~iNSURR~iNCE MANAGEMENT SERVICES Sealed Proposal for: KERR COUNTY Medical Stop Loss, TPA Services, Life Insurance and AD&D ~~~~~ ~~ Copy #i ~, INSU NCE MANAGEMENT SERVICES Sealed Proposal for: KERR COUNTY Medical Stop Loss, TPA Services, Life Insurance and AD&D Copy #1 :J YJ ~t ~ 4 r=^ V M~ 4.1. ~o ~~~ Ij zo ~~ I a -- ~ =s-. ~_ ~_ ~, ; ° -- c~ ~_ I~ - - i ,~._. f. I ~ ~~ ~~ ~ ,,, ~ y u ~t~ n ~G ' ~ ~k _~ .~ ~ ~. ia~„c.~ 1' n ~ O a~i n ~ 'a~ CL S C1. ~ ~ -c l_ ~~ rl ? 4 ~; ~~~ Ia I wi a ~~ w j h I ~~ ~n ~ N L ~~ :~ N ~ U h ~ ~ ~ I ~. o *~+ U ~ ~ I, ~i _ m .~,? (n ~ ~s+~.a..R++~• t"' r~- - -- 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 $101.09 $16,679.85 $200,158.20 Child 31 $172.04 $5,333.24 $63,998.88 Spouse 21 $229.29 $4,815.09 $57,781.08 Family 26 $300.24 $7,806.24 $93,674.88 Composite NIA N/A NIA N/A Aggregate Premium 243 $7.79 $1,892.97 $22,715.64 Composite Aggregate Attachment Pts. Single 165 $434.02 $71,613.30 $859,359.60 Child 31 $702.08 $21,764.48 $261,173.76 Spouse 21 $769.09 $16,150.89 $193,810.68 Family 26 $1,037.14 $26,965.64 $323,587.68 HIGH PLAN $ 50,000 Specific Deductible Basis for Deductible: Incurred 15 months Paid 12 months. Number of Rates Monthly Premium Annual Premium Participants Specific Premium: Single 165 $82.06 $13,539.90 $162,478.80 Child 31 $143.49 $4,448.19 $53,378.28 Spouse 21 $187.47 $3,936.87 $47,242.44 Family 26 $248.91 $6,471.66 $77,659.92 Composite NIA NIA NIA NIA Aggregate Premium 243 $7.90 $1,919.70 $23,036.40 Composite Aggregate Attachment Pts. Single 165 $449.15 $74,109.75 $889,317.00 Child 31 $728.51 $22,583.81 $271,005.72 Spouse 21 $798.35 $16,765.35 $201,184.20 Family 26 $1,077.71 $28,020.46 $336,245.52 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 $67.66 $11,163.90 $133,966.80 Child 31 $121.44 $3,764.64 $45,175.68 Spouse 21 $155.65 $3,268.65 $39,223.80 Family 26 $209.42 $5,444.92 $65,339.04 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 $460.70 $76,015.50 $912,186.00 Child 31 $748.83 $23,213.73 $278,564.76 Spouse 21 $820.86 $17,238.06 $206,856.72 Family 26 $1,108.98 $28,833.48 $346,001.76 INSURANCE MANAGEMENT SERVICES .. 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 SPECIFIC PREMIUM EMP ONLY $101.09 $82.06 $67.66 $52.77 EMP/CHILD $172.04 $143.49 $121.44 $129.65 EMP/SPOUSE $229.29 $187.47 $155.65 $129.65 EMP/FAMILY $300.24 $248.91 $209.42 $129.65 AGGREGATE PREMIUM $7.79 $7.90 $7.91 $14.00 AGGREGATE FACTORS EMP ONLY $434.02 $449.15 $460.70 $408.59 EMP/CHILD $702.08 $728.51 $748.83 $809.44 EMP/SPOUSE $769.09 $798.35 $820.86 $781.26 EMP/FAMILY $1,037.14 $1,077.71 $1,108.98 $1,062.00 ADMINISTRATION FEE* $34.75 $34.75 $34.75 $37.97 TYPE OF CONTRACT 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 $200,158.20 $162,478.80 $133,966.80 $104,484.60 EMP/CHILD 31 $63,998.88 $53,378.28 $45,175.68 $48,229.80 EMP/SPOUSE 21 $57,781.08 $47,242.44 $39,223.80 $32,671.80 EMP/FAMILY 26 $93,674.88 $77,659.92 $65,339.04 $40,450.80 ADMINISTRATION FEE* 243 $101,331.00 $101,331.00 $101,331.00 $110,720.52 TOTAL FIXED COST $539,659.68 $465,126.84 $408,101.88 $377,381.52 ESTIMATED CLAIMS $1,310,345.38 $1,358,201.95 $1,394,887.39 $1,310,673.12 EST. ANNUAL LIAB. $1,850,005.06 $1,823,328.79 $1,802,989.27 $1,688,054.64 ATTACHMENT POINT $1,637,931.72 $1,697,752.44 $1,743,609.24 $1,638,341.40 MAX. PLAN LIAB. $2,177,591.40 $2,162,879.28 $2,151,711.12 $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 w ith an estimated annual cost of $18,342.36 based on a benefit of $20,000 per employee. Notes and Contingencies: 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 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. X10) 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 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. ~rrr' ,, INSURANCE MANAGEMENT SERVICES Managing Care for You ~n- Participating Employee Per Month $34. CLAIMS ADMINISTRATION Medical Included COBRA / HIPAA Administration I Includedl PPO ACCESS & ADMINISTRATION Texas True 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 Includedl 'IMS REPORTING SYSTEM Included ' Online Reports, Hard Copy Reports & AdHoc Reports (IMS May charge for complex report requests) (PRINTING OF EMPLOYEE BOOKLETS I Actual Vendor Costl (PRINTING OF PPO DIRECTORIES l Not Included PRODUCTION OF GROUP ID CARDS ~ Includedl ~i~rr` INSURANCE MANAGEMENT SERVICES Managing Care for You CLAIMS ADMINISTRATION Dental $3.00 Vision $1.50 STD $0.50 FLEXIBLE 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, Inc. 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 Ag~-egate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD&D Health Reimbursement Arrangement Cafeteria Plan (1RS code 125) Administration Prescription Benefit Management CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTIIER RESPONSIBILITY MATTERS Name Of Entity:Insutance 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 ofhad 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 antitnzst statutes or commissiarr 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 apphcation/proposal had one or more pubhc transactions (Federal. State, Local} terminated for cause or default. I understand that a false statement on this certification may he grounds for rejection of this proposal or teirrtination of the award. In addition, render 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. _ P CK_ SAnI~J_ERS, V. P. CF (MARKETING 'ame and itle uthorized Representative (Typed) Signature o Authorize epresentative Date 08/30/2007 1 am unable to certify to the above statements. My explanation is attached. ''\r~' '' Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group "Perm Life and AD&D Health Reimbursement Arrangement Cafeteria Plan (IRS code I25) Administration 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 co^.fer 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 Count;. 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 hoeing exercised their person's official discretion; power or duty with respect to this proposal; the proposer certif es 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, tnrstee, agent or employee of Kerr County in connection with information regarding this proposal, the submission of thrs proposal, the award of this proposal or the performance, delivery or sale pursuant to this proposal. 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. COti1I'ANY: ~ Manx ement Services AGENT NAME: PRTR ,K S RS AGENT SIGNATL~FZI:: ADDRESS: 731 N. Taylor CITY: Amarillo STATE: "I`exas ZIP CODE:?9107 TELEPHONE: 806-373-5944 FAX: 806-373-3121 FEDERALTINti: 75-2355889 ANDiOR SOCIAI. SECURITY #.~ No Deviations. DEVIATIONS FROM SPECIFICA170NS IF ANY (Attach documents as necessary or state No Deviations): Conflict of Interest Questionnaire For Vendor or Other Person DO1nQ Business with a Local Government Entity This questionnaire is being filed in accordance with chapter 176 of the Local Govemment 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 Govemment 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 ] ofthe year for which the activity described in Section 176.006(a) Local Govemment Code. is pending and not later than the 7~' business day after 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 enrty 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 of the 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. Si ~T~nature of pers dot business with the Datc Governmental entity i~ll•d ~wr Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD&D Health Reimbursement Arrangement Cafeteria Plan (IlZS code 125) Administration Prescription Benefit Management Individual Stop Loss Insurance (ISL)/Aggregate Stop Loss Insurance (ASL) Request for Proposal Submission Form ~rr+ fir.' 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). 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 5. KERB COUNTY will only consider stop loss insurance policies meeting the following: e. Insurance Company Quotation Document with all terms clearly listed f.. Waive Actively at Work Provisions 6. Renewal rate must be received by KERB 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 Benefit 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: 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? 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. Taylor, Amarillo Texas, 79107 ~1~/ c. Mailing Address: P.O Box 15688, Amarillo Texas, 790105 d Contact Person: Christina~Smith e. Telephone Number: 806-373-_5944 f. Type of Business Entity: -Corporation X General Partnership Sole Proprietorship Registered Limited Liability Partnership _ Limited Liability Company 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: 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 ~r-" 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. Bankruptcy 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 Page ~ 3 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 KERB 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 l0 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 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 precertifications, etc.) • Copies of case management progress notes • Copies of all provider bills (refunds, exception payments, overpayments) • Copies of EOBs Page ~ 4 9. 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 KERB 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 I5. 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 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. Page ~ 5 19. Do quoted rates include advance funding for: a. Specific Claims? X Yes No If no, additional cost to provide: b. Aggregate Claims? f 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 +9.0% +2.0% c. BOBS No data No data d. CNN No data No data e. Beechstreet +2._5% +1.2% f. Other (Name) Page ~ 6 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 ~ 7 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 - Natrick Sanders - 10 years; llirector 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 l0 years of service with IMS and l5 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 10 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 ~ 8 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 (CES) 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 ~ 9 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 1-800-687-5944. 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. `~r+ Page ~ 10 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 direetly 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 ~ 11 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 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 ED[. 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 at one 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 ~ 12 6. How many checks are provided in your cost assumptions? As stated in the question above there is no additional charge for checks. L What U.R. services are performed in-house? Utilization Review 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. 3. 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 4. 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 ~ 13 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 1. 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 P-an 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. fir' Page ~ 14 4. What is the cost of printing the 500 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. 5. 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. 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, 1MS 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 ~ 15 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 afl 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 $5.00 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 ~ 16 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 11-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"/0. The dispensing fee is -0- (zero). Page ~ 17 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 defmition 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 (MUDB) 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, 1MS will share 50% of the rebates payable to IMS for Kerr County. ''~r-'' Page ~ 18 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 F&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., treatment/prevention) 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 ~ 19 • Approach to treatment • Formulary consideration • References. Other information that may be provided includes but is not limited to: ~hr-" • 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. Efficac 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-a roved indications • Better adverse-effects rofile, includin lower fre uenc and diminished severit ^ Fewer contraindications or recautions • Greater efficac as shown b well controlled com arative clinical trials • Im roved or uni ue dosin schedule • Im roved or uni ue 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 ~ 20 including 14 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 ~ 21 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: rr+' • 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 611 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 ~ 22 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 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 ~ 23 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 ~ 24 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, real-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 (25 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 Mlle/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. 