state, zip code and telephone number of home office of firm. Branch office location(s), if any. Insurance Management Services 731 N. Taylor Amarillo, TX 79107 Toll Free- 1-800-687-5944 Local- 806-373-5944 2. Is your company awholly-owned subsidiary or a division of another company? If so, please identify the company name and address. In addition, please list all owners (if not publicly owned), and all affiliated companies. Insurance Management Services is not a subsidiary or division of another company. 3. Have any principals of the firm ever been named in a lawsuit dealing with the management/administration of a Section 125 Cafeteria Plan? No, none of our principals have ever been named in a lawsuit dealing with our management or administration of a Section 125 Plan. 4. How many clients are currently served? Please provide the largest group, the smallest group and the number of employees covered. We serve 145 clients with an average of 186 employee lives, or 333 covered lives. 5. What is the maximum processing time that will occur between receipt of claims and reimbursements to the members? Our current average processing time is 15 days. 6. What is the size of your staff? IMS has 100 full-time employees and 5 part-time employees. 7. List staff experience of the employees that will be handling Kerr County's account. IMS had two full-time employees who are dedicated to our Cafeteria Plan Administration. These two, both have a number years experience working with FSA's, HRA's and HSA's. 8. List the office location intended to service Kerr County. Insurance Management Services 731 N. Taylor Amarillo, TX 79107 9. Is there a toll free number for employees and/or Kerr County to speak to a customer service representative? If so, what are the hours? Our toll free number is 1-800-687-5944, customer service representatives are available Monday through Friday 8:30-S:OOpm central time. 10. Does your firm perform discrimination studies as to eligibility, contributions and benefits under the plan? If so, how frequently? IMS will run discrimination tests at the request of the plan holder. 11. Does your company offer debit card services? If so, please explain in detail. We offer a debit card for use with our Section 125 flexible spending accounts. This card gives participants the ability to utilize their flex benefits without having to submit a paper claim. The debit card requires a minimum of 20% of total annual elections at all times for those who elect the debit card feature. Page ~ 38 ADMINISTRATION 1. Describe the computerized system used to collect, assimilate and integrate the data of the program. Our Section 125 software is the same program we utilize for claims payment, GBAS. This is a fully integrated software package that contains claims, customer service, eligibility, accounting, and Section 125 modules. 2. Provide a sample of your Administrative Service Agreement. Please see attachment "K" for our sample Administration Agreement. 3. Provide a sample of your Plan Document. Please see attachment "L" for a sample of our standard Plan Document. 4. Describe your capabilities for Direct Deposit. We do have direct deposit capabilities for flexible spending accounts. 5. Provide samples of worksheets and/or any materials that will be provided to Kerr County for educational purposes. Please see attachment "M" for our Marketing Material that will be provided to Kerr County at no additional cost. 6. Describe your process for entering enrollment information into your system. Most groups choose to enter their eligibility data electronically via the IMS website or through a data download. However, some groups do still send eligibility information in hard-copy form. The eligibility administrator manually enters the information when it is received in paper form from these groups. 7. What electronic or Web-based services does your company offer? Can claims be filed via fax or through other electronic means? Do you charge additional fees for this service? We do accept claims via fax or paper, and do not charge additional fees for this service. Flexible spending account balance information is available to the participants on our website. 8. Does your firm provide monthly, quarterly, or annual account statements directly to the participating employees? If so, please explain in detail the process and if there are any additional fees associated with Employee Account Status statements. Account statements are issued quarterly to the participant and monthly to the group. There are no additional fees for account statements. 9. Provide a sample of Section 125 reports generated for employees and Kerr County. Provide a sample of any other reports that you believe may be useful to Kerr County on a regular basis. Please provide sample reports that would be utilized for bank reconciliation. Please see attachment "N" for our sample Section 125 reports. ORGANIZATION STRUCTURE 1. Any Administrator must have filed and be approved with the State of Texas. If a TPA is later rejected by the State, it will be considered grounds for dismissal. 2. Is your organization for profit or non-profit? Insurance Management Services is a for profit organization. Page ~ 39 3. Are you an affiliate of an insurance carrier or independently owned and managed? Insurance Management Services is independently owned and managed. 4. If you are a multiple site organization, are certain services delegated to specific locations or are all services available at any location? IMS does not have multiple locations. LIABILITY PROTECTION & BANKING REFERENCE 1. Please disclose the amount of liability insurance protection currently in force. The selected Administrator must provide confirmation of coverage. IMS currently carries $1,000,000.00 Errors & Omissions insurance. Please see attachment "A" for a copy of our E & O policy. 2. Is the company and all employees bonded? If so, please provide details. IMS Fidelity Bond coverage is with Zurich American Insurance Company. Coverage limit is $1,000,000.00. 3. Are employees covered by workers compensation insurance while performing services on site at Kerr County? a. { }Yes { X }No PRICES/FEES 1. Provide schedules of fees for each Plan. Indicate whether fees or services are contingent upon the sale of any products to Kerr County and the conditions under which the products would be sold. For a complete detailed listing of our prices and fees please see the section entitled "Proposal". 2. Are the fees due payable on the first of the month, quarterly, annually or combination of these? All administration fees are due on the first of every month. 3. Is a fee structure available that incorporates various levels of participation? Yes, we charge aper-participating-employee fee. This fee can vary depending upon whether the participant chooses to utilize the debit card. 4. Do you intend to receive any commissions from the vendors servicing Kerr County? No, we charge an admin fee for these services. 5. Explain any methods to be utilized to control expense. We have edits in our claim system that ensures that only eligible 213 expenses are reimbursed. 6. Provide a fee for administering the Medical and Dependent Care Spending Accounts with and without a Debit Card option. Our administration fee for these services is $5.00 per participating employee per month with or without the debit card. HISTORY Page ~ 40 1. Briefly explain the development of your organization and your corporate business objectives. IMS was formed in June, 1983, with a mission of offering unequalled service for the Self Insured Health Benefits Market. Over the years, due to this commitment to excellence, our organization has continued to grow. We now have three companies providing administration service for over 50,000 covered lives. 2. Explain how long you have been in business and how long you have been providing Section 125 Administration services. IMS has been in business and providing Section 1.25 services for 24 years. UNIQUE CHARACTERISTICS 1. What do you feel is unique about your firm that will offer the best value to Kerr County for Section 125 Administration services? [MS provides full administrative services as quoted, monthly reporting, custom reporting as requested, and plan reviews as requested. IMS will continue provide the outstanding customer service we are known for. 2. Please comment on any other characteristics of your organization that are considered unique in the industry. IMS will work with the County to implement cost savings methods or plans for future periods. We will keep the District apprised of developments in the insurance industry and will be prepared to administer any programs that tit the District's vision. In the 24 years IMS has been in business, we have developed a business model to manage claims which results in the highest possible savings and superior customer service for our clients. This is evident through 98% business retention. WELLNESS AND PREVENTION QUESTIONNAIRE: 1. Provide an executive summary of the wellness services you provide. '~/` The WorldDoc Prescription Plan Audit Service & employee wellness website is available. Please see Attachment "Q" for a program explanation, and the full program offerings are more fully described in the recommendation section below. This service can only be accessed by using the Caremark drug card. WorldDoc Wellness Program services include: For the Employee WorldDoc 24/7 Health Management System for each employee and dependent on the plan: • Personal Health Assessment (health risk assessment) • Chronic Condition Assessments • Personal Evaluation System • Medical Library • Rx Comparison Tool • Personal Health Record • Healthy Living Program • Rx Data Imports • Refill Reminders • Generic Reminders • Medication History - Rx claims display • 24/7 Nurse Line For the Employer Page ~ 41 RX Data Integration & Reporting • Quarterly Aggregated Utilization & Health Reports • Quarterly Pharmacy Financial Rx Claims Review (audit) • Claim-based intervention analysis via employee mail outs. • Population Health Stratification Analysis 2. Are wellness and prevention medical services your main line of business? If not, please explain in detail where and how wellness fits into your business plan. No, as primarily a medical claims payor for many years, IMS has always looked for additional means for our clients to save money. To that end, we have been offering Disease Management & Wellness Programs for the last few years. These programs are proven to help lower overall healthcare costs for our clients. HEALTH RISK ASSESSMENT (HRA) SERVICES: 1. Describe the Health Risk Assessment (HRA) tool your organization offers. Please attach a sample. IMS has partnered with an industry leading care Management Company to deliver an integrated package of Wellness services to its client base with a focus on providing its members with tools to modify their behavior. The WorldDoc system is designed to assist users in self-care as well as dealing with the health needs of their spouses, children, parents, or other family members. WorldDoc helps consumers make better healthcare decisions. Asa result, employees and employers save costs through healthcare education, prevention and individually tailored wellness initiatives. See attached HRA sample questions. 2. In what languages are your HRA, website, and employee materials available? Our materials for HRA are available in English and Spanish. 3. What is the average participation rate for your clients? Of all employer HRA plans, participation is around 95%. 4. Explain your experience designing incentive systems to drive participation, including your most successfully designed incentive program. Please see attachment "Q" for incentive systems. 5. Please complete the grid below with a checkmark or specific answer if your HRA includes the feature described. Please see below. 6. How often do you recommend that the members have an HRA? At least annually, however, we prefer semi-annually. 7. Please describe turnaround time for each of the following areas: a. Providing the HRA results to individuals. Response for HRA is immediately upon completion of the HRA b. Contacting individuals for possible interventions. Our program will contact members within 30-45 days, and periodically throughout the year depending on interventional programs that are implemented Page ~ 42 c. Providing Kerr County with a summary report of the initial HRA results. As soon as HRA is completed, a summary report can be supplied within 10 working days, and then quarterly to the client. 8. Please describe how your company would communicate with individuals to assist them in understanding how to utilize the HRA and how to interpret the results. IMS Managed Care would communicate with individuals about initiating the completion of the HRA through several different avenues, including direct communication via direct mail, or through a Health Fair, or by phone. 9. Describe how your company will set and reach HRA participation goals? The IMS Managed Care Wellness Coordinator would work with the Client/Employer group to set goals achievable based on the demographics of the client. Most groups are encouraged to have a Wellness committee, and had a dedicated "Wellness Champion" to support the goals of the company. Setting goals is completed through a team approach and will involve IMS Managed Care and the client. 10. Do you recommend using incentives? If so, please describe sample incentives your company might recommend. Incentives and Disincentives are very appropriate when starting a Wellness Program. Incentives may include free testing for the "Know Your numbers" campaign. Also disincentives may include increase premium fees, or increased deductible for failure to meet stated company goals. Incentives and Disincentives should be organized around the goals of the company, and appropriate for the population of individuals. 11. How is the individual's HRA record updated in working with the disease management staff? HRA are updated as often as the individual requests to update the HRA. This information is current, and is available to the UM staff from retrieval from the system at any time. 12. Do you monitor and report individual HRA changes from year to year? When the member makes changes to the HRA, the member may print the HRA at any time. Cumulative data is tracked and can be reviewed by the company as a whole as often as quarterly Page ~ 43 HRA PRODUCT FEATURE Included? Web-based HRA Yes Pa er-based HRA Can be rinted Biometric clinic based Can be included Provides information on confidentiali Yes Provides information on how data will be used Yes DATA COLLECTED Health status Yes Chronic conditions Yes Famil health histo Yes Medications If provided, es Lifestyle risks Yes Safe Yes Preventive exams Yes Immunizations Yes Biometrics Yes Readiness to thane Yes INDIVIDUAL RESULTS High-risk clinical situations are identified and appropriate steps can be taken for immediate intervention. Yes Score communicated Yes Focus/ riori of individual's health/lifes le areas are communicated Yes Health im rovement recommendations are made Yes Action ste s rovided Yes Can o to s ecific to its within web site ~ Yes Summ re ort is available online Yes Summ re ort can be rinted Yes Links to additional health information are available Yes Provides information or links to risk reduction ro ams es Employer can customize messages on their URL to include references and links to internal ro ams or other vendors Yes EMPLOYER REPORTS Web-based/electronic re orts available Re orts can be rinted Yes Lifes le risks are re orted Yes Health status are re orted Yes Chronic conditions are re orted Yes Page ~ 44 IMPLEMENTATION & COMMUNICATION STRATEGY: 1. Please provide a proposed communication plan for introducing an onsite wellness program and reference the ongoing communication process. Outline your company's responsibilities in these processes. Please include copies of your educational materials and timelines for distribution. See Attachment "Q" for this information. 2. How can employees communicate with the medical team? Employees may communicate with the Nurse assigned to the Wellness program, or they may contact the 24 nurse line - if this service is made available to them. 3. Discuss the frequency and type of communications that eligible persons will receive throughout the program period. Members will receive information automatically on areas of concern (HRA driven) 2-3 times per month via email. Additional educational information and program information can be disseminated via direct mail, or posters, as often as monthly. 4. Provide your web address and any access codes needed to explore your services. You may visit our website at: www.imstpa.eom 5. How would you suggest reaching spouses? Spouses and eligible dependents can be reached through the program, if the program is designed to include those individuals. Page ~ 45 Kerr County ~"` Health Benefit Plan Proposal 2008 Contents • A-Errors and Omissions Coverage • B -Subrogation Letters • C -Excess Carrier List • D -Sample Report Package • E -Sample EOB • F -Caremark Drug List • G -Caremark Standard Report Package • H -Caremark Specialty Standard Report • I -Caremark Benefit Communication Booklet • J -Caremark Participant Brochure • K - Admin Agreement • L-Standard Plan Document • M -Marketing Material • N -Sample Section 125 Reports • O -References • P -World Doc Program Information • Q- HRA Information `atiSURAti'c ~'~~ AMERICAN INTERNATIONAL SPECIALTY LINES INSURANCE COMPANY ~ y A Capital Stock Company {herein called the "Company"} ~MPAN 175 Water Street A Member Company New York, N.Y. 10038 of American International Group, inc. POLICY NUMBER: 965-I6-38 REPLACEMENT OF POLICY NUMBER: 494-51-74 THIS 15 A CLAIMS MADE POLICY-PLEASE READ IT CAREFULLY THIRD PARTY ADMINISTRATORS PROFESSIONAL LIABILITY INSURANCE POLICY NOTICE: THIS INSURER 1S NOT LICENSED IN THE STATE OF NEW YORK AND IS NOT SUBJECT TO ITS SUPERVISION. NOTICE: THE LIMITS OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR LEGAL DEFENSE. FURTHER NOTE THAT AMOUNTS INCURRED FOR LEGAL DEFENSE SHALL BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT. DECLARATIONS Item 1. Named Insured: IMS MARKETING, INC. Address: 817 S. POLK, SUITE 101. P.O. BOX 15688 AMARILLO. TX 79101 Item 2. Policy Period: From: October 21, 2006 To: October 2I , 2007 (12:01 A.M. standard time at the address stated in item 1) Item 3. Limits of Liability: linclusive of defense expense}: $1.000,000 each wrongful act or series of continuous, repeated or interrelated wrongful acts $I , 000.000 aggregate Item 4. Deductible: $50, 000 each wrongful act or series of continuous, repeated ar interrelated wrongful acts item 5. Premium: $29.864 7I9197I 52948 (1192) ORIGINAL 1 Item 6. Retroactive Date: October 1. 1989 Producer. CAPITOL SPECIAL RISKS Address: 1899 POWERS FERRY RD SE STE 100 ATLANTA , GA 3 0339- 5553 ~~.~ 7191971 AUTHORfZED REPRESENTATIVE Or Countersignature Iln states where appficabfel 52948 (1 / 92) //~J$(f 2 ^ r INSURANCE MANAGEMENT SERVICES PHONE 806.373.5944 P.O. 80X 15688 AMARILLO, TEXAS 79'EQ5 EMPLOYEE SUBROGATION RE: Insured: John Smith Claimant: John Smith Group: ABC Company Dear Mr. Smith: We represent ABC Company employee benefit plan that provides your medical benefits. This plan includes a "Subrogation" provision. This provision, which helps to control the cost of your benefit program, permits recovery of benefits paid as a result of negligent third parties. Information provided with your claim indicates that the expenses may have resulted from injuries or illness due to the negligence of a third party. Under the plan provision described above, there is no coverage for such expenses to the extent that they are reimbursable as a result of third party liability action. However, the plan does allow temporary benefits to be paid on such claims pending t12e results of a third party liability action. In order for provisional benefits to be paid on an ongoing basis, the following information must be submitted by you to our offtce: * Reimbursement Agreement: The enclosed agreement should be signed by you and the injured party if a dependent, indicating your agreement that, should a recovery be realized from a negligent third party, the plan will be reimbursed. '~ General Liability Information/ Motor Vehicle Accident: All questions on the enclosed questiorulaire must be completed in full. This will enable us to determine whether your claim would be subject to the subrogation provision and, if so, what actions should be taken by us to assure that your claim is processed in accordance with this provision. Should you have any questions regarding the Subrogation Provision or this letter, please feel free to contact us. Sincerely, Claims Department Enclosures: Reimbursement Agreement Questionnaire '~/ INSURANCE MANA~E~IENT SERVICES PHONE 8l)6-373-5944 P.O. BOX 15688 AMARELLO, TEXAS 79165 ATTORNEY SUBROGATION May 26, 2004 Frank Fertita Attorney at Law 8550 United Plaza Blvd, Suite 204 Baton Rouge, LA 70809 Insured: John Smith Claimant: John Smith Group: ABC Company Date of Accident: 09/13/2003 Dear Mr. Fertita: We represent the ABC Company 1-Iealth Benefit Plan which insures John Smith. The plan includes a provision which permits recovery of medical benefits paid as a result of the actions of negligent third parties. Enclosed for your review is a copy of the portion of the plan which addresses Subrogation. Also enclosed is a reimbursement agreement signed by Mr. Smith. Please construe this letter as formal notification of the plan's lien against any third party recovery for the above loss. We would also appreciate your arranging to copy us on all pertinent communication. Upon request, we will supply copies of the payments made and charges incurred. Thank you for your anticipated cooperation in this matter. Respectfully, Claims Deparhnent Enclosures: Copy of Plan Document page Copy of Reimbursement Agreement cc: Insured INSURANCE MANAGEMENT SERVICES PHONE 80&-373-5944 P.O. BOX 75688 AMARILLO, TEXAS 79105 THIRD PARTY SUBROGATION May 2G, 2004 Progressive Insurance Company ATTN: Belinda Stewart 434 S. Sheiwvood Forest Blvd, Suite 290 Baton Rouge, LA 70817 Your Insured: William Winebreruzer, Benjamin Rodgers Claim Number: Unknown Claimant: John Smith Group: ASC Company We represent the ABC Company Employee Benefit Plan which insures John Smith. The plan includes a provision which permits recovery of medical benefits paid as a result of the actions of negligent third parties. Enclosed for your review is a copy of the portion of the plan which addresses the right to recover. Also enclosed is a reimbursement agreement signed by John Smith. Please construe this letter as formal notifcation of the plan's lien against any third party recovery for the above loss. In view of the above circumstances, Gve request that you protect die plan's interest relative to any releases and/or payments made as a result oCthe above Ions. If you would like copies of the charges incurred and payments made under the plan, please advise and we will forward the same. I would like to take this opportunity to thank you for your anticipated cooperation in this matter. Sincerely, Claims Department Enclosures: Copy of Plan Document page Copy of Reimbursement Agreement cc: Insured REIMBURSEMENT AGREEMENT AND ASSIGNMENT OF PROCEEDS FROM THIRD PARTIES ~ Name of Plan: ABC Company Name of Participant: John Smith 1 f you are executing this assignment on behalf of another person, state the person's name: N/A and relationship to the Participant: Self Under the terms oftlte Plan, established by ABC Company, benefits paid to a Participant for which such Participant has a claim against any third party are conditioned on the Plan being reimbursed. The Plan requires that no benefits be paid on beltal f of the Participant until the necessary documents are executed to protect the Plan's right of recovery. Based on the information obtained, the Administrator believes that you may have a claim against another person or entity {"third parry") for payment of medical expenses related to the illness or injury caused by such third parry. Therefore, the Administrator must cease making further payments for such expenses until this Agreement is executed. The Plan recognizes that a delay in payment of medical expenses by those who are legally obligated to make such payments may impose undue hardship on you as a Participant. To enable you to satisfy theses financial obligations while at the same time preserving the assets of the Plan, the Plan permits pre-payment of benefits on your behalf if you assign to the Plan the right to recover the amounts advanced froth any proceeds which you are entitled to receive From the third party which is determined to be responsible far payment of such amounts. By executing this Agreement you hereby grant the Plan the right to recover all the amounts, which have been or will be paid on your behalf that are related to the illness or injury caused by the third party. The Agreement means: 1. You assign to the Plan the right to receive reimbursement from any proceeds, which you, or the Participant on whose be}talf you execute this agreement, are entitled to receive from the responsible third party. It does not matter lto~v the proceeds are obtained, what they are called, or whether or not the proceeds indica#e a portion is intended as reimbursement of medical expenses paid by the Plan. 2. You agree the Plan is entitled to reimbursement from the gross proceeds of any such recovery and that such reimbursement must be paid first, before any deductions are made from the gross proceeds to which you are entitled. 3. You agree the amount to be reimbursed to the Plan will include payments made by the Plan before or after the date of this assignment which are for medical expenses advanced related to the illness or injury for which you have a claim against the third party. =1. You agree to notify the Administrator promptly of any action you take seeking recoveries from any third parties or will be advanced under the Plan. You also agree to execute and deliver any documents necessary to assist the Plan to obtain recovery from the persons or entities that are legally responsible. ~. You agree to provide the Administrator all necessary information to allow it to establish the Plan's right to recover under this agreement. The Administrator will notify any person who is or may be legally liable that the Plan has a first lien on the amounts to be recovered. 6. The Plan is not obligated to pay legal or other fees to assist you in suc}t recovery. 7. This assignment may not be revoked after the date on which the Plan first advances benefits pursuant to this Agreement. 3. [f you are executing the assignment on beltal f of another, you certify that you are legally atttitorized to execute this Agreement. It is important that you understand the significance ofthis document. You should consult counsel to ensure that you wtderstand the legal ramifications ofthis Agreement. Your signature below represents that you are a Participant under the teens oftlte Plan or are legally authorized to execute this Agreement on behalf of Participant, and that you assign to the Plan any and al] interest to any recovery ~vlticlt you may hereafter obtain from any third party relating to the illness or injury for which the Plan has advanced medical expenses under the terms ofthis Agreement. Executed this day of Z00_ Signature, WITNESS: Motor Vehicle Accident Third Party Reimbursement 1. Plan members fiill name: Social Security Number:_ ?. Injured Persons Full Name: Relationship to Insl~red:_ 3. Is it correct that the medical treatment received was the direct result of an accident? Yes No 4. Date of Accident:_ Location of Accident: Time of Accident: 5. Did the police investigate loss? Yes No If police investigated, was it city, county, or state police? 6. Did you receive a ticket? Yes No **PLEASE P.ROVfDE A COPY OF THE POLICE REPORT 7. Please give a description of the accident. (Be Specific) ~,r $. Please give the Warne and address of the other driver or drivers. 9. Please give the name and address of the other driver's insurance company. 10. Please give the telephone number and person to contact at the other driver's insurance company. 11. Please give the name, address, and telephone number of your attorney. 12. Have you already filed a claim or received settlement? Yes No 13. No suit or claim will be started because: 14. Other comments: Signature Date REIMBURSEMENT AGREEMENT AND ASSIGNMENT OF PROCEEDS FROM THIRD PARTIES +1rr Name of Plan: ABC Company Name of Participant: John Smith If you are executing this assignment on behal f of another person, state the person's name: NIA and relationship to the Participant: Self Under the terms of the Plan, established by ABC Company, benefits paid to a Participant for which such Participant ltas a claim against any third party are conditioned on the Plan being reimbursed. The Plan requires that no benefits be paid on behalf of the Participant until the necessary documents are executed to protect the Plan's right of recovery. Based on the information obtained, the Administrator believes that you may have a claim against another person or entity ('`third party") for payment of medical expenses related to the illness or injury caused by such third party. Therefore, the Administrator must cease making Further payments for such expenses until this Agreement is executed. The Plan recognizes that a delay in payment of medical expenses by those wlto are legally obligated to make such payments may impose undue hardship on you as a Participant To enable you to satisfy theses financial obligations while at the same time preserving the assets of the Plan, the Plan permits pre-payment of benef is on your behalf ifyou assign to the Plan the right to recover the amounts advanced from any proceeds whicft you are entitled to receive from the third party which is determined to be responsible far payment of such amounts. 13y executing this Agreement you hereby grant the Plan the right to recover all the amounts, whicft Rave been or will be paid on your behalf t}tat are related to the illness or injury caused by the third party. The Agreement means: I . You assign to the Plan the right to receive reimbursement from any proceeds, ~vlticlt yotr, or the Participant on tivltose behalf you execute this agreement, are entitled to receive from the responsible third party. It does not matter how tltc proceeds are obtained, what they are called, or whether or not the proceeds indicate a portion is intended as reimbursement of medical expenses paid by the Plan. ?. You agree the Plan is entitled to reimbursement from the gross proceeds of any such recovery and that such reimbursement must be paid first, before any deductions are made From the gross proceeds to which you are entitled. 3. You agree the amount to be reimbursed to the Plan will include payments made by the Flan before or after the date of this assignment which are for medical expenses advanced related to the illness or injury for which you have a claim against the third party. 4. You agree to notify the Administrator promptly of any action you take seeking recoveries From any third parties or will be advanced under the Plan. You also agree to execute and deliver any documents necessary to assist t}te Plan to obtain recovery front the persons or entities that are legally responsible. 5. You agree to provide the Administrator all necessary information to allow it to establish the Plan's right to recover under this agreement. The Administrator will notify any person ~vlto is or may be legally liable that the Plan Itas a first Eien on the amounts to be recovered. 6. The Plan is not obligated Eo pay legal or other fees to assist you in such recovery. 7. This assignment may not be revoked after the date on which the Plan first advances benefits pursuant to this Agreement. 8. t f you are executing the assignment on behalf of another, you certify that you are legally authorized to execute this Agreement. [t is important that you understand the significance of this document. You should consult counsel to ensure that you understand the legal ramifications of this Agreement. Your signature below represents that you are a Participant under the terms of the Plan or are legally authorized to execute t}tis Agreement on behalf of Participant, and that you assign to the Plan any and all interest to any recovery which you may hereafter obtain from any third party relating to the illness or injury for witiclt the Plan has advanced medical expenses under the terms of this Agreement. WITNESS: Executed this day of Signature, 200_ \rr General Liability 1. Insured Name: SS# Injured Person Name: 2. Date of Accident Time of Accident Were Police or Emergency Units called (Yes or No)? If called, please identify. IF YES, PLEASE PROVIDE A COPY OF THE POLICE REPORT. 3. Location of Accident (in detail) 4. Description of Accident 5. Name and address of the person or persons who caused the loss or are responsible. d. Name, address and telephone number of responsible party's insurance company. 7. The name, address and telephone number of yol~r attorneys. 8. Name, address and telephone number of responsible party's attorney {if available). 9. Will suit or claim be made against the responsible party (Yes or No). If not, please explain why? 10. Other comments Signed: Date, SUBROGATION If a Participant or Dependent has medical expenses as a result of an Injury or accident for which a #hird party is, or may be, held responsible, the Plan Administrator may make advance expense reimbursements to, or payments on behalf of, such Participant or Dependent, subject to the Plan's subrogation rights. However, before any such reimbursements or payments will be conditionally made, the Participant or Dependent (or the Dependent's legal guardian if the Dependent is a minor) shall execute an agreement that acknowledges and affirms (1) the conditional nature of the reimbursements or payments and (2) the Plan's rights or subrogation, as provided for below. If a Participant or Eligible Dependent receives any benefits arising out of an Injury or Illness for which the Participant or Dependen# (or the Participant's or Dependent's guardian or estate) has, may have, or asserts any claim or right to recovery against a third party or parties, then any payment or payments under this Plan for such benefits shall be made on the condition and with the understanding that this Plan will be reimbursed. Such reimbursement will be made by the Participant or Dependent {or the Participant's or Dependent's guardian or estate} to the extent of, bu# not exceeding, the total amount payable to ar on behalf of the Participant or Dependent (or the Participant's or Dependents guardian or estate) from: (1 } any policy or contract from any insurance company or carrier (including the Participant's or Dependent's insurer) and/or (2) any third party, plan or fund as a result of a judgment or settlement. The Participant or Dependent on behalf of himself (or his guardian or estate} acknowledges and agrees that this Plan will be reimbursed in full before any amounts (including attorney fees incurred by the Participant or Dependent or his guardian or estate) are deducted from the policy, proceeds, judgment or settlement. This Plan will be subrogated to all claims, demands, actions and right of recovery against any entity including, bu# not limited to, third parties and insurance companies and carriers (including the Participant's ~,. or Dependent's Insurer) to the fullest extent permitted by law in the appropriate jurisdiction. The amount of such subrogation will equal the total amount paid under this Plan arising out of the Injury or Illness for which the Participant ar Dependent (or the Participant's or Dependent's guardian or estate} has, may have or asserts a cause of action. In addition, this Plan will be subrogated for attorney's fees incurred in enforcing its subrogation rights under this Section. The Participant or Dependent on behalf of himself (or his guardian or estate} specifically agrees not to do anything to prejudice this Plan's rights to reimbursement or subrogation. In addition, the Participant or Dependent on behalf of himself (or his guardian or estate) agrees to cooperate fully with the Plan and Administrator in asserting and protecting the Plan's subrogation rights. The Participant or Dependent on behalf of himself (or his guardian or estate} agrees to execute and deliver all instruments and papers (in their original form} and do whatever else is necessary to fully protect his Plan's subrogation rights. Finally, the Participant or Dependent on behalf of himself (or his guardian or estate) specifically agrees to notify the Administrator, in writing, whatever benefits are paid under this Plan that arise out of any Injury or Illness that provides or may provide the Pfan subrogation rights under this Section. Failure to comply with the requirements of this Section by the Participant or Dependent (or his estate or guardian) may, at the Administrator's discretion, result in a forfeiture of benefits under this Plan. Name of Stop Lass Market Relationship Since preferred Status S metra 1987 Yes HCC Benefits 1992 No Preferred TPA Pro ram Sun Life Financial 1995 Yes IMG-SL 1998 No Preferred TPA Pro ram NBR 1999 Yes AIG 2000 No Preferred TPA Pro ram R.E. Moulton 2000 Yes Mutual of Omaha 2001 Yes Zurich 2003 Yes TPAC Underwriters 2004 Yes SLG 2005 Yes Cairnstone 2006 Yes Chubb 2006 Yes Perico 2007 No Preferred TPA Pro ram IIS 2007 No Preferred TPA Pro ram IISI 1995 Yes INDEX Renewal /Mid-Year Reports • Plan Cost Synopsis • Plan Cost Containment • Average Cost per Employee • Monthly Cost Benchmarks • Network Discounts and Utilization • Plan Summary Monthly Reports • Aggregate • Individual Reinsurance • Top 50 Paid Claims • Top 30 Charge Types • Top 30 Providers • Non-PPO Claims • Payment History • Caremark Quarterly Reports • Average Length of Stay • Pre-Certification Summary • Average Length of Stay for All Groups " ~~ ': lNS ~~~ 5123456 Client: ABCCampnny 01/01/2006 -12/31/2006 Fixed Costs Plan Cost Synopsis Fixed Costs 01/01/2003 -12/31/2003 $300,840.15 Reinsurance PremiumsMUTUAL OF OMAHA ~ - _ - $368,027.00 Administratio= -_ IMS S668,867,15 $332,382.60 Reinsurance PremiumsMUTUAL OF OMAHA $359,44500 Admintstr~ - - iMS $691,827.60 Total Fixed Costs t Tota! Fried Costs Variable Costs Variable Costs Medical Claims $6,18 Medica(Ciaims prescription Claims ~ ~ $710,177.31 Prescription - ~ Reinsurance Reimbursements - Omer Specif+c ($1,006,570.81) Reinsurance Reimbursements _~ Over Specific - -- Total 1 a atr~ 6 el Casts __ _~ ~ ,021,84 Toth! Variable Costs $6,558,888.99 Total Plan Cost ----~ Total Plan Cost Avg_ Total R0: $246 72 Enrollment: E0: b58 7847 EquivalentRa[es: EF: $6L6.80 EF: 623 7475 $4,036,279.52 ~- - $ 1637 OS A9 ($237,083.341 54,436,247 76 ~s,~28,o~5.z~ Avg Total E0: $199.02 Enrollment: EO: 677 1228 Equir'alenl Rates: EF: $49754 EF: 588 7058 Actual reimbursements may vary. Over Specif c reimbursement figures are based on claims over specific which have been filed with the carrrer. Notes: re ate figures aze based on the Calculated Attachment Point, minus monthly claims. Overagg g FSA,Medica,PF~,Prece~bftcafionlCueManagemant Administration fees include c-0b`~'~' °1Se~e Managemen~, ~opsis P~aH ~0st 5y ~ ..-- E ~^ 5123436 DNS Client; ABCC~ o% p1/0112006.12/31~2006 _~~ Medical ClaimsLess AnY germbmsemenis .prescription Claims ministration /A ~geinsurance Premiers 12°I. 01!01/2005 -12131/2005 ~ A~rrinisuation ~geinsurance Premimns the can1er. $ements may vary whichhavebeen~~ledaurth bur monthly claims Actual reim oser s~cific nnclaims minus ti{yna8ement based ent Point, res are Adaebm r,~yt;on~Cssa bursementfr aontheCalculated edlcalP4o.w~em ~iCic reim emmi, pSA, M Aver s4 ures are base ~ gscase~tanaa dotes: peer agBrcgete ~~ cobs . ,~,~„istrationfeeS include Medical Claims Less AnY gemrbursements M `prescription Claims ,, .Y~~ `~ ~iNS Plan Cost Containment ;; U E WINACEMIENT SERVICES Client: ABCCompany 5123456 01/01/2006 -12/31/2006 ToM1 __ Amount % of Total Totn! SubtrdttedChnrges $14,092,976.06 100.00% S°bmittedCharges Ineligible ($2,753,353.45} 19.54% Ineligible Includes duplicate bills, medical claim review, reasonable & customary, and charges not covered by plan. Employee Cast Sharing ($1 179 158 99) Deductible $359,736.87 Co-Pay $0.00 OOP $819,420.12 Discounts* ($3,857,050.55) ABC Clinic $50.00 BeechStreet $51,390.55 PPOofOklahoma $3,193,971.96 OMN[ Networks $22,146.80 PHCS $458,934.62 PHCS Healthy Directions $123,525.25 ManagedCazeDiscounts $7,031.37 Reinsurance Reimbursements ($1,006,570.81) OverSpeci6c $1,006,570.81 Over Aggregate $O.OD OtherSnvings ($33,561.15) COB $33,561.15 Net Paid Claims f $5,263,281.11 COST CONTAINMENT SAVINGS 01/01/2005 -12/31/2005 Amount % of Total $10,414,345.64 100.00% ($2,693,427.35) 25.86% Includes duplicate bills, medical claim review, reasonable & customary, and charges not covered by plan. 8.37% Employee CostShnring $973,504.59) 9.35% Deductible $354,406.01 Co-Pay $0.00 OOP $619,098.58 27.37% Discounls* ($2615127.30) 2511°k BeechStreet $389,916.30 PPOofOklahoma $2,223,805.88 OMNI Networks $556A7 PHCS $849.05 ABC Clinic $0.00 PHCS Healthy Directions $0.00 7.14% Reinsurance Reimbursements ($237,083.34) 2.28% Over Specific $237,083.34 Over Aggregate $0.00 0.24% OtherSnvings COB $114,054.66 37.35% Net Paid Claims f ($114,054.66) 1.10% $3,781,148.40 36.31% 62.65% COST CONTAINMENT SAVINGS 63.69% ' The percentages on this report are based on Total Charges Submitted which include Non-PPO and Ineligible charges, The Network Discount and [Jtilization report shows true network discount percentages based on eligible charges and discounts for each nehvork. '( This report does not reflect voids or refunds, The net paid claims amount is not meant to match the paid claims amount on the Aggregate report. went Phan Cost Contttin t ~ X123456 ~~ anY Client: ABCCD~ o11o1nao~ ,12~~1~00b r csD °unts Cost Sharing ~6mPl0Yee Mlneligibled Claims pNet P vings ether ~~monts /Relmb/~ 2~°~0 380 °~° g~°I° 01/01/2005 -12/31/2005 °unts C°st Sharng ~EmPlOrble ~NetrPaidClaims bother ~~nm ,ts ~Reim~ 25°I0 Utilization repofl shows ~' rietwork discount nelig>ble eharges.'~eNetwotkDiscount and O~dl Non'pp negate report which include the Agg es gubmrtted ount on ,fob} Chang ork, atcl+the paid claimsam rt ue based on for each netw giant to m thrs repo discounts ount is not m es on es and * T'he percentag eligible rararg ~e net paid claims ~` pereentageSbased °n _,.,r does not reflect voids or refunds. 9°I° ! ~ !~ - ~NS NCE MANAGEMENT SERhICES Client: ABC Company Inel Code Inel Description 5123456 Ineligible Charges Breakout Report Date: 01/01/2006-12/3/!1006 515 516 452 509 529 PEN 569 545 534 902 524 508 588 528 447 519 481 513 STU 596 SOl 517 563 581 PRX 572 UNB 526 589 527 498 543 521 IAP 594 CPT 538 592 480 EXPENSE IS A DUPLICATE OF A CLAIM PREVIOUSLY PROCESSED. EXPENSE IS NOT A POLICY BENEFIT NON-PPO HOSPITAL CHARGES W[LL BE REIMBURSED AT 50%OF THE CONTRACTED PPORATES--THIS INELIGIBLE AMOUNT IS THE CONTRACTED PPO RATE. CHARGES INCURRED AFTER COVERAGE IS TERMINATED ARE NOT ELIGIBLE. EXPENSE IN CONNECTION WITH PRE-EXISTING CONDITION. PLEASE REFER TO YOUR ORIGINAL DENIAL. FURTHER ACTION ON THIS CLAIM IS PENDBIG RECEIPT OF ADDITIONAL INFORMATION THIS 1S A POSSIBLE PRE-EXISTING CONDITION. BENEFITS MAY BE LIMITED. INFORMATION REQUESTED FROM THE INSURED HAS NOT BEEN RECEIVED. CHARGES ARE INELIGIBLE AS NO COVERAGE IS IN EFFECT OR THIS DEPENDENT [S NO LONGER AN ELIGIBLE DEPENDENT. PAID FROM COB SAVINGS CLAIMS NOT SUBMITTED WITHIN ELIGIBLE CLAIMS PERIOD CHARGES INCURRED PRIOR TO THE EFFECTIVE DATE ARE NOT ELIGIBLE. MATERNITY COVERAGE FOR DEPENDENT CHILDREN IS EXCLUDED BY YOUR PLAN. PLEASE SUBMIT THE PRIMARY CARRIER'S WORKSHEET. ADDITIONAL PER PERSON M/N DISORDER DEDUCTIBLE HAS BEEN APPLIED. EXPENSE EXCEEDS THE USUAL AND CUSTOMARY CHARGE MEDICAL NECESSITY HAS NOT BEEN ESTABLISHED. CHARGES EXCEED THE MAXIMUM ALLOWED ON THE SCHEDULE OF BENEFITS, OUR RECORDS INDICATE THIS DEPENDENT NO LONGER MEETS THE AGE REQUIREMENT UNDER THE PLAN. CHARGES IN CONNECTION WITH CUSTODIAL CARE, EDUCATION OR TRAINING, OCCUPATIONAL THERAPY FOR MENTAL/NERVOUS CONDITIONS, OR EXPEN EXPENSE EXCEEDS POLICY'S ROOM AND BOARD LIMIT DENTAL EXPENSE OF THIS NATURE IS NOT ELIGIBLE UNDER THE MEDICAL PLAN. EXPENSE NOT APPROVED BY THE PRECERT COMPANY, PLEASE PROVIDE DETAILED DESCRIPTION OF THIS CHARGE. PENDING PRE-EXISTING INVESTIGATION. NO MORE THAN THREE MODALITIES, PROCEDURES, UNITS ALLOWED PER DAY, CERTAIN CHARGES HAVE BEEN IDENTIFIED AS UNBUNDLED ACCORDING TO THE CLAIMS EDIT SYSTEM, CHARGES ARISING OUT OF OR IN THE COURSE OF ANY OCCUPATION FOR WAGE OR PROFIT (WORK-RELATED CONDITIONS) HEARING AIDS ARE EXCLUDED FROM YOUR PLAN. EXPENSE HAS BEEN COORDINATED W[TH THE PRIMARY CARRIER. CHARGES RELATED TO THE TREATMENT OF OBESITY ARE NOT COVERED UNDER YOUR PLAN. PRE-ADMISSION CERTIFICATION WAS NOT OBTAINED, CHARGES INCURRED INCONNECTION W[TH ASELF-INFLICTED BVJURY, ILLNESS, OVERDOSE, OR ATTEMPTED SU]C1DE. THE DIAGNOSIS CODE IS NOT COMMONLY ASSOCIATED W[TH TH[5 PROCEDURE CODE ACCORDING TO THE CLAIMS EDIT SYSTEM. EXCEEDS THE MAXIMUM ALLOWABLE FOR ALLERGY SERUM ACCORDING TO THE PLAN INVALID CPT/CDT OR HCPC CODE. PLEASE REF[LE WITH CORRECT CODE. RENTAL OF DURABLE EQUIPMENT [S COVERED ONLY WHEN MEDICALLY NECESSARY AND ORDERED BY YOUR PHYSICIAN. EYE REFRACTIONS, ORTHOPTICS, VISION TRAINING, VISION THERAPY, OR FITTING OF EYEGLASSES AND CONTACT LENSES (OR RELATED EXAMS) ARE EXC THIS ITEM IS CONSIDERED PURCHASED, Ineligible Amount $1,022,288.51 $349,116.32 $253,778.91 $200,444.59 $178,859.84 $144,386.32 $] 19,173.71 $90,515.17 $57,151.36 $36,859.80 $29,267.56 $27,247.02 $22,191,58 $21,40225 $20,312.24 $18,266.52 $16,970.87 $16,884.95 $14,601.75 $ f 2,377.99 $L2,139 81 $9,183.25 $7,298.01 $6,461.47 $6,455.57 $5,381.36 $3,728 40 $3,674.32 $3,447.46 $3,337.27 $2,934.30 $2,832.22 $2,800.00 $2,500.85 $2,310.10 $1,827.00 $1,723.83 $1,712.02 $1,489 81 $1,466,10 ~' ~V ~ Ineligible Charges Breakout i INS E MANAGEMENT SEIZIIICES Client: ABCCompnny 5123456 ReporlDate: 01/01/2005-12/31/2005 Inel Code Inel Description Ineligible Amoun[ 515 EXPENSE IS A DUPLICATE OF A CLAIM PREVIOUSLY PROCESSED. $1,356,261.46 534 CHARGES ARE INELIGIBLE AS NO COVERAGE [S [N EFFECT OR THIS DEPENDENT IS NO LONGER AN ELIGIBLE DEPENDENT. $251,645.07 529 EXPENSE IN CONNECTION WITH PR&EXIST[G CONDITION. PLEASE REFER TO YOUR ORIGINAL DENIAL. $184,801.37 452 NON-PPO HOSPITAL CHARGES WILL BE REIMBURSED AT 50%OF THE CON"l"RACTED PPORATES--THIS INELIGIBLE AMOUNT IS THE CONTRACTED PPO RATE. $120,781.92 545 INFORMATION REQUESTED FROM THE INSURED HAS NOT BEEN RECEIVED. $100,136.54 569 THIS IS A POSSIBLE PRE-EXISTING CONDITION. BENEFITS MAY BE L[M[TED. $97,619.62 509 CHARGES INCURRED AFTER COVERAGE IS TERMINATED ARE NOT ELIGIBLE. $80,354.99 588 MATERNITY COVERAGE FOR DEPENDENT CHILDREN IS EXCLUDED BY YOUR PLAN. $66,923.00 563 EXPENSE NOT APPROVED BY THE PRECERT COMPANY. $61,606.20 528 PLEASE SUBMIT THE PRIMARY CARRIER'S WORKSHEET. $59,889.68 599 INFORMATION REQUESTED FROM THE PROVIDER(S) HAS NOT BEEN RECEIVED. $50,539.27 587 COBRA PREMIUM HAS NOT BEEN RECEIVED. $37,682.09 508 CHARGES INCURRED PRIOR TO THE EFFECTIVE DATE ARE NOT ELIGIBLE. $29,694.96 578 WE HAVE FILED THIS CLAIM WITH YOUR PRESCRIPTION CARD COMPANY. $25,132,38 527 EXPENSE HAS BEEN COORDINATED W[TH THE PRIMARY CARRIER. $21,868.96 447 ADDITIONAL PER PERSON M/N DISORDER DEDUCTIBLE HAS BEEN APPLIED. $19,513.00 501 EXPENSE EXCEEDS POLICY'S ROOM AND BOARD LIMIT. $15,764.50 513 CHARGES EXCEED THE MAXIMUM ALLOWED ON THE SCHEDULE OF BENEFITS. $13,568.32 PRX PENDING PRE-EXISTING INVESTIGATION. $1 ],799 60 481 MEDICAL NECESSITY HAS NOT BEEN ESTABLISHED. $10,352.83 S l6 EXPENSE IS NOT A POLICY BENEFIT $9,347.60 517 DENTAL EXPENSE OF THIS NATURE IS NOT ELIGH3LE UNDER THE MEDICAL PLAN. $6,956.00 519 EXPENSE EXCEEDS THE USUAL AND CUSTOMARY CHARGE. $6,756.09 543 PR&ADM[SSION CERTIFICATION WAS NOT OBTAINED. $5,500 00 902 PAID FROM COB SAVINGS $5,473.66 510 BALANCE FORWARDSICASH RECEIPTS ARE NOT ACCEPTABLE $4,346.93 PEN FURTHER ACTION ON THIS CLAIM I5 PEND]NG RECEIPT OF ADDITIONAL INFORMATION. $4,19928 521 CHARGES 1NCDRRED 1N CONNECTION WITH ASELF-INFLICTED INJURY, ILLNESS, OVERDOSE, OR ATTEMPTED SUICIDE. $3,483 00 524 CLAIMS NOT SUBMITTED WITHIN ELIGIBLE CLAIMS PERIOD $3,115.74 572 NO MORE THAN THREE MODALITIES, PROCEDURES, UNITS ALLOWED PER DAY. $3,017.39 810 NON PPO FACILITY DEDUCTIBLE AND NON PRE-CERT PENALTY $2,500.00 530 TREATMENT RELATED TO INFERTILITY IS NOT COVERED UNDER THE PLAN. $2,410.4] UIS THIS PROCEDURE HAS BEEN IDENTIFIED AS BE]NG INCIDENTAL ACCORDING TO THE CLAIMS EDIT SYSTEM. $1,946.08 STU OUR RECORDS INDICATE THIS DEPENDENT NO LONGER MEETS THE AGE REQUIREMENT UNDER THE PLAN $1,654 00 523 EXPENSE ]S COVERED BY OTHER INSURANCE COMPANY. REFER TO THE COORDINATION OF BENEFITS AND/OR SUBROGATION SECTION OF YOUR PLAN, $1,486.71 FUD SHOULD BE INCLUDED W]THIN THE GLOBAL PACKAGE CONCEPT $1,347.00 809 SERVICES NOT PERFORMED AT A PPO FACILITY OR BY A PPO PROVIDER. $1,291.05 581 PLEASE PROVIDE DETAILED DESCRIPTION OF THIS CHARGE. $1,223.23 596 CHARGES [N CONNECTION WITH CUSTODIAL CARE, EDUCATION OR TRAINING, OCCUPATIONAL THERAPY FOR MENTALINERVOUS CONDITIONS, OR EXPEN $1,121.09 526 CHARGES ARISING OUT OF OR IN THE COURSE OF ANY OCCUPATION FOR WAGE OR PROFIT. (WORK-RELATED CONDITIONS) $1,102.92 Average Monthly Cost Per Employee ~~~~ ABC COMPANY ;~M1SU NIANAGEI~NT SERVICES Total Cost Medical Claims $: $; $: Fixed Costs Dental Claims X2/0112001- 02!01/2002 - 02/01/2003. 02/01/2004 - 02!01/205 - 01/31/2002 01/31/2003 01/31/2004 01/31/2005 0113U2006 0210112001- D210112002 - 0210112003 - 02101/2004 - 02/O1/2005 - Ol/3ll2002 01/3]/2003 01/31/2004 01131/2005 01131!2006 0210112001- 02!0112002 - 0210112003. 02/0112004 - 02101!2005 - 01/3112002 0113112003 0113112004 01/3112005 0113]/2006 02/0112001- 02101/2002 - 0211/2003 - 0210112004 - 02101/2005 - 01I3U2002 01131/2003 01131/2004 01131!2005 01131/2006 ~~ ~ ~~~ ~ (guns C Prescripion $45 $1 $1 llisabiiitV Clams t~,y Cost PeY Employee Average 1Vion AsccoltirANY .~--- 0210112004. 0210112005 • 0210112003 ' 0113112005 0113112006 0210112001 ' 0210112002 - 01!31!2004 011302002 01131!2003 4 440 ~nrallment 021002004. 0210112005 021002003 - 0113112005 011302006 0210112001- 0210112002' 0113112004 0113112002 011302003 OL~u~«°°- 0113V~u°' 0113112002 ~ 0210112004' 0210112005 0210112003 • 01!3112005 01131!2006 0 0210112002 • 0113112004 O~O112001' O1f3112003 0113112002 ~ ~" ABC Company v. ~ational/Regional Averages Month! Cost Benchmarks Y ~NSU CE IYIANAGEIVIENT SERVICES otiolrzoo6 - iar~lrzoo6 IMS 2005 Average -All Clients $1,000 $900 $soo $soo $600 $500 $400 $300 $200 $100 ®SingleRate-Monthty ^FamityRate-Montly $0 $1,000 $900 $soo $soo $600 $500 $400 $300 $200 $100 ®Single Rate -Monthly $0 ^FamityRate-Monthty ABCCompany All Small Firne All Large Firms (3-199 Workers) (200 ar M ore Workers) By Industry $ L,000 $900 $soo $soo $600 $500 $400 $300 $200 $100 $0 ABC Company South West ®Single Rale -Monthly ^ Family Rate-Monthly ®Single Rate - M onlhly ^FamityRate-Monthly Source: Kaiser/HRET Survey of Employer-Sponsered Health Benefits: 2005. Note, Premiums include Fixed Costs, Medical Claims, and Prescriptions Page 1 of 2 Miningl Manufacturing TransportatioN Retail Finance Service StatelLocal HeafthCare Construction! Communicatbnsl Government Wholesale Utility By Firm Size By Region % ~ I ' ~ ABC Company ~.. JationaURegional Averages ~' '~ I ~ Monthly Cost Benchmarks ~INSU E MANAGEMENT Sf.RYICES olioi~xoob - tz~~lizoo6 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $D ABC Company $14,000 $12,000 $10,000 $8,000 $6,000 .$4,000 $2,000 $0 ABC Company Annual Rates, by Firm Size $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 AIISmaIlFirms (3'69 AIILargeFirms(2DOor •S1ngiercate-nnnuai ABC Company Workers) MoreNbrkers) ^FamilyRate-Annual Annual Rates, by Industry Miningl Manufacturing Transportationl Construction/ Communications! Wholesale Utilhy Source: Kaiser/HRET Survey of Employer-Sponsered Health Benefits:2005. Note: Premiums include Fixed Casts, Medical Claims, and Prescriptions ®Single Rate-Annual ^ F am ily Rale -Annual Retail Finance Service StatelLocal Health Care Government ^Single Rate-Annual ^ Family Rate -Annual Annual Rates, by Region Page 2 of 2 South Nkst INS NCE ~ANAf ENT SERVICES Network Discounts Network Discounts and Utilization Place ojService Network Totall3ligi6le Ckarges Discount % Discount Physician OMNI Networks $87,219.65 $33,897.00 38.86% BeechStreet $65,717.23 $25,059.76 38.13% PHCS $137,564.36 $53,786.13 39.10% PHCS Healthy Directions $1,450.00 $300.00 20.69% POSTotals: $291,951.24 $113,042.89 38.72% Lnpatient Hospital OMN[Networks $52,541.35 $32,158.47 61.21% BeechStreet $22,362.10 $6,396.74 28.61% PHCS $249,386.91 $106,664.92 42.77% POSTotals: $324,290.36 $145,220.13 44.78% OutpnNent Hospital OMN[Networks $23,704.48 $9,837.99 41.50°~ BeechStreet $48,577.12 $10,499.47 21.61% PHCS $127,136.51 $39,816.65 31.32°h POSTotnls: $199,418.11 $60,154.11 30.16°k Other Facility OMNI Networks $9,018.04 $5,367.36 59.74°k BeechStreet $12,480.98 $3,408.51 27.31°k PHCS $14,404.91 $3,357.54 23.31% PHCS Healthy Directions $334.00 $50.10 15.00% POSTotals: $36,237.93 $12,203.51 33.68°k Report Totals: $851,897.64 $33Q620.64 38.81% Note: This report does not reflect voids and refunds. l ~,. ~~,~~~ ~' INSU CE MANAGEMENT SERVICES Network Discounts and Utilization Network Utilization Network Utilization Network Total Eligible Chnrges % of Grnnd Total # Unique Clmts Non-PPO $109,108.81 11.35°k 100 OMNI Networks $172,483.52 17.95% 96 BeechStreet $149,137.43 15.52°k 109 PHCS $528,492.69 54.99% 113 PHCS Healthy Directions $1,784.D0 0.19% 3 Total: $961,006.45 100.00% 421 ^ BeechStreet ^Non-PPO ^ OMNI Networks ^PHCS ^PHCS Healthy Directions 0% l6% 11% 55% l8% Note: This report does not reflect voids and refunds. ~ ~ ~ Plau Su .,.r mmary ABC COM PANY (S999999) Report From: 1 0/Ol/2004 . X9/30/2005 Aggregate Fixed Costs Aggreg. Accum. Total OverSPec Net Accum Payable Pnya6le Accum Employee Covernge Atchmt. Atchmt. Clnims Adj /Not Claims Net By To Aggreg. Month EE / EF DE / DF Admin Fees Reinsurance PPO Fees PCS Fees Month Point Paint Paid Covered Pnid ClmPd Reins. Reins. Pnynble Oci 237 45 0 0 $5,356 $10,546 $1,269 $0 Oct 121,953 121,953 41,404 0 41,404 41,404 0 0 0 Nov 230 47 0 0 $5,263 $10,471 $1,247 $664 Nov 121,254 243,207 91,663 0 91,663 133,067 0 0 0 Dec 238 47 0 0 $5,415 $10,717 $1,283 $439 Dec 124,046 367,253 63,846 0 63,846 196,913 0 0 0 Jan 244 43 0 0 $5,453 $10,611 $1,292 $421 Jan 122,652 489,905 83,387 D 83,387 280,300 0 0 0 Feb 240 45 0 0 $5,415 $10,633 $1,283 $450 Feb 123,000 612,905 65,029 0 65,029 345,329 0 0 0 Mar 236 47 0 0 $5,377 $10,656 $1,274 $484 Apr 237 45 D 0 $5,356 $10,541 $1,269 $464 Mar 123,348 736,253 81,394 0 81,394 426,723 0 D 0 May 233 47 0 0 $5,320 $10,563 $1,260 $660 Apr 121,953 858,206 102,097 0 102,097 528,820 0 0 0 Jun 236 47 D 0 $5,377 $10,656 $1,274 $440 May 122,301 980,507 84,543 0 84,543 613,363 0 0 0 Jul 234 48 D 0 $5,358 $10,667 $1,269 $450 Jun 123,348 1,103,855 94,944 0 94,944 708,307 0 0 0 Aug 231 49 0 0 $5,320 $10,647 $1,260 $470 Jul 123,522 1,227,377 94,168 0 94,168 802,475 0 0 0 Se 235 47 0 0 $5,358 $10,625 $1,269 $939 Aug 123,347 1,350,724 126,299 0 126,299 928,774 0 0 0 Totals: 2831 557 0 0 64 370 127 332 15 246 5 880 Se 122 999 1473 723 167 645 0 167 645 1096 419 0 0 0 Plan Cost Containment Totat Amount % of Tatut SubmittedCbarges $2,015,837.44 100.00% lnetigible ($152,354.85) 7.56% Deductible ($129,571.73) 6.43% Co-Pay ($51,563.85) 2,56% OOp ($129,639.86) 6.43% Ducounts* ($680,360.21) 33.75% COB ($369.51) 0.02% Nel Paid Claum $871,937.43 43.25% Cost Containment Savings 56.75% *The percentages on thrs report are based on Total Charges Submitted which include Nnn-PPO and Ineligible charges. syeeifieAmoanr: $sa,ooo SpecifrcReinsurance PrenoteAmount: $30,000 *************** Contr actto Date *************** Claimant Number LaseredAmt Paid Over Reimbursement Balance S999999.0012-1 $55,111 $0 $0 $0 S999999-0056-1 $45,154 $0 $0 $0 S999999-0229-1 $41,082 $0 $0 $0 S999999-0351-2 $34,662 $0 $0 $0 Totals: $176,010 $0 $0 $0 Place ojService Network Discounts Total Eligible Charges Discount % Discount Physician $930,708.98 $295,611.05 31.76% Inpatient Hospital $360,940.39 $188,974.37 52.36% Outpatient Hospttal $421,930.55 $178,428.52 42.29% OtherFacility $51,991.21 $17,366.27 33.40% Totals: $1,765,571.13 $680,360.21 38.54% Note: This report does not reflect non-PPO charges. Network Utilization Network Total Ettgib!¢ Charges % of Totat Non-PPO $97,911.46 5.25% OMNI Networks $1,701,810.82 91.32% BeechStreet $63,760.31 3.42% 10/2 8/20 04 1:46:09 PM Pnge 1 of 2 Plan Sammar .r ABC COMPANY (5999999) 4 Report From; 10/Ol/200 .09/3012005 Top 5 Adult Female Diagnoses Unique Employee ICD &Descrpfion Clmts Allowed Charges Cost Shnrin Pard 174.9 -Mal neopl breast NOS 2 $35,712 $3,317 $32,395 473.9 -Chronic sinusitis NOS 5 $30,271 $4,324 $25,948 592.1- Calculus of ureter 6 $29,545 $6,869 $22,675 414.01- Cor AS-native vessel 2 $19,610 $0 $19,610 V72.3 -Gynecologic examination 99 $14,418 $30 $14,388 Totals: 114 $129,556 $14,540 $115,016 Relation Member Months Relation Summary Employee Allowed Charges CostShnrin Pard Paid PMM DEPENDENT 573 $84,089 $25,337 $58,752 $103 SELF 3,187 $1,005,265 $253,286 $751,979 $236 SPOUSE 476 $82,946 $32,035 $50,911 $107 Totals: 4,236 $1,172,300 $310,656 $861,641 $203 Age Croup Member Months Age Group Allowed Charges Summary Employee Cost Sharin Paid Paid PMM 24 and Younge 898 $175,866 $56,729 $119,138 $133 25- 29 586 $92,264 $34,929 $57,335 $98 30- 39 845 $292,014 $81,023 $210,991 $250 40-49 866 $193,370 $61,866 $131,504 $152 50.59 761 $319,154 $66,061 $248,094 $326 60 and Older 280 $104,631 $10,051 $94,580 $338 Totals: 4,236 $1,172,300 $310,658 $861,641 $203 Member Cender Months Gender Summary Employee Allowed Charges Cosf Sharin PmA Pnid PMM FEMALE 2,869 $828,918 $230,338 $598,580 $209 MALE 1,367 $343,382 $80,320 $263,061 $192 Totals: 4,236 $1,172,300 $310,658 $661,641 $203 ICD &Descrpfion Top S Adult Male Diagnoses Unigue Employee Cl~ Allowed Charges Casf Sharin Paid 724.5 -Backache NOS 4 $21,746 $285 $21,461 722.0 - Cerv disc displacment 4 $18,735 $3,732 $15,003 427.31-Atrial fibrillation 1 $14,260 $D $14,260 361.03 -Part RD-giant tear 1 $13,685 $0 $13,685 722.4 -Cervical disc degen 3 $13,585 $3,078 $10,507 Totals: 13 $82,011 $7,094 $74,916 ICD &Descrpfion Top 5 Children Diagnoses Unique Employee Clmfs AUowed Charges Cost Sharin paid 823.82 - Fx tibia w fibula NO5~1 1 $20,904 $2,274 $18,630 V20.2 - Routin child health exam 22 $4,798 $118 $4,680 823.22 - Fx shaft fib wlib-clstl 1 $5,126 $1,786 $3,339 646.91- 0th CCE-delivered 1 $3,600 $900 $2,700 646.63-GU infection-antepartum 1 $2,831 $751 $2,080 Totals: 26 $37,258 $5,829 $31,429 10/28/20041:46:10 PM Page 2 of 2 Report Run Date: l0~i1005 9: ~~~ AGGREGATE REPORT Report Range: l0/01/2004-09/30/20 ,~~ISU CE MANAGEMENT SERVICES ~c ~~~ FUND NUMBER: 89999 INCURRED RUNIN: 36 CARRIER NAME: GE FINANCIAL PAID RUNOUT: 0 CONTRACT TYPE: BENEFIT CONTRACT PERIOD: 10101/2004 - 09/3DI2005 MINATTACHMENTPOINT.• 1,388,653 CENSUS: SINGLE FAM/LY SINGLE FAMILY SINGLE FAMILY SINGLE FAMILY MONTH MED MED DENT DENT VIS VIS RX RX 349 872 OCT 237 45 NOV 230 47 DEC 238 47 JAN 244 43 FEB 240 45 MAR 236 47 APR 237 45 MAY 233 47 JUN 236 47 JUL 234 48 AUG 231 49 SEP 235 47 Aggregate - Accammodalion - Aggreg. AccunG Med Dent ~s RX Other Total Net Accum Payable Payable Accum. Atchmt AlchnrL Claims Claims Claims Claims Claims Claims Over Not Claims Net By To Aggreg. Month Point Point Paid Paid Paid Paid Paid Paid Spec Covered AdJ Paid Cim Pd Reins. Reins. Payable OCT 121,953 121,953 28,929 0 0 12,475 0 41,404 0 0 0 41,404 41,404 0 0 0 NOV 121,254 243,207 69,025 0 0 22,638 0 91,663 0 0 0 91,663 133,067 0 0 0 DEC 124,046 367,253 55,584 0 0 8,262 0 63,846 0 0 0 63,846 196,913 0 0 0 JAN 122,652 489,905 59,399 0 0 23,988 0 83,387 0 0 0 83,387 280,300 0 0 0 FEB 123,000 612,905 45,605 0 0 19,424 0 65,029 0 0 0 65,029 345,329 0 0 0 MAR 123,346 736,253 63,578 0 0 17,816 0 81,394 0 0 0 81,394 426,723 0 0 0 APR 121,953 858,206 79,997 D 0 22,100 0 102,097 0 0 0 102,097 528,820 D 0 0 MAY 122,301 980,507 65,147 0 0 19,395 0 84,543 0 0 0 84,543 613,363 D 0 0 JUN 123,348 1,103,855 73,837 D 0 21,107 0 94,944 0 0 0 94,944 708,307 0 0 0 JUL 123,522 1,227,377 81,198 0 0 12,970 0 94,168 0 0 0 94,168 802,475 0 0 0 AUG 123,347 1,350,724 107,532 0 0 18,766 0 126,299 0 0 0 126,299 928,774 0 0 0 SEP 122,999 1,473,723 131,944 0 0 35,702 0 167,645 0 0 0 167,645 1,096,419 0 0 0 Page 1 of 1 ~~~ ;;,~~lSU E MA~JIGEMENT SERVICES Fuud 59999 Contract Period 02/01/2005 - 01I311200f Group Specific Limit $60,000 Group Prenote: $30,000 50% Specific Reinsurance Report ABC COMPANY Report Range 02/01/2005 - 01/31/2006 Carrier Name: Incurred Run-In Paid Run-Out GE FINANCIAL 36 months 0 months ********* Month 01/2006 ********* ************ ****** Year to Date ************** Indivdual Name Claimant Name Lasered Spe SSN Relation Paid Over Reimbursement Paid Over Reimbursement Balance EMPLOYEE #1 129.45.6789 CLAIMANT#1 SPOUSE $15,339.45 $0.00 $0.00 $55,110.92 $0.00 $0.00 $0.00 EMPLOYEE #2 i23~45~6798 CLAIMANT#2 SPOUSE $1,038.31 $0.00 $0.00 $45,154.23 $0.00 $0.00 $0.00 EMPLOYEE #3 12845.6799 CLAIMANT #3 SPOUSE $102.00 $0.00 $0.00 $41,082.35 $0.00 $O.DO $0.00 EMPLOYEE#4 125~45*Sfi99 ' CLAIMANT#4 SPOUSE $58.15 $0.00 $O.DO $34,662.18 $0.00 $0.00 $0.00 Group Totals: $16,537.91 $0.00 $0.00 $176,009.68 $0.00 $0.00 $0.00 Friday, October 29, 2004 Page 1 of 1 TOP SO PAID CLAIMS R~ .~~ ~` Individual and Claimants ~NSU E ~ANAGErVIENT SERVICES ABC coMPArn~ Pnid From: Ol/01/2005 To: 01/31/2006 Client: ABC COMPANY 5999999 EmployeeName Claimant Name Relationship Allowed Charges JOHN DOEI JANE DOEI DEPENDENT $52,826.94 JOHN DOE2 JANE DOE2 DEPENDENT $46,130.32 JOHN DOE3 JANE DOE3 DEPENDENT $46,465.35 JOHN DOE4 JANE DOE4 DEPENDENT $37,074.03 JOHN DOES JANE DOES DEPENDENT $31,712.16 JOHN DOE6 JANE DOE6 DEPENDENT $28,585.68 JOHN DOE7 JANE DOE7 DEPENDENT $26,605.40 JOHN DOE8 JANE DOE8 DEPENDENT $21,435.40 JOHN DOE9 JANE DOE9 DEPENDENT $22,950.01 JOHN DOE10 JANE DOE10 DEPENDENT $15,341.16 JOHN DOEI1 JANE DOEI1 DEPENDENT $15,896.89 JOHNDOEI2 JANEDOEI2 DEPENDENT $16,828.94 JOHN DOE13 JANE DOE13 DEPENDENT $15,559.54 JOHN DOE14 JANE DOE14 DEPENDENT $14,733.89 JOHN DOE15 JANE DOE15 DEPENDENT $16,287.44 JOHN DOE16 JANE DOE16 DEPENDENT $13,026.80 JOHN DOE17 JANE DOEl7 DEPENDENT $13,940.87 JOHN DOEl8 JANE DOE18 DEPENDENT $15,005.24 JOHN DOEl9 JANE DOE19 DEPENDENT $13,025.50 JOHN DOE20 JANE DOE20 DEPENDEM $12,472.74 JOHN DOE21 JANE DOE21 DEPENDENT $12,081.02 JOHN DOE22 JANE DOE22 DEPENDENT $13,455.37 JOHN DOE23 JANE DOE23 DEPENDENT $11,834.23 JOHN DOE24 JANE DOE24 DEPENDENT $11,203.52 JOHN DOE25 JANE DOE25 DEPENDENT $11,379.60 JOHN DOE26 JANE DOE26 DEPENDENT $10,936.17 JOHN DOE27 JANE DOE27 DEPENDENT $8,929.53 JOHN DOE28 JANE DOE28 DEPENDENT $10,355.66 JOHN DOE29 JANE DOE29 DEPENDENT $10,017.72 JOHN DOE30 JANE DOE30 DEPENDENT $9,838.99 JOHN DOE31 JANE DOE31 DEPENDENT $8,923.94 JOHN DOE32 JANE DOE32 DEPENDENT $7,806.46 JOHN DOE33 JANE DOE33 DEPENDENT $10,091.19 JOHN DOE34 JANE DOE34 DEPENDENT $8,751.88 JOHN DOE35 JANE DOE35 DEPENDENT $7,471.45 JOHN DOE36 JANE DOE36 DEPENDENT $8,480.14 ;PORT Deductible $1~ $203.00 $1,975.00 $350.00 $500.00 $500.00 $1,000.00 $1,000.00 $2,000.00 $350.00 $350.00 $350.00 $500.00 $350.00 $2,000.00 $350.00 $1,000.00 $2,000.00 $1,000.00 $925.00 $350.00 $2,000.00 $1,000.00 $1,000.00 $1,942.34 $1,335.00 $0.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $350.00 $2,ooa.oo $1,000.00 $650.00 $1,000.00 Co-Pay $6 $580.00 $510.00 $120.00 $2so.oo $360.00 $30.00 $596.00 $415.00 $517.00 $300.00 $440.00 $54.00 $2zo.oo $90.00 $140.00 $450.00 $866.00 $256.00 $270.00 $280.00 $60.00 $300.00 $210.00 $300.00 $265.00 $8o.ao $127.00 $386.00 $150.00 $300.00 $193.00 $468.00 $256.00 $30.00 $265.00 OutOfPocket COB $3,946.87 $0.00 $1,231.40 $0.00 $3,000.00 $0.00 $2,000.00 $0.00 $2,062.40 $0.00 $2,000.00 $0.00 $3,000.00 $0.00 $2,094.26 $0.00 $3,000.00 $0.00 $1,035.87 $0.00 $2,000.00 $0.00 $2,814.05 $O.DO $2,098.00 $O.DO $2,395.87 $0.00 $3,000.00 $0.00 $2,ooo.ao $o.oo $2,573.77 $0.00 $2,643.59 $0.00 $2,615.61 $0.00 $2,426.37 $0.00 $2,616.15 $0.00 $2,903.42 $0.00 $2,430.15 $0.00 $2,381.30 $0.00 $1,914.68 $O.OD $2,124.54 $0.00 $1,689.43 $0.00 $2,072.84 $0.00 $1,649.71 $0.00 $1,816.32 $O.OD $1,oo7.s2 $a.oo $1,174.62 $0.00 $1,566.54 $0.00 $1,551.22 $0.00 $1,ooo.oa $a.oo $1,446.59 $0.00 Report Date:02/29/200 PAID CLAIMS REPORT Individunl and Claimnnk Total Paid % OfTotal $46,650.07 4.84% $44,115.92 4.57% $40,980.35 4.25% $34,604.03 3.59% $28,859.76 2.99% $25,725.68 2.67% $22,575.40 2.34% $17,745.14 1.84% $17,535.01 1.82% $13,438.29 1.39% $13,246.89 1.37% $13,224.89 1.37% $12,907.54 1.34% $11,768.02 1.22% $11,197.44 1.16% $10,536.80 1.09% $9,917.10 1.03% $9,495.65 0.98% $9,153.89 0.95% $8,851.37 0.92Mo $8,834.87 0.92% $8,491.95 0.88°k $8,104.08 0.84°h $7,612.22 0.79°k $7,222.58 0.75% $7,213.63 0.75°k $7,160.10 0.74°k $7,155.82 0.74% $6,982.01 0.72°k $6,872.67 0.71% $6,616.12 0.69% $6,088.84 0.63% $6,056.65 0.63% $5,944.66 0.62°k $5,791.45 0.60°k $5,768.55 0.60°k ~~~ ~NISU CE MANAGEMENT SERVICES Paid From:.02/01/2005 Client: ABC COMPANY To: 01/31/1006 Employee Name Claimant Name TOP SO PAID CL~ IMS REPORT 5999999 Individual and Claimants ABC COMPANY Relationship Allowed Charges Deductible ~.. Report Date:02/29/200 PAID CLAIMSREPORT Individual and ClnimanL Co-Pay Out Of Pocket COB Total Paid %OfTotal JOHN DOE37 JANE DOE37 DEPENDENT $9,994.83 $2,000.00 $540.00 $1,771.16 $O.DO $5,683.67 0.59% JOHN DOE38 JANE DOE38 DEPENDENT $8,947.66 $1,777.60 $120.00 $1,657.89 $0.00 $5,392.17 0.56% JOHN DOE39 JANE DOE39 DEPENDEM $6,850.65 $1,132.00 $150.00 $254.58 $0.00 $5,314.07 0.55% JOHN DOE40 JANE DOE40 CEPENDEM $6,746.98 $350.00 $20.00 $1,250.60 $0.00 $5,126.38 0.53% JOHN DOE4l JANE DOE41 DEPENDENT $7,287.42 $1,000.00 $67.00 $1,318.93 $0.00 $4,901,49 0.51% JOHN DOE42 JANE DOE42 DEPENDENT $5,388.42 $749.24 $204.00 $0.00 $0.00 $4,435.18 0.46% JOHN DOE43 JANE DOE43 DEPENDEM $6,877.43 $1,202.25 $150.00 $1,174.73 $0.00 $4,350.45 0.45% JOHN DOE44 JANE DOE44 DEPENDENT $7,559.31 $1,620.50 $690.00 $934.76 $0.00 $4,314.05 0.45% JOHN DOE45 JANE DOE45 DEPENDENT $6,095.93 $500.00 $1,100.00 $255.55 $0.00 $4,240.38 0.44% JOHN DOE46 JANE DOE46 DEPENDENT $6,824.92 $500.00 $160.00 $2,272.46 $0.00 $3,892.46 0.40°h JOHN DOE47 JANE DOE47 DEPENDENT $5,118.10 $350.00 $120.00 $765.96 $0.00 $3,882.14 0.40% JOHN DOE48 JANE DOE48 DEPENDENT $5,980.18 $1,000.00 $134.00 $1,032.04 $0.00 $3,814.14 0.40°h JOHN DOE49 JANE DOE49 DEPENDEM $4,972.45 $350.00 $160.00 $664.49 $0.00 $3,797.96 0.39°k JOHN DOE50 JANE DOE50 DEPENDENT $4,938.01 $290.40 $240.00 $641.15 $0.00 $3,766.46 0.39°k $731,045.46 $47,692.33 $14,719.00 $91,277.69 $0.00 $577,356.44 59.86% ,:~ I ~, ~NSUE NuINAGE~IEMT SERYICE$ PnidFrom: 02/01/2005 To: 01/31/2006 CUent: ABCCOMPANY 5999999 Chazge T}Pe Code Description PAID CLAIMS REPORT Top 30 Charge Types ABC COMPANY owed Charges Deductible -Pay Of Pocket B eportDate:02/29/1006 PAID CLAIMS REPORT Charge Types Total Paid PCS PCS Presrxiptions 234,643.93 0.00 0.00 0.00 0.00 234,643.93 OHS Outpatient Surgery Hospital 175,439.30 7,694.83 0.00 29,090.46 0.00 138,654.01 SO Outpatient Surgery 89,534.18 9,277.47 O.OD 14,556.34 0.00 65,700.37 SRG Surgery Per Diem 74,467.19 761.40 O.OD 8,694.70 0.00 65,011.09 OV Office Visit 93,001.1b 1,097.88 35,539.00 338.58 47.94 55,977.75 51 Inpatient Surgery 61,744.00 6,223.70 0.00 9,621.56 O.DO 45,898.74 HM Hospital Misc 31,192.47 0.00 0.00 59.46 O.DO 31,133.01 LBDR LablPathology Physician Charges 34,321.31 1,474.31 4,347.85 194.15 O.DO 28,305.00 CT Chemotherapy 27,436.85 0.00 0.00 466.25 0.00 26,970.60 XRDR X-Ray In Doctor's Office 32,936.21 3,793.21 2,288.00 1,620.71 0.00 25,234.29 WLB Wellness Benefit 24,486.28 52.00 0.00 0.00 0.00 24,434.28 AO Outpatient Anesthesia 28,260.14 2,097.51 0.00 4,041.38 0.00 22,121.25 XRAY OutpatientX-Ray 37,681.16 11,879.23 0.00 5,738.88 65.66 19,997.39 MED Medical Per Diem 23,743.10 1,130.40 0.00 3,480.93 0.00 19,131.77 MRI MRI 27,844.48 7,831.86 0.00 2,907.55 0.00 17,105.07 SF Office Surgery 33,250.10 13,629.55 0.00 3,474.58 0.00 16,145.97 INJ Injections 17,711.82 214.12 539.00 1,419.89 0.00 15,538.81 ER Emergency Raom 21,862.85 3,071.50 0.00 4,463.95 0.00 14,327.40 HXR HospitalX-Ray 19,268.04 2,714.79 0.00 2,041.12 441.22 14,070.91 ODX Diagnostic Test 17,594.92 2,607.D0 833.00 662.95 56.47 13,435.50 AI InpalientAnesthesia 15,734.50 572.24 0.00 2,571.71 0.00 12,590.55 LAB Outpatient LablPathotogy 15,112.85 2,424.34 0.00 685.39 0.00 12,003.12 HLAB Lab/Pathology-Hosptal 14,475.43 1,750.04 0.00 754.70 0.00 11,970.69 CTS CT Scan 17,280.00 4,035.78 0.00 1,852,37 D.OD 11,391.85 OB OB Per Diem 13,200.00 0.00 0.00 3,300.OD D.OD 9,900.00 CH Chiropractic CA 21,142.57 11,100.05 0.00 2,051.26 0.00 7,991.26 ICU Intensive Care 9,529.56 0.00 0.00 1,905.91 0.00 7,623.65 SMV Serious MN Office Visit 1D,983.37 0.00 3,33D.00 64.00 0.00 7,589.37 DME Dura Medical Equipment. 11,120.07 2,091.81 0.00 1,492.27 D.OD 7,535.99 WXL Preventive Care X-Ray and Lab Charges 8,016.39 552.24 O.DO 36.90 0.00 7,427.25 OTHR All Other Charge Types 169,809.21 32,096.47 4,687.00 2D,943.37 -221.78 112,304.15 GientTotals: 1,412,823.43 130,173.73 51,563.85 128,531.32 389.51 1,102,165.02 Page 1 oJl -~ ~'~~,"\ PAID CLAIMS REPORT ~ ~~~~' ~ ABC COMPANY Top 30 Providers Paid From: 02/Ol/Z005 To: 01/31/2006 Report Dafe:02/29/2006 Cheat: ABC COMPANY 8999999 PAID CLAIMS REPORT Providers Provider Name ProviderT[NNumber AllowedCharees Deductible Co-Pay Out OfPocker COB To[alPaid BAPTIST ST ANTHONYS HOSPITAL 75-0800669 419,233.85 29,819.18 20.00 58,977.90 0.00 330,416.77 IMS-PCS 75-2355889 240,523.93 0.00 0.00 0.00 0.00 240,523.93 JAMES CLARKSON MD 75-2312574 30,726.35 0.00 480.00 470.62 0.00 29,775.73 NORTHWEST TEXAS HOSPITAL 23-2236976 31,717.25 3,147.50 0.00 2,027.73 441.22 26,100.80 JASONEYSASAGAMD 75-2741195 20,676.00 1,000.00 80.00 1,799.69 0.00 17,796.31 J TAYLOR CARLISLE MD 75-1628161 18,900.96 76.00 600.00 2,452.88 0.00 15,772.10 MICHAEL KENDALL DPM 75.1973851 14,651.75 546.00 300.00 3,135.87 0.00 10,669.88 WILLIAM BANISTER MD 75-2767405 13,442.00 0.00 60.00 3,000.00 0.00 10,382.00 ROBERT W PAIGE MD 75-1710492 11,590.00 0.00 190.00 1,534.50 0.00 9,865.50 TIMBERLAWN MENTAL 23-2853139 12,146.59 200.00 0.00 2,389.32 0.00 9,557.27 WGLENN FRIESEN MD 75-1628161 10,731.91 350.00 280.00 1,302.39 0.00 8,799.52 HARRINGTON CANCER CENTER 75-1578415 9,411.20 814.10 300.00 O.DO 0.00 8,297.10 BRET D ERRINGTON MD 01-0632038 8,103.50 0.00 60.00 97.69 0.00 7,945.81 BILL S BARNHILL MD 75.2134834 6,191.00 606.00 150.00 1,722.23 0.00 5,710.77 BRITKARE HOME MEDICAL LTD 75-2598926 7,502.08 1,225.32 0.00 640.93 0.00 5,435.83 ROBERT TAYLOR MD 75-1390545 5,421.50 0.00 0.00 34.40 0.00 5,387.10 BOB TUCKER MD 45-9846691 8,364.00 2,416.14 180.00 617.06 0.00 5,150.80 STEPHEN J USALA MD PHD 75.2622850 5,676.00 7.00 620.00 157.00 0.00 4,894.00 JAMES SCOTT MCCOWN MD 75.2251516 5,605.00 0.00 0.00 920.40 0.00 4,884.60 CAROLA KIESLING MD PA 43-1971626 5,834.00 0.00 295.00 1,025.75 0.00 4,513.25 MARKAHULSEYMD 75.1628161 5,894.25 293.00 910.00 268.60 0.00 4,422.65 RONALD THANE MORGAN MD 75.2964271 6,674.00 684.56 445.00 1,212.60 0.00 4,331.84 GARY POLK MD 75-1628161 6,489.40 1,152.00 328.00 842.06 0.00 4,167.34 JAMES HALE MD 75.2239700 5,617.00 0.00 1,470.00 O.DO 0.00 4,147.00 KYLE KENNEDY, MD 20.0446384 5,866.25 460.00 90.00 1,281.50 0.00 4,034.75 MICHAEL GUTTENPLAN MD 71.0907006 5,511.00 794.00 713.00 0.00 0.00 4,004.00 JONATHON B GENTRY MD 75-2874150 4,196.00 0.00 240.00 0.00 O.DO 3,956.00 JAKE LENNARD MD 75-1628161 5,087.50 0.00 176.00 1,033.12 0.00 3,678.38 SHILPA SARALAYA MD 75-2898245 4,742.99 239.00 608.00 44.00 0.00 3,851.99 KEITH BJORK MD 75-2550465 4,624.00 122.50 120.00 736.16 0.00 3,645.34 ALL OTHER PROVIDERS NIA 469,470.15 66,219.43 42,848.85 40,606.92 -51.71 299,846.66 Client Totals: 1,412,823.43 130,173.73 51,563.85 128,531.32 389.51 1,102,165.02 Page 1 of I NON- PPO Claims Paid Report r~ ~ ABC COMPANY ,,,~ CE MANAGEIr~HT SERYI~CES Pnid From: 01/01/2005 To: O1B1/2006 Report Dnte:01/04/1006 Client: ABC COMPANY 5999999 NON-PPO Division: PREMIUM NON-PPO Specialty Provider/ClaimentName City, State Zip Procedure Type TotalCharRe Ineligible Deductible Co-Pay OulOfPocket COB Total Paid AMARILLO, TX GE ABDUL THANNOUN MD AMARILLO, TX 79119-6405 CLAIMANT#15 AMARILLO, TX 79103 M 208.00 208.00 0.00 0.00 0.00 0.00 D.DO PTH ARLENE L LIBBY, MA GREENSBORO; NC 27415.3508 CLAIMANT #42 AMARILLO, TX 79123 M 59.00 59.00 0.00 O.OD O.DO O.OD 0.00 FP DAVID BRISTER MD AMARILLO, TX 7$106 CLAIMANT#41 AMARILLO, TX 79110 M 96.00 96,00 0.00 0.00 O.DO 0.00 0.00 HEM-0 G NARAYANAPILLAI,Mp AMARILLO, TX 79159 CLAIMANT#22 AMARILLO, TX 79124 M 29.00 29.00 0.00 0.00 0.00 0.00 0.00 CLAIMANT#23 AMARILLO, TX 79124 M 92.00 92.00 0.00 0.00 0.00 0.00 0.00 CLAIMANT#24 AMARILLO, TX 79124 M 69.00 69.00 0.00 0.00 0.00 0.00 0.00 CLAIMANT#25 AMARILLO, TX 79124 M 5.00 5.00 0.00 0.00 0.00 0.00 0.00 CLAIMANT#26 AMARILLO, TX 79124 M 46.00 46.00 0.00 0.00 0.00 0.00 0.00 OBG GARY K PERSON, MD RFM ATHENS fi~A 30608 CLAIMANT #49 AMARILLO, TX 79123 M 115.00 115.00 0.00 0.00 0.00 0.00 0.00 RfJO 4ARY ROSE MD AMARILLO, TX 79105 CLAIMANT #20 AMARILLO, TX 79124 M 15.00 15.00 0.00 0.00 0.00 0.00 0.00 CLAIMANT #21 AMARILLO, TX 79124 M 75.00 75.00 0.00 0.00 0.00 0.00 0.00 HEAR JAMES CLARKSON MD AMARILLO, TX 7'8159 CLAIMANT #3 AMARILLO, TX 79108 M 111.00 111.00 0.00 0.00 0.00 0.00 0.00 CLAIMANT #4 AMARILLO, TX 79108 M 111.00 111.00 0.00 O.DO 0.00 0.00 0.00 CLAIMANT #5 AMARILLO, TX 79108 M 37.00 37.00 0.00 0.00 0.00 0.00 0.00 CLAIMANT #6 AMARILLO, TX 79108 M 37.00 37.00 0.00 0.00 0.00 0.00 0.00 FP JAMES HALE MD AMARILLO,-TX 79106 CLAIMANT #19 AMARILLO, TX 79103 M 62.00 62.00 0.00 0.00 0.00 0.00 0.00 Page 1 of 4 ' ~ NON- PPO Clairrrs Paid Report ~ ~~ ~~~~~'~' ~~~ ABC COMPANY PaiAFrom: 02/0!/1005 Ta: 01/3//2000 ReportDate:02/04/2006 Client: ABC COMPANY 5999999 NON-PPO Division: PREMIOM NON-PPO Specialty Provided Claimant Name City, Stele Zip Procedure Type Total Charge Ineligible Deductible Co-Pay Out Of Pocket COB Total Paid R JAMES J NE=WMAN, P}ID MDr AMARILLO, TX 79159 CLAIMANT#10 AMARILLO, TX 79106 M 39.00 0.00 39.00 0.00 0.00 0.00 0.00 CLAIMANT#11 AMARILLO, TX 79106 M 234.00 0.00 234.00 0.00 0.00 0.00 0.00 CLAIMANT#12 AMARILLO, TX 79108 M 39.00 0.00 39.00 0.00 0.00 0.00 0.00 CLAIMANT#13 AMARILLO, TX 79108 M 39.00 0.00 39.00 0.00 O.DO 0.00 0.00 CLAIMANT#40 AMARILLO, TX 79108 M 39.00 0.00 39.00 0.00 0.00 0.00 0.00 CLAIMANT#7 AMARILLO, TX 79108 M 228.00 0.00 228.00 0.00 0.00 0.00 0.00 CLAIMANT#8 AMARILLO, TX 79108 M 234.00 0.00 234.00 0.00 D.DO 0.00 0.00 CLAIMANT#9 AMARILLO, TX 79108 M 39.00 0.00 39.00 0.00 D.DO 0.00 0.00 IM JOSEPH G NU6HES, MD VESTAVIA HILLS, AL 35242=2531 CLAIMANT #45 AMARILLO, TX 79123 M 175.00 175.00 0.00 0.00 0.00 0.00 O.OD CLAIMANT #46 AMARILLO, TX 79123 M 28.00 28.00 0.00 0.00 O.DO 0.00 0.00 CLAIMANT #47 AMARILLO, TX 79123 M 15.00 15.00 0.00 0.00 0.00 0.00 0.00 CLAIMANT #48 AMARILLO, TX 79123 M 59.00 59.00 0.00 0.00 0.00 0.00 0.00 A ifENT S(3RAJJA MD AMARILLO, TX 79108 CLAIMANT #14 AMARILLO, TX 79109 M 112.00 112.00 0.00 0.00 0.00 0.00 O.OD CLAIMANT #17 AMARILLO, TX 79109 M 355.00 355.00 0.00 0.00 0.00 0.00 O.OD CLAIMANT #18 AMARILLO, TX 79109 M 55.00 55.00 0.00 0.00 0.00 0.00 0.00 L1 LABDRATORY CORP OF AM~RIC BURLINGTON, NC 27218 CLAIMANT #29 AMARILLO, TX 79124 M 25.00 25.00 0.00 0.00 0.00 0.00 O.OD IM MARY JOHN BAXLEY, MD GREENSB4R0, NC 27401 CLAIMANT#43 AMARILLO, TX 79123 M 25.00 25.00 0.00 0.00 0.00 O.DO 0.00 CLAIMANT #44 AMARILLO, TX 79123 M 30.00 30.00 0.00 0.00 0.00 0.00 0.00 DC RANDOLPHJANLIREWSDC AMARILLI2,TX 19149 CLAIMANT #37 AMARILLO, TX 79107 M 75.00 75.00 0.00 0.00 0.00 0.00 0.00 FP RICHARD H BECHTOL, MD AMARILLO, TX 79119 CLAIMANT #31 AMARILLO, TX 79121 M 7.00 7.00 0.00 0.00 0.00 0.00 O.OD CLAIMANT #32 AMARILLO, TX 79121 M 7.00 7.00 0.00 0.00 0.00 0.00 0.00 CLAIMANT #33 AMARILLO, TX 79121 M 95.00 95.00 0.00 0.00 0.00 0.00 O.OD CLAIMANT #34 AMARILLO, TX 79121 M 106.00 106.00 0.00 0.00 0.00 0.00 O.OD CLAIMANT #35 AMARILLO, TX 79121 M 94.00 94.00 0.00 0.00 0.00 0.00 0.00 Page 2 of 4 ~~ ~ ~~ NON PPO Cl im P id R t ~~~ - a epor a s ABCCOMPNAY Paid From: 02/0!/1005 To: 01/3]/2006 Report Date:OZ/04/2006 Client: ABC COMPANY 5999999 NON-PPO Division: PREMIUM NON-PPO Specialty ProviderlClaimantName City, State Zip Procedure Type Total Charge Ineligible Deductible Co-Pay Out Of Pocket COB Total Paid IM SNILPASARALAYAMD AMARILLO, TX 791A6 CLAIMANT#38 AMARILLO, TX 79107 M 65.00 65.00 0.00 0.00 O.OD 0.00 0.00 CLAIMANT #39 AMARILLO, TX 79107 M 28.00 28.00 0.00 0.00 0.00 0.00 0.00 A SUSAN RUDD WYNN MD SORT WORTH, TX 76107 CLAIMANT#30 AMARILLO, TX 79121 M 156.00 156.00 0.00 0.00 0.00 O.DO 0.00 CLAIMANT#36 AMARILLO, TX 79121 M 75.00 75.00 0.00 0.00 0.00 0.00 0.00 CD W GLENN FRLESEN M6 AMARILLQ TX 7910b CLAIMANT #16 AMARILLO, TX 79106 M 50.00 50.00 0.00 0.00 0.00 0.00 0.00 CANYON, TX PAID 'f0 EMPLOYEE CLAIMANT #28 CANYON, TX 79015 M 180.00 180.00 0.00 0.00 -105.28 -105.28 105.28 01 AMARILLO ARTIFICIAL LIMB & BRA AMARILLQ,. TX: ?9107 CLAIMANT #58 CANYON, TX 79015 M 108.00 108.00 0.00 0.00 0.00 0.00 0.00 FP GARNETT BRYAN'MD AMARILLO; TX 79106. CLAIMANT #57 CANYON, TX 79015 M 130.00 130.00 0.00 0.00 0.00 0.00 0.00 R JAMES NEWMAN, MD AMARILLO;'TX 79105 CLAIMANT #27 CANYON, TX 79015 M 32.00 16.61 0.00 0.00 12.31 6.15 3.08 i NORTHWEST TEXAS HOSPITAL AMARILLO, TX :79105 CLAIMANT #1 CANYON, TX 79015 M 965.50 0.00 0.00 O.OD 386.20 0.00 579.30 1 PEGOS VALLEY MEDICAL CENT PECOS, NM $7552 CLAIMANT #56 CANYON, TX 79015 M 87.98 0.00 87.98 0.00 0.00 0.00 0.00 OBG R MOSS HAMPTON, MO AMARILLb, TX 79119 CLAIMANT #54 CANYON, TX 79015 M 85.00 85.00 0.00 0.00 0.00 0.00 0.00 CLAIMANT #55 CANYON, TX 79015 M 2,400.00 2,400.00 0.00 0.00 0.00 0.00 0.00 7 TEXAS MEDICAID &NEALT1iCARE AUSTIN, TX 78720 CLAIMANT #2 CANYON, TX 79015 M 20.71 20.71 0.00 0.00 0.00 0.00 0.00 CLAIMANT#50 CANYON, TX 79015 M 8.14 8.14 0.00 0.00 0.00 0.00 0.00 CLAIMANT#51 CANYON, TX 79015 M 203.87 203.87 0.00 0.00 0.00 0.00 0.00 CLAIMANT#52 CANYON, TX 79015 M 8.14 8.14 0.00 0.00 0.00 0.00 0.00 CLAIMANT#53 CANYON, TX 79015 M 8.14 8.14 0.00 0.00 0.00 0.00 0.00 DivisronTotals: 7,932.48 5,972.61 978.98 0.00 293.23 -99.13 687.66 Page 3 of 4 Claims Paid Report NpN. PP4 ABC COMPANY s~P°~nA1e! NoN•PPo J ~ t~+~,~~pp,,,,.....r--„1'ftyC~ Total Paid ~L~ COB j((~(j ~11AAA CaPaY DutOtPocket Deductible •9913 687.66 To: 01f3112006 5999999 Ineligible 293.23 p~pt/ZOOS NON•PPO Total Charge p 60 Pnid From' ABC COMPNAY Procedure TvDe 948,96 Zro 5,972.61 Ctienf: Stale 7,832.48 City. e am $peciallY Provider) Clavr~ant Groap Totals; $66 858.21 a T}us r~oA excludes pte~~pon and prescription fees which totals ~~~ Doge d of 4 !. ~ ~~, ,,;~~SU CE MANAGEII~NT S~RI~CES Pnid From: 01/01/2006 To: 01/31/1000 Client: ABC COMPANE Division: PREMIl/M Individual Name Claimant Name PAID CLAIMS REPORT ABC COMPANY Payment History 5999999 lneurredDate Paid Date Status Report Date:01/04/2006 PA/D CLAIMSREPDR7 Payment History Paid To Check Number CheckAmoum *** EMPLOYEE #1 *** CLAIMANT #1 09/08/2004 09128!2004 A JACK D WALLER MD 14839 $10.00 Individual Totals: $10.00 *** EMPLOYEE #2 *** CLAIMANT #27 10108/2004 10/2712004 A CARLOS PLATA-BERNAL MD 15092 $253.00 Individual Totals: $253.00 *** EMPLOYEE #3 *** CLAIMANT#28 07123!2004 0910112004 A BAPTIST STANTHONYSHOSPITAL 14593 $925.67 CLAIMANT #32 0713012004 0910112004 A ABDUL THANNOUN MD 14594 $513.60 CLAIMANT #31 0911312004 09!2812004 A TEXAS TECH UNIV HSC 14922 $39.00 CLAIMANT #30 09!2412004 09/2912004 A ABDUL THANNOUN MD 15022 $36.00 CLAIMANT #29 0913012004 10/27/2004 A CARLOSPLATA-BERNAL MD 15093 $113.00 CLAIMANT #33 10!0812004 10/27/2004 A STEPHEN J USALA MD PHD 15094 $167.00 IndividualTota(s: $1,796.27 *** EMPLOYEE #4 *** CLAIMANT #35 0910812004 09/2812004 A JACK D WALLER MD 14923 $155.00 CLAIMANT #34 09!1312004 09/2912004 A EARL C SMITH MD 15023 $71.00 Individual Totals: $226.00 *** EMPLOYEE #5 *** CLAIMANT #43 08102!2004 0910112004 A RICHARD H BECHTOL, MD 14595 $38.00 CLAIMANT #44 07119/2004 0910112004 A RICHARD H BECHTOL, MD 14596 $157.00 CLAIMANT #48 07129/2004 09!0112004 A LAWRENCE SCHAEFFER MD 14597 $802.00 CLAIMANT #41 08106/2004 09101/2004 A DAMON ALAN CROSS DC 14598 $37.40 CLAIMANT #39 08119/2004 09109/2004 A KENT SORAJJA MD 14636 $88.00 CLAIMANT #45 07119/2004 09114/2004 A R L BRECKENRIDGE, MD 14660 $47.91 CLAIMANT #36 0810412004 09120/2004 A ROBERT PINKSTON MD 14784 $228.80 CLAIMANT #37 08/1912004 0912012004 A BAPTIST ST ANTHONYS HOSPITAL 14785 $702.00 Page 1 oj2 l { I ~ PAID CLAIMS REPORT 1 E ~~~~, ~~~ ABC COMPANY Payment Histor~~ Pnid From: .01/01/2006 To: 01/31/2006 Client: ABC COMPANY Division: PREMIUM Individual Nanre Claimant Name 5999999 Report Date:01/Ol/2006 PAID CLAIMS REPORT Papment History Paid To Check Number CheckAmaunt tncurred Date Paid Date Status CLAIMANT #46 08119/2004 09120/2004 A BRANCH ARCHER MD 14786 $184.00 CLAIMANT #38 08117/2004 09120/2004 A KENT SORAJJA MD 14787 $408.60 CLAIMANT #47 08118/2004 09120/2004 A ANTHONY V BASS OD 14786 $85.D0 CLAIMANT #40 08127/2004 09128/2004 A DAMON ALAN CROSS DC 14924 $37.40 CLAIMANT #42 09117/20D4 0912912004 A DAMON ALAN CROSS DC 15024 $51.00 Individual Totnts: $2,867.11 *** EMPLOYEE #6 *** CLAIMANT #49 07126!2004 09101/2004 A EVA SILVA, MA LPC 14599 $7D.48 CLAIMANT #51 08112/2004 D9/0912004 A EVA SILVA, MA LPC 14637 $70.48 CLAIMANT #50 08124/2004 09/14!2004 A EVA SILVA, MA LPC 14661 $70.48 Individual Totals: $211.44 *** EMPLOYEE #7 *** CLAIMANT #53 0813012D04 09126!2004 A SUSAN NEESE, MD 14849 $203.00 CLAIMANT #54 08/3112004 0912812004 A GAYLE BICKERS MD 14850 $48.00 CLAIMANT #55 06!3112004 D9/28120D4 A BAPTIST ST ANTHONYS HOSPITAL 14851 $78.78 Individual Totnts: $329.78 *** EMPLOYEE #7 *** CLAIMANT #56 07!2112004 09/01!2004 A GARY ARAGON MD 14600 $70.00 CLAIMANT #57 09!14/2004 09/28120D4 A VINODKUMAR S PATEL MD 14925 $110.00 CLAIMANT #52 09!2312004 0912912004 A BOB TUCKER MD 15025 $150.00 Individual Totnts: $330.00 Division Totnts: $6,023.60 Group Totnts: $6,023.60 Page 2 of 2 FINANCIAL DETAIL REPORT REPORT-ID TMSSL852-01 ALL CLAIM S PAGE A! R NUMBER :123456 BILL ACCT : IHFO POLICY NBR: TIME : 21:41:01 21:41:01 CARRIER IMS1 GROUP : 0123 DATE : 0010012006 SPONSOR NAME :INSURANCE MANAGEMENT SERVICES CLIENT NAME :ABC COMPA NY CLAIMS PROCESSED FROM 00 / 00! 2006 THROUGH 00 / 00 12006 MGDI D CLAIMI PHRMCY ID EMPLOYEE RX PHYSICIAN DATE DRUG DAY MS PRI A INGREDIENT SALES PHARM COST ADJSTMNT NUMBER NUMBER NAME AGE CD NUMBER NUMBER FILLED CODE QTY SUP GB AUTH W COST TAX FEE SHARE AMOUNT 3200425 58526533801 DOE, JOHN 51 MH 6899484 BK2390831 7114/2006 OOODDOOOOOOD 30.00 3D SB 122.26 0.00 1.85 25.00 99.11 3200425 58526533801 DOE, JOHN 51 MH 6906397 BK2390631 7111/2006 OOOODOOOOOOD 30.00 30 SB 13.08 O.DO 0.00 13.08 0.05 ID TOTALS: 135.34 0.00 1.85 38.08 99.16 3202873 45390929701 DOE, JOHN 55 MH 6545294 AS3237991 7110/2006 000000000000 60.00 30 SB 28.48 O.OD 1.85 25.00 5.57 ID TOTALS: 28.48 O.OD 1.85 25.00 5.57 3209358 58571103701 DOE, JOHN 27 MH 1097387 BF8054556 7!1312006 OOOOOOOOOOOD 40.00 9 SB 17.99 0.00 0.00 17.99 0.04 3209358 58571103701 DOE, JOHN 27 MH 1097063 BS5855943 711212006 000000000000 20.00 3 MG 23.15 O.OD 1.85 25.00 0.00 ID TOTALS: 41.14 O.OD 1.85 42.99 0.04 3720679 45443746501 DOE, JOHN 29 MH 0633555 806466468 7111!2006 000000000000 60.00 30 MG 74.74 0.00 1.85 25.00 52.21 ID TOTALS: 74.74 0.00 1.85 25.00 52.21 3723310 44352969701 DOE,JOHN 55 MH 0200638 BC1615636 711712006 OOOOODOOOOOD 90.00 90 SB 243.37 O.DD 1.85 50.00 195.22 ID TOTALS: 243.37 O.DD 1.85 50.00 195.22 4500004 21442475801 DOE,JOHN 60 MH 9336059 BC1615636 81812005 000000000000 5.00 30 MG D 45.00 O.OD 0.00 45.00 0.00 4500004 21442475801 DOE,JOHN 60 MH 9336060 BC1615636 818!2005 000000000000 3.00 30 MB 0 45.00 0.00 0.00 45.00 0.00 4500004 21442475801 DOE,JOHN 61 MH 9336059 BC1615636 4111/2006 OOOOOD000000 5.00 30 MG 51.00 0.00 0.00 50.00 1.00 4500004 21442475801 DOE,JOHN 61 MH 9417809 BCi615636 411112006 OOOOODODOOOD 3.OD 30 S8 51.00 O.DD 0.00 50.00 1.00 ID TOTALS: 192.00 O.DO 0.00 190.00 2.00 4507565 46123408701 DOE, JOHN 48 MH 0160437 AS2559839 718/2006 000000000000 100.00 100 MG D 28.52 0.00 1.85 25.00 5.37 4507565 46123406702 DOE, JANE 46 FH 0174057 BP5558412 718!2006 OOOOODD00000 28.00 28 SB 25.08 0.00 1.85 25.00 1.93 ID TOTALS: 53.60 O.OD 3.70 50.00 7.30 4508808 45495753101 DOE, JANE 27 FH 0980784 AP6259281 7/21(2006 OOOODODOD000 30.00 30 SB D 102.42 0.00 1.65 35.00 69.27 ID TOTALS: 102.42 O.DD 1.65 35.00 69.27 4510663 45182344701 DOE, JOHN 46 MH 0471146 BL8025149 711012006 OOOOOOD00000 150.00 30 MG 198.39 0.00 1.85 50.00 150.24 ID TOTALS: 198.39 0.00 1.85 50.00 150.24 4510663 45390861401 DOE, JANE 57 FH 0466230 AM2244200 711812006 000000000000 30.00 30 MG 0 14.99 0.00 0.00 14.99 0.00 ID TOTALS: 14.99 O.OD 0.00 14.99 0.00 4518001 45376486801 DOE, JOHN 56 MH 0342366 AM7329D65 711012006 000000000000 30.00 30 SB 73.68 O.DD 1.65 35.00 40.53 4518001 45376488801 DOE, JOHN 56 MH 0327329 AN9533173 7/912006 OOOOODOD0000 60.00 30 SB 28.48 O.OD 1.65 25.00 5.56 4518001 45376488801 DOE, JOHN 56 MH 0327394 AN9533173 7/912006 OOOOOODD0000 60.00 30 MG 91.28 0.00 1.85 35.00 58.13 4518001 45376488801 DOE, JOHN 56 MH 0331869 AN9533173 7/912006 DOOOOOD00000 30.00 30 MG 23.15 0.00 1.65 25.00 0.12 ID TOTALS: 216.59 0.00 7.40 120.00 104.34 4518657 45223327802 DOE, JANE 36 FH 0255956 BG0914689 7111!2006 000000000000 100.00 16 MG 39.53 O.DD 1.65 25.00 16.38 ID TOTALS: 39.53 O.DD 1.65 25.00 16.38 P DENOTES PERFDRMANCE MANAGEMENT FEE APPLIED ~o,~~,~g CAIZEMAf~K FINANCIAL DETAIL REPORT REPORT-ID TM55L852.01 ALL CLAIMS PAGE: AIRNUMBER :123456 BILL ACCT : IHFO POLICYNBR: TIME 21:41:01 CARRIER IMS1 GROUP : 0123 DATE : 00/00/2006 SPONSOR NAME :INSURANCE MANAGEMENT SERVICES CLIENT NAME :ABC COMPA NY CLAIMS PROCESSED FROM DO / OD J 2006 THROUGH 001 OD J2006 MGD/ D CLAIMI PHRMCY ID EMPLOYEE RX PHYSICIAN DATE DRUG DAY MS PRI A INGREDIENT SALES PHARM COST ADJSTMNT NUMBER NUMBER NAME AGE CD NUMBER NUMBER FILLED CODE QTY SUP GB AUTH W COST TAX FEE SHARE AMOUNT 4531061 45270491101 DDE, JOHN 60 MH 4055191 AB0957069 711312006 OODDOOOOOODD 30.00 30 MG 0 102.97 O.OD 1.85 50.00 54.82 ID TOTALS: 102.97 O.OD 1.85 50.00 54.82 4532316 48262572601 DOE, JOHN 58 MH 6629479 AB8475495 7!1312006 OODDD0000000 4.00 7 SB 48.15 0.00 1.85 50.00 0.00 4532316 48262572601 DOE, JOHN 58 MH 2220978 AK6555897 711812006 000000000000 30.00 30 SB 17.32 0.00 0.00 17.32 0.02 4532316 48262572601 DOE, JOHN 58 MH 6634984 AK6555897 7!1312006 000000000000 30.00 30 SB 105.10 0.00 1.85 35.00 71.95 ID TOTALS: 170.57 0.00 3.70 102.32 71.97 4552837 29648532301 DOE, JOHN 55 MH 0145291 AF6874956 7!1112006 OOODOOOOOOOD 100.00 50 SB 0 23.15 O.OD 1.85 25.00 0.23 4552837 29648532301 DOE,JOHN 55 MH 0160391 AF6874956 711012006 OOODD0000000 30.00 30 MG 0 10.99 O.DD 0.00 10.99 0.06 ID TOTALS: 34.14 0.00 1.65 35.99 0.29 4561432 45808409001 DOE,JOHN 50 MH 0191263 AP2260735 7!2112006 000000000000 60.00 30 MG 32.68 O.OD 1.85 25.00 9.95 ID TOTALS: 32.88 0.00 1.85 25.00 9.95 4569616 45525291702 DOE, JANE 50 FH 7375264 AL1440279 711412006 OOODOOOOOOOD 30.00 30 MG 14.72 0.00 0.00 14.72 0.07 ID TOTALS: 14.72 O.OD 0.00 14.72 0.07 4569654 45173323901 DOE,JOHN 37 MH 7313549 AT2511473 7!2112006 000000000000 84.00 84 SB 0 72.36 O.OD 1.85 25.00 49.50 ID TOTALS: 72.36 O.OD 1.85 25.00 49.50 4572699 45588720001 DOE, JOHN 55 MH 7416001 AL3135945 711612006 OOODOOOOOOOD 90.00 90 MG 520.01 0.00 1.85 35.00 486.86 4572699 45588720001 DDE,JDHN 55 MH 7416002 AL3135945 711612006 OODDOOOOOOOD 90.00 90 MG 0 168.56 O.DD 1.85 35.00 135.41 4572699 45588720001 DOE,JOHN 55 MH 7420900 AL3135945 711612006 OOODDOOOOOOD 30.00 30 SB 96.02 O.OD 1.85 50.00 47.87 4572699 45588720001 DOE, JOHN 55 MH 7425632 AL3135945 7!1612006 OOODD0000000 90.00 90 MG 0 247.63 O.DD 1.85 35.00 214.48 ID TOTALS: 1032.22 0.00 7.40 155.00 884.62 4596225 46227851401 DOE,JOHN 44 MH 0945814 BB6406256 711512006 OOOD00000000 90.00 90 SB 222.70 0.00 0.00 100.00 122.70 4598225 46227851401 DOE, JOHN 44 MH 9146053 BB6406256 711512006 OOODD0000000 180.00 90 MG 0 97.24 0.00 0.00 50.00 47.24 ID TOTALS: 319.94 O.DD 0.00 150.00 169.94 4596225 46362259901 DOE, JOHN 66 MH 0192416 A66168856 711812006 OOODD0000000 180.00 90 SB 0 425.29 0.00 0.00 100.00 325.29 4596225 46362259901 DOE, JOHN 66 MH 1050521 AT2708797 711812006 000000000000 90.00 90 SB 0 186.21 0.00 0.00 70.00 116.21 4596225 46362259901 DOE, JOHN 66 MH 1050527 AT2708797 7!18/2006 000000000000 90.00 90 SB 42.40 0.00 0.00 42.40 0.00 4598225 46362259901 DOE, JOHN 66 MH 1050534 AT270B797 7!1812006 000000000000 90.00 90 SB 205.55 0.00 0.00 70.00 135.55 4598225 46362259901 DOE, JOHN 66 MH 1050542 AT2708797 7118/2006 OOOD00000000 180.00 90 SB 44.96 0.00 0.00 44.96 0.00 4598225 46362259901 DOE, JOHN 66 MH 1050547 AT270B797 711812006 OODDDOOOOOOD 90.00 90 SB 0 125.64 0.00 O.OD 70.00 55.64 4598225 46362259901 DOE, JOHN 66 MH 1623406 AT270B797 711812006 OOODD0000000 240.00 80 MG 32.58 0.00 O.OD 32.58 0.00 ID TOTALS: 1062.63 O.DD O.OD 429.94 632.69 4598225 46417723401 DOE, JOHN 45 MH 0747811 AS2559839 711912006 OOODOOOOOOOD 90.00 90 MG 0 296.60 O.OD O.OD 100.00 196.60 ID TOTALS: 296.60 0.00 O.OD 100.00 196.60 4598225 46496045301 DOE, JOHN 50 MH 9548645 AP6259281 712112006 OODDD0000000 135.00 90 MG 317.69 0.00 O.OD 70.00 247.69 ID TOTALS: 317.69 0.00 O.DD 70.00 247.69 ' P~ENOTES PERFORMANCE MANAGEMENT FEE APPLIED ~~,o~s CAREMAI~K . IHFO POLICV NBR: TM55L852-01 BILL ACCT . p123 REPGRT-lD ,,123456 GROUP VICES A i R NUMBER IMSI NAGEMENT 5ER CARRIER ME INSURANCE t~ ..- FINANCIAL pETAIt REPORT pLL CLAIMS ~ SALES DENIED PAID INGREDIENT TAX OLAIM CLAIM COST COUNT COUM p,p0 4,797.31 0 45 SpdNSOR NA '. ABC COMPA TOTAL FDR GUENT NAME INVOICE ADJUSTMENT ADJUSTMENT COUNT COUNT 0 GROUP TOTALS PAGE. 21 41'Ai TIME ~ 00100!2008 DATE '. THROUGH ~ 10012000 CLAIMS PROCESSED FROM00! 00! Z0~ COST pHARM SHARE FEE 1,D99.78 44.40 gp19.87 TOTAL PAID CLAIMS TOTAL ADJUSTMENTS 0.00 3p19.87 NET TOTAL ~E~IA~` p.(lbee~`'tUYS~ Financial Detail Report _ ___ _ ___ _ _ The I*inaneial Itai[ Report pravi-:des a:' detailed kstirtg of aka Cl~i'1s en behalf;; of plan palcipants. A detail of paid claims, denied claims, and adjusted., elaim~ is pr~~~~~cf. ~, varier of report a€~d total options are availa~le* Following are definitions of each field on the Financial Detail Report: COLUMN DEFINITIONS + Pharmacy Number: The Caremark identification number of the pharmacy where the prescription was filled. + "Identification Number: The employee identification number, usually the Social Security Number. "Member of Employee Name: The name of the plan participant or patient. AGE: The age of the patient. CD: A code which denotes the patient's sex and relationship to the plan participant. Code will be blank for adjustments. Code definitions are as follows: MH =male holder FH =female holder MS =male spouse FS =female spouse MC =male child FC =female child MD =male dependent FD =female dependent + Rx Number: The unique number given a prescription by the pharmacist when the drug was dispensed. Physician Number: The prescribing physicians' identification number, usually the DEA number. Prescribing physician information is reported if it is transmitted to Caremark with the claim record. + Date Filled: The date the prescription was filled at the pharmacy. '*' Drug Name: The name of the drug dispensed. "' Drug Strength: The strength of the drug dispensed. "* Drug Form: The dosage form of the drug, e.g. tablet, liquid. *" Druo Code: The National Drug Code assigned to the prescription dispensed. uantit : The number of units dispensed. Day's Supply: The number of days for which the drug was dispensed. MSGB: Two letter code to denote the type of drug dispensed. Code definitions are as follows. SB: Single source innovator drug. MB: Multi-source branded drug. This is the brand name for a prescription that is no longer on patent. MG: Multi-source generic drug. It is a less expensive alternative to a multisource branded drug. Managed Access/Prior Authorization Indicator: One or two letter code to denote the type of Managed Access override or Prior Authorization used. Code definitions are as follows: CAREMA-F~tC /I ~: rl 51_tt F- d~"L.''1~,. 30 (Extended): MDP > 30% Disp: The percentage of claims dispensed with more than 30 days supply that were qualified to be dispensed at higher days supply. MDP > 30% Average Davs: The average days supply of the qualified maintenance drug program claims that were dispensed with more than 30 days supply. Information Management Reports -December 2004 1 ~ a v 0 3 m v 3 m O 3 N Q) N 3 N O O A KEY PERFORMANCE FACTORS REPORT REPORT-ID TMS1L652-O1 PAGE: 4 A/R NIIMBER CARRIER: GROIIP: TINE: 05.33.16 SPONSOR NAME: DATE: 11/OZ /2004 CLIENT NAME CLAIMS PROCESSED FROM 10/31/2003 THROIIGH 10/29/2004 MEMBER DRUG COST COST SHARE CLAIMS AMOUNT PMPM GENERIC TIME ELIGIBLE/ PAYABLE TOTAL AMOUNT/ TOTAL AMOUNT/ TOTAL AMOUNT/ CLAIMS/ i UTILIZ./ t DAN 1 k ANP/ k COST SFIARE t/ PERIOD k UTILIZING CLAIMS AVG PER CLAIM AVG PER CLAIM AVG PEA CLAIM CLAIMS AMT k SUBSTIT, t FORM. k U6C DENIED CLAIMS AMP t NDV 2003 9,657 5,961 318,819 80,097 238,721 1.28 46.1 25,9 79.1 7.1 25,1 45.8 57.98 13.44 40.05 51.26 90.7 91.5 6.6 74.9 DEC 2003 9,668 6,296 306,380 76,920 229,459 1.34 47.4 17.5 79.1 5.7 25.1 46.9 49.05 12,32 36.74 49.16 91.2 91.6 6.4 74.9 JAN 2009 6,521 7,605 410,710 103,707 307,002 1.17 48.0 28.7 77.8 6.6 25.3 42.3 54.01 13.64 40.37 47.OB 90.4 91.6 5,2 74.7 FBE 2004 6,433 8,293 463,443 115,634 347,809 1.29 48.0 25.4 77.7 6.8 25.0 44.3 SS.BB 17.99 41.94 59.07 90.2 90.8 5.3 75.0 MAR 2004 6,411 8,339 971,541 116,601 354,941 1.30 48.3 24.2 78.3 6.9 24.7 45,0 56,55 13.98 92.56 55.36 90.0 91.8 5,2 75,3 APR 2001 6,366 12,074 687,315 169,060 518,255 1.90 47.0 29,3 78.1 6.0 24.6 51.6 56.93 14,00 42.92 81.91 89.7 92.4 5,0 75.4 MAY 2004 6,166 8,052 507,148 118,727 388,420 1.29 46.4 21.9 78.4 6.8 23.4 45.0 fi2.9B 14.75 /8.24 61,99 89.7 91.9 5.1 76.6 JUN 2009 6,208 7,606 452,455 106,891 345,564 1.23 9fi,5 22.7 19.0 6.B 23.6 93.2 59.49 14.05 45.13 55.66 89.7 91.7 5.3 76.9 JUL 2004 6,164 7,344 429,689 104,012 325,677 1.19 47.6 23.2 78.3 6.9 24.2 92.9 58.51 14,16 44.35 52.84 89.6 92.2 5.9 75.8 AUG 2004 6,106 7,461 463,340 108,956 354,383 1.22 47.7 26.8 78.6 7.5 23.5 43.5 62.10 14.60 47.50 SB.01 90.1 92.1 5.6 76,5 SEP 2004 6,097 7,629 458,917 107,131 351,786 1.25 47.1 26.2 78.7 6.7 21.3 44.9 60.15 14,04 46.11 57.70 89,8 91.6 5.6 76.7 OCT 2004 6,066 11,930 742,055 767,371 574,683 1.97 48.4 27.0 78.5 6.3 22,6 91,8 62.20 14.03 48.17 94.79 90.1 91.6 5.3 77.4 TOTALS AND 71,963 98,540 5, 711, B1B 1,375,113 4,336,705 1.77 47.4 25.2 78.4 6.6 24.1 AVERAGES 45.5 57.96 17.95 44.01 60,26 90,0 91.7 5.5 75.9 5,997 AHEM ItC1~51~iI~t~S 2L1~~9 4~[x'lE' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 ~ 2 Denied Claims Summary Savings Report The Denied Claims Summary Report identifies savings resulting from claim denials. Caremark claim processing edits virtually eliminate unauthorized or imprudent use of the drug benefit. All denials occur at the .point of service Edits included on this report are grouped into three categories: ^ Eligibility edits deny claim payments when a plan participant or family member is not authorized by the plan to receive a drug benefit. ^ Plan design edits deny payments to plan participants or dependents when they try to obtain prescriptions that do not fall within their plan specifications. ^ Claim edits are denials associated with particular requirements of the claim itself, or are protection for the plan sponsor from paying claims more than once. Following are definitions of each field and formulas for each field which involve calculations on the Denied Claims Summary Savings Report: COLUMN DEFINITIONS Claims: The total number of claims in each category identified in the report. Percentage of Total Claims Denied: The claims in each denied claim category as a percentage of total denied claims. Formula: (Denied claims within the category =total denied claims) x 100 Percentage of Total Claims Submitted: The claims in each denied claim category as a percentage of all claims submitted to Caremark. Formula: (Denied claims =total submitted claims) x 100 Amount Denied: The drug cost for total submitted claims by the pharmacist and for denied claims. ROW DEFINITIONS Total Claims Submitted: The total number of claims submitted to Caremark by pharmacies or plan participants. All payable and denied claims as well as drug utilization review reversals are included in these claim counts Total Claims Denied Under DUR: The total number of denied claims and the dollar amount saved by drug utilization review alerts. Information Management Reports -December 2004 13 Denied Claims Summary Savings Report (continued) Eligibility Denials: Filled After Termination Date: Prescriptions filled after plan participant's termination of prescription benefit coverage. Filled After Expiration Date: Prescriptions filled after group's benefit expiration date. Spouse Not Eligible: Prescription filled for ineligible spouse or plan participant. Dependent Over Age Limit: Prescription filled for dependent who is older than age limit specified in plan design. Dependent Not Covered: Prescription filled for ineligible dependent of plan participant. Cardholder Not Eligible: Prescription filled for ineligible plan participant. Fill Prior to Effective Date: Prescription filled before group's benefit effective date. Total Eligibility Denials: The total number of denials as a result of eligibility edits. Plan Design Denials: Item Not Covered: Prescriptions filled for excluded drug. Refill Too Soon: Insufficient time interval between prescriptions for same drug. Refills Not Covered by Plan: Prescription refills not covered by plan design. Managed Access Auth. Rect.: Prescription or prior authorization needed to pay claim. Prescriber Not Covered by Plan: Doctor's prescriptions not covered by plan. Total Plan Design Denials: The total number of denials as a result of plan design edits. Claim Edit Denials: Already Paid: Claim was already paid on a previous claim payment cycle. Stale Dated: Claim is received 12 months after date of fill. Incomplete Directs: Claims submitted by plan participants have insufficient information to be processed. Duplicate Claim: Claim was already paid during the same Caremark payment cycle. Total Claim Edit Denials: The total number of denials as a result of claim edits. Total Other Claims Denied: The total number of claims denied due to other miscellaneous reasons. Total Claims Denied Excluding DUR: The total number of denied claims and dollar amount saved by submitted claims not involving a drug utilization review alert. Total Claims Denied: The grand total of denied claims for all reasons. Information Management Reports -December 2004 14 0 3 m 0 v m m 3 m 3 A m 0 O m n m 3 Q m N 0 0 A REPORT-ID A/R NUMBER SPONSOR MANS CLIENT NAME DENIED CLAIMS SUMMARY SAVINGS REPORT : TMS1L655-01 BY DECREASING DENIED AMOUNT PAGS• 1 CARRIER: ALL GROUP: ALL TIME: 20.35.92 DATE: 11/14/2004 CLAIMS PROCESSED FROM 10/01/2004 THROUGH 10/31/2004 ~ OF ~ OF TOTAL TOTAL CLAIMS CLAIMS AMOUNT CLAIM9 DENIBD SUBMITTED DENIED TOTAL CLAIMS SUBMITTED 180,430 TOTAL CLAIMS D8NI8D DNDER DDR 18,261 72.55 10.12 1,779,473.87 FILLED AFTER TBRMINATION DT8 2,699 10.72 1.49 192,759.18 FILL PRIOR TO EFFECTIVE DATE 17 .06 .00 1,341.51 SPOUSB NOT ELIGIBLE 0 .00 .00 .00 CARDHOLDER NOT BLIGIBLS 0 .00 .00 .00 FILLBD AFT8R EXPIRATION DATE 0 .00 .00 .00 DEPENDENT NOT COVSRBD 0 .00 .00 .00 DEPENDENT OVER AGS LIMIT 0 .00 .00 .00 TOTAL BLIGIBILITY DENIALS 2,716 10.79 1.50 194,100.69 ITEM NOT COV8R8D BY PLAN 2,656 11.34 1.58 231,252.29 REFILL T00 SOON 942 3.74 .52 90,010.11 PRIOR AUTHORIZATION RBQVIRBD 152 .60 .OB 53,431.08 RBFILLS NOT COVERED SY PLAN 0 .00 .00 .00 PRESCRIBBR NOT COVSRBD BY PLAN 0 .00 .00 .OD ITEM NOT COV8R8D BY MGD ACC 0 .00 .00 .00 TOTAL PLAN DBSIGN DBNIALS 3,950 15.69 2.18 379,693.48 ALREADY PAID 91 .36 .OS 9,737.88 INCDMPLETE DIRECTS 1 .00 .00 .00 STALE DATED 0 .00 .00 .00 DUPLICATB CLAIM 0 .00 .00 .00 TOTAL CLAIM EDIT DENIALS 92 .36 .OS 9,737.68 TOTAL OTHER CLAIMS DENIED 149 .59 .08 9,744.72 TOTAL CLAIMS DENIED SXCL DUR 6,907 3.62 588,276.77 TOTAL CLAIMS DENIED 25,168 13.94 2,367,750.69 1t ~r1p stc7ris undr ct~' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 16 Carrier/Group Summary Report The CarrieNGroup Summary Report summarizes cost and utilization data by employer group. This allows. comparisons to be made between each group and over-all utilization. Following are definitions of each field and formulas for each field, which involve a calculation on the Carrier/Group Summary Report: COLUMN DEFINITIONS Carrier Name: Name of individual divisions of business. Carrier ID#: Numeric indicator that defines individual divisions of business within a carrier. Eligible Emplovees (Membersl: The number of eligible employees or members (if eligibility is tracked at the dependent level). Percentage of Utilizing Emplovees (Members): The percentage of employees or members (if eligibility is tracked at the dependent level) who have submitted one or more claims. Payable Claims: The total number of payable claims including those paid by the plan sponsor and participant. Average Cost Share per Claim: Average amount paid by the plan participant for each claim. Average Amount Paid per Claim: Average amount paid by the plan sponsor for prescription drugs. Claims (Per Member Per Month) PMPM: The number of payable claims per employee (member) per month. Amount Paid (Per Member Per Month) PMPM: The plan cost per employee (member) per month. Cost Share Percentage: The percentage of drug cost paid by the plan participant. Amount Paid Percentage: The percentage of drug cost paid by the plan sponsor. Information Management Reports -December 2004 17 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 18 0 3 v 0 v v m 3 m m 0 y 0 N O N 3 N N O O A REPORT-ID TM53L653.O1 A/R NUMBER SPONSOR NAME: CLIENT NAME CARRIER/GROUP SUMMARY REPORT PAGE: 1 TIME: 07.11.24 DATE: 11/02/2004 CLAIMS PROCESSED BETWEEN 09/17/2004 AND 10/29/2009 fiLIGIBLE t UTILIZING PAYABLH COST SHARE AMOUNT PAID CLAIMS AMOUNT PAID COST ANOUNS' NAME ID q MEMBERS MEMBERS CLAIMS PER CLAIM PER CLAIM PMPM PMPM SHARE } PAID t 4,721 75.8 16,735 18.77 50.55 3.54 178.96 27,1 77.9 1,025 fi4.8 3,048 17.20 99.66 2.97 296.35 11.7 88.3 136,163 42.6 154,951 16.03 56.33 1.14 64.10 22.2 77.8 217,984 41,8 237,745 18.92 52.10 1.09 56.82 26.6 73.4 TOTALS: 359,899 42.6 412,479 17.79 53.97 1.15 61.86 24.8 75.2 GRAND TOTALS: 892,0.69 4D.3 1,040,634 13.36 53.31 1.17 62.36 20.0 80.0 AHEM ~t LT~Stit'F'~J Z(llt{9 G[~lf' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 20 Pharmacy Activity Summary Report The Pharmacy Activity Summary Report lists high volume pharmacies in descending order of claims paid. This information can be used to evaluate the effectiveness of preferred provider networks.. A subtotal of chain and independent pharmacies is provided. Following are definitions of each field and formulas for each held, which involve a calculation on the Pharmacy Activity Summary Report: Pharmacv Number: The Caremark identification number of the pharmacy where the prescription was filled. Pharmacv Name: The name of the pharmacy where the prescription was filled. Payable Claims: The total number of payable claims including those paid by the plan sponsor and participant. Utilizing Members: The number of plan participants obtaining prescriptions at a given pharmacy. Ingredient Cost: Total Ingredient Cost Paid: Total ingredient cost paid. Ingredient Cost Average per Claim: Ingredient cost per payable claim. Formula: Ingredient cost _ number of payable claims Drug Cost: Total Drug Cost Paid: The total dollar amount paid for prescriptions, including ingredient cost, dispensing fee, applicable performance fee, and sales tax. Formula: Ingredient cost paid + dispensing fee + applicable performance fee + sales tax Drug Cost Average per Claim: Drug cost per prescription dispensed. Formula: (Ingredient cost paid + dispensing fee + applicable performance fee + sales tax) number of payable claims Cost Share: Cost Share Amount: The amount saved by the plan sponsor as a result of participant cost sharing (coinsurance, deductibles, benefit maximums, etc.). Formula: Front end deductible amount paid by participant + coinsurance + benefit maximum + copayment/stop loss Cost Share Average per Claim: Average amount paid by plan participant for each prescription dispensed. Formula: Total amount paid by plan participant _ number of payable claims Information Management Reports -December 2004 21 Pharmacy Activity Summary Report (continued) Amount Paid: Total Amount Paid: The total amount paid by the plan sponsor for prescription drugs. Formula: (Ingredient cost paid + dispensing fee + sales tax) -participant cost share amount Amount Paid Average per Claim: Average amount paid by the plan sponsor for each claim. Formula: Total amount paid by the plan sponsor -payable claims Percentage of AWP: Indicates the percentage of the average wholesale price (AWP). Formula: (Ingredient cost paid =full average wholesale price) x 100 Percentage of Usual ~ Customarv: The percentage of usual and customary price when applicable. Formula: (number of claims =total number of claims) x 100 Percentage of Maximum Allowable Cost: The percentage of multi-source drugs that have been influenced by the generic incentive program. Formula: (number of MAC claims _number ofmulti-source claims) x 100 Percentage of Dispensed as Written: The percentage of multi-source drugs that are dispensed as written (DAW ). Formula: (number of DAW claims =number ofmulti-source claims) x 100 Percentage of Generic Utilization: The percentage of claims that are dispensed generically. Formula: (number of generic claims _ number of total claims) x 100 Percentage of Generic Substitution: The percentage ofmulti-source claims that are dispensed generically. Formula: (number of generic claims - number of multi-source claims) x 100 Average Days Supply: Average days prescribed for the drug. MDP Extended: Percentage Dispensed: The percentage of claims dispensed with more than 30 days supply that were qualified to be dispensed at higher days supply. Average Davs Supply: The average days supply of the qualified maintenance drug program claims that were dispensed with more than 30 days supply. Information Management Reports -December 2004 22 3 3 v 0 3 v v m 3 m A O1 0 N C7 N O N 3 N N O O A N W PHARMACY ACTIVITY SUMMARY REPORT -TOP 200 PHARMACIES BY DECREASING CLAIM COST ALL CLAIMS REPORT-ID TM53L625-O1 A/R NUMBER CARRIER: ALL GROUP: ALL SPONSOR NAME: CLIENT NAME PAGE: 1 TIME: 00.02.22 DATE: 11/14/2009 CLAIMS PROCESSED BETWEEN 10/01/2009 AND 10/31/2004 MDP ING. COST DRUG COST COST SHARE AMOUNT PAID GENERIC BXTfiNDED PHARMACY ID / PAYABLE UTILISING TOTAL AMOUNT/ TOTAL AMOUNT/ TOTAL AMOUNT/ TOTAL AMOUNT/ t AWP/ 4 MAC/ k UTIL./ AVG DAYS t DISP./ PHARMACY NAME CLAIMS MEMBER AVG PER CLAIM AVG PER CLAIM AVG PER CLAIM AVG PfiA CLAIM t UBC t DAW t BUGS. SUPPLY AVG DAYS 1 12,178 5,045 1,941,394 1,941,394 369,625 1,571,768 TD.7 42.2 31.2 B6 159.{2 159.42 30.35 129.07 O.D 9.1 88.1 2 358 326 561,190 561,141 8,971 552,669 82,0 0,0 1.4 28 1,567.43 1,567.93 23.66 1,543.71 1.1 0.0 100.0 3 6,067 1,956 370,920 372,794 87,695 285,099 19,0 44.5 43.3 26 61.14 61.45 14.45 46.99 0.8 6.4 93.2 4 4,952 1,6{9 301,193 305,556 72,749 232,807 79.8 39.0 41.2 26 fi1.42 61.70 11.69 47.01 0.8 B.0 91.7 5 3,648 1,113 234,184 235,207 53,166 182,041 79.7 40.8 {1.5 26 64.20 64.98 31.57 49.90 2.5 8.1 91.8 6 3,741 1,302 213,217 219,372 53,176 161,196 78.5 39.4 41.6 25 56.95 57.26 11.20 43.05 0.8 fi.5 93.3 7 3,465 1,250 212,138 213,197 50,719 162,173 79.4 39.8 43.5 24 61.22 61.57 14,64 96.89 0.6 6,6 97.0 8 2,661 864 159,510 160,362 37,490 122,872 78.0 79.5 46.1 25 59.94 60.26 14.09 46.18 0.7 5.4 99.2 9 2,227 737 1)6,732 137,469 33,292 lO6,I2] 79.1 93,1 45.2 35 61.40 61.73 14.03 47.70 D.3 4.9 94.4 10 2,170 714 173,082 133,727 30,698 103,028 79.7 36.0 43.5 25 62.48 62.78 14.41 48.37 0.9 9.0 90.5 11 2,248 783 1)2,725 133,434 32,257 101,176 79.2 38.5 93.9 25 59.04 59.36 14.35 45.01 0.2 4.9 93.5 12 2,310 716 170,453 131,150 32,033 99,116 78.3 44.5 42.7 26 56.47 56.77 13.87 42,91 0.9 7.5 91.8 13 2,203 698 130,106 130,763 )0,784 99,979 78.7 41.9 41.9 26 59.06 59.36 13.97 45.38 0.6 6.6 92.9 14 2,109 698 122,094 122,690 70,549 92,141 78.0 46.2 41.9 26 57.89 58.17 11,49 41.69 2.4 7,0 92.8 15 1,947 637 119,687 120, 3D1 26,929 93,371 79.6 44,6 44.3 26 61.47 61.79 13.87 47.96 0.8 6.2 93.6 16 1,869 662 116,897 117,441 26,691 90,799 80.0 40.4 41.0 26 62.55 62.84 19.28 48.56 0.4 7,8 91.5 }l c7I~ Sk2t'1S tt~lli~J t47tC~ s 0 3 m 0 m m m 3 m A W a 0 .l N O N O 0) Q O) N O O A A PHARMACY ACTIVITY SUMMARY REPORT -TOP 200 PHARMACIES BY DECREASING CLAIM COST ALL CLAIMS REPORT•ID TM53L625-O1 A/R NUMBER CARRIER: ALL GROUP: ALL SPONSOR NAME: CLIENT NAME PAGE: 14 TIME: 00.02.22 DATfi: 11/14/2004 CLAIMS PROCESSED BETWEEN 10/01/2004 AND 10/31/2004 ~. MDP ING. CGST DRUG COST COST SNARE AMOUNT PAID GENERIC EXTENDED PHARMACY ID / PAYABLE UTILIZING TOTAL AMOUNT/ TOTAL AMOUNT/ TOTAL AMOONT/ TOTAL AMOUNT/ t AWP/ }MAC/ t UTIL./ AVG DAYS k DISP./ PHARMACY NAME CWIMS MEMBER AVG PER CLAIM AVG P8R CLAIM AVG P8R CLAIM AVG PER CLAIM } U6C } DAW } SUBS, SUPPLY AVG DAYS TOP 200 150,099 10,942,622 10,984,398 2,359,112 8,629,286 77.3 40.9 12.9 30 AR TOTALS 72.92 73.20 15.69 57.51 1.3 6.0 93.2 NON TOP 200 12,131 672,522 677,079 178,740 498,338 78.0 40.9 48.1 25 AR TOTALS 54.99 55.36 14.61 40.74 2.8 5.1 93.7 TOTAL 162,290 11,615,345 11,661,477 2,53),852 9,127,625 77.3 40.9 93.3 30 AR TOTALS 71.57 71.86 15.61 56.24 1.4 5.9 93.2 ~~~~~~~i h all strrrks wrt#i L4?ItC` a 3 v 0 v v m 3 m m V 0 Ut C1 O1 O W Q 01 N O A REPORT-ID TM53L625-O1 A/R NUMBER CARRIER: SPONSOR NAME: CLIENT NAME PHARMACY ACTIVITY SUMMARY REPORT -TOP 20 CHAINS BY DECREASING CLAIM COST - ALL CLAIMS PAGE: 1 TIME: 04.29.49 DATE: 10/03/2004 CLAIMS PROCESSED BETWEEN 07/01/2004 AND 09/30/2004 N N GROUP: ALL ING. COST DRUG COST CDST SNARE AMOUNT PAID GENERIC CHAIN ID / PAYABLE ULILIEING TOTAL AMOUNT/ TGTAL AMOUNT/ TOTAL AMOUNT/ TDTAL AMODNT/ 1 AWP/ k MAC/ 4 UTIL./ AVG DAYS CHALN NAME CLAIMS MBMBER AVG PBR CLAIM AVG PER CLAIM AVG PBR CWLM AVG PBA CLAIM t UBC k DAN t SUBS. SUPPLY 1 2,970,553 794,984 164,187,783 169, 969, 63fi 91,724,709 128,639,927 76.4 57.8 46.6 29 55.27 57.22 13.91 93.31 2.9 6.9 87.8 2 2,019,495 700,830 307,638,704 110,758,912 27,711,426 83,047,516 76.1 63.2 48.3 29 53.30 54.84 13.72 41.12 3.3 7.5 91.1 3 1,381,881 516,361 78,970,379 81,811,047 20,126,795 61,684,252 76.1 64.8 49.8 32 57.15 59.20 14.56 44,64 3.1 11.5 87.6 4 1,230,548 946,255 64,543,845 66,745,053 16,907,011 49,838,041 76.3 SB.7 47.3 31 52.45 54.29 13.79 40,50 12.0 6.J 91.8 5 823,722 287,415 46,375,897 47,941,254 11,982,364 35,958,889 76.1 66,9 47,1 32 56.25 58.20 14.55 43.65 0.7 6.9 89.7 6 724,782 227,226 37,/82,390 38,958,428 9,421,548 29,536,879 75,7 66.1 44.9 29 51.72 53.75 13.00 40.75 ].3 11.6 87.3 7 412,613 154,018 28,904,027 29,502,971 7,227,603 22,274,870 77.8 62.4 40.7 3B 70.05 71,50 17.52 53.98 2.9 15.2 81.4 8 461,871 156,233 25,142,174 25,810, SB6 6,487,609 19,)22,977 75.7 62.8 45.7 31 59.44 55,89 14.05 41.84 2.] 9.7 89.9 9 459,305 151,582 24,902,470 25, BSD, 305 6,309,931 19,540,274 75.3 66.4 47.2 32 54.22 56.28 13.74 12.54 3.6 9.9 88.7 10 291,157 85,966 17,229,562 17,870,657 4,323,911 13,546,742 76.8 63.5 44.4 72 59.18 61.78 14.85 46.53 2.6 8.4 87.4 11 261,410 83, 6fi9 13,410,787 13,736,014 3,423,862 10,312,151 74.3 65.5 47.5 31 50.72 51.95 12.95 79.00 3.2 8.8 90.4 12 171,950 48,627 9,413,194 9,681,630 2,381,262 7,306,368 75.0 66.1 46.9 31 52.90 54.44 17.38 41.06 1.5 B.0 88.9 13 134,938 50,673 8,987,839 9,244,858 2,272,419 6,972,438 78.3 60.6 40.9 36 66.61 68.51 16.84 Sl.fi7 3.0 14.7 89.1 19 146,038 47,861 8,090,534 8,296,281 2,088,096 6,208,185 77.2 62,5 43.3 30 55.10 56.81 14.10 92.51 4,9 B.9 90.0 15 136,713 56,946 7,583,768 7,8D2, 360 1,989,059 5,813,300 76.2 56.1 45.5 32 55.47 57.07 14.55 42.52 10.4 9.5 A9.3 16 126,792 42,577 7,462,699 7,716,107 1,882,902 5,833,205 75.5 68.6 98.8 34 59.07 61.07 14.90 46.17 1.2 9.9 89.5 ~~~/~~~i~1~~~Ll~l~~~~ }t rtit stitr~Cs ux~r 4lattir' 0 3 0 m m m m O1 V 0 N 0 0l N 3 O' 0l N O O A N m REPORT•ID TM53L625-D1 A/R NUMBER CARRIER: SPONSOR NAME: CLIENT NAME PHARMACY ACTIVITY SUMMARY REPORT -TOP 20 CHAINS BY DECREASING CLAIM COST ALL CLAIMS GROUP: ALL PAGE: 2 TIME: 04.29.49 DATE: 10/03/2009 CLAIMS PROCESSED BETWEEN 07/01/2004 AND 09/30/2004 I116. COST DRUG CGST COST SHARE AMOUNT PAID GENERIC CAAIN ID / PAYABLE UTILIZING TOTAL AMOUNT/ TOTAL AMOUNT/ TOTAL AMOUNT/ TOTAL AMOUNT/ k AWP/ t MAC/ k UTIL.I AVG DAYS CHAIN NAME CLAIMS MEMBER AVG PER CLAIM AVG PER CWIM AVG PER CWIM AVG pER CLAIM 1 U6C 1 DAW k SUBS. SUPPLY 17 131,979 44,823 7,298,646 7,502,457 1,878,793 5,623,664 76.6 63.8 42.0 30 94,92 56.85 14.24 42.61 1.4 11.7 87,0 18 129,891 38,968 6,448,513 fi,632, 919 1,656,333 4, 97fi,586 76.0 69.1 41.9 29 51.22 52.69 13.16 39.53 1.6 10.8 88.4 19 124,412 47,875 6,344,331 6,569,707 1,675,991 4,893,716 73.8 63.8 53.4 30 50.99 52.81 17.47 39.33 6.0 5.8 93,4 20 97,348 29,664 5,295,457 5,481,295 1,367,232 4,114,062 77.3 59.6 41.9 Z9 54.90 56.31 14.04 42.26 2.8 15.8 82.6 halt starts uardr r4rr1?' QUANTUM Alert Performance Summary Report The QUANTUM Alert Performance Summary Report summarizes activity of the point-of-sale drug utilization review (POS DUR) program. Statistics are provided for the current month and 12-month period. The report- includes general client information, DUR activity statistics (for paid, reversed and rejected claims with DUR alerts) and grand totals far all DUR activity. Following are definitions of each field on the QUANTUM Alert Performance Summary Report: ROW HEADINGS Elig Lives: Eligible Lives. The total number of eligible lives on the POS DUR program during the current reporting month. Util Members: Utilizing Members. The number of members who utilized their drug benefit during the current reporting month. Current Mo: Current Month. Data for the current reporting month. Last 12 Mo: Last twelve months. Cumulative data for the current 12-month period. COLUMN HEADINGS # Paid Claims 8 Cost: The total number of claims paid (with and without DUR alerts). The adjudicated claim cost for all paid claims (with and without DUR alerts). # Reversed Claims 8 Cost: The total number of claims reversed by the dispensing pharmacy (with and without DUR alerts). The adjudicated claim cost for all reversed claims (with and without DUR alerts). # Reiected Claims & Cost: The total number of claims rejected by the adjudication system (for DUR or non-DUR reasons). The adjudicated claim cost for all rejected claims (for DUR or non-DUR reasons). DUR ACTIVITY SECTIONS Paid Claims: This section provides information on paid claims with DUR alerts. Reversed Claims: This section provides information on paid claims with DUR alerts that were reversed by the dispensing pharmacy. Reiected Claims: This section provides information on claims that were rejected by the POS DUR system. ROW HEADINGS DUR Alert Edit: This column lists the types of DUR edits which occurred. Drug Age: Drug may be contraindicated due to the member's age. Drug-Drug Inter: The drug interacts with another drug being taken by the member. Drug Pregnancy: High-risk drug that causes birth defects or a contraindicated drug when the patient history indicates pregnancy. Information Management Reports -December 2004 27 QUANTUM Alert Performance Summary Report (continued) Drug Disease: Drug may be contraindicated due to a medical condition of the member. Disease states are inferred from drug therapy. Late Refill: The member is refilling the prescription late. May indicate non-compliance with therapy. Therapeutic Dup: Two drugs, or two different strengths of the same drug, taken by the member represent duplicative therapy. Drug Allergy: Possible allergy to the medication being dispensed. This edit requires clients to provide member's drug allergy history. Low Daily Dose: The dose being taken is below the normally recommended minimum dose. Non-CS High Daily Dose: The drug is not a controlled substance. The dose is above the normally recommended maximum dose. CS Excessive Claims: The drug is a controlled substance. The member has received at least four refills of the drug in the last 90 days. CS High Daily Dose: The drug is a controlled substance. The dose is above the normally recommended maximum dose. Non-CS Excessive Util: The drug is not a controlled substance. The member is refilling the prescription too early. This may represent excessive use of the drug or non-compliance with therapy. CS Excessive Util: The drug is a controlled substance. The member is refilling the prescription too early. This may represent excessive use of the drug ornon-compliance with therapy. Total: The total number of individual edits for each column. Net Claims: The net total of each column based on unique claims. If a claim has more than one DUR alert, it will only be counted once to calculate number of claims, percent of claims with DUR alerts, and claim costs for the Net Claims totals. Grand Total: The sum of the "Total" lines from the Paid Claims, Reversed Claims and Rejected Claims sections of the report. Net Grand Total: The sum of the "Net Claims" lines from the Paid Claims, Reversed Claims and Rejected Claims sections of the report. COLUMN HEADINGS # of DUR Alerts: The total number of DUR alerts generated by the POS DUR system. # Claims w/DUR Alerts: The total number of claims that generated one or more DUR alerts by the POS DUR system. DUR Alert: The percent of total claims (total paid claims + total reversed claims) that had DUR alerts. Claims Cost: The adjudicated claim cost of claims that had DUR alerts. MTD: Month-to-date. Data for the current reporting month. Last 12 Months: Cumulative data for the current 12-month period. Information Management Reports -December 2004 28 0 3 m o' 3 m m m 3 m A m 0 N v m m 3 m N 0 0 A N l QUANTUM ALERT PERFORMANCE / MONTHLY SUMMARY RUN DATE: 11/30/2004 ID: TP89L312-O1 DRUG UTILIZATION REV IEW FOR CYCLE MONTH ENDING 11/ 26/2004 PAGE: 1 CARRIER: q PAID CLAIMS & COST ~ REVERSED C LAIMS & COST # REJECTED CLAIMS & COST ELIG LIVES 1,365 CURRENT MO 1,449 $87,373.37 7T $4,013,40 54 $1,404.42 UTIL MBRS 563 LAST 12 MO 18,596 $1,052,252.34 1,134 $74,223.48 915 $20,373.03 LAST 12 LAST 12 LAST 12 LAST 12 DUR ALERT EDIT MTD MONTHS MTD MONTHS MTD MONTHS MTD MONTHS DRUG AGE 30 386 30 386 1.96 1.95 $2,201.60 $26,376.33 DRUG-DRUG INTER 59 501 44 369 2.88 1.87 $2,080.76 $14,988.15 DRUG PREGNANCY 41 530 41 530 2.68 2.68 $3,394,40 $26,955.91 DRUG DISEASE 50 638 40 484 2.62 2.45 $763.43 $11,028.79 LATE REFILL 70 715 70 715 4.58 3.62 $2,847,75 $32,724.59 THERAPEUTIC DUP 223 3,161 183 2,483 11.99 12.58 $6,508.95 $81,069.94 DRUG ALLERGY 00 00 00 00 0.00 0.00 $0.00 $0.00 LOW DAILY DOSE 11 140 11 140 0.72 0.70 $96.06 $1,002.43 NON-CS* HIGH DAILY DOSE OB 112 08 112 0.52 0.56 $611.90 $7,440.21 CS* HIGH DAILY DOSE 04 64 04 64 0,26 0.32 $128.51 $1,793.59 NON-CS* EXCESSIVE UTIL DO 00 00 00 0,00 0.00 $0.00 $0.00 CS* EXCESSIVE UTIL 00 00 00 00 0.00 0.00 $0.00 $0.00 CS* EXCESSIVE CLAIMS 05 55 OS 55 0.32 0.27 $42.75 $605.05 TOTAL: 501 6,302 436 5,336 28.57 27.05 $18,676.11 203,984.99 NET CLAIMS: 373 4,581 24.44 23.21 $16,459.01 ,175,926.99 DRUG AGE ~ 00 22 00 22 0.00 0.11 $0,00 $1,910.28 DRUG-DRUG INTER O1 21 O1 16 0.06 0.08 $16.56 $656.18 DRUG PREGNANCY OS 36 OS 36 0.32 0.18 $1,343.02 $2,989.01 DRUG DISEASE 04 64 04 40 0.26 0.20 $62.47 $806.89 LATE REFILL 04 35 04 35 0.26 0.17 $56.84 $1,024.38 THERAPEUTIC DUP 13 176 11 136 0.72 0.68 $385.02 $5,178.57 DRUG ALLERGY 00 00 00 00 0.00 D.00 $0.00 $0.00 LOW DAILY DOSE 02 13 02 13 0.13 0.06 $0.00 $229.80 NON-CS* HIGH DAILY DOSE OS 16 OS 16 0.32 0.08 $195.19 $575.44 CS* HIGH DAILY DOSE 00 03 00 03 0.00 0.01 $0.00 $2.47 NON-CS* EXCESSIVE UTIL 00 00 00 00 0.00 0.00 $0.00 $0.00 CS+ EXCESSIVE UTIL 00 00 00 00 0.00 0.00 $0.00 $0.00 CS* EXCESSIVE CLAIMS 00 02 00 02 0.00 0.01 $0.00 $100.31 TOTAL: 34 388 32 319 2.D9 1.61 $2,059.12 $13,473.33 NET CLAIMS: 26 278 1.70 1.90 $1,943.42 $12,479.01 NON-CS* EXCESSIVE UTIL 31 386 31 386 2.03 1.95 $1,404.42 $20,296.67 CS* EXCESSIVE UTIL 00 07 00 07 0.00 0.03 $0.00 $76.36 TOTAL: NET CLAIMS: 31 393 31 31 393 2.03 1.99 $1,404.42 $20,373.03 393 2.03 1,99 $1,404.42 $20,373.03 GRAND TOTAL: 566 7,083 499 NET GRAND TOTAL: 430 * CS = CONTROLLED SUBSTANCE NON-CS = NON CONTROLLED SUBSTANCE ~ CALCULATION USES PAID + REVERSED CLAIMS AS THE DENOMINATOR 6,050 32.69 30.66 $22,139.65 $237,831.35 5,252 28.17 26.61 $19,806.85 $208,779.03 ~~~~~. jt ~1 StaflfS WII~J ~'*?!! THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 30 QUANTUM Alert Drug Therapy Impact /Outcome Report The QUANTUM Alert DUR Impact/Outcome Report assesses the overall effectiveness of the point-of-sale drug utilization review (POS DUR) program as measured by changes in drug therapy following DUR alerts to network pharmacies. Data provided is for current quarter and for the calendar year-to-date period. Following are definitions of each field and formulas for each field, which involve a calculation on the QUANTUM Alert DUR Impact/Outcome Report: COLUMN HEADINGS Current Quarter: Quarter-to-date. Data for the current reporting quarter. YTD: Calendar year-to-date. Data for the current reporting year. ROW HEADINGS No. Alerts Issued: The total number of DUR alerts generated by the POS DUR system. No. DUR Alerts Reversed: The total number of claims with DUR alerts reversed by the dispensing pharmacy. No. Alerts Resolved or Therauv Discontinued: The total number of DUR alerts that did not recur for the same member/drug during subsequent fills, or the drug involved in the DUR alert was discontinued. Total No. Positive Chans~es: The total number of positive changes. Formula: number of dur alerts reversed + number of alerts resolved or therapy discontinued Percent of DUR Alerts Resolved: The percentage of DUR alerts in which a positive change was measured. Formula: (total number of positive changes _ number of alerts issued) x 100 No. EU Alerts Issued: The total number of Excessive Utilization alerts and associated claim rejects generated by the POS DUR system. The Excessive Utilization edit monitors for members refilling prescriptions too early, this may represent excessive use of a drug ornon-compliance with therapy. No. EU Claims Not Paid: The total number of claims rejected by the POS DUR system for Excessive Utilization, which are not paid (i.e. no override of the reject occurred). Percent EU Claims Not Paid: The percentage of claims rejected by the POS DUR system for Excessive Utilization, which are not paid (i.e. no override of the reject occurred). Information Management Reports -December 2004 31 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 32 DATE 09/27/2004 ID: TP89L436-O1 Drug Utilization Review (DUR) Services PAGE 1 QUANTUM Alert Concurrent DUR Program DUR Impact/Outcome Report ------------------------- For the Quarter Ending 09/2004 CARRIER THE FOLLOWING DATA REPRESENT POSITIVE CHANGES IN DRUG THERAPY MEASURED THIS QUARTER FROM DUR ALERTS ISSUED DURING THE PREVIOUS QUARTER ENDING 06/2004 CLINICAL DUR ALERTS: No. Alerts Issued No. DUR Alerts Reversed No. Alerts Resolved or Therapy Discontinued Total No. Positive Changes Percent of DUR Alerts Resolved EXCESSIVE UTILIZATION (EU) ALERTS: No. EU Alerts Issued No. EU Claims Not Paid Percent EU Claims Not Paid CURRENT YTD QUARTER ----------------- ------------- 1,364 3,960 83 226 255 848 338 1,074 24.8 27.1 CURRENT YTD QUARTER ------------------------------ 102 292 102 292 100.0 100.0 dt~+ 5$s2Y1~ t~C'1T~7 CE3t~'" Information Management Reports -December 2004 33 `err THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 34 QUANTUM Alert DUR Cost Savings Report The QUANTUM Afert ..DUR Cost Savings Report summarizes drug costs savings for the client by three drug u#ilization review (DUR) edits that are directed toward reducing drug utilization. These three edits are Therapeutic Duplication (duplicative/redundant drug therapy); High Daily Dose (high drug doses); and Excessive Utilization (excessive or early refills of prescriptions by members). Statistics are provided for Drug Cost Savings measured within the current quarter from DUR alerts issued during the previous two quarters. Following are definitions of each field and formulas for each field, which involve a calculation on the QUANTUM Alert DUR Cost Savings Report: COLUMN HEADINGS Current Quarter: Quarter-to-date. Data for the current reporting quarter. YTD: Calendar year-to-date. Data for the current reporting year. ROW HEADINGS Duplicative/Redundant drug therapy: Estimated drug cost savings from reduction or resolutions of duplicative drug therapies following Therapeutic Duplication DUR alerts to pharmacies. High Drug Doses: Estimated drug cost savings from reduction of drug doses following High Daily Dose DUR alerts to pharmacies. Excessive or Early Refills: Estimated drug cost savings from claim rejects by the Excessive Utilization DUR edit. Total DUR Savings: Sum of the three DUR edits Formula: duplicative/redundant drug therapy + high drug doses + excessive or early refills Total DUR Cost Savings: Sum of the three DUR edits DUR Savings Per 100 Eligible Lives: DUR savings based on aper-100-lives parameter. Formula: (total dur savings =total eligible lives) x 100 DUR Savings Per 100 Total Claims: DUR savings based on aper-100-claims parameter. Formula: (total dur savings =total claims) x 100 DUR Savings as Pct of Total Claim Costs: The percentage of DUR savings of the total drug program costs paid by the client. Formula: (total dur savings : total drug program cost) x 100 Ratio: DUR Savings to Cost of DUR: Measurement of return on investment based on savings achieved compared to fees paid for the POS DUR program. If no DUR fees were paid, ratio may still be calculated. Formula: (total dur savings =total dur fees paid) : 1 Information Management Reports -December 2004 35 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 36 DATE 09/27/2004 ID: TP89L437-O1 Drug Utilization Review (DUR) Services PAGE 1 QUANTUM Alert Concurrent DUR Program DUR Cost Savings Report ----------------------- For the Quarter Ending 09/2004 CARRIER THE FOLLOWING DATA REPRESENT DRUG COST SAVINGS MEASURED THIS QUARTER FROM DUR ALERTS ISSUED DURING THE PREVIOUS TWO QUARTERS ENDING 03/2004 AND 06/2004 DUR SAVINGS Savings Achieved from Management of: ---------------------------------------- CURRENT QUARTER Duplicative/Redundant drug therapy $18,026.98 High Drug Doses $1,106.16 Excessive or Early Refills $2,273.09 ---------------------- TOTAL DUR SAVINGS $21,406.23 COST BENEFIT ANALYSIS Total DUR Cost Savings DUR Savings Per 100 Eligible Lives DUR Savings Per 100 Total Claims DUR Savings as Pct of Total Claim Costs Ratio: DUR Savings to Cost of DUR YTD $49,869.23 $3,805.58 $6,781.67 $60,456.48 CURRENT YTD QUARTER ---------------------------------------- $21,406.23 $60,456.48 $1,647.90 $4,538.77 $467.28 $401.62 8.02 7.43$ 0.00 to 1 0.00 to 1 ~~~~~If^~~~~~i h t:11 s-Gsrt~ a. nth z carte Information Management Reports -December 2004 37 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 38 Drug Utilization Summary Report The Drug Utilization Summary Report identifies data on the most frequently dispensed drugs. Among the uses of this report is the ability to identify opportunities for physician intervention, generic substitution, etc. Following are definitions of each field and formulas for each field which involve a calculation on the Drug Utilization Summary Report: Drug Name: The name of the drug. Strength: The strength of the drug. Form: The dosage form of the drug, e.g. tablet, liquid, etc., indicated by numerical code. There are more than 60 commonly used drug form codes. Drug Code: The national drug code assigned to the prescription dispensed. Manufacturer: The drug manufacturer. Drug Type: 'Two-letter code to denote the type of drug dispensed. Code definitions are as follows: SB: Single source innovator drug. MB: Multi-source branded drug. This is the brand name for a prescription that is no longer on patent. MG: Multi-source generic drug. It is a less expensive alternative to multi-source branded drug. Pavable Claims: The total number of payable claims including those for which the plan sponsor and plan participant are responsible. Percentage of Pavable Claims: The percentage of payable claims for the drug listed. Ingredient Cost: Total ingredient costs for the drug listed. Ingredient Cost Average per Claim: Ingredient cost per prescription dispensed. Formula: Ingredient cost _ number of payable claims Percent of Total Ingredient Cost: The ingredient cost percentage for each drug. Cumulative Percentage of Ingredient Cost: A cumulative percent calculated from the percentage of total ingredient cost. Information Management Reports -December 2004 39 Drug Utilization Summary Report (continued) Drug Cost: The dollar amount for the drug listed, including ingredient cost, dispensing fee, and sales tax. Drug Cost Average per Claim: Drug cost per prescription dispensed. Formula: (ingredient cost + dispensing fee + sales tax) _ number of payable claims Percent of Drug Cost: The total drug cost for each drug as a percentage of total drug cost for all drugs in the entire group. Average Quantity: Average number of units dispensed per prescription for the drug. Average Davs Supply: Average number of drugs dispensed. Percentage of AWP: Indicates the percentage of the average wholesale price (AWP) processed by pharmacies. Formula: (ingredient cost =full average wholesale price) x 100 Percentage of Formulary: * The percentage of claims that are Premier Rx. Percentage of Generic Substitution:* The percentage of multisource claims that are generically dispensed. MDP Extended: Percentage Dispensed: The percentage of claims dispensed with more than 30 days supply that were qualified to be dispensed at higher days supply. Average Davs Supply: The average days supply of the qualified maintenance drug program claims that were dispensed with more than 30 days supply. * Drug Type available at national drug code level only * Percentage of Formulary available at generic level only * Percentage of Generic Substitution available at generic level only Information Management Reports -December 2004 40 1 DRUG UTILIZATION SUMMARY REPORT -TOP 200 DRUGS BY DECREASING CLAIM COST 3 ALL CLAIMS REPORT-ID TM53L6 15-O1 PAGE: 18 0 ~ A/R NUMBER CARRI ER: GROUP: ALL TIME: 04.52.10 SPONSOR NAME: DATE: 11/29/2004 ~ CLIENT NAME: CLAIMS PROCESSED BETWEEN 10/29 /2004 AND 11/26/2004 m 3 m A ~ INGREDIENT COST CUM t DRUG COST CUM t AVBAAGB O NDC NAME DRUG PAYABLB k OF TOTAL AMOUNT t ING. ING. TOTAL AMOUNT t DRUG DRUG QUANTITY t AMP ~ NDC - MANUFACTURER TYPB CLAIMS CLAIMS AVG PBR CLAIM OUST COST AVG PER CLAIM COST COST DAYS SUP, N O 1 SB N 327 1,5 77,414 4.0 4.0 77,882 4,0 4,D 5.6 83.7 ~ N 236.74 238.17 S1.B 3 ~ 2 SB N 200 0.9 36,854 1.9 5.9 37,141 1.9 5.9 0.1 84.2 184.27 185.71 58.5 N O A 3 SB N 164 1.2 33,120 1.7 7.6 74,088 1.7 7.6 0.6 87.8 127.73 119.12 59.4 4 SB N 113 0.5 25,614 1.3 8.9 25,830 1.3 8.9 17.4 81.8 226.94 228.59 48.6 5 SB N 250 1.2 13,516 1.2 10.1 27,952 1.1 1D.1 1,2 85.2 94.07 95.81 16,6 6 H8 N 106 0.5 21,276 1.1 11.2 23,413 1.1 11.1 0.5 83.3 200.7E 202,01 61,7 7 SB N 135 0.6 21,017 1.1 12.3 21,217 1.1 11.7 6,1 84.0 155.68 157,17 44.8 B BB N 62 0.3 ID, 957 1.1 11.4 21,040 1.1 13.4 11.7 89.1 337.96 339.37 61.4 9 SB N 1D D,0 20,956 1.1 14.5 20,969 1.1 14.5 0.8 86.0 2,095.61 2,096.94 45.0 10 SB N 96 O.l 20,166 1,0 15.5 20,299 1.0 15.5 D.6 83.7 210.06 211.45 54.2 11 SB N 158 D.7 18, 8fi7 1.0 16.5 19,085 1.0 16.5 7.4 83.6 119.42 120.79 53.7 ]2 SB N 127 0.6 18,726 1.0 17.5 18,901 1.0 17.5 3.6 83.4 147.45 148,83 53.8 13 SB q 187 0.9 18,480 1,0 18.5 18,771 1.0 18.5 20.0 84.5 98.83 1D0.3B 50.6 # - FORMULARY * - MDP ~4/~~~~~1~~~~1~~~~; ~ & - MAC h rr17 s-~a-~s wi~13 c4~r~` THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 42 s 3 m 0 m m m 3 m A 0 N v N n m 3 Q (D N O A A W 1 DRUG UTILIZATION SUMMARY REPORT -TOP 25 DRUGS BY DECREASING CLAIM COST ALL CLAIMS REPORT-ID TM53L615-O1 A/R NUMBER CARRIER: SPONSOR NAME: CLIENT NAME: PAGE: 1 GROUP: ALL TIME: 03.31.32 DATE: 10/03/2004 CLAIMS PROCESSED BETWEEN 07/01/2004 AND 09/30/2004 INGREDIENT COST TNERAPEUPIC CLASS PAYABLE k OP TOTAL AMOUNT t ING CLAIMS CLAIMS AVG PEA CLAIM COST 1 3,519 7.5 557,914 13.4 158.54 2 2,407 5.1 d7/,21fi 11.4 197.02 3 2,418 5.2 362,726 B.7 150.01 4 4,333 9.2 275,685 6.6 63.62 5 2, 6fi3 5.7 276,225 6.6 103.73 6 2,437 5.2 248,620 6,0 102.03 7 2,024 9,3 248,620 6.0 122.84 8 3,274 7,0 199,336 4.8 6 D.BB 9 1,553 3.3 110,507 3.1 90.47 10 928 Z.0 119,742 2.9 129. D3 11 2,269 4.8 98,085 2.1 43.23 12 882 1.9 92,691 2.2 105.04 13 1,576 3.1 90,470 2.2 s7.a1 * - MDP # - FORMULARY & - MAC CUM t DRUG COST CUM t AVERAGE k FORM INC, TOTAL AMOUNT i DRUG DRUG QUANTITY t ANP t GEN COST AVG PER CLAIM COST COST DAYS SUP, 5UBST. 13.4 567,508 1J .3 13.3 0.0 80.7 99.3 160,13 55.3 97,6 24.8 478,086 11.3 24.6 0.0 76.7 94,4 198.62 S1.D 77,3 33.5 366,670 8.7 33.3 0.0 78.2 96.7 151,63 46.0 94.1 40.1 282,765 6.7 4D.0 0.0 67.4 97,p 65,26 50.5 84.5 46.7 280,710 6.6 46.6 0.0 70.4 97.6 105.41 44.9 85.8 52.7 252,658 6.0 52.6 0,0 74.7 99.1 103.68 41.7 75.1 58.7 251,894 5.9 58.5 0,0 81.5 84,2 124.45 38.4 69,9 63.5 204,675 4.8 63.3 0.0 65.5 95.2 62.52 49.6 87.5 66.9 143,086 3./ 66.7 0.0 82.2 88.9 92.14 40.1 85.5 69.8 121,395 Z.9 69.6 D.0 77,8 99.1 130.76 37.3 71.4 7Z.2 102,190 2,9 72.0 0.0 65.2 65,4 95.04 15.2 87,4 74.4 94,108 2.2 74.2 0.0 78.5 97.7 lOfi .70 35,1 94,6 76.6 97,059 2.2 76.4 0.0 81.6 92.6 59.05 53,] 41.A h c~tl s&rrts 4cndr c4n~' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 44 s 0 3 m m 3 m >J W 0 N O N O W 3 Q N N O O A A CR DRUG UTILIZATION SUMMARY REPORT -TOP 200 DRUGS BY DECREASING CLAIM COST ALL CLAIMS REPORT-ID TM53L615-O1 A/R NUMBER CARRIER: ALL GROUP: ALL SPONSOR NAME: CLIENT NAMfi: PAGE: 1 TIME: 23,45.12 DATE: 11/13/2004 CLAIMS PROCESSED BETWEEN 10/01/2004 AND 10/31/2004 INGREDIENT CGST CUM t ORUC COST CUM t AVERAGE t PORM GENERIC DRUG NAME DRUG PAYABLE t OF AL AMOUNT t ING, ING. TOTAL AMOUNT t DRUG DRUG QUANTITY t AWP GEN GENERIC CODE NUMBER TYPE CLAIMS CLAIMS AVG PER CLAIM COST COST AVG PER CLAIM COST COST DAYS EUP, SUBST. 