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 ~ 26 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. err' 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 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 ~ 27 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: `hi~r~" 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 90J10 for generics and SO/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 ~ 28 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 CD-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 stuffer ^ 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 Doctor" 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. i`r' Page ~ 29 - Caremark's drug conflict interaction checking system automatically determines when abrand- namedrug has a generic equivalent. The pharmacist will dispense the generic alternative, provided that the physician has not written "llispense 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. `err' Page ~ 30 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 I% increase in generic dispensing rate. 33. What financial advantage would KERB 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. ~rr® 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) Debit -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 -l8 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 ~ 31 • 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 Benefifs 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) 'ire/ Page ~ 32 • 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 ~ 33 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 ~ 34 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 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 "1" 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 COi1NTY. 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 ~ 35 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 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 participant/dependent 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 active/eligible 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 ~iirtr-' notice. Client acknowledges that as a part of the claims audit it shall not be entitled to audit: (i) Page ~ 36 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 ~ 37 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. ~r 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 COiJNTY? 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 KERB COiJNTY 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 ~ 38 Cafeteria Plan Administration 1. Name, address, city, state, zip code and telephone number of home office of firm. Branch office location(s), if any. [nsurance Management Services ~' 731 N. Taylor Amarillo, TX 791.07 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 fum 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? tf 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 t7ex benefits without having to submit a paper claim. The debit ~r+` Page ~ 39 card requires a minimum of 20% of total annual elections at all times for those who elect the debit card feature. 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. Page ~ 40 2. Is your organization for profit or non-profit? 'fir Insurance Management Services is a for profit organization. 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. Page ~ 41 HISTORY 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 12.5 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? IMS 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. REFERENCES ~rir+ 1. Provide the names, addresses, telephone numbers and contact names for three of your clients. For each client listed, provide the number of employees covered (on your capacity as a Section 125 Administrator). Also state whether or not any of the Section 125 Administration Agreements with these firms are on a fee for services rendered basis. Please see Attachment "O" for our references. 2. Please include a resume of the contact person responsible for this case. (Christina's) Christina Smith Hire Date: 05/1994 Function: Marketing Manager Experience Insurance Management Services - 0511994 to Present Western Merchandiser, Warehouse Accessories -12/1993 to 05/1994 Hancock Fabric, Cashier - 07/1991 to 10/1991 Jack in the Box, Cashier - 06/1988 to 11/1988 Education Baker High School - 1985 to 1988 Amarillo College - 1989 Page ~ 42 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 RXData 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 partneredwith 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. World Doc 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. ~r~' Page ~ 43 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 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. Page ~ 44 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 DM 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 ~ 45 ~Ir' ~/ IIRA PRODUCT FEATURE Included? Web-based HRA Yes Pa er-based HRA Can be printed 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 Lifes le risks Yes Safety Yes Preventive exams Yes Immunizations Yes Biometrics Yes Readiness to chap e 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 ics within web site Yes Summary 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 ~ 46 IMPLEMENTATION & COMMUNICATION STRATEGY: l . 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 (H RA 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.com 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. fir` Page ~ 47 Kerr County "` Health Benefit Plan Proposal 2008 Contents • A -Errors and Omissions Coverage • 6 -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 ~~SU~NC ~'~~ AMERICAN INTERNATIONAL SPECIALTY LINES INSURANCE COMPANY C i OMPPN A Capital Stock Company {herein called the "Company") 175 Water Street A Member Company New York, N.Y. 10038 of American International Graup, inc. POLICY NUMBER: 965-16-38 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 15 NOT LICENSED IN THE STATE OF NEW YORK AND 1S 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. FOLK. SUITE 101. P.O. BOX 15688 AMARILLO. TX 79101 Item 2. Policy Period: From: OCtObt?r 2T , 2006 To: October 21. 2007 (12:01 A.M. standard time at the address stated in Item 1) Item 3. Limits of Liability: (inclusive of defense expense): $1.000.000 each wrongful act or series of continuous, repeated or interrelated wrongful acts $1, ooo, ooa aggregate each wrongful act or series of continuous, repeated or interrelated wrongful acts Item 4. Deductible: $50, 000 Etem 5. Premium: $29,864 7I91971 ORIGINAL 52948 11 / 92) //*rJ$(/ _ _ 1 ^ r INSURANCE MANAGEMENT SERVICES PHONE 8U6-373.5944 P.Q. BOX 75688 AMARILLO, TEXAS T9105 EMPLOYEE SUBROGATION 12E: Insured: John Smith Claimant: Sohn 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 the 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 office: * 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 questioru~aire 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 r INSURANCE ('~ANAGE~IENT SERVICES PHONE 806-373-5944 P.O. BOX 15688 AMARELLO, TEXAS 79145 ATTORNEY SUBROGATION May 26, 2004 Frank Fertita Attorney at Law 8550 United Plaza Blvd, Suite 200 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 Health Benefit Plan which insures John Smith. The plan includes a provision which penr-its 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 Department Enclosures: Copy of Plan Document page Copy of Reimbursement Agreement ~ cc_ Insured INSURANCE MANAGEMENT SERVICES PHdNE 806-373.5944 P.O. BOX 15688 AMARILLO, TEXAS 791 a5 THIRD PARTY SUBROGATION May 2G, 2001 Progressive Insurance Company ATTN: Belinda Stewart 434 S. Shettivood Forest Blvd, Suite 290 Baton Rouge, LA 70817 Your Insured: William Winebreruler, Benjamin Rodgers Claim Number: Unknown Claimant: John Smith Group: ABC Company We represent tl-te AEC Company Employee Benefit Plan which insw-es 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 notif cation of the plan's lien against any third party recovery for the above loss. In view of the above circumstances, we request that you protect the plan's interest relative to any releases andlor payments made as a result of the above Ioss. 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 Smitlt 1 f you are executing this assignment on betta[f of anatlter person, state the person's name: N!A and relationship to the Participant: Self Under the teens of the 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 behalfof 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 party. Therefore, the Administrator must cease making further payments for such expenses until this Agreemen# 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 Plart the right to recover the amounts advanced from any proceeds which you are entitled to receive from the third party which is determined to be responsible for payment of such amounts. E3y executing this Agreement you hereby grant the Plan the right to recover all t}te amounts, which have been or will be paid an 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 ham any proceeds, which you, or the Participant on whose behalf you execute this agreement, are entitled to receive from the responsible third party. It does not matter }tow the proceeds are obtained, what they are called, or wEtether or not the proceeds indicate 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 tktat 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 ofthis 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 the Plan to obtain recovery from 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 who is or may be legally liable that the Plan Etas a first lien on the amounts to be recovered. 6. The Plan is not obligated to pay Iegal 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. 3. If you are executing the assignment an behalf of another, you certify that you are legally authorized to execute this Agreement. It is important that you understand the significance ofthis docwnent. Yau should consult counsel to ensure that you understand the legal ramifications ofthis Agreement. Your signature below represents that you are a Participant under t}te terms of the Plan or are legally authorized to execute this Agreement on behalf of Participant, and that you assign to the Plan any and all interest to any recovery wlticlt you may hereafter obtain from any tktird party relating to t}te illness or injury for wlticlt the Plan Itas advanced medical expenses under the terms ofthis Agreement. Executed this day of 200 WITNESS: Signature. Motor Vehicle Acciden# Third Party Reimbursement 1. Plan members fiili name: Social Security Number:. 2. Injured Persons Full Name: Relationship to Ins«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 *x*PLEASE PROVIDE A COPY OF T1E•IE POLICE REPORT~r 7. Please give a description of the accident. (Be Specific) 8. Please give the name 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 eIaim tivill be started because: 1~1. Other continents: Signature Date REIMBURSEMENT AGREEMENT AND ASSIGNMEiVT OF PROCEEDS FROM THIRD PARTLES fir' Name of Plan: ABC Company Name of Participant: John Smith If you are executing this assignment on behalf 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 4vhich such Participant has a claim against any third party are conditioned on the Plan being reimbursed. The Plan reduires that no benefits be paid on behalf of the Participant until the necessary documents are executed to protect the P[an's right of recovery. Based on the information obtained, tl~e 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 who are legally obligated to make such payments may impose undue hardship an you as a Participant. To enable you to satisfy theses financial obligations while at the same time preserving the assets of the Plan, tl~e Plan permits pre-payment of benefits on your behalf if you assign to the Plan the right to recover the amounts advanced from any proceeds which you are entitled to receive from the third party which is determined to be responsible for payment of such amounts. 13y executing this Agreement you hereby grant tl~e 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 tlsird 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 behalf you execute this agreement, are entitled to receive from the responsible third party. [t does not matter how the 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 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. 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 the Plan to obtain recovery from the persons or entities that are legally responsible. 5. You agree to provide the Administrator all necessary information to al[aw 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 such recovery. 7. This assignment may not be revoked after the date on which the Plan first advances benefits pursuant to this Agreement. 8. I f you are executing the assignment on behalf of another, you certify that you are legally authorized to execute this Agreement. It is important that you understand the significance ofthis document. You should consult counsel to ensure that you understand the legal ramifications ofthis Agreement. Your signature below represents that you are a Participant under the teens of the Plan or are legally authorized to execute this Agreement on behalf of Participant, and that you assign to the Plan any acid all interest to any recovery which 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 200_ WITNESS: Signature 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. G. Name, address and telephone ntnnber of responsible party's insurance campairy. 7. The name, address and telephone number of your attorneys. 8. Name, address and telephone number of responsible party's attorney {if available). 9. Wilt suit or claim he made against the responsible party (Yes or No). If not, please explain why? 1~. Other comments Signed: Date ~'" SUBROGATION 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 Pian Administrator may make advance expense reimbursements ta, 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) shah 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. ff a Participant or Eiigible Dependent receives any benefits arising out of an Injury or Illness for which the Participant ar 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 parry 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, 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/ar (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, 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 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 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 far 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 Par#icipant 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 ar 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. `.r Name of Stop Loss 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 MANAGEMENT SERVICES SAMPLE REPORT 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 .y Q ^''~ .~ V a~ `1 b Q N /J ~i Z ~~ •• ~ ? V 0 N O O w O O N N b O O O O `r Y U r C ~' G 0 0 0 ~O O ~D N ~h l~ ~ V N M 7 OD (y O~ r M ~f1 01 64 I! 69 69 O O J I ~ o h U , n ~ w ,,, [y vi U . ~ a ~ ti O O i r [~ h O o o 'I ~ I M ~D 69 it 69 I 69 ~~ O O v o y O U 'Ct °' ~ +.~ ~'. •y ~ 0 U O '~ E U Q N v~ O 69 ~ M M ~ ~ O O ~ ~ M M 69 69 b ~ ~ N N b M Q YS N ~--i ii U Y ~~ Y y d i F ~ U U C la y ° ~ c O ',~ U ~ a ~ ~ ~ ~ ~ w '..~ M M 00 00 ~n l~ O '. ~ O1 ~ ~ ~ ~, O ~ ~ h ~ O ~ , o o l~ O .. 00 69 6v 69 m ~ y ~ m ~ I ~ li d ~ i ~ ~ V U C '.°' ' r ~ c ,ti C'' ~ ~ ; O r \ U h F Q. OV' N 7 O v1 ~ ~ ~ ~ .-- ~ 6R 69 O R W W d 4' r e W ~ N 00 O N ~n ~ O Q ~ m ~ ~ ~ W d 0 w ~ W ~ ~_ N ~O 69 64 O GL W W d C m Oa W R H ~ v ~ r Op M ~ ~ w OO W H w c H U U N ~ 7 U C A ~ w ~ g A '~ A A = i F ~ i D 4 3 ~ ~ ~ /=1• f U t ti •~ 0 ~~ ~O U ti N W U W N F- z W r~' 'W^ L Q Z !Q i ~~ b h Q N h O O ti N O O 0 0 O N ti 0 N 1 O 0 0 CC e 0 co o~ N r t .~ T a d ti ti ~ ~ .a •~ ~ U o 0.~. _~ ^ a> O ~ U U '~ cad ~ a A y ~ .~ ~ a. d oC ^ ^ ^ ^ a ti E ~. T C d ~ ~ E U o Q. ~ ~ ~ .~ .~ ~ U ~ `' O .. a ~ ti ~ c ~ a ^ ^ ^ ^ T ti C N m U ~; w Z U C N w C 0 G .a Q O s Q N 1 N Q 0 0 O O 0 v M V v O .., \ I ~O •~ '~V ~' o U ti ', [r '' 7pdp.' G Z ~ ~ r \ iii c ~'1 o o o O Z ti ~ r 3 ~i, ~+ O O ~ O N b y a 1 ~ 0 ~ O O v ~ ti N V O W H Z ~ ~ O I r W ° U I ~ ~ U ~ ., Z ~ y °i .oo ~~` v 0 m 00 N (h r N M rn m N U9 0 .~ ti 0 O M lf'7 CJ M n N ,moo ti 0 M O V 0 M rn by U U _~ 'O ~ ~ ~ ~ ~ U ~ °~ > r ~ ~ ~ G ~ ~ U ~ ~ o ~ ~ ~ N o v F ~ U Y ~0 3 ~ 3 ~ V pO+ .~ w ~ C W 0 M O O O r O U R ~ ~ U a. o ~ . ~ b U ~ :o ~'j > e ~ °' o `e ~ ~ U y,. ~ O ~ fS. ~ ti y -o ~ ~ ~° N y 3 .~ °' ^ U b S W 0 N O M N_ _~ O N ~- O 00 0 0 ~n CO O 00 O fPr m ~ O ~ O M GO 69 69 A x T ~ .ti a a. ~ Q V ~ V Q 0 M r N lA O O O M I~ O a0 O od o 0 n ~ v ~ W M OO ~ M U ~ +y.. .a a a s Q U ~ V A 0 N N M M O O M N O N h ~ 0 0 M 00 O O O O co Sri cfl of o 0 O ~ ~ fR fR O W ~ 00 Q~ M 69 fR 00 N ~ N N ff~ rHi 0 .° ~, i _ X Q ~ ~ T c~a 3 0 ~ ~` .~ ~ y _ ~ ~• ° z ~ x z v ~ z U V U O am x s cC a c . ¢ o . r 00 O r O O O O ~ (O O N ~ O ~ O O O N r O O .- fD sf N ~"> ~ 67 f~ ate- M N EH (h O O l!') ' M l7 N c0 M O N ~ ~ ~ n 'cf ~ fR fR to ti e v o C] o C] ~ ~ ~ 3 s ~ v ~ x is U ~ z °' x V ~ o z~~ en e ~ v v ~ s w a 0 a a ~ e C 0 0 O O V' O v EH ~ O M O M O 00 V3 O n M N 0 M O M O O v n M M O (D '7 O r .~. ~ U ~ oA y ~ ~ ~ ~ ~ c ~ ~ U ~', 0 0 N M O ' (h ~' O I ~ ~ N M b9 M O N 00 O ~ 0 I~ 47 0 f!4 CO ~ O ~ i» V :: ~ uq ~ ', y~l ~- ra d ~ s' ~ ', U ;° > O > O CO ~ Q „r~ U o` (y ti z \° 0 M ~./ z ~I Vl WI l H' ~ II O U 0 N N H W z H 0 H 0 w 4 i o > > o ,~ C i ti a b o ~. H '1N~ •~ vv fi V w V b a N ti Z C V V 0 0 N M N ti N ti b O O bA y U ~ °~ ~ V '~ y G ~ H ~ ~-°'~ Qw~zox ^~^^^ ~o .~ o ~ ~ ~ U ~ ~ U '~ ~ c a ~ `~ ~ a ° a..w'°" °' E ~ ~ ~~'~ Qw.,zox 0 N 0 0 O 0 r M 0 a \° 0 M 0 N O N ~ ~.1 w ~4 V ~: .~ O O N b O N ti ti O +d. C Q O d 0.', O r0 d ti ~ M ~ ~ ~ M ~ ~ M o00 N O ~ N N ~ ~ ~ ~ 01 00 N O V V1 M V M R N OM N O 00 ~ O 00 O 00 ~ 00 ~D o0 V ~ ~ M vl ~ ~ [~ r .-. N N ~ O 7 [~ O~ M oo v~ ~--~ 00 V l~ [~ 7 N O O O l~ M N_ O~ ~D 00 .--~ l~ 7 ~/l oo l~ ~--~ h ~ ~ 7 O~ O ^ ~O (~ ~ O I~ M 00 ~ ~ h 00 N C 7 M M M O O N N o0 ~O ^ [~ V o0 M ~--~ Vl ^ oo N N ~--~ V M N Q^ ~ ~D M ^ ~--~ N 7 V M [~ ~O 7 M O~ 00 00 v'~ M a0 [~ l~ 7 7 N O~ M O ~ 7 O~ O l~ b O l~ N ^~ O o0 ~O ~O V N N O~ l~ ~ ~ ~ M M M M N N N N N ~--~ ~--~ ~ ~--~ N V ~ O ~ 7 ^-' O~ V1 M N N N N N •.• •-• •-• 69 b9 69 69 69 69 b9 fA 64 b9 b9 b9 to d9 6A EH 69 64 EH O M N N EH 69 69 b9 b4 6R 69 EH EH EA b9 69 b9 b9 ^ 69 69 69 fA N3 fH 69 O H O w z :~ O Q Q a a, x O W Q 0 w 0 v O z Q b Q M N r c O V IZI fi ~~ U F w W U a ate. d O z w w a. w e 0 c q r a z Q O 0 x w Q a. a z 0 H a. U O z z H z 0 h H W z c~ z F= W a z Q a a 0 0 U O z w C] O U O 0 w H z x a x 0 r r m Q w 0 z d z z_ F z o Q ~, w .. x U U O a x H ~ ~ w O q O O F U v z ~" w v' w H U', y vi ~D N Q~ Qi z ~ v1 d' N 7 00 00 00 h O~ ~--~ M ~ ~O ^• l~ M .-. ~ N z ~ ~ [~ W M ^• P. V ~ oo N O ~--~ V1 O N W ~p ~ M O N O o0 N 'Q ~--~ 40 ^ t^ p~ O ~-+ ~D ~O CG [~ N o0 N O~ V N ¢ O~ M O~ 00 ti ~ vi v v~ ~n L4 ~n ~n ~n rn ~ ~ v'1 v~ V ~n C ~n V] v~ v-~ ~n v~ ~n P. ~n r7 ~ ~ ~ v ~n ~n ~n U ~n ~n v w o~ z V v ;O ,ao o~ O O M N ti h O N 1 O ti O C A r 0 b a N H z W W C9 Q cZ i C ~W ~4. !~ V _~~ e O ~0 d ti ~D h l~ N V N 01 O O oo ~ ~ ~ oo V" O O N O M O O O~ O ~O M oo O 7 O~ O ^ a0 O ^ O ~/1 M O~ N 7 O M O~ vi ~D O~ O N ~O N O O~ M O~ O v1 M ~D o0 ~O O O O ~O O~ N O l~ M O 7 O O h O O N O O~ .-+ v1 ^ ^ ~ ~ er M ~O O~ a N ~ N W M 7 00 O~ N l~ ~ ~ O M ~ O~ M vi t~ O O ~ 7 ~O l~ ^ M ^ N ~O V O CO M v1 N O o0 M o0 T M ~D ^ ~O ~O Q~ h 7 ~n ~ O r 7 O~ 00 ^ ^ O ^ ~ vi oo V O~ N N O N ~O o0 l~ .-• ~O M 01 ~O o0 ~ ~O ~D .--~ oo h ~ N [~ M M ~ r ~ 7 M ~-. ~ ~-. O v1 7 ~ ~ V M N N --, ~LJ ~--~ V O O l ~ O ~O ~--~ Oi O l~ ~ vi --~ O~ vi M ~ O ~ l0 l0 ~ ~ V V M M M N N --~ ~ ~ ~ ~ ~ ~ .--i ~/1 V1 00 N O O~ 00 ~O \O h V1 M N N N •--~ •-+ •-• ~-• 69 b9 69 bA b9 fA 69 d9 69 fA f/~3 fA 69 69 69 69 6R 69 69 69 M N ,-• FH 69 69 fA 69 b4 (A 6A 6R 69 b9 69 69 b9 b9 ^ 6R 69 69 69 z 0 h 0 w z a 0 F W Ll .a Ca rA w F ~ w a U W U U F w W z w co v a 0 a d F- O z w z a w 0 C U d q ti c7 z d O U ~. w L1 a~. Q x a Q 0 a d H z a a a w x H .~_ Z ~ Co ~ _ ~~~ v y ~ 7 O~ N N ~ ~ m M oo ~ r o0 00 [~ r ^• M '~ ,-• ~ r ~ M N O Z .-• 7 N O O ~ ~ N ~ O oo O~ N M N ~l1 7 ~ O o0 ~ N ~ W O h N V O ^ CY. 00 ^ ^ ^ 7 O ~--~ W N N h V ti v~ ~n ~n 7 ~n v~ v~ v~ ~n ~n ~n ~n v-, ~n ~n V ~n ~n Cl. 7 ~n v~ v-, v-, rn vi P. ~n ~n ~n oo v~ 7 cn ~ w oo ~ ~ ~ 0 W r~. ~., z o a V ~. ~ U fi bQ ~~4 O V 0 U w ~ ~ M cn N N ~--~ 69 69 69 b9 Ei4 69 69 64 69 o ° o N N O M N p O ~ ~ O ~ O ~ N N O M N p O M ~ O ~ O ~ N N ~O M N p O N M O ~ O ~ N N O M N p O ~ N O ~ O O N N O M N p O ~~ o o ° N_ N O M N p O ~' ~ O ~ O ~ N N O M N ~ O M ~ O ~ O O N N O M N p O N M O ~ O ~ N N O M O ~ _ N O ~ O ~ N N O M N p O s v w r U ti V o o N_ N O M N p O ~ ~ O ~ O ~ N N O M N p O M ~ O ~ O ~ N N O M N p O N M O ~ O ~ N N O M N p O N ~ O O ~ N N O M N p O ~ ~ o ° o ° N_ N O M N p O 7 ~ O ~ O ~ N N O M N p O M ~ O ~ O ~ N N O M N p O N M O ~ O ~ N N O c\ N p O ~ N O ~ O ~ N N O ~ N p O ti W a~ '1 r'1i 'Ir 'Z rQ\ a' V U R' W ~_ W ~"~ Z in, ~--~ ~~ r-~.,, v V 0 r V O V Oi 4` ~ ~ M MO N N ~--~ O 69 ~ 69 69 64 b9 69 69 69 69 O p O p N N OO M N p O ~ ~ O ~ O ~ N N O M N p O M ~ o ° o ° N N O M N p O _ N O p O p N N ~ M N p O v~ ~ O p O p N N ~ .-r OO M N p O ~ ~ O p O p N N O M N p O M ~ O p O p N N O M N p O N M O p o ° N N O M O p ~ N O p O p N N O M N p O Oa O i w h V ti ti ~ 69 6~9 64 ~ 64 6~9 ~, ~ O ~ O p N_ N O M N p O C ~ O p O p N N O M N p O M ~ O p O ~ N N O M N p 0 N M O p O p N N O M N p O ~ N O p O p N N OO ~' N p O ~ ~ O ~ O p N N O M N p O 7 ~ O p O N N ~ O M N p O M ~ O p O ~ N N o `~' N p O N M o ° o ° N N O M N p O ~ N O p O p N N O .M~-. N p O Q V i b O Z` U N w. O1 M ~ ~Q N ti ~ O O ~a N ''' 'Y` o ti o v ~o I~7 ~N O ~~ 'V~ a L = C C O ~ ~ ~ N ~ l0 N ~ ~ d ~' m ~ c_ ~ ~ LL e a~ L a E U U m Q 69 T ~` t L C C O ~ d ~ m ~ ~ N _ m ~ c ~ ~ LL t ~ O ^~ lLL ~ d o '~ 0 0 a3 N _ Q „ Y o w ~~ ~ Q ro C E 0 U U m Q 0 0 0 0 0 0 0 o O O O 0 0 o O O O O O O O 69 O O~ oo [~ ~O ~ ~ cn N r. 69 FA 69 69 64 69 69 69 69 69 _T ~ L f, C C O ~ ~ ~ A N ~ l0 ~ ~ T v ~ ` ~ LL 1 ~ ~ ~ ? r o Q ~ O ~ N 0 0 0 0 0 0 0 0 0 o O O O O O~ O eo O [~ O ~O O ~n O 7 O M O N O b9 -~ ~ 69 69 b9 69 69 69 69 6A b9 ti ~ ti ~~ T ~ L t C G O ~ ~ ~ N ~ R ~ ~ ~ d ~' O1 c ~ !n LL d A U r m m 2 ~p C U N J C ~ d m ~ N ~ d U .~ N U C .~ 00 ~ ~ T ~ U r d ~ c ~ m E r ~ U c U l0 G N C ~ O N ~ U N C ~ ~ LO G > U C o. E 0 U U Q7 Q O O O O O O O O O O O O O 69 N O ~ ~D V N 69 69 6A 6A 69 69 O N O W 0. z i Q V Q O .~ C O N '~ 1 ~ v O ~ ti ~ ~ Q ~ J ti ~"~ fi ~ o ~ O U U .v 'a^'1 ti iy Ol N ~~ Q Q C C C C a a d ~ N N ~ ~ O T rn E C_ N N LL N O T C N O. E O U U !b Q > > c c ,per a a d ~ d ~ `c ~ a ~ ~ E ~ (~ LL a' O 0 O m d N Y ii m o J Q C~J N h E `m ~o E Q C a E 0 U U 00 Q C C C C a a d ~ f6 f6 Q' ~ N ~_' rn E C_ ~ ~ ~ d l6 U L_ N C1 U N J C ~ `y l0 ~ d 2 N U C ~ N C C O O ~ ~ T ~ U O C a ~ c E m E F O U c m 5 c ~ 0 m ~ U 41 C ~ ~ y O G U c a E 0 U U ¢1 Q O O O O O O O O O O O O O O O 69 O O O O O O O V N_ O_ ~ ~O 7 N ~ ~ ~ ~ 69 69 6A N O A P. ~ i °o N L:. ~ N ~ s x ~ ti C S. f v O ~ fl. H . W G w o a~i ~ . 7 h ~ !~ jj T C U N O R V] ,~. i 0 0 0 0 0 0 0 0 0 0 0 0 0 ~ 0 0 0 0 0 0 .N-i C W ~ 7 N b9 b9 6A 69 6A 6A O O O O O O O O O O O O O 69 O O O O O O N_ O_ co ~O d' N 6A 69 69 69 ~ ~i 0 `Iv !\ ~V '~v O •V A 0 0 0 0 0 0 o a o 0 0 o a o 0 0 o a to 0 c0 ~ O Q~ N f~ a0 O N c0 V' O OD CO f0 I~ N O~~ lCJ GO M I~ M M O O W eD aO O O 00 W N V O O~ M~ M 00 M M M N M f0 N~~ ~ N M M O N N M M O Cfl M O O h ~ O I~ ~ fD O O ~ W O 00 O I~ M 69 M N to 69 fH 69 ~ lA M fD O fD N M O O r ~ ~ N f~ tfi ~ r~ ui r ~ OD CO M EA 69 b9 fA m ~ st N e0 ~ h O N 00 f0 ~ O ~ M t00 r M ~ O H9 69 69 V ~ O ~ N M .- W ~ ~ tND oOD O lli M M N N O m ~ N ~ ~ ~ ~ 69 0 a =1 O Y U C .x Q X N ~ z ~ °' x °' z b W ~ U U~ ~ ~ U V ~ ~ Px, '~,~. a , ~ ~ Ox. ', m r . W ~ . ~ ~ ~ m x I Z ~ o w d W _' I I ~ c ~ h ue fi 4 ,s , ~ ti a z ~ ~ z r A ~ ~ Z 1~ ~ M O I~ ~ O ~ O O f~ O O N aD ~ 00 ~ ~ ~ M fA fR K3 fD d0 N ~- M ~ ~- ~ O O I~ M N I~ ~ ~ v ri oo n M ~ b9 ~ ~3 U3 0 Y 3 ;, U ~ ~ O m ax. .Q i c 0 M ~ ~ ~ ~ 1~ a0 n O ~ a0 O ~ ~ M ~ M Efl (D ~ ~ (fl fR O O W O O ~ O O M V O ~ ~ M O W N ~ ~ 01 ~ b9 b9 0 0 U ~_ ~ Q otT. 3 ;, ~ ~ ~ ~ z ~ x L V] V] ~ U U O W ax. a v i 0 M O N r M O n M N c6 M EA a O N O O M M O EH 0 ci d a `; C ;~ O 0 d 0 v •~ ++` Z O ti '~ fi V p~ V •~ A N W W N h- Z W '~ W Q z Q '~i J~ ~~ '[""~.o Vl O U N ..k Q ~ g T ' ~ ~ s a~ ° o, z z O a - + x a ^ ^ ^ ^ ^ 0 .~ a i O 3 w O 0 0 U Y C+ O f0 O M M 0 0 0 ~ N v C z C V O oooeoo ~ ~ N O 01 O M m ~ O O r r r~ O O d iO C U . 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'., /~ ;: tc+`r. 01 :. °a ~~ og R N .. Q N ~ O O W Q ~ d H o ~. a w N J ~ ~a W "'~ DV J 'J Q J . Q U Z Q Z LL C[ m z } U d ~ W U LL N ~ = O (Q .. ~ Z H W U d w a0¢ mc~7~y z ° W d N ~ ~ _ ~ U ~ M(n (nm H ~ ? Q W W Q W ~ CO Z ~ ~ ~ w ~ Z Oz¢zz w~aa~ [c ¢UCnU W QO ~ o ~ 0 4 0 M O cJ N fn ~ ~ W J ~ ~ U ~ F of ~ 0 ' ~ 2 ~ a ¢ ~ U cn J J H Q Q W Z O O ~ H F- W Q W ~ d~ v w J X O Q Q O (n F O H Z W c7 ~ ~ W F n ~o Z U ~z a oQ~ dU~ 0 o ~ wiz Z J 7 woUO ~ o ~ w og LL F ~ Z OQO z w w~ U V~iz J Q 0 ~ H a 11~ ~°~' iG !r l: (~ V a Financial Detail Report The Financial E3etaif Report 'prQVides a detailed listing t3f af] clams orb behalf'' cif plan par~icipar~ts. A detail of paid claims, denied claims, and adjus~i~d clai~s'is prouid~d. A uariety'€~f rep©rt a€~d total options ar_e auaiiable.