1 q 40,790 0.8 5,620,791 2.1 2.1 5,695,991 2.1 2.1 3.B 85.7 100.0 137.80 139.64 31.1 .0 2 # 59,504 1.2 5,202,741 1.9 4.0 5,312,011 1.9 4.D 0.0 85.7 100.0 87.44 89.27 39.7 .0 3 # 34,751 0.7 4,599,894 1.7 5.7 4,668,402 1.7 5.7 0.0 85.9 100.0 132.37 131.39 33.8 .0 / # 35,728 0.7 4,371,430 1.6 7.3 4,437,261 1.6 7.3 0.1 85.7 100.0 122.35 134.20 38.4 .0 5 # 35,501 0.7 3,180,311 1.4 8.7 3,846,963 1.4 8.7 6.8 BS.B 100.0 106.48 108.36 )1.9 .0 6 # 28,813 D.6 3,244,386 1.2 9.9 3,299,977 1.2 9.9 0.0 85.9 100.0 112.60 114.53 )0,9 .D 7 # 34,595 0.7 3,135,403 1.2 11.1 3,199,224 1.2 11.1 0.5 85.8 100.0 90.63 92.18 38.0 .0 B # 20,798 0.4 2,949,755 1.1 12.2 2,988,450 1.1 12.2 0.0 84.8 100.0 141.83 143.69 30.7 .0 9 q 16,847 0,3 2,575,221 1.0 13.2 2,606,826 0.9 13.1 0.0 85.7 100.0 152,86 154.74 37.2 .0 30 29,311 0,6 2,357,040 0.9 14,1 2,906,446 D.9 14.0 0.0 85.5 70.5 80.41 82.10 32.0 .0 11 q 29,400 0.6 2,166,052 0,8 14.9 2,219,352 O.B 14.8 0.0 85.7 100.0 73.68 75.49 32.5 .0 12 q 35,888 0.7 2,128,598 0.8 15.7 4,195,403 0,8 15.6 0.0 85.8 100.0 59.31 61.17 39.4 .0 17 # 22,260 0.5 4,121,641 0.8 16.5 4,164,690 0.8 16.4 0.0 85.6 100.0 95.31 97.16 33.7 .0 * - MDP # - FORMULARY & - MAC ~~~I~ ~ ~~ all s&trts untfi L47i4." THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 46 Prescriber Activity Summary Report This report identifies physicians' prescribing practices by ranking physicians on the basis of drug cost. Information about physicians' prescribing patterns for formulary, source, DAW and performance drug prescribing where applicable is provided. This information allows the client to target specific physicians for intervention that can improve the efficacy and cost effectiveness of prescription drug therapy. Following are definitions of each field and formulas for each field, which involve a calculation on the Prescriber Activity Summary Report: Prescriber Name: The physician name if available. Prescriber Number: The prescribing physician's identification number, usually the DEA number. Prescribing physician information is reported if it is transmitted to Caremark with the claim record. Utilizing Members: The number of eligible employees or members (if eligibility is tracked at a dependent level) who obtained prescriptions from a given physician. Payable Claims: The total number of payable claims, prescribed by a particular physician. Claims Per Utilizer Per Month: The average number of claims per utilizing employee (or member) per month. Ingredient Cost Per Utilizer Per Month: The average ingredient cost per utilizing employee (or member) per month. Ingredient Cost Per Claim: Average ingredient cost per prescription by physician. Percentage of Multi-source Claims: The percentage of total drugs prescribed by a physician that were dispensed with amulti-source drug. Percentage of Formulary Claims: The percentage of total drugs prescribed and dispensed that were included on plan sponsor's forrnulary. Percentage of Preferred Claims: The percentage of total drugs prescribed and dispensed that were performance drugs based on the Caremark Performance Drug List (if applicable). Percentage of Dispensed as Written: The percentage of multi-source drugs that are physician dispensed as written (DAW). Formula: (number of DAW claims _number ofmulti-source claims) x 100 Percentage of Generic Utilization: The percentage of generic drug claims prescribed and dispensed. Formula: (number of generic claims =total number of claims) x 100 Information Management Reports -December 2004 47 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 48 s s 3 0 3 m 3 N W 3 m m a 0 N m n m 3 Q m N O O A A l REPORT-ID TM53L635-O1 A/R NUMBER CARRIER: ALL SPONSOR NAME: CLIENT NAME PRESCRIBER ACTIVITY SUMMARY -TOP 200 PRESCRIBERS BY DECREASING CLAIM COST PAGE: 1 GROUP: ALL DATE: 11/13/2004 CLAIMS PROCESSED BETWEEN 10/01/2004 AND 10/31/2004 PRESCRIBER NAME PRESCRIBER OTILIZING ID 0 MEMBERS 1 1,461 2 21 3 52 4 454 5 324 6 393 7 324 8 245 9 B2 10 98 11 242 12 310 13 453 14 236 15 231 CLAIMS PER ING. COST 3 MIILTI- PAYABLE UTILIZER PER UTILIZER ING. COST SOURCE t GEN CLAIMS PER MONTH PER MONTH PER CLAIM CLAIMS t FORM ~ PREF ~ DAW 1 UTILIZ 2,364 1.62 92.85 57.39 55.7 94.2 86.3 82.6 53.5 33 1.57 5,352.11 3,405.09 36.3 51.5 100.0 50.0 30.3 82 1.58 1,557.97 987.98 17.0 93.9 97.7 100.0 2.4 1,135 2.50 169.10 67.64 38.0 92.2 87.3 87.8 35.1 849 2.62 236.41 90.22 30.5 92.7 88.5 92.5 25.8 979 2.99 179.18 71.93 37.9 90.4 87.5 83,3 35.4 817 2.52 209.20 82.96 44.6 92.5 90.2 70.0 93.4 668 2.73 257.98 94.62 22.4 96.1 96.3 92.3 14.6 133 1.62 695.73 428.94 32.3 91.7 95.8 0.0 32.3 225 2.30 496.22 216.13 66.2 93.3 63.1 50.0 65.3 533 2.20 197.73 89.78 32.2 93.2 87.4 77.7 25.5 627 2.02 153.73 76.01 31.5 91.8 88.9 100.D 29.8 848 1.87 105.04 56.11 92.3 96.2 87.5 90.0 41.1 600 2.54 200.78 78.97 32.6 94.8 94.3 92.0 22.1 507 2.19 201.06 91.61 34.5 93.2 92.1 97.8 25.4 ~_n~1~. ~'CN/ Bt~'Tds tt'Fl~7 ~~ THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 50 FINANCIAL REPORTS Information Management Reports -December 2004 51 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 52 Financial Summary Report The Financial Summary Report identifies claims by source (e.g. retail, mail, directs) and by cost component. such as, ingredient cost,. dispensing fees, plan participant cost share amounts and administrative fees. Total number of claims dollar amounts and averages are provided. In addition, adjustment amounts. are included on a separate line on the report. The Financial Summary Report is an excellent tool for monitoring how prescription dollars are spent. Following are definitions of each field and formulas for each field, which involves a calculation on the Financial Summary Report: COLUMN DEFINITIONS Mail-Order Pharmacy: Claims and amounts submitted to Caremark from mail-order pharmacies. Dollar Average per Claim: Average amount for claims submitted from mail-order pharmacies. Retail Pharmacy: Numbers and dollar amounts of claims submitted to Caremark by retail pharmacies, including those pharmacies submitting claims under the Caremark Maintenance Dispensing Program (MDP). Dollar Average per Claim: Average dollar amount per claim for prescriptions submitted by retail pharmacies, including Maintenance Drug Program (MDP). Direct Reimbursements: Numbers and dollar amounts of claims submitted by plan participants. Dollar Average per Claim: Average dollar amount per claim for prescriptions submitted by plan participants. Totals: The total numbers and dollar amounts of claims submitted to Caremark from all sources. Formula: Mail order pharmacy + retail pharmacy + direct reimbursements =totals ROW DEFINITIONS Claim Category: An indicator which identifies the source of the claim (e.g. retail, mail-order or direct) from plan participants. Submitted Claims: The total number of claims submitted to Caremark by pharmacies or plan participants. All payable and denied claims as well as drug utilization review reversals are included in this claim count. Formula: Number of payable claims + number of denied claims + drug utilization review reversals Denied Claims: The number of claims denied payment by Caremark. Payable Claims: The total number of claims, including those for which the plan sponsor and the plan participant are responsible. Submitted Drug Cost: The total ingredient cost, dispensing fee and sales tax submitted by pharmacies or plan participant. Includes all denied claims and DUR reversals. Formula: Ingredient cost claimed + dispensing fee + sales tax Information Management Reports -December 2004 53 Financial Summary Report (continued) Processed Below AWP: The ingredient cost for claims processed below average wholesale price. Reduced to MAC: The ingredient cost for claims that are reduced to maximum allowable cost. Processed At Submit: The ingredient cost for claims processed at the submitted ingredient cost. Special Processing: The ingredient cost for those claims that required special handling. Total Ingredient Cost: The total ingredient cost which includes processed below AWP, reduced to MAC, processed at submitted and special processing. Pharm Dispense Fee: Dispensing fee paid. Pharm Perform Fee: Product Selection Incentive (PSI) fee paid. Pharmacy Fees: The sum of the Pharmacy Dispense fee and Pharm Perform Fee. Sales Tax: Sales tax when appropriate. Total Drug Costs: Total drug cost amount includes ingredient costs, dispensing fees and sales taxes. Deductible Paid: Out of pocket, front-end amount paid by plan participant. Coinsurance Paid: Cost share amount paid by plan participants. If a front-end deductible is included in plan design, coinsurance payments begin after deductible is satisfied. Benefit Maximum Paid: Payments made by plan participants after exceeding the benefit maximum, as determined by plan parameters. A benefit maximum is a pre-set level of eligible drug benefit payment, beyond which no coverage is available. Stoaloss Copavment: Stoploss, or out of pocket maximum amount paid by plan participant. Once this amount is reached by the participant, the benefit level is changed, as determined by the plan parameters. Total Cost Sharing: The dollar amount saved by implementation of cost sharing options. Claims Amount: The total prescription amount for which the plan sponsor is responsible. Formula: (Ingredient cost + dispensing fee + sales tax + (PRx fee, if applicable) -participants cost share amount) Adjustment Amount: Total amount of adjustments. Administrative Fees: Administrative fees for which the plan sponsor is responsible. Total Amount: The total amount for which the plan sponsor is responsible including claims amount and administrative fees. Total (Claim + Adi): The total net amount of the claims and adjustment amounts Invoice Adjust Count: The total net count of the adjustments. Optional display. Information Management Reports -December 2004 54 3 m o' m m m m 3 m A m 0 N m m 3 v N 0 0 A REPORT-ID TM55L654-O1 A/R NUMBER CARRIER: SPONSOR NAME: CLIENT NAME: GROIIP: ALL FINANCIAL SUMMARY REPORT ALL CLAIMS 1, PAGE: 44 TIME: 10:54:02 DATE: 11/28/2004 CLAIMS PROCESSED FROM 10/30/2004 THROUGH 11/26/2004 ER AI / RE / / / CLAIN CATEGORY HARMACY P CLAIM HARMACY P CLAIM REIMBURSEMBNT3 CLAIM TOTALS CLAIM SUBMITTBD CLAIMS 3,092 20,092 26 23,210 DENIED CLAIMS 300 1,556 14 1,870 PAYABLE CLAINS 2,792 18,536 12 21,390 SUBMITTED DRDG COST 721,005.78 233.18 1,991,699.11 99.13 1,092.80 40.11 2,713,747.69 116.92 PAID 88LOYf ANP 468,540.02 209.73 1,330,592.46 102.09 34.89 34.89 1,799,167.37 117.83 REDIICED TO NAC 25,609.30 45.98 100,450.47 19.10 0.00 0.00 126,059.77 21.67 PAID AT SUBMITTED 60.00 60.00 10,081.43 59.30 658.95 59.90 10,800.38 59.34 SPCL PROCESSING 0.00 0.00 351.51 4.82 0.00 0.00 351.51 4.82 TOTAL ING COST 494,209.32 177.01 1,491,475.67 77.77 693.84 57.82 1,936,379.03 90.74 PBARM DISPENSE F8S 0.00 0.00 34,177.30 1.84 0.00 0.00 34,177.30 1.60 PHARN PERFORM FSS 0.00 0.00 94.60 0.00 0.00 0.00 44.60 0.00 PHARMACY FEES 0.00 0.00 34,221.90 1.85 0.00 0.00 34,221.90 1.60 SALES TAR 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL DRUG COST 494,209.32 177.01 1,475,697.77 79.61 693.84 57.82 1,970,600.93 92.34 DEDUCTISLB PAID 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 COINS[7tANC8 PAID 753.70 0.27 135,936.77 7.33 93.00 7.75 136,783.47 6.41 BENEFIT NARIMDN PAID 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3TOPLOSS COPAYMSNT 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOT C03T SHARING 753.70 0.27 135,936.77 7.33 93.00 7.75 136,783.47 6.41 PGM CALCULATION 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 CLAIMS AMOUNT 993,955.62 176.74 1,339,761.00 72.28 600.84 50.07 1,833,817.96 85.93 AD14IN F88S PAID 0.00 0.00 2,944.05 0.15 59.00 2.27 3,003.05 0.13 TOTAL AMOUNT 993,455.62 176.74 1,342,705.05 72.44 659.84 59.99 1,836,820.51 86.07 ADJUSTMENT AMOUNT 0.00 41,713.76- TOTAL (CLAIM + ADJ) 493,455.62 1,296,047.24 INVOICE ADJDST COUNT 0 475- C L A I M S 8 R E A R D O N N B Y M O N T H FEB EMP 0 0.00 MAR EMP 0 0.00 MAY EMP D DEP 1 O.OD DEP 1 0.00 DEP 3 ADJ EMP 0 0.00 ADJ 8MP 0 0.00 ADJ EMP 0 DSP 0 0.00 DSP 0 0.00 DSP 0 SSP ffidP 1 29.89 OCT EMP 552 44,828.18 NOV EMP 11,443 DEP 3 235.83 DEP 413 33,557.17 DBP 8,922 ADJ HMP 0 0.00 ADJ EMP 129 9,743.02-ADJ EMP 113 DEP 0 0.00 DEP 107 8,872.39- DEP 126 0.00 41,713.76- 600.84 1,792,103.70 0 475- O F F I L L 0.00 AIIG EMP 0 0.00 5.00 DEP 1 5.00 0.00 ADJ EMP 0 0.00 0.00 DEP 0 0.00 1,052,595.71 702,560.68 10,058.43- 12,970.50- ~~ ~~ ~~ ~~ ~~ ~ v ~ ~ ~ lA tt [2~ SYr7/'~S i19~ ems` THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 56 Financial Detail Report The Financial Detait Report provides a,detailed listing of all claims on behalf of plan participants. A detail of paid claims, denied claims, and adjusted claims is provided. A variety of report and total options are avaiiable.* Following are definitions of each field on the Financial Detail Report: COLUMN DEFINITIONS Pharmacy Number:+ The Caremark identification number of the pharmacy where the prescription was filled. Identification Number:+•' The employee identification number, usually the Social Security Number. Member of Employee Name:"* The name of the plan participant or patient. AQe: The age of the patient. CD: A code which denotes the patient's sex and relationship to the plan participant. Code will be blank for adjustments. Code definitions are as follows: MH =male holder FH =female holder MS =male spouse FS =female spouse MC =male child FC =female child MD =male dependent FD =female dependent Rx Number:+ The unique number given a prescription by the pharmacist when the drug was dispensed. Physician Number: The prescribing physicians' identification number, usually the DEA number. Prescribing physician information is reported if it is transmitted to Caremark with the claim record. Date Filled:+ The date the prescription was filled at the pharmacy. Drust Name:"' The name of the drug dispensed. Drug Strens~th:"" The strength of the drug dispensed. Drup Form:"* The dosage form of the drug, e.g. tablet, liquid. Drus~ Code:'*' The National Drug Code assigned to the prescription dispensed. Quantity: The number of units dispensed. Days Supply: The number of days for which the drug was dispensed. MSGB: Two letter code to denote the type of drug dispensed. Code definitions are as follows: SB =Single source innovator drug. MB =Multi-source branded drug. This is the brand name for a prescription that is no longer on patent. MG =Multi-source generic drug. It is a less expensive alternative to amulti-source branded drug. Managed Access/Prior Authorization Indicator: One or two letter code to denote the type of Managed Access override or Prior Authorization used. Code definitions are as follows: Information Management Reports -December 2004 57 Financial Detail Report (continued) Managed Access Codes: A =Multiple overrides, consisting of any combination of overrides, B =Copay override, C =Covered authorization for a drug that is normally excluded, D =Claim rejected for lack of prior authorization, E =Exclusion authorization for a drug that is normally covered, F =MAC penalty override, M = MDP authorization for non-MDP drug, P =Plan limitation override for quantity and/or days supply, T =Trial period override for MDP, U =Trial period and tiered Copay override for MDP, V =Vacation supply override. Prior Authorization Codes: CD =Pharmacy keying error, CB = Chargeback -the patient never picked up the first prescription and is at the pharmacy requesting a new prescription, CP =Compounds -pharmacy is processing two claims, CR =Client Request -the Plan Sponsor has allowed early refill, DP =Duplicate Prescription, ID =Increase in dosage, MB =Multiple Births, MS =Miscellaneous, PS =Pharmacy software, VA =Vacation Supply request. DAW Indicator: Dispensed as written will provide claims information for those clients utilizing a generic incentive program. Code definitions are as follows: DAW 0 = Generic or Singfe source drug. DAW 1 =Physician dispensed as written. DAW 2 =Patient dispensed as written. DAW 3 =Pharmacy dispensed as written. DAW 4 = No generic available. DAW 5 =Brand dispensed, priced as generic. Ingredient Cost: The ingredient cost for the prescription, for paid claims only. Tax: The sales tax where applicable, for paid claims only. Pharm Fee: The sum of the Product Selection Incentive (PSI) fee and the dispensing fee for paid claims only. Cost Share: The amount saved by the plan sponsor as a result of participant cost sharing (copayment, coinsurance, deductibles, benefit maximums, etc.), for paid claims only. Claim/Adjustment Amount:+ The total prescription for paid claims for which the plan sponsor is responsible. Formula: (Ingredient cost + dispensing fee + sales tax + (PRx fee, if applicable) -participants cost share amounn etc Aolustment Amount for aowstments. ' Plan sponsor can choose one or more of the following options: (1) Subtotals by tD Number (if ID number is included on the report). (2} Totals by Group Number. (3} Totals by Carrier Number. (4) Totals by A/R Number. Note: Totals reflect the net of paid claim and adjustment amounts Optional Invoice Adjustment Count: Net of all adjustment counts Total FDR Adjustment Count: Total Count of Each Adjustment Total Paid Claims: Total of all paid/denied claims Total Adjustments: Total of alt adjustments Net Total: Total of all Paid/Denied claims +/- Adjustments " Plan sponsor can choose one of the following options: (1) Include both Identification Number and Member/Employee Name. (2) Excludeboth Identification Number and MemberlEmployee Name. (3) Include Identification Number onty. (4) Include Employee/Member Name only. '•' Plan sponsor can choose one of the following options: (1} Drug Code. (2) Drug Name, Drug Strength, and Drug Forrn. (3} Exclude Drug Code, Drug Name, Drug Strength, and Drug Form. + Denotes fields o ulated for adjustments. Other fields are blank. Information Management Reports -December 2004 58 a 3 m 0 m m 3 m A m 70 0 N O) O Ol 3 Q N O O A REPORT-ID TM55L852-O1 A/R NUMBER BILL ACCT: CARRIER GROUP SPONSOR NAME: CLIENT NAME FINANCIAL DETAIL REPORT ALL CLAIMS POLICY NBR: PAGE: 18 TIME: 22:10:01 DATB: 11/27/2004 CLAIMS PROCESSED FROM 11/13/2004 THROUGH 11/26/2004 MCD/ D CLAIM/ PHRMCY ID EMPLOYEE A% PHYSICIAN DATE DRUG DRUG DRUG DAY MS PRI A INGREDIENT SALES PHARM COST ADJSTMNT tHRABER NUMBER NAME AGE CD NUMBER NUMBER FILLED NAME STRNG FORM QTY SUP GB AUTl3 W COST TA% PEE SHARE AMOUNT 52 MS 11/16/2004 2MG CAPS 30.000 30 MG D 9.87 0.00 0.00 8.00 1.87 52 MS 11/23/2004 1GM TABL 60.000 30 SE 32.00 0.00 0.00 11.00 21.00 52 MS 11/23/2004 48.16 ENTE 240,000 30 MB 0 386.27 0.00 0,00 11.00 375.17 ID TOTALS: 928.1{ O. DO 0.00 30.00 398.11 26 141 11/22(2004 0,025 OPTH 5.000 25 SB DENIED PILLED AFTER TERI4INATION DTE ID TOTALS: 0.00 0.00 0.00 0.00 0.00 50 MS 11/19/2004 O.OSt E7CCE 50.000 15 SE 71.91 0.00 0.00 11.00 60.91 50 MS 11/21/2004 {DOMG TAHL 5.000 5 SB 45.48 0,00 0.00 11.00 34.48 ID TOSAL9: 117.39 0.00 0.00 11.00 95.39 60 FH 11/19/2004 SOOMG CAPS 40,000 30 MG 0 18.6{ 0.00 0.00 8.00 10.64 60 FH 11/19/2004 7.5-5 TABL 20.000 7 MG 0 3.61 0.00 0.00 ).61 0.00 ID TOTALS: 12.25 0.00 0.00 11.61 10.64 65 FH 11/21/2009 {OMG TABL 90.000 90 MG 0 42.47 0.00 0.00 e.oa 34.47 65 FH 11/23/2001 20M0 ENTS 30.000 3D BB 119.6E 0.00 0.00 11.00 108.62 65 FN 11/21/2009 50MCG NASA 17.000 30 SB 65.94 0.00 0.00 11.00 59.94 65 FH 11/22/2009 1-lt 10.000 20 BB 44.28 0.00 0.00 11.00 33.28 IO TOTALS: 272.71 0.00 0.00 91.00 131.33 /9 PH 11/24/1001 0.151 OPTH 15.000 14 SB DBNIED FILLED AFTER TERMINATION DTE ID TOTALS: 0.00 0.00 0.00 0.00 0.00 66 FH 11/17/1001 O. SMG TABL 180.000 90 MG 0 18.90 O. DO O.DO 8,00 10.90 66 FH 11/26/2004 lOMEQ SUST 90.000 90 1%i 0 19.61 0.00 0,00 8.00 11.61 67 MS 11/26/2001 12.SM CAPS 90.000 90 MG 0 28.66 0.00 0.00 8.00 10.66 ID TO'CALS: 67,17 0.00 0.00 21.00 43.17 {5 FH 11/19/2004 325-1 TABL 180.000 22 MG 0 DENIED DUA 6YCESSIVE UTILIZATION 45 FN 11121/2004 325-4 TABL 180.000 22 MO 0 40.36 0.00 0.00 8.00 32.36 45 FH 11/24/2004 SOOMG TABL 30.000 10 MU 0 6.23 0.00 0.00 6.23 0.00 {5 FH 11/24/2004 100MG CAPS 30.000 5 MG 0 11.60 0.00 0.00 8.00 3.60 ID TOTA]S: 58.19 0.00 0.00 22.23 35.96 65 PH 11(18/2004 5-500 TABL 110.000 30 MG 0 17,18 0.00 0.00 8.00 9.18 ID TOTALS: 17.18 0.00 0,00 8,00 9.18 61 FH 11/19/2004 300MG TABL 9D. 000 90 MG 0 16.25 0,00 0.00 8.00 8.25 64 FH 11/22(2004 0.3MG TABL 9D. 000 90 BB 81.29 0.00 O.OD 11.00 70.29 64 FH 11/29/2004 30MG 90.000 90 EB 379.48 0.00 0,00 11,00 368.98 6J MS 11/13/2004 INTB 255.000 15 MB 0 18.97 0.00 0.00 11.00 7.47 ID TOTALS: 495,49 0.00 0.00 41.00 454.99 41 MS 11/11(2004 25MG TABL 90.000 JO MG D 8.39 0.00 0,00 8.00 0,39 ID TOTALS: 8,39 O. DO O. DO 8.00 0.39 SB FN 11/12/2004 40MG TABL 30.000 30 SB 122.07 0.00 0.00 11.00 111.07 58 FH 11/22/2004 150MC TABL 30.000 JO MB 0 16.23 0.00 0.00 11.00 5.23 ID TOTALS: 138.30 0.00 0.00 22.00 116.30 i R rr11 atrtP3s ur}#~~ e4rr~' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 60 OPTIONAL REPORTS Information Management Reports -December 2004 61 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 62 Performance Mail Savings Report The Performance Mail Savings Report identifies successful mail interventions and provides client ingredient cost share of savings within a reporting period. Following are definitions of each field and formulas for each field which involve a Performance Mail Savings calculation on the Performance Mail Savings Report: Intervention Category: Classification of a drug by disease state. Brand to Brand Interventions: Total number of Brand to Brand interventions performed for a reporting period. Brand to Generic Interventions: Total number of Brand to Generic interventions performed for a reporting period. Member Identification Number: The employee identification number, usually the Social Security number. Date of Fill: The date the Dispensed Drug was filled at the pharmacy. RX Number: The prescription number of the Dispensed Drug. Targeted Drug Name: The name of the originally prescribed drug for which an interchange was performed. Targeted Ingredient Cost: Ingredient cost for Targeted Drug. Dispensed Drua Name: The name of the drug dispensed as a result of an interchange. Dispensed Ingredient Cost: Ingredient cost paid for Dispensed Drug. Ingredient Cost Savings: The difference between the contracted price for the Targeted Drug and the actual cost paid for the Dispensed Drug Formula: Targeted Ingredient Cost minus Dispensed Ingredient Cost. Caremark Share: The share of savings fee billed to client on per claim basis. Net Savings: Ingredient Cost Savings minus Caremark Share. Total Ingredient Cost Paid for All Mail Claims: Total amount paid for all claims processed at the Caremark mail service pharmacies. Information Management Reports -December 2004 63 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 64 s 0 m 0 m m m m 3 m A T) 0 N O: N 3 Q 0) N O O A PERFORMANCE MAIL SAVINGS REPORT REPORT-ID RP04008Z-01 A/R NUMBER CARRIER: ALL GROUP; ALL SPONSOR NAME: CLIENT NAME PAGE: 1 TIME: 20.50.19 DATE: 10/02/2004 CLAIMS PROCESSED BETWEEN 09/01/2004 AND 09/30/2004 TOTAL INGREDIENT COST PAID FOR ALL MAIL CLAIMS; $155,216.72 INTERVENTION CATEGORY MEMBER DATE RX TARGETED TARGETED DISPENSED DISPHNSHD INGREDIBNf ADVANCEPCS NET IO OP FILL NUPBER DRUG NAME INGREDIENT COST DAUG NAME INGRBDIHNT COST COST SAVINGS SHARE SAVINGS ANGIO II AECEPTOR BLOC 09/24/2004 $139.20 $128.16 511.04 $5.52 $5.52 09/28/2001 $139.20 $126.43 $12.77 $6.38 $fi.39 09/01/2004 $139.2] $128.36 $11.07 $5.53 $5.54 09f 21 /2004 $129.46 $128.16 $1.30 $0.65 $0.65 09/14/2004 $139.23 $128.16 $11.07 $5.53 55.54 09/18/2004 $139.20 $326.43 $12.77 $6.38 $6.39 09/10/2009 $258.92 $151.95 $106.97 $53.48 $53.49 09/02/2004 $127,12 $126.43 $0.69 $0.34 $0.35 09/22/2004 $129.45 $126.43 $3.02 $1.51 $1.51 INTERVBNTION CATEGORY SUBTOTAL 9 ............:........:..a...........:.....:.:::...:...... $1,341.01 $1,170.31 $170.70 $85.32 $85.38 ....: ......................:::..:...................~...:......a..a.:......o.v.e...sass...:.. HMG CO-A REDUCTA5E INH 09/15/2001 $353.26 $205.35 $147,91 S73.95 $73.96 09/17/2004 $353.28 $276.70 $76.58 $38.29 $38.29 09/11/2004 $353.26 5205.35 $147.91 $73.95 $73.96 INfBRVENfION CATEGORY SUBTOTAL 3 $1,059.&0 $687./0 $372,90 $1&6.19 $186.21 NON•STEROIDAL ANTI-INP 09/22/2004 $21.55 $5.95 $15.57 $7.78 $7.79 INTERVENTION CATEGORY SOBTOTAL 1 $21.55 $5.98 $15.57 $7.78 $7.79 ...: .........................:...........:....:...:..:..~:.::..:................a....................:....:::............::........................o..:.:...........:..:....... RESPIRATORY BETA AGONI 09/17/2004 $35.31 $8.57 $26.74 $13.37 $13.37 INTERVENTION CATEGORY SUBTOTAL 1 $35.11 SB. 57 $26.74 $13.37 $13.37 ~I~r~~~~~~~1~~~t,~,r ~' !t rrlf starts ~~ u7JL"` THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 66 Performance Rx Interchange Detail Report The Performance Rx Interchange Detail Report can be used to determine successful retail interchanges within a reporting period and by therapeutic class. Following are definitions and calculations of each field and formula identified on the Performance Rx Interchange Detail Report: Theraaeutic Class: Classification of a drug by disease state. Claim Tvpe: Atwo-letter code to denote the claim transaction type: RP -Retail Paid Transaction RR -Retail Reversal Transaction Member Identification Number: The employee identification number, usually the Social Security Number. Date of Fill: The date the performance drug was filled at the pharmacy. Rx Number: The prescription number. Non-PDL Dru~t Name: The name of the drug for which an interchange was performed. PDL Dru4 Name: The name of the drug dispensed as a result of an interchange. Class Totals: The total number of retail interchanges performed. Grand Totals: The total number of retail interchanges performed. Total Charges: The total amount charged for the completed billed interchanges reported. Information Management Reports -December 2004 67 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 68 s 3 o' 3 m m 3 m A m 0 O W 3 Q m N O O A rn 1 REPORT-ID RP04002Z-O1 A/R NUMBER CARRIER: ALL SPONSOR NAME: CLIENT NAME PERFORMANCE RX INTERCHANGE DETAIL REPORT PAGE: 1 GROUP: ALL TIME: 07.03.10 DATE: 11/27/2004 CLAIMS PROCESSED BETWEEN 10/29/2004 AND 11/26/2004 CLAIM DATE RX THERAPEUTIC CLASS TYPE MEMBER OF FILL NUMBER NON POL DRUG NAME PDL DRUG NAME HMG CO-A REDUCTASE INHIBITOR RP 11/12/2004 RR 10/18/2004 RP 11/22/2004 ------------------------------------------------------------------------------------------------------------------------------------ CLASS TOTAL: 1 NON-STEROIDAL ANTI-INFLAMMATOR RP 11/22/2004 RP 11/23/2004 CLASS TOTAL: 2 PROTON PUMP INHIBITORS RP 11/08/2004 RP 10/31/2004 ------------------------------------------------------------------------------------------------------------------------------------ CLASS TOTAL: 2 TOTAL CHARGES GRAND TOTAL: 5 160.00 ~~~' ~t atl statets ands c air ` THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 70 Retail Programs Savings Summary Report The Retail Programs Savings Summary Report identifies savings by measuring market share improvement. It reflects. how Caremark helps save ingredient costs and focuses on the ingredient cost per claim trends resulting from the retail intervention programs. Following are definitions and formulas for each field, which involve a calculation on the Retail Programs Savings Summary Report: Total Ingredient Cost: Discounted drug cost excluding dispensing fee and member cost share. Number of Claims: Total number of paid retail claims. Average Ing. Cost per Claim: The average ingredient cost paid per prescription. Formula: total ingredient cost T total number of paid retail claims Average Ing. Cost per Claim w/o Programs: The ingredient cost per claim that would have been reached if retail intervention programs had not been implemented and the drug mix stayed the same as the baseline period. Formula: (total ingredient cost + total ingredient cost savings) ~ total number of paid retail claims Total Savings per Claim: The difference between the average ingredient cost per claim with programs in place and the average ingredient cost per claim had the programs not been implemented. Formula: average ing. cost per claim -average ing. cost per claim w/o programs Total Ingredient Cost Savings: A summary of ingredient cost savings achieved through market share improvement in Therapeutic Classes. Information Management Reports -December 2004 71 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 72 0 3 REPORT-ID RP04009Z-02 ~ A/R NUMBER CARRIER: ALL v SPONSOR NAME: ~ CLIENT NAME m 3 m RETAIL PROGRAMS SAVINGS SUMMARY REPORT PAGE: 1 GROUP: ALL TIME: 21.57.06 DATE: 10/02/2004 CLAIMS PROCESSED FROM 07/01/2004 THROUGH 09/30/2004 A m 0 N 0 ~ TOTAL INGREDIENT COST $ 3 NUMBER OF CLAIMS v m N ~ AVERAGE ING. COST/CLAIM $ o AVERAGE ING. COST/CLAIM - W/0 PROGRAMS $ 784,261 $ 777,424 $ 719,969 $ 2,281,654 14,805 13,844 12,898 41,547 52.97 $ 56.16 $ SS.B2 $ 54.92 53.17 $ 56.31 $ 56.06 $ 55.11 .20 $ .15 $ .29 $ .20 2,937 0.41 $ 2,095 0.31 $ 3,103 0.41 $ 8,135 Q2 TOTAL TOTAL SAVINGS/CLAIM $ TOTAL INGREDIBNT COST SAVINGS $ J W ~~~ ~S ~ 3kJYkS IUlPl7 Citlk 0.41 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 74 Therapeutic Class Analysis Report The Therapeutic Class Analysis Report lists all drugs within the therapeutic drug classes in the Performance Drug Program. This report will also indicate for each drug dispensed, which were preferred and which were non-preferred. Totals are presented by class, preferred drugs, non- preferred-drugs, all. other drugs and a grand total. The preferred drug may be less expensive than that listed due to manufacturer volume discounts. Following are definitions of each field and formulas for each field, which involve a calculation on the Therapeutic Class Analysis Report: Therapeutic Class: The name of the Performance Rx therapeutic class associated with the drug listed. Drug Name: The name of the drug dispensed. Preferred Drup List Indicator: Aone-letter code to denote the type of drug dispensed. Code definitions are as follows: P =preferred drug N =non-preferred drug Payable Claims: The total number of payable claims, including those paid by the plan sponsor and the plan participant. Formula: (Number of payable claims =total number of payable claims in the Therapeutic Class) x 100 Percentage of All Claims: The percentage of payable claims in the defined category as compared to all payable claims. Formula: (Number of payable claims by category _ number of all payable claims) x 100 Ingredient Cost Paid: The ingredient cost paid for the drug listed. Percentage of Ingredient Cost in Class: The percentage of ingredient cost paid for this drug as compared to the total ingredient cost paid within the Therapeutic Class. Formula: (ingredient cost paid =total Therapeutic Class ingredient cost paid) x 100 Percentage of Ingredient Cost All Claims: The percentage of ingredient cost paid in the defined category as compared to the total ingredient cost paid for all claims. Formula: (ingredient cost paid =total ingredient cost paid for all claims) x 100 Information Management Reports -December 2004 75 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 76 0 3 m o' 3 m m m 3 m A m 0 N v m N 3 Q m N 0 A J J PERFORMANCE RX THERAPEUTIC CLASS ANALYSIS REPORT ALL CLAIMS REPORT-ID RP04001G-Ol A/R NUMBER CARRIER: ALL GROUP: ALL SPONSOR NAME: CLIENT NAME PAGE: 1 DATE: 11/29/2004 CLAIMS PROCESSED FROM 10/29/2004 THROUGH 11/26/2004 } CLAIMS IN AVG $ DOLLARS IN $ ING COST THERAPEUTIC DRUG PDL NUMBER THERAPEUTIC $ ALL INGREDIENT ICP/ THfiRAPEUTIC ALL CLASS DRUG NAME TYPE IND OF CLAIMS CLAS5 CLAIMS COST PAID CLAIM CLASS CLAIMS ACE INHIBITORS MG N 3 3.4} 5,7} ,p} MB N 1 1.1$ 3.6$ .0$ MH N 1 1.1$ 1.2$ .D$ MG 0 3 3.4$ 2.1$ ,0$ MG 0 3 3.4$ 2.2$ .0$ MG 0 4 4.6$ 6.4$ .0$ SB 0 1 1,1$ 1.4$ .0$ SB P 6 6.9$ 10.?$ .0$ SB P 12 13.9$ 24.7} .2$ MG P 1 1.1$ .5$ .0$ MG P 7 8.1$ 4.7$ .0$ MG P 29 33.7$ 23.4$ .2$ MG P 15 17.4$ 12.7} .1$ 70 81.3$ 1.7$ $1,794.05 $25.63 76.9$ .7$ 5 5.8$ .1$ $248.60 $49.72 1D.6} .0$ 11 12.7$ .2$ $288.09 $26.19 12.3$ .1$ 86 2.0$ $2,330.74 $27.10 .9$ ACE/CALCIUM CHANNEL BLOCI(ER SB 0 23 92.0$ 95.3$ .9$ SB 0 2 8.0$ 9.6$ .0$ 25 100.0$ .6$ $2,533.15 $101.33 100.0$ .9$ 25 .6$ $2,533.15 $101,33 .9} ANGIO II RECEPTOR HLOC](ERS SB N 2 2.7$ 1.8} .0} SB N 1 1.3$ 1.2} .O$ SB N 5 6.9$ 6.9$ .1$ SB N 16 22.2$ 25.8$ .4$ SB N 2 2.7$ 2.0$ .0$ SB N 2 2.7} 1.7$ .0$ SB 0 8 11.1$ 7.6$ .1$ SB 0 9 12.5$ 9,9} ,1} ** REBATES NOT FACTORED IN THIS REPORT ** ~~f~~• ~t (f~ 5'k~F7'S fUlt~? et2TT' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 78 USC Activity Report By Decreasing Ingr Cost The USC Activity. Report By Decreasing Ingr Cost identifies the top therapeutic classes referred to as "USCA codes in this report. Therapeu#ic classifications group drugs by general category such as antibiotics, oral contraceptives, etc. The generic code groups all drugs, both brand name and generic, with the same chemical composition, strength and dosage form. The default for the therapeutic classes is top 100 USC /top 20 GENERIC. This parameter may be changed. This report is produced monthly and may be sorted by decreasing claim count or cost. Following are definitions of each field identified on the USC Activity Report: USC: The three-digit number that represents each therapeutic class. Generic: The five-digit number that represents all drugs with the same chemical composition, strength and dosage form. Rank: Sequential ordering of generic class and USC class. Classification Name: The name of the therapeutic class associated with the USC code listed. Strength: The strength of the drug. Form: The dosage form of the drug, e.g. tablet, liquid, etc. Payable Claims: The number of payable claims. Ingredient Cost: The ingredient cost paid for the drug. Average Ingredient Cost per Claim: Average ingredient cost per prescription dispensed within the therapeutic class and generic codes listed. Avg Quantity: Average number of units dispensed for all claims within the therapeutic classes and generic codes listed. Avg Days Supply: Average number of days supply of all prescriptions within the therapeutic classes and generic codes listed. Total Members: Total number of plan participants who submitted claims. Percent of Generics Dispensed: The number of generic prescriptions dispensed as a percentage of the total number of claims within the therapeutic or generic class listed. Percent of Generic Dollars Dispensed: The total generic ingredient cost payable as a percentage of the total ingredient cost payable within therapeutic class or generic class. Cumulative Percentage Ingredient Cost: Total ingredient cost for the therapeutic classes listed represented as a percentage of total ingredient cost for all drugs for the entire group. These percentages are cumulative for each therapeutic class listed. Information Management Reports -December 2004 79 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 80 s 0 3 Dl 0 m m W 3 m A m 9 0 z N 0 N 3 v N N O O A USC ACTIVITY REPORT BY DECREASING INGR COST TOP 10 USC CLASSES /TOP 10 GENERIC CLASSES REPORT-ID TM53L675-O1 PAGE: 3 A/R NUMBER CARRIER: GRWP: ALL TIME: 05.19.05 SPONSOR NAME: DATE; 11/29/2004 CLIENT NAME CLAIMS PROCESSED BETWEEN 10/29/2004 AND 11/26/2004 USC GENERIC INGREDIENT COST COEE 4 ___________ _____ ________ PAYABLE ____.____._.._. ._.._.___._ AVG AVC TGTAL 4 GNRC 4 GNRC INGR RANR CLASS RANK CLASS CLASSIFICATIDN NAME STRENGTH FDRM CLAIMS TOTAL AMOUNT AVG / CLM QUANTITY DAYS SUPPLY MEMBERS DISP $ DISP 0057 B 40832 300MG CAPSULE 9 1,065.05 118.00 74 1D 8 100.00 100.00 9 91911 1000- TAB,SR 12H 11 1,008.88 92.00 37 11 11 0.00 0.00 10 61199 200MG SUSP RBCON 26 934.98 36.00 21 5 26 0.00 0.00 B 311 TOTAL BB9 32,923.19 36.00 44 39 899 61.64 28.11 46.86 1 14851 SOMC TABLET 30 2,130.90 71.00 4) 43 30 0.00 0.00 2 97262 2DMG TAHI,E1' 110 1,862.09 17,00 /S 90 110 99,09 98.10 7 48544 lOMG CAPSULE 22 1,790.22 B1.OD 50 10 22 0.00 0.00 4 14854 100.2 TABLET 12 1,351.65 113.00 57 50 12 D,OD 0.00 5 47261 1DMG TABLET 127 1,342.20 11.00 38 37 126 97,63 91.93 6 14853 1DOMG TABLET 14 1,147.87 82.00 79 39 14 0.00 0.00 7 37090 5-20M CAPSULE 15 1,13].2) 76.00 34 31 15 0,00 0.00 B 04749 150MG TABLET 16 1,123.96 70,00 98 45 16 0.00 0.00 9 47263 4DMG TABLET 50 1,098.07 22.00 IZ 39 50 300.00 100.00 10 73545 32MG TABLET 9 909.76 101.00 S4 44 9 D, 00 a.oo 9 641 TOTAL 947 31,970.90 72,00 49 23 359 75.16 16.97 49.70 1 15085 15MG TABLET 9 3,656.97 406.00 30 30 1 0.00 0.00 2 19082 lOMG TABLHT 9 2,818.93 313.00 33 30 7 0.00 0.00 3 18537 lOMG TABLET 7 1,852.96 265.00 26 26 6 0.00 0.00 9 67661 25MG TABLHT 13 1,830.30 341.00 BB 75 12 0.00 0.00 5 lfi1)6 1MG TABLET 9 1,7)4.12 197,00 61 31 B 0.00 0,00 6 67662 100MG TABLHT 7 1,741.98 249.00 90 47 7 0,00 0.00 7 15086 20MG TARGET 1 1,552.95 1,553.00 90 90 1 0.00 0.00 8 16138 3MG TABLET 4 1,341.36 335.00 56 45 4 0.00 0.00 9 14163 1MG TABLET 50 1,109.72 22.00 42 19 43 100.00 100.00 10 67665 300MC TABLET 3 999.36 333.00 50 50 2 0.00 0.00 10 021 TOTAL 193 31,701.16 162.00 26 16 166 21,24 2.18 52.99 1 05701 100MG TABLET 25 5,476.30 219.00 13 17 23 0.00 0.00 2 05700 SOMG TABLET 22 4,276.73 191.00 11 11 22 0.00 0.00 3 18040 SOOMG TAB.SR 24H 12 2,988.04 249.00 130 50 11 0.00 0.00 4 DS)02 25MG TABLET 9 2,860.52 318.00 17 19 9 0.00 0.00 5 46132 5MG TABLET 13 2,503.62 193.00 30 12 11 0.00 0.00 6 19592 lOMG TABLET 15 2,416.60 161.00 9 11 17 0.00 0.00 7 19594 lOMC TAB RAPDIS 14 2,196.11 157.00 9 9 19 0.00 0.00 B 50741 6MG/0 RIT, REFILL S 2,186.75 477.00 3 10 5 0.00 0.00 9 15174 40MG TABLET 6 1,182.61 197.00 14 2D 5 0.00 0.00 30 19977 2.5MC TABLET / 983.49 246.00 16 15 4 0.00 0.00 ~~~~~~~~f 7~~7 UIIS~'7F't5 tt"Jd? tt39`Y~ THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 82 Managed Access Confirmation Report -Drug Code Modifications The Drug Code Modification report will provide the plan sponsor with a confirmation report for any changes, deletions or additions made to their drug benefit. Following are definitions of each field and formulas for each field, which involve a calculation on the Drug Code Modification Report: COLUMN DEFINITIONS Dru4 Code: The national drug code assigned to the prescription dispensed. Drug Name: The name of the drug. Strens~th: The strength of the drug. Form: The dosage form of the drug, e.g. tablet, capsule. Date Benin: The beginning date of fill that will require prior approval for coverage. Date End: The date of fill in which authorization will expire. This authorization is valid to this date not through this date. Postinst, Date: The date the record was posted to our database for monitoring. Postinct Time: The time the record was posted to our database for monitoring. Action: This will provide the client the action taken to the existing table entry. Information Management Reports -December 2004 83 ''wrr' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 84 s s 3 ~_ 0 3 m m 3 m A A v 0 O N N 3 v m N O A W MANAGED ACCESS CONFIRMATION REPO REPORT-ID TMS1L600-O1 DRUG CODE MODIFICATION PAGE: 1 A/R NUMBER CARRIER: GROUP: ALL TIME: 00.09.58 SPONSOR NAME: DATE: 11/06/2004 CLIENT NAME PROCESSED FROM 10/01/2004 THROUGH 10/31/2004 AFTER DAYS HEGIN END P O S T I N G DRUG CLASS DRUG NAME STRENGTH FORM HOURS QTY SUPPLY DATE DATE DATE TIMB ACTION 23374 OMALIZUMAB 75MG VIAL 10/12/2004 12/31/2099 10/15/2004 09:38:31 ADD 12671 PEGINTERFERON A BOMCG KIT 10/01/2004 12/31/2099 10/04/2004 15:06:99 ADD ]2672 PEGINTERPERON A 120MC KIT 10/01/2009 12/31/2099 10/04/2004 15:06:54 ADD 12673 PEGINTERFERON A 150MC KIT 10/01/2009 12/31/2099 10/04/2004 15:06:58 ADD 14179 RIBAVIRIN 200MG CAPSULE 10/01/2004 12/31/2099 10/04/2004 15:07:03 ADD 18287 PEGINTERPERON A 180MC VIAL 10/01/2004 12/31/2099 10/04/2004 15:07:07 ADD 18926 PEGINTERFSRON A 180MC KIT 10/01/2004 12/31/2099 10/04/2004 15:07:10 ADD 19966 OMALIZUMAB 150MG VIAL 10/01/2004 12/31/2099 10/04/2009 15:07:17 ADD 20582 EFALIZUMAB 125MG KIT 10/01/2004 12/31/2099 10/04/2004 15:12:04 ADD 20907 RIBAVIRIN 40MG/ SOLUTION 10/01/2004 12/31/2099 10/04/2004 15:08:55 ADD 22220 RIBAVIRIN/INTER 600.3 KIT 10/01/2004 12/31/2099 1D/09 /2004 15:09:00 ADD 22221 RIBAVIRIN/INTER 1000- KIT 10/01/2009 12/31/2099 10/04/2004 15:09:03 ADD 22222 RIBAVIRIN/INTER 1200- KIT 10/01/2004 12/31/2099 10/09/2004 15:09:06 ADD 22223 RIBAVIRIN/INTER 600-3 KIT 10/01/2009 12/31/2099 10/04/2004 15:09:08 ADD 22224 RIBAVIRIN/INTER 1000- KIT 10/01/2004 12/31/2099 10/04/2004 15:09:11 ADD 22225 RIBAVIRIN/INTER 1200- KIT 10/01/2009 12/31/2099 10/04/2009 15:09:14 ADD 23374 OMALIZUMAB 75MG VIAL 10/12/2004 12/31/2099 10/15/2009 15:44:01 ADD 46472 INTERFERON ALFA 6r4dU/ VIAL 10/01/2004 12/31/2099 10/04/2009 15:09:19 ADD 47511 INTERFERON ALFA 3MMU/ KIT 10/D1/2004 12/31/2099 10/04/2004 15:09:23 ADD ~~~~~' h all starts uada e.srza• ~r-. THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 86 Managed Access Confirmation Report: Authorization Modifications Managed access will enable the client to monitor their drug benefit. The client controls claims payment for certain prescriptions prescribed to individual employees, without restricting the benefit to their entire business. It will allow the client to .restrict prescribing and dispensing of medication except from a designated provider or pharmacy. Following are definitions of each field and formulas for each field, which involve a calculation on the Authorization Modifications Report: Beneficiary Name: Patient's name Beneficiary No: The employee identification number, usually the Social Security number. Auth Tvpe: Level of drug class (example: NDC, USC class, NDC class) Drus1 Name: Drug name Begin Date: The begin date of fill that will require prior approval for coverage. End Date: The date of fill in which authorization will expire. This authorization is valid to this date not through this date. Sex: The sex of the plan participant. Relationship: The relationship of the plan participant as it relates to the employee. Date of Birth: The birth date of the plan participant. Lock InlOut: Indicates whether the Provider, Pharmacy or Chain is set for a Lockin or a Lockout Lockin: The Primary and/or Secondary Provider, Pharmacy or Chain is authorized to dispense medication to the plan participant. Lockout: The Primary and/or Secondary Provider, Pharmacy or Chain is not authorized to dispense medication to the plan participant. Pharmacy Primary 8~ Secondary: The pharmacy number set for Lockin or Lockout Provider Primary 8~ Secondary: The provider number set for Lockin or Lockout Chain Primary 8~ Secondary: The chain number set for Lockin or Lockout Plan Limit Overrides -Quantity and Days Supply: Indicator that triggers an override for those drug classifications that have a quantity or days supply limits that differ from the plan design. Apply to MDL: Indicator that triggers whether the Managed Drug Limitation (MDL) should apply for the specific drug. NO or = Do not apply MDL YES =Apply MDL to specific drug Information Management Reports -December 2004 87 Managed Access Confirmation Report: Authorization Modifications (continued) Posting Date: The date the record was posted to our database for monitoring. Posting Time: The time the record was posted to our database for monitoring. Posting Bv: The Caremark identification of the person that entered the authorization. Authorized Bv: Identifies the person at the plan sponsor who signed the managed access authorization that is forwarded to Caremark. Maintenance Drug Plan: Indicates if the drug will be considered maintenance and as such pay in accordance with Caremark maintenance drug program, specific to the client. Possible values are: NO = No MDP Processing YES =Process only as MDP for this cardholder NT =Override the trial period for this cardholder/drug SC/NT =Override the trial period and use a single copay for this cardholder/drug Copav Types: Identifies copay type being utilized for this record if overridden from normal copay type. Copav Amount: Identifies copay dollar amount or percentage utilized for this record if overridden from normal copay amount. MAC Penalty Copav: Identifies the override of the MAC penalty copay for specific patient/drug. Bypass Step Therapy: Overrides Step Therapy for a specific cardholder/drug. NO or = Do not bypass Step Therapy ~' YES =Bypass Exclusive and Prerequisite Step Therapy E =Bypass Only Exclusive Step Therapy P =Bypass Only Prerequisite Step Therapy Bypass MaiorRx: Overrides MajoRx program for a specific cardholder/drug. NO or = MajoRx will apply YES =Bypass all MajoRx programs Bypass Maxdose: Overrides the maximum dose allowed for a specific drug. NO or = Do not bypass Maxdose YES =Bypass Maxdose for specific drug Information Management Reports -December 2004 88 a 3 v 0 3 v v m 3 m A m a 0 m m m 3 Q W N 0 0 A MANAGED ACCESS CONFIRMATION REPORT AUTHORIZATION MODIFICATIONS REPORT-ID TMS1L600-02 PAGE: 39 A/R NUMBER CARRIER: GROUP: TIME: 00.15.41 SPONSOR NAME: DATE: 11/06/2004 CLIENT NAME PROCESSED FROM 10/01/2004 THROUGH 10/31/2004 THE FOLLOWING ITEM HAS BEEN ADDED TO YOUR MANAGED ACCESS AUTHORIZATION LIST: BENEFICIARY NAME: LOCK IN/OUT BENEFICIARY N0: PHARMACY PRIMARY POSTING DATE :10/19/2004 AUTH TYPE IS GENERIC CLASS SECONDARY POSTING BY C82331 DRUG NAME IS EPOETIN ALFA PROVIDER PRIMARY POSTING TIME :13:18:40 BEGIN DATE 10/19/2004 SECONDARY AUTHORIZED BY END DATE 12/30/2D04 CHAIN PRIMARY CARLA BRANWELL SEK FEMALE SECONDARY MAINTENANCE DRUG PLAN: NO DATB OF BIRTH 03/1953 APPLY TO MDL YES COPAY TYPE NORMALLY NOT COVERED - COVERED BY M/A PLAN LIMIT OVERRIDES: NO COPAY AMOUNT BYPASS MAXDOSE: NO QUANTITY MAC PENALTY COPAY: NO BYPASS MAJORX NO DAYS SUPPLY: BYPASS STEP THERAPY N THE FOLLOWING ITEM HAS BEEN ADDED TO YOUR MANAGED ACCESS AUTHORIZATION LIST: BENEFICIARY NAME: LOCK IN/OUT HBNEFICIARY N0: PHARMACY PRIMARY POSTING DATE :10/01/2004 AUTH TYPB IS GENERIC CLASS SECONDARY POSTING BY C5119A DRUG NAMB IS LEUPROLIDE ACETATE PROVIDER PRIMARY POSTING TIMH :12:17:37 BEGIN DATE 09/30/2009 SECONDARY AUTHORIZED BY END DATE 10/04/2009 CHAIN PRIMARY A. BOSLEY SEK FEMALE SECONDARY MAINTENANCE DRUG PLAN: NO DATE OP BIRTH 11/1965 APPLY TO MDL YES COPAY TYPE NORMALLY COVERBD - OVERRIDEN BY M/A PLAN LIMIT OVERRIDES: YES COPAY AMOUNT BYPASS MAXDOSE: NO QUANTITY MAC PENALTY COPAY: NO BYPASS MAJORX NO DAYS SUPPLY: 89 BYPASS STEP THERAPY THE FOLLOWING ITEM HAS BEEN ADDED TO YOUR MANAGED ACCESS AUTHORIZATI ON LIST: BBNEFICIARY NAME: LOCK IN/OUT BENEFICIARY N0: PHARMACY PRIMARY POSTING DATE :10/07/2004 AUTH TYPE IS GENERIC CLASS SECONDARY POSTING BY PD758 DRUG NAME IS LEUPROLIDE ACETATE PROVIDER PRIMARY POSTING TIME :12:12:49 BEGIN DATE 09/30/2004 SECONDARY AUTHORIZED BY END DATE 10/10/2009 CHAIN PRIMARY A. BOSLEY SEK FEMALE SECONDARY MAINTENANCE DRUG PLAN: NO DATE OF BIRTH 11/1965 APPLY TO MDL YES COPAY TYPE NORMALLY COVERED - OVERRIDEN BY M/A PLAN LIMIT OVERRIDES: YES COPAY AMOUNT : BYPASS MAXDOSE: NO QUANTITY MAC PENALTY COPAY: NO BYPASS MAJORS NO DAYS SUPPLY: 84 BYPASS STEP THERAPY ro ~~~~C~~I~'I~-. ~1 Qn bit7Y~S il"lt~7 tt71p~ THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 9~ Managed Access -Due to Expire Report This report identifies Managed Access authorizations that will expire within the next sixty days and allows you to selectively extend them. The report must be returned to Caremark within thirty days to ensure the authorizations are extended before they expire. Expiring authorization will only be reported once. No further notification wil! be issued. Following are definitions of each field for each field on the Managed Access - Due to Expire Report. COLUMN DEFINITIONS Extended (YIN): Indicate whether the authorization should be extended by writing Y (yes) or N (no) in the space provided. New Expiration Date: Write the new expiration date in the space provided. Carrier Group #: The carrier group number assigned to the patient's group by Caremark. ID Number: The patient's identification number, usually the social security number. Patient Name: The name of the member or employee. Date of Birth: The date of birth of the member, employee, or dependent. Sex: The sex of the member, employee, or dependent. Authorization Type: The type of authorization and information related to the authorization. For example, the name of the drug authorized for the patient. Original Authorization Date: The original date of the authorization. Original Expiration Date: The original expiration date of the authorization. Information Management Reports -December 2004 91 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 92 3 m 0 3 m m 3 m A m v 0 O m N 3 v m N 0 0 A REPORT-ID TMS1L624-O1 A/R NUMBER CARRIER: SPONSOR NAME: CLTENT NANE MANAGED ACCESS DUE TO EXPIRE WITHIN 90 DAYS GROUP: 8000 PAGE: 78 TIME: 05:07:48 DATE: 11/06/2004 EXTEND NEW EXP. DATE OF (Y/NI DATE ID NUMBER PATIENT NAME BIRTH SEX AUTHORIZATION TYPE ------ --/--/---- 03/1953 F DRUG INCLUSION: HPOETIN ALFA AUTH -DRUG ID: GC25115 DRUG STRENGTH: 4DOD0 0/ML DRUG FORM: VIAL APPLY TO MDL: YES BYPASS MAXDOSE: NO BYPASS STEP THERAPY N _.____ ._/../.-_. 12/1968 F DRUG INCLUSION: GLUCOPHAGE XR AUTH - DRUG ID: ND000870606313 DRUG STRENGTH: SOOMG DRUG FORM: TAB; SR APPLY TO MDL: YES BYPASS MAXDOSE: NO BYPASS STEP THERAPY N AUTHORIZED BY: -._...-----•--------------------- DATE: ---------- ORIGINAL ORIGINAL AUTH DATE EXP DATE 10/19/2004 12/30/20D9 09/21/2004 12/31/2004 + + + + + + + + r + r + + + + + + + + r + + + + + + E N D 0 F R E P 0 R T + + + * r + + + + + + + r + + r + r + r + + r N W ~~.~I°1~-~4~~~~1f~ c2~ S1`AF~S iL'f#~3 tNll'~ THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 94 CAREMA K It ~t1Z stets?s ~wit~i care Gaining Greater Control Over Your Entire Specialty Spen he potential and increasing availability of specialty medications has created new challenges for organizations looking to provide affordable, quality care. Unlike traditional medications, specialty medications tend to be more expensive and can he administered in a variety of settings. They can also be covered under both the pharmacy and medical benefit, making accurate cost and reimbursement data even more difficult to capture. Through a comprehensive reporting system, Caremark Specialty Pharmacy Services can help you manage specialty pharmacy costs and measure program effectiveness. The proven, flexible information technology platform of Caremark provides: • Immediate access to participant-level pharmacy and medical claim data • Unlimited capabilities for educated analyses, including drug trend analysis, program evaluation and marketplace forecasting • Proactive monitoring of particular specialty therapies and new medications in the pipeline The value to our customers is the ability to leverage this information to help make better management decisions about their specialty program. That's why Caremark provides you with the reporting tools you need to clearly focus on initiatives that improve your plan participants' health outcomes, and ultimately lower overall healthcare costs. Specialty Pharmacy Insight A Custom Look at Your Plan eror a Recognizing that timely, actionable information is important to your organization, Caremark provides a complete financial and clinical analysis (on an annual and quarterly basis) through its Specialty Pharmacy Insight report. Using your actual claims and utilization data, this exceptional in-depth reporting package: Analyzes your overall program performance Summarizes total utilization of specialty medications Compares your total utilization from the previous year Benchmarks your data to similar companies/organizations Identifies potential opportunities for enhancing your plan performance Captures current industry trends Recommends action plans for addressing new developments and emerging specialty therapies in the pipeline _ _ _ _ __ Specialty Pharmacy Insight not only demonstrates CAREIN,AI~C the value of your specialty pharmacy program, it x ~ ~' also puts industry trends into perspective so you can measure and achieve better results. gs Rrr4ptrot4ry97nciralVinw ,1~9!'S C XOtA1R Asthma 136 'ROPE Hu~ap Growth htamwn• T9i E Hemoph~ka 5 FATE F8 HemophiCa !! REFACTO Hemophilia 9 N!1rRORN AO Humor OrowM Homw?M 78 GENOTROPIN Human Growth Homana 59 7ERE2VME Owchan +E NUTROPoN Human Growth Homwna 35 MONONIN! Ntat~hYw 9 RAPTNA P4oria8b 79 tiNdMAG~Rp$D Mkor+AbwlmihuuoylOlwNN i0 HEMOFIL M Hmmophi4a 7 s ~,~+ ~t tax f 7 351,72 5% ~~~~ Specialty Pharmacy Insight report a Alpha•1 Arritrypsin Defiderxy 1 2 S - E 31.049 14 t8~ f St,7~0 S t,854,742 COigWantS Gttwd+ur< t 3 t 6 S 93 t 846:779 S 2.598 3 813.790. Hemalopaeocs 16 18 f 85,096 S 104,729 77 t~ ~ 9,553.924 # 11,252.274 Hepati6sC 14 12 S 775,758 S 88.089 ortrgM 8 8 t 84„987 S t+tl~fa x; ~: J J ,._. oerlf ..J 1 SnecHK Dr~syay. RxNavigator ~taiie Information a our i erti~ To assist you in making more informed business decisions, we encourage your organization to access information through our proprietary Web-based data mining tool, RxNavigator. Unique to the industry, this state-of-the-art reporting system offers unlimited options for generating reports on your plan's performance. From running preprogrammed reports to performing the most sophisticated analyses, you can find the answers to your clinical and business questions in a matter of minutes. You can even view all specialty claims, covered under both the medical and pharmacy benefit, for a more complete picture of your total specialty pharmacy costs. 