* 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. *** Druq Name: The name of the drug dispensed. *** Druq Strength: The strength of the drug dispensed. *** Druq Form: The dosage form of the drug, e.g. tablet, liquid. *** Drug 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: CAREMAE~C ~,,,,- Financial Detail Report Cont'd Managed Access Codes: A = Multiple overrides, consisting of any combination of overrides, B = Copay override, C = Covered authorization fora drug that's normally excluded, D = Claim rejected for lack of prior authorization, E = Exclusion authorization fora drug that's normally covered, F = MAC penalty override, M = MDP authorization fora 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 Single 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. Inoredient 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/Adistmnt Amount: 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 amount) OR Adjustment Amount for adjustments. Ptah sponsor can choose orie or mare of the fatf©~vivr~g optiens: (i} Subtatafs by ID tYumber {if ID number is included on the report). (2) Tntats byGraup'Alumber, `" (3) Totats by Carrier Number. (~) Tatats byA/it Number. Note: Totats reflect the net of pa}d ctair~ and ad,~ustrner~t arnour~ts _ _ Optional fnvoice Adjustment Count Net ©~ att adjpstment count$ Total FL?R Ad~'ustment Count; Total Count of Each Adjustment Total Paid Gfaims; Totaf of afi pa~dfdenied ctaims Total Adjus[ments: ' T©tat of off a~ ustmeri[s rtat; Totaf of all Paid/Qenied claims +l- Atijustmer:ts CAREMAI~K r IM ANAGED CARE. IN PNDNE I$ODJ 66T-3D2D AO BO% ~5i88 AMARILLO, TX T9t05 CASE UTILIZATION MANAGEMENT SUMMARY Case: ABC COMPANY Case No: S999999 Current Previous Last Two Period: 04/01/2006 Thru 06/30/2006 Period Period Periods (3 Months) (3 Months) (6 Months) Employee /Dependents Total (Monthly Average) 750 779 764 Inpatient Acute Days 13 6 19 Total Admissions 4 3 7 Average Length Of Stay (LOS) 3.250 2.000 2.714 Annual Inpatient Days per 1000 Members 69 31 50 Annual Admissions per 1000 Members 21 15 18 Inpatient Emergency Medical Days 8 3 11 Total Admissions 2 1 3 Average LOS 4.000 3.000 3.667 Inpatient Emergency Surgical Days 5 1 6 Total Admissions 2 1 3 Average LOS 2.500 1.000 2.000 Inpatient Scheduled Medical Days 0 0 0 Total Admissions 0 0 0 Average LOS 0.000 0.000 0.000 Inpatient Scheduled Surgical Days 0 2 2 Total Admissions 0 1 1 Average LOS 0.000 2.000 2.000 Intensive Care Unit Days 0 0 0 Total Admissions 0 0 0 Average LOS 0.000 0.000 0.000 Skilled Nursing Unit Days 0 0 0 Total Admissions 0 0 0 Average LOS 0.000 0.000 0.000 Inpatient Rehabilitation Days 0 0 0 Total Admissions 0 0 0 Average LOS 0.000 0.000 0.000 Inpatient Transplant Days 0 0 0 Total Admissions 0 0 0 Average LOS 0.000 0.000 0.000 ~,r' ~ IM ANA ED CARE. INC. PNDN£ IS00J 567.7020 PO EfDX 15688 AMARILLO, TX T9t0S CASE UTILIZATION MANAGEMENT SUMMARY Case: ABC COMPANY Case No: S999999 Current Previous Last Two Period: 04/01/2006 Thru 06/30/2006 Period Period Periods (3 Months) (3 Months) (6 Months) ', Employee /Dependents Total (Monthly Average) 750 779 764 Inpatient Mental Health/Chemical Dependency Days 0 3 3 Total Admissions 0 1 1 Average LOS 0.000 3.000 3.000 Inpatient Mental Health Days 0 0 0 Total Admissions 0 0 0 Average LOS 0.000 0.000 0.000 Inpatient Chemical Dependency Days 0 3 3 Total Admissions 0 1 1 Average LOS 0.000 3.000 3.000 *Not Included In Inpatient Acute Day Totals Inpatient Complicated OB and Pre-Term Infants 13 0 13 Total Admissions 1 0 1 Average LOS 13.000 0.000 13.000 Inpatient Complicated OB Days Total Admissions Average LOS 0 0 0.000 0 0 0.000 0 0 0.000 Neonatal Intensive Care Days Total Admissions Average LOS 13 1 13.000 0 0 0.000 13 1 13.000 ~+' '. U 1 rV 1 I~ 8 K F O s Q N C e W°a Y 0 N 0 M O H O (p N O ~ N N n ~ O ~ O ~ .. N N io ~ ~ c U ~ o m n~ O O ~ d' O F L ~j ~~ Yt ., 4 a r yw' QQ ON O W ~ ~. } ~~ W U ENO J Q Q Q Q Z 0 ~ LL O C UL QF 2C LL ~F F- 4 Z i i~= o q o 0 0 N o v~ v e- N ~ a v m N II NII ~II III III MI a O ~ N h ~ r W W H S O Z ~ J J ~ O O W w ~ ~ N ~ ~ O a ~ ~ w a Q 0 N u> N O in f0 1~ 0 N n O Q rn cn O M 0 N io N ~ ~ ao ~ 0 N ~ O Q ~* N 0 N rn O 0 O N C~ N ~ O Q ~ 0 O N V N ~ O J ~ 0 O N N N u7 O ~ ~ 0 O N M O fD O 0 O N (D O tD O ~ ~ a y a Z Z ~ ~ U U g ~ Q Z ¢ U ~ ¢ U r ~ O O ~ ~ a ~ . d ~ a~ w ~ ~ o Z Q ~ ~ F ~ °~ E ~ ~ U ~ ~ ~ ~ ~ O a a a o N a ~ rn v co M v ~ M a c a> o ~ Ln N N C d ( ~ m m r~i r°0i ~ 'o v U m ~ ~ rn 0 v 0 m rn o N x W N 4 n m m ro °- r ` u1 V' N V' c ~ U ~ O ~ Ol ~ O 07 ~ O O M O W O T ~ N ' N w ~ r N st ~ ~f1 ~ ~ ~ ~ ~ ~ ~ ~ O a~ rn m a M r IMS ANAGED CARE. INC. PHQHf [860J !667-3D2D PD EtDX 456&6 AMARILLO. 7X 79405 CASE UTILIZATION MANAGEMENT SUMMARY Case: COMBINED TOTALS FOR ALL GROUPS Case No: *** ALL *** Current Previous Last Two Period: 04/01/2006 Thru 06/30/2006 Period Period Periods (3 Months) (3 Months) (6 Months) Employee /Dependents Total (Monthly Average) 58,937 58,700 58,819 Inpatient Acute Days 1639 1706 3345 Total Admissions 395 433 828 Average Length Of Stay (LOS) 4.149 3.940 4.040 Annual Inpatient Days per 1000 Members 111 116 114 Annual Admissions per 1000 Members 27 30 28 Inpatient Emergency Medical Days 693 730 1423 Total Admissions 173 182 355 Average LOS 4.006 4.011 4.008 Inpatient Emergency Surgical Days 155 220 375 Total Admissions 39 66 105 Average LOS 3.974 3.333 3.571 Inpatient Scheduled Medical Days 4 0 4 Total Admissions 2 0 2 Average LOS 2.000 0.000 2.000 Inpatient Scheduled Surgical Days 474 401 875 Total Admissions 145 145 290 Average LOS 3.269 2.766 3.017 Intensive Care Unit Days 262 230 492 Total Admissions 32 36 68 Average LOS 8.188 6.389 7.235 Skilled Nursing Unit Days 0 22 22 Total Admissions 0 2 2 Average LOS 0.000 11.000 11.000 Inpatient Rehabilitation Days 51 103 154 Total Admissions 4 2 6 Average LOS 12.750 51.500 25.667 Inpatient Transplant Days 0 0 0 Total Admissions 0 0 0 Average LOS 0.000 0.000 0.000 M r IMS A AGED CARE. INC. PNDH£ (800) 667.3020 PD BDX 75688 AMARIl49, TX 79fD5 CASE UTILIZATION MANAGEMENT SUMMARY Case: COMBINED TOTALS FOR ALL GROUPS Case No: *** ALL *** Current Previous Last Two Period: 04/01/2006 Thru 06/30/2006 Period Period Periods (3 Months) (3 Months) (6 Months) Employee /Dependents Total (Monthly Average) 58,937 58,700 58,819 Inpatient Mental Health/Chemical Dependency Days 71 68 139 Total Admissions 18 14 32 Average LOS 3.944 4.857 4.344 Inpatient Mental Health Days 63 65 128 Total Admissions 17 13 30 Average LOS 3.706 5.000 4.267 Inpatient Chemical Dependency Days 8 3 11 Total Admissions 1 1 2 Average LOS 8.000 -3.000 5.500 *Not Included In Inpatient Acute Day Totals Inpatient Complicated OB and Pre-Term Infants 280 5a 33a Total Admissions 22 5 27 Average LOS 12.727 10.800 12.370 Inpatient Complicated OB Days 27 15 42 Total Admissions 5 3 8 Average LOS 5.400 5.000 5.250 Neonatal Intensive Care Days 253 39 292 Total Admissions 17 2 19 Average LOS 14.882 19.500 15.368 INSU NCE MANAGEMENT SERVICES Insurance Management Services P.O. Box 15688 Amarillo, TX 79105 Forwarding Service Requested 14817 0.5824 MB 0.309 ~~~~n~nt~~~~n~~nnn~~n~~~i~~~nu~~~~~n~~nn~~~~n~~~~ JOHN DOE 1234 MAIN STREET TEXAS CITY, TX 12345 Type of Service Service Dates Total Ineligible Code Charges Amount 0100 HOSP ROOM/BOARD 12/30/04-12/31/04.. 733.00 256.55 804 0200 INTENSIVE CARE 12/30/04-12/31/04. 2248.00 786.80 804 0500 HOSPITAL MISC 12/30/04-12/31/04 _ - - 11344.70. - --- - 4289.47 804 _ Claim Totals 14325.70 5332.82 PSR9801?U[NI ~~ Employee Benefit Statement .Document #: 0565432150 EOB #: 20054321-321 Patient #: 12345678987 Insured: JOHN DOE Patient: JANE DOE Group: ABC COMPANY 'Group #: S123456 Location: ABC DIVISON 1 Date: 05/02/05 Provider: DR PEPPER Total Co-Pay Deductible Paid Total Eligible At -- Benefits 476.45 100% 476.45 1,461.20 ' 100% 1,461.20' 7,055.23 100% 7,055.23 _- 8992.88 8,992.88 Adjustments 0.00 Benefits Paid Provider and/or Insured 8_,992.88 Patient Responsibility 0.00 Accumulators Payment To Amount __ Individual Medical Deductible Met to Date 972.00 DR PEPPER 8,992.88 Family Medical Deductible Met to Date 1,589.50 Family Medical Out of Pocket Met to Date 4,000.00 +lividual Medical Out of Pocket Met to Date 3,000.00 'Messages - _ _ _ _. 804 DISCOUNT THROUGH BEECH STREET/CAPP CARE. PATIENT IS NOT RESPONSIBLE FOR DISCOUNT. Refer to your Summary Plan Description for more detail. Contact 1MS or your Employer if you arc unable to find this provision. ERISA: If you disagree with the decision on your claim, you have the right to appeal this determination. See reverse side for more detail. esx~xoizaa >~ z- ~.r Employee Benefit Statement Document #: 0565432150 EOB #: 20054321-321 'Patient#: 12345678987 ',Insured: JOHN DOE Patient: JANE DOE Group: ABC COMPANY Group #: S123456 Location: ABC DIVISON 1 Date: 05/02/05 Provider: DR PEPPER **IMPORTANT DOL CLAIMS REGULATIONS If you are receiving less than full reimbursement (i.e., deductibles, coinsurance, co-payments, ineligible, and discount deductions) and disagree with this determination, the claimant or claimant's authorized representative must submit in *writing or electronic proof that the claim for benefits is covered and payable under the Plan's provisions, including (a) all facts and theories supporting your claim, (b) a statement of the reason(s) for disagreement with the handling of the claim, and (c) any material/information that indicates that the claim does not fall within the referenced Plan provision. If you do so, it may be that some or all of the claim will be payable under the Plan. The claimant or claimant's representative has 180 days from receipt of this notice to file the first appeal and 60 days to file the second appeal. Appeals may be mailed to IMS, PO Box 15688, Amarillo, TX 79105. For additional questions regarding the claimant's adverse benefit determination and the appeals process, please call 806-373-5944 or 800-687-5944 and speak with a customer service representative. This Plan allows for two appeals of an adverse benefit determination. In compliance with ERISA and the regulations hereunder, each appeal provides full and fair review of an adverse benefit determination. After receipt of the appeal, the first appeal will be adjudicated within 36 hours for an urgent-care claim, 15 days for anon-urgent, pre-service claim, and 30 days for apost-service claim. The second appeal will be afforded the same amount of time for adjudication as the first appeal. If you receive an adverse benefit determination following the final appeal, you have the right to bring a civil action under aion 502(a) of ERISA. n internal rule, guideline or protocol was relied upon in making this determination, a copy of which will be provided to the claimant free of charge, upon written request. The claimant is entitled to receive reasonable access to and copies of all documents, records and other information relevant to your claim for benefit free of charge, upon written request. DEFINITIONS • Adverse Benefit Determinations means a denial, reduction or termination of, or a failure to provide or make payment of (in whole or in part) 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. • Urgent Care Claim means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the claimant's ability to regain maximum function, or, in the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. • Pre-Service 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., such as pre-certification or prior authorization.) • Post-Service Claim means any claim for a benefit under a group heath plan that is not apre-service 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. *Urgent Care Claim appeals will be accepted orally. **The above regulations apply to your Health Plan at its next anniversary date on or after July 1, 2002, but not later than January 1, 2003. CARE1vIfA~. ;f _ . April 2007 Performance Drug List Updated 05/01/2007 The Caremark Performance Drug List is a guide within select therapeutic categories for clients and their plan participants. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand name medicine to treat a condition. These preferred brand name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only and not meant to be all-inclusive. This list represents brand products in CAPS and generic products in lower case italics. Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered by administered by Caremark. Ask your doctor to consider prescribing, when Caremark. As a way to help manage healthcare costs, authorize generic medically appropriate, a preferred medicine from this list. Take this list substitution whenever possible. If you believe a brand name product is along when you or a covered family member sees a doctor. necessary, consider prescribing a brand name on this list. Please note: ^ Your specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. ^ For specific information regarding your prescription benefit coverage and co-pay' information, please visit our Web site at www.caremark.com or contact a Caremark Customer Care representative. ^ Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand name product or generic equivalent in place of your original prescription. ANTIBACTERIALS § CEPHALOSPORINS cefac/or cepha/exin OMNICEF § ERYTHROMYCINS/ MACROLIDES azithromycin clarithromycin erythromycins BIAXIN XL § FLUOROQUINOLONES ciprofloxacin tablet AVELOX CIPRO SUSPENSION CIPRO XR LEVAQUIN § PENICILLINS amoxicillin amoxicillin-clavu/ana to dic/oxacillin penicillin VK § TETRACYCLINES doxycycline hyclate ~nocycline tetracycline Please note: ^ Generics should be considered the first line of prescribing. ^ This drug list is not inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. ^ The plan participant's specific prescription benefit plan may have a different co-pay' for specific products on the list. ^ Unless specifically indicated, drug list products will include all dosage forms. ^ Log in to www.caremark.com to check coverage and co-payments' for a specific medicine. § MISCELLANEOUS § ACE INHIBITOR/ metronidazo/e DIURETIC COMBINATIONS sulfamethoxazo/e- fosinopril- trimethoprim hydroch/orothiazide § ANTIFUNGALS lisinopril- f/uconazole hydrochlorothiazide itraconazo/e quinapril- LAMISILTABLET hydrochlorothiazide ANTIVIRALS § HERPES AGENTS acyclovir VALTREX §INFLUENZA AGENTS amantadine rimantadine TAMIFLU ACE INHIBITOR/CALCIUM CHANNELBLOCKERS LOTREL TARKA ANGIOTENSIN II RECEPTOR ANTAGONISTS( COMBINATIONS ATACAND'/ATACAND HCT AVAPRO/AVALIDE COZAAR/HYZAAR § ACE INHIBITORS fosinopril lisinopril quinapril ALTACE ANTILIPEMICS ANTILIPEMIC COMBINATIONS VYTORIN § BILE ACID RESINS cho/estyramine WELCHOL CHOLESTEROL ABSORPTION INHIBITORS ZETIA § FIBRATES fenofibrate TRICOR § HMG-CoA REDUCTASE INHIBITORS pravastatin sim vasta tin LIPITOR NIACINS/COMBINATIONS ADVICOR NIASPAN § BETA-BLOCKERS ateno/ol metopro/ol nado/ol proprano/ol COREG COREG CR TOPROL-XL § CALCIUM CHANNEL BLOCKERS diltiazem ext-rel nifedipine ext-rel verapamil ext-rel NORVASC CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS CADUET § DIGITALIS GLYCOSIDES digoxin § DIURETICS furosemide hydrochlorothiazide meto/azone spirono/actone- hydroch/orothiazide torsemide triamterene- hydrochlorothiazide ANTIDEPRESSANTS § MISCELLANEOUS AGENTS bupropion bupropion ext-rel mirtazapine WELLBUTRIN XL Your specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. For specific information, visit our Web site at www.caremark.com or contact a Caremark Customer Care representative. § SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) '`a/opram ioxetine paroxetine sertraline LEXAPRO PAXIL CR § SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)' venlafaxine CYMBALTA EFFEXOR XR MIGRAINE SELECTIVE SEROTONIN AGONISTS IMITREX MAXALT ZOMIG MULTIPLE SCLEROSIS AGENTS COPAXONE REBIF ANDROGENS ANDROGEL TIDIABETICS § BIGUANIDES metformin metformin ext-rel INSULINS APIDRA HUMALOG HUMULIN LANTUS LEVEMIR NOVOLIN NOVOLOG A ACCU-CHEK STRIPS AND KITSS ACCUNEB ACTONEL ACTONEL WITH CALCIUM ACTOPLUS MET ACTOS acyc/ovir ADVAIR ~WICOR INSULIN SENSITIZERS ACTOS AVANDIA INSULIN SENSITIZER/ BIGUANIDE COMBINATIONS ACTOPLUS MET AVANDAMET INSULIN SENSITIZER/ SULFONYLUREA COMBINATIONS AVANDARYL MEGLITINIDES PRANDIN § SULFONYLUREAS glimepiride glipizide glipizide ext-rel § SULFONYLUREA/ BIGUANIDE COMBINATIONS glipizide-metformin g/yburide-metformin SUPPLIES ACCU-CHEK STRIPS AND KITSS BD INSULIN SYRINGES AND NEEDLES ONETOUCH STRIPS AND KITSS BISPHOSPHONATES ACTONEL ACTONEL WITH CALCIUM FOSAMAX FOSAMAX PLUS D CONTRACEPTIVES § MONOPHASIC YASMIN YAZ § TRIPHASIC ORTHO TRI-CYCLEN LO § EXTENDED CYCLE ethinyl estradiol- levonorgestrel TRANSDERMAL ORTHOEVRA VAGINAL NUVARING a/buterol ALLEGRA-D° ALPHAGANP ALTACE amantadine amoxicillin amoxicillin-clavulanate ANDROGEL APIDRA ASMANEX ESTROGENS § ORAL estradiol estropipate CENESTIN ENIUVIA PREMARIN § TRANSDERMAL, ESTROGENS estradiol CLIMARA ESTRADERM VIVELLE VIVELLE-DOT ORAL ESTROGEN/ PROGESTINS PREMPHASE PREMPRO § PROGESTINS medroxyprogesterone PROMETRIUM SELECTIVE ESTROGEN RECEPTOR MODULATORS EVISTA § THYROID SUPPLEMENTS levothyroxine SYNTHROID ~~ § HZ RECEPTOR ANTAGONISTS ranitidine § PROTON PUMP INHIBITORS omeprazo/e NEXIUM PREVACID § BENIGN PROSTATIC HYPERPLASIA doxazosin finasteride terazosin FLOMAX ASTELIN ATACANDZ ATACAND HCT ateno/ol AVALIDE AVANDAMET AVANDARYL AVANDIA AVAPRO AVELOX azithromycin § URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel DETROL DETROL LA ENABLEX OXYTROL VESICARE § ANTICOAGULANTS warfarin COUMADIN ANAPHYLAXIS TREATMENT AGENTS EPIPEN EPIPEN JR § ANTICHOLINERGICS SPIRIVA ANTICHOLINERGICI BETA AGONISTS COMBIVENT DUONEB ANTIHISTAMINES, LOW SEDATING ZYRTEC° § ANTIHISTAMINES, NONSEDATING fexofenadine § ANTIHISTAMINE/ DECONGESTANTS ALLEGRA-D° ZYRTEC-D 12 HOUR° BETA AGONISTS § SHORT ACTING a/buterol ACCUNEB PROAIR HFA PROVENTIL HFA XOPENEX B BD INSULIN SYRINGES AND NEEDLES BENZACLIN BETIMOL BETOPTIC S BIAXIN XL brimonidine 0.2% bupropion bupropion ext-rel LONG ACTING FORADIL SEREVENT LEUKOTRIENE RECEPTOR ANTAGONISTS SINGULAIR NASAL ANTIHISTAMINES ASTELIN § NASAI STEROIDS fluticasone NASACORT AQ NASONEX RHINOCORT AQUA STEROID/BETA AGONISTS ADVAIR STEROID INHALANTS ASMANEX FLOVENT PULMICORT DERMATOLOGY § ACNE erythromycin- benzoy/ peroxide tretinoin BENZACLIN DIFFERIN DUAC RETIN-A MICRO OPHTHALMIC § BETA-BLOCKERS, NONSELECTIVE timo/o/ ma/eate solution BETIMOL BETA-BLOCKERS,SELECTIVE BETOPTIC S PROSTAGLANDINS LUMIGAN TRAVATAN XALATAN § SYMPATHOMIMETICS brimonidine 0.2% ALPHAGANP C CADUET cefac/or CENESTIN cepha/exin cho/estyramine CIPRO SUSPENSION CIPRO XR ciprofloxacin tablet citalopram Your specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. For specific information, visit our Web site at www.caremark.com or contact a Caremark Customer Care representative. c/arithromycin CLIMARA COMBIVENT IPAXONE ~1REG COREG CR COUMADIN COZAAR CYMBALTA D DETROL DETROL LA dic/oxacillin DIFFERIN digoxin diltiazem ext-rel doxazosin doxycycline hyc/ate DUAC DUONEB EFFEXOR XR ENABLEX ENJUVIA EPIPEN EPIPEN JR erythromycin- benzoy/ peroxide erythromycins ESTRADERM estradiol ~tropipate 'hinyl estradiol- levonorgestrel EVISTA F fenofibrate fexofenadine finasteride FLOMAX FLOVENT f/uconazo/e f/uoxetine f/uticasone FORADIL FOSAMAX FOSAMAX PLUS D fosinopril fosinopril- hydroch/orothiazide furosemide G. glimepiride glipizide glipizide ext-rel glipizide-metformin g/yburide-metformin H HUMALOG HUMULIN hydroch/orothiazide HYZAAR 1 IMITREX itraconazo/e LAMISIL TABLET LANTUS LEVAQUIN LEVEMIR levothyroxine LEXAPRO LIPITOR lisinopril lisinopril- hydroch/orothiazide LOTREL LUMIGAN M MAXALT medroxyprogesterone metformin metformin ext-rel meto/azone metoprolol metronidazo/e minocycline mirtazapine N nado/ol NASACORT AQ NASONEX NEXIUM NIASPAN nifedipine ext-rel NORVASC NOVOLIN NOVOLOG NUVARING O omeprazo/e OMNICEF ONETOUCH STRIPS AND KITSS ORTHO EVRA ORTHO TRI-CYCLEN LO oxybutynin oxybutynin ext-rel OXYTROL P paroxetine PAXIL CR penicillin VK PRANDIN pravastatin PREMARIN PREMPHASE PREMPRO PREVACID PROAIR HFA PROMETRIUM proprano/ol PROVENTIL HFA PULMICORT Q quinapril quinapril- hydroch/orothiazide R ranitidine REBIF RETIN-A MICRO RHINOCORT AQUA rimantadine 5 SEREVENT sertraline simvastatin SINGULAIR SPIRIVA spirono/actone- hydroch/orothiazide su/famethoxazo/e- trimethoprim SYNTHROID T TAMIFLU TARKA terazosin tetracycline timo/o/ ma/eate solution TOPROL-XL torsemide TRAVATAN tretinoin triamterene- hydroch/orothiazide TRICOR V VALTREX venlafaxine verapamil ext-rel VESICARE VIVELLE VIVELLE-DOT VYTORIN W warfarin WELCHOL WELLBUTRIN XL X XALATAN XOPENEX Y YASMIN YAZ ZETIA ZOMIG ZYRTEC° ZYRTEC-D 12 HOUR° FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This Caremark Drug List is not inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. Specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. The plan participant's prescription benefit plan may have a different co-pay' for specific products on the list. Unless otherwise indicated, drug list products will include all dosage forms. This list represents brand products in CAPS and generic products in lower case italics. Generics listed in therapeutic categories are for representational purposes only and are not meant to be all-inclusive. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to www.caremark.com to check coverage and co-payments for a specific medicine. § Generics are available in this class and should be considered as the first line of prescribing. ' Co-payment or co-pay means the amount a plan participant is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. ' Atacand should be reserved for patients who meet CHARM (Candesartan in Heart Failure -Assessment of Reduction in Mortality and Morbidity) trial criteria. ' Indicates the proposed mechanism of action, based on the American Psychiatric Association Summary of Treatment Recommendations. ° Higher co-payments may apply depending on the plan participant's specific prescription benefit plan. Log in to www.caremark.com to find the co-payment under a specific plan. s An Accu-Chek or OneTouch blood glucose meter will be provided at no charge by the manufacturer to those individuals currently using a meter other than Accu-Chek or OneTouch. For more information on how to obtain a blood glucose meter, call toll-free: l -800-588-4456. Participants must have Caremark Mail Service benefits to qualify. "cur privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. ~,~emark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. `his Caremark Drug List contains prescription brand name medicines that are registered or trademarks of pharmaceutical manufacturers that are not affiliated with Caremark Rx, Inc. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. ©2007 Caremark Rx, Inc. All rights reserved. www.caremark.com 15045-2-0407 Information Management Reports ~~ ~: 4 4'. ,g 4 ~4 ~ 3 .~ a q ~'. 'g } g Information Management Reports -December 2004 CAREMARK fNFORMATION MANAGEMENT REPORTS TABLE OF CONTENTS I. Overview of Caremark Information Management Reporting ........................................... 3 fl. STANDARD REPORTS ......................................................................................................... 7 Key Performance Factors Report ................................................................................................. 9 Denied Claims Summary Savings Report .................................................................................... 13 Carrier/Group Summary Report .................................................................................................... 17 Pharmacy Activity Summary Report ............................................................................................. 21 Pharmacy Activity Summary Report by Top XXX Pharmacies Pharmacy Activity Summary Report by Top XXX Chains QUANTUM Alert® CONCURRENT DUR REPORT SERIES DUR Performance Summary Report ................................................................................ 27 DUR tmpact/Outcome Report ........................................................................................... 31 DUR Cost Savings Report ................................................................................................. 35 Drug Utilization Summary Report ................................................................................................. 39 Drug Utilization Report by NDC Drug Utilization Summary Report by Therapeutic Class Drug Utilization Summary by Generic Class Prescriber Activity Summary Report ............................................................................................ 47 Prescriber Activity Summary by Top Prescribers III. FINANCIAL REPORTS ........................................................................................................ 51 Financial Summary Report ........................................................................................................... 53 Financial Detail Report ................................................................................................................. 57 IV. OPTIONAL REPORTS ......................................................................................................... 61 Performance Mails"" Savings Report ............................................................................................. 63 Performance Rxs"" Interchange Detail Report ............................................................................... 67 Retail Programs Savings Summary Report .................................................................................. 71 Therapeutic Class Analysis Report .............................................................................................. 75 USC Activity Report by Decreasing Ingredient Costs ................................................................... 79 Managed Access® Reports Managed Access Confirmation Report: Drug Code Modifications ..................................... 83 Managed Access Confirmation Report: Authorization Modifications ................................. 87 Managed Access: Due to Expire Report ........................................................................... 91 Information Management Reports -December 2004 1 THIS PAGE LEFT INTENTIONALLY BLANK information Management Reports -December 2004 OVERVIEW OF CAREMARK INFORMATION MANAGEMENT REPORTING '; Information Management Reports -December 2004 THIS PAGE LEFT INTENTIONALLY BLANK '~.