0-9 10-19 20-29 30-39 40-49 50-s9 60-69 70-79 80-89 Participant Age RxNavigator screen shot 52so,ooo 5200,000 5150,000 5100,000 550,000 0 Highlighted features within RxNavigator include: • Exporting results to other Microsoft applications • Graphing results for presentations • Drilling down to more detailed levels of information • Editing reports to more closely meet your specific needs • Saving reports to give you the ability to utilize reports on an ongoing basis DRILL- 11AVUrIp~ From: Ta: Oarlieipan! C~nd~r DEACIass ~ ~ Drug Dosage Name fe.ck~~~drit Drug Ust Drug Manufacturer Drug Strength Name _I ' r Kem oarant vhile dnl6na Caremark also provides full training and support to ensure that you and your staff receive the maximum benefit from using RxNavigator. r Unknown 1 $4,883,92 r Famale 32 $331,735.60 34$233,675.43 8 $18,951.47 r Male 6 $736,654.88 53 $570,330.18 68 $579,S55A2 4 $5,953.78, RxNavigator screen shot t ~~ Advanced Clinical Outcomes Reporting { a ~ ` ~ ~ 9j A Closer Lo k at Your Return n Invest~~ j< ~t s#`~4{~~ Advanced Clinical Outcomes Reporting provides an in-depth look at your plan population managed by the Caremark Total Specialty Care Management program. This comprehensive offering helps to ensure that your plan participants are using specialty medications appropriately and cost-effectively, maximizing outcomes and minimizing unnecessary expenditures. Designed to go beyond providing simple cost savings information, Advanced Clinical Outcomes Reporting details: • The number of cases that underwent a prospective, concurrent and retrospective review, as well as those cases meeting/not meeting guidelines • Cost savings associated with ensuring the appropriateness of therapy • Clinical outcomes achieved by plan participants With these enhanced clinical and reporting services, you can help your plan participants achieve measurable results related to their conditions, which in turn, helps you decrease your total healthcare costs. Ad Hoc Reporting Customi~~ad Reporting Sol ti ns Most of your ad hoc reporting needs can be met through our Web-based reporting tool, RxNavigator. However, there might be times when your unique research needs fall outside of the system's otherwise robust capabilities, requiring additional support and data sources. To help accommodate these types of requests, Caremark delivers customized reports that apply to your specific criteria. Customized reports are available as: • One-time custom reports • Custom production reports placed into a production environment and generated on a regular schedule Cost may vary depending on the complexity of the project, however, Caremark will calculate an estimate prior to proceeding with your request. Make Managing Your Specialty Program More E#fective For nearly 30 years, Caremark has remained at the forefront of the specialty pharmacy industry by applying innovative technological solutions and working together with its customers to deliver exceptional value. Unlike other companies relying on data warehouses for internal marketing purposes, Caremark provides the focused information and resources you need to optimize critical business decisions. For more information about Caremark reporting tools and services, contact your Caremark account representative. CAREMA It u0 srrrors,. ~itb cure. www.caremark.com 800-223-7745 m,iOM Caremark. N. ~glii~~eserved. Your Prescription Benefit SamP~e Your Logo Goes Here Prepared for ~~ 1~t alI sMsis wrfh cmt" In this booklet, you'll find ^ Making the Most of Your Prescription Benefit Program ^ Getting Your Prescription Filled ^ Helpful Tips ^ Extra Care -the Caremark Difference ^ Prescription Drug Claim Form ^ Mail Service Order Form ^ Your Personal Prescription Benefit Program - A convenient pull-out guide with details about your individual prescription benefit program ^ Caremark Drug List - A wide selection of brand name products identified as preferred -safe, effective, and reasonably priced ~r ^ Generics -Identical to Brands at Lower Cost ^ Common Brands with Generics Available Note: In this booklet we talk about co-payment. Co-payment or co-pay means the amount a participant is required to pay for a prescription in accordance with a Plan, which maybe a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. Your privacy is important to us. Caremark holds any information about your health in confidence. All our employees are trained regarding the importance of protecting your privacy. 8888888-CTC50-0104 It all starts with Care.. . Your health is our primary concern at Caremark. As your pharmacy benefit manager, its our goal to ensure that you receive the medicine you need for your medical condition. In addition, we provide a range of information and services to support your health and make your healthcare experience as pleasant and convenient as possible. 8888888-CLC50-0204 Making the Most of Your Prescription Benefit Program Many people use their prescription benefit more often than any other part of their health coverage. It's such an important part of your healthcare that it pays to take a few minutes to review the material included in this booklet. Here you'll find all the information you need to fill your prescriptions at the most reasonable cost. For more detailed information on your personal prescription history and benefit, as well as general health information from the Mayo Clinic, please visit www.caremark.com. Caremark's commitment to you includes: ^ Helping you get the appropriate prescription for any medical condition covered under your plan. ^ Supporting your overall health and well-being. ^ Making your healthcare experience comfortable and convenient. 8888888-CBC50-0204 Getting Your Prescription Filled Under your pharmacy benefit program, you can get your prescriptions filled at a participating retail pharmacy or through the Caremark Mail Service Program. For New Prescriptions Retail pharmacy 1. To find a participating pharmacy near you, go to www.caremark.com or call your Caremark Customer Care number. 2. At the pharmacy, present your prescription along with your ID card. 3. Make sure that the pharmacist has accurate information about you and your covered dependents, including dates of birth and gender. 4. The pharmacist will look up your benefit information on the computer to verify coverage and dispense the prescription. 5. If given the choice, always Ask for Generics5"^ Caremark Mail Service Program Caremark Mail Service Pharmacies provide a convenient and cost-effective way for you to order medicine you'll be taking for a long time. Follow these steps to make sure you have a continuous supply. 1. Let your doctor know you would prefer a generic. 2. Ask for two prescriptions: one for along-term supply as defined by your coverage; the other for immediate use. Have the short-term prescription filled at a participating retail pharmacy. 3. Complete a Mail Service order form and send it to Caremark along with your original long-term prescription. 4. You can expect your medicine to arrive approximately 14 calendar days after Caremark receives your order. You will receive a new Mail Service order form and pre-addressed envelope with each shipment. 5. If your plan requires payment, you can provide payment information when you place your order or an invoice will be included with the prescription when it is delivered. For Refills Retail pharmacy If your doctor has ordered refills, let your pharmacist know when you are ready to reorder. Caremark Mail Service Program You can order refills by mail. 1. At www.caremark.com, your online prescription service is the most convenient way to order refills and inquire about the status of your order any time of the day or night. You will need to register and log in for secure service. 2. By phone. Call your Customer Care number for fully automated refill service. Have your ID number ready. 3. By mail. Attach the refill label provided with your last order to a Mail Service order form. Enclose your payment with your order, if your plan requires a payment. Helpful Tips When you visit your doctor ^ Let your doctor know that you are interested in using prescription products that are appropriate for you and cost-effective. ^ If you need a prescription, ask for a generic and ask your doctor to authorize generic substitution when medically appropriate. (Find out more about generic prescription medicine at the end of this book.) ^ In case no generic is available, take this booklet along and share the Caremark drug list of preferred brand products with your doctor. This can save you money. ^ Make sure your doctor indicates number of refills, if appropriate, on the prescription. ^ If your doctor tells you that you will be taking a certain medicine for a long time, ask for both ashort-term and a long-term prescription. If you have questions about your prescription drug For information about your prescribed medicine, log on to www.caremark.com at any time, day or night You can also talk to a pharmacist or nurse by calling your Customer Care number. If you have prescriptions at anon-participating pharmacy Contact a Caremark participating retail pharmacy and tell the pharmacist where your prescription is currently on file. If possible, have your prescription bottle with you when you make the call so you can answer any questions. The pharmacist will contact the non-participating pharmacy and make the transfer for you. When you pick up the prescription, bring along your benefit information so that the pharmacist can verify coverage. Extra Care -the Caremark Dif~`erence As your pharmacy benefit provider, Caremark is dedicated to helping you get the medicine you have been prescribed. In addition to this service, we are committed to supporting your overall health and making your healthcare experience as convenient and comfortable as possible. Here are some of the extra services we provide. Keeping you informed. If you have questions about medicine you've been prescribed, or about your health condition, you can contact a pharmacist by calling your Customer Care number. You can also learn more by logging on to www.caremark.com. From our Web site you can access health information from the Mayo Clinic, one of America's most respected healthcare institutions. Making cost-effective prescription choices. If there is a less expensive alternative to a medicine you have been prescribed, Caremark may contact your doctor and ask whether it might be appropriate to substitute another product. In most cases these alternatives are generic equivalents or branded products included on our drug list. It is our policy never to make such a substitution without your doctor's approval. Providing Specialty Pharmacy Services. Certain chronic and/or genetic conditions require special pharmacy products, often in the form of injected or infused medicines. Caremark provides these products directly to patients along with special support, including regular phone calls to answer questions about using the drug. Every participant is also provided with apharmacist-led CareTeam for ongoing support and counseling. Caremark offers Specialty Pharmacy Services for: ^ Asthma ^ Crohn's Disease ^ Gaucher's Disease ^ Growth Hormone Deficiency ^ Hematopoietics ^ Hemophilia, von Willebrand Disease and related bleeding disorders ^ Hepatitis C ^ Immune Disorders ^ Multiple Sclerosis ^ Oncology ^ Psoriasis ^ Pulmonary Hypertension ^ Rheumatoid Arthritis ^ RSV Prevention To learn more about our Specialty Pharmacy Services, please visit www.caremark.com or call CaremarkConnect® at 1-800-237-2767. Your Personal Prescription Bene~it Program A Convenient Pull-Out Guide ~~a~. ~~~ 1T For immediate drug needs or For maintenance or long-term short-term medicine medicine You Will Pay: • $XX for each generic prescription • $XX for each generic prescription • $XX for each brand name • $XX for each brand name prescription on the Primary Drug prescription on the Primary Drug List List • $XX for each brand name • $XX for each brand name prescription not on the Primary prescription not on the Primary Drug List Drug List Day Supply =day supply =day supply Limit: Refill Limit: None None Have More Questions? 3 Easy Ways To Contact Caremark 1. www.caremark.com Caremark.com is a hassle free, round-the-clock way to order refill prescriptions, check order status and get important drug information. Please see the inside front cover for more details. 2. 1-800-XXX-XXXX Call toll-free for the Caremark fully automated refill phone service. 3. Caremark Customer Care Call 1-XXX-XXXX to speak to a Caremark Customer Care representative, 24 hours a day, 7 days a week. You may also email Customer Care 24 hours a day, 7 days a week at customerservice@caremark.com. When you call or log in, be ready to provide: • Participant's ID number provided by your plan • Participant's date of birth • Your VISA, Discover, MasterCard or American Express number with expiration date, if your plan requires a payment Need Another Prescription ID Card? Additional ID cards can be obtained by calling Caremark Customer Care at 1-800-XXX-XXXX. scri Lion Fined Through the Getting Your Pre ue ~.ogram Caremark Mad ~" ail service Pharmacies across th eU~ive.a o ~ articipants whereVe~ed by reg+ster Caremark operates four m rovide quick service top harmacies are sta harmaasts States to p our mail service p d harma~+st~ our p ensure your safety, our neighborhoo P In addoblems lust like y oss+ble p pharmac+sh • r~,ipt+on to make sure it's filled torte Y• , check eat p is reviewed to identify any p your prew nmedication~ You maybe prescribed. with ou get a Day Supply Um~t -day supply of medicine when Y ies. Ask et up to a -- ail Service Pharmac lus refills, You can g h the Caremark Mo a `day supply P pr~ription filled throng escription for up your doctor to write a pr riate' lion for the when clinically aPprOp our prescrip to the e law, Caremark must filly our doctoruup one edication prescribed by does not eq Please vantity of m lus 2 refills exact G I limit. "34-days P 90-day supp y ritten for "90-days.' prescription w referred method of tions ted, the p I include you Payment Op orders are accep a merits, situp Y ex iratio While checks and money erican Express number and P a merit is by credit card. For credit card p Mail Service order form. p Y Discover, MasterCard or he endQ$ed VISA, ace provided on date in the sp s after ome ~efivery Convenient N ,on. Your package will include a new ex ect Your medicine t ~+arrive 14 calendar aYou will also You can p our prescrip Iicable. Caremark receives Y rnvoice, if uPPour prescribed medicinE Mail Service order fore f nd~rmation ~macy receive the same tYP a retail p that you would receive from ' Lion Filled at a Mail pharm~3' Getting Four prescrip ou have a Ray SuppiY Crmrt day pply of medicine each time Y rite a su Ask your doctor to w You can get up to a = harmacy. when clinically tion filled at a reta~idpay supply plus refills, prescript+on for up to a _' prescrip appropriate. ou may obtain at a retaiQU use Refill limit term medicines. However, if Y , There is no limit to thnanCe oelongefills Y medicine you will be tak+ng pharmacy for mainte the Caremark Maii u may Save mon Y or for a long Time, y° Retail Pharmacies a~icipating Pa~icipating includes over 55,000 p independent Car+'ma~ more than 20,000 a~,com• Caremark's Retail Pro9 including visit ~r.carem pharmacies nharm~ctles'. Far a full listmg~ community P eneraiiy more convenient and atin retail pharmacy is g Basil access information a articip 9, riate payment. Using p . wing pharmaoesa d the apPrOp less expensive. Part+cip ro ram ork when you use a our pharmacy benefit p g about Y additional PaPQ1w You will no attic patinger to I Pharmacy. r Caremark P ou use a n Retail PharmacieQUr prescription if Y Non-Participating amore for y st cases, you will p Y ark network. You will hens Youtwiipi need In mo harmacY• with the pharmacy outs+de the ton rice at the p rescrip ~ included in this booklet, along percent of the p formo Caremark for reimbursement of to submit the P tion tea e pt(s} original presenPes. covered exp Count on Safe and Effiective. Better Value" Generic medicines are widely seen as one of the best ways to save money on prescription drugs. In fact, generic drugs save consumers an estimated $8 to $10 billion a year at retail pharmacies, according to the Congressional Budget Office. Here are the most important facts about generic medicines: ^ All generic medicines that have been approved for substitution have been reviewed by the FDA and found to be as safe and effective as the equivalent brand product. ^ The companies who make generic medicines must meet the same FDA manufacturing and quality standards as the ones who make brand products. ^ Generic medicines usually cost much less because their manufacturers do little advertising, and did not have to invest in the original research, development, and testing of the drug. ^ A generic drug will be a different color or shape, but is the same as the brand drug in: - Strength (number of milligrams, etc.) - Dosage form (pill, liquid, cream, etc.) - Quality - Active ingredient - Effectiveness (how it works in the body) Ask your doctor to approve generic substitution whenever appropriate. You can use these FDA-approved products with confidence and the knowledge that you are saving money. Also, please be assured that Caremark will never give you a generic instead of a brand name product without your doctor's permission. The drug names listed on the following page are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with Caremark Inc. These trademarks are included here for informational purposes only and are not intended to imply or suggest affiliation between Caremark Inc. and such third-party pharmaceutical companies. 8888888-CTS50-0104 Common Brands with Generics Available The drugs listed here include some of the most commonly prescribed brand medicines that have FDA-approved generic equivalents. If you are taking one of these medicines, you may be able to save moriey by taking the generic equivalent. There are many more brand medicines that have generics available. To find out if a medicine you've been prescribed has a generic available, please go to www.caremark.com, call your Caremark Customer Care number or ask your doctor or pharmacist. BRAND NAME I GENERIC DRUG NAME I COMMONLY USED FOR* ATIVAN® ~ lorazepam ~ Anxiety BUSPAR® buspirone HCI Anxiety CARDURA® doxazosin mesylate High Blood Pressure, Enlarged DARVOCET-N® DYNACIN® ESTRAC E® GLUCOPHAGE® IMDUR® PEPCID® PRINIVIL®/ PRINZIDE® PROZAC® RITALIN® ULTRAM® VASOTEC® ZESTRIL®/ ZESTORETIC® ZIAC® propoxyphene napsylate/ acetaminophen minocycline HCI estradiol metformin HCI isosorbide mononitrate famotidine lisinopril lisinopril/hydrochlorothiazide fluoxetine HCI methylphenidate HCI tramadol HCI enalapril maleate lisinopril lisinopril/hydrochlorothiazide bisoprolol/hydrochlorothiazide Prostate Pain Infection Hormone Replacement Diabetes Angina (Chest Pain) Ulcer, Heartburn High Blood Pressure, Heart Failure Depression Attention Deficit Hyperactivity Disorder (ADHD) Pain High Blood Pressure, Heart Failure High Blood Pressure, Heart Failure High Blood Pressure *This list indicates common uses for which the drug is prescribed Some medicines are prescribed for more than one condition. Please discuss all treatments with your doctor. ~. C~~~~Cm h alt starts unth care BIN # 610029 Plan Code CRK Group Code XXXXX Issuer (80840) ID 123456789 Name John Q. Proof SAMP~~ 88888@@-ID01-0204 harmacy to at~ng retail fj When you ask to any particip e brand i of medication. th present this card supp y uivalent to shoh-term et the eq saVe money. obtain your medicine, You g and could harmac~es eneric med~c-nei For additional p for a g roved ustomer name FpA-app ricss"" ando~ or call Caremark's C Count o Gene arks go to w,Nw.carem x XXX.Xxx Care. r Care, (XX tome CUS s to: e artment Submit Claim rk Claims D p Carema 686p45 -6465 p'~ ~ Bntonio, TX 18268 San A ~.. ^ Q. Will 1 still be able to use my existing prescription ID card? Will the ID cards change? A. You can continue to use your existing ID card to fill all of your retail prescriptions. Until notified differently your current card will continue to be active and will allow for accurate claim processing. Again, it is the BIN, Group and/or PCN numbers from your plan ID card that are the key values in processing your claim accurately. Q. Will my service be interrupted during the transition of the AdvancePCS name to Caremark? A. It is our intent and commitment to you to continue "business as usual." Q. Who or where do 1 call for more information? A. For more information on Caremark please call the number listed on the back of your ID card or visit vvvvw.caremark.com For more information on Caremark please call the number listed on the back of your ID card or visit www.caremark.com Caremark have become one ~ ~, Beginning with the 2005 plan year, you a will come to know us as Caremark... ...an organization that is excited about providing you with high quality service from people who care for a living... ^ ^ CAREMlAU~(~,K® hall starts unto r~ © Caremark Inc All rights reserved 13646-09D4 Over the next few months you will notice some changes... The following is an overview of what you can expect to see: ~ . AdvancePCS rescription benefit pl You will AdvancePCS, Your p art of Caremark. are administrator, rs now p e level of serurce you receive the~l h new opportunities to continue ed to along in the future. accustom our quality of care enhance Y will begin to see the Aver the next few months, Y°u Caremark in our name transitiofrom the delivery of AdvancePCS with you- to Customer daily interacti ~~~ materials for 2005, rescription open enrolVm sites, p such as Care phone interacti en et~ ether chan9wer time In labels, forms, signag will be phased in ID card prescription ID cards, our existing ou can continue to use y fact, Y our retail prescriptions. to fill all of Y rovide you It is our intent tin other words puring this tran~etl customer service, with unrnterrup "business as usual." ark and AdvancePCS has bination of Carem our capablGties, The com enhanced neater value strengthened andovide you even g enablmh enha ped products and services. throug lease call the phone If you have any question~ePription ID card or visit number listed on your p wWw,caremark.com~ -> " FYeq~entlY Asked guesti°ns cePCS Web site still be {~, Will the Ad d function the same? available an will be able ~mning January 1, 2005 through A, Yes, beg e {unctronality ou access to access the ark com Should y v,rwvu.carem a{ter January 1, 2005, Y°u all of the functronallty AdvanceRx.com will still be a Divided nloy previously p ating retail Gists in particip of the ? ~, Will Pharma be made aware ark. pharmacies vancePCS and Carem combination °f Ad tl underway to ent, co-insubination ofyment Q, Will mY c0"paym of the com change beau nd Caremark? AdvancePCS a will not change A No Y o{ AdvancePCS and our pathe comb'inat pin nes because °{Your plan sponsor determoUe{ Y°Ur Caremark nand will notify Y Ian desig Please contact your plan benefit p ode. about your changes are m uestions sponsor if y°be ef~ goverage prescription e the Frequently Asked Questions for Please se ation. more inform ail Service change? com has Q, Will M AavanceRx. A. As part of the comb~r'ation, all Service art of the Caremark M months, become p ork. Qver the next few harmacY name as well as Pharmacy netw tlon packaging you will see the P our prescrip materials, name references on Communication change to Caremark, materials lin ~ belsgetc) prescr~p X10 ervice will not change but y Pharmacy Services for chronic Q, Will Specialty conditions change timely our prescriptions In a ou'll A, Caremark will fill y nd ou can rest ase~ se vice from our manner a Y uallty custom receive higha macies. specialty p e{{orts are Curren Y ating retail I A, Communication acists in particip educate retail pharm binatron of ut the com harmacist pharmacies abo Caremark. I{ Your p lease our prescription p AdvancePCS a rocessing Y lan ID card so the has diffi theYpharmacist your p Group andl0r provide reference the BIN, this pharmacist car' our card because ortant to process your claim PCN numbers from y information is imp accurately. ber on the harmacist can also call the num Thep card for assistance. back of your ID an ePCSaand Caremark? Q- N/ill my poct of Ad combination underway to currently A, Communication efforts are Gate doctors about the combination of edu Caremark, AdvancePCS and ADMINISTRATION AGREEMENT THIS AGREEMENT IS MADE EFFECTIVE January 1, 2008, and is entered into between IMS Marketing, Inc. D.B.A. Insurance Management Services ("IMS") and KERR COUNTY (the "Plan Sponsor"); and WHEREAS, the Plan Sponsor has established the KERR COUNTY Health Benefit Plan (The "Plan"), under which certain benefits are to be paid from the Plan Sponsor's assets; and WHEREAS, IMS has developed systems, procedures, and facilities to receive, examine, pay and otherwise process claims for benefits, and to perform other administrative duties. NOW, THEREFORE, in consideration of the following mutual covenants, the Parties to this Agreement concur as follows: IMS shall perform for the Plan the administrative services set forth in the Administrative Services Exhibit which is attached hereto and made a part hereof. The parties intend that IMS shall not be deemed a "fiduciary" for the Plan within the meaning of the Employee Retirement Income Security Act of 1974 ("FRIBA"). Accordingly, the services to be performed by IMS shall be limited to those set forth in the Administrative Services Exhibit and the performance by IMS of such services shall be subject in all respects to review by the Plan Sponsor within the framework of policies, interpretations, rules, practices and procedures made or established by the Plan Sponsor. IMS shall have no discretionary authority or control with regard to managing or investing The Plan's assets. IMS shall perform the administrative services set forth in the Administrative Services Exhibit in accordance with the terms and conditions of the Plan and within the framework of policies, interpretations, rates, practices and procedures made or established by the Plan Sponsor, provided that such terms and conditions and framework are consistent and compatible with the description of services set forth in the Administrative Services Exhibit and with all applicable laws or regulations. The Plan Sponsor agrees to pay or cause the Plan to pay to IMS for the administrative services provided under this Agreement the fees set forth in the Fee Exhibit, which is attached hereto and made a part hereof. The term of this Agreement shall be for a period of one year commencing on the Effective Date of this Agreement as stated above and shall be automatically renewed for successive one-year periods, unless terminated as hereinafter provided. Either party shall have the right to terminate this Agreement, effective on any anniversary date of this Agreement, or, after the first anniversary date of this Agreement, effective on the first day of any month, by giving the other party at least 30 days advance written notice of intent to do so. Upon termination of this Agreement, if IMS is to continue processing claims, the Plan Sponsor shall pay to IMS the fees specified in the attached Fee Exhibit. IMS shall have no responsibility, risk, liability or obligation for the funding of the Plan or for any extended liabilities of the Plan whether resulting from the termination of the Plan or from a change to fully or partially insured funding methods. Such responsibility, risk, liability or obligation shall reside solely with the Plan Sponsor, Plan participants, and such other entities as designated in the Plan. The Plan Sponsor agrees to indemnify and hold harmless IMS against any loss, damage, expense, judgment, or other liability including legal fees arising out of or resulting from IMS' performance of services hereunder where IMS has adhered to the framework of policies, interpretations, rules, practices and procedures made or established by the Plan Sponsor or has otherwise performed its services without negligence or willful misconduct and in accordance with industry practices. KERR COUNTY Plan Sponsor By Title Date INSURANCE MANAGEMENT SERVICES By Title President Date 09/01/2007 THIS AGREEMENT IS SUBJECT TO THE STANDARD TERMS AND CONDITIONS ATTACHED HERETO AND MADE A PART HEREOF. STANDARD TERMS AND CONDITIONS Professional Services. Except as otherwise specifically provided in any Services Exhibit attached hereto, IMS shall not provide any legal services to the Plan nor shall it be responsible for providing the services of an independent accountant or auditor. Additional Services. Without the prior written approval from IMS, the Plan Sponsor shall make changes in the Plan effective only on the anniversary dates of the documents governing the Plan, unless otherwise required by applicable law or regulation. In the event such changes require additional services to be performed by IMS, the cost of such services shall be borne by the Plan Sponsor and the Plan Sponsor agrees to pay such costs upon receipt of an invoice for such services from IMS. Books and Records. IMS shall maintain at its principle administrative office adequate books and records of all transactions pertaining to services provided by this Agreement in the administration of the Plan. The books and records shall be maintained for the term of this Agreement and for a seven-year period following termination of this Agreement. All books and records more than seven (7) years old will be destroyed. IMS shall only disclose information in such books and records (1) in response to a court order; (2) for an examination conducted by the State Insurance Commissioner; (3) for an audit or investigation conducted under the Employee Retirement Income Security Act of 1974 (29 U.S.C.1001, et seq.); (4) to a written request of the insurer or the Plan Sponsor; or (5) with the written consent of the identified individual or his or her legal representative. Upon termination of this Agreement, IMS shall deliver to the Plan Sponsor or Plan Sponsor's designee, upon written request, applicable books and records. The Plan Sponsor agrees to pay all costs incurred by IMS in providing such books and records including, but not limited to, reproduction costs and mail costs. Any request for plan information will be furnished in the standard format of the IMS database. The Plan Sponsor agrees to pay all costs incurred by IMS in providing such data and further agrees to relieve IMS of any responsibility or cost associated with transforming such data to other formats. Any transfer of books and records to the Plan Sponsor or Plan Sponsor designee shall be reported to the Commissioner of Insurance for the State of Texas in writing by IMS. IMS shall be entitled to retain copies of all such books and records at its own expense. Independent Contractor. It is understood and agreed by the parties hereto that IMS is engaged to perform services under this Agreement as an independent contractor. Assignments. IMS shall not assign nor delegate to any person or entity the duties, obligations or responsibilities imposed upon it by this Agreement without the prior written approval of the Plan Sponsor. ~cntire Agreements: Amendments. This Agreement including the exhibits hereto and any amendments hereto set forth the full and complete understanding of the parties. Any Administrative Agreement previously executed by the parties hereto shall be void as of the effective date of this Agreement. This Agreement may be modified or amended only pursuant to a written instrument executed by both parties hereto. Invalidity. If any provision of this Agreement is declared invalid or unenforceable, the remaining provisions shall nevertheless remain in full force and effect. Force Maieure. Notwithstanding any provision of this Agreement to the contrary, neither IMS nor the Plan Sponsor shall have any liability to the other for a failure of performance resulting from any cause beyond its control. Enforcement; Overpayments. IMS shall have neither the responsibility nor the obligation to take any action, legal or otherwise, against the Plan Sponsor or any participant in the Plan or other person to enforce the provisions of the Plan. In the event that the Plan Sponsor desires to engage the services of IMS for such purposes, such services shall be engaged in and rendered only pursuant to a separate written agreement between the parties. IMS shall use reasonable efforts to recover any loss resulting from an error in the processing of any claims under the Plan, but shall not be required to initiate legal proceedings for such purpose. Expenses. Except as specifically otherwise provided in this Agreement, the Plan Sponsor shall be solely responsible for the normal and usual costs and expenses incurred in operation of the Plan including all costs attributable to professional services contracted for and provided in connection with the administration of the Plan by IMS at the direction of the Plan Sponsor. IMS shall be responsible for paying the costs and expenses incurred in connection with the maintenance and operation of its facilities. Written Notice. IMS shall be entitled to conclusively rely on any written communication received from the Plan Sponsor which is reasonably believed to be genuine and which is also signed by a person with authority to issue such communication. IMS shall be under no duty to investigate or inquire as to the truth, accuracy, or completeness of such communication. ADMINISTRATIVE SERVICES EXHIBIT PLAN SPONSOR: KERR COUNTY EFFECTIVE DATE: JANUARY 1, 2008 IMS shall provide the following services: 1. Consult with the Plan Sponsor and make recommendations concerning Plan design and Plan changes. 2. Obtain, evaluate, and make recommendations on insurance for limiting the liability of the Plan Sponsor for benefits provided by the Plan. Recommendations will be based on, but not limited to, an evaluation of the company providing the proposal and IMS experience with that company, contract provisions being proposed, and quoted rates. 3. Provide the Plan Sponsor with standard IMS forms for enrollment and on-going operation of the Plan. 4. Maintain Plan benefit information and participant eligibility information and provide such information to providers, participants, and insurance companies as needed. 5. Enroll and delete participants at the direction of the Plan Sponsor in accordance with Plan provisions. The decision to accept or reject, late enrollees, those required to furnish evidence of good health, will be made by the insurance company insuring the Plan, not IMS. That decision will be based on that company's internal underwriting guidelines. 6. Provide Plan Sponsor with monthly bill detailing premium due, reconcile bill and collect payment from Plan Sponsor. Upon receipt of payment, IMS will deposit payment into the IMS Premium Trust Account and will issue individual checks for payment of all billed and collected premium. Insurance company premium is not considered paid until it is received by the insurance company from IMS. 7. Examine claims submitted for payment from Participants of the Plan. 8. Ascertain from claimant whether other insurance coverage may be responsible for payment of the claim in whole or part. 9. Correspond with claimants if additional information is needed to process the claims. '~11rr'10. Calculate benefit amounts to be paid by the Plan in accordance with the Plan Instrument or other written instructions from the Plan Sponsor. 11. Process, issue, and distribute checks and explanation of benefits to Plan participants, hospitals, physicians, Plan Sponsor, or others as applicable and keep records of such disbursements. 12. Notify claimants in writing of claims determined to be ineligible, indicating the reasons for such determination. 13. Provide the Plan Sponsor with monthly reports summarizing claims that have been paid by IMS under this Agreement. 14. Annually prepare & submit Form 1099-MICS covering service providers which receive claim payments made by IMS under this Agreement. 15. Provide the Plan Sponsor with data maintained by IMS for preparing reports required under "FRIBA". 16. Attend meetings with Plan Sponsor as reasonably requested by Plan Sponsor and as necessary for proper administration of the Plan. 17. IMS will comply with all applicable state and federal laws. 18. Other: COBRA/HIPAA Services Exhibit which is attached hereto and made a part hereof. COBRA/HIPAA SERVICES EXHIBIT PLAN SPONSOR: KERR COUNTY EFFECTIVE DATE: JANUARY 1, 2008 The Plan Sponsor's COBRA responsibilities shall be: 1. Provide each covered employee and/or dependent spouse with written notice of his or her continuation of coverage rights under the Plan. 2. Notify IMS, in writing, of the date of a qualifying event IMS shall provide the following COBRA services: 1. Notify qualified beneficiaries of their rights to continue coverage by certified/return receipt mail. A copy of this letter will be mailed to the Plan Sponsor. 2. Maintain files of acceptance or declinations or no responses until sixty (60) day expiration. 3. Receive elections from qualified beneficiaries and notify the Plan Sponsor of an acceptance. 4. Receive premiums and prepare paperwork for proper disbursements and allocation of funds. The Plan Sponsor's HIPAA responsibilities shall be: 1. Submit complete and accurate employment health coverage data to IMS, in a timely manner. IMS shall provide the following HIPAA services: ~/I. Issue a letter to qualified beneficiaries stating the length of his or her Pre-existing condition exclusion period. 2. If documentation is received from a qualified beneficiary the pre-existing letter will be revised showing the correct exclusion period. 3. Issue Certificates of Credible Coverage for any participant as necessary. FEE EXHIBIT PLAN SPONSOR: KERR COUNTY EFFECTIVE DATE: JANUARY 1, 2008 The fee payable to IMS for the services performed under this Agreement to which this Exhibit is attached shall be as follows: 1. An initial set-up fee of n/a for preparation of the Plan Document. The Plan Sponsor will be responsible for actual vendor cost of printing employee booklets. 2. A monthly administrative fee for each employee enrolled during each month that this Agreement is in effect as follows: All Inclusive Administration Fee $ 34.75 Administration fee includes the following services: o Medical o Pre Certification /Case Management o COBRA/HIPAA o PPO o Disease Management o HRA with Debit Card ~" 3. By written request from the Plan Sponsor, IMS will process run-off claims for ninety (90) days after the termination date of this agreement for an amount, payable in advance, equal to the administrative fee for the last full month immediately preceding the termination date multiplied by three (3). IMS will continue run-off administration longer than the above ninety (90) day period by written request from the Plan Sponsor, and the fee will be $30 per Explanation of Benefit (EOB) until such service is no longer required. 4. Upon termination of this agreement, IMS shall provide the following reports to the Plan Sponsor: o Census Report o Paid claims Report o Accumulator Report o Pending Report Additional reports and/or eligibility data will be furnished, upon request by the Plan Sponsor, for an additional fee as referenced in the "Books and Records" section of this agreement. PLAN DOCUMENT HEALTH BENEFIT PLAN FOR THE EMPLOYEES OF: ABC COMPANY TABLE OF CONTENTS INTRODUCTION ...........................................................................................................................................1 SCHEDULE OF BENEFITS .................................................................................................................... ......3 DEFINITIONS ......................................................................................................................................... ......5 ELIGIBILITY FOR COVERAGE .............................................................................................................. ....21 EFFECTIVE DATE OF COVERAGE ...................................................................................................... ....23 TERMINATION OF COVERAGE ............................................................................................................ ....24 PRE-EXISTING CONDITIONS LIMITATIONS ....................................................................................... ....26 PRE-ADMISSION CERTIFICATION ....................................................................................................... ....28 SUPPLEMENTAL PRESCRIPTION DRUG PROGRAM ........................................................................ ....31 THIS IS WHERE THE DRUG PLAN FROM CAREMARK WOULD BE INSERTED .............................. ....32 PREVENTIVE CARE BENEFIT .............................................................................................................. ....33 PREFERRED PROVIDER ORGANIZATION (PPO) .............................................................................. ....33 MAJOR MEDICAL EXPENSE BENEFITS .............................................................................................. ....34 CASE MANAGEMENT ............................................................................................................................ ....39 GENERAL PLAN EXCLUSIONS AND LIMITATIONS ............................................................................ ....40 HEALTH CLAIM PROCEDURES FOR POST SERVICE CLAIMS ......................................................... ....43 APPEALS OF ADVERSE BENEFIT DETERMINATIONS ...................................................................... ....46 INTERNAL RULES, GUIDELINES OR PROTOCOL .............................................................................. ....50 PRIVACY STANDARDS ......................................................................................................................... ....51 COORDINATION OF BENEFITS (COB) ................................................................................................ ....54 SUBROGATION, REIMBURSEMENT, AND THIRD PARTY RECOVERY PROVISION ....................... ....58 CONTINUATION OF COVERAGE ......................................................................................................... ....60 GENERAL PROVISIONS ........................................................................................................................ ....63 NOTICE OF ENROLLMENT RIGHTS .................................................................................................... ....64 ERISA RIGHTS ....................................................................................................................................... ....66 ADMINISTRATIVE INFORMATION ........................................................................................................ ....67 INTRODUCTION Whereas ABC Company, hereinafter referred to as the "Company", hereby establishes the benefits, rights and privileges which shall pertain to Participating Employees, hereinafter referred to as "Participants", and the Eligible Dependents of such Participants, as herein defined, and which benefits are provided through a group medical plan established by the Company and hereinafter referred to as the "Plan". PURPOSE -The purpose of the Plan Document is to set forth the provisions of the Plan which provide for the payment or reimbursement of all or a portion of "Eligible Medical Expenses", as herein defined. EFFECTIVE DATE -The effective date of the Plan is October 1, 2005. PLAN SUPERVISOR -The supervisor of the Plan is: Insurance Management Services P.O. Box 15688 Amarillo, Texas 79105 (806) 373-5944 www.imstpa,com PLAN NUMBER -The Plan number is 501. NAMED FIDUCIARY AND PLAN ADMINISTRATOR -The Named Fiduciary and Plan Administrator is: ABC Company ~, The Named Fiduciary and Plan Administrator shall have the authority to control and manage the operation and administration of the Plan. The Plan Administrator may delegate responsibilities for the operation and administration of the Plan. The Company shall have the authority to amend the Plan, to determine its policies, to appoint and remove supervisors and agents, fix their compensation (if any), and exercise general administrative authority over them. The Administrator has the sole and discretionary authority to determine eligibility for benefits, to review and make final decisions on all claims for benefits including, without limitation, factual determinations; and to construe the terms of the Plan including without limitation, correcting any defect, supplying any omission and reconciling any inconsistency. EMPLOYER IDENTIFICATION NUMBER -The Employer Identification Number is 12-3456789 CONTRIBUTIONS TO THE PLAN -The amount of contributions to the Plan are to be made on the following basis: The Company shall from time to time evaluate the costs of the Plan and determine the amount to be contributed by the Company and the amount to be contributed (if any) by each covered Participant. Notwithstanding any other provision of the Plan, the Company's obligation to pay claims otherwise allowable under the terms of the Plan shall be limited to its obligation to make contributions to the Plan as set forth in the preceding paragraph. Payment of said claims in accordance with these procedures shall discharge completely the Company's obligation with respect to such payments. In the event that the Company terminates the Plan, then as of the effective date of termination, the Company and covered Participants shall have no further obligation to make additional contributions to the Plan. INTRODUCTION (Cont'd) PROTECTION AGAINST CREDITORS - No benefit payment under this Plan shall be subject in any way to alienation, sale, transfer, pledge, attachment, garnishment, execution or encumbrance of any kind, and any attempt to accomplish the same shall be void. If the Company shall find that such an attempt has been made with respect to any payment due or to become due to any Covered Person, the Company in its sole discretion may terminate the interest of such Covered Person or former Covered Person in such payment, and in such case shall apply the amount of such payment to or for the benefit of such Covered Person or former Covered Person, his spouse, parent, adult child, guardian of a minor child, brother or sister, or other relative of a dependent of such Covered Person or former Covered Person, as the Company may determine, and any such application shall be a complete discharge of all liability with respect to such benefit payment. PLAN AMENDMENT -This Document contains all the terms of the Plan and may be amended from time to time by the Company. Any changes so made shall be binding on each covered Participant and on any other Covered Persons referred to in this Plan Document. TERMINATION OF PLAN -The Company reserves the right at any time to terminate the Plan by a written instrument to that effect. All previous contributions by the Company shall continue to be issued for the purpose of paying benefits under the provisions of this Plan with respect to claims arising before such termination, or shall be used for the purpose of providing similar health benefits to Covered Persons, until all contributions are exhausted. PLAN IS NOT ACONTRACT -This Plan Document constitutes the entire Plan. The Plan will not be deemed to constitute a contract of employment or give any Participant of the Company the right to be retained in the service of the Company or to interfere with the right of the Company to discharge or otherwise terminate the employment of any Participant. PLAN TYPE -This Plan is aself-insured program of benefits consisting of an "Employee Welfare Benefit Plan" under the Employee Retirement Income Security Act of 1974 (FRIBA) and any Amendments thereto. ~r PARTICIPATING EMPLOYERS - A complete list of the employers sponsoring this Plan may be obtained by participants and beneficiaries upon written request to the Plan Administrator, and is available for examination by participants and beneficiaries. Participants and beneficiaries may receive from the Plan Administrator, upon written request, information as to whether a particular employer is a sponsor of the Plan and, if the employer is a plan sponsor, the sponsor's address. IN WITNESS WHEREOF, the Company has executed, and the Plan Supervisor has acknowledged, this Plan Document as of the Plan Effective Date shown therein. By: By: Witness ABC Company Date: Date: ABC Company SCHEDULE OF BENEFITS Effective Date: October 1, 2005 The following is a summary of the benefits, subject to co-payments, deductibles, percentages and limitations, provided to you and any covered dependents. Please note the Calendar Year Deductibles are always applicable, unless the schedule states they are waived. PLEASE REFER TO THE LIMITATIONS AND EXCLUSIONS FOR ADDITIONAL EXPLANATIONS. Ma'or Medical Ex ense Benefit PPO "Non-PPO Calendar Year Deductible Individual Famil $500 $1,500 $1,000 $3,000 Percentage Payable After Deductible or Co-Payment unless otherwise stated below 80% 50% Out of Pocket Maximum Individual Family $2,000 $5,000 Excluding any applicable Deductibles and Co- Pa ments PPO and Non-PPO Deductible and Out of Pocket maximums wiR be considered inte rated. Physician Services (In office) Office Visits/ X-Ray/ Lab/ Injections/ Diagnostic Medical Procedures /Medical Supplies Office Surgery and Related Expenses Maximum Payment per Office Visit -Excess subject to deductible, percentage payable and out of pocket maximums Allergy Treatment Testin , In'ection Serum & Su lies $20 Co-Pay, 100% 80% 0% 50% 50% 0% Other Miscellaneous Ph sician Services 80% 50% Preventive Care Office Visits Other Outpatient Facilities $25 Co-Pay, 100% 100% 50% 50% Calendar Year Maximum $500 Chiropractic Care 80% 50% Maximum Calendar Year Benefit $1,500 Out atient Laborato /Radiolo Services 80% 50% Emergency Services Emergency Room Facility (Co-Pay waived if Admitted) Emer enc Room Ph sicians $50 Co-Pay, 80% 80% $50 Co-Pay, 50% 50% Ambulance Services 80% 50% Hospital Services Inpatient/Outpatient: 80% 50% Hospital Admission Deductible Non Pre-certified IP Hospital Penalty Deductible $500 $250 Hospital Room & Board Limitation Intensive Care Unit Average Semi-Private Avera a Intensive Care Inpatient and Outpatient charges for emergency room, radiology, anesthesiology and pathology services rendered by a Non-PPO Ph sician will be paid the same as Covered Expenses for a PPO Ph sician if such services are erformed at a PPO facili SCHEDULE OF BENEFITS (Cont'd) Ma'or Medical Ex ense Benefit PPO *Non-PPO Outpatient Rehabilitation, Speech, & Occupational Thera 80% 50% Physical Therapy 80% 50% Daily Benefit Maximum per condition Maximum Number of Treatments Per Condition Three (3) modalities, procedures, units 12 Visits The Maximum Number of Treatments is waived for an additional treatments, which are due to medical necessit . Chemothera ,Radiation Thera & Dial sis 80% 50% Extended Care Services Home Health Care 80% 50% Calendar Year Maximum Maximum er Visit 100 Visits $60 Skilled Nursing Facility 80% 50% Calendar Year Maximum 30 Da s Hospice Services 80% 50% Plan Benefit Maximum $10,000 Materni Ex ense Benefit 80% 50% Routine Nurse Care /Newborn Care 80% 50% Mental and Nervous Disorders: Inpatient Mental and Nervous Hospital Per Admission Deductible and Hospital Pre- certification Penalties apply 80% 50% Plan Maximum Number of Inpatient Hospital Days 30 Outpatient Mental and Nervous 50% 50% Office Visits Other Outpatient Facilities Maximum Number of Out atient Visits Per Cal Year 30 Char es will never a 1 toward satis i n an Out of Pocket maximums. Prosthetic/Orthotic A liances 80% 50% Durable Medical E ui ment 80% 50% Medical Su lies 80% 50% Diabetic Su lies excludin Insulin ands rin es 80% Covered ex enses will be considered PPO and will accumulate towards PPO deductible and Out of Pocket Maximum amounts. Plan Benefit Maximum $2,000,000 Prescription Drug Plan Retail - Up to a 34 day su I Mail Order - Up to a 90 da su I Generic Co-Payments Brand Name, Preferred Co-Payments Brand Name, Non-Preferred Co-Pa ments $10 $20 $30 $20 $40 $60 Generic Drugs are required if available. If Participant purchases a Brand Name Drug when alternative Generic Drug is available, the Participant is responsible for the cost difference between the Brand Name and the Generic Drug, in addition to the Co-Pa ment, unless the Ph sician writes "Dis ense as Written". * PPO Benefits will apply for: 1. Procedures which cannot be performed by a PPO Provider. 2. Hospital Admission or treatment in a Non-PPO Facility or by a Non-PPO Provider due to an Emergency. * Non-PPO charges will be reimbursed by the Plan based on Usual & Customary. 4 DEFINITIONS Certain words and phrases used in this Plan Document are listed below, along with the definition or explanation of the manner in which the term is used for the purposes of this Plan. Masculine pronouns used in this Plan Document shall include masculine or feminine gender unless the context indicates otherwise. Wherever any words are used herein in the singular or plural, they shall be construed as though they were in the plural or singular, as the case may be, in all cases where they would so apply. ADVERSE BENEFIT DETERMINATION -The term "Adverse Benefit Determination" means a denial, reduction or termination of, or a failure to provide or make payment (in whole or part), for a benefit, including any such denial, reduction, termination or failure to provide or make payment that is based on a determination of a Participant's or beneficiary's eligibility to participate in a Plan. ALCOHOL AND DRUG DEPENDENCY TREATMENT CENTER -The term "Alcohol and Drug Dependency Treatment Center" means a facility that provides a program for the treatment of Alcoholism and Drug Abuse by means of a written treatment plan that is approved and monitored by a Physician. This facility must be: (1) affiliated with a Hospital under a contractual agreement with an established system for patient referral; (2) accredited by the Joint Commission on Accreditation of Hospitals; or (3) licensed, certified, or approved as an Alcohol and Drug Abuse Treatment Program or Center by any state agency that has the legal authority to do so. ALCOHOLISM. DRUG ADDICTION OR SUBSTANCE ABUSE -The term "Alcoholism, Drug Addiction or Substance Abuse" means the pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social or occupational functions and which constitutes alcohol or drug dependency. ~; ALTERNATE CARE -The term "Alternate Care" means medical treatment or care that is provided in lieu of the benefits specified in this Plan, because it may be provided in a less comprehensive setting or because it is less expensive. Alternate Care must be (a) recommended by the Case Manager for a Covered Person; (b) Medically Necessary and (c) approved by the Plan Administrator. If the Plan Administrator determines that medical treatment or care is Alternate Care for a Covered Person in one instance, it shall not be obligated to determine that the same medical treatment or care is Alternate Care for other Covered Persons under this Plan in any other instance. ALTERNATE RECIPIENT -The term "Alternate Recipient" shall mean any Child of a Participant who is recognized under a Medical Child Support Order as having a right to enrollment under this Plan as the Participant's Eligible Dependent. For purposes of the benefits provided under this Plan, an Alternate Recipient shall be treated as an Eligible Dependent, but for purposes of the reporting and disclosure requirements under ERISA, an Alternate Recipient shall have the same status as a Participant. AMBULATORY SURGICAL CENTER -The term "Ambulatory Surgical Center" means an institution or facility, eitherfree standing or as a part of a Hospital with permanent facilities, equipped and operated for the primary purpose of performing surgical procedures and to which a patient is admitted to and discharged from within atwenty-four (24) hour period. An office maintained by a Physician for the practice of medicine or dentistry, or for the primary purpose of performing terminations of Pregnancy, shall not be considered to be an Ambulatory Surgical Center. AMENDMENT -The term "Amendment" means a formal document that changes the provisions of the Plan Document, duly signed by the authorized person or persons as designated by the Plan Administrator. DEFINITIONS (Cont'd) ANTIGEN DOSE -The term "Antigen Dose" means the amount of antigen administered in a single injection, whether drawn from single or multiple vials. The number of doses shall be equal to the number of "units" reported by the provider of service. APPROPRIATE HEALTH CARE PROFESSIONAL -The term "Appropriate Health Care Professional" means a person who meets all of the following requirements: 1. Must be a Physician or other health care professional who is licensed, accredited or certified to perform specified health services under state law; 2. Must have appropriate training and experience in the field of medicine involved in the decision; and 3. Was not consulted in connection with the benefit determination that is the subject of the appeal, nor is a subordinate of the person who was consulted. AUTHORIZED REPRESENTATIVE -The term "Authorized Representative" means the person who the Claimant appoints to act on his behalf with respect to a benefit claim or appeal of a denial. AUDIOLOGIST -The term "Audiologist" means a person who: (1) has a master's or doctorate degree in Audiology from an accredited College or University; and (2) is certified by the American Speech-Language and Hearing Association. BENEFIT PERCENTAGE -The term "Benefit Percentage" means that portion of Eligible Medical Expenses to be paid by the Plan in accordance with the coverage provisions as stated in the Plan. It is the basis used to determine any Out-of-Pocket expenses in excess of the annual Deductible which are to be paid by the Participant. BENEFIT PERIOD -The term "Benefit Period" refers to a time period of one year, as shown on the Schedule of Benefits. Such Benefit Period will terminate on the earliest of the following dates: 1. The last day of the one year period so established; or 2. The day the Plan Benefit Maximum applicable to the Covered Person becomes payable; or 3. The day the Covered Person ceases to be covered for Major Medical Expense Benefits. BIRTHING CENTER - A facility, duly licensed by the political jurisdiction where located and operating pursuant to that license, which: 1. Is operated primarily as a facility for the delivery of children following a normal, uncomplicated Pregnancy; 2. Is operated under the direct, full-time supervision of a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), or a Registered Nurse (R.N.); 3. Is equipped to perform routine diagnostic laboratory tests, and to handle medical emergencies; 4. Maintains adequate, written medical records for each patient; and 5. Has a written agreement with at least one local Hospital for immediate acceptance of patients who develop complications or require Hospital Confinement. CALENDAR YEAR -The term "Calendar Year" means a period of time commencing on January 1st and ending on December 31st of the same given year. 6 DEFINITIONS (Cont'd) CASE MANAGER -The term "Case Manager" means an entity or person that reviews the cost effectiveness or prescribed courses of treatment forthe Covered Person and includes assessing, planning, implementing, coordinating and evaluating health related service options, under the terms of an agreement with Employer. CERTIFICATE OF COVERAGE -The term "Certificate of Coverage"m eans a document that provides evidence of prior health coverage for a Covered Person, as required by HIPAA. CHIROPRACTIC CARE -Any services, supplies, diagnostic procedures and/or treatment provided by a Doctor of Chiropractic. CLAIMANT -See Covered Person CLOSE RELATIVE -The term "Close Relative" means the spouse, parent, brother, sister, child, or spouse's parent of the Covered Person. COBRA -The term "COBRA" refers to the Consolidated Omnibus Budget Reconciliation Act of 1985 or any provision or section thereof, which is herein specifically referred to, as such act, provision or section may be amended from time to time. COBRA CONTINUEE -The term "COBRA Continuee" means a person who is receiving continuation coverage under a group health care plan maintained by the Company. A person shall cease to be a COBRA Continuee on the date that the "maximum required period" ends for the "qualifying event" giving rise to his continuation coverage or if earlier, when COBRA coverage terminates hereunder. COLLEGE -See definition of University. COMPANY -The term "Company" means ABC Company and any other affiliates that adopt the Plan. CONCURRENT CLAIM -The term "Concurrent Claim" means a claim that arises when the Plan has approved an on-going course of treatment to be provided over a period of time that involves a reduction or termination by the Plan of such course of treatment (other than by plan amendment or termination) or number of treatments. CONFINEMENT -The term "Confinement" means a period of time when an individual becomes confined in a Hospital or Skilled Nursing Facility due to an Illness or Injury. CONVALESCENT PERIOD -The term "Convalescent Period" means a period of time commencing with the date of Confinement by a Covered Person to a Skilled Nursing Facility. Such Confinement must meet all of the following conditions: 1. Such Confinement must commence within fourteen (14) days of being discharged from a Hospital; and 2. Said Hospital Confinement must have been for a period of not less than three (3) consecutive days; and 3. Both the Hospital and skilled confinements must have been for the care and treatment of the same Illness or Injury. A Convalescent Period will terminate when the Covered Person has been free of Confinement in any and all institutions providing Hospital or nursing care for a period of ninety (90) consecutive days. Anew Convalescent Period shall not commence until a previous Convalescent Period has terminated. CO-PAYMENT -The term "Co-Payment" means the amount of payment shown in the Schedule of Benefits that is due and payable by a Covered Person to a Provider at point of service. DEFINITIONS (Cont'd) `~'` COSMETIC PROCEDURE -The term "Cosmetic Procedure" means any plastic or reconstructive surgery done primarily to improve the appearance of any portion of the body, and for which there is no Medical Necessity and from which no improvement in physiological function could be reasonably expected. Examples of Cosmetic Procedures are as follows: surgery for sagging or extra skin; any augmentation or reduction procedures, rhinoplasty and associated surgery; and any procedures utilizing an implant. COVERED EXPENSE -The term "Covered Expense" means any Medically Necessary treatments, services, or supplies that are not specifically excluded from coverage elsewhere in this Plan. COVERED PERSON -The term "Covered Person" means any Participant or Dependent of a Participant meeting the eligibility requirements for coverage as specified in this Plan, and properly enrolled in the Plan. CREDITABLE COVERAGE -The term "Creditable Coverage" means health coverage under a group health plan, HMO, an individual health insurance policy, COBRA, Medicaid or Medicare that is not followed by a Significant Break in Coverage and excludes coverage for liability, limited scope dental or vision benefits, specified disease and/or other supplemental-type benefits as defined by the final regulations of HIPAA Portability Act. CUSTODIAL CARE -The term "Custodial Care" means that type of care or service, wherever furnished and by whatever name called, which is designed primarily to assist a Covered Person, whether or not Totally Disabled, in the activities of daily living. Such activities include, but are not limited to: bathing, dressing, feeding, preparation of special diets, assistance in walking or getting in and out of bed, and supervision over medication which can normally be self-administered. DEDUCTIBLE -The term "Deductible" means a specified dollar amount of Covered Expenses which must be incurred during a Benefit Period before any other Covered Expenses can be considered for payment according to the applicable Benefit Percentage. DEPENDENT -The term "Dependent" means: The Participant's legal spouse who is a resident of the same country in which the Participant resides. Such spouse must have met all requirements of a valid marriage contract in the State of marriage of such parties. A marriage license or common law certificate may be required. The Participant's child who meets all of the following conditions: a. Is a resident of the same country in which the Participant resides; b. Is unmarried; c. Is a Natural Child, stepchild, grandchild, legally adopted child, child for whom legal adoption proceedings have been initiated if such child has been placed in your home, or a child who has been placed under the legal guardianship of the Participant. A Natural Child qualifies as a Dependent at the time of birth. A Natural Child means a child that is related by birth and is not an adopted child, a stepchild, a foster child, niece, nephew, or grandchild. d. Is less than nineteen (19) years of age. This requirement is waived if the child is at least nineteen (19) years of age but less thantwenty-five (25) years of age, is dependent upon the Participant for support, and meets the definition of Full-Time Student as defined by the Plan. The age requirement above is also waived for any mentally retarded or physically handicapped child, provided that the child is incapable of self-sustaining employment and is chiefly dependent upon the Participant for support and maintenance. Proof of incapacity must be furnished to the Company, and additional proof may be requested from time to time. DEFINITIONS (Cont'd) DEPENDENT (Cont'd) 3. As required by the federal Omnibus Budget Reconciliation Act of 1993, any child of a Plan Participant who is an Alternate Recipient under a Qualified Medical Child Support Order (QMCSO) and has a right to enroll in the Plan as a Dependent of a Participant. Those situations specifically excluded from the definition of a Dependent are: 1. A spouse who is legally separated or divorced from the Participant. Such spouse must have met all requirements of a valid separation or divorce contract in the State granting such separation or divorce; 2. Any person on active military duty; 3. Any person eligible for coverage under this Plan as an individual Participant; 4. Any person who is covered as a Dependent by more than one Participant of the same Company. DEPENDENT COVERAGE -The term "Dependent Coverage" means eligibility under the terms of the Plan for benefits payable as a consequence of Eligible Medical Expenses incurred for an Illness or Injury of a Dependent. DURABLE MEDICAL EQUIPMENT -The term "Durable Medical Equipment" means equipment which is: 1. Able to withstand repeated use; 2. Primarily and customarily used to serve a medical purpose; 3. Not generally useful to a person in the absence of Illness or Injury; 4. Appropriate for use in the home. EFFECTIVE TREATMENT -The term "Effective Treatment" means a program of Alcoholism or Drug Abuse therapy that is prescribed and supervised by a Physician and meets either of the following: 1. The Physician certifies that afollow-up program has been established which includes therapy by a Physician, or a group therapy under a Physician's direction, at least once per month. 