~ Information Management Reports -December 2004 OVERVIEW OF CAREMARK INFORMATION MANAGEMENT REPORTING Information is an essential element of managed prescription benefits. To effectively manage prescription costs and quality of care, it is important to have reports which allow analysis of the basic elements of the prescription benefit including employee demographics, utilization, prescribers, drug mix, total cost, employee cost sharing, success of managed care interventions and ultimate cost to the sponsor. Caremark Information Management Reports capture these data elements to analyze information in multiple ways to access trends, identify problems and target areas for intervention. These reports are an essential planning tool that enables plan sponsors to develop strategies to further enhance their prescription benefit programs. Caremark offers a comprehensive package of management reports to meet the unique needs of each client. A description of each of the reports available through Caremark follows. Samples of each report are included in this manual. `\rr- `~trr Information Management Reports -December 2004 '~Mrr THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 STANDARD REPORTS Information Management Reports -December 2004 THIS PAGE LEFT INTENTIONALLY BLANK ~~rr Information Management Reports -December 2004 Key Performance Factors Report The Key Performance Factors Report summarizes drug program interventions that help to effectively manage the prescription benefit. The report includes information fora 12-month period, tracking changes in utilization, claims denial, generic dispensing, drug benefit costs and savings achieved. Following are definitions of each field and formulas for each field, which involve a calculation on the Key Performance Factors Report: Time Period: Cycle (calendar) month and year Employees (Members): Eligible: The number of eligible employees or members (if eligibility is tracked at the dependent level). A total and average member count is provided. Utilizing: 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 far which the plan sponsor or participant is responsible. Drug Cost: Total Drug Cost: The total dollar amount for prescriptions, including ingredient cost, dispensing ~ fee, and sales tax. Formula: Ingredient cost + dispensing fee + sales tax Drug Cost Average per Claim: Average claim amount for which the plan sponsor or participant is responsible for each payable claim. Formula: (Ingredient cost + dispensing fee + sales tax) -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 by participant + coinsurance + benefit maximum + copayment/stop loss Cost Share Average per Claim: Average amount for which the plan participant is responsible for each claim. Formula: Total cost share amount _ payable claims Claims Amount: Total Claims Amount: The total prescription amount for which the plan sponsor is responsible. Formula: (Ingredient cost + dispensing fee + safes tax + (PRx fee, if applicable) - participant cost share amount) Information Management Reports -December 2004 Key Performance Factors Report (continued) Claim Amount Average per Claim: Average amount for which the plan sponsor is responsib{e. Formula: Total claims amount _ payable claims Per Employee (Member) Per Month: Claims: The number of payable claims per emplayee (member) per month. Claims Amount: The plan cost per employee (member) per month. Generic: 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 of multi-source claims that are dispensed generically. Formula: (number of generic claims _ number of multi-source claims) x 100 Percentage of Dispensed as Written: The percentage ofmufti-source drugs that are doctor dispensed as written (DAW 1). Formula: (number of DAW 1 claims _ number of multi-source claims) x 100 Percentage of Formulary: The percentage of claims that are Formulary. Percentage of AWP: Indicates the percentage of the average wholesale price (AWP) Formula: (Ingredient cost _ fuN average wholesale price) x 100 Percentage of Usual and Customary: The percentage of usual and customary price when applicable. Formula: (number of U&C priced claims _ number of submitted claims) x 100 Percentage of Claims Denied: The percentage of submitted claims denied. Formula: (number of denied claims _ number of submitted claims) x 100 Cost Share %: The percentage of drug cost for which the plan participant is responsible. Claims Amount %: The percentage of drug cost for which the plan sponsor is responsible. MDP > 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 Days: The average days supply of the qualified maintenance drug program claims that were dispensed with more than 30 days supply. ~rrr` Information Management Reports -December 2004 10 ~~~// {-~ O NW 1r ^~1 V J rQ W W U 5z 1~N~ W NO I~1 W^ I~ W a ~n w a .-i o 0 0 0 f+l N N PI \ \ fV Q1 U1 O N O \ \ ri O rl e-1 x O C7 ~ N W q H x F +.. M w e m c .-~ n r o r .n N m m r ~ . QS N S Na W ~ N r N~ a rvN .gym N~ .n rv n r N n N n N r N r N n N r N r N rv n \ ~ qq N .7 O M U V O ~ o W n m o r w r r. ~. m ~o a m is ~o r ~ ~ v O ~, r o W Q c U m r n n m (l] 3 .b r m m m m m m m `n r N N N N N N N N ~ a 5 r r r r r n r n r r r r ~ s . w U ~+ r.o mm n r O ~ a 3 K N m O rn ~ a W N rv m N m N m N m N m N m rn m N m rv N N~ N~ N ! y Q \ H a ' F : o N U . a .gym am O uFa a r, i ~ Nrv ~ ~o 3 _ m N ., ~. m ~aU ,~ N dN QN N~ ,~ e m ~ ~ r de ~ r W .~ a N W ~o> H DFa a ~ O W fly ill N O N a H m a q N b G U e r m m m r r r r .+ ~ a ~ z e~ v e v ~ ~ ~ ~ e ~ e m ~ ~ N ~ w .~ W n a ~~5 a w x ~~ 1-1 x f w .~- ~ o z w n N N N N ~ S o S S ~~ " " a a o ff o W `'~ w \ a a H 4«l D z 4 Q W W pW, Q~q .J U R. F W ~ 4~ /j !!1 U F a z O h n. ~ a F ~ 4 ~ O OF 4 Information Management Reports -December 2004 c~ t'+ v 'v .~ v '~+: :.. T.. 1..a ~Jl ~. 11 ~rr+ err' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 12 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 Tatat 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 900 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. ~irrr 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. Fitted 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. ~w'' Managed Access Auth. Req.: 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 aft reasons. Information Management Reports -December 2004 14 .~ N V~ V~ a o 0 0 0 b N N M \ V~ rl O ri M N \ \ rl O ri ~ w ~ w p a H q x H a 0 0 H 0 O ~ a w ~ a O w m W ~ V z o a C~ ~ ~ zQ ~ >Q C/~ W W W Q ~~~tt~~ V ~z ~¢ ~~ ~U Q W U Q Q ~4 a Z w W o Q a 0 a a a a w H a 0 a ut .. .. a w H a z o ~ z a a o H a a ~ v F[~+ W r m mri00000 Hinooooo 01 b ofe-1m000 NHOOOO m w m000 mooo m m N r r r V~ b Z P H O W rf r 'tl' m r1 to a~ r M p O ri N o r-1 ul ri M N O V~ ~ 01 b ~ M r r M r r V~ r b r N 0 u1 r a O1 r r N r-i O~ ri V~ Ol e-1 N O M M Ol Ifl N V' r M 01 Q1 Ol m m ut r b M ri N a W au~H N rnooooo0 o mNaoooo m ~nooo ut m N a w~C~E+ .-+ .roooooo in ~n~noooo H o000 0 o m m O H ~Hj H d° E N~ r0-f H e~ rl N M M U '~ m aura ~n Nbooooo m a~aoooo rn booo b m r*.K~W ut roooooo r Mrbooo b Mooo M u~ O F H H O .at zz N O O r1 M ul d~° E .7 W r H .-~ H H Ua m o .~ rnrooooo b bNN000 O .-I rioo N al r m ~ M b m .-i rl ~ w~ u1 rn m a~ o b H T N b r m Of e-1 p~ ~ p~ r-1 o m N N N M b ~ U m ei N a ww w w a~ ~ a a~au a a ~ H 'r ~ a H> ao ~ w ~ w~a~ w w a E+H (DHaH a s amwz a >H-+ x HwaH~www H ~w ow>w zb ~ .~'~ w ~[*.roaHy U' H HaO H N m E+wHE+W°a m aoNOFapt a a H w H aHw°zao~ ~ >u°,aUOZ> aA ~ H ~ HaFaHZO a °vo°oa°u ~ aww~ ~ a~xA~~~ w FH~zwF a aw~H u a aawoa°°w ~ xa~aa°z ~ ~''ac~ a F w wxwZ~ F aaau F ~wH ~ o aaa aww O HOHU1 0 ~oaa F F aa0 aaa H ~wHWW~ N aU~a o HHa Hww FwawaH azFa F wo-.m waa HaaaaH aH~na Information Management Reports -December 2004 a m w a H W U a w N H W H ~ H W U W z a a qH w m U O H a a ~ F N 0 F W H W a w H a Ea+ 0 E r fi .yr~ r Y w r ti .'~-. ": 15 ~+" THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 16 Carrier/Group Summary Report The Carrier/Group 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 Employees (Members): The number of eligible employees or members (if eligibility is tracked at the dependent level). Percentage of Utilizing Employees (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. {nformation Management Reports -December 2004 17 '~1w' ~Ii`r THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 18 7 N~N 41. O W w rf G C1. N~~/ 4L \N~/ L4 HNI ~-~ x U ~w~rc Noo •oo .-i N N ri\\ •N Ql h O N O\\ .-a O ri r-1 ^ m m ~ ~d a ~ ~ r ~ m U' ~f-+ m Ro a F o y ~ ~ rW~ F pi Q r vp U UI b N N Q~ N .~ N N O z g w a m F W n a ~ ° m .. N ~ a m ~ ~ ~ N a N ~o '° .n Q w w N V H 4 ~ ~ a U P. n N .-i .i .. n ~ O H ~q( 7 V ~ . N U o O K ~n ~n L W ~n m S a u~ ~n W ~~ ~ rv N P U F m a „ .. oW ,~, .. ., .. U a w a m u+ m r o a~ ~ `~ ., m ~ m s v ~o ~ d r V .+ r~ N V U ~ ~ ~~ W N QI m b aD W r ~p E < < < < W a m n LD R' N .. W r o N tp ~pp c ~ I a .. r aW w s ., N ~•, m .i 0 r~ a F W s w Z a , cr Q z P4 z a a ~ O F z ~ o a O W ~K ~ + w~aa aFtcnv Information Management Reports -December 2004 ,W 1 ?M V "~ '1•.. v •a N t J~ '~J ~f) V C ti 19 ~Irr+' `\ry 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 field, 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 payab-e claim. Formula: Ingredient cost _ number of payable claims ~1rr' 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: Totat 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 fhe 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 8 Customary: 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 of multi-source c/aims) 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 of multi-source claims that are dispensed generically. Formula: (number of generic claims _ number ofmulti-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 Days Suppiy: 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 ~' W U Q Q-. Q N O H i ~ O W ~ ~ ~ ~U~ ~z~ Q N ~ Q E--+ W ~_ U~ Q U Q Q !1. .-1 N s} O N O O ~ON N N \ O \.-~ • C t"/ O .-1 \ O\ O N ~ ... mwW C?~Nw Q~+Qo a F!]o N .i 0 ti W W F W [L n W W U O a a f a u a a a n. D O C a a Q fY W H fK O N a L7 . ..W w A~z~ ~~o~ axorW+ w~aa art v1U Q G W \ ~ og~a E W Gf ^ F ~ X Ott W > + 4 r N A d am w am a~~ ~~m ~r~ 4 O e Ut N o ~p N ~ r v 0 0 < n o n r'r n e n n O < < o e D. V r'+ O r 0~ N N 3 w 4 ~ m 0 m C m m o m o m o 0 0 r r r m r r r r r r~ r r r r r r r m .~. o ~..{ m r m rv rv ~n 4I~``,, .] N~ ors a+0 U ,n e W a a ao> ~F ±g~ H N .+ m¢ b alt r N N N o m V+ ~ ~ N N m N ¢ + r /i U~ ~ ~ r~ n r~ m N .-~ ~ .-~ O p N N H W maa oI~ ; a f m~ rm ~~.~ ? m `". ro N r n ~ r ~ c 00 V ~ vi _ v ~n ~ ~ vvi m., ~ V T4. e N ~~ N rv N ~. .~ x - V" W . ~ n .-~ n .+ ~+ .. .-~ ^aa ., G F U E. a ,[Z+ H ON P N m r r~ Ul "J ~ ~ V 0 o u o e ~ ~~ ~ a ¢ M ~, N N N ., .. .. .. ., ,, W _ ti .» .~ ti~a ~ F C~ o> [- a 2 ¢ r ~' W ^ N m r r N Qi r r ~p ~O ~D ~o ~+ f tli n .~ .~ r .~ a W .. f W m .] H O ¢ (q '~ rf N 4 Y 4 N ~ a n n n rv N N rv N rv N ~ na. U .. ~ W ~d ^ Z w ~ Y U q~ qx~ Y a a Information Management Reports - December 2004 u +i H k iX ~l yam/ ` 23 fir` r~ H U ~N W a c 0 N a ~o 0 (x ~ C/] ?~ U QC~Q ~~U ~ W '"'~ (/;0./~ }. U F- W ~_~ E", ~" Q U `~ C Q (1. V' V'N [FO .+NOO • O N N N \ O \ N • 'd' r'1 O N \ O \ O • ~ 0. www C~EFc Q~+Qo aFG1o N O z w w F W W A W W W 0 a a a V a a 5 0 a Q ca .~ oV N b a r~ ~w a awwzz a~°~ o zw aao~ w\aa aa~nv A wpm ~~~o W p ~ Y Q y O d a vOi a ~z .a. m 2 W d .+~ +~ V 3 ~o d U 3 a Q a 41~~ dou ~d~ ~aa oa CIF 4 ~f ~~~ t-d~ m a a o~o o a i E ~~~ ufu a ~ a a a R F U O K of y ~ a OO V A4 K W c~aa z a .. .. ~o> F a c~ za .. w N [9 H ~ aW i-+ F_ W t9 a s m.. a ~ >. ., 4 V .+ ~. d ~w d~ oz N ~ a ~ .Wi ~ L ~ O O F a O a 4 a O a O Q a O F Q z c- Information Management Reports -December 2004 s i~ N ~~ .~ M1 N 24 Cn 1 Q r_ U O cv ~+ Q E"" E"" i ~ ~o W `-' ~~~ ~U~ Q~~ ~ZU ~~Q ~w U Q U Q I~ Q a a ~E ~~~ ~ a a OFa q~ V L U 4 K a~ a ^ F ~ F 4 qHq a ~n ~ rv r rv v< r N~.l r00 ~. rv ~ _ o v m r r. N m 0 ~ O .O m ~p P O~ U ~uri r. u~ muei v r ro~ m o~n rm ouNi K N y P b N r[ rv N [at 2 Q G r ~o .> N, rv n rv ,y °i m m r n .. ~ ~ ~ .. F 4 »~ N a ~ ° p _ m n ~° m w . , m m e u, a ~., m m rv a ~ - r ~ a ~ ~ - m ~ e < a n rv ~ .. ., ., .. ~d oz •• z z.. ~i~ o~o~ w~Ga a S~nu Information Management Reports December 2004 r ~3 r ~~. r M i~ L~ ^b `~+. _ h `ti 25 Q U O N Q. O ~' ~' ~ ~ L-. C xU ~~ W ~" ~~J; ~U~ QUQ ~~U ~ W '-1 }' w ~~ r-r ~.. U~ Q U v N of d'O C O O •ON ~ N \ N \ O •riM ? O \ O\O~ O O •~~ W W W C~~Fv r(H rto aFAo 0 w w 3 F W L9 A W N W U O a a Q a U a a 5 0 C7 a' W cacQd~ oU N a .... ~ .. W A~zz a~°~Z o zw aao~ w\aa a~¢mu N !~ ~+ a a o a a > y a a M m z~~ ~y~ Q 4 O a u 3 W Q O ~ E a~~ aou ~d a a a oa d~o> [- a f ~~~ a u-iaa °H~ [°- a s ~~~ ~ou Fda ~ a a A F C7 F Q Ntq rv n N .,m m ~ .7 e ~ m o O O U m N U e K H w ~' = Q 6 ~ b b N ~Fa 2 ~ r .+ w N m '+ f a w v ~, o ~v ~+ F w m ca f r 4 Q ~ !..] Q U m a .. ., ,. ~d pz •• z z.. ~~ u Information Management Reports -December 2004 r ~++ h ~~ :.• v ~t^ M1 i~ kl '.'~'+. _ t. 26 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 for ail 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 & 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 & Cost: The total number of claims reversed by the dispensing pharmacy (with and err without DUR alerts). The adjudicated claim cost for all reversed claims (with and without DUR alerts). # Rejected Claims 8 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. Rejected 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 or non-compliance with therapy. r 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 "`w' F V' H o U 0 N iii O (n M '~ \ H H U WW ^ F C7 W FC ~C F ^a u w h a a N M ~o V' M or d' M ~ O l?N w In N H rn O m H 'd' d' W ~ M M U .i N O N ~ ~ O V' d' o cA yr r N ~ t/T \ H l0 Q N a ~ u H H q W 2 >+ a r ~r W.H r , H a ~+ W ~ F ao x~ F zw ~u F ~~, ~ w ~U O MN U r N U r n~ O of i G. r N UJ m U1 ~ +n o H O W ~ ~ W U ~ aw q a H a a 2 WO aH ~ rnlo a[-~ wm Q ~~ N H H m a .