2. It includes attendance at least twice a month at meetings of organizations devoted to the therapeutic treatment of Alcoholism or Drug Abuse, whichever condition is being treated. Treatment solely for detoxification or primarily for maintenance care is not considered Effective Treatment. Detoxification is care aimed primarily at overcoming the aftereffects of a specific episode of drinking or Drug Abuse. Maintenance care consists of the providing of an environment without access to alcohol or drugs. ELIGIBLE MEDICAL EXPENSES -See Covered Expenses EMERGENCY -The term "Emergency" means an Illness or Injury which if not immediately treated would jeopardize the person's life or cause serious health impairment. EMERGENCY ADMISSION -The term "Emergency Admission" means admission to a Hospital for an Illness or Injury which, unless immediately treated on an Inpatient basis, would jeopardize the person's life or cause serious health impairment. 9 DEFINITIONS (Cont'd) EMPLOYEE -The term "Employee" means an individual: 1. Whose relationship to an Employer is within the meaning of "Employee" for Federal tax withholding purposes; and 2. Who is not a Leased Employee, treated as an independent contractor by an Employer or any employee of such person, even if such person is later reclassified as an Employee on the payroll records of an Employer, or is otherwise compensated by an Employer outside of its normal payroll. A former Employee may be treated as an Employee hereunder during the time that such individual is receiving COBRA continuation coverage under this Plan. ENROLLMENT DATE -The "Enrollment Date" means the first day of coverage or, if there is a Waiting Period, the first day of the Waiting Period. ERISA -The term "FRIBA" refers to the Employee Retirement Income Security Act of 1974 as amended, or any provision or section thereof which is herein specifically referred to, as such Act, provision or section may be amended from time to time. EXPERIMENTAL OR INVESTIGATIONAL -The term "Experimental or Investigational" means the services, supplies, care, and treatment which does not constitute acceptable medical practice. A drug, device, procedure or treatment will be determined to be Experimental or Investigational if the Plan Administrator determines (in its sole discretion) that any of the following apply: 1. The service, procedure, treatment, drug or supply is under study or in a "clinical trial" to evaluate its toxicity, safety or efficacy for a particular diagnosis or set of indications. "Clinical trials" includes but is not limited to phase I, II and III clinical trials. 2. If required by the FDA, approval has not been granted for marketing; or 3. A recognized national medical or dental society or regulatory agency has determined, in writing, that it is Experimental, Investigational or for research purpose; or 4. The written protocol used by the treating facility or the protocol or protocols of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is Experimental, Investigational or for research purposes. FAMILY -The term "Family" means a Covered Person and his eligible dependents. FMLA -The term "FMLA" refers to the Family Medical and Leave Act of 1993, or any provision or section thereof, which is herein specifically referred to, as such act, provision or section may be amended from time to time. FULL-TIME EMPLOYEE -The term "Full-Time Employee" means a basis whereby a Participant is employed, and is compensated for services, by the Company for at least the number of hours per week stated in the eligibility requirements. The work may occur either at the usual place of business of the Company or at a location to which the business of the Company requires the Participant to travel. 10 DEFINITIONS (Cont'd) ~"''` FULL-TIME STUDENT -The term "Full-Time Student" means a Participants Dependent child who enrolls at the beginning of the Spring Semester (January 1 -August 31) or the Fall Semester (September 1 -December 31) in an accredited school, College, or University for the minimum number of hours required by that institution to meet Full-Time Student status. It is the Employee's responsibility to forward proof of Full-Time Student status each semester. A Dependent child that meets the requirement ofFull-Time Student will be considered aFull-Time Student for purposes of eligibility under this Plan for the entire length of the applicable semester, as defined above, including the semester of graduation. A Dependent child that enrolls at the beginning of either the Spring or Fall Semester, as defined above, in an accredited school, College, or University forthe minimum number of hours required by that institution to meet Full-Time Student status and subsequently drops to part-time student status during the semester, will be considered aFull-Time Student for purposes of eligibility under this Plan for the remainder of that semester, as defined above. GENETIC INFORMATION -The term "Genetic Information" means information about genes, gene products, and inherited characteristics that may be derived from an individual or a Family member. This includes information regarding carrier status, information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, Family histories, and direct analysis of genes or chromosomes. HIPAA -The term "HIPAA" refers to the Health Insurance Portability and Accountability Act of 1996, as amended, or any provision or section thereof or regulation hereunder, which is herein specifically referred to, as such act, provision or section may be amended from time to time. HOME HEALTH CARE AGENCY -The term "Home Health Care Agency" means a public or private agency or organization that specializes in providing medical care and treatment in the home. Such a provider must meet all of the following conditions: 1. It is primarily engaged in and duly licensed, if such licensing is required, by the appropriate licensing authority to provide skilled nursing services and other therapeutic services; 2. It has policies established by a professional group associated with the agency or organization. This professional group must include at least one Physician and at least one Registered Nurse (R.N.) to govern the services provided and it must provide for full-time supervision of such services by a Physician or Registered Nurse; 3. It maintains a complete medical record on each individual; 4. It has afull-time administrator. HOME HEALTH CARE PLAN -The term "Home Health Care Plan" means a program for continued care and treatment of the Covered Person established and approved in writing by the Covered Person's attending Physician within seven (7) days following termination of a Hospital Confinement as a resident Inpatient, and is forthe same or related condition forwhich he was hospitalized. The attending Physician must certify that the proper treatment of the Illness or Injury would require continued Confinement as a resident Inpatient in a Hospital in the absence of the services and supplies provided as part of the Home Health Care plan. HOSPICE -The term "Hospice" means a health care program providing a coordinated set of services rendered at home, in Outpatient settings or in institutional settings for Covered Persons suffering from a condition that has a terminal prognosis. A Hospice must have an interdisciplinary group of personnel which includes at least one Physician and one Registered Nurse (R.N.), and it must maintain central clinical records on all patients. A Hospice must meet the standards of the National Hospice Organization (NHO) and applicable state licensing requirements. 11 DEFINITIONS (Cont'd) ~/ HOSPICE BENEFIT PERIOD -The term "Hospice Benefit Period" means a specified amount of time during which the Covered Person undergoes treatment by a Hospice. Such time period begins on the date the attending Physician of a Covered Person certifies a diagnosis of terminally ill, and the Covered Person is accepted into a Hospice program. The period shall end the earliest of six (6) months from this date or at the death of the Covered Person. Anew Benefit Period may begin if the attending Physician certifies that the patient is still terminally ill; however, additional proof may be required by the Plan Administrator before such a new Benefit Period can begin. HOSPITAL -The term "Hospital" means an institution which: is licensed and operated in accordance with the laws which pertain to Hospitals where it is located; is engaged primarily in providing medical care and treatment to ill and injured persons on an Inpatient basis at the patient's expense; maintains on its premises all the facilities necessary to provide for diagnosis and medical and surgical treatment of an Illness or an Injury; such treatment is provided by or under the supervision of Physicians with continuous twenty-four (24) hour nursing services by Registered Nurses; and is a provider of services under Medicare. Under no circumstances will a Hospital be other than incidentally, a place for rest, a place for the aged, a place for drug addicts, a place for Alcoholics, or a nursing home. HOSPITAL MISCELLANEOUS EXPENSES -The term "Hospital Miscellaneous Expenses" means the actual charges made by a Hospital in its own behalf for services and supplies rendered to the Covered Person which are Medically Necessary for the treatment of such Covered Person. Hospital Miscellaneous expenses do not include charges for Room and Board or for professional services (including intensive nursing care by whatever name called), regardless of whether the services are rendered under the direction of the Hospital or otherwise. ILLNESS -The term "Illness" means a bodily disorder, disease, physical sickness, mental infirmity, Functional Nervous Disorder, (refer to definition of Mental Illness or Disorder and Functional Nervous Disorder) or ~ Pregnancy of a Covered Person. A recurrent Illness will be considered one Illness. Concurrent Illnesses will be considered one Illness unless the concurrent Illnesses are totally unrelated. All such disorders existing simultaneously which are due to the same or related causes shall be considered one Illness. INCURRED EXPENSES -The term "Incurred Expenses" means those services and supplies rendered to a Covered Person. Such expenses shall be considered to have occurred at the time or date the service or supply is actually provided. INJURY -The term "Injury" means a condition caused by accidental means which results in damage to the Covered Person's body from an external force. Any loss which is caused by or contributed to by a hernia of any kind will be considered a loss under the definition of Illness, and not as a loss resulting from accidental Injury. INPATIENT -The term "Inpatient" refers to the classification of a Covered Person when that person is admitted to a Hospital, Hospice, or Skilled Nursing Facility for treatment, and charges are made for Room and Board to the Covered Person as a result of such treatment. INTENSIVE CARE UNIT -The term "Intensive Care Unit" means a section, ward, orwing within the Hospital which is separated from other facilities and: Is operated exclusively for the purpose of providing professional medical treatment for critically ill patients; Has special supplies and equipment necessary for such medical treatment available on a standby basis for immediate use; 12 DEFINITIONS (Cont'd) INTENSIVE CARE UNIT (Cont'd) 3. Provides constant observation and treatment by Registered Nurses (R.N.'s) or other highly trained Hospital personnel. LATE ENROLLEE -The term "Late Enrollee" means a Participant or eligible Dependent who enrolls under the Plan other than during: On the earliest date on which coverage can become effective for the individual under the terms of the Plan; or 2. A special enrollment period. LEASED EMPLOYEE -The term "Leased Employee" means an individual who is not paid through an Employer's payroll and who is typically compensated by a company (e.g., an employee leasing company or temporary agency) other than an Employer. LICENSED PRACTICAL NURSE -The term "Licensed Practical Nurse" means an individual who has received specialized nursing training and practical nursing experience, and is duly licensed to perform such nursing services by the state or regulatory agency responsible for such licensing in the state in which that individual performs such services. MEDICAL CHILD SUPPORT ORDER -The term "Medical Child Support Order" shall mean any judgment, decree or order (including approval of a domestic relations settlement agreement) issued by a court of competent jurisdiction that: Provides for child support with respect to a Participant's Child or directs the Participant to provide coverage under a health benefits plan pursuant to a state domestic relations law (including a community property law); or 2. Enforces a law relating to medical child support described in Social Security Act §1908 (as added by Omnibus Budget Reconciliation Act of 1993 §13822) with respect to a group health plan. MEDICALLY NECESSARY -The term "Medically Necessary" means health care services, supplies or treatment which is appropriate and consistent with the diagnosis and which, in accordance with generally accepted medical standards, could not have been omitted without adversely affecting the patient's condition or the quality of medical care rendered. To be appropriate, the service or supply must: Be care or treatment, as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or Injury involved and the person's overall health condition; 2. Be a diagnostic procedure, indicated by the health status of the person and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or Injury involved and the person's overall health condition; and 3. As to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any alternative service or supply to meet the above tests. In determining if a service or supply is appropriate under the circumstances, the Plan Administrator will take into consideration: Information provided on the affected person's health status; 2. Reports in peer reviewed medical literature; 13 DEFINITIONS (Cont'd) MEDICALLY NECESSARY (Cont'd) 3. Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; 4. Generally recognized professional standards of safety and effectiveness in the United States for diagnosis, care or treatment; 5. The opinion of health professionals in the generally recognized health specialty involved; and 6. Any other relevant information brought to the Plan Administrator's attention. In no event will the following services or supplies be considered to be Medically Necessary: 1. Experimental or Investigational services or supplies; 2. Those that do not require the technical skills of a medical, a mental health or dental professional; or 3. Those furnished mainly for the personal comfort or convenience of the person, any person who cares for him or her, any person who is part of his or her Family, any healthcare provider or healthcare facility; or 4. Those furnished solely because the person is an Inpatient on any day on which the person's disease or Injury could safely and adequately be diagnosed or treated while not confined; or 5. Those furnished solely because of the setting if the service or supply could safely and adequately be furnished in a Physician's or a dentist's office or other less costly setting. MEDICARE -The term "Medicare" means the programs established by Title I of Public Law 88-98 (79 Statutes 291) as amended entitled "Health Insurance for the Aged Act", and which includes Parts A & B and Title XVIII of the Social Security Act (as amended by Public Law 89-97, 79) as amended from time to time. MENTAL ILLNESS OR DISORDER AND FUNCTIONAL NERVOUS DISORDER -The term "Mental Illness or Disorder and Functional Nervous Disorder" means a disease commonly understood to be a Mental Disorder whether or not it has a physiological or organic basis and for which treatment is generally provided by or under the direction of a Physician. A Mental or Nervous Disorder includes, but is not limited to: Schizophrenia Bipolar disorder Pervasive Mental Development Disorder (Autism) Panic disorder Major depressive disorder Psychotic depression Obsessive Compulsive disorder Paranoid and other psychotic disorders This disease must not be merely an expected response to a particular stimulus and must be defined in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association). MHPA -The term "MHPA" refers to the Mental Health Parity Act of 1998 which prohibits a group health plan that provides both medical/surgical benefits and mental health benefits from imposing either aggregate lifetime limits or annual limits on mental health benefits unless the Plan also imposes the limits on "substantially all" medical and surgical benefits. 14 DEFINITIONS (Cont'd) ~' MINOR EMERGENCY MEDICAL CLINIC -The term "Minor Emergency Medical Clinic" means a freestanding facility which is engaged primarily in providing minor Emergency and episodic medical care to a Covered Person. Aboard-certified Physician, a Registered Nurse, and a Registered X-Ray Technician must be in attendance at all times that the clinic is open. The clinic's facilities must include x-ray and laboratory equipment and a life support system. For the purposes of this Plan, a clinic meeting these requirements will be considered to be a Minor Emergency Medical Clinic, by whatever actual name it may be called; however, a clinic located on or in conjunction with or in any way made a part of a regular Hospital shall be excluded from the terms of this definition. NAMED FIDUCIARY -The term "Named Fiduciary" means ABC Company, which has the authority to control and manage the operation and administration of the Plan. NATIONAL MEDICAL SUPPORT NOTICE- The term "National Medical Support Notice" or "NMSN" shall mean a notice that contains the following information: 1. Name of an issuing state agency; 2. Name and mailing address (if any) of an employee who is a Participant under the Plan; 3. Name and mailing address of one or more Alternate Recipients (i.e., the child or children of the Participant or the name and address of a substituted official or agency that has been substituted for the mailing address of the Alternate Recipients); and 4. Identity of an underlying child support order. NATURAL CHILD -The term "Natural Child " means a child that is related by birth and is not an adopted child, a stepchild, a foster child, niece, nephew, or grandchild. NEWBORN -The term "Newborn" refers to an infant from the date of his birth until the initial Hospital discharge or until the infant is seven (7) days old, whichever occurs first. NMHPA -The term "NMHPA" refers to the Newborns' and Mothers' Protection Act of 1996. This includes a provision for Pregnancy-related care under the Federal law, allows benefits for the mother and Newborn to include a minimum Hospital/facility length of stay of forty-eight (48) hours following a normal vaginal delivery or ninety-six (96) hours following a Cesarean section delivery. NURSE PRACTITIONER -The term "Nurse Practitioner" means a Registered Nurse with at least a master's degree in nursing and advanced education in the primary care of particular groups of clients. Capable of independent practice in a variety of settings, and is licensed and registered in the state where he/she practices. OPEN ENROLLMENT DATE -The initial Open Enrollment Date established by the Plan will be October 1, 2005. Thereafter the Open Enrollment Date will be October 1 of each year. OPEN ENROLLMENT PERIOD -The term "Open Enrollment Period" means the period of time established by the Plan Administrator during which eligible Late Enrollees who have not previously enrolled in the Health Plan may do so. The Open Enrollment Period is the thirty (30) day period immediately preceding the Open Enrollment Date established by the Plan. ORTHOTIC APPLIANCE -The term "Orthotic Appliance" means a casted external device intended to correct any defect in form or function of the human body. OUT-OF-POCKET -The term "Out-of-Pocket" means all expenses paid by the Participant for Covered Expenses under the Plan, but not paid by the Plan, excluding any applicable Deductibles and Co-Payments. 15 DEFINITIONS (Cont'd) ~" OUTPATIENT -The term "Outpatient" refers to the classification of a Covered Person when that Covered Person received medical care, treatment, services or supplies at a clinic, a Physician's office, or at a Hospital if not a registered bed-patient at that Hospital, an Outpatient Psychiatric Facility or an Outpatient Alcoholism Treatment Facility. OUTPATIENT ALCOHOLISM TREATMENT FACILITY -The term "Outpatient Alcoholism Treatment Facility" means an institution which provides a program for diagnosis, evaluation, and Effective Treatment of Alcoholism; provides detoxification services needed with its Effective Treatment program; provides infirmary-level medical services or arranges with a Hospital in the area for any other medical services that may be required; is at all times supervised by a staff of Physicians; provides at all times skilled nursing care by licensed nurses who are directed by a full-time Registered Nurse (R.N.); prepares and maintains a written plan of treatment for each patient based on medical, psychological and social needs which is supervised by a Physician; and meets licensing standards. OUTPATIENT PSYCHIATRIC FACILITY -The term "Outpatient Psychiatric Facility" means an administratively distinct governmental, public, private or independent unit or part of such unit that provides Outpatient Mental Health services and which provides for a psychiatrist who has regularly scheduled hours in the facility, and who assumes the overall responsibility for coordinating the care of all patients. PARTICIPANT -The term "Participant" means an Employee who meets the eligibility requirements and who is properly enrolled in the Plan. PARTICIPANT COVERAGE -The term "Participant Coverage" means coverage hereunder providing benefits payable as a consequence of an Injury or Illness of a Participant. PHYSICIAN -The term "Physician" means a legally licensed medical or dental doctor or surgeon, chiropractor, osteopath, chiropodist, podiatrist, optometrist, or certified consulting Psychologist, licensed social worker and licensed professional counselor to the extent that same, within the scope of their license, `4~-+ are permitted to perform services provided in this Plan. A Physician shall not include the Covered Person or any Close Relative of the Covered Person. PHYSICIAN ASSISTANT-The term "Physician Assistant" means a specially trained and licensed individual who performs tasks usually done by physicians and works under the direction of a supervising physician. PLACEMENT FOR ADOPTION -The term "Placement for Adoption" means that a child has been placed in the home and living with the Participant after the formal legal adoption proceedings have been initiated. PLAN -The term "Plan" means without qualification, this Plan Document. PLAN ADMINISTRATOR -The term "Plan Administrator" means the Company, which is responsible for the day-to-day functions and management of the Plan. The Plan Administrator, in its sole discretion, may employ persons or firms to process claims and perform other Plan connected services. PLAN BENEFIT MAXIMUM -The term "Plan Benefit Maximum" means the maximum Plan benefit (as set forth in the Schedule of Benefits) payable under this Plan. PLAN SUPERVISOR -The term "Plan Supervisor" means a person or firm hired by the Plan Administrator to perform claims processing and other specified administrative services in relation to the Plan. The Plan Supervisor is not an insurer of health benefits under this Plan, or a fiduciary of the Plan and does not exercise any of the discretionary authority and responsibility granted to the Plan Administrator. The Plan Supervisor is not responsible for the Plan financing and does not guarantee the availability of benefits under the Plan. POST-SERVICE CLAIM -The term "Post-Service Claim" is any claim for a benefit under a group health plan a is no a re- ervice Non-Urgent Claim. It is further defined as any claim with respect to which plan approval is not a prerequisite to obtaining medical services and payment is being requested for medical care already rendered to the Claimant. 16 DEFINITIONS (Cont'd) PRE-ADMISSION CERTIFICATION -The term "Pre-Admission Certification" means a determination of the number of days of Hospital Confinement which are Medically Necessary for the care or treatment of a person's Illness or Injury. PRE-ADMISSION CERTIFICATION COMPANY -The term "Pre-Admission Certification Company" means IMS Managed Care, Inc., a company employed by the Plan Administratorto review all hospitalizations, and establish Medical Necessity and length of stay of Hospital Confinements. PRE-EXISTING CONDITION -The term "Pre-existing Condition" means any Sickness, Illness, Disease or Injury (other than Pregnancy), regardless of cause, for which medical advice, diagnosis, care or treatment was recommended or received, by or from a health care provider or practitioner duly licensed to provide such care under applicable state law and operating within the scope of practice authorized by such state law, during the six (6) months immediately prior to the Enrollment Date. PRE-SERVICE NON-URGENT CLAIM -The term "Pre-Service Non-Urgent Claim" means a request for review or approval that a Plan requires as part of the process of receiving a benefit in advance of obtaining medical care, even if such review or approval does not guarantee that the Plan will ultimately grant the benefit (i.e. pre-certification or prior authorization). PREFERRED PROVIDER ORGANIZATION (PPO) -The term "Preferred Provider Organization (PPO)" is a network of medical providers which the Plan uses to obtain discounts for the Plan and Plan Participant. A current list of PPO providers may be obtained from the Plan Administrator or the Plan Supervisor. PREGNANCY -The term "Pregnancy" means that physical state which results in childbirth, abortion, or miscarriage, and medical complications arising out of or resulting from such state. PSYCHIATRIC CARE -The term "Psychiatric Care", also known as psychoanalytic care, means treatment for a Mental Illness or Disorder, a Functional Nervous Disorder, Alcoholism or Drug Addiction. PSYCHOLOGIST -The term "Psychologist" means an individual holding the degree of Ph. D. and acting within the scope of his license. QUALIFIED MEDICAL CHILD SUPPORT ORDER -The term "Qualified Medical Child Support Order" or "QMCSO" is a Medical Child Support Order that creates or recognizes the existence of an Alternate Recipient's right to, or assigns to an Alternate Recipient the right to, receive benefits forwhich a Participant or Dependent is entitled under this Plan. In order for such order to be a OMCSO, it must clearly specify the following: 1. The name and last known mailing address (if any) of the Participant and the name and mailing address of each such Alternate Recipient covered by the order; 2. A reasonable description of the type of coverage to be provided by the Plan to each Alternate Recipient, or the manner in which such type of coverage is to be determined; 3. The period of coverage to which the order pertains; and 4. The name of this Plan. In addition, a National Medical Support Notice shall be deemed a OMCSO if it: 1. Contains the information set forth in the definition of "National Medical Support Notice"; 2. Identifies either the specific type of coverage or all available group health coverage. If the Company receives an NMSN that does not designate either specific type(s) of coverage or all available coverage, the Company and the Plan Administrator will assume that all are designated; or 17 DEFINITIONS (Cont'd) UALIFIED MEDICAL CHILD SUPPORT ORDER (Cont'd) 3. Informs the Plan Administrator that, if a group health plan has multiple options and the Participant is not enrolled, the issuing agency will make a selection after the NMSN is qualified, and, if the agency does not respond within 20 days, the child will be enrolled under the Plan's default option (if any); and 4. Specifies that the period of coverage may end for the Alternate Recipient(s) only when similarly situated Dependents are no longer eligible for coverage under the terms of the Plan, or upon the occurrence of certain specified events. However, such an order need not be recognized as "qualified" if it requires the Plan to provide any type or form of benefit, or any option, not otherwise provided to the Participants and Eligible Beneficiaries without regard to this provision, except to the extent necessary to meet the requirements of a state law relating to medical child support orders, as described in Social Security Act §1908 (as added by Omnibus Budget Reconciliation Act of 1993 §13822). REGISTERED NURSE -The term "Registered Nurse" means an individual who has received specialized nursing training and is authorized to use the designation of "R. N." and who is duly licensed by the state or regulatory agency responsible for such licensing in the state in which the individual performs such nursing services. RELEVANT INFORMATION -The term "Relevant Information" includes documents, records and information if: 1. It was relied upon in making the benefit determination; 2. It was submitted, considered or generated in the course of the benefit determination, whether or not it was relied upon; 3. It demonstrates compliance with the requirements of the new regulations that claim determinations are made in accordance with plan documents and that, where appropriate, the plan provisions have been applied consistently with similarly situated Claimants; or 4. It constitutes a statement of policy or guidance with respect to the plan concerning the denied benefit for the Claimant's diagnosis, whether or not it was relied upon. RESIDENTIAL TREATMENT -The term "Residential Treatment" means a program which is organized and staffed to provide both general and specialized non-hospital based interdisplinary services twenty- four (24) hours a day, seven (7) days a week for persons with behavioral health disabilities or disorders; victims or perpetrators of domestic violence or other abuse; or persons needing treatment because of eating or sexual disorders; gambling or Internet addictions. Residential treatment services are organized to provide environments in which the person resides and receives services from personnel who are trained in the delivery of services for persons with behavioral health disorders or related problems. ROOM AND BOARD -The term "Room and Board" refers to all charges by whatever name called which are made by a Hospital, Hospice or Skilled Nursing Facility as a condition or occupancy. Such charges do not include the professional services of Physicians nor intensive nursing care by whatever name called. SCHOOL -See definition of University. SEMI-PRIVATE -The term "Semi-Private" refers to a class accommodation in a Hospital, or Skilled Nursing Facility in which at least two (2) patients' beds are available per room. 18 DEFINITIONS (Cont'd) '~'" SIGNIFICANT BREAK IN COVERAGE -The term "Significant Break in Coverage" means a period of sixty- three (63) consecutive days or longer during each of which the Covered Person did not have Creditable Coverage. Periods of no coverage during an HMO affiliation period or Waiting Period shall not betaken into account for purposes of determining whether Significant Break in Coverage has occurred. For this purpose, an HMO affiliation period or Waiting Period means a period of time that must expire before health insurance coverage provided by an HMO becomes effective. SKILLED NURSING FACILITY -The term "Skilled Nursing Facility" means an institution, or distinct part thereof, operated pursuant to law and which meets all of the following conditions: 1. It is licensed to provide, and is engaged in providing, on an Inpatient basis, for persons convalescing from Injury or Illness, professional nursing services rendered by a Registered Nurse (R.N.) or by a Licensed Practical Nurse (L.P.N.) under the direction of a Registered Nurse and physical restoration services to assist patients to reach a degree of body functioning to permit self-care in essential daily living activities; 2. Its services are provided for compensation from its patients and under the full-time supervision of a Physician or Registered Nurse; and 3. It provides twenty-four (24) hour per day nursing services by licensed nurses, under the direction of a full-time Registered Nurse; and 4. It maintains a complete medical record on each patient; and 5. It has an effective utilization review plan; and 6. It is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics, mental retardates, custodial or educational care, or care of Mental Disorders; and 7. It is approved and licensed by Medicare. This term shall also apply to expenses incurred in an institution referring to itself as a Sub-acute Nursing Facility, Extended Care Facility or any such other similar nomenclature. SPECIAL ENROLLEE -The term "Special Enrollee" means an Employee or Dependent who is entitled to and who requests Special Enrollment: 1. Within thirty (30) days of losing other Creditable Coverage; or 2. For a newly acquired Dependent, within thirty (30) days of the marriage, birth, adoption, or placement for adoption. SPEECH-LANGUAGE PATHOLOGIST -The term "Speech-Language Pathologist" means a person who: (1) has a master's or doctorate degree in speech pathology orspeech-language pathology from an accredited College or University; and (2) is certified by the American Speech-Language and Hearing Association. TOTAL DISABILITY (TOTALLY DISABLED) -The term "Total Disability" means a physical state of a Covered Person resulting from an Illness or Injury which wholly prevents: 1. In the case of a Participant, from engaging in any and every business or occupation and from performing any and all work for compensation or profit; and 2. In the case of a Dependent from performing the normal activities of a person of like age and sex in good health. UNIVERSITY -The term "University" means an institution accredited as a College, School or University by the State in which the institution is located. URGENT -See Emergency 19 DEFINITIONS (Cont'd) USERRA LEAVE -The term "USERRA Leave" refers to a leave of absence taken by an Employee Participant for a call to military duty that is protected by the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended from time to time. USUAL AND CUSTOMARY -The term "Usual and Customary" refers to the designation of a charge as being the usual charge made by a Physician or other provider of services, supplies, medications, or equipment that does not exceed the general level of charges made by other providers rendering or furnishing such care or treatment within the same area. The term "area" in this definition means county or such other area as is necessary to obtain a representative cross section of such charges. Due consideration will be given to the nature and severity of the condition being treated and any medical complications or unusual circumstances which require additional time, skill or expertise. WAITING PERIOD -The term "Waiting Period" means the time that must pass before an Employee or Dependent is eligible to enroll in the Plan. Notwithstanding the foregoing, the time between the date a Late Enrollee or Special Enrollee first becomes eligible for enrollment under the Plan and the first day of coverage shall not be treated as a Waiting Period. WELL-BABY CARE -The term "Well-Baby Care" means medical treatment, services or supplies rendered to a child or Newborn solely for the purpose of health maintenance and not for the treatment of an Illness or Injury. 20 ELIGIBILITY FOR COVERAGE Coverage provided under this Plan for Participants and their Dependents shall be in accordance with the Eligibility for Coverage, Effective Date of Coverage, Termination of Coverage and Continuation of Coverage under the COBRA provisions as stated in this Plan Document. Any change in the amount of coverage available to a Covered Person occasioned by a change in the Participant's classification shall become effective automatically on the classification change date. PARTICIPANT ELIGIBILITY - A Participant eligible for Participant Coverage under this Plan shall include only Full-Time Employees who meet all of the following conditions: Is employed by the Company on a permanent full-time basis for at least thirty (30) regularly scheduled hours per week; and 2. Has been continuously employed for a period of thirty (30) days, which is the Waiting Period. For purposes of the above requirements only, an Employee shall be deemed continuously employed if the Employee is absent from work due to a health factor. It is important to note that, as set forth in the section entitled "Participant Effective Date," the Employee must actually report for and begin work in order for his coverage to become effective. Independent contractors, Leased Employees and temporary employees shall not be deemed to meet the definition of "Employee" or "Full-Time Employee." A Participant eligible for Dependent Coverage shall be any Participant whose Dependents meet the definition of a Dependent as stated earlier in the Plan. Each Participant will become eligible for Dependent Coverage on the latest of the following: The date he becomes eligible for Participant Coverage; or The date on which he first acquires a Dependent; or If both the husband and wife are employed by the Company, and both have Dependent children eligible for Dependent Coverage, either the husband or wife but not both, may elect Dependent Coverage for their eligible Dependent children. DEPENDENT ELIGIBILITY - A Dependent will be considered eligible for coverage on the date the Participant becomes eligible for Dependent Coverage, subject to all limitations and requirements of this Plan, and in accordance with the following: A spouse will be considered an eligible Dependent from the date of marriage, provided the spouse is properly enrolled as a Dependent of the Participant within thirty (30) days of the date of marriage. 2. A Newborn Natural Child will be eligible from the moment of birth for Injury or Illness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities or prematurity, provided the child is properly enrolled as a Dependent of the Participant within thirty (30) days of the child's date of birth. This provision shall not apply nor in any way affect the normal maternity provisions applicable to the mother. 3. If a Dependent is acquired, other than at the time of birth for a Natural Child, due to a court order, decree, marriage, adoption or Placement for Adoption, that Dependent will be eligible from the date of such court order, decree, marriage, adoption or Placement for Adoption for Injury or Illness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities or conditions related to prematurity, provided that this new Dependent is properly enrolled as a Dependent of the Participant within thirty (30) days of the court order, decree, marriage, adoption or Placement of Adoption. 21 ELIGIBILITY FOR COVERAGE (Cont'd) ~r+ 4. A child may become eligible for Dependent Coverage as set forth in a qualified medical child support order (QMCSO). The Plan Administrator shall have sole discretion to determine whether a medical child support order is qualified and for administering the provision of benefits underthe Plan pursuant to a qualified medical child support order. The Plan Administrator may seek clarification and modification of the order, up to and including the right to seek a hearing before the court or agency which issued the order. No Dependent shall be denied enrollment in the Plan due to his confinement in a hospital or other health care institution or inability to engage in normal life activities. RETIREE ELIGIBILITY Coverage for retirees and eligible Dependents of retirees will automatically terminate upon the earliest of the following dates: A. The date that the retiree or spouse become eligible for Medicare; B. The date that the retiree or spouse reaches age 65; C. For other Dependents, the date that Dependent ceases to be an eligible Dependent as defined in the Plan or the date that both retiree and spouse are no longer covered by the Plan; D. The date that the retiree fails to make any required contribution; E. The date that the Company terminates retiree coverage; F. The date that the Plan is terminated. 22 EFFECTIVE DATE OF COVERAGE PARTICIPANT EFFECTIVE DATE -Participant Coverage under the Plan shall become effective on the first of the month coinciding with or next following the date the Participant becomes eligible, provided written application for such coverage is made on or before such date. If application is made after the initial date of eligibility (otherthan during a special enrollment period available to Special Enrollees), the Participant shall be a Late Enrollee and, coverage for the eligible Employee shall not become effective until the end of the next Open Enrollment Period. In order for an Employee's coverage to become effective, an Employee must actually report for and begin work. If the Employee is unable to report for and begin work as scheduled (even if such inability is due to a health factor), then his coverage will become effective on such later date when the Employee reports for and begins work. DEPENDENT EFFECTIVE DATE - A Dependent of a Participant who makes written request for Dependent Coverage hereunder, on a form approved by the Plan Administrator, shall be subject to the provisions of this article, becomes covered as follows: 1. If the Participant makes such written request on or before the date he becomes eligible for Dependent Coverage he shall become covered, with respect to those persons who are then his Dependents, on the date he becomes eligible for Participant Coverage. 2. Except as otherwise provided under "Dependent Eligibility" (i.e., for Newborn, adopted, and newly acquired Dependents) or as provided under the "Special Enrollment Effective Date"be low. If the Participant makes such written request after the date on which he is eligible for Dependent Coverage those persons who are then his Dependents shall be Late Enrollees, and coverage for the eligible Dependent shall not become effective until the end of the next Open Enrollment Period. SPECIAL ENROLLMENT EFFECTIVE DATE -Eligible Employees and Dependents are permitted to enroll in this Plan upon loss of other group health coverage if enrollment is requested by the Employees within thirty (30) days of loss of coverage. The Special Enrollee must meet the following conditions: 1. The Employee or Dependent had other Creditable Coverage or was under a COBRA continuation provision at the time coverage was offered by this Plan and the Employee stated in writing that coverage under another plan was the reason for declining enrollment; and 2. The Employee or Dependent lost such coverage due to divorce, legal separation, death, termination of employment, reduction of hours, termination of employer contribution, or established COBRA coverage exhausted. Loss of coverage because of non-payment of premium is not a condition to qualify for Special Enrollment. An Employee who is already enrolled in a benefit option may enroll in another benefit option underthe Plan if a Dependent of that Employee has a special enrollment right in the Plan because the Dependent lost eligibility for other coverage. The Employee must make written application for special enrollment in the new benefit option within 30 days of the date the other health coverage was lost. The effective date for the above Special Enrollee shall be the day following the loss of other group health coverage provided proper enrollment is completed within thirty (30) days of loss of coverage. DEPENDENT SPECIAL ENROLLMENT EFFECTIVE DATE -Newly acquired Dependents of eligible Participants shall be Special Enrollees and eligible to enroll without a Waiting Period if enrollment is requested within thirty (30) days of the following: 1. A Natural Child's date of birth; or 2. Date of final legal adoption; or 3. Date of Placement for Adoption; or 4. Date of marriage. The effective date of coverage for the above Special Enrollee shall be the Natural Child's date of birth, date of final legal adoption, date of Placement for Adoption, or date of marriage provided proper enrollment is received within thirty (30) days. The eligible Employee and/or Employee's Spouse of the newly acquired Dependent that are not covered by the Plan shall also be a Special Enrollee eligible to enroll with the newly acquired Dependent. The effective date of coverage will be same as that of one Dependent being added as explained above. 23 TERMINATION OF COVERAGE PARTICIPANT TERMINATION -Participant Coverage shall automatically terminate immediately upon the earliest of the following dates: 1. At the end of the month in which the Participant's employment terminates; or 2. Date the Participant ceases to be in a class of Participants eligible for coverage; or 3. Date the Participant fails to make any required contribution for coverage; or 4. Date the Plan is terminated; or with respect to any Participant benefits of the Plan, the date of termination of such benefit; or 5. Date the Participant dies. PARTICIPANT REINSTATEMENT - A Participant whose coverage terminates by reason of termination of employment and who resumes employment with the Company within a ninety (90) day period immediately following the date of such termination shall become eligible for reinstatement of coverage on the date he resumes employment. DEPENDENT TERMINATION -The Dependent Coverage of a Participant shall automatically terminate immediately upon the earliest of the following dates: 1. Date the Dependent ceases to be an eligible Dependent as defined in Plan; or 2. Date of termination of the Participant's coverage under the Plan; or 3. Date the Participant ceases to be in a class of Participants eligible for Dependent Coverage; or 4. Date the Participant fails to make any required contribution for Dependent Coverage; or 5. Date the Plan terminated; or with respect to any Dependent's benefit of the Plan, the date of termination of such benefit; or 6. Date the Participant dies. FAMILY AND MEDICAL LEAVE ACT OF 1993 -All previous provisions including Eligibility For Coverage, Effective Date of Coverage, and Termination of Coverage are intended to be in compliance with the Family and Medical Leave Act of 1993 (FMLA). To the extent the FMLA applies to the Company, group health benefits maybe maintained during certain leaves of absence at the level and underthe conditions that would have been present as if employment had not been interrupted. Employee eligibility requirements, the obligations of the employer and Employee concerning conditions of leave, and notification and reporting requirements are specified by the FMLA. Any Plan provision which conflicts with the FMLA are superseded by the FMLA to the extent such provisions conflict with the FMLA. A Participant with questions concerning any rights and/or obligations should contact the Plan Administrator or his employer. 24 TERMINATION OF COVERAGE (Cont'd) `~"" MEDICAL LEAVE OF ABSENCE - A Participant whose active work ceases because of Illness or Injury and whose employment has not terminated shall be considered employed by the Company for the purposes of his coverage under the Plan, and such coverage may continue until the Company, acting in accordance with a policy which precludes individual selection, terminates such coverage, but not beyond the period ending twelve (12) months after the date that active work ceases because of Illness or Injury. This continuation provision neither expands nor limits the requirement of the FMLA. LEAVE OF ABSENCE - Coverage on a Participant whose active work ceases due to an approved leave of absence granted for reasons otherthan Injury or Illness and whose employment has not terminated may be continued until the Company, acting in accordance with a policy which precludes individual selection, terminates such coverage, but not beyond the period ending three (3) months after such leave of absence began. This continuation during a leave of absence neither expands nor limits the requirement of the FMLA. TEMPORARY LAYOFF - A Participant whose active work ceases due to a temporary layoff shall be considered employed by the Company for the purpose of his coverage under the Plan, and such coverage may continue until the end of the month in which the layoff began. MILITARY LEAVE ACT -Notwithstanding anything in this Plan to the contrary, with respect to any Employee Participant or Dependent who loses coverage under this Plan during the Employee's Participant's absence from employment by reason due to a USERRA Leave, no Pre-Existing Condition exclusion or Waiting Period may be imposed upon the reinstatement of such Employee's Participant's or Dependent's coverage upon re- employment of the Employee unless the Pre-Existing Condition exclusion or Waiting Period would have otherwise applied to such Employee Participant or Dependent had the Employee Participant not been on a USERRA Leave. 25 PRE-EXISTING CONDITIONS LIMITATIONS ~ APre-existing Condition limitation will apply for all Employees and Dependents entering or reentering the Plan after the Effective Date, except as set forth in the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). Expenses relating to Pre-Existing Conditions will be paid up to a maximum of $1000. Coverage will be available for such condition on the day immediately following the expiration of twelve (12) months or, in the case of a Late Enrollee, eighteen (18) months after the Enrollment Date. A Participant has the right to demonstrate any Creditable Coverage, and the applicable period shall be reduced by any Creditable Coverage unless that Creditable Coverage occurred before a Significant Break in Coverage. WAIVERS OF THE PRE-EXISTING CONDITION LIMITATION -The Pre-existing Condition limitation shall not apply to a newborn, an adopted Child under age 18 or a Child under age 18 placed in the home of a covered Employee in anticipation of adoption, provided that the child has had Creditable Coverage at any time during the first 30 days following the birth, adoption (or placement for adoption). Genetic Information shall not be treated as aPre-Existing Condition in the absence of a diagnosis of the condition related to the Genetic Information. PROOF OF CREDITABLE COVERAGE - A Participant may prove Creditable Coverage by either of two methods: For Creditable Coverage effective on or after July 1, 1996, the Participant may present a written Certificate of Coverage from the source or entity that provided the coverage showing: a. The date the Certificate was issued; b. The name of the group health plan that provided the coverage; c. The name of the Participant or Dependent to whom the Certificate applies, and any other information necessary for the Plan providing the coverage specified in the certificate to identify the individual, such as the individual's identification number under the plan and the name of the Participant if the certificate is for (or includes) a Dependent; d. The name, address, and telephone number of the plan administrator or issuer providing the Certificate; e. A telephone number for further information (if different); f. Either: A statement that the Participant or Dependent has at least 18 months (546 days) of Creditable Coverage, not counting days of coverage before a Significant Break in Coverage; or ii. The date any waiting period (and affiliation period, if applicable) began and the date Creditable Coverage began; and g. The date Creditable Coverage ended, unless the Certificate indicates that coverage is continuing as of the date of the Certificate; or 26 PRE-EXISTING CONDITIONS LIMITATIONS (Cont'd) ~/ 2. If the Participant for any reason is unable to obtain a Certificate from another plan (including because the prior coverage was effective prior to July 1, 1996), he may demonstrate Creditable Coverage by other evidence, including but not limited to documents, records, third-party statements, or telephone calls by this Plan to a third-party provider of medical services. This Plan will treat a Participant as having provided a Certificate if that individual: a. Attests to the period of Creditable Coverage; b. Presents relevant corroborating evidence of some Creditable Coverage during the period; and c. Cooperates with the Plan Administrator's efforts to verify his status. A Participant has the right to request a Certificate from his prior health plan, and the Plan Administrator will help the Participant in obtaining the Certificate. NOTICE OF THE PRE-EXISTING CONDITION LIMITATION EXCLUSION If, within a reasonable time after receiving the information about Creditable Coverage described above, the Plan Administrator determines that exclusion for Pre-existing Conditions applies, it will notify the Participant of that conclusion and will specify the source of any information on which it relied in reaching the determination. Such notification will also explain the Plan's appeals procedures and give the Participant a reasonable opportunity to present additional evidence. If the Plan Administrator later determines that an individual did not have the claimed Creditable Coverage, the Plan Administrator may modify its initial determination to the contrary. In that case, the individual will be notified of the reconsideration; however, until a final determination is reached, the Plan Administratorwill act in accordance with its initial determination in favor of the Participant for the purpose of approving medical services. 27 PRE-ADMISSION CERTIFICATION PRE-ADMISSION CERTIFICATION PROCEDURES - When a Physician says that a Covered Person must go into the Hospital, the Covered Person or his Physician must call the Pre-Admission Certification Company at the toll-free number assigned to the Plan. It is the Covered Person's responsibility to advise his doctor of the Pre-Admission Certification requirement and to provide him with a copy of the signed Physician Information/Consent Form. For pre-scheduled admissions, the Covered Person or Physician should secure certification from the Pre-Admission Certification Company prior to the Covered Person's or his Dependent's actually entering the Hospital. It is the Covered Person's responsibility to see that the Pre-Admission Certification Company is notified. For Emergency Admissions, either the Hospital, a Physician or a Family member must telephone the Pre-Admission Certification Companywithin 48 hours or on the first business day following weekend/holiday admissions. For detailed information regarding admissions for childbirth, see the section entitled "Hospital Admissions for Childbirth" below. To contact IMS Managed Care, Inc., call or write to the following address: IMS Managed Care, Inc. P.O. Box 15688 Amarillo, Texas 79105 (800) 687-3020 or (806) 373-6666 EFFECT OF PRE-ADMISSION CERTIFICATION PROCEDURES -Covered charges shall not include any charges which are Incurred on any day of Confinement which is in excess of the number of days deemed by the Pre-Admission Certification Company to be Medically Necessary; and no benefits will be paid for such charges. Failure to notify the Pre-Admission Certification Company of apre-scheduled admission or an Emergency Admission will result in a reduction of benefits, if any, as stated in the Schedule of Benefits, on charges related to that admission, except as required by applicable law with respect to childbirth. HOSPITAL ADMISSIONS FOR CHILDBIRTH -Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). WHEN HEALTH CLAIMS MUST BE FILED - APre-Service Non-Urgent Claim (including a Concurrent Claim that also is apre-Service Non-Urgent Claim) is considered to be filed when the request for approval of treatment or services is made and received by the Pre-Admission Certification Company in accordance with the Plan's procedures. Upon receipt of this information, the claim will be deemed to be filed with the Plan. The Pre-Admission Certification Company will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested as provided herein. This additional information must be received by the Pre-Admission Certification Company within 45 days from receipt by the Claimant of the request for additional information. Failure to do so may result in claims being declined or reduced. 28 PRE-ADMISSION CERTIFICATION (Cont'd) TIMING OF CLAIM DECISIONS -The Pre-Admission Certification Company shall notify the Claimant, in accordance with the provisions set forth below, of any Adverse Benefit Determination (and, in the case of Pre- Service Non-Urgent Claims and Concurrent Claims, of decisions of claims) within the following timeframes: PRE-SERVICE NON-URGENT CLAIMS - If the Claimant has provided all of the information needed to process the claim, in a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the claim, unless an extension has been requested, then prior to the end of the 15-day extension period. 