~ ~~ •~- a 00 ~~ FN zH w tK F ~W a U1 M ~m M U1 rl 0 N a F a w o a Q U w W Cn H ~ of ua H H a~ W Nx r-+ F HO ~~ A F M U1H01 Q1COMHOVOOUI 001 MHrnrU1 OlO~NUl000 0101 1Dm Ulm V~OIONOMOOU) d~10 rmInNNlovrov~rnvz•vro mN Mmmoro owr 10 mrn 10 V'10 .-IN ri r/r ri MU1 N rl N .--1 M m L}t?[? O r UTL}LTVTUTL} N .-( ~~ olooMUilnoloo~ooln ,-~,~ ' 10rwwrmoornlnoor ~o .-aowr~rcoolor+moocv tom O m0110 V'OU}OIHN+R[?V~ rU) ~~ NOMrmU1 V}l0H {/1_ 10W ~~ ~V7 N N M N 10 m l0 i?V1U} V}L} r1 H ~N ~N U7 U)r mU1N mOOlONOOr U1 .-1 'r+x rnmlo~louiorlnMOON oN ] f-~ ?HZ H'-INNMNOOOOCOO rM • ~ ~ H N N :a > ^ 10mmNmOlONN1DOON rc 1 ~ 4•m l01p U10~OrU1NOOM U1 d' ~-INNNC'H OOOOOOC mC• H N N 1 N (n lp 61 0 •d~ U1 M O O N V' O O U) m H +Hx mIOMmHmOs}~HIDOOUI Mm F M M In ' U1rNOH OOOOC O ~ N U1 F a w F a w a a ' a ' W w a O H ^ W ~ ~ ~.m aH H ^ > H a 0.. q>»cj~U w~ ~ w acnww Fu ^ cnxHw» zz~w roc~~svHH H cnaUC~^H^Xc~V] 2RCaHa x wcncn ouwHE~ wr x ww wpwcnwDaa u uv c~aaHwwaH+ H+ xx Q^a^xaFtFcmxcnww •• ~ ^ U U cq a]~~FW~3z+z++ H acelzcK xxoomocncn ^^^Q~H^azuzuu ••~ au E°- z Information Management Reports -December 2004 mm.-i 01mrOOV~r00~ MH ' N HOmMUtOmd'V~OOM MO 0100110CmOO~U1N000 M01 .-1 U1mONrL}N rt?Vft/f0 rr mlornmo~ Nl[1 .~ wm H N H U) M N v? +~ vrir H .~ ~~ O mNrV~NOOT0000 NN olnowmooo.-ioooo .-~w OlOM N10 U1001f10000 O1M 41 ri V'10 U1 m[/1 V}01 UT LT 4I UT US C' i11MVTiRM H OOl V? UT H N H ~ ~~ .Immormolom~oo~ .-~o r-IOr-I ry.11p0000000 lD7 0000000000000 ~~ Ot0 N1D 1DNOMN0000 Ol0 OOMNNrO~-IM0000 Or 0 0 0 0 0 0 0 0 0 0 0 0 0 N H N10100 U11D0 MlDMOON Ohm Nr-IMd~MMOf-I ri0000 r1r ~I M N OHU)V~V~~-IO NU10000 N10 ooooo,-+0000000 MN NH10 V'Ul l00MlOMOON m NNM1DMr0~-~I x10000 m .+ M O.-1 U)V'V'MONU10000 [} O O O O O H 0 0 0 0 0 0 0 M W w a O ~H~»» ^W] ~ ~w aH H ^'/ H a a. Q~+v~~U ~u q cwnxHw» W hOC~FCUHH ~ zaaHcti x wcncn ~w]wcwnm~aa ~ vv 7QgaAaaaH+ H+ xx ~ ~ a~`~ouxuww cn a~~aaFw~3z+ z+ + H ~aaaa xaoou,o~nm ~^^^^ H^azuzuu au ow - Hz r 10 M M 10M 00 l0 lp M M mr rr N(? MM O O O N N N ~ ~N NO NN wo ww d'O cr ~ O L} O O V' [ri V' rl H . 1 ~ ~V1 Ul M Ol al Ql O 01 01 H O N H M O M M 00 00 N O N N 10r MM m0 Q\61 M M M ri O r1 H Mo MM l0r M m O Ol M M ~o M O M a a wH >~ H U1 w~ uH Z WtWq U ~u~w 1U aW ~z+ H~ {Oul C zv F~ 7 W z U1 M M O .~+ rn Mr mr rm M O N N ~~ Ul U1 1o m Old M O r~-1 m N 01 N ~ u1 ~ ~~ b ~ O t0 M N mr ~~ N m M N O N U) Ul O N ~~ `v M ~~ t~ .~ v fi 1 M `ra° Q\ O mM W wv zU Q F ~a O U? M q r2-~ m W ~ o ao r pW F^ ox OF zm °za t0 (n U1 II ~ ~ Q U ~ U z O^ zw W a w > w U~ z+ w Ft^ U1 H ~aa m qw as •o °ao a(-~ FrH~~ Oq U.] H~ uU ~F UU C7 2 + ow 29 ~w+ 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 Therapy 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 Changes: 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 or non-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 ~' 'Ors THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 32 ~11/'' ID: TP89L436-O1 Drug Utilization Review (DUR) Services QUANTUM Alert Concurrent DUR Program DUR Impact/Outcome Report ------------------------- For the Quarter Ending 09/2004 DATE 09/27/2004 PAGE 1 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 Chances 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% It tz11 s-tizrfs at~ttJ* ccTYtY'" Information Management Reports -December 2004 33 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 34 QUANTUM Alert DUR Cost Savings Report The QUANTUM Alert DUR Cost Savings Report summarizes drug costs savings for the client by three drug utilization 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 DuplicativelRedundantdvug 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. 'il>~r 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: dup/icafive/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 ~rr+ ~'irtr' 'fir THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 36 ~r+ 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 Dcses $1,106.16 Excessive or Early Refills $2,273.09 TOTAL DUR SP.VINGS $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 CURRENT QUARTER $21,406.23 $1,647.90 $467.28 8.02 0.00 to 1 YTD $49,869.23 $3,805.58 $6,781.67 $60,456.48 YTD $60,456.48 $4,538.77 $401.62 7.43 0.00 to 1 ~t radl s-C:xr7s .< ~t}~ ~ ~rr3 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 Utili2ation 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 mare than 60 commonly used drug form codes. Drug Code: The national drug code assigned to the prescription dispensed. Manufacturer: The drug manufacturer. Druq 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. Payable Claims: The total number of payable claims including those for which the plan sponsor and plan participant are responsible. Percentage of Payable 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} ~'" Druq Cost: The dollar amount for the drug listed, including ingredient cost, dispensing fee, and sales tax. Druq Cost Average per Claim: Drug cost per prescription dispensed. Formula: (ingredient cost + dispensing fee + sales tax) _ number of payable claims Percent of Druq 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 Days 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 Days 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 Percents a of Generic Substitution available at eneric level onl Information Management Reports -December 2004 40 W O dl C .-~ ~ O O Q ~ ~ O 0 N a '-~ O~~ ~U~ ~z~ o ~, ~~Q ~ U xW QQ z 0 N H C7 (L^~, /--~1 • O O N N N Ul \ \ • 01 lD d' N N O \ \ r~ ri ri e - i ( ~~ 7 W W W FC Q ~"~ Q ~f' 3 N W F Q o In ~ a m m m m m m m m m ~ m m m m m N ~ >a m[-~ p ~ ..N ~v e~ NOD vlr .+m 4 '"~ ~. Om o w N Ne ~ ~a~ N . ~ .z o . ] .-. 4 b v .n ul N N in w Q dG W W ~ ^ F O ~ ~' a 0 O In Q W r m O U c u ,. ., ., ., ., ., ., W ~ (' E c tX a ~ o < ., ., .. .. .. .. ., ., .. .. ., ., ~~ cn H a U f Nm r~ o~ rn~ m .,n EE-- nom N mr ~m 5'; ~In mo i r`" """ ^~' Nrv rv Nrv N., rvn, Nh ca „ ~~ , a U 4: N c~ a ~:~~ -. F Q F azo ~ ~ r m ~., ~ ., z~ o .. ., .. ~ ., ., .. .. . .. : . . .. ~ `" 1p `° " U N r m o ~ In m o ~ ~ ~< r ~ ~ ~ E. z ~ ~ ..N m N n , H~ r h n H N N N N N N .i N n~ N O N N .+ .y .~ .y Q fY `~ a ^ IJ maa `~' UFV ~ Z O> F F 4 w a O m m n o o r ~o m a ~~ ~, .. o o o ., ~ o 0 0 o a o 0 0 y~ w~ a f ,~ .. ~, M N N ~, N .. ~ ., .. ~5 a~ x w a ~ ~~ ~a o U a ~ R ~ a ~~ a a Y a x a a a ~ F ¢ m m t~ p~ m m m {n m m m m ~ v m l7 m N N m U: N fn N ~ ~ G: ri a ~ m~i F' a ~ .. .. z W zs ~ ~ A W 2 Q u t-, m z Z a ~ ~ o z w a. cz O I-1 w~a..a [x r.C rn U Information Management Reports December 2004 • t iN •. r. T N t h _ h cz Q a w~U Q 1 I i ' ~ ~ ~ t~ i 41 ~rr-' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 42 N~N ~ /W/-~ 4-I ~ O ~U N aQ O~~ ~U~ ~2~ p ~; U W Q JN-~ rU, W nW ~M w O ~-, E-- Q N_ J E--' r~ v Q r-I N d' V' M O O • O O rl N N M \ \ • M O M O f1 O \ \ O 01 .-/ O A z W W W a a q o F O ~ Z F .~ O tll m ~ N 0~ N ~ O~ ~f1 O X07 mrn a re ~in min v~ .n r .. v ~ m ~ rm mr mm am m mr m m mm mr nom rn my t` O z °• r a a in m ~ [ii ~e r . a ~ W m r r ~c r r m m ~ ,n r r m W ~ i~ ~ WF~ ~.~u~ o0 00 ~n om or o.-. ors o,. ~~ W o N r ~ e o„°, °v° °< ° m, °v °n ~ , Q b Q ° .. n .n W U O O N U r a ~ h ° uo u ., N ~ ., ~ ~ e ~ ~ ~ H ] y r ~p o (, m N v n Q O ., r. e e `v N N N N ,Z2aq ~n~ o~ e N n•7 ~ ~n , H o~~ ~, e ~, N N N N . ~~ N° . U W .v .~ as ao> n F .C F, " r ~ O V .. N n e e .n ~n m e `~ e r r r co F ~c o Z m ~` ~ O m .c ~o ~o ~o e n ., ,.. N N rv N m~ Or`H ' ~ ~ o m a o.. U . ice . ,o roo ~ ~ o r im ov vo 0 e a ~~ m~ N r~ r ~ o N ~ ~ ~OU ~~ am u i .n m o ~ N m m., m W~ N c~ n rri N N i r N p, . , O W waa ~ ca O z~> a .. ~- a wm °~ r y ~ ~, ,~ ~, ~, ~, r M N e .. ~, x w H J f !L' o m m 4 r~ ~ N N o U N N N ~ ., r, a u G ~, a t~ ~ .. .. V ~ w A w z ~ ~ a H m z a a a ~ ° z o z w F w ~ a, a a a m u Information Management Reports -December 2004 i 7w h ,J k r y4~ 1 w°~.. l a a a a~u ~o~ ~~~ + xt 43 ~rrr THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 44 ~..~ Q ~ O N a~ O~~ ~, U ~z~ o ~, ~~Q }~ U L~ W 5QQ I~ z _O Q N ~_ N r~ V Q r/ N V' W ri O O • O O In N N V~ \ \ • M ri M rl M N \ ri O r-1 r-1 W W W K U` ~ F ~zH o0 00 00 00 0 0 a' H Q,' ~' a W ul 0 0 0 0 o ui o 00 00 o o o a F Q O o 0 0 0 0 0 ° ° ° ° ~~~ ° o ~ r o o o 0 r-1 O a r r Q ~ O ap ~ m m m aD m m m m m m m ~ r W wNa [t] a y Or OaD .ip m0~ 00~ Uf O Or ON 00 ON K~V1 ON N OM 00 ~DN 00 Om Or ON W i~ n n~ n m n ~] n n n .w n m rr » 4 ~ Q b0 Q W Cn ~ ~ o r r•~ m ~ ~ N p O ~ r ~ W Q m rn ~ U .. ., ~ .. O a ~ ~ ~. m ~ ~ O N .. .. .. n .. ., .+ o 0 0 0 0 ~ cr yi U ~ p .,ry Np ~ Mm °`e ~ pM ~ e O ~ ~` Of N ~ FOU ~p ~N ~ ~ - ~ h e ~ vQ O~~ e~ U W _ _ a c. ~ ~ p p r, ,., - ~ N N N N N N u a ~F> o~~ r ° r F r N ~ v i ~~~ N p ~ ~ m ~ ~ ~ ~ ., ., 2 vFi r e m y 0 N r+ ,~ ,y n ,. ,..' .~ r o 0 0 0 °F~ p °M p m N p aG r- oa n ZO~ rr r O P p O ~ O ~ m N.i ~.i ^t0 r~~ b~ N K N ,~ O W _ _ W a a v, ~„ p p ,., ,., ~, rv n N N N N a ~ ~H~ ~FQ w O ~ r r r r r in wf o~+ 0 0 0 0 0 •+ 0 0 0 0 0 0 0 ~ r4 U W ~~ ~ a ~ p ~, ~ ~, ~ N ~, N .. N N ~, N a a w H 0.' ~ a o U o~ a a ~ a ~ ,~ a a s a a a a a w F wm z~ w o0 a Q w z z uo ~ a a ~ m 2 z~ o z w ~~ a a o H w ~ a a a a m U Information Management Reports -December 2004 e ~~ .~ e h 1 >+ rz a a~u ~O~ ~~~ ~ xr: x 45 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 formulary. 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 of multi-source claims) x 100 Percentage of Generic Utilization: The percentage of generic drug claims prescribed and dispensed. Formula: (number of generic claims =tots! number of claims) x 100 Information Management Reports -December 2004 47 `®r `~11/ THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 48 ~' 1w1~1~ W U NW W a O Q F..~ a ~ OU E ' C Q U z !~ Q ~" ~"~ H ~ ~-. U ~ L:7 U }. Q ~ W aNs W U Nw {~ a ~~~~ N O O '0O N t r•N N zH In rv1 a r+ m a v 1D r1 r1 vt in~~ wa m ,y '+ ~ •f'1 rl U'H ~') O N 111 Vl Il) f'1 d' N 111 111 Ol N N Vl (`'1 r-1 M f-~ " lfl rl r'1 N rat V' rl t+t l0 N N W N N N\\ dO ~ r-i O r-1 .-1 ry 3 ~ o o m In r1 o r~ o o r o 0 o m w, '• •• Q q N m O u1 O O r m N rn r'1 m O r N O O r O O N r f. J ~~F f, m In r o m m rn Q r-1 FC a' ,", o N w M o r rn u1 In N r1 m rr d' m u1 r1 .~ w ~ ~ [~ !L' a 10 m O o r r m r O 1p 111 M r m r V' N ~ .~ ~ m m m m m m m io m m m m m ~, ~ ~ 0 H ~ N 111 ~ N r V 111 N r C'1 N m N m N z W O W V' m H u1 t'1 m N m N rn O m N m 1p m N m t+) m r'1 m N ~p yI N ~ W m m rn m g F ~ W W r,wcq Fug r r, o o w m 10 .r rn N N In rn ~ ,n q W I2' H ~r~ Ul In tD r1 r ~ m r O r V' N N lD N N N N aT V] O.-7 / r1 r~ v N r1 1o r1 r1 c ri r-1 U] m U k7 an U a F L 01 01 m C N M ~O N V' r'1 m N r a U1H O f'1 m T lD N 01 O1 1p Q1 rl r O H 01 ~p U r In r r O N N V m ~p O1 lD ~p m N !q ' V IA O m 1p 01 r m Q~ N .~ m r N r 61 ~ - z w d' Ot d' N ~ ~-, Hd V a F W x t/1 .+ r o .y m o m rn N r1 r~ v m ~ w N E. ~ H 0 m H m ~-+ c ~-+ N m r N r r o r o U. -7 N N r rn 1o rn m r In io r r1 v1 0 .1 f rn w In ~ m r o In m m m In 0 0 0 crya~a t~l .-v N .r N N ~D C' N H H N N a z u1 .-1 . . a W a 0.' N r m O N O~ N r'1 N O O N r V' Ol w cti x n.w~ ~ In In u1 m o v1 r ~ r1 N o m In .a (t)H O ~ H H N N N N N N N N N N N N ~a~ ~~w v a v r~ N In rn c1 r m ri v1 r1 r m o r ~ r-1 m r~ v r 1c n N rn N c o 0 W a V1 r't - m N m 10 .-~ N V1 ~D m l0 Ul ~~ N ti a Q av a a a C~ l0 N N 111 c l/1 v N r'1 m d' ul ' N m N O n ~D O `7' V' ~'1 r'1 N N1 d N m 01 ap N ' lfl t'1 rt a N 0. ' N f 1 V' N N O Hm ~ PS a F H w LL LL J a a w Q m~ H 0.' O a V H w G7 H w a a r r o U r1 a w ~ z F a W w ~ a ~ u Qmzz w 1 ~ a a~°z a pS O H '' N `^ w 1^ ~ r m m o ti .-~ ~ N , rn c In w~a,a . ~ .~ .. rzamu Information Management Reports -December 2004 49 ~r- ~, THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 50 'err 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 Financia{ 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 safes 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. `M1ir' 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. Stoploss Copayment: 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 ~N {..L w ~' } ~ N Q ~ J cn U J ~ Q J U z Q z a N P P ~ V' O O O N MnV'N W 0000 V~ Or100 Ii0 MM n 0000 • O O U'r'F.. at mbMm n b0100 M OWOO VSO o11-i O 0000 w N N 'J H . . . . . . . . . . . . . . ~ ~ ~ ~. ~j ~ ~N~C 001 r-IOriO ~ Ot000 b0 V10 tD 01!100 NN m m O N N N() ri ri ri \ \ ri ri 1"I r'1 x o-i~ait~ C9 H p v] o0o m nnmrl M o00o M onoo no soul ri b o ut a F g a ~ romM 1O MrMU1 o Mbrno m owoo ao a•o v1 n n n F+ H ~ n nrnoH m naHO o oMOO Mo nM o M M O M~-1.-+ a~ ~culoln r nwN o m m rio N .~ o H N N n r10mM M .~ N b n n m0 m n H sN . . . . O M 01b0 b V• V~ O b b MM b rl N O 1-1 OiNr-i M M M n M M M M a• 01 N n nr1 m 0f r-1 e-1 m m n O N rl rd r-1 rl 1-1 ,-{ M O rl \ q q r-1 01000 N 0000 N 01n00 1110 nn O1 O ~H H m0010 m 0000 m On00 n0 ON 01 (~ h a A•.~ O V•0010 n 0000 n On00 n0 ON w w a M ut 1n ut u1 ut ~ t/'U a o00o r~mnlo q o00o nbv~ul W a w onnoo Inocoo N H O1b111n W U ullnom w .... 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O1 MOe-1 V• M M n M M M V• y ~ 01 MN V V' rl ri M M N .y .