2. If the Claimant has not provided all of the information needed to process the claim, then the Claimant will be notified as to what specific information is needed as soon as possible, but not later than 5 days after receipt of the claim. The Claimant will be notified of a determination of benefits in a reasonable period of time appropriate to the medical circumstances, either prior to the end of the extension period (if additional information was requested during the initial processing period), or by the date agreed to by the Pre-Admission Certification Company and the Claimant (if additional information was requested during the extension period). CONCURRENT CLAIMS - Plan Notice of Reduction or Termination - If the Pre-Admission Certification Company is notifying the Claimant of a reduction or termination of a course of treatment (other than by Plan amendment or termination), before the end of such period of time or number of treatments, the Claimant will be notified sufficiently in advance of the reduction or termination. This will allow the Claimant to appeal and obtain a determination on review of that Adverse Benefit Determination before the benefit is reduced or terminated. 2. Request by Claimant Involving Non-Urgent Care - If the Pre-Admission Certification Company ~.r' receives a request from the Claimant to extend the course of treatment beyond the period of time or number of treatments that is a claim not involving urgent care, the request will be treated as a new benefit claim and decided within the timeframe appropriate to the type of claim (either as aPre-Service Non-Urgent Claim or aPost-Service Claim). 3. Calculating Time Periods -The period of time within which a benefit determination is required to be made shall begin at the time a claim is deemed to be filed in accordance with the procedures of the Plan. 29 PRE-ADMISSION CERTIFICATION (Cont'd) NOTIFICATION OF AN ADVERSE BENEFIT DETERMINATION -The Pre-Admission Certification Company shall provide a Claimant with a notice, either in writing or electronically, containing the following information: A reference to the specific portion(s) of the Plan Document upon which a denial is based; 2. Specific reason(s) for a denial; 3. A description of any additional information necessary for the Claimant to perfect the claim and an explanation of why such information is necessary; 4. A description of the Plan's review procedures and the time limits applicable to the procedures, including a statement of the Claimant's right to bring a civil action under Section 502(a) of ERISA following an Adverse Benefit Determination on final review; 5. A statement that the Claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the Claimant's claim for benefits; 6. The identity of any medical or vocational experts consulted in connection with a claim, even if the Plan did not rely upon their advice (or a statement that the identity of the expert will be provided, upon request); 7. Any rule, guideline, protocol or similar criterion that was relied upon in making the determination (or a statement that it was relied upon and that a copy will be provided to the Claimant, free of charge, upon request); 8. In the case of denials based upon a medical judgment (such as whether the treatment is Medically Necessary or Experimental), either an explanation of the scientific or clinical judgment for the ~, determination, applying the terms of the Plan to the Claimant's medical circumstances, or a statement that such explanation will be provided to the Claimant, free of charge, upon request. 30 SUPPLEMENTAL PRESCRIPTION DRUG PROGRAM This benefit is designed to supplement the Major Medical Expense Benefit of this Plan. The Company has contracted with the Plan Supervisor to supply each covered person with a plastic I. D. card issued by the prescription drug program vendor for the purchase of eligible prescription drugs. All Co-Payments that a covered person is responsible for under this Supplement are separate from and in addition to any other deductible(s) in this Plan. DEFINITIONS Co-Payment -Portion of the covered prescription charge due which is the responsibility of a covered person. The covered person is responsible for the Co-Payment each time a prescription is filled. Generic Drugs -Drugs not protected by a trademark, usually descriptive of the drugs chemical structure. Brand-Name Drugs -Drugs produced and marketed exclusively by a particular manufacturer. These names are usually registered as trademarks with the Patent Office and confer upon the registrant certain legal rights with respect to their use. Legend Drugs -Those drugs which cannot be purchased without a prescription from a Physician or dentist. CLAIMS PROCEDURES - 1. When a covered person has a prescription for a covered drug, three steps must be followed: a. Present the prescription drug I. D. card with the prescription; b. Fill out the insured's portion of the voucher and sign; and c. Pay the Co-payment and receive the medication. 2. Should a covered person not have the prescription drug I. D. card or purchase a covered drug from a pharmacy not participating in the prescription drug program, the following steps should be followed: a. Pay for the entire cost of the medication; b. Obtain and complete a Direct Prescription Drug Claim Form; and c. Send the claim form with prescription receipt directly to the prescription drug program vendor. The prescription drug program vendor will pay the appropriate amount directly to the cardholder, usually within thirty (30) days. A formula is used to calculate the amount of reimbursement and the resulting payment may not total 100% of the billed charges. Consequently, it is advantageous to use the prescription drug I. D. card and participating member pharmacies when available. 31 SUPPLEMENTAL PRESCRIPTION DRUG PROGRAM (Cont'd) ~w- This is where the Drug Plan from Caremark would be inserted. 32 PREVENTIVE CARE BENEFIT All charges incurred by a Covered Person in connection with routine Tests, X-Ray and Lab will be eligible for reimbursement up to the CalendarYear Maximum Benefit as stated in the Schedule of Benefits. This benefit includes but is not limited to Office Visits, Routine Eye Exams, Routine Hearing Exams, Routine Tests, Immunizations, Well Baby Care, Pap Smears, Mammograms, Blood Pressure Tests, Cholesterol Screening, Inoculations and Prostate Screening. This benefit does not include charges for eyeglasses, or hearing aids nor does it include nursery charges or miscellaneous services and supplies for a healthy Newborn child. Any portion of the charges, exceeding such maximum allowable amount, is not eligible for reimbursement under the Plan. PREFERRED PROVIDER ORGANIZATION (PPO) The Company has entered into a Preferred Provider Organization (PPO) agreement to give Plan Participants access to Providers that have agreed by contract to charge rates, that in most cases, are below the prevailing rates of Non-PPO Providers. The Plan has agreed, as an incentive for Plan Participants to use these PPO Providers, to reimburse charges at a higher level than those incurred at Non-PPO Providers. The different levels of benefits are as stated in the Schedule of Benefits. It is the ultimate responsibility of the covered Person to confirm that the Provider being utilized is a PPO Provider in order to obtain the best reimbursement on charges by the Plan. A listing of Participating PPO Providers can be obtained by contacting the Plan Administrator. In the event of an Emergency medical condition that makes it impossible to obtain treatment by a PPO Provider, the Plan will reimburse charges at the PPO level. The Plan Supervisor will review all circumstances related to the Emergency, including Physician notes if necessary, in determining whether or not the charges qualify as an Emergency and qualify for reimbursement at the PPO level. 33 MAJOR MEDICAL EXPENSE BENEFITS BENEFIT PERCENTAGE AND DEDUCTIBLE -Upon receipt of Proof of Loss, Eligible Medical Expenses as defined by the Plan, which are in excess of any applicable Deductible and Co-Payments will be paid as stated in the Schedule of Benefits. All Eligible Medical Expenses incurred in the Benefit Period in excess of the Out- of-Pocket maximum will be paid at 100%, unless otherwise stated in the Plan. Mental and Nervous charges are never payable at 100% and do not accumulate toward the Eligible Medical Expenses that will be paid at 100%. The Deductible applies to the eligible charges of each Benefit Period, but it applies only once for each Covered Person within a Benefit Period regardless of the number of Illnesses. However, if the individual Deductibles of the Family members reach a maximum as stated in the Schedule of Benefits during the same Benefit Period, no further Deductible applies to any member of that Family during that Benefit Period. Any expenses incurred during the last three (3) months of such Benefit Period and accumulated towards the Deductible will be applied toward the following Benefit Period Deductible requirement. The Hospital Admission Deductible, if applicable, is applied to each Inpatient Hospital admission. This deductible is in addition to the Deductible as stated above and is taken even in the event that the Individual Deductible or Family Deductible for the Benefit Period has been satisfied. If two (2) or more members of the same family receive injuries in the same accident, and as a result of those injuries, incur covered expenses during the same benefit period in which the accident occurs, only one Major Medical Deductible Amount will be deducted from the total eligible expenses incurred. If the Plan's benefit period is established on a calendar-year basis, charges which were used toward satisfying the cash deductible and other eligible out-of-pocket expenses under any prior plan of insurance coverage for the year in which this Plan was originally effective shall be accepted by the Company toward satisfying the cash deductible and out-of-pocket expenses of this Plan, upon receipt of documented proof of such full or partial satisfaction. ALLOCATION AND APPORTIONMENT OF BENEFITS -The Company reserves the right to allocate the Deductible amount to any eligible charges and to apportion the benefits to the Covered Person and any assignees. Such allocation and apportionment shall be conclusive and shall be binding upon the Covered Person and all assignees. AUTOMATIC RESTORATION/REINSTATEMENT OF MAXIMUM BENEFIT -The total Major Medical Expense Benefits payable for all of a Covered Person's Illnesses shall not exceed his Plan Benefit Maximum, as specified in the Schedule of Benefits, even though he may not have been continuously covered. If less than the full Major Medical Plan Benefit Maximum applicable to the Covered Person is available at the beginning of a Benefit Period (as a result of benefits paid or payable with respect to charges previously incurred), the used portion of the Major Medical Plan Benefit Maximum shall automatically be restored to the extent of: The amount needed to restore the full Major Medical Plan Benefit Maximum applicable to the Covered Person; or 2. $1,000.00 Whichever is less. 34 MAJOR MEDICAL EXPENSE BENEFITS (Cont'd) ~"'` CHANGES IN COVERAGE CLASSIFICATION - If a change in the coverage classification of a Covered Person which would otherwise decrease the Plan Benefit Maximum applicable to the Dependent becomes effective in accordance with the terms of the Plan, such decrease shall apply immediately with respect to the Major Medical Expense Benefits applicable to the Covered Person, except that if the Covered Person is Totally Disabled on the date of change, the decrease shall not apply to the benefits payable for eligible charges incurred during the subsequent period of continuous Total Disability within the Benefit Period in which the change occurs and due solely to the Illness or Injury which caused the Total Disability. COVERED EXPENSES - In order to be eligible for benefits under this provision, expenses actually incurred by a Covered Person must meet all the following requirements: 1. They are administered or ordered by a Physician; and 2. They are Medically Necessary for the diagnosis and treatment of an Illness or Injury unless otherwise specifically included as a Covered Expense; and 3. They are not excluded under any provision or section of this Plan. Covered Expenses include, but are not limited to, the following: Charges made by a Hospital for: Daily Room and Board and general nursing services, or Confinement in an Intensive Care Unit, not to exceed the applicable maximum limits shown in the Schedule of Benefits. However, nursery charges for a healthy Newborn Dependent child will be considered Covered Expenses. If the Hospital has only private rooms, the room allowance will be the daily Room and Board rate most commonly charged by a similar institution in the area for asemi-private room with two (2) or more beds. Necessary service and supplies other than Room and Board furnished by the Hospital, including Inpatient miscellaneous service and supplies, Outpatient Hospital treatments for chronic conditions and Emergency room use, physical therapy treatments, hemodialysis, and x-ray and linear therapy. Charges incurred for such miscellaneous services and supplies by a healthy Newborn Dependent child will be considered Covered Expenses. c. Expenses incurred in connection with a Hospital Confinement shall be subject to an Inpatient Deductible as stated in the Schedule of Benefits if applicable. Successive periods of Hospital Confinement will be considered one Confinement if such subsequent admissions result from or are contributed to by the same or related cause, unless such Confinements are separated: In the case of a Participant, by a return to active work for a period of at least one day; or b. In the case of a Dependent, by a period of ninety (90) consecutive days from the date of discharge of the immediately preceding Hospital Confinement. 35 MAJOR MEDICAL EXPENSE BENEFITS (Cont'd) Charges made by a Skilled Nursing Facility for the following services and supplies furnished by the facility. Only charges incurred in connection with convalescence from the Illness or Injury for which the Covered Person is confined will be eligible for benefits. These expenses include: a. Room and board, including any charges made by the facility as a condition of occupancy, or on a regular daily or weekly basis such as general nursing services. If private room accommodations are used, the daily Room and Board charge allowed will not exceed the facility's average semi- privatecharges or an average semi-private rate made by a representative cross section of similar institutions in the area; b. Medical services customarily provided by the Skilled Nursing Facility, with the exception of private duty or special nursing services and Physician's fees; c. Drugs, biologicals, solutions, dressings and casts, furnished for use during the Convalescent Period, but no other supplies. Charges made by a Hospice for: a. Nursing care by a Registered Nurse, a Licensed Practical Nurse, a vocational nurse or a public health nurse who is under the direct supervision of a Registered Nurse; b. Physical therapy and speech therapy when rendered by a licensed therapist; c. Medical supplies, including drugs and biologicals and the use of medical appliances; d. Physician's services; or e. Services, supplies, and treatments deemed Medically Necessary and ordered by a licensed Physician. 4. The services of a legally qualified Physician for medical care and/or surgical treatments including office, home visits, Hospital Inpatient care, Hospital Outpatient visits/exams, clinic care, and surgical opinion consultations. Also included are services of a resident or intern of a Hospital or a Physician Assistant under the direct supervision of a Licensed Physician. 5. Fees of Registered Nurses (R.N.'s) or Licensed Practical Nurses (L.P.N.'s) for private duty nursing and Licensed Nurse Practitioner for office care acting within the scope of their License. 6. Treatment or services rendered by a licensed physical therapist in a home setting or at a facility or institution whose primary purpose is to provide medical care for an Illness or Injury. 7. Benefits will be paid for care and treatment of loss or impairment of speech or hearing provided by an Audiologist (Master's or Doctorate Degree inAudiology) orSpeech-Language Pathologist (Master's or Doctorate Degree in speech pathology or speech-language pathology). Benefits will be paid as for Illness. 8. Charges for professional ambulance service to the nearest facility where Emergency care or treatment is rendered. 9. Charges for drugs requiring the written prescription of a licensed Physician; such drugs must be necessary for the treatment of an Illness or Injury. Prescription Drugs are limited to a thirty (30) day supply. 10. Charges for x-rays, including one routine low-dose mammography on an annual basis forfemales age thirty-five (35) or older, microscopic tests, and laboratory tests, which shall include one routine annual pap test and the related office visit. 36 MAJOR MEDICAL EXPENSE BENEFITS (Cont'd) 11. Charges for professional and technical components for automated lab charges. 12. Charges for radiation therapy or treatment. 13. Charges for the processing and administration of blood or blood components, but not for the cost of the actual blood or blood components if replaced. 14. Charges for oxygen and other gasses and their administration. 15. Charges for electrocardiograms, electroencephalograms, pneumoencephalograms, basal metabolism tests, or similar well-established diagnostic tests generally approved by Physicians throughout the United States. 16. Charges for the cost and administration of an anesthetic. 17. Charges for ostomy supplies, sterile dressing change kits, sutures, casts, splints, trusses, crutches, braces, or other necessary medical supplies, with the exception of dental braces or corrective shoes. 18. Initial charges for the rental of a wheelchair, Hospital bed or other Durable Medical Equipment required for temporary therapeutic use, orthe purchase of this equipment if economicallyjustified, whichever is less. Prior rental amounts will reduce the purchase price. 19. Charges for artificial limbs, eyes or larynx, but not the replacement thereof. Initial charges for prosthetic/Orthotic Appliances and replacement or repair only if necessitated by skeletal growth. Orthotic Appliances must be custom molded. 20. Services for voluntary sterilization for Participants and Dependent Spouses. 21. Charges made by a licensed Ambulatory Surgical Center or Minor Emergency Medical Clinic when treatment has been rendered. 22. Services and supplies in connection with transplant procedures, subject to the following conditions: a. The transplant must be recognized as anon-Experimental procedure by the American Medical Association. b. A second opinion must be obtained prior to undergoing any transplant procedure. This mandatory second opinion must concur with the attending Physician's findings regarding the medical necessity of such procedure. The Physician rendering this second opinion must be qualified to render such a service either through experience, specialist training or education, or such similar criteria, and must not be affiliated in any way with the Physician who will be performing the actual surgery. c. If the donor is covered under this Plan, Eligible Medical Expenses incurred by the donor will be considered for benefits. d. If the recipient is covered under this Plan, Eligible Medical Expenses incurred by the recipient will be considered for benefits. Expenses incurred by the donor who is not ordinarily covered under this Plan according to Participant eligibility requirements, will be considered Eligible Medical Expenses to the extent that such expenses are not payable by the donor's plan. In no event will benefits be payable in excess of the Maximum Plan Benefit still available to the recipient. e. If both the donor and the recipient are covered under this Plan, Eligible Medical Expenses incurred by each person will be treated separately for each person. f. The Usual and Customary cost of securing an organ from a cadaver or tissue bank, including the surgeon's charge for removal of the organ and a g ospital's charge for storage or transportation of the organ, will be considered a Covered Expense. 37 MAJOR MEDICAL EXPENSE BENEFITS (Cont'd) 23. Charges made by a Home Health Care Agency for care in accordance with a Home Health Care Plan. Such expenses include: a. Part-time or intermittent nursing care by a Registered Nurse (R.N.) or by a Licensed Practical Nurse, a vocational nurse, or public health nurse who is under the direct supervision of a Registered Nurse; b. Certified home health aides under the direct supervision of a Registered Nurse; or c. Medical supplies, drugs and medicines prescribed by a Physician, and laboratory services provided by a Physician, and laboratory services provided by or on behalf of a Hospital, but only to the extent that they would have been covered under this Plan if the Covered Person had remained in the Hospital. Specifically excluded from coverage under this benefit are the following: a. Services and supplies not included in the Home Health Care Plan. b. Services of a person who ordinarily resides in the home of the Covered Person, or is a Close Relative of the Covered Person. c. Services of any social worker. d. Transportation services. 24. Physician's charges for obstetrical service are paid on the same basis as for an Illness, including the mother's prenatal care. Benefits are not provided for a Pregnancy of a Dependent child. 25. Newborn care following a delivery, charges for circumcision and routine care of a Newborn child, while confined in the Hospital and less than seven (7) days old. 26. Charges for Psychiatric Care rendered by a Physician or certified and licensed social worker under the direct supervision of a Physician, subject to the percentages and amounts listed in the Schedule of Benefits. 27. Treatment, care, and services for expenses in connection with medical complications and Effective Treatment of Drug Abuse will be treated the same as any other Mental/Nervous condition if confined as an Inpatient in a Hospital which does not have a section which is a Drug Dependency Center. If an individual is confined as a full-time Inpatient in a Drug Dependency Centerfor Effective Treatment of Drug Abuse, Room and Board expenses and expenses for other necessary services and supplies furnished by the center will be considered as any other Mental/Nervous condition. 28. Treatment, care, and services in connection with Alcoholism are covered as any other Mental/Nervous condition, and will be subject to the same Exceptions, Limitations, and other provisions of this Plan. In addition to a Hospital, care, treatment, and services in connection with Alcoholism will be covered in an Alcohol Dependency Treatment Center and will be considered as any other Mental Nervous condition. 29. Any services, supplies, diagnostic procedures, and/or treatment provided by a Doctor of Chiropractic. 38 MAJOR MEDICAL EXPENSE BENEFITS (Cont'd) 30. Charges made by a licensed Birthing Center and incurred while coverage is in force. This benefit is paid for charges made by the center, and not for charges made separately by any Physician for services provided at the center. 31. Charges for reconstruction of the breast on which a mastectomy has been performed; surgery and reconstruction of the other breast to produce symmetrical appearance; and charges for prostheses and physical complications of all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending Physician and the patient, as required by the Women's Health and Cancer Rights Act. 32. Charges for Prostate Specific Antigens (PSA) and the related office visit. 33. Charges for surgery to correct a functional defect which results from a congenital and/or acquired disease or anomaly. 34. Charges for surgery to correct a seriously disfiguring condition resulting from an accidental injury. 35. Charges for thirteen (13) Antigen Doses per quarter, not to exceed a thirteen (13) week supply. The Plan shall not be responsible for the re-mixing of vials or for replacement due to an instance of breakage or misplacement, within the above timeframe. 36. Any services and/or treatment provided by a licensed Physical Therapist, subject to the percentages and amounts listed in the Schedule of Benefits. 37. Charges for acupuncture performed by a Physician, when Medically Necessary. CASE MANAGEMENT The Case Manager will assess the continuing care needs in catastrophic and chronic high cost medical care cases and discuss with the attending Physician less costly Alternate Care. Coverage may be provided for less costly medical services and supplies, even though such alternatives are not specifically covered by the Plan. This does not, however, cover expenses that are considered Experimental or Investigational as set forth in the Plan or are provided only as a convenience to the Covered Person, the Covered Person's Family orthe health care provider. Coverage for Alternate Care is subject to the same overall Plan Benefit Maximum, Co- Payment, Deductible and/or Out-of-Pocket requirements that apply to the medical care being replaced. Although the Case Manager may suggest to the Physician less costly Alternate Care, the final decision on patient care and treatment is the responsibility of the Covered Person, the Family, and the attending Physician. If the Case Manager suggests less costly Alternate Care, the Plan will reimburse at that lesser rate, even if the Covered Person elects more costly care. 39 GENERAL PLAN EXCLUSIONS AND LIMITATIONS The following exclusions and limitations apply to expenses incurred by all Covered Persons: 1. Charges incurred prior to the effective date of coverage under the Plan or after coverage is terminated. 2. Charges incurred as a result of war or any act of war, whether declared or undeclared, or caused during service in the armed forces of any country. 3. Charges for any services or supplies provided in connection with an occupational sickness or an injury sustained in the scope of and in the course of any employment whether or not benefits are or could be provided under Workers' Compensation. 4. Charges incurred while confined in a Hospital owned or operated by the United States Government or any Agency thereof, or charges for services, treatments or supplies furnished by the United States Government or any Agency thereof except those charges in connection with an Illness or Injury that are unrelated to a military or U. S. Government activity. 5. Charges incurred for which the Covered Person is not, in the absence of this coverage, legally obligated to pay, or for which a charge would not ordinarily be made in the absence of this coverage. 6. Charges resulting from or occurring during the commission of a crime, illegal act, felonious act, orwhile engaging in an illegal occupation or act, or aggravated assault by the Covered Person, including, without limitation, illegally driving by the Covered Person while underthe influence of alcohol or drugs, but excluding minor traffic violations. 7. Charges incurred in connection with aself-inflicted Injury, Illness, or overdose as well as, injuries or Illnesses which are a result of an attempted suicide. 8. Charges incurred for routine medical examinations, preventive treatment or routine health check-ups, nutritional supplements, or immunizations not necessary for the treatment of an Injury or Illness unless specified as a Covered Expense in the Plan. 9. Charges incurred for services or supplies which constitute personal comfort or beautification items, television or telephone use, or in connection with Custodial Care, education or training, occupational therapy for Mental/Nervous conditions, or expenses actually incurred by other persons. 10. Charges incurred for Cosmetic Procedures, unless specifically shown as a Covered Expense elsewhere in this Plan. 11. Charges incurred in connection with services and supplies which are not necessary fortreatment of the Injury or Illness, are in excess of Usual and Customary charges, are not recommended and approved by a Physician, or treatment or tests not related to the diagnosis given, unless specifically shown as a Covered Expense elsewhere in the Plan. 12. Charges for services, supplies or treatments not recognized by the American Medical Association as generally accepted and Medically Necessary for the diagnosis and/or treatment of an active Illness or Injury; or charges for procedures, surgical or otherwise, which are specifically listed by the American Medical Association as having no medical value, unless specified as a Covered Expense elsewhere in the Plan. 13. Charges for elective abortions. 14. Charges for services rendered by a Physician, nurse, or licensed therapist if such Physician, nurse, or licensed therapist is a Close Relative of the Covered Person, or resides in the same household of the Covered Person. 15. Charges incurred outside the United States if the Covered Person traveled to such a location for the sole purpose of obtaining medical services, drugs, or supplies. 40 GENERAL PLAN EXCLUSIONS AND LIMITATIONS (Cont'd) 16. Charges for hospitalization when such Confinement occurs primarily for physiotherapy, hydrotherapy or rest care, or any routine physical examinations ortests not connected with the actual Illness or Injury. 17. Charges for Physicians' fees for any treatment which is not rendered by or in the physical presence of a Physician or charges for Physicians working outside the scope of their license, unless otherwise stated in the Plan. 18. Charges incurred in connection with eye refractions, orthoptics, vision training, vision therapy, including but not limited to automated lamellar keratoplasty (ALK or LK), astigmatic keratotomy (AK), photo refractive keratotomy (PRK-laser), radial keratotomy (RK), the purchase or fitting of eyeglasses, contact lenses, or such similar aid devices. This exclusion shall not apply to the initial purchase of eyeglasses or contact lenses following cataract surgery. 19. Charges incurred in connection with the purchase or fitting of hearing aids, or such similar aid devices. This exclusion shall not apply to the initial purchase of a hearing aid if the loss of hearing is a result of a surgical procedure performed while coverage is in effect. 20. Charges incurred for dental care and treatment, dental surgery, dental appliances or treatment of temporomandibular joint syndrome unless otherwise stated in the Plan, however, benefits will be payable for charges incurred (1) for an alveolectomy, for a gingivectomy, or the removal of impacted teeth (no allowance for other extractions) on an Outpatient basis, unless Hospital Confinement is deemed to be Medically Necessary by the attending Physician and (2) for treatment required because of accidental Injury to sound natural teeth effected solely through external means. An Injury incurred as a result of biting or chewing shall not be considered an accidental Injury. Such expenses must be incurred within six (6) months of the date of accident. Section (2) of this exception shall not in any event be deemed to include charges for treatment for the repair or replacement of a denture. 21. Charges related to or in connection with fertility studies, sterility studies, procedure to restore or enhance fertility, artificial insemination, or in-vitro fertilization, including but not limited to, gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT), donorsperm, surrogate parenting fees, or premature removal of subdermal implants for purpose of conception. 22. Charges for professional services on an Outpatient basis in connection with Mental Illness, Alcoholism, Drug Addiction, Functional Nervous Disorders, Mental or Nervous Disorders of any type or cause, or for psychiatric or psychoanalytic care for any reason, unless such services are rendered by a Physician. Such charges are payable as defined in the Schedule of Benefits. 23. Charges for professional nursing services if rendered by other than a Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.), unless such care was vital as a safeguard of the Covered Person's life, and unless such care is specifically listed as a Covered Expense elsewhere in the Plan. 24. Charges resulting from or in connection with the reversal of a sterilization procedure. 25. Charges as a result of or in connection with the pregnancy of a Dependent child. 26. Charges for Experimental procedures, drugs, or research studies, or for any services or supplies not considered legal in the United States. 27. Charges for Well-Baby Care, including the usual, ordinary and routine care of a Newborn unless otherwise stated in the Schedule of Benefits. 28. Charges for services, treatment or care of any kind of Chemical Dependency if the Participant is convicted in any court of Law and is required by the court, or arranges in lieu of conviction, to undergo care or treatment as an alterative to, or in addition to, fine or imprisonment. 41 GENERAL PLAN EXCLUSIONS AND LIMITATIONS (Cont'd) 29. Chiropractic treatment for children up to age sixteen (16) will be excluded unless Medically Necessary. 30. Charges for Durable Medical Equipment for: (1) special features or supplies for Durable Medical Equipment, which are not part of the basic equipment, including but not limited to, electric beds or electric wheelchairs; (2) maintenance, repairs or replacement. 31. Charges in connection with the treatment for obesity, including but not limited to, gastric intestinal bypass surgery. 32. Charges for surgical procedures for snoring. 33. Charges for corrective shoes and shoe inserts. 34. Charges for wigs or prosthetic hair. 35. Charges for equipment considered dispensable or convenient for use in the home, including but not limited to, overthe counter bandages and dressings; foam cervical collars, air conditioners, humidifiers, dehumidifiers, and other personal comfort items. 36. Charges incurred for massage therapy, unless otherwise specifically shown as a Covered Expense elsewhere in this Plan. 37. Charges for postage and handling or sales tax. 38. Charges for delivery fees or compounding fees of drugs or IV Therapy. 39. Charges for Hospice Bereavement Counseling for individuals or family, unless specifically shown as a Covered Expense elsewhere in this Plan. 40. Charges by a Physician for contacting a Covered Person by phone, fax or a-mail or charges for ordering a prescription. 41. Charges for Prescription Drugs or medicines which are covered under the Supplemental Prescription Drug Program portion of this Plan, which has its own Exclusions and limitations. 42. Charges that have been previously processed (duplicate charges). 43. Charges for sleep studies or related expenses performed in the home. 44. Charges for Residential Treatment except charges related to or for the treatment of Alcoholism, Drug Addiction or Substance Abuse performed at an approved Alcohol and Drug Dependency Center or Hospital. With respect to any Injury which is otherwise covered by the Plan, the Plan will not deny benefits otherwise provided for treatment of the Injury if the Injury results from an act of domestic violence or a medical condition (including both physical and mental health conditions). 42 HEALTH CLAIM PROCEDURES FOR POST SERVICE CLAIMS The procedures outlined below must be followed by Covered Persons ("Claimants") to obtain payment of health benefits under this Plan. HEALTH CLAIMS -All claims and questions regarding health claims should be directed to the Plan Supervisor. The Plan Administrator shall be ultimately and finally responsible for adjudicating such claims and for providing full and fair review of the decision on such claims in accordance with the following provisions and with the Employee Retirement Income Security Act of 1974, as amended ("FRIBA"). Benefits under the Plan will be paid only if the Plan Administrator decides in its discretion the Claimant is entitled to them. The responsibility to process claims in accordance with the Plan Document may be delegated to the Plan Supervisor; provided, however, that the Plan Supervisor is not a Fiduciary of the Plan and does not have the authority to make decisions involving the use of discretion. Each Claimant claiming benefits under the Plan shall be responsible for supplying, at such times and in such manner as the Plan Administrator in its sole discretion may require, written proof that the expenses were incurred or that the benefit is covered under the Plan. If the Plan Administrator in its sole discretion shall determine that the Claimant has not incurred a covered expense or that the benefit is not covered under the Plan, or if the Claimant shall fail to furnish such proof as is requested, no benefits shall be payable under the Plan. Under the Plan, there are three types of claims: Pre-Service Non-Urgent, Concurrent and Post-Service. See the section entitled "Definitions" for more details. KEY POINTS TO REMEMBER The Plan Supervisor reserves the right to require a physical examination by a Physician of its choice as a condition of payment of any claim. All claims for benefits must be filed by the Participant with the Plan Supervisor. It is the Participant's responsibility to see that Physician bills, medical bills and Hospital charges get to the Plan Supervisor. Proper payment cannot be made without these bills. WHEN HEALTH CLAIMS MUST BE FILED -Health claims must be filed with the Plan Supervisor within one-hundred eighty (180) days of the date charges for the service were incurred. Benefits are based upon the Plan's provisions at the time the charges were incurred. Charges are considered incurred when treatment or care is given or supplies are provided. Claims filed later than that date shall be denied. A Post-Service Claim is considered to be filed when the following information is received by the Plan Supervisor, together with the standard claim form used by the provider of service: 1. The date of service; 2. The name, address, telephone number and tax identification number of the provider of the services or supplies; 3. A yearly fully completed, signed and dated W-9 is required from the provider, if the provider accepts assignment; 4. The place where the services were rendered; 5. The diagnosis and procedure codes; 6. The amount of charges; 7. The name of the Plan; 8. The name of the covered employee; 9. The name of the patient, and 10. Information on other insurance, if applicable. 43 HEALTH CLAIM PROCEDURES FOR POST SERVICE CLAIMS (Cont'd) ~''" Upon receipt of this information, the claim will be deemed to be filed with the Plan. The Plan Supervisor will determine if enough information has been submitted to enable proper consideration of the claim. If not, the Plan Supervisor must notify the Claimant as to what specific information is needed to process the claim. The Claimant has forty-five (45) days from receipt of the notice to provide the specified information. Failure to do so may result in claims being declined or reduced. TIMING OF CLAIM DECISIONS -The Plan Administrator shall notify the Claimant, in accordance with the provisions set forth below, of any Adverse Benefit Determination within the following timeframes: 1. If the Claimant has provided all of the information needed to process the claim, in a reasonable period of time, but not later than 30 days after receipt of the claim, unless an extension is needed, then prior to the end of the 15-day extension period. 2. If the Claimant has not provided all of the information needed to process the claim and additional information is requested during the initial processing period, then the Claimant will be notified of a determination of benefits prior to the end of the extension period, unless additional information is requested during the extension period, then the Claimant will be notified of the determination by a date agreed to by the Plan Administrator and the Claimant. EXTENSIONS -This initial thirty (30) day processing period may be extended by the Plan for up to 15 days, provided that the Plan Administrator both determines that such an extension is necessary due to matters beyond the control of the Plan and notifies the Claimant, prior to the expiration of the initial 30-day processing period, of the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. CALCULATING TIME PERIODS -The period of time within which a benefit determination is required to be made shall begin at the time a claim is deemed to be filed in accordance with the procedures of the Plan. NOTIFICATION OF AN ADVERSE BENEFIT DETERMINATION -The Plan Administrator shall provide a Claimant with a notice, either in writing or electronically containing the following information: 1. A reference to the specific portion(s) of the Plan Document upon which a denial is based; 2. Specific reason(s) for a denial; 3. A description of any additional information necessary for the Claimant to perfect the claim and an explanation of why such information is necessary; 4. A description of the Plan's review procedures and the time limits applicable to the procedures, including a statement of the Claimant's right to bring a civil action under Section 502(a) of ERISA following an Adverse Benefit Determination on final review; 5. A statement that the Claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the Claimant's claim for benefits; 6. The identity of any medical or vocational experts consulted in connection with a claim, even if the Plan did not rely upon their advice (or a statement that the identity of the expert will be provided, upon request); 7. Any rule, guideline, protocol or similar criterion that was relied upon in making the determination (or a statement that it was relied upon and that a copy will be provided to the Claimant, free of charge, upon request); 44 HEALTH CLAIM PROCEDURES FOR POST SERVICE CLAIMS (Cont'd) '~rr++ 8. In the case of denials based upon a medical judgment (such as whether the treatment is Medically Necessary or Experimental), either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Claimant's medical circumstances, or a statement that such explanation will be provided to the Claimant, free of charge, upon request. If the Claimant believes a claim has been denied wrongly, the Claimant may appeal the denial. See the section entitled "Appeals of Adverse Determinations" for more information. 45 APPEALS OF ADVERSE BENEFIT DETERMINATIONS FULL AND FAIR REVIEW OF ALL CLAIMS - In cases where a claim for benefits is denied, in whole or in part, and the Claimant believes the claim has been denied wrongly, the Claimant may appeal the denial and review pertinent documents. The claims procedures of this Plan provide a Claimant with a reasonable opportunity for a full and fair review of a claim and Adverse Benefit Determination. More specifically, the Plan provides: 1. Claimants at least 180 days following receipt of a notification of an initial Adverse Benefit Determination within which to appeal the determination and sixty (60) days to appeal a second Adverse Benefit Determination; 2. Claimants the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits; 3. For a review that does not afford deference to the previous Adverse Benefit Determination and that is conducted by an appropriate Named Fiduciary of the Plan, who shall be neither the individual who made the Adverse Benefit Determination that is the subject of the appeal, nor the subordinate of such individual; 4. For a review that takes into account all comments, documents, records, and other information submitted by the Claimant relating to the claim, without regard to whether such information was submitted or considered in any prior benefit determination; 5. That, in deciding an appeal of any Adverse Benefit Determination that is based in whole or in part upon a medical judgment, the Plan Fiduciary shall consult with an Appropriate Health Care Professional, who is neither an individual who was consulted in connection with the Adverse Benefit Determination that is the subject of the appeal, nor the subordinate of any such individual; 6. For the identification of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with a claim, even if the Plan did not rely upon their advice; 7. That a Claimant will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Claimant's claim for benefits in possession of the Plan Administrator or the Plan Supervisor; any internal rule, guideline, protocol or other similar criterion relied upon in making the adverse determination; and an explanation of the scientific or clinical judgment forthe determination, applying the terms of the Plan to the Claimant's medical circumstances. FIRST APPEAL LEVEL REQUIREMENTS FOR FIRST APPEAL -The Claimant must file the first appeal in writing within one hundred-eighty (180) days following receipt of the notice of an Adverse Benefit Determination. To file an appeal in writing, the Claimant's appeal must be addressed as follows or faxed to the following numbers: For Post Service Claims: Insurance Management Services Customer Service Representative P.O. Box 15688 Amarillo, TX 79105 (806) 373-6646 For Pre-Service Non-Urgent Claims: IMS Managed Care UR Nurse P.O. Box 15688 Amarillo, TX 79105 (806) 373-1458 46 APPEALS OF ADVERSE BENEFIT DETERMINATIONS (Cont'd) It shall be the responsibility of the Claimant to submit proof that the claim for benefits is covered and payable under the provisions of the Plan. Any appeal must include: 1. The name of the Employee/Claimant; 2. The Employee/Claimant's social security number; 3. The group name or identification number; 4. All facts and theories supporting the claim for benefits. Failure to include any theories or facts in the appeal will result in their being deemed waived. In other words, the Claimant will lose the right to raise factual arguments and theories which support this claim if the Claimant fails to include them in the appeal; 5. A statement in clear and concise terms of the reason or reasons for disagreement with the handling of the claim; and 6. Any material or information that the Claimant has which indicates that the Claimant is entitled to benefits under the Plan. If the Claimant provides all of the required information, it may be that the expenses will be eligible for payment under the Plan. TIMING OF NOTIFICATION OF BENEFIT DETERMINATION ON FIRST APPEAL -The Plan Administrator shall notify the Claimant of the Plan's benefit determination on review within the following timeframes: 1. Pre-Service Non-Urgent Claims - Within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the appeal. 2. Concurrent Claims -The response will be made in the appropriate time period based upon the type of claim -Pre-Service Non-Urgent or Post-Service. 3. Post-Service Claims - Within a reasonable period of time, but not later than 30 days after receipt of the appeal. CALCULATING TIME PERIODS -The period of time within which the Plan's determination is required to be made shall begin at the time an appeal is filed in accordance with the procedures of this Plan, without regard to whether all information necessary to make the determination accompanies the filing. MANNER AND CONTENT OF NOTIFICATION OF ADVERSE BENEFIT DETERMINATION ON FIRST APPEAL -The Plan Administrator shall provide a Claimant with notification in writing or electronically, of a Plan's Adverse Benefit Determination on review, setting forth: 1. The specific reason or reasons for the denial; 2. Reference to the specific portion(s) of the Plan Document or Summary Plan Description on which the denial is based; 3. The identity of any medical or vocational experts consulted in connection with the claim, even if the Plan did not rely upon their advice; 47 APPEALS OF ADVERSE BENEFIT DETERMINATIONS (Cont'd) 4. A statement that the Claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Claimant's claim for benefits; 5. If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination, a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination and that a copy ofthe rule, guideline, protocol, or other similar criterion will be provided free of charge to the Claimant upon request; 6. If the Adverse Benefit Determination is based upon a medical judgment, an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Claimant's medical circumstances, will be provided free of charge upon request; 7. A description of any additional information necessary for the Claimant to perfect the claim and an explanation of why such information is necessary; 8. A description of the Plan's review procedures and the time limits applicable to the procedures; and 9. A statement of the Claimant's right to bring a civil action under section 502(a) of ERISA, following an Adverse Benefit Determination on final review. FURNISHING DOCUMENTS IN THE EVENT OF AN ADVERSE DETERMINATION - In the case of an Adverse Benefit Determination on review, the Plan Administrator shall provide such access to, and copies of, documents, records, and other information described in items 3 through 6 of the section relating to "Manner and Content of Notification of Adverse Benefit Determination on First Appeal" as appropriate. SECOND APPEAL LEVEL *~r ADVERSE DECISION ON FIRST APPEAL; REQUIREMENTS FOR SECOND APPEAL -Upon receipt of notice of the Plan's adverse decision regarding the first appeal, the Claimant has sixty (60) days to file a second appeal of the denial of benefits. The Claimant again is entitled to a "full and fair review" of any denial made at the first appeal, which means the Claimant has the same rights during the second appeal as he or she had during the first appeal. As with the first appeal, the Claimant's second appeal must be in writing and must include all of the items set forth in the section entitled "Requirements for First Appeal." TIMING OF NOTIFICATION OF BENEFIT DETERMINATION ON SECOND APPEAL -The Plan Administrator shall notify the Claimant of the Plan's benefit determination on review within the following timeframes: 1. Pre-Service Non-Urgent Ciaims - Within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the second appeal. 2. Concurrent Claims -The response will be made in the appropriate time period based upon the type of claim -Pre-Service Non-Urgent or Post-Service. 3. Post-Service Claims - Within a reasonable period of time, but not later than 30 days after receipt of the second appeal. CALCULATING TIME PERIODS -The period of time within which the Plan's determination is required to be made shall begin at the time the second appeal is filed in accordance with the procedures of this Plan, without regard to whether all information necessary to make the determination accompanies the filing. 48 APPEALS OF ADVERSE BENEFIT DETERMINATIONS (Cont'd) MANNER AND CONTENT OF NOTIFICATION OF ADVERSE BENEFIT DETERMINATION ON SECOND APPEAL -The same information must be included in the Plan's response to a second appeal as a first appeal, except for (i) a description of any additional information necessary for the Claimant to perfect the claim and an explanation of why such information is needed; and (ii) a description of the Plan's review procedures and the time limits applicable to the procedures. See the section entitled "Manner and Content of Notification of Adverse Benefit Determination on First Appeal." FURNISHING DOCUMENTS IN THE EVENT OF AN ADVERSE DETERMINATION - In the case of an Adverse Benefit Determination on the second appeal, the Plan Administrator shall provide such access to, and copies of, documents, records, and other information described in items 3 through 6 of the section relating to "Manner and Content of Notification of Adverse Benefit Determination on First Appeal" as is appropriate. DECISION ON SECOND APPEAL TO BE FINAL - If, for any reason, the Claimant does not receive a written response to the appeal within the appropriate time period set forth above, the Claimant may assume that the appeal has been denied. The decision by the Plan Administrator or other appropriate Named Fiduciary of the Plan on review will be final, binding and conclusive and will be afforded the maximum deference permitted by law. All claim review procedures provided for in the Plan must be exhausted before any legal action is brought. Any legal action for the recovery of any benefits must be commenced within one (1) year after the Plan's claim review procedures have been exhausted. APPOINTMENT OF AUTHORIZED REPRESENTATIVE - A Claimant is permitted to appoint an Authorized Representative to act on his behalf with respect to a benefit claim or appeal of a denial. An assignment of benefits by a Claimant to a provider will not constitute appointment of that provider as an Authorized Representative. To appoint such a representative, the Claimant must complete a form, which can be obtained from the Plan Administrator or the Plan Supervisor. In the event a Claimant designates an Authorized Representative, all future communications from the Plan will be with the representative, rather than the Claimant, unless the Claimant directs the Plan Administrator, in writing, to the contrary. 49 INTERNAL RULES, GUIDELINES OR PROTOCOL ~,. Below are the administrative processes that are used in operating the Plan to satisfy basic fiduciary standards of conduct under ERISA. These procedures are utilized for consistent decision-making that may or may not result in documents or information that can be disclosed pertaining to an individual claims decision. To receive more information concerning these concepts, free of charge, please make a written request to the Plan Supervisor. UTILIZATION REVIEW -The plan utilizes InterQual Criteria which is an industry standard for guiding healthcare insurers, plans, and providers toward medical best practices and care settings. Criteria are clinical statements that help determine the appropriateness of a proposed medical intervention. They are used to determine if the intervention is indicated, based on the clinical data, or requires further review. Criteria are an objective tool used to support a clinical rationale for decision-making and are an integral component of the utilization management program. The Criteria reflect clinical interpretations analyses and cannot alone either resolve medical ambiguities of particular situations or provide the sole basis for definitive decisions. The Criteria is intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determinations concerning the type or level of medical care provided, or proposed to be provided, to a patient. Specifically, InterQual Criteria allows for the efficient screening of cases with the goal of referring only those cases truly needing medical review. InterQual Criteria allow the non-physician reviewer and the provider to efficiently identify the majority of cases where an intervention is warranted, in both the inpatient and outpatient settings. The Criteria does not replace provider judgment; rather it serves as a tool to promote sound and efficient utilization management. CLAIMS EDIT SYSTEM -The Claims Edit System Knowledgebase (referred to as CES) helps identify inappropriate coding relationships and the line item information on provider medical bills. Application of the CES Knowledgebase allows claims processors and adjudicators to identify potentially incorrect or inappropriate coding relationships by a single provider, for a single patient and/or for a single date of service. CES shows coding relationships for CPT, HCPCS and ICD-9 codes. These three nomenclature and classification systems are the healthcare industry standards used to report procedures, professional/ancillary ~irr- services, supplies, drugs, anesthesia services, and diagnosis. Because the practice of medicine is not an exact science, the billing and reimbursement of medical services is a process with many complexities. To construct the multiple edits that are found in the CES Knowledgebase, clinical staff found it necessary to formulate a set of rules in the form of clinical concepts. The clinical concepts are guidelines established specifically and only for the CES Knowledgebase. PPO FEE SCHEDULES AND PPO PROVIDERS -The Plan utilizes a Preferred Provider Organization (PPO) fee schedule for medical procedures performed by Providers that participate in the PPO Network. The Participating Providers and the PPO Fee Schedule are subject to change at any time with written notice from the Preferred Provider Organization (PPO). CPT CODE MODIFIER -The CPT coding system includestwo-digit modifier codes, which are used to report that a service or procedure has been "altered or modified by some specific circumstance" without altering or modifying the basic definition or CPT code. Certain modifiers may affect the Usual and Customary fee for that procedure. USUAL & CUSTOMARY -The Plan uses medical pricing data, a pricing approach which combines the use of a relative value scale along with charge data by geozip (geographical area), and/or Medicare pricing in calculating Usual & Customary allowances. Relationships between procedures are also used in determining potential allowable charge amounts. The Plan uses the Usual & Customary allowance for medical procedures performed by providers that do not participate in the PPO Network. Usual & Customary allowances do not apply to Emergency Admissions in a Non-PPO facility. NON-PPO AMBULATORY SURGICAL FACILITY-Ambulatory surgical facility allowables are subject to local PPO allowables, and/or Medicare pricing and are at the discretion of the Plan Administrator. 50 PRIVACY STANDARDS 1. Disclosure of Summary Health Information to the Plan Sponsor In accordance with the Privacy Standards, the Plan may disclose Summary Health Information to the Plan Sponsor, if the Plan Sponsor requests the Summary Health Information for the purpose of (a) obtaining premium bids from health plans for providing health insurance coverage under this Plan or (b) modifying, amending or terminating the Plan. "Summary Health Information" may be individually identifiable health information and it summarizes the claims history, claims expenses or the type of claims experienced by individuals in the plan, but it excludes all identifiers that must be removed for the information to be de-identified, except that it may contain geographic information to the extent that it is aggregated by five-digit zip code. 2. Disclosure of Protected Health Information ("PHI") to the Plan Sponsor for Plan Administration Purposes In order that the Plan Sponsor may receive and use PHI for Plan Administration purposes, the Plan Sponsor agrees to: a. Not use or further disclose PHI other than as permitted or required by the Plan Documents or as Required by Law (as defined in the Privacy Standards); b. Ensure that any agents, including a subcontractor, to whom the Ptan Sponsor provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such PHI; c. Not use or disclose PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor, except pursuant to an authorization which meets the requirements of the Privacy Standards; d. Report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of which the Plan Sponsor becomes aware; e. Make available PHI in accordance with Section 164.524 of the Privacy Standards (45 CFR 164.524); f. Make available PHI for amendment and incorporate any amendments to PHI in accordance with Section 164.526 of the Privacy Standards (45 CFR 164.526); g. Make available the information required to provide an accounting of disclosures in accordance with Section 164.528 of the Privacy Standards (45 CFR 164.528); h. Make its internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the Secretary of the U.S. Department of Health and Human Services ("HHS"), or any other officer or employee of HHS to whom the authority involved has been delegated, for purposes of determining compliance by the Plan with Part 164, Subpart E, of the Privacy Standards (45 CFR 164.500 of seq); i. If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the PHI infeasible; and 51 PRIVACY STANDARDS (Cont'd) Ensure that adequate separation between the Plan and the Plan Sponsor, as required in Section 164.504(f)(2)(iii) of the Privacy Standards (45 CFR 164.504(f)(2)(iii)), is established as follows: The following employees, or classes of employees, or other persons under control of the Plan Sponsor, shall be given access to the PHI to be disclosed: Director of Employee Benefits Human Resources Director Plan Auditor Chief Financial Officer Any staff designated by one of the above positions. A complete list may be obtained free of charge from your Plan Sponsor, upon written request. ii. The access to and use of PHI by the individuals described in subsection (i) above shall be restricted to the Plan Administration functions that the Plan Sponsor performs for the Plan. iii. In the event any of the individuals described in subsection (i) above do not comply with the provisions of the Plan Documents relating to use and disclosure of PHI, the Plan Administrator shall impose reasonable sanctions as necessary, in its discretion, to ensure that no further non-compliance occurs. Such sanctions shall be imposed progressively (for example, an oral warning, a written warning, time off without pay and termination), if appropriate, and shall be imposed so that they are commensurate with the severity of the violation. "Plan Administration" activities are limited to activities that would meet the definition of payment or health care operations, but do not include functions to modify, amend or terminate the Plan or solicit bids from prospective issuers. "Plan Administration" functions include quality assurance, claims processing, auditing, monitoring and management of carve-out plans, such as vision and dental. It does not include any employment-related functions or functions in connection with any other benefit or benefit plans. The Plan shall disclose PHI to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor that (a) the Plan Documents have been amended to incorporate the above provisions and (b) the Plan Sponsor agrees to comply with such provisions. 3. Disclosure of Certain Enrollment Information to the Plan Sponsor Pursuant to Section 164.504(f)(1)(iii) of the Privacy Standards (45 CFR 164.504(f)(1)(iii)), the Plan may disclose to the Plan Sponsor information on whether an individual is participating in the Plan or is enrolled in or has disenrolled from a health insurance issuer or health maintenance organization offered by the Plan to the Plan Sponsor. 4. Disclosure of PHI to Obtain Stop-loss or Excess Loss Coverage The Plan Sponsor hereby authorizes and directs the Plan, through the Plan Administrator, to disclose PHI to stop-loss carriers, excess loss carriers or managing general underwriters (MGUs) for underwriting and other purposes in order to obtain and maintain stop-loss or excess loss coverage related to benefit claims under the Plan. Such disclosures shall be made in accordance with the Privacy Standards. 5. Other Disclosures and Uses of PHI With respect to all other uses and disclosures of PHI, the Plan shall comply with the Privacy Standards. 52 SECURITY STANDARDS Disclosure of Electronic Protected Health Information ("Electronic PHI") to the Plan Sponsor for Plan Administration Functions To enable the Plan Sponsor to receive and use Electronic PHI for Plan Administration Functions (as defined in 45 CFR § 164.504(a)), the Plan Sponsor agrees to: a. Implement Administrative, Physical, and Technical Safeguards that reasonably and appropriately protect the Confidentiality, Integrity and Availability of the Electronic PHI that it creates, receives, maintains, or transmits on behalf of the Plan; b. Ensure that adequate separation between the Plan and the Plan Sponsor, as required in (45 CFR § 164.504(f)(2)(iii)), is supported by reasonable and appropriate Security Measures; c. Ensure that any agent, including a subcontractor, to whom the Plan Sponsor provides Electronic PHI created, received, maintained, or transmitted on behalf of the Plan, agrees to implement reasonable and appropriate Security Measures to protect the Electronic PHI; and d. Report to the Plan any Security Incident of which it becomes aware. Any terms not otherwise defined in this section shall have the meanings set forth in the Security Standards. 53 COORDINATION OF BENEFITS (COB) The following COB Rules shall govern entitlement to benefits notwithstanding any contrary provision in the Plan. INTRODUCTION -The COB Rules provide aclaim-payment procedure which may enable a Covered Person to receive, from all health plans (including government plans) under which the Covered Person is covered, total payments up to but not more than, the full amount of a Covered Expense. Generally, when this Plan is the Primary Plan with respect to a Participant or Dependent, it pays full Plan benefits for the claim. When this Plan is the Secondary Plan with respect to a Participant or Dependent, it will pay the amount set forth in the section entitled "Effect On The Benefits Of This Plan" below. CASES WHERE THIS PLAN IS SECONDARY PLAN -When there is a basis fora claim underthis Plan and under another plan, this Plan is a "Secondary Plan" which has its benefits determined after benefits of the other plan, unless: 1. The other plan has rules coordinating its benefits with Benefits under this Plan; and 2. Both the rules of the other plan and the rules in the section entitled "Ordering Rules" below, require that Benefits under this Plan be determined before benefits under the other plan. Otherwise, this Plan is "Primary Plan." If this Plan is the Secondary Plan, the other plan will be the Primary Plan. If this Plan is the Primary Plan, the other plan will be the Secondary Plan. ORDERING RULES -This Plan determines its order of benefits using the first (in numeric sequence) of the following rules that is applicable: Participant/Dependent -The benefits of the plan which covers the recipient of Covered Services as a Participant are determined before those of the plan which covers the recipient of Covered Services as a Dependent. 2. Child of Parents Not Separated or Divorced - Except as stated in the section entitled "Ordering Rules" subsection (3), below, when this Plan and another plan cover the same child as a Dependent of different persons, called "parents": a. The benefits of the plan of the parent whose birthday falls earlier in a Calendar Year (month and day) are determined before those of the plan of the parent whose birthday falls later in that year; but b. If both parents have the same birthday, the benefits of the plan which covered the parent longer are determined before those of the other plan which covered the other parent for a shorter period of time. However, if the other plan does not have the rule described in (a), above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits. Child of Separated or Divorced Parents - If two (2) or more plans cover a recipient of Covered Services as a child of divorced or separated parents, benefits for the child are determined in this order: a. First, the plan of the parent with custody of the child; 54 COORDINATION OF BENEFITS (Cont'd) b. Then, the plan of the Spouse of the parent with custody of the child; and c. Finally, the plan of the parent not having custody of the child. However, if the terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. The section (C) above, does not apply with respect to any claim determination period or plan year during which any benefits are actually paid or provided before the entity has such actual knowledge. Active/Inactive Employee -The benefits of a plan which covers the recipient of Covered Services as an Employee who is neither laid off nor retired (or as that Employee's Dependent) are determined before those of a plan which covers such person as a laid off or retired Employee (or as that Employee's Dependent). If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, the rule of this subsection (D) is ignored. Longer/Shorter Length of Coverage - If none of the above rules determines the order of benefits, the benefits of the plan which covered the recipient of Covered Services longer are determined before those of the plan which covered such person for the shorter time. For a Qualified Beneficiary who has elected Continuation of Coverage under this Plan and is covered under another group insurance arrangement, this Plan will always be considered secondary payor to the other group insurance arrangement. SUBMISSION OF CLAIMS -Claims should be submitted to the Primary Plan first. Any balance remaining after payment by the Primary Plan should then be submitted to the Secondary Plan. Claims for Covered Services not covered under this Plan will not be considered Covered Expenses even though they are covered under another plan which covers a Participant or a Dependent. EXCHANGES OF INFORMATION - In order to administer the COB Rules, the Plan Supervisor may exchange information about any Claim with the carrier of any other plan which covers a Participant or a Dependent. As part of this process, the Plan Supervisor may require a Participant to provide relevant information. EFFECT ON THE BENEFITS OF THIS PLAN - If this Plan is a Secondary Plan with respect to (and its benefits are determined after those of) one or more other plans, the amount of Covered Expenses for which a Covered Person shall be reimbursed in a Claim Determination Period shall be the lessor of: (a) the Covered Expenses that would otherwise be payable under this Plan in the absence of these COB Rules with respect to an Allowable Expense incurred by the Covered Person during the Claim Determination Period; or (b) the Covered Expenses minus the actual benefits payable by the other plan. When another plan provides benefits in the form of services, the reasonable cash value of each service rendered shall be considered both an Allowable Expense and a benefit payable. Amounts payable by this Plan will never exceed the total liability of this Plan. When Covered Expenses of this Plan are reduced in accordance with these COB Rules, each separate Covered Expense shall be reduced in the same proportion and then charged against any applicable benefit limit of this Plan. OTHER RULES - If payment made under another plan includes an amount that should have been paid under this Plan, the Plan Administrator may pay that amount directly to that other plan. Any amount paid under the preceding sentence shall be treated as a Covered Expense paid under this Plan, and such amount shall not be paid again. With respect to benefits provided in the form of services, the amount of a "payable made" shall equal the reasonable cash value of the benefits provided in the form of services. If the amount of any payment made by this Plan is more than should have been paid under these COB Rules, the Plan may recover the excess from: The Covered Person to whom, or on whose behalf, payment was made; 55 COORDINATION OF BENEFITS (Cont'd) 2. Any insurance company that should have made such payment; 3. Any other plan that should have made such payment; 4. Any service provider to whom such payment was erroneously made; or 5. Any other individual or entity which should have made such payment or which received the benefit of such erroneous payments. With respect to benefits provided in the form of services, the amount of payments made shall equal the reasonable cash value of any benefits provided in the form of services. DEFINITIONS 1. ALLOWABLE EXPENSE -The term "Allowable Expense" means any medically necessary, Usual & Customary item or expense for health care, which is covered (without regard to any applicable Deductible or Out of Pocket limit) at least in part by this Plan covering the person for whom the claim is made. In the case of HMO (Health Maintenance Organization) plans, this Plan will not consider any charges in excess of what an HMO provider has agreed to accept as payment in full. Further, when an HMO is primary and the Participant does not use an HMO provider, this Plan will not consider as Allowable Expenses any charge that would have been covered by the HMO had the Participant used the services of an HMO provider. 2. CLAIM DETERMINATION PERIOD -The term "Claim Determination Period" means, with respect to each person subject to these COB Rules, a Calendar Year; provided, however, that a Claim Determination Period shall not include any part of a Calendar Year during which such person has no ~r coverage under this Plan or any part of a Calendar Year before the date these COB Rules or a similar coordination of benefits provision is effective with respect to such person. PLAN -The term "Plan" as used herein will mean any plan providing benefits or services for or by reason of medical or dental treatment, and such benefits or services are provided by: a. Group insurance or any other arrangement for coverage for Covered Persons in a group whether on an insured or uninsured basis, including but not limited to: i. Hospital indemnity benefits; and ii. Hospital reimbursement-type plans; b. Hospital or medical service organizations on a group basis, group practice and other group pre- payment plans; c. Hospital or medical service organizations on an individual basis having a provision similar in effect to this provision; d. A licensed Health Maintenance Organizations (HMO); e. Any coverage for students which is sponsored by, or provided through, a school or other educational institution; 56 COORDINATION OF BENEFITS (Cont'd) f. Any coverage under a government program (other than Medicaid), and any coverage required or provided by any statute; g. Group automobile insurance; h. Individual automobile insurance coverage on an automobile leased or owned by the Company; i. Individual automobile insurance coverage based upon the principles of "NO-Fault" coverage. This does not apply to Personal Injury Protection (PIP) coverage in the state of Texas; j. Any plans or polices funded in whole or in part by an employer or deductions made by an employer from a person's compensation or retirement benefits; or k. Labor/management trusteed, union welfare, employer organization or employee benefit organization plans. COORDINATION WITH MEDICARE - A Participant and his spouse (ages 65 and over) may, at the option of such Employee, elect or reject coverage under this Plan. tf such Employee elects coverage under this Plan, the benefits of this Plan shall be determined before any benefits provided by Medicare. If coverage under this Plan is rejected by such Employee, benefits listed herein will not be payable even as secondary coverage to Medicare. To the extent required by federal regulations, this Plan will pay before any Medicare benefits. There are some circumstances under which Medicare would pay its benefits first. In these cases, benefits under this Plan would be calculated as secondary payor. The Participant will be assumed to have full Medicare coverage (that is, both Part A & B) whether or not the Participant has enrolled for the full coverage. If the Provider accepts assignment with Medicare, covered expenses will not exceed the Medicare-approved expenses. If any Participant is eligible for Medicare benefits because of End Stage Renal Disease, the benefits of the Plan will be determined before Medicare benefits for the first 18 months of Medicare entitlement (with respect to charges incurred on or after February 1, 1991 and before August 5, 1997), and for the first 30 months of Medicare entitlement (with respect to charges incurred on or after August 5, 1997), unless applicable federal law provides to the contrary, in which event the benefits of the Plan will be determined in accordance with such law. 57 SUBROGATION, REIMBURSEMENT, AND THIRD PARTY RECOVERY PROVISION The Plan includes a Subrogation, Reimbursement and Third Party Recovery Provision. When this provision applies is described below: If a Participant or Dependent has medical expenses as a result of an Injury or accident for which a third party is, or may be, held responsible, the Plan Administrator may make advance expense reimbursements to, or payments on behalf of, such Participant or Dependent, subject to the Plan's subrogation rights. However, before any such reimbursements or payments will be conditionally made, the Participant or Dependent (or the Dependent's legal guardian if the Dependent is a minor) shall execute an agreement that acknowledges and affirms (1) the conditional nature of the reimbursements or payments and (2) the Plan's rights of subrogation, as provided for below. The Plan Administrator, on behalf of the Plan, has the right to pursue any action to enforce its subrogation rights and its reimbursement rights against a third party. If a Participant or Dependent receives any benefits arising out of an Injury or Illness for which the Participant or Dependent (or the Participant's or Dependent's guardian or estate) has, may have, or asserts any claim or right to recovery against a third party or parties, including but not limited to any party's liability insurance and uninsured/underinsured motorist proceeds, then any payment or payments under this Plan for such benefits shall be made on the condition and with the understanding that this Plan will be reimbursed. Such reimbursement will be made by the Participant or Dependent (or the Participant's or Dependent's guardian or estate) to the extent of, but not exceeding, the total amount payable to or on behalf of the Participant or Dependent (or the Participant's or Dependent's guardian or estate) from: (1) any policy or contract from any insurance company or carrier (including the Participant's or Dependent's insurer) and/or (2) any third party, plan or fund as a result of a judgment or settlement. As a condition of receiving benefits underthis Plan, the Covered Person agrees that acceptance of benefits is constructive notice of this provision in its entirety and agrees to reimburse the Plan for 100% of the benefits provided without reduction for attorney's fees, costs, comparative negligence, limits of collectability or responsibility, or otherwise. If the Covered Person retains an attorney, then the Covered Person agrees to only retain one who will not assert any common law doctrines that would reduce the Plan's right of recovery, such as the common fund or made-whole doctrines (as such doctrines are defined by the applicable jurisdiction). Reimbursement shall be made immediately upon collection of any sum(s) recovered regardless of its legal, financial, or other sufficiency. If the injured person is a minor, any amount recovered by the minor, the minor's trustee, guardian, parent, or other representative, shall be subject to this provision regardless of whether the minor's representative has access or control of any recovery funds. This Plan will be subrogated to all claims, demands, actions and right of recovery against any entity including, but not limited to, third parties and insurance companies and carriers (including the Participant's or Dependent's Insurer) to the fullest extent permitted by law in the appropriatejurisdiction. The amount of such subrogation will equal the total amount paid under this Plan arising out of the Injury or Illness for which the Participant or Dependent (or the Participant's or Dependent's guardian or estate) has, may have or asserts a cause of action. In addition, this Plan will be subrogated for attorney's fees incurred in enforcing its subrogation rights under this Section. The Participant or Dependent on behalf of himself (or his guardian or estate) specifically agrees not to do anything to prejudice this Plan's rights to reimbursement or subrogation. In addition, the Participant or Dependent on behalf of himself (or his guardian or estate) agrees to cooperate fully with the Plan and Plan Administrator in asserting and protecting the Plan's subrogation rights. 58 SUBROGATION, REIMBURSEMENT, AND THIRD PARTY RECOVERY PROVISION (Cont'd) ~""', The Covered Person, on behalf of himself and each beneficiary of a payment made on the Covered Person's behalf, by accepting benefits under this Plan, agrees (1) to sign any documents requested by the Plan including, but not limited to, reimbursement and/or subrogation agreements as the Plan or its agent(s) may request; (2) to furnish any other information as may be requested by the Plan or its agent(s), (3) that this Plan shall first be promptly reimbursed for any payments made to or on the Covered Participant's behalf under the Plan out of any monies recovered as a result of any lawsuit, judgment, order, award, settlement, compromise, arbitration or other arrangement (regardless of whether or not there has been full recovery or such sums are allocated to any particular type of loss, damage or expense), and (4) to include all benefits paid or payable under the Plan in any liability or other claim against a third party. Failure or refusal to execute such agreements or furnish information does not preclude the Plan from exercising its right to subrogation or obtaining full reimbursement. Any settlement or recovery received shall first be deemed for reimbursement of expenses paid by the Plan. Any excess after 100% reimbursement of the Plan may be divided up between the Covered Person and their attorney, if applicable. The Covered Person agrees to take no action that in any way prejudices the rights of the Plan. If it becomes necessary for the Plan to enforce this provision by initiating any action against the Covered Person, then the Covered Person agrees to pay the Plan's attorney's fees and costs associated with the action regardless of the action's outcome. The Plan Sponsor has the authority to interpret, construe and construct all of the terms and provisions of the Plan in its discretion, and reserves the right to make any changes or determinations, including factual determinations, that it deems necessary or appropriate, including without limitation, reconciling any inconsistency, resolving any conflict and supplying any omission. If the Covered Person takes no action to recover money from any source, then the Covered Person agrees, by accepting any benefits from the Plan, to allow the Plan Administrator to initiate its own direct action for subrogation or reimbursement on behalf of the Plan. ~'' Finally, the Participant or Dependent on behalf of himself (or his guardian or estate) specifically agrees to notify the Plan Administrator, in writing, whenever benefits are paid underthis Plan that arise out of any Injury or Illness that provides or may provide the Plan subrogation rights underthis Section within thirty (30) days of the date that the Injury or Illness arises. Failure to comply with the requirements of this Section by the Participant or Dependent (or his estate or guardian) may, at the Plan Administrator's discretion, result in a forfeiture of benefits under this Plan. The Plan administrator, on behalf of the Plan, shall have a first and primary lien against the proceeds of any settlement, award orjudgment that results from a claim, lawsuit, or other action by or on behalf of a Covered Person for whom benefits were paid under the Plan. Notice of the lien is sufficient to establish the Plan's lien against the third party or insurance carrier. The Plan Administrator shall be entitled to (1) deduct the amount of the lien from any future claims payable to or on behalf of the Covered Person if the lien is not promptly repaid or otherwise promptly recovered by the Plan Administrator, or the Covered Person or other claimant fails to promptly notify the Plan Administratorof apayment received from a third party or insurance carrierthat is subject to the Plan's rights, and (2) to otherwise take any action that the Plan Administrator deems necessary or appropriate, in its discretion, to enforce the Plan's subrogation rights and its reimbursement rights to the full extent possible. 59 CONTINUATION OF COVERAGE Federal law gives certain persons the right to continue their health care benefits beyond the date that they might otherwise terminate. The entire cost (plus a reasonable administration fee) must be paid by the continuing person. Coverage will end if the covered individual fails to make timely payment of contributions or premiums (within a maximum of forty-five (45) days during initial premium/contribution and thirty (30) days thereafter). Failure to do so will result in claims being denied. This law is referred to as "COBRA",which stands for the Consolidated Omnibus Budget Reconciliation Act of 1985. Generally, COBRA applies to employers with twenty (20) or more full/or part-time Employees. Employees should check with their Employers to see if COBRA applies to them. BENEFITS AFFECTED BY COBRA There are two (2) categories of benefits that may be continued under COBRA. 1. "Core benefits" are Medical Benefits. Any COBRA continuance option must include core benefits for which the person was covered just prior to the COBRA "qualifying event" (an event which qualifies a person for continued coverage under COBRA). 2. "Non-core benefits" include Dental Benefits, Vision Care Benefits and Flexible Spending Accounts under Section 125 (Cafeteria-type) plans. If the "qualified beneficiary" (a person eligible for COBRA continuance) was covered by these non-core benefits prior to termination, the individual may, but is not required to, continue them under COBRA. Which non-core benefits, if any, are to be continued will be indicated by the qualified beneficiary at the time of COBRA enrollment. Life insurance, accidental death and dismemberment benefits and weekly income or long term disability benefits (if a part of the Employer's plan) are not considered for continuance under COBRA. MAXIMUM TIME PERIODS -Continuation will be available for a qualified beneficiary up to the maximum time period shown in item (1 ), (2) or (3) below. Combined qualifying events will not continue a beneficiary's coverage for more than thirty-six (36) months beyond the date of the original qualifying event, or when the qualifying event is "entitlement to Medicare", the thirty-six (36) month continuation period is measured from the date of Medicare entitlement. Up to eighteen (18) months for an Employee and his covered Dependent(s) when coverage terminates due to reduction of hours worked, or termination of employment for reasons other than gross misconduct. Note: An individual who is disabled and his covered Dependent(s) may have COBRA coverage extended (and an extra fee charged) from eighteen (18) months to twenty-nine (29) months, furthermore, even if the disabled individual is a covered minor Dependent, his entire Family can extend their COBRA coverage for an additional eleven (11) months provided that: a. The individual is determined as being disabled for Social Security purposes and the disability occurs at any time during the first sixty (60) days of COBRA coverage. b. The individual notifies the Plan Administrator within sixty (60) days of the Social Security Administration's determination of disability and within the original eighteen (18) month COBRA period which applies to the person. 60 CONTINUATION OF COVERAGE (Cont'd) 2. Up to thirty-six (36) months for: a. A covered child who ceases to be an eligible Dependent; b. A covered Dependent of a deceased Employee; c. A former covered Spouse whose coverage ceases due to divorce or legal separation; or d. A covered Dependent when the Employee's coverage ceases due to eligibility for Medicare. 3. There is a special continuation period for Retired Employees and their Dependents when the Employer declares bankruptcy under Title 11 of the United States Code and the Retired Employees and their Dependents lose substantial coverage within one year before or after the date the bankruptcy proceedings commenced. Coverage will be continued for each person until the date of that person's death. However, the surviving Spouse or children of a deceased Retired Employee may continue coverage for up to a maximum of thirty-six (36) months following the Retired Employee's death. For this item 3, coverage does not terminate when the person becomes eligible for Medicare. Continued coverage may also cease before the end of the maximum period on the earliest of: 1. The date that the Employer ceases to provide a group health plan to any Employee; or The date that the qualified beneficiary first becomes, after the date of election, (a) covered under any other group health plan (as an Employee or otherwise), or (b) entitled to benefits under Medicare (except as stated in item 3 above). However, a qualified beneficiary who becomes covered under a group health plan which has aPre-Existing Conditions limit must be allowed to continue COBRA coverage for the length of aPre-Existing Condition or to the COBRA maximum time period, if less. Effective January 1, 1997 the COBRA law has been amended which provides that if a person has COBRA coverage and becomes covered under another plan that has aPre-Existing Condition provision that is offset by prior coverage credits, then COBRA coverage can be terminated because the person is covered under another group plan and has satisfied the Pre-Existing Condition provision with prior coverage credits. NOTICE REQUIREMENTS When coverage terminates due to an Employee's death, termination or eligibility for Medicare, the Employer has thirty (30) days in which to notify the Plan Administrator of the qualifying event. When coverage terminates due to divorce, legal separation or change of Dependent status, the qualified beneficiary has sixty (60) days from the qualifying event or from the date coverage terminates in which to notify the Ptan Administrator that the qualifying event has occurred. Complete instructions on how to elect continuation will be provided by the Plan Administrator within fourteen (14) days of receiving notice of the qualifying event. Covered Persons then have sixty (60) days in which to elect continuation. The sixty (60) day period is measured from the later of the date coverage terminates or the date notice of the right to continue is sent. If continuation is not elected in that sixty (60) day period, then the right to elect continuation ceases. 61 CONTINUATION OF COVERAGE (Cont'd) ~'` PERSONS ON USERRA LEAVE -Any Participant who is absent from active employment on a USERRA Leave (and any covered Dependent of such Participant) may elect to continue coverage under this Plan for up to twenty-four (24) months. If the Covered Person elected to continue coverage under USERRA before December 10, 2004, the maximum period for continuing coverage is eighteen (18) months. To continue coverage, the Participant must comply with the terms of the Plan, and pay any required contributions. USERRA also requires, regardless of whether continuation of coverage was elected, that coverage be reinstated immediately upon return to employment, so long as the Covered Person complies with the requirements set forth under USERRA. The cost of continuing coverage will be: For leaves of thirty (30) days or less, the same as the contribution required from similarly situated Participants; For leaves of thirty-one (31) days or more, up to 102% of the contribution required from similarly situated Participants and the Participating Employer. Note: For complete information regarding your rights under USERRA, contact your Participating Employer. 62 GENERAL PROVISIONS EXAMINATION -The Company shall have the right and opportunity to have the Covered Person examined whose Injury or Illness is the basis of a claim hereunder when and so often as it may reasonably require during pendency of claim hereunder. PAYMENT OFCLAIMS -All Plan benefits are payable to the Participant, or subject to any written direction of the Participant. All or a portion of any indemnities provided by the Plan on account of Hospital, nursing, medical or surgical services may, at the Participant's option and unless the Participant requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the Hospital or person rendering such services; however, if any such benefit remains unpaid at the death of the Participant or if the Participant is a minor or is, in the opinion of the Company, legally incapable of giving a valid receipt and discharge for any payment, the Company may, at its option, pay such benefits to any one or more of the following relatives of the Participant: wife, husband, mother, father, child, or children, brother or brothers, sister or sisters. Any payment so made will constitute a complete discharge of the Company's obligation to the extent of such payment and the Company will not be required to see the application of the money so paid. RIGHTS OFRECOVERY -Whenever payments have been made by the Company with respect to allowable expenses in excess of the maximum amount of payment necessary to satisfy the intent of this Plan, the Company shall have the right, exercisable alone and in its sole discretion, to recover such excess payments. FREE CHOICE OFPHYSICIAN -The Covered Person or Covered Dependents shall have free choice of any legally qualified Physician or surgeon and the Physician-patient relationship shall be maintained. WORKERS' COMPENSATION NOT AFFECTED -This Plan does not take the place of, and does not affect any requirement for coverage by Workers' Compensation Insurance. CONFORMITY WITH LAW - If any provision of this Plan is contrary to any law to which it is subject, including but not limited to ERISA or HIPAA, such provision is hereby amended to conform thereto. STATEMENTS - In the absence of fraud, all statements made by a Covered Person will be deemed representations and not warranties. No such representations will void the Plan benefits or be used in defense to a claim hereunder unless a copy of the instrument containing such representation is or has been furnished to such Covered Person. MISCELLANEOUS -Section titles are for conveniences of reference only, and are not to be considered in interpreting this Plan. No failure to enforce any provision of this Plan shall affect the right thereafter to enforce such provision, nor shall such failure affect its right to enforce any other provision of this Plan. 63 GENERAL PROVISIONS (Cont'd) {`~""' PLAN ADMINISTRATOR'S DUTY TO ISSUE CERTIFICATES OF CREDITABLE COVERAGE - The Plan Administrator shall issue certificates of Creditable Coverage to a Covered Person whose coverage terminates (and to such individuals upon their written request within twenty-four (24) months of the date of coverage termination). In addition, a Certificate of Coverage will be provided upon request at any time while the individual is covered under a plan. A plan is required to use reasonable efforts to determine any information needed for a certificate relating to dependent coverage. In any case in which an automatic certificate is required to be furnished with respect to a Dependent, no individual certificate is required to be furnished until the plan knows (or making reasonable efforts should know) of the Dependent's cessation of coverage under the plan. A certificate may provide information with respect to both a Participant and the Participant's Dependents if the information is identical for each individual. If the information is not identical, certificates may be provided on one form if the form provides all the required information for each individual and separately states the information that is not identical. All certificates of Creditable Coverage that must be issued as the result of the occurrence of a Qualifying Event as such term is defined in the section of this Plan entitled "Continuation of Coverage" shall be issued to the Covered Participant no later than the time the Plan Administrator provides the notice of COBRA to the Qualified Beneficiary under the section of this Plan entitled "Continuation of Coverage." All certificates of Creditable Coverage that must be issued upon termination of coverage (including termination of COBRA coverage) when no COBRA Qualifying Event has occurred at such time, shall be issued by the Plan Administrator as soon as possible after the coverage has terminated. The Plan Administrator shall respond in a reasonably prompt manner to any request for certification of Creditable Coverage by categories of coverage and may charge the party requesting such certification by categories of coverage a reasonable amount for the preparation of such certification. PLAN ADMINISTRATOR'S DUTY TO ISSUE NOTICES UNDER THE WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998 -The Plan Administrator shall provide each eligible employee a notice at ~"'" enrollment and to each covered employee and covered dependent annually thereafter describing the Plan's benefits for a person who has a mastectomy with respect to: 1. Reconstruction of the breast on which the mastectomy was performed; 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prosthesis and physical complications in all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the patient. NOTICE OF ENROLLMENT RIGHTS If an Employee declines enrollment for himself or his Dependents (including his spouse) because of other health insurance coverage, he may in the future be able to enroll himself or his Dependents in this Plan, provided that he request enrollment within thirty (30) days after the other coverage ends. In addition, if an Employee has a new Dependent as a result of marriage, birth, adoption, or placement for adoption, the Employee may be able to enroll himself and his Dependents, provided that he requests enrollment within thirty (30) days after the marriage, birth, adoption or placement for adoption. 64 ASSIGNMENT OF BENEFITS ~,r Benefits for medical expenses covered under this Plan may be assigned by a Covered Person to the provider; however, if those benefits are paid directly to the Employee, the Plan shall be deemed to have fulfilled its obligations with respect to such benefits. The Plan will not be responsible for determining whether any such assignment is valid. Payment of benefits which have been assigned will be made directly to the assignee unless a written request not to honor the assignment, signed by the Participant and the assignee, has been received before the proof of loss is submitted. 65 ERISA RIGHTS ERISA RIGHTS -Each Participant in this Plan is entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Participants shall be entitled to: 1. Examine without charge, at the Plan Administrator's office, all Plan documents, including insurance contracts and Plan descriptions. 2. Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator. The Administrator may make a reasonable charge for the copies. 3. Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish each Participant with a copy of this Summary Financial Report. In addition to creating rights for Plan Participants, ERISA imposes obligations upon the people who are responsible for the operation of the Employee Benefit Plan. The people who operate the Plan, called "Fiduciaries" of the Plan, have a duty to do so prudently and in the interest of the Plan Participants and beneficiaries. No one, including the Participant's employer or any other person, may fire the Participant or otherwise discriminate against the Participant in any way to prevent the Participant from obtaining a benefit from the Plan or exercising his rights under ERISA. If a Participant has any questions about the Plan, he should contact the Plan Administrator. If a Participant has any questions about his rights under ERISA, HIPAA or other applicable law, you should contact the nearest office of The Employee Benefits Security Administration (EBSA), U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquires, Pension and Welfare Benefit Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. RIGHTS OF PLAN - If medical benefits are paid on behalf of an Employee and/or Dependent and it is later determined that the Employee and/or Dependent was not eligible for these benefits, the Employee and/or Dependent shall immediately reimburse the Plan for such over-payment. ~r 66 ADMINISTRATIVE INFORMATION NAME OF PLAN: SPONSORING EMPLOYER ADDRESS: SPONSOR'S EMPLOYER IDENTIFICATION NUMBER: SPONSOR'S TELEPHONE NUMBER: PLAN ADMINISTRATOR: ADDRESS: ADMINISTRATOR'S TELEPHONE NUMBER: AGENT FOR SERVICE OF LEGAL PROCESS: TYPE OF ADMINISTRATION: PLAN NUMBER: PLAN YEAR: PLAN SUPERVISOR'S ADDRESS: Health Benefits Plan for the Employees of ABC Company 12-3456789 ABC Company The Plan Administrator at the address above. Contract administration. The Plan is administered by a third party administrator. 501 A Calendar Year ending December 31 Insurance Management Services P.O. Box 15688 Amarillo, Texas 79105 www.irnstpa.com PLAN SUPERVISOR'S TELEPHONE NUMBER: (806) 373-5944 or (800) 687-5944 67 Don'tThinkA ,flexible Spending Account is Right For You? ~~{~HK Yes, it's that time of year again, and a Health Care Flexible Spending Account (FSA) is being offered as part of your benefits program. Access to your FSA will be as easy as a swipe of a Card. So, if you haven't considered an FSA in the past, it's time to take another look. There are several new features! Participation in an FSA makes sense. Let's face it, you work hard for your money ^nd want to keep as much of it as you can. when participating in an FSA, your annual Tontribution amount is deducted from your paycheck pre-tax (before federal income, state income - in most cases -and Social Security taxes are deducted), each pay period, in equal installments throughout the year. You then have those tax-free dollars to pay for health-related, out-of-pocket costs not covered by your insurance for you, your spouse and dependents -- things like co-pays, deductibles, dental and vision expenses. So, every dollar you set aside saves you on taxes and increases your spendable income. You may say, "I'm healthy. I don't get sick," or, "I hardly ever go to the doctor." We hope that's true. But what about all the other health care expenses "healthy" people have? The occasional prescription, dental work or new glasses? Not to mention eligible over-the-counter (OTC) items. Even if you think your expenses may be just a couple hundred dollars, you'll be surprised at how much an FSA can help! r '~ EVOLUTION The easiest way to access your FSA is in the Cards! Now that you see the benefits of signing up for an FSA, there's also a feature that makes your FSA easy to access -Benny'" Your Card for Better Benefits. Benny" is a special benefits debit card that contains the value of your annual FSA election amount, letting you use the Card to pay for qualified health care expenses such as: • Covered prescription co-pays and deductibles • Health plan deductibles • Doctor and emergency room co-pays • Orthodontics • Lasik surgery and eyeglasses • Coinsurance • Out-of-pocket dentist or other provider fees • Patient due balances • Mail service and online prescriptions co-pays and deductibles • And more! Simply swipe Benny'" each time you incur a qualified health care expense at locations that accept MasterCard or Visa, and the amount of your purchase will be deducted from your FSA -automatically. It's that easy! By using Benny'", you no longer need to pay up front, file claims and wait for reimbursement. You simply save your receipts in case you need them to verify an expense later. With BennyT", your FSA is: Cash flow friendly -You don't have to use cash at the time of purchase. Easy - A simple swipe of the Card makes it hassle-free! Convenient-There are no forms to fill out. Automatic -Funds are immediately deducted from your FSA at the time you incur the expense. Simple to track -Your current balance is available 24/7 online. If you have participated in an FSA in the past, perhaps now is the time to increase your contributions. If you're not currently participating in a health care FSA, How's the time to enroll. An FSA is a valuable benefit -and Benny'" can make it even better! Sign up today, and let the savings begin! Look for additional information about the Benny'" Benefits Debit Card in your enrollment materials. The average family of four in the U. S. can expect to pay close to $1,bQQ on expenses like office visits, prescription co-pays, dental work and new glasses - or an unexpected hospital stay. And, if that $9,600 were put into an FSA, the family could save over $400. Benny" can be a Debit MasterCard" Card or a Debit Visa"` Card 02005 Evolution Benefits, Inc. Use Your Health Care Flexible `" Spending Accounts (FBAs) Wisely... Take a look at the many ways your FSA can work for you. Know Your FSA Eligible and Ineligible Expenses The FSA is an IRS-sanctioned benefit, meaning you can use pre-tax dollars to cover eligible expenses. The IRS defines eligible health care expenses as amounts paid for the diagnosis, cure, mitigation or treatment of a disease, and for treatments affecting any part or function of the body. The expenses must be primarily to alleviate a physical or mental defect or illness. To help you better understand what is and isn't eligible, we've developed a list of both. This list is not meant to be all-inclusive. Other expenses not specifically mentioned may also qualify (for additional information, please visit www.EvolutionBenefits.com). Dental Services Dental X-Rays Dentures Exams/Teeth Cleaning ., Extractions Fillings Gum Treatment Oral Surgery <, Orthodontia/Braces Lab Exams/Tests Blood Tests X-Rays Cardiographs Laboratory Fees ;_; Metabolism Tests Spinal Fluid Tests Urine/Stool Analyses Vision Services Eye Examinations Eyeglasses Contact Lenses Laser Eye Surgeries Artificial Eyes Prescription Sunglasses Radial Keratotomy/LASIK Medical Treatments/ Procedures Acupuncture Alcoholism (inpatient treatment) Drug Addiction Hearing Exams Hospital Services Infertility In Vitro Fertilization Norplant Insertion or Removal Physical Exam (not employment related) Physical Therapy Reconstructive Surgery (if medically necessary due to congenital defect or accident) Rolling Speech Therapy Sterilization Transplants (including organ donor) VaccinationsJlmmunizations Vasectomy and Vasectomy Reversal Weight Loss Programs (as prescribed by your doctor) Well Baby Care Medical Equipment Supplies and Services - Abdominal/Back Supports Ambulance Services Arches/Orthopedic Shoes Contraceptive, prescribed Counseling Crutches Guide Dog (for visually/ hearing impaired) Hearing Devices and Batteries Hospital Bed ~. Lead Paint Removal (if not capital expense and incurred for a child poisoned) Learning Disability (special school/teacher) :; Medic Alert Bracelet or Necklace _~- Oxygen Equipment Prescribed Medical and Exercise Equipment Prosthesis Splints/Casts or Support Hose (if medically necessary) Syringes Transportation Expenses (essential to medical care) Tuition Fee at Special School for Disabled Child Weight Loss Drugs (to treat specific disease) Wheelchair Wigs (hair loss due to disease) Medication Insulin Prescribed Birth Control and Vitamins Prescription Drugs Obstetric Services . Lamaze Class Midwife Expenses OB/GYN Exams OB/GYN Prepaid Maternity Fees (reimbursable after date of birth) Pre and Postnatal Treatments Practitioners Allergist Chiropractor Christian Science Dermatologist Homeopath Naturopath Osteopath Physician Psychiatrist Psychologist EVOLUTIOfv Eligible Expenses -Over-The-Counter Items Use Your Health Care Flexible Spending Accounts (FBAs) Wisely... This document Is confidential to Evolution Benefits, Inc. and may not be used, copied or disclosed except with express prior written consent of Evolution Benefits, Inc. ©Copyrigh[ Evolution Benefits, Inc. 2005 -All rights reserved. EvawTlaly In September 2003, the IRS added certain over-the-counter (OTC) medicines to the list of products eligible for coverage under FSA programs (see IRS Revenue Ruling 2003-102). These OTC products are reimbursable if they are used to alleviate or treat personal injuries, sickness and current illness, but not when used for general health purposes. You should note that, although the IRS sets the general rules for FSA programs, individual employers have the final determination of which expenses are covered and how OTC purchases can be made in the FSA program they offer. In most cases, receipts may be required to validate the purchase. . . ~ ~ • Acne Preparations Allergy and Sinus Medications (Antihistamines, Claritin, Asthma Flow Meters and Nebulizers, Primatene Mist, Nasal Spray and Strips) Baby Care (Petroleum Jelly, Diaper Rash Ointment, Thermometers, Pediatric Electrolyte Solutions) Cough, Cold and Flu Medications (Syrups, Capsules, Rubs, Drops) Condoms and Contraceptive Devices Diabetes Care/Accessories (Blood Test Strips, Glucose Tester, Glucose Food, Monitors and Kits) Digestive Aids (Antacids, Laxatives, Lactose Intolerance Medications) Eye Care (Contact Lens Solution, Eye Drops, Reading Glasses) First Aid Products (Antibiotics, Analgesics and Ointments, Bug Bite and Anti-itch Medications, Sunburn Cream, Bandages, Gauze, Pads and Elastic Bandages, Rubbing Alcohol, Wart Removal Products, Supports and Braces, First Aid Kits, Wound Care Products, Tape and Gloves) Foot Care (Cushions, Pads, Creams, Anti-fungal Medications) Health Monitors and Medical Equipment (Blood Pressure and Heart Rate Monitors, Crutches, Medical Bracelets, Cholesterol Tests) Hemorrhoid Treatments Homeopathic Medicines Incontinence Supplies Lice and Scabies Treatments Nausea and Motion Sickness Medications Pain and Fever Reduces (Aspirin, Acetaminophen, Ibuprofen, Menstrual Cycle and Migraine Medications, Muscle/Joint Pain Relief Creams and Balms, Heating Pads) Pregnancy Products (Ovulation Monitor, Pregnancy Testing Kits, Prenatal Vitamins) Smoking Cessation Products (Nicotine Patches, Gum and Lozenges, Inhalers) Toothache and Teething Pain Relievers Weight Loss Drugs (to treat a specific medical condition) Check your plan document or Plan Administrator's web site for more information. Expenses to promote general health are not eligible expenses unless prescribed by a physician for a specific medical ailment. This list is not meant to be all-inclusive. Please visit www. EvolutionBenefits. com for more information. The IRS does not allow the following expenses to be reimbursed under FSAs: Baby-sitting and Child Care Contact Lens or Eyeglass Insurance Cosmetic Surgery/Procedures Dancing/Exercise/Fitness Programs Diaper Service Electrolysis Personal Trainers or Exercise Equipment w Hair Loss Medication Hair Transplant Health Club Dues :z Insurance Premiums and Interest Long Term Care Premiums Marriage Counseling Maternity Clothes Vitamins or Nutritional Supplements ~~ Swimming Lessons Teeth Whitening/Bleaching ~ ~ ~ Visit us at www.EvolutionBenefits.com or call 1-866-88-BENNY and press 1 for more information. ,., iry~ { ~ ... . BennyM can be a Debit MasterCard"' Card or a Dcbit Visaa Card. ,,>,, EB CHCO10 040605 Use your card at Walgreens for FSA-eligible products including: • Prescriptions • OTC Allergy & Digestive Medications • Non-prescription Aspirin • Contact Lens Solution • Diabetes Test Strips • Asthma Mist • Smoking Cessation Aids • Blood Pressure Monitors • Hydrogen Peroxide • Antibiotic Ointments This list is just a few of the commonly covered items. Consul[ your Summary Plan Description for details. Paperless FSA Capability for Prescriptions and OTC Purchases What could be easier than taking full advantage of pre-tax savings with the convenience of a card? Prescriptions and OTC shopping with virtually no request for receipts from your administrator! We are pleased to announce that effective 1/1/06, you will be able to use the Benny benefits debit card (or other Benny-powered card), to purchase both prescriptions and FSA-eligible over-the-counter (OTC) products at Walgreens without needing to provide receipts to verify the eligibility of most purchases. This capability is offered by Evolution Benefits and Walgreens to make it easier for you to take advantage of pre-tax savings on health-related products. Here's How it Works 1. The participant brings their prescriptions, OTC products and other purchases to the register and the clerk rings up the items. 2. The participant presents their Benny® benefits debit card and swipes it for payment at the counter. 3 If the card swipe transaction is approved (e.g., there are sufficient funds in the account, etc.), the amount of the FSA-eligible purchases is deducted from the participant's account balance and no receipt follow-up is required. The clerk will then ask for another form of payment for the non-FSA-eligible items. 4. If the card swipe transaction is declined, the clerk will ask for another form of payment for the total amount of the purchase. 5. The Walgreens receipt will identify the FSA-eligible items with an "F" and also provide a subtotal of the FSA-eligible purchases and the sales tax paid. 3:08 D!I Start shopping NOW. What could be easier? r ~' For more information, call your administrator at the number on the back of your Card. EVOLUTION ~~~~/L~fL1. CC-036 1 ~ 0205 ~~~~ I's Bill S_ EaanY you !or allwixiq xe to seav you toddy. s17 l0 1435 dodos ooi RFN/ 0123-4sti7-8901-234s-6769 F TYL~iOL lA 3.99 CRaL7t=RS 1 .89 F WALFfIID lA 2.99 sUBTOrAL 7.97 A•51 SALfS rAX .39 rtrrAL s.zs ~1 ACCT1wRf xw rfw wY~a{ CAiDIT CARD 7.37 CASH .69 CHAHGY .00 TOTAL 1511 ITBP~: 6.98 TOTAL F6A ITEl'B TAX: .39 ~~I~~~~~~~~~~~~~~~~~II~~~~~~~~I~~~~~~~~~~~~~~~II~ sss nih st, D•.rli.la, n ~~~~~~~~~~~~~~~~ STORS: [3331 s55-1212 F~FLZXIBLS srmmID1G ACCOtBR ITIH (FSA) Tw,xc Yov FOR FASTBR SEIKZCi, [:ALL 7A( YOUR OR DLAICi I2 O!i HOIIR$ IB ADVAIiCt Did You Know? FSA Eligible Products • OTC Allergy & Digestive Medications • Saline Mists • Diaper Rash Ointments • Diabetes Test Strips • Asthma Mist ``r • Smoking Cessation Aids • Contact Lens Solutions • Blood Pressure Monitors • Hydrogen Peroxide • Antibiotic Ointments This list is just a few of the commonly covered items. Consul[ your Summary Plan Description for details. r New 100% Paperless OTC Purchase Capability You can now use your Benny'" Card to purchase over-the-counter (OTC) products eligible under Flexible Spending Accounts (FBAs), through a new partnership between Evolution Benefits and drugstore.com, the top online retailer for health and wellness products. Shopping Online - Here's How it Works • Login to your administrator's Web site and click on BennyBuys where you'll access drugstore.com. • Click on FSA Store at the bottom of the page and you'll see drugstore.com icons identifying the more than 2,100 OTCs typically eligible for FSA reimbursement. • As you select the products you wish to buy, they'll automatically be separated into eligible and non-eligible "shopping baskets". dru store g~ - m,aK~. em.r p,.,,.d ..,i a. w,a home SALF yhnmttr ~y~~ •rpq -y 6nC houuhoM u' ry40mm dt --- PrYS..c OTC Ik10 RMIiRr,DY~.C~IYMw TaYIMSU.. 4dOfr{ r.., s.. ~ s, s5 „~~ ~s...a.,,.-m a ~ ~~„~ y0.~^^~ ------------------~ ~~~~ ~ ~~ ~o Special Savings For • Upon checkout, eligible items are automatically deducted from your Benny"" Card and you'll be asked for an alternative payment method to pay for items that don't qualify for pre-tax reimbursement. drugstore.com -OTC Shopping with NO paperwork hass/e! • 3 times the selection of typical drugstores • Over 5 million customers since 1999 • Featured product savings • Everyday low prices. • FREE 3-Day Shipping on orders of $49 or more For more information about this new feature, call the number on the back of your Card. 1 BennyTM Cardholders ~ 1 I Introductory Offer ~ I I For a limited time, get ~ 10% off any purchase on drugstore.com. I I 1 ~ Receive 10% off your initial order. ~ I Logon to www.drugstore.com/benny ~ I I Offer expires 1/31/06. ~ I Cardholders also I Earn 5% Of Purchase I I I in drugstore.com dollars ~ ~ : ~; r . ~ ~ w- F ~~ ~ - _L .I ~ , ,~ ,,~ Start saving today. ' ~ ~ ~ :• :• EVOLUTION drugstore=to PD-003A 100705 E 1~~ rte, . Great Prices & Assortment: Acuvue, Freshlook, Focus Dailies, and many more. Vision Direct carries major brands at incredible prices -guaranteed. They'll even meet or beat any reputable online competitor's price. Easy Ordering Ordering is easy. Simply locate your contact lenses by clicking on the ~ manufacturer or the lens type, enter your prescription details, and follow the prompts. Money-back Guarantee If you aren't satisfied with your lenses, return them within 30 days of receipt in the original containers to Vision Direct for a full refund. *Refunds exclude shipping and handling charges. ." Start saving today. Log on to www.VisionDirect.com and see for yourself. i New 100% Paperless Contact Lens Purchase Capability! We are happy to announce that Benny"" and VisionDirect.com, the leading global supplier of replacement contact lenses, have teamed up to create the first-of-its-kind 100 percent paperless system for purchasing contact lens eligible under your flexible spending accounts (FBAs). - This unique partnership offers you the world's largest - .. selection of contact lenses -all at guaranteed ~ ~~ ` low prices, making it even easier for you to ` ~~ '~~~ '' ~, DAIL~S'~ .,~ manage your health care needs. ~ ~ F, ,~~,.~,~,E~ ~ Benny Goes Shopping Online - Here's How it Works • Log onto your administrator's Web site and click on the BennyBuys.com link where you will be able to access the VisionDirect.com site. ...,~,AC - k: ,~., w.. ~ cuvu£ :,,.u FM"~ FRI es ~, Mi4N1' Wi j." ; ~ ~ • You will be prompted to set up an account and enter your Benny"" or Benny-powered FSA Card number as the form of payment. Once you have saved your FSA debit card information, VisionDirect.com wi[I automatically identify this Card as an FSA card. This will allow you to purchase only FSA eligible items when checking out. However, the system does allow you to enter alternative payment methods for items not qualifying for tax-advantaged reimbursement. Upon check out, eligible items are deducted from your benefit debit card. And that's it! i Special Savings For ~ BennyTM Cardholders i Introductory Offer ~ For a limited time, get ~ 1 ~ 110% off any purchase on VisionDirect.com. ' 1 ~ ~ Enter coupon code FSABENNY and ' 1 ~ ~ make your FSA dollars go further. ~ 1 ~ ~ Logon to www.VisionDirect.com or ~ ~ call 1.800.VisionDirect (847.4663). ~ ~ ' ~ Offer expires 1.31.06 ~ ~ ~ ~ ~ Fast, easy and convenient -Contact Lens shopping with no paperwork hassle. EVOLUTION VisionDirect com o~.M.~~, :,cir~zgs~torP.cAmi. Company Statement Pages 1 Case: SABC123-001 Reporting Period: 0fi/O1/2007-06/01/2008 ABC GROUP Pay Cycle: W ABC LANE Print Date: OS-6ep-2007 ABC TX 79101 Benefit: HEALTH REIMBURSEMENT ACCOUNT Ann, ***** Month •**** •+*+++* Year To Date ••••***+ Pending Unreimb Advan Employee Name Certq Employee ID Elec Cont Reimb Cont Reimb Balance Claims Elec Reimb DOE,SOHN 0002 500.00 0.00 0.00 500.00 0.00 500.00 0.00 500.00 Benefit Totals 500.00 0.00 0.00 500.00 0.00 500.00 0.00 500.00 Total Contributions far Cycle W: 500.00 Total Distributions for Cycle W: 0.00 Account Balance for Cycle W: 500.00 Division Totals 500.00 0.00 0.00 500.00 0.00 500.00 0.00 500.00 0.00 Company Statement Page: 2 Case: SABC123-003 Reporting Periods Db/01/2007-D6/01/2008 AHC GROUP Pay Cycle: W A$C LANE Print date: D5-Sep-2007 ABC TX 79101 Benefit: HEALTH REIMBURSEMENT ACCOUNT Ann. +++++ Month ++**+ `*`•"` Year To Date ++++++++ Pending Unreimb Advan Employee Name CertN Employee ID Elec Cont Reimb Cont Reimb Balance Claims Elec Reimb DOE, JANE 0003 500.00 0.60 0.00 500.00 6.00 500.00 0.00 500.00 Benefit Totals 500.00 0.00 0.60 500.00 0.00 SOO.DO 0.00 500.00 Total Contributions for Cycle W: 500.00 Total Distributions for Cycle W: 0.00 Account Balance for Cycle W: 500.00 Division Totals 500.00 0.00 0.00 500.00 O.OD 500.00 0.00 500.00 0.00 Case Totals 1000.00 0.00 0.00 1000.00 O. DD 1008.00 0.00 1000.00 D.DO AHC C3ROUP Statement of Account For Period Ending 06/01/2007 ID# FYE 06/01/2008 CC# SASC1230002 Div 001 JOHN DOE Code Benefit Description Annual £leek Contributions Payments Balance HRA1 HEALTH REIMBURSEMENT A 500.00 SOD.4D 0.00 590.D0 Totals 500.00 D.DO SDO_DO ABC GROUP Btatement of Account For Period Ending 06/01/2067 IDS{ FYE 06/01/2008 CC# : SABC1236003 Div 003 JANE DOE Code Benefit Deacripticn Annual Elect Contributions Payments Balance HRA1 HEALTH REIMBURSEMENT A 500.00 500.80 O.DD 500.00 Totals 500.00 0.00 500.00 INSUR~iNCE MANAGEMENT SERVICES REFERENCES CURRENT GROUPS Amarillo ISD Dan Slaughter 7200 I-40 West (g06) 326-1498 Amarillo, TX 79106 Potter County Janie Brown 900 S. Polk, Room 705 (g06) 349-4835 Amarillo, TX 79101 Baptist St. Anthony's Bob Williams 1600 Wallace Blvd. (g06) 212-5200 Hospital Amarillo, TX 79106 or ~® Health M~n~gement Systems 00000 ' ' - to 35% of hoice f°r up atment of c are is the tre • ble SeMf c • , S, now ava~la odor visit • ations are d . on medic rescr~pt~ tin Over g00 p r. 1es resul he counts a reined overt itions~ hom ~ 00 coed are. or more than a as doctor c F e outcom the Sam „~S cr~t;~al noses ct ~~Se~f.d~ag Torre WortdD~~. ~_.} ~,~:~ ~~ ~N,.r - lation ages' s the p°pu increase a will on~Y ~ t should I d° ~Id is sick, wha My chi t? it? ~ lose we1gh do ~ preVent How Gan ~ m family, how racer runs ~n y o they d°~ Breast ca T~, what d ~ ~ es~ ommerc~als on ective medicin see drug c ost cost-efl I Ibuythem it? 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Idedicai Llbrard ~lhntisPaiiants;,'antlnfo Gat rc c~a Oecisian-mal:ino , . ttat;ers 6f Dmo~esl FaVes Silent E~fare ! lS Panol Heal[h Exoress The mordhl, health newsletter horre,revs temppn,,>38cemmonlraticns: ever; krr ~';. ~ ., .. ,,, l~l ,..,. ~..; ~~ WM _._ The filbanng dens need year attention: tneeagee Tne Meat nkaaa4p and eVsaa m your secure matlbax. General health news Pulled from Reuters News Service Surveys Chat Transcripts from Care Navigator Manage favorites Health Forum Group specific Post health related messages for peer comment Health forum ~;1ewthe latest5 posts pelow: WorldD~e ~.,~s,,.~.,em~,:r„~ ®"„;w. <. ® %~ , ®s ~, ® ~. ~,•, ®wr .ve H~. $UN Sa Let us lmow ® ~ houothers m,~ .r Mm.nu WF.. -~~~ „r.,.~M,,,,,~, ~ ~-, ...~,.,rti.o~Tb Fully moderated -~ -~ ~. ,~o.. - - - Email notification of responses to wow ~ J.w+n ' A,rr rn. 'rw+,p~ _. I posts ~; ~.,. ', aa. _.. _aiffa7i"n ~~ '~~'=fiisfNat"` ,.,. n ~' '~• ,:oxxsuJ„ ~, 4d JEVNTe I.rvW~. 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'MU`e '14tH ~t' / health ~ NbrldDae __ ahd Repofl;mNeanFn~Wre +TG.Y~4lln „ r,~ ~ µ . ~ r + n is iie.a „ .~ nlE.~++r~+ m NetlNM'^FeVIJ h .. o " .. +ewMMd UMM±MM ~afM('rt1Wi' ,weinu g Comparison Objective evaluation of hospital quality and costs Side-by-side evidence-based comparisons Results for over 175 specific procedures Individualized report criteria: Patient volume Mortality rate Unfavorable outcomes Time spent at the hospital COSfS WorldD,~c,. mprowng ea a ucmg os s Return on Investment for Personal Evaluation S stem Em to ees 10,000 Beneficiaries 20 000 Cost Model # office visits er uarter er em to ee 1.2 # total OV er uarter 12 000 Value er office visit $ 100 uarterl $ at risk $ 1,200 000 Annual sent on OV $ 4 800 000 PEPM on rima care includes acute meds $ 40 PES Savin s Model World Doc Ado tion Rate 50% # PES visits er uarter er em to ee 0.8 # PES visits er uarter 4,000 of PES visits for sim le roblems 50% # PES visits for sim le roblems 2000 o timized self care 40% resulted in office visits 35% avoided office visits 25% # avoided office visits 500 Value er office visit $ 100 uarterl $ Savin s from avoided office visits $ 50,000 Annual savin s $ 200 000 Annual.. PEPM sauin s 1.67 000000 Self-care is the treatment of choice in 35% of office VISItS. Usage of Personal Evaluation System saves unnecessary office visits for acute care 25% of those who use Personal Evaluation System avoid office visits WorldD~,c, mprov-ng ea a uc-ng os s and modifiable risk factors including diet, exercise, cholesterol levels, smoking history, and body mass index. Cardiovascular Mealth Health Po elation . Unhealth Po u~ation # of Em to ees >35 10000 10000 Avera e a e 45 45 Av 10 ear Risk CV event 3% 6% # annual Heart Attacks 30 60 Cost per Heart Attack $ 50,000 $ 50,000 Total Cost 1 500 000 3 000 flOO O O O O OO WorldD~c~ ... _:...~ from 311j ,,,..~~ Cost Mini% .. _.,~ric lJtilr2a ~IDEPI2E ~~1TORS 12,463 65% ~g68,Rd8 -„'""ate Perch./ OTON 13,933 51°Jo 5Q,9'#9 ~9Q ..---'"' ~'rn~' PR P 1,1~ HY EgZENCS ES 49 912 HYPGGLyCEM ad on3~ day supply quantities• rand and Generic perscripnons ~ bas Gross CostlRxl + l Generic Gross CostlRx) Cost peT B a Monthly Brand verage Month Y Monthly Gross ~ pverag Ratel x A Esn~nated Rates)1 ' ericUtdi2ation Nl' Utilixat Gross CostP~ Generic ~oYprnjected G~ dough 5l3112p02 Projected volume x (1 ' projected ((Claim volume . 3l112~~~ ((Claim of 124,445 from istics based on average m°nthly ehgrbility PMPM scat w r dD~` Inhibitors (Ppfs~ Shift to prilosec ETC end Proton pump rnimization: ~g311l2007 through'~131~a07 Cost M' from _. _...,~Pd Claims Ave More Clair Volttme pPl Imo' xame 2,857 NEXIUM 2,090 PRE~ACID 1,452 pROTONiX 705 ACIPHEX 64 --~'"~ oat~y Brand ,~o~~ndPPl Avert ..Gross Cos~30,?~$, Gross Cost $151 $432,497.30 $148 $309,816.44 $119 $172,846.66 $155 $109,24388 $194 $12,391.12 P 036 795,41 proses ©TC ~r~ 90% ected Shift Rate to Prrlosec a Prof o 70°~Q 50 (o ~arrent pPi Gross Cost PMi'M ~ $1.16 rosr„„CpSt $0.67 $0.48 $028 $0.17 $1.63 4 $0,48 $0,35 $0,21 $0.12 $0,01 i 5"" 9 X0.29 $021 $0.13 $0.07 $0.01 411 $25.00 $0.83 $25.00 $0.46 $25.00 $0.29 $25.00 $0.03 $1 $25 ~ . .