~ ri .~ rl ri ri rl W 01-100 NMrnn a 1nrlNo a ~ 1nwHr1 w a m Mmoo rl 0000 .-1 onoo no ao a~ ~t DH H nrnoo 0 0000 0 onoo No no n .... . ... .... .. .. . ~~ M mutoo n 0000 n 0000 00 bo b w M oab n n n n a a ~A~A ~A~A ~ 0y a NON m N000 N 0000 N 0000 00 NO N O N O a ~ Q U (,~ W 01001 n OMOO M 0000 M On00 n0 b0 b O b U £ a O a U ~ ~ ul 00100 01 0000 O1 OMOO MO 1110 u1 O u) 0000 O1M00 O M N O V~Ob O O ut 111 ul in u1 0000 mm00 o Into N N n n v w v .. x a ~ ~ ~ ~ ~ ~ ~ 0000 rnlnoo w H .-+ m In .r p. M M M N M H N bN Ol 01 O1 01 01 N tK a n a v w v d• d• H 0 1 U w m b W q U SL ut O p ~hw.cA O W HH hq~ 0.-100 .-IMOo y U W H W W U q rt U ~ HC9 b v] W qH xl~ q Z p >+ H Vi C9 UH x O SG ~ Da C9 HA', 7l H p O ~ H .. .. o ~~H a ~~p~pgocHn v aw~ a aa~=1a H~a ~a ~ ~ ~ q w ~ ~ H q~~ q 30PW x HW ~ q wU~U O~ Ova ~ q U q OHU1U H qa H a a U W a ~t H~ z It wU w a o a oD~ m ~ ~W a U 1 a U H w H WgHa a to H H Hm F w F w a s a s H O ~~.a1 Hqa H OOWIta ~ W O HpHO Oa to O U Wp£,W W W a w z ~ HwR1 H U H as H Uv~Wa H ~x H v2 .7 O ~gktp ~q~q O ?. H ',pE]H ~ Apga O a px~y a HH 1t a a O H ~ pwa ~ awaa H as vi wHOWH ~~ ~, o ~ 04 h a w ~ a a a It VI U U [nqa o~ aaavl gUWVI U ~ H H w ~ cwn Information Management Reports -December 2004 r 4i~ Y k h 1 .,, f+ ys~ ~B '~v h 55 `t11r THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 56 Financial Detail Report The Financial Detail 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 available.'` 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. Aae: 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 Ru 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. Druq Name:*** The name of the drug dispensed. Druq Strength:*** The strength of the drug dispensed. Druq Form:*** The dosage form of the drug, e.g. tablet, liquid. Druq Code:*'* The National Drug Code assigned to the prescription dispensed. Quanti :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 ``rr 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 Single 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. Pharm Fee: The sum of the Product Selection Incentive (PSI) fee and the dispensing fee for paid claims only. Tax: The safes tax where applicable, 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 amount) UK ACl1USiment Amount for aUlUStmentS. ' Plan sponsor can choose one or mare 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 AlR 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 paidldenied claims Total Adjustments: Total of all 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 MemberlEmployee Name. (2} Exclude both Identification Number and Member/Employee Name. (3} Include Identification Number only. (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 Form. (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 ~ ~ ~ ~ 0 ~ O O N .i .. ~ N N N r1 C7 ~ F a F Q ^~ LL /'w/~/ LL ~_ (cn Q C t~ ~ J ~ U Q J U Q Z Z {..L !C ao z U H a 0 a 0 N r-1 x O a F 0 O H rl O a W Q W u; W V O o. .-I U 'dam ., w um ~~ m F U U a a. a p a o ~ H x o m C7 N a F W R: ~ o w z a H m z a rx a H ° z o x z w n. a a o H w ~ Ft a. a a a v w u .~, a morv.v. o '"m O~ v rN~m.+ o o.a nor ~coo~n mm mmrm a G T t0 ~D ^ r~l O ~D O~ O N m O .yNm O OeUf 00 Tmen.y O ONOn NOnm O~O~ mOmr~ 00 .ymV Um~ ~Nnn mnO. N H nO~(1nN N.-~N v n n r m v ., .. FW 000000 0 000 0.-~.~a 00000 00 0000 orlon o0 0 00 m0.' 0 0 O 0 0 0 O m ~O 0 0 0 0 0 0 0 0 0 O N O N 0 0 0 0 0 0 0 0 0 °~ .:o o r m o mmmd m,~m~ m~ m .i .yn N.-~N r .iNHO N N .i .y .fie mm .-.NN ~W 0000 Fo 000 000 00000 Fo 0000 0000 00 00000 00 00000 Qw 0000 qo 000 000 00000 qo 0000 0000 00 00000 00 0 w a 0000 po 000 000 00000 20 0000 Moooo 00 00000 00 000 O F F z 2 .N. a ~x 000 Fo 000 ooc 00000 Fo 0000 ~ooo0 0000 00 0000 00 0 0000 Woo00 oce oco aR °. a x°. M °O fQF 0000 Wo 000 000 00000 Pilo 0000 0000 00 00000 00 000 ~+ ~ m `~ 4 W ~ p u w w a o .-+mm o ~.. nor mNmrm 'a' a ~a e mONN w0 O.en m~0 N w0 m.D .-a pn pw 0 ra .. N o .y .~ r v .~. umi r.ti .. mP mm Wo n.. ., " rm,e ~ U o N n e .. .. C7 p w °w cpu O ~ ~ O p pQ3 0 0 0o a 000 0000 0 0 0 0 0 o~-.~ faa f C7 sms tm/1 m V6i ,E~ ~ mNm N f~~ iEEE ~ f fmllmf ~ lOlf ~ ~'~ OOON O~ NON O~~ Qv nnn N N r T .v mp. NN n O.T pm n n~ m m m VI m m m m m m m oooa 00 .] ooa ooa oooo~ oa oooa ooooa oa ooooa oa ooa oooR( .( oo.t ooR 0000.( oq ooo.[ oooo.t o4 0004 0.( 004 ~ 000E of ooF OoF 0000E of 000E ooOOF+ or. 0000E of ooF d of mE O~nE oo~ OoroF ~nF 000E 0000E of v+OF of ooF n ~n m n .~ Np O p eN^ ~L1 ~w .y ~O .y .+ nC] .Nip mm rvo rnQ nnQ ao a~~Z ~ xa as ~a~Za ~ ~~°r~' ~a~a~aa ~ ~a ~ ~d ~a G1w OF W O W F OF F wZ O FmU FFFU F FFCc~~ vF FF ~K VS~ 0 00 ov+ ff~y. u~i~~ eoo onF. S o0 m N.~e O O Jfr .-r O O nnm.-~ N nOn N ems. 7~ a pz p W W <~ pH w W ~~ O mmm mm S2 S2.'LS S txm rSSS S SSxm 2~ u f£s ~ i~ ww wwww w wwE ww w w wwwf f ww w NN m~n~e m.ur ~ m~,m N ~~ ~~ a ~,~,~ eeee .~ ~ee~ a m,~ W rw os~ az p LC ..~ m 0.W a~ Information Management Reports - December 2004 i i.+ v i~= }h~ N ^~'i .59 ~rrN" THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 60 OPTIONAL REPORTS Information Management Reports -December 2004 61 ~rr-' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 62 Performance Mail Savings Report The Performance Maif 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 filed 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. ~r+r Targeted Ingredient Cost: Ingredient cost for Targeted Drug. Dispensed Drug 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. mow' Information Management Reports -December 2004 63 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 64 Q Q • 0 0 Y y Y O N N Y Y tl n U1 \ \ u ° • x w N~ In s~ m~ .+ 1x1 xD N ~ n X xo r e ' u O O M z O~ ~ N P r r Y N n b N O ~ w> xR N N N V1 N N N N , m Y r M r b X N~ Y N Y -~ H O Z N N N tl ' N N 1n ~ Y ° . N ~ r P N tl Y N p N (7] y W W W RG Y P 'u' C7 ~ F rt H A'i a' ~ Y N 'e a F Q o ° • _. o In N ~, X, n n » r ~ N a an N e I v n m tl m rv ~• r M u M ' ' \ ri O W Wd~ Z Y1 b m~ N b n o .y N N N H N N N 4x h m n b N m r m N N N • m Y U r N ~ r N n n 1 U n ~ \ ~ / L Q i > m tl N M ~~ x N !ti P p z u n e N W e u ~ '~. gW m s r r r r of `~' tl Y ., m .. ~ o ° r : x r x n W F E. 5 Z o ~ ~ o r o r ~ o r u m In a p e ~ ,~ P r ~ fA w > ^ Q .~-, , a N ...Ni o H N N N N N N o n ~• Y to r v r e .~ N .i Y ~ Y .m. N .u'. r ro ~ • (~ W m K N X N N i U1 • ~ fn Y N~ N/B Y W ~ C7 F n Y Y P ~ ~ ~/] 2 W X tl tl P • U) W ~ X ° Y y Y • u ~ y y y Q N Y Y ~i E • X / B y a F N ti m b .a .i ,n .~ p P N O YI rv, r n O f 0 m N m P r P ` 1 / [f] ^ OU m ry xp .y b 1p O Y t[1 b N m ' n U1 m B P . L ~ H W y [+ 2 'Z N N N ,xf N N .-1 .i .+ t N N r 0 N N N ~ ° N ~ B N to W W (1 R N N N v? N N N N - X rn m P Y B ^ P W ~ P ^ C 2 u u n i x xl N Y 7 P ,y n , ' b B L ^ W W n p e ^^ ~ w Y J z z w a ~ e " ~ W a .+ BY ^ ^ ~ ° P ° B fY 4 F N v f+ O m .n N N N i~ m X ,/t p O [~ ^ » w [ n .-1 ~ N N N r .-1 N N N x/1 VI N N Vx N~ ° P r- N m m N N N N P O N H~ N Y N 0 m N~ m V1 N J W W N 1 - n • Y 7 N ~ t ~ ~ ~ Y Y tl z n ~ ~ u o ~ P n y h tl ' N Y Y ° ,4 .a w ~ tl Y C) ~ ~' z P' ] Y X a. F a P p ~1 ~ Y M P d' ~ Y ' ' ,.] ~~ a o 0 0 0 0 o o o r : , ~ w H a W N ry o 0 0 0 0 N N N X v ~ \ ai .] ^ w0 .y O N r p H ~ O O o 0 0 0 0 0 0 O O O A O O (X ~ M ,y Q n • o U a N a a N m a ~ w w a i a X a i a a a n a a o ~^ ~° F: Y o ~ F ^ ~ p F ~ a (y .7 {Y J x 'J • 'J Q1 a ~ r V ~ n 11 r y ~ N M r ~ . N P r i >. .. .. .. 0 ao (~ f9 ott C7 Y W owo X ooc ~ $ w O W W F w O w P C~ u x w ~ w F 4 P w ~ F W ~ U d b b U Y ~ ~ j U P r( P ~ P q Q: Q W z ~ ^ X U Z f G 2 4 U P Z I m V n 2 P H [Q 'j. W O W O f W O• ^ O x Y O N H~ O F a ~z N ~ a ~ Y c ~ tl ° ~Z X z z W w ' ~ w F : > o O 2 a ~ o a ~i > P N Ct+ GK O ~ u w n ~ w a m u ~ ~ Ul U ~ H ~ ~ ~+ • Y ~ w ~ 2 , r P q ~ r, p Info rmation Management Reports -December 2004 65 err 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: Therapeutic Class: Classification of a drug by disease state. Claim Type: 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 Drug Name: The name of the drug for which an interchange was performed. PDL Druq 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 O W NX~ W WQ U E-~ zW QQ ~w ro z W Q W U a~ W F--' z .-+ o w r n I n H o o u i n ' n u u u 0 o II 1 II I II II M N N it I II ' II I O \ \ II I II I ~ ~ 11 I 11 I 11 II l~ N N II I 11 I II II O \ \ II I 11 I II II .--i r-1 I II I II II r-I H I II I it 11 1 I II II II II ~ ' II II I ; H II I I 6 II II II " w w w I II II I 11 II I II II V' .~ F w I II I II I I II it a F Q o ° ' n I II u II ~ n I u I u 0 2 u I u I n n u n N u I u I u u \ c9 u I n I n n m ~ u . u ~ 11 I n I n n O u I n I n u u O II I II I n '-' a n I n I II II ^ u ~ u I u n n u z a ~ n ~ u u w n u I u n I u n n ~ n u I I u n u n n w u ~ u u I n n n ^ u ~ n ~ u n u ^ 11 u u n I u u n u w u u u n m u ~ u n u m u ~ u ~ u n w U w u u n n . I u u n u O ~ n ~ n I n n a z u I n u n a' u ~ n I u u U n ~ u I u n m D u ~ n I u ~ a u n I n n n H ^ I I ; I I t I I I I ra II II I II 11 11 II II II V ^ II I II II II °' u I n ~ n u z ~ u II I I u II I n 11 n II O I n . n I u n 2 I u II I n II I I n II n II a I II n II I I II II II I II 11 II 11 II II W II II II II Xm u ~ u ~ u n ag "L7 .4 n II II II I I I n II II 11 I I i n n n it n II II 11 d' V' C' II II 11 C V' ~ II II II V' V' i II II it II II it .a o 0 o n o o a o o n u .] o0o n oo I II oo n u W H N N N I II N N II N N I 11 II F G. \\\ a \\ ~ n \\ I n n Q N m N 11 N M I II m H I 11 II ^ R. HHN II NN I II Orl I II II Q \\\ 11 \\ t II \\ II II rIOH I II HH II HO II II ~-+ r+ r+ it ~ .~ a r+ .-+ ~ u n rn II ~ u ~ u n w u n n n U u ~ u I n u a u n i n u I n n u u r.( a II II I 11 II U a w u I u u u o .a m u n ~ n n .a o ~ ~ u I u I u n w u ~ n n n Fo .. ~ u n I n u O~ p+ u I u . u tl F .-+ ~ u u I n u o u ~ u n n a u I n u n U u ~ n ~ n u ~ w ii II 11 II Ha aan. n wa ~ ii as ~ ii ii rr~~~• aaa a as . n as n u .7 .7 F n I n I u u .7 U n u I u n rS n u I n n u u ~ n n a II n a n n n u n u w u o ~ u ~ n u I-+ a .-+ u F I N n I N u n In a O u u I n n a F u u u u ~"I Q H II I n II 11 o U a7 n I u n n I H II II Ii n N x II rs. II Cn I II 11 N z II Z II a II II O H II H 11 Q n 11 o n n F u n ~ W II H 11 H 1 II II O rn (f) II F ~ II IA II II rL a U~ ~C Q F II u ~ I II u H x I ~ II u 11 u I-~ U ~ n n 2 1 u u .. .. w .. u Q Il a H • 11 rl ~ •• ii ~ •• u ii a~ w ~ H a a ;; A ~ a n a ~ a u u a ^ W z ~ ~ F u O F u ~ I F ii ii F H al 2 t I O u a ~ O u !L I O u n O a ~ w o F n w F n I F u u F E O F a n F n 2 ~ u u 0 2 W ~ U ~ ii ~ ~ !f~ 0 o m u n q a a o H W C7 Q n Z I Q ii o ~ ~ II u Z r b w\a a x ~ u o I u a ~ ai ii u : a~~ U F x ~ U n z ~ U n a I U n n t9 Information Management Reports -December 2004 ^ h ti .% Vj K `. 69 ~11rrr 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: Tota! number of paid retail claims. Average Ing. Cost per Claim: The average ingredient cost paid per prescription. Formula: total ingredient cost =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 err' THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 72 r,~~~ 0 0 0 o 0 t~ N N lfl \ \ N O ri O f'1 N \ \ O Ol r/ O x w w w a ~ ~ F o a F Q X F 0 O O r O LX w Q W U) W i) U a a F V C!] ~, ~ ~ O cn a cn w ~~ ~~ F-~-e ~1 W a a Q I w Q a (7 a a a x w H a x N rt o U N rn O O W O a a .. .. ~ .. ~ W o w z 2K, ~-+ m z a a ° z o z w a pG o ~-+ w ~ a a x a m v Information Management 0 V' r N .-1 O VI lfl O' Ol .-~ N M ~ N ti r~ 'i r-1 'd' 1f1 to to C9 R( m v N O F N +? t? i? 4} N v 0 mm Nip are ~ m m o N o rn m ti 1 ~~ ~ 0 N 'fl ~fl t' ~ r+ a~ r N LT N t!1 VT M 0 ~~ ~~ ~~ N V N !+l N 01 v c0 O ~ ~ r r+1 U1 lfl N r ti N r d. N lA N VT In X a 0 ,, ui r r o r ~O O 01 .~1 N r'1 N m ~ N t'1 Q V' U1 l(1 N m N a~ r VT N t!T N V} 0 x a o m ~ U 3 Z H i ~ Q E E W ~ as ~ O O \ \ H H H Q O O U ~ W ~ + U U ~ W ~ Q[ ~.l C7 Q wU C7 C7 Zw a zz Ha ~~ zo az ti ww v~.. a c~ c~ F ~ Q F ~ Q Reports -December 2004 .~ +. r r M1 `~~r 73 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 74 Therapeutic Class Analysis Report The Therapeutic Class Analysis Report fists 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 Drug 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 ~,r THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 76 N~ w a w _~ X '~ ~z wd~ z~~ ~~ ~vU OUJ ~y,~d wW 0.~ w C~ [~ Hrnva• rioo •oo O N N N\\ •~~ tnNN O\\ ri ri r~rl x . ..~ www~ C7~F0 aE AF O 0 N 01 N H E O rK Cc. Q w w U a. w V a a Q O a 0 a a a a w H a a ~Q OU 0 0 O a craw owz~d Hw z a. a ~2 o zw aaoH w\aa R'QU)U F cn .a ,w ae as ow .a dP w ,a .w ,w ow ,x ,a do w ,a ,w v .p ea aP ew a~ ~ va ,w a^ oa Oaf o00 0000 oNOON., roHm mo rnm oo~-evoo r+r, a~ z FC H U d^ z H ~J H Cn ~ eM dP oV oW eV dP aW ap d^ aM d^ dP ep d^ aW aM eV eW eV sV eW oW eW oW oW d^ oV V] wm rIDN r/ N V'a r r tllr v r O~~pM MAO O mN OlmOr ~D 6~ a GL Q ~fl M r1 N N ~p .-/ O~ .r M N lD O N Ifl ~} O ri N ~p V1 N N r O~ a a U NN NN r riN O~ O N A w ti x ~H M N 01 O M M \ f (~ G], H Q H Q N d' N N O O F -l ~N~~ N.y U y N ~n o m v ~n ~n H C] o ~o o r '..-~ zH ammo MM H w OiCmM MM r M U) Ul Q ~ N w ~' rl N N N C7 O cn v} !? v~ zu a U .w ,w ,r+ ,w ,,, ,,, S r .~ N o ~o ~o H H N aM U 2 U H H eW oW oV eW o`P d^ eW cW d'+ eV d^ oW ep eW d^ oW dP oW eV aW eW d^ oK d~ oV ew d^ ~w~ ~r+•+ ~ *~~ ~o+'+~-+rv Mmr o0 o rMrnNrr l,~n H [V f( M N N M