- ent Savor s pe+ I,OSEC $1, ' PRl 7.168. supply a°antities• ric erscriptions is based on 30 day Gene p Gross Cost per Brand and Gross Cosh) + Estimate prioathty e Monthly Brand Gross Cost(Rx) x Averag e Ivlonthiy Generic anon Rates)} verag ected Gross Cost PMPM ected Generic Utrl~ tion Rate) x A Proj ~rolume x C1 _ P volume x proSected Generic Utiliza h 513112007 ((Claim (Claim 4 445 firom3f112007 tbroug based on average monthly eligibility of 12 > PMp1\r1 statistics 2 W ao~~ simvastatin Cwt 1,tpitorM ,.,.--r'P~ ~,ted Foss $0.313 itor to Generie Ave Mom PMp $p,365 $0.186 ost M' ' iza Shit3B~~~7 theoagh 513tl20D1 A~ M°~ ~ sunv~atul doss Cost $0.411 $p,211 ro~ro tion: ~,tptior Gro Cos~30 D~ ~' $0,52 $p.248 $0,149 pspensed Claims troro Giaims ~ Graff frost CosU $ 8~ ~ $0,31 $p,125 $0.114 Volume Lr oto $p,101 $0.100 $g,7~ $tg4,149.03 $93 $0,053 $p.05b Elaine 1,941 gg,82 ~~~ ~Z~93'~~ ~• i~ is 1~~ LET $115,136.32 $45 $0.056 l3 19~ao 20MG TAB 1,243 $43 $0.9d ~~4~~g3,69 Sl&,12t-• e L[PITGR G TABLET YMpM tA.3 ~ L1P]TOR 40M $14,420.84 12,{~~/o TAT~20MGTABLET 485 $21,052,10 pollar'~`dn 45834 'ected $351> Pro ent ~aviQ 51MVA5 gpN1GTABLE 4,1G3 ProjeCledYete SIM~ASTA~N • ~ is based an 30 day, supP~ quantities. r grand and Generic perscriptto Cost(Rx1 + Generic Gross CostlRx) Gross Cost pc d Gross e N1ont1rly tedNlonthly verageMontblyBr~' verag Estima ates}l x A t~l>zation Rate) X A Cost PMPM" Utilization R ected Ge~ricV . , ctedGross proyectedG~~laimVolumcxProj Proje Volume x l ~ ough Sf3112pp1 ((C1aim 4 445 gom 31112g01 for based on averagc m°mhly eligibility of 12 , PA,1PNi statistics 3 for dD~~ C f f PBM Name Location Drug Type # Rx Ing Cost AWP Cost AWP Disc PBM 1 Mail Order Brand 227 $67,031.00 $83,459.76 -19.7% Generic 6 $576.69 $1,201.50 -52.0% MAC-Generic 73 $5,954.45 $12,404.07 -52.0% Retail Brand 4,221 $382,581.10 $443,891.17 -13.8% Generic 158 $3,833.71 $7,491.93 -48.8% MAC-Generic 5,498 $107,804.60 $228,412.77 -52.8% PBM 2 Mail Order Brand 57 $16,917.97 $21,676.86 -22.0% Generic 3 $553.67 $1,141.20 -51.5% MAC-Generic 27 $3,031.56 $6,245.48 -51.5% Retail Brand 1,058 $96,969.63 $112,378.99 -13.7% Generic 43 $1,282.15 $2,695.91 -52.4% MAC-Generic 1,634 $38,687.43 $84,756.86 -54.4% PBM 3 Retail ........... Brand 3,890 $356,248.32 $413,123.06 -13.8% Generic 104 $3,779.20 $9,338.32 -59.5% MAC-Generic 2,339 $62,184.49 $121,212.24 -48.7% 4 Member 83 (Mod) NDC Fill Date Complete Drug Name Disp Qty Rx Count Actual Total Cost Est Disp Fee Est Ing Cost AWP Cost AWP Disc MAGCeneric 2,339 66,745.54 $4,561.05 $62,164.49 $121,212.24 -48.7°/ A0020964 49884039877 1/112007 FLUTICASONE PROPIONATE SOMCG SPRAY 16 MAC-Generic $58.15 $1,95 $56.20 $75.20 -25.300/a A0020964 50111043401 111!2007 TRAZODONEHCLl00MGTABLET 30 MAC-Generic $974 $195 $779 $2190 -64.4° A0020983 59762306001 Ill/2007 AZHHROMYCIN250MGTABLET 6 MAC-Generic $36.69 $1.95 $34.74 $46.68 -25,6' A0020962 59762491004 111/2007 SERTRALINB HCL l00MG TABLET 30 MAC-Generic $62.73 $1.95 $60.78 $81.30 -25.2% A0020950 00093101042 117/2007 MUPIROCM2°/OINT.(GM) 22 MAC-Generic $3376 $1.95 $31.81 $42.68 -25.5% A0020892 0009322640] 112/2007 AMOXICILLIN815MGTABLET 20 MAC-Generic $1478 $1.95 $12.83 $1740 -26.3% A0020919 00168007038 LI212007 ERYTHROMYCIN SMGIG OINT.(GM) 3 MAC-Generic $6.00 $1.95 $405 $4.92 -177°/a A002D902 00168020160 112/2007 CLINDAMYCIN PHOSPHATE I%SOLUTION 60 MAC-Generic $1375 $1,95 $11.80 $24.00 -50,8% A0020964 00378180301 11212007 LEVOTHYROXINE SODBJM 50MCG TABLET 30 MAC-Generic $925 $1.95 $7.30 $1020 -28,4% AW20949 00378180501 117/2007 LEVOTHYROXINESODB1M75MCGTABLET 30 MAC-Generic $10 U4 $1.95 $8.09 $1110 -27100/a A002D977 00591033501 1/2/2007 ACYCLOVIR400MG TABLET 124 MAC-Generic $1329 $1.95 $11.34 $26908 -958% A002D891 00406035805 112/2007 HYDROCODONE WIACETAMINOPFIEN 7.S-500MG TABLET 20 MAC-Generic $6.88 $1.95 $4.93 $700 -296°/a A0020891 00406035805 112/2007 HYDROCODONE WIACETAMINOPHEN 7.S-SOOMG TABLET 20 MAC-Generic $6.88 $1.95 $4.93 $700 -296% A0020950 00472016315 1/7/2007 NYSTATINIOOOOOU/GCREAM(GM) 30 MA4Generic $5.50 $1.95 $3.55 $540 -34.3% A0020904 00555083102 117/2007 WARFARIN SODRJM IMG TABLET 30 MAC-Generic $14.83 $195 $12.68 $1740 -26.(P/o A0020904 51672403201 11212007 WARFARINSODNMSMGTABLET 30 MAC-Generic $16.69 $1.95 $14.74 $2010 -26.7% A0020910 00781502207 1I7/20W METHYLPREDNISOLONE4MGTABDSPK 21 MAC-Generic $11.80 $1.95 $985 $10..07 -300°/ A0020941 63300.065705 117/2007 CEPHALEXAI SDOMG CAPSULE 20 MAC-Generic $14.29 $1,95 $12.34 $24.60 -49,8' A0020891 65162057050 117/2007 IBUPROFEN SOOMG TABLET 60 MAC-Generic $11.32 $1.95 $9.37 $1740 -06.1% A0022440 00093083201 11312007 CLONAZEPAM O.SMG TABLET 30 MA4Generic $Z 13 $1.95 $518 $22.50 -770°/a A002D906 00378104901 Ili/2007 DOXEPINHCLIOMGCAPSOLE 100 MAC-Generic $1005 $195 $8.10 $32.00 -74.7% A0020906 00378104901 113/2007 DOXEPINHCLIOMGCAPSULE 60 MAC-Generic $6.70 $1.95 $4.75 $19.20 -75.300/a A0020895 00165070701 113/2007 BISOPROLOL FUMARATE/IICTZ IO-6.25MG TABLET 30 MAC-Generic $2739 $1,95 $25.44 $34.20 -25,6% A0020967 00555087702 1/3/2007 FLUOXETWE HCL 20MG CAPSULE 30 MAC-Generic $1313 $1,95 $11.18 $8010 -860% A0020897 00527144308 11312007 SULPAMFTHOXAZOLEITRIMETHOPRIM800d60MGTABLET 6 MAC-Generic $4.57 $195 $2.62 $540 •51.5% A0020895 00781107705 113/20W ALPRAZOLAA10.SMGTABLET 30 MAC~Generic $6.85 $1.95 $4.90 $25.20 -806% A0020949 49864024303 1/312007 CEFPROZB, SOOMGTABLET 42 MAC-Generic $286.56 $1,95 $284.61 $37968 -25,0°/a A0020906 63304042601 113/20W GLEVIEPIRID82MGTABLET 30 MAC-Generic $16.37 $1.95 $14.42 $]9.50 -26.1% A0020963 63304077401 1/3/2007 LORAZEPAM 2MG TABLET 30 MAC-Generic $2503 $I 95 $2308 $38.40 -39.9' A0020973 59930156001 11312007 ALBUTEROL9DMCGAEROSOL 17 MAC-Generic $1776 $1.95 $1581 $2142 -26.2°/ A0020940 00093066116 114120W ALBUTEROL SULFATE 2MGt5ML SYRUP 50 MAC-Generic $4.15 $1.95 $220 $3.50 -371% A0020973 00258361801 1/412007 BENZONATAT8200MGCAPSULE 30 MAC-Generic $44.62 $1.95 $42.67 $59.40 -28.2°/a 5 Wor1dD~C. ~, (Mod) NDC Fill Date Complete Drug Name Disp Qty Rx Count Actual Total Cost Est Disp Fee Est Ing Cost AV/P Cost AWP Disc Brand 3,890 363,833.82 $7,585.50 $356,248.32 $413,123.06 -13.8% 00173073001 1/112007 WELLBUTRINXL150MGTAB.SR24H 60 Brand $22047 $L95 $218.52 $24120 -9.4% 60575045719 111!2007 TRIKOF-D 600-28-58TAB.SRI2H 30 Brand $18.08 $L95 $16.13 $20.70 -22.1% 00062125115 11112007 ORTHOTRI-CYCLENL07DAYSX3LOTABLET 28 Btand $45.99 $L95 $44.04 $52.36 -15.9% 00074929613 11212007 SYNTHROID112MCGTABLET 30 Stand $1270 $1.95 $15.75 $18,90 -16.7% 00074929613 11212007 SYNTHROID112MCGTABLET 30 Brand $17.70 $L95 $15.75 $18.90 -16.7% 00088222507 11212007 KETEK PAK 400MG TABLET 10 Brand $52.40 $L95 $50.45 $60.00 -15.9% 00173069600 11212007 ADVAIRDISKUS250-SOMCGD6KWIDEV 60 Brand $175.60 $L95 $173.65 $195,00 -10.9% 00173073001 11212007 WELLBU7RINXL150MGTAB.SR24H 30 Brand $111.09 $L95 $109.14 $120.60 -9.5% 00186504031 1Y212007 NEXIlIM4DMGCAPSULEDR 30 Brand $134,31 $L95 $132.36 $158,10 -16.3% 00430057014 11112007 ESTROSTEPFES-7.9.7 TABLET 28 Breed $48.12 $L95 $46.17 $54,88 -15.9% 00555904558 11212007 AVIANE0,1.0.02TABLET 28 Brand $28.07 $L95 $26.12 $35.28 -26.0% 00456045801 11212007 ARMDURTHYROID30MGTABLET 30 Brand $5.38 $1.95 $3.43 $4.50 -23.8% 004300570]4 11212007 ESTROSTEPPES-7.9-7 TABLET 28 Btand $48.12 $L95 $46.17 $54,88 -15.9% 00555904558 11212007 AVIANE01.002TABLET 28 Btand $28.07 $1.95 $26.12 $3528 -26,0% 00456201001 11212007 LEXAPROIOMGTABLET 30 Btand $72.83 $L95 $70.88 $84.30 -15.9% 52544093528 11212007 TRINESSA7DAYSX328TABLET 28 Brand $31.19 $L95 $29.24 $39,20 -25.4° 52544093528 11212007 TR[NE8SA7DAYSX328TABLET 28 Btand $31.19 $L95 $29.24 $39.20 -254° 52544093628 11212007 NECON 7 DAYS X 3 TABLET 28 Btand $25.85 $1.95 $23.90 $3220 -25.8% 00603749539 11212007 ZOLENEHC 10.10-]ItvII.DROPS l0 Breed $15.35 $L95 $13.40 $18.20 -264% 50419040203 11212007 YASMW 28 Q03-3MG TABLET 28 Brand $43.90 $1.95 $41.95 $49.84 -L5,8% 10922062502 0212007 FINACEAIS%GEL 50 Brand $92.20 $L95 $90.25 $107.00 -15,7% 49502050001 11212007 EPIPEN 0.3MGI0.3 PEN INICTR 1 Brand $49.48 $1.95 $47.53 $56.54 -IS 9% 59310057920 0212007 PROAIR FIFA 90MCG AER WIADAP 8 Brand $32.73 $1.95 $30.78 $34.56 -10,9% 6 Vlto rtd Dec b PBM Name Location Drug Type # Rx Ing Cost AWP Cost AWP Disc Contract Variance PBM 1 Mail Order Brand 227 $67,031.00 $83,459.76 -19.7% -22% $1,93239 Generic 6 $576.69 $1,201.50 -52.0% -50% -$24.06 MAC-Generic 73 $5,954.45 $12,404.07 -52.0% -50% -$247.59 Retail Brand 4,221 $382,581.10 $443,891.17 -13.8% -16% $9,712.52 Generic 158 $3,833.71 $7,491.93 -48.8% -50% $87.74 MAC-Generic 5,498 $107,804.60 $228,412.77 -52.8% -60% $16,439.49 Total 10,183 $27,900.50 Variance/Rx $2,74 PBM 2 Mail Order Brand 57 $16,917.97 $21,676.86 -22.0% -22% $10.02 Generic 3 $553.67 $1,141.20 -51.5% -50% -$16.93 MAC-Generic 27 $3,031.56 $6,245.48 -51.5% -50% -$91.18 Retail Brand 1,058 $96,969.63 $112,378.99 -13.7% -16% $2,571.28 Generic 43 $1,282.15 $2,645.91 -52.4% -50% -$65.80 MAC-Generic 1,634 $38,687.43 $84,756.86 -54.4% -60% $4,784.69 Total 2,822 $7,192.07 Variance/Rx $2,55 PBM 3 Retail Brand 3,890 $356,24832 $413,123.06 -13.8% -16% $9,224.95 Generic 104 $3,779.20 $9,338.32 -59.5% -50% -$889.96 MAC-Generic 2,339 $62,184.49 $121,212.24 -48.7% -60% $13,699.59 Total 6,333 $22,034.58 VariancefRx $3.48 7 WortdD~,c Sponsored by 1MS Managed Care, lnc. Powered by WorldDoc Wellness is the human process of being aware and actively working toward better health and a healthier lifestyle. Organizational Wellness Programs address this concept for all workers in a' company with the design and implementation of a network of smaller, topical programs that move individuals toward a healthier, more vital, safe, secure and fulfilling way of living. An organizational Wellness Program moves outside the parameters of Workplace Health and Safety and takes an organization into an area that addresses a worker's life in its totality, taking a holistic and life-in-balance approach and view. IMS has partnered with an industry leading care Management Company to deliver an integrated', package of Wellness services to its client base with a focus on providing its members with tools to' modify their behavior. The WorldDoc system is designed to assist users in self-care as well as 'dealing with the health needs of their spouses, children, parents, or other family members. WorldDoc helps consumers make better healthcare decisions. As a result, employees and employers save costs through healthcare education, prevention and individually tailored wellness initiatives. At lNe1/nessYl/orks, we can design and implement a highly effective workplace Wellness Program specifically tailored to your needs utilizing the WorldDoc system. The private label version of the WorldDoc Health Support System offers a unique and seamless means of giving participants a greatly expanded set of health tools. It also allows the Payer access to reports and service components that give them the ability to optimize care while containing cost. IMS partners with each client to ensure that the system is provided in a format that is specific to the needs of their user population and meets the company's goals and objectives for health care. 1NorldD~c, HeaHfi Managrmrn! Systrm WORLDOC SUPPORT COMMUNICATION -A KEYTO SUCCESSFUL t'OAULATION HEALTH MANAGEMENT This section is devoted to the employee communication tactics. After all, even the most innovative health management program needs participation to be successful. We have created this document to ease the implementation of your population health management solution and help guide you to successful communication with your members over the next year. Our experience shows that the more you communicate with your emplayeeslmembers, the mare positive results and increased portal utilization you are likely to see. Frequent use of the member health portal means that your organization's rriembers will become more health educated and likely to spend less money on healthcare. Considering the importance of communicating efifectively with your members, establishing a communications plan is crucial. In this binder you will find templates of communication materials that are intended to be distributed throughout the next year. We strongly recommend you work with us on creating and committing to an annual communication calendar that generates the most interest and participation. For example, February is Healthy Heart month; therefore, sending our heart information would make sense for this month. In addition, the communications calendar considers seasonal health issues, making efforts to target concerns that may be on people's minds at a certain time of the year. HOVE/ 70 RUN A SUCCESSFUL tOMMUNICA710N CAMPAfGN In the following, we will walk you through the steps to develop your own, organization-specific communications plan. Make sure to fottow these 5 steps: I. Plan for success -decide on the Length of the campaigns, ways to communicate, frequency and topics of communications II. Involve your C-level management team -make sure you get the "buy-in"from the Management team (you may even consider rewarding mid-management for their departments' participation) Ill. Execute the campaign -stay committed to the dates IV. Report results. - let,your members know haw many of their colleagues participate; share the success stories V. Plan for next year's campaign WOpLDDOC-ADNIINIS7RATIVE BINDER WorldD~c. TM Health rtAuiagement Syttem WORLDOC 5!lPPOR7 Designing a campaign When you are working on preparing your campaign, try #a answer the following questions: 1. When do i want to offiicially launch the program? 2. In the past, what methods of communication have we used to communicate with our employees/members successfully? (Put simply, whenever we had a message to share with everyone in the organization, how did we reach them?} Check all that apply. We used: ^ Posters O Information included in D Word of mouth paycheck envelope (paycheck ^ Speech by a manager staffers) ^ E-mails ^ Brochures in mailboxes O Newsletters ^ Table tents in common areas ^ Flyers ^ Other 3. in the past, when we had to communicate something important to our members, we always wanted to use: ^ Posters ^ Information included in ^ Word of mouth paycheck envelope (paycheck O Speech by a manager staffers) ^ E-mails ^ Brochures in mailboxes ^ Newsletters D Table tents in common areas ^ Flyers ^ Other Every company is different -- different people, different industry, in short a different culture. As the WorldDoc Champion, it is important fior you to identify some of the factors that make your organization unique, that is, to identify a communications method framework - a fancy way of saying how you get the message to your members. Now, use the attached Communications Calendar template and fill it out with dates, types of communication channels and topics. First, focus on the first three months of the campaign. Use two of the "established methods° (used in previous communications) far every one of the "wanted" methods (desired new communication methods). Make sure to take note of the event months. We recommend that you distribute six different communications to your members within in the first three months of launching your WorldDoc system. From our experience, t WOFiLDDbC-ADMtN157AATlyE HINDER 2 UUo rtd Dec, MealthManagementSystem COMMUNICAT10N5 CALENDAR six is the magic number of "opportunities to see" the materials that result in strong brand recognition and top of the mind awareness of the employee benefit. The first three months are crucial to get a person to change his/her behavior. Maybe you recognize having said to yourself: °l need to get in better shape. I need to exercise. l am going to change my behavior - it will be great!" Studies show that it takes about six weeks to start a new lifestyle regimen. Instead of allowing six weeks, we double the time for your communications to take effect. !Vow that you have defined how to communicate this great, new benefit to your ca-workers, it is time to answer the quest!an °Whaf do I communica#e?" We provide you with examples of all methods of communication you can use. You may use as many of the materials as possible, as well as allow your creativity to find additional ways of conveying the benefi#s of the program to your team members. !f you feel that there are communication venues that we have not covered, but you would like to use in your organization, please contact our Customer Experience Team to discuss your ideas - we are always interested in listening to your ideas! Throughout the year, we will develop additional communication materials and send these to you for your consideration. Start with Management campaign (prior to the official Eaunchj -use Why WarldDoc flyers, internal presentations, and promotion of the Health Risk Assessment to help them understand the value and the benefits of the product. Once your management team is well aware of and enthused about the program, you are ready to roll out the program to the rest of your group members. First start with materials explaining what the program is and its value to the members and their family -"what's in it forme"; make sure that the °How to use" materials are available far all your members. Consider incentives to drive participation. When introducing the program, using letters or emails or even quotes from the CEO or President of the company is a great way to reinforce your company commitment to improving employees' health and providing the most valuable benefits for them. Don't ignore the power of one-on-one presentations: ansite training and demonstrations are great ways of presenting the program. WaRtDDOC - COMMUNICATIONS Wor1dD~~. Health Management system C O M M !J N I C A 71 O N S C A L E N D A tt Once your members know what the program is all about and what purpose does it serve you can start focusing more on the specific features #hat are directly linked to your particular goals. Health Risk Assessment are the great mean to start, they allow #o collec# base information on your population and adjust further communications to best match the health profile of your group. The further into the campaign, the less frequent communications have to be. Switch from product-specific to health-oriented, educational messages: quarterly hea#th news letters, season specific health tips and Did You Know emails... During the next enrollment period, make sure that the campaign regains its original strength. It is always good for participation and utilization levels of the program to have boosts in the campaign to refocus those who might have lost their momentum in being engaged in their health. t r WORLDDOC - COMM,i1NI:CA710NS 4 Using WortdDoc to Improve and Manage Heatth User Training Guide Wa rld Dec Health Sappart Systems Using WorldDoc to Improve and Manage Health Wo rtd DEC, Htalth Management System Table of Contents Welcome to 1X/orfdDoc ................................................................................................... 2 About WorldDoc .........................................................•---................................................. 3 Healthcare Consumerism ............................................................................................... 3 Privacy and Security ...................................................................................................... .. 4 Navigation -Finding Your Way on the WorldDoc Site ........................................... .. S WorldDoc Features ....................................................................................................... .. G When to Use WoNdDoc ............................................................................................... 22 How To ............................................................................................................................ 23 Troubleshooting ............................................................................................................ 24 Summary ......................................................................................................................... 25 Warldlaoc Inc., Confidential _ 1 Using WarldDoc to Improve and Manage Health Wo rtd Dec. Hralth tdanagemem System Welcome to WorldDoc Welcome to WorldDoc Health Management System! Wor]dDoc's Health Management System offers users excellent opportunities to better understand health conditions and treatment options. WorldDoc users can educate themselves before they need to see a doctor and determine when it is appropriate to apply self-care. WorldDoc, hence, will often serve as a resourceful tool that may save both time and money. It is important to give the WorldDoc users a good start with informative instructions an how to set up their personal account; how to navigate the WorldDoc site; when to use the site and how to access it. This guide addresses these issues as well as provides some background information on WarldDoc, Inc. WarldDoc Inc., Confidential 2 Using WorldDoc to lmprove and Manage Health Y Yo rtd D~e, __ _.. Heahh Marwgemcn[ System About WorldDoc The Company WorldDoc, Inc. provides advanced Health Management Systems for payers, purchasers and providers of healthcare, improving health and reducing costs. WorldDoc was founded in 1999 by a group of board-certified physicians to help consumers make more informed health decisions. Today, WorJdDoc offers the solutions MyHealth 24/7, a Personal Health Management System; WorldDoc 12x[, a Pharmacy Benefits Manager; and WorldDoc Tx=-[, a Care Gap Management tool. Together these products consolidate and communicate .information throughout the entire healthcare continuum. Healthcare Consumerism It is the WorldDoc's firm belief that the next major driver of healthcare will encompass patient /consumer empowerment. Americans increasingly consume more healthcare and medications. By educating themselves, people can learn to make better healthcare decisions, prevent disease and/or choose to get care only when self-care is not on option. People need appropriate information to make good choices. That is where WorldDoc comes in to play. While the United States has quality health services available, fewer and fewer Americans can afford to access these services. And despite rapid medical advances, Americans are not any healthier as a nation. Increasing healthcare costs result in a shortage of healthcare resources available for uninsured and at-risk populations. At the same time, this situation creates an environment where consumers must be active participants of the healthcare process and recognize that they have personal stake in healthcare expenditures and the results achieved_ WorldDoc, Inc. develops Health Management Systems that seek to provide the participation and information resources needed to empower individuals to take a leadership role in persanaI health and wellness decision-making. The Health Management Systems benefit patients, providers and payers of healthcare. WorldDoc lnc., Confidential Using WorldDoc to Improve and Manage Health ~Q rld Dec Hearth Managemrnl Sysxm Privacy and Security ~ Our users trust us with sensitive, personal information. We are awaze of the responsibility that comes with their trust. Therefore, WorldDoc uses the same Internet security tools that major banks use. We have designed our system and architecture to maintain the highest Ievel of security. A high quality firewall provides the first layer of security between the system and the public Internet. All traffic is protected with industry-leading encryption technology. WorldDac uses VeriSign~ for encryption, server authentication and eCommerce services. VeriSign is the leading provider of digital trust services and the parent company of the world's largest domain administrator, Network Salutionsc~. Mare importantly, we use the encryption throughout a WorldDoc user's entire site visit (not just on the login page}. In addition, WorldDac has provided a supplementary layer of protection by preventing direct access to our database server and backup server. Unwanted parties cannot infiltrate the server directly because there is no physical IP address assigned to it; it is "hidden" from the Internet. To authenticate the servers, WorldDoc maintains a Secured Server Certificate with a specific identification number, ensuring users that WorldDoc owns the servers in use. WorldDoc does not sell or trade email addresses, and you will not receive advertising as a result of giving your email address to WorldDoc. We merely use your email address to serve you if you opt in to receive health-related information from us. ~r Wor]dDoc will never share your personal health information in a manner that violates HIPAA standards. You own your health information, and you choose if you want to shaze it with healthcare providers, family members or caregivers. WorldDac does produce aggregated usage reports to evaluate the effectiveness of our services. No individual users are identified from these reports. WorldDoc conducts user satisfaction surveys, in which your participation is totally voluntary. WorldDoc regards you, the user, as our mast important customer. We work hard to maintain your trust and confidence. WarldDoc Inc., Confidential Using WorldDoc to Improve and Manage Health Wo r1d Die, - FieailhASana emenlSystem Navigation -Finding Your Way on the WorldDoc Site There are several ways of navigating the WorldDoc site. You may use the Navigation Battens, Tabs, Drop-down Menu, Utility Baz and Footprints. In the picture below, you can see where these tools are located- -,.._ ,~ :UVortd D ~ site wide search Aar ~~°~'~,..-~yi aszt ~ It~h~sr~tag Tacit Sys~ts~m ..:~ : . tticking on the logo and taglMa always .take you back to Chi homapaga. tt~attfi t rymptdm swhutloe m~dka! library wealth h~rit»n Thafe in Ii[i7. trou use them t0 ,.. ttavigatewlthln a main sacUon of the worldDOt seta. pharrnaey \.J n7 health pl.t t u.va, So.urm t caamunkalb ~ _. , sa~» 'J° .~°dfas ._... r.Qme3.lO~i rkrranN evalus . _~ ,, ~e» ........... lntrty focusareas you will find spaclalry roplu. ~: t~„z~ This is the utlliry bar. q you Click on they care huvlgamr, you wilt gat options to contact a nurse. I .. to scut a Uric to a pogo to your favorites, click Sava to favorites. !f you clkk on vrhtt fag:, you wlil get a printer-friertdy version of the page. The footprint navigation harps youbacktraek howyou arrived at a page. WorldDoc Inc„ Confidential These era the htavlgaUan Buttons. ~y dlcldrtg an a Navigation falcon, you wUl get to a main section (content atagory) of the WortdDac site. «~ To access pages you have pralousfy savsd, eNck on lMy Favorites. 5 Using WorldDoc to Improve and Manage Health Wo rtd D>~,e, Heal[h Management Sys[em WoridDoc Features The WorldDoc site is divided into six main sections. By clicking on the navigation buttons on the left side of the site, users can access the different sections. Below you will find a description of each section. Sections Health & Symptom Eva/nation Once you enter this section, you can choose to click on either the Personal Evaluation System or the Assessment area. The Personal Evaluation System walks you through a 4-step process to learn more about pain or illnesses you may have. The Assessment area contains Health Risk Assessments (HRAs) to evaluate your health and risk factors. The HRAs will be described later in this guide. Personal Evaluation System Step 1: Choose area of concern Click on apart of the Body. Or, choose a symptom area. Or, choose a specific Symptom in [he drop-down menu. WorldDoc Inc., Confidential 6 Using WorldDoc to Improve and Manage Health Vllorld Hcalth Manaocment5 Step 2: Confrm symptom ~~ hNllh 1 rymplam tvtlualion ~" ~ ! ~-$~"'~' °"0~°r°^ ~ a!i°n°I O1aU'I~ tae v ®birx roe r.T~ylci ®u.s 1: grort~r ~ras rf7. h.tUha :.A~i ~___.__ aymyam t . _...... -- - I .v.laanoe < _ _. awdkal ~,. ,_.. ,._.~__ ._.._. ~j Uhwry Rfeti l~Chense arey afsoncem 2CanDan symptom 3 Nnswer quesSorrs ~ AeNew rPztill t t:ot~h YaaltA Mlpen ~ you heYelndfealedpursymptgmto 6e Cough. ~Phann.ry ltllemat~ot,torcandclewingoteYendaukueGlmughDlemaum. 1 ; ProlonpadcgtghallwgrswicadDlood.iLwedspdumdssatwsmedicaiattneion J ,ar Y.drY tu.~ I e~ nns,)ownl i `°°"""k~b^~ Take rre to tlt ~ Chitdten'a vmien~ nwfaaia~nu ~ 1 : " to tlr detd step,ya~ wi• arwwa asYtlple.cbake queatlstn wrAtea by a pl t spoclaaat to hepyon a,.r.... ~ ~ detetmlrhstltetatnedyaagabldn. Step 3: Answer questions ~1 hYIUI i fymplam N7kta11011 ~: heels t a.nwem en~s~umi ; ppaonaien }W~l'on syakm :V//J ®ITnl1: WCF.••y~o• ~N•.p la.wNf @V~: N7. Yadlh t ryy~erpp~.~ - _... . I awtaalloe ( _._:... :... _ ... ~.. m.dua ~ _.-._ - ,.._.. _... ... . ---.,... .. . . 4>ayy I ~ ~e 1 Chacae me e! mnaam :~ 2 Confirm mmslem 3 Mw.tt quaatign5 4 ReviaW reeWt . ~ ~: I :Please answer the tntlnwinp glimllaep ao tnnt we may EeoerhHPYOU wIatYOwheeldr Yrdlh Mlpen ~ ltdsbfsr. xenauwN ,y, ~ pbmracy Howfonphrveyouiwdaeanph? ~ h.Jih tu.. 01.3 days.' ~ ~ 01tn2wsdca e....imunhs ~ .. ^mrwekallnr 021n 8 weelia OMUa than 2 months "°' ~ How many ysan have Yon smoked dgarettes3 !: ~.._... _. ..... _ O Nan.. hn a norMemoker j._.... ` O B.Iween t and 10 yeah ' °aQ•, " i 08etween 7D and 25 yaanc :1p_ ' O YAare Ihtn 15 yams ~ ... .. 1 I - . # ~ poyo~f eoupq upaay's~satra (mucoa)7 f~~ ONo, its rirogly dry Wh~~ Octe.~',a~u~'sn~m:. 08,jpod 8ltp4d (some goad) ;Hew you had o isrn In the pat z deya7 O Na O1Ja fowr, lwt cwaatbrg a tat Ofw.r belwarl tD4 and t01.i degrees F ~ O Peru moth ihrail 101.5 F Wa;]dDoc Inc., Confidential Canfinn that the symptom you chose is correct. Click on `~1ext Step". Fill in the questionnaire and click "Next Step" at the bottom of the form {button sat displayed). 7 Using WarldDoc to improve and Manage Health World Step 4: Review results r~ health 6symptom artusgpn ~~ ~i6 "'"`'"°" "f°r1°r'""j~~td0"a°"'~'1o0Aa~O1 ®ISW)r (it MVr~SV ~Si;k I01]•URtt v~l fie, ObR~k1S;N tlfllltl ~ ... ~~:`1~ ... . Wei WSIDII t.. ; .. - ar.dlnt &tag~'rhnaseareaetcaneem -17 Canfirm~!!+me~m . ~;Arlswer'odestlnns CR¢hewrestals U6rary I hfsftl ? Ptaiuelor.Jo• Smith kltpen You indicated a Cough. o, r*~uY Click on the possible t Thin ie nal a cuhstitats for a medical eualuatian hr a 4censed physician. Your praGle suggests ttce fpGowing pasaihi6tias. CGck an the ppssrbddipa and rsad the dzplanatian and treatment aptipnp, Wt hope this helps conditions to get !7' MdIF pt., i you with your health decisions. more details. lffn,iamAf s ' Ppdblfldas: °0A1T"'aQarO"' i Nome Sev~thytLwsl `,, 'aiygwgrun ' ~pER RESPIR4TORYTRACT INFECTION O -. .rr: .--~-~ i' i BRONCHfTLS.ACUFE O _ lottaYereZ.:: afilaAeatirwr 4.._._..._..... ~~5. ACIIFE ~ lflslil~i >.y~. . taatL» .....- _.... . ' ~hta ~s...+.pyr,trrHt. C3rrotsr~.vwt ii By clicking on a condition, you will be transferred to the Medical Library. Step 1: Review info Afdkarm rm ,SIDfcr phT:sttame~aw.e!les.au!! ~ , .,r., Read the info and see if ,~ ~ ~ rlf..r. ~ ,.~ ~~~~-~,~> ~ ~,~,, ~ wrmprtlt~tldlfs~tmsttidh - ' .._ ._ . _ _ _. it fits your symptoms. If r 3~fr ~wro ;~:tt; .:a;m=~~+~' ~,_._.~.........__. ~...,..,:....... r not hit the back button Mats IrIPk^ ~ wslnrrrr~. .. ~ ; of your Internet browser. a-•~~. ;we. anwltls a s:wsup or Wlmon a Inr anuses two ptorvrt a! a ~ _ ; l ~ '>illlrs N4dfwP) Th! amAfs ors arfiWd oWla Irt M! pores ath! t~ Jwy1rJ1AIN.a : wanaa.gt3 fdnebMt rarkoar ~ ~ ;rw.l•^rR+! ZhulontlufClMlalNUlaamMedb bee nelM01 !moll l0/rtlnpafor li O O O 0.:. : r.O alwrllrrrn sauk . TMmisiparrWwu!lAballdballd;«LbonfoMfrMlfy! ~~~~: ~ i . If the info fits your HO1i ~'~ . TbslOUnaOaou!!slrlbtyldheMrrrYlslyfs. . rnltrwawlw.lfrlbepfabeutlAnfad ~ ~„~..klrla symptoms, click "Next ~ . TnssarunaaaArseswsbadwtnareoatlrot4llnssfapAaueor In!lbra Od,m,,,,r, Ste " at the bottom of ~ . .0, C~T4!C. rk fD Nk k dktlu_ p _ w~niw ~L..~_._---. TM•MWilhNppSApntlM1TlMlamwlpslo+anbnaflsreaandoran wrdwMrtp.amaa.~aar.nu ~ arrurnaTh.rat.auourwmsna O °~°~mr'''~' i r••~~ :< . Life a e utton not p .~ .. .~ . ic~apA.~ ~~maAr~wpM~m al~iprolrrv~~a . O o~:cnr ~ diS la Bd. ~~ ---~ Aa!lfirAlYS MNioVl Wean tJrgrslin0 ol}h iouMSfatll~fnf r p~u~;n~i.k;:isn ~ tflfilSt~~bmAOF.lIf MINA 06tls Yl OpYI TAl116M lNdl~fllStl rytanaadwdrAVdthaet ucaAbaljaulpr Tnl e ~4x".. ~ t s~`°..` ~ Olw pe lmumrn m !ecl SmaarAlrs d !n!nlnwf and sin !lnRasnla t~ t WorldDoc Inc., Conf dential S Using wor]dDoc to Improve and Manage Health World Q~@jC, Frealdt ManagemrntSystem Step 2: Check Treatment medical library haahh i iintuatkn ra.d~eal health h.tpen phamuey ray haallh Jan aaw, fatumr i eamawaratbm sH facaaaraar ~jI t .....__ .... _ f ,nr~~vwlra i ,~.J ~i :medea~fW.w;ltayitrnimmna ~. ®IT9Ch CiR ~iriQYtBI ~:i'+t N•llrGrG.i ~rw: ~~ udeJa;,::a.eoNnis ~g~l~tufYren•.inrne~ `~sreprae~aaetnw,r ) . ' .. ~... Mda slraisltls Ia traeA s badartal IntaotEon attbe Binuaes, Arttlbloyes tray help b, keatlhe JnlpCbfut apd yrsyuit'camppnltgns. In add111•tiri, airier medit~tlass tkc nasal sprays anA deeortpastarttamay beused bdecease . ~ .: ; tissue aweDiny and open Boe ostFa far beaer dralnaDe- ~~ O ^p:i i 2 . DrinlrNanbofllulda. j . E thr:~v . RwiaaoHnlsihumldlAeruvapwaerintltobedrDOmatstytittolaaease ~,,,r~ the motature level M the nose. ~ _ .. ._" Q canviioeaemaeeadocfa~_ llterearesawraloveHhe-countermediWdansthalarehelpfa]:Nasaf ' Ii ~;,,am~ E daconyssiantaprays,8 8whfrhshdnkswaUsnmumusmemhraneslntlra ! ~rrsridr nose,Cart bB USadtar>hreaba faun days. tanDeru+e can leSUil hl @re Aaee ~ '-.. '~~ ~ ~ bemminp7ddidad'tothasptay.TheybemtnelesseRerNasatblaod _ - i O. i vesselatbea'iabauad'andawallupsmlesslhedaconIIastanttspiesant. =~'- ~ ErmmplesairmsaldeeonpeslameWaYslndude t ~ o nancnrttx~bove , i .away nasalapray r . &aatha Frae ~ ~ ' • Ddatan aM.ddFonelcannmis <•.: . .' . NeasmaoMna Slnex F ..., Read about the different treatment options and determine if you need to see a doctor or if you can apply self-care. Then, click on "Neat Step" {button not dispIayed). Step 3: Give Feedback. In the feedback form on the right side of the screen, you can let WorldDoc know how helpful the information was to you. After you checked one of the radio buttons, click "Send". WorldDoc Inc., Confidential 9 Using WarldDoc to Improve and Manage Health ~Q rld Di Hearth nnanagemcnt Systen ,,, Modica/Library In the Medical Library, you can search information by entering keywords such as "belly ache", "runny nose" or "back pain". You can choose from a list of search results to find articles on conditions and treatment options, as well as video clips. (~ lpid{VllfbruY ~y-,:dt:xrqucata I ®o,sR.a. a.mi~ ~... n a.~ o ~r+z o.n ©~.uw ®3r.slfh i rYrrrpba ~ Ja*!R~3l~l .WtY\flee 1 1~~ ...~ '.a~'.~ ~''~.~i~.k. ~:5. O ,.. ~ ~ j IWrtlY TRrlaDawdnDarsyouresarcRrosuDSUnadWbtDtatlassslmitcRRfphest ! ~~~yI ~ `~ Y[Nt/ RYeadoalswwnetYwteleeldrlDtarandwotddpldtaddmanalhilp,59Lls ' ~ :i. i~:EalararrrsJ;pkssar , ~J 6dpsrt V i 1ClC ~MLnc .' doaeAieildr ` ~~ low 6iclr pain ph.rmtly r ~~ .~ ~ ' p m 1dMleir ~ e ambirredkuaDOtlYJetrecarNJtnmwnor Q8 Normal Pancreas 6landCOl6can ,: , .. .. , ew betkpelrtvdttpihf IIelaD hse eis w ;' O ~lrulLSUrrr ewi.hruiui ~ bDplepa.ThlsrotlgtlertafpalnmeYlmori tlfeerJtlnmeDtutmgte ~ Li3lHi9G OsereremdtmaeNl e.nr.r.+raJfara .. et144'r nar..:nodkeam Pinerexthli '.QSeChijvtirw~.,- e Low balk Piln Dunne Pmpaanc+r (~ EsaahieiRs ~OSmrh j- ~'- i i ! punnDprsOnencYtRereeremsmot!vioue bodY.usrryallfuee thsnDutiiwomin's !u-!~IIle tOserthFJU3.art/ •: . ... '"•".. -.. .. ~ thinDq tM ahQDH k.rer back eroi Jd i ii will is tri lrti tt ®Eiaahaaeal Uker ~ ~ ~~ sec Ndeo: qr/ !c O 1iYt~ilitl ~ P ... i ~ er.Cl~laplh: ~ I^ 1 i.. ~.I $mf1r P~!daa a'~Y~ •.:. ;~ ~~ ' e LawhxkPaln ~ ewitNemoNeamrmnl ea M b B k ®PJarmnl Thraif ;.® ~ .. .... -~ :riea.. yp se pi ! o ~peRaRlifAasetontlmisttammoe (ltaoerEmlrti[artN ~ C~bllTralhnrt . . ~ W ~' !leeOR ibfiWlleeM tlYlidi doctor. MOR OliebitlifeUDeaplivAl ®Esoohaaeat ~ -" .. . f d6 +l a -:- '~ ~ ! .._...... .. ._.J _ ~erodon-Hiroei a r l M1 Fina~??j.Aa , ~' ~. __ ~ m.MU1n.r.w: nQfletM . ~~~ FleQtdtrr ~. _.._.. .. ! (~ LawirPbdamen ,: 1. Enter your search word, for example "low back pain". 2. Click on "search". Health Helpers In Health Helpers, you find health quizzes to evaluate how your lifestyle affects certain conditions; BMI and Calorie Calculators; and a tracker that shows the development of your health overtime {based on the information you provide in the Health Risk Assessments). WorldDac Inc., Confidential 10 Using WarldDoc to Improve and Manage Health 1No rld Dec, Health M1laaagement System J hultb hel, af ~~ LYShc2~7~ 01'a'"1°~" r ®oe~l. i1 a.ye/ ~ ra.. u-b.tCU 8r~a+r tapa ©NF~altm + - ~ i fympb>n , , f audk>i hb+~ Heaah Halpars are a sulp al tools tleafpnedto .~ ~ j inla ~u manfpe your hfeGh. 6eled fnytoolhan ' - 4. ~raie th.m scve pa semmaoef below brhbm tha cbnespondlna ~ hetltb { pba~ove. A 111 Mlpan I ( pharmsry e ~ ~ - 14~Fffllh fUt1 `, { - - E wiw•~rnneaf j ~ iiRS~~::.n~7~~:Si~i'w~-~ ~~S.~r~-.°~~'.~iJ?I~~.3e,~i'rx-r ~'~i ~- temuteitYlela ~}~Id.MM{ ! ~ ' TeftyourHfeMlQwilb CekulefeyoUrbady .,.: ~ -~ -- ; howalw . b~leaerlesatqutrtas. maueawellu .._. .. ruammentled calode WorldDac lnc., Coni"idential ] I Using WorlciDoc to Improve and Manage Health Wo rtd Die, Hcaitfr Management System Pharmacy The Pharmacy section allows you to search for information on medications, compare prices and potential drug substitutions and locate a pharmacy. Displayed below is the Pharmacy Overview page. phannuy 7749¢: ~trlraoc: ®Y1l.:•~T N.S^W ®A..IC I..+~.t r~v+DA• A~ ' i^^Iiha ._ yrpka t o -~ ~...._. .. __--. ~ 1 ThoPharmagasdionWp>oriaddOOCHaaahAtonrDamrnsttlyslemcardatn^ t Md1A tMmrtuaon7ohalpyruwmparea8aspocbaf,ahdloammaraatraul.mor^ ® h^I •n ~ Shoo 17,000 medkoDone, tJCa 1ha tabs aoorr ar8nk5 batawla acteac bola p sndlydormaifor- I ® ^ry MVta (Iles ~ •Hleh•desa P~nMillore lntroaSC Heart n, hRiek Zil44I ~~letl the tXJil Heon ; rimed Panef Urae J ~, , wryJma•.i ~ ~ a' c^a,nrnkuwm Z8511L tnf^aumu _ ' •9looderecaure-Gidne.stong„trihl~adto k7~3lDf __..... .. k91~ CNehre^ ' f ~~ ~ Predn~olane fr977ID8p~8 ~L.._._.._... Pr^vacrd mus_ iw , _. ~~ ~, 7}. i I _. Rx Comparison Step I :Enter drug c~~ ~~: ~ aontansm Y phamucy ®o.x,~„~..•~S~M ®,«, ,.,,,~,,.,~. ~rr~+.cuc• Qa..,...~M: ^~tha TO compare - -....-. ~,,^aD.n _ medications, click on ~..k.r - the tab named "Rx awry ' ThaA^GamDarison lcacoych loolhafpayou MOlrliarmodan onamntlkcaon lhmyaupxe wcancldm takn4.lf h^Jth i wa8aak,fnlcarchmuacrdBdcP~7lMmrnaBonandDrkccancomDaraWerWps.Inthtsway,yarwnmata Comparlson". 1dMp ! ea7rAannadchaka6^IwamtawfnamrdruD^,Pahodc.nrslansanuwenfhrramfwmookatfan5. ~ Ph~•^mt' -. .. _. ~:6tep7 ahtor dar0 ,Bteplselotl oVYnDBr 81eP~enlar quannt7 ;, 61eP 4: renewrasuRs p aY h^^n1 fL.r B1T6t~ CODE (79118 , ~ pJ^fdta d^L~mina m^dlcaiWn pduelocdbr^ur a^^) ~ •..^.f•~^•~.5 Enter the name of cw•a^rrcama~ lalfBlT3F141AE0FTFEE1RtIG705f6RClt (ar^nt^rJastwmru lcw tsttan mthe mooKatlonl ou want the dru g y to compare. { ThefWIOnMDIr#onnatlanlSDRSenteafoprortaef~DUwI5rDa55IDie ~,°^ ~ apamatNO traotmard aypana ah6 o5Pmatetl pncmD kr9mtrit~tar ~•~ir^e` ._ ~ eoiuaapnaf paryasu aNp. Mt MonQeaMyour preecdpDOn moat oe ~ anararttrd t79adr Dhtak4vt ~~ " " Next Step . Click • nmer Prescnm!an rRrl pesowcee aTaote WoridDoc loc., Confidential 12 Using WorldDoc to lutprove and Manage Health Wo rtd Dec, Step 3: Enter quantity I~~m„h, ~.q~nc r:ooryoruan brrlib t at+nplsr. e~alWllan _ .. . pwlltrl i ... ~ .. .... .. -. ... Yb~Yr ~ .....____.. ~ .._...r. ,., r ~ Bteat~entpr drue ~j~p,2selsce streneth fitep3 artrr quantdy tHteA; +eMew izsult4 JI A~dlb ' ~ - -- ... _._ .._. _...._~. . _..~.___~ __...... bdpn ~ YOIAt1EDICAl101t N1E0lLt)FIXOFEii+rDiNEMt1~,t60fJp.TABt.ET ybon~ry ~ B/TBt~yOttANTRY: C~TABLETB r ~ ADP TOY'WitHEALIHtiEa^ g:haclr6wNadtl lNS metlkaagn la YOUr )teaga Faes) aqr b.rrh )Nn Balsams msakalttlnEdfgn tlratyqu are beaanp wan aIK tlnrq antl cuck'nmq sup' a1 cawnue: a ~y •..n.lew.ua Q FtLgt[q[ Ibi0D5 ~ptgl9lp tan~uwNaia ~ ONtYESNi-TICWtAi ~a.i"ro eq~iwanu_ ~p00NTNNOWOttNOTLiSiHp of .....- t Check the drug type and strength you want to compare (example: oral suspension and 30 mg.). Click "Next Step". Enter the monthly quantity of the drug. Check what condition the drug aims to treat. Click "Next Step". WorldDoc Inc., Confidential ] 3 Step 2: Select strength Using WorldDoc to Improve and Manage Health j/~/O ~.,~~ ~~~. Health M1landgemrnJ Syslcm Step 4: Review results. Compare your current medication with alternatives including prices (before copays). Ctarrent Medication --'~' Alternative _ Medications --"~" wapr~kattom ~ AtLEflRAisa Erantl•nane rrotlka6nn vAYch is oAwr b qul pgw+cbc-YMI~a trera Is as paoerfcvxslan I ~aYapaala, ptala ira elAOlOlahflaN OppOaa Nal CllGn Wf[lYmlKh beCaf ~7lul. ALkYaW tlCCbrWnalnBr Wq'0(i wuan.s_ 4 marecammeaGeaapamavasmiOntDanphlrorywt r .. -._.._ ....._.-._...._.... .. l ~ ~ l Ntm iapib119 antll11d7mines arB n6atl p)r aparpYprallemc antl po ed mlln PaopEe a(aepY.Trte/ are aaw ----~ araflaWetrrertna•ceunlatAlluipkminplctclhamaatcammonduonlcrondroonusb~cuNtce6t~lac.Cla :~ f ' baalcaihanapaykraacUonocwrlapMlhcnosa.taanaGarylcnaWan,achomkalcalladh3slamNels ~*Y1a~ta ; nNaced by>fiebodY•MlWatamiaea>~rk by htacldnp Cia ocf~nolMatamkne on the Uesuea ErnaMeu In lhn 3 _ ,_ I~~ aparpkroaptmaa. ~ (( ~ j ~ALLEGRA(YOIIRCt• 7RRf]~ftbRUt}) ... ', w taal Fn.rmaeYtJ marsh atrpptp - fian.po E - .. _ ____-.-..___ 7'bsta ara ipemathe meatcationa taAtLEZiihA 7nsae.mamwtl[msmtq artaamucn OeRfrwiue Ntreapn9 Your cmtaUlan Werecaiamatid aaldnppw tlormratrmdfhafupavittp memcasone W sea atna~mlpru ne appropnate faryau i .~~p ri~uN1~1 AIF7~~ 1` ~ ... ,. P ± . ....~ ._.... .. _ ._. ...~.. s .....-._~M__ __..,_ __ ®SEDA7NGANiYiSfAYlES _ ' FROYE7FIALNEHCLQ'ROYEI}I~HEHCI.y S7p.00 ' OtPHENHYDRlWpaEHCL{pIPHENHYOR+WUVEHW IO7q it0.ltp ~. i ~ ~t....~___-_...__-~ .............. ...._..........._....._.. --._... l ~, .... --_ _..- ,. ~tsriMOGg7taVS ~ i MEDRO%YPRCOE97ERONEACETATpE0R07fWR00EHTEAOd~ACE'I~ S20Ap ` .--. J._..__..._..~_.~ ___ ........................._._..._ . WarldDoc Inc., Confidential 74 Using WorldDoc to Improve and Managc Health V Vo rld D~e, Nealth Management System ~ My Health Fi/es WorldDoc helps you build a collection of personal health data and stares it in a Personal Health Record. The record helps you follow the status of your health over time as well as the medications you take. This section allows you to manage your Saved Files and Favorites. my health f Iles ~: my neatlh sxs :overview launch rare naxipacot ~ F3..E LO favOnies ~ P^m pope (}~ tiepin Q1~rsi1 health t symptom ~.sp avaluatlon i1t~! i--~ ~ _ , medical ~ _ _, .. _.. . Ilbrary ,The Overview gives a summary of key lntarmation. CNck on any link ar tad to Det more detailed info. { health ~ .. ..... :..:.. .......:.. .. helpers 1 (~) pharmacy i r>a~ Linda VWson t+b medkxtions on tie ~ l ~ "' Undo " _ '::. ~''~% '~ /~ health ilos T"-` ~' f ` r eme~ Iw~dsnn~vahoo.com rer~~ ~ ~ ~~~ No I ~ pttwp. IIoast Casinos ~3 nsws,farumsi I ' ~% eommuNestions ~ 1 ! g>oodpreazla~ 133 .. .., .,.7.. ..... _ ~. , '" Tr Lnvat ~_ ocussrau Hama -alatlortaWp: ~ ChoiGdaot g,! , J.... _---- ( phOt1~ , alYelgYt 155 PoS:~ Heignt 5 !ed 4 inches _, Body Mass: 2& r .-T ......_~ 1 ; qgx ,~i, lieaEh Aye: ,3Q, Haaeh SCOTa: 4 ` 1 marrr.• j •" ~ Sax Female ! l ~ C. - ..---- . . . ........... r Phony . News, Forums & Communications News, Forums & Communications is the place to go to contact fellow site members. In the forums, you can respond to questions and comments or start your awn discussion topics. In this section, you will also find azchives with health tips, as well as transcripts from your chats using the Care Navigator. WorldDoc Inc., Con6dcntial 15 Using WorldDoc to Improve and Manage Health World Health Management 3 Get Started! How to Set up Your Account To get started with WorldDoc, users need to register on the site. This is haw it works: 1. Go to www.imstpa.com 2. Click an the "Online Services" at the bottom of the left hand menu WorldDoc Iac., Confidential 16 CTsing WarldDoc to Improve and Manage Health Wo rid D~~, 3. If you aze a First time user of the ONLINE services at www.imstpa.com, click an "Request Your Employee Password Here". (Please follow the instructions provided - and a Password will be e-mailed to you. Once you have received the password, then you may proceed with # 4 below) 4. If you are not a first time user, and already have a Password, Please enter your SSN and Password 5. Select Log In War]dDoc Inc., Confidential I7 Using WorldDoc to Improve and Manage Health Y Y ~ rtd D~c, Health Management System 6. Click on the "I agree" button if you a~ee to the statements contained in the authorization. WorldDoc.Inc., Confdential 18 Using WarldDoe to Improve and Manage Health ~11o rld 7. To access WorldDoc, click on "My WorldDoc Center" on the menu located an the left side of your screen. Select your name from the list of dependents on your plan. Please read the disclaimer, and select "Enter." VlWarldDoc Inc., Confidential ] 9 .. ~ .«. -,~.~. Tm „~ Using WorldDoc to lmprove and Manage Health Wo rld Dec. S. You are ready to begin using the features in WorldDoc? _ ._.,_ _ _: -, ~ Ea wr Tar ~+ - ... . _ : , ;~ WorldDoc lnc., Confidential 2Q Using Wor]dDoc to Improve and Manage Health Y V o rld Die kcalllt fAanagementSystem Next Step -Health Risk Assessment ``~' A good way ofmaking WorldDoc YOUR personal health manager is to take the Health Risk Assessment (HRA} located in the Health & Symptom Evaluation section. Once you have filled out the form, your personal data will be visible in different sections of site every dme you login. You maybe asked some questions far which you don't have the information. That's ok. Skip that question and came back to it at a future time when you have the information requested. Far example, if you don't know the exact cholesterol Ievel, skip ahead to the general question about your cholesterol. We recommend that you retake the Assessment every 6 months. To take the Health Risk Assessment: 1. Click on the button an the left side of the screen that says Health & Symptom Evaluation. 2. Anew page wi1I display. On that page, click "Go to Assessments". 3. Now you have the chaise of a general Health Risk Assessment (recommended for eVeryOAe); a Geriatric Assessment (generally for people over 75); and condition maintenance assessments for diabetes, congestive heart failure and coronary artery disease. Click on "Take Assessment" far the type of assessment you want view. 4. A form with questions will display. Answer the questions and click "Next Step". 5. The Health Risk Assessment now generates a Report Card that provides you a `~IeaIth Age".Based on the information you entered, the risk meter shows if you are in a "Healthy Zone", "Moderate Risk Zone" ar "High Risk Zone" for certain conditions. 7n addition, the Report Cazd makes suggestions for lifestyle improvement, and you can ogt in to receive monthly health tins from WarldDac. h,/ ~y.. .w... ~~. ~ tee.., k.rna ®'r""~ .rtlwuwf s.4rr ~ -~ a-f r ~' ~ t41nt Sawwary a.allA eeyv! a~ MJfk 1Jy G,hwlA.I{ealdoftlah llwa.rlfefRtor JoM lialet Vf VfN.ee 17MeitS0a2066 T71aS6 PY CQEfrem fe eer]Il.mH N.atrf mek A..e..mrmj ,h.n...r Jshn, uco rdpy to thr IMaltlt RNIf Awe.owm. you an as Waldry u tha ova wr Melfh>Y~ M~.Iwea ~ Ufdwwnauky, Yaw lleahh Ape u mach h1pMrCuuyaur reveal epe. We hiphiy ommmeM """"'f"1p'" ~ rovlewtap rM rldf afeur fdterl W low m Iwn how m improve your Malfta. .w.+.. -._ But nmembet this 3a Wy e'meepaAa' d ynu fxnsnf arnp health Yaur'hedilia.ee'may impwa or decyne aceednp b your afxime. Wtfi some brsaa an Wtwaad hom yfaa Woma. yeu ten .. dpnieWly imgw yem beahh and Inver your dak d YetMatetiap druuea ly mdeirfp Idutyu rJfanpaa and tddnp ncaraofended aemffhfp eaama Ior comrfon awwat fhfgtwe inei_ +eM.. ---.... N tM US. mo>a dnnlu en emued by o few rypee dtTnuaeo. Scnannp ltpe aM GhWyla chanpha ~._._.. _ .._ .; i are ft6ctire larferd ~+D your dolt dtlyinp ttom tau dthaae fold d'uWn. Ya Wn ttfen ghoul ~. ....... ~ ~rAal Iut to Wu and rtlun, dclran oaa d the 6aeeaea irad on tln IeR 7Aie a e+Pe~y ~ ~ ~ i ~ ~ ended iyeu ra in pn 76ph' or'kAoderW'tiahmn fhr a ~parliedar diaaale. . 1 Rtat Yelttt _____ i emre hS doeel t3mre Using WorldDoc to lmprove and Manage Health UUorldD~c, Health Management System When to Use Wor[dDoc Wor]dDoc's resources should to be used as a reference anytime a user has a health related issue, except for obvious medical emergencies. Below, you will find some examples of situations when it would be useful to consult WorldDoc. When You Are Experiencing Symptoms of lltness Before making the trip to a doctor, go to the Wor]dDoc site and the Health & Symptom Evaluation to decide you need to see a doctor, or if you could apply self-care options. Before a Doctor's Appointment If you are prepared for the doctor's visit, you will be able to ask the right questions about your condition, medications and treatments. You can find the information you need to prepare on the WorldDoc site. You can print pages and bring them to the doctor by clicking on "Print Page" in the upper right comer of the screen. After a Doctor's Appointment After a doctor's visit, you can go to WorldDoc to learn more about the conditions and treatment options that you and your doctor talked about. In the Medical Library, you can look up medical terms that the doctor may have used and you did not understand. You can also lookup prescribed medications in the Pharmacy section to compare if there is a generic or an over-the-counter medication that you could take, saving you money on prescriptions. Track Chronic Conditions or General Health Sometimes it can be hard to keep track of all your health-related information. WorldDoc offers a Personal Health Record ]ocated in the section MyHealth Files (button~on the left side of the screen). As the name indicates, this is your collection of personal health data so that you can track the status of your health overtime as well as the medications you are taking. Evaluate Overall Heatth and Risks By taking WorldDoc's Health Risk Assessment located in the Health & Symptom Evaluation's Assessment section, you can find out how you are really doing and how you need to improve your lifestyle to get better health. WorldDoc Inc., Conf dentiat 22 Using WorldDoc to Improve and Manage Health World How To... ~ Do you still have questions on how to use WorldDoc's Personal Health Management System? Here are quick references how to... ...assessyour health status_- Click on the Health & Symptom Evaluation button on the left side of the page. Then click on Health Risk Assessment. ...frnd a medication: Click on the Pharmacy button on the left side of the page and then click on the tab labeled Drug Search. Type the name of the medication in the search field once in the Drug Search tool. ...learn more about pain or an i//ness.- Click on the Medical Library button on the left side of the page. Type a key word such as "stomach" or "runny nose" in the seazch box. Choose from the search results. You can also click on the Health & Symptom Evaluation button on the left side, and then click on the Personal Evaluation System to go through a process of evaluating a specif c pain or illness that you may have. ...getin touch with anurse.- Just click on the button on the upper right side of the page that reads "Launch Care ~'""'' Navigator". Once the window has opened, you will have several options to contact a licensed nurse. ...save a page orsearch resu/t thatyou wou/dlike to east/yfindagain: Wherever on the site you are, you can always click on "Save to Favorites" located on the upper right side of the page. You can access your favorites at any time, from any page, by clicking on "My Favorites", located in the lower Ieft corner of the page. Sometimes, you may go through several steps to evaluate a condition and arrive at a page with suggested treatments. On such a page, there may be a button that says "Save to Files". If you click on the button, the file will be stored and you can access it from My Health Files under the tab "Saved Files". -..print a page.• Click on "Print Page" that is located in the upper right corner. You will get a printer friendly version chat is easy to read. I may be a good idea to bring it to your doctor! Using WorldDoc to Improve s-nd Manage Health ~r Wo rid 7roub~eshooting Below we have listed a few things you can do if you have problems using the WaridDoc site. Care Navigator The "Care Navigator" allows you to consult a licensed nurse by online chat or email. The purpose of the Care Navigator is to answer questions about information you cannot find on the site and guide you to the right information. The Care Navigator is located in the Utility Bar in the right upper comer of the WorldDoc site. If you click on `~..aunch Care Navigator", the window you see in the picture below opens. It asks you how you want to contact a nurse. Click on the preferred option -chat ar email. Welcane to the Care NavinaAOr. i am your persanaE assistant in managing your heaah. Choose the method Dywhich you'd Elko to communicate: We can message to real time between the hours oC gam to 4pm pacific standard time Send me a description aTwhere I can help and I'{t gat back to you within 24 hours. Lost Passwords If you cannot think of your password, click on "Forgot your Password?" on the WorldDoc login page in the Members' Area. A window asking far your email address will pap up; fill in the email address and click on "Ga". A password will be emailed to you. Technical problems 7f you are experiencing technical problems, you can email WorldDoc at info@warlddoc.com. WorldDoc Inc., Confidential 24 Using Wor]dDoc to Improve and Manage Health ~Q rtd D~c~ HdiNh M~nagement5 em Summary WorldDoc's Personal Health Management System is a powerful tool helping individuals to manage their health. The more a person uses the WorldDoc site, and the more information he/she gathers, the better the outcomes will be. Naturally, individual goals may vary. Some WorldDoc users have chronic diseases for which they need to see a specialist regularly. WarldDoc can help them keep track of medications and lab results, and they can Iearn more about their specific conditions and treatments. Other War]dDoc users are generally healthy and just need occasional medical assistance. Regazdless of your situation, WorldDoc will be there to support you in all your health issues. WorldDoc Inc., Confdentiai ZS lNarldD~c. Health Management System GOAL WOIRKSHEET Setting and recording goals for member adoption (the number of members who register on the site) and utilization (the number of members using the site) have been effective in keeping members aware of their WorldDoc benefit. By setting goals for the members, the on-site "WorldDoc Champion" will be conscious to keep encouraging members to use WorldDoc and see the return of distributing communication materials. The following Goa! Strategy Worksheet can be used to set goals with the guidance of WorldDoc's Account Management team. 90 DAYS POST IMPLEMENTATION 180 DAYS POST 1MPLFMENTATiON POPULATION SIZE POPULATION SIZE NUMBER OF REGISTERED USERS NUMBER OF REGISTERED USERS ADOPTION 9~b ADC)PTEON °i5 UTIUZA71ON 9~o UTILIZATION 9~a NUMBER OF COMPLETED HRAs NUMBER OF COMPLETED HRAs HEALTH GOALS Suggestions• 1. Decrease Number of Doctor's Visits 2. Decrease the number of members taking a brand name medication 3. Arrange Employee >-ieaithfair 4, etc. MARKETING GOALS Suggestions' i. Distribute three WorldDoc communication pieces monthly 2. Send on.e WorldDoc communication to homes bimonthly 3. etc. W.O.RLDDOC -ADM1Ati57RA7tVE BtNDEIt MARKETING COLLATERAL 1 •' i ~' / ` i 1 1~ i1 i i ~ ~1~ ~~C`~-I.Y~Ep~U~A~IDl~t~fiO,R~COINS.UMER S ~ t ~;. ~0, ~ ~ Emaiis centered on i & Email Biweekly Every other Users receive them directly in their c in Q A ~E ~ ; one top Wednesday. email inboxes. . ~ format. _ _ i'~tsa` : ` ~` ~"s~ Health Campaigns Email Monthly Monday of the last Account Managers send electronic ~ ~: " ~ '~~"c~ based on topics in 113 flyer, stuffier week of the month. versions to Clients who wish to y a. •' ~ Communications 11 x 17 Poster distribute to members. ,~ Calendar. For posters, WD can print and mail - f ~ to interested clients. ' -~ ~ s ~ ~ Seasonal-specific, PDI= Quarter-y Summer PDi= to interested clients who wish e double-sided one Fall to distribute to members. Will also ` ,~.,~ , , page newsletter Winter be posted on the WD site for ~~ -;t~ ~~~ '~ ~ is . ~~ S rin download. D ~a'~e Spectfi~ One-page o ~ , ; A informational t PDF approximately 2 per month. Posted on web site ~~ ~~c ~~ ,~~;'~ ` = snapshot of serious fFraK Sx~l C} ~~h^ ~ ~" ~, _ ~~a ~ and common . ~ '~~ " ~ ~ °~ diseases. ' ~elalt -"'"s ''" Users opt-in from Email Monthly Last business day Users receive them directly in their ` ~ _ ~ WD site to receive of each month. email inboxes, tips on any of 7 to ICs. {~w,u~t~uuuc~,;~rn~uKAms : ,, , , ; , WOAL""DDOC~`P~QMOTIONAL'`` 1 "T~~ ~'~ ' - Communication Banner ad As Requested Banner ad is posted on users' home t~ . ~ aimed at specific - page _ users - '~o n ~ Users gain paints for Tracked When clients Jointly determined Points are tracked electronically by ,a d' completing activities electronically purchase the by client and WD. WD. Client is responsible for on WD site program Need 3-6 months of determining and distributing prizes. lead time to ..~ im lement. " Poster, flyers, staffer PDF; jpg Always available At time of rollout or Email ar paper '~ health fair Magnets, wallet PDF; jpg Always available At time of rollout or Email ar paper cards health fair '; Postcard; magnet PDF; jpg Always available At time of rollout or Email or paper health fair ' `~. Poster PDF Always available At time of rollout or Email or paper ~ health fair , ~~ ey t°' Poster, trifold PDF; jpg Always available At time of rollout or Email or paper ene is y -` ~~ ~ ' brochure, postcard, health fair "~~' ~ > staffers IN~1~~"ah~b~~ar~I'`~~ y Poster PDF Always available At time of rollout or Email or paper ;~ ~~', `{~'~~~.ru~ ,r', health fair o~e : eal~ 1/3 stuffier PDF; jpg Always available At time of rollout or Email or paper ~ ' ", health fair ' ~c #~ ~k~, ~ , ~ Poster;113 staffer PDF; jpeg Always available At time of rollout or Email or paper health fair i;AS_O,l~,l`~W,OAL~D,D, OC~ 13usirtiess,foBusi ,. ness' .;. ~ :: ;. , .. ~ .. _ . s. ~; ~ ~'4)~'~.' ~ Product brochure Glossy foldout; Always available Always available PDF can be emailed describing 2417 PDF Glossy foldout is paper for features nonelectronic distribution jyo~ : Product brochure Glossy foldout; A{ways available Always available PDF can be emailed ,F, ~ describing TX PDF Glossy foldout is paper for I features nonelectronic distribution ~~ , " Product brochure Glossy faldaut; Always available Always available PDF can be emailed y' ' describing Rx PDF Glossy foldout is paper far ' ,~ features nonelectronic distribution ~, a Corporate PDF Quarterly Oct, Jan, May, Aug PDF to all clients, Available on WD Newsletter, Double- corporate site. sided one-page Heaj~~~'ca a ~' `V~ News for TPAs, Onlinelemail Quarterly Sep, Dec, Feb, Email blasted from Salesforce e~; ,! , ~~ I #o brokers Ma 2 H~It-t~rldiD~c, GET TO KNOW WORLDDOC -POINT SYSTEM The purpose: The purpose of this program is to provide an incentive for employees to recognize and explore the value of WorldDoc's health management system as a tool for better health management along the continuum ofhealth. Basic Rules: This program allows for flexibility and adjustment of the point rules to client's needs. For completing certain activities on the WorldDoc's personal health management system site, program participants are rewarded with points. Collected points (once reach qualifying minimum} maybe redeemed to receive prizes Orland enter drawings to win more valuable rewards. The value and prizes/rewards themselves will be determined by the client. It will also be client's responsibility to cover the cost of the prize purchase and distribution. Process: The program is set up to last from 3 to b months and is designed to provide reoccumng encounters with the site, each introducing different features and tools. On a bi-monthly ~' basis employees (with the assistance of the WorldDoc Champion on the client site) will be receiving invitation to revisit the site and explore particular site areas. Each of 6-12 invitations explains where an employee should go on the site and what task should they complete. Depending on the complexity of a task an employee may collect between 20 and 250 points. iogistlu WorldDoc will prepare email and ready-to-print communication templates promoting the program as we]I as each of the programs stages (including instructions for each of the tasks to be accomplished} It will be client's responsibility to print distribute information, promote the program (with WorldDoc's template communication materials} and encourage participation. Point Tracking and Reporting Each participant will be able to review their point history by accessing the Points & Rewards section of My Health Files. l~tarl~D~c. At the end of the program client will receive report detailing number ofparticipants and the amount of paints they have collected. - ' iNealfh RUs~CyAsses,~ment ~ ~~ :~~_.~.~,..r:~x::f~,~,~ _,~~~a.~_.~~~w ...ti.:,,~a.~... , _.-, . _... ., complete HRA 250 Personal=Evafuat~on`System .. ~ ;, . `~.~. "'".k~ ~ ,, y . ~- ~f ;~` - cornplete aspecific symptom evaluation 200 - t='^ x.'!a" r nr-~-, .r..{is~,,.'r••rn ~:' T ~ ~ .rue~zr4~"ass+~~4x>:,~rx~-~r..~,~s~~.x"i, lily Heatthr~iles 5 a ~. ~~ ~.~ ~~x~ - ... update persona! info (including email address) 100 visit My chart 20 visit My medications 20 visit Preferences 20 visit Health analysis 20 visit Wellness plan 20 visit Points & rewards 20 visit Favorites 20 visit Saved files 20 visit Claims` 20 ``~tr-° visit El~gibiltty* 20 ;.:Rx Compar#son Too1;._... z :t~r...z...~r:~~~:~.~'~ ~ ;~~, ~....~r p x,T_.x:....~. ;~.~._ ~r..::..?~,..`.... ~.::~ complete specific Rx com ~~ n 200 .. _ ~ =, ~ ~r~~ ~ ~~~.k~~~~, a ~ ,~ y~ ~ ~~ review specific condition 20 review specific treatment 20 review all sections of a specific focus area ("evalua#e", "research", "treat", "next step"} 80 (20x4} review Frequently Asked Questions 20 Health Helpers .. .. _ .- .. - . }.. z~~:.":.~; ~ ~- ~, Visit CIu1ZZeS 20 visit calculators 20 visit trackers 20 visit treatment reviews'` 20 visit hospital comparison'' 20 Wor]dDoc will work with the client to determine minimum amount of points a participant must accumulate to qualify far prizes and/or drawings. *For the clients who purchased and implemented this feature Throughout the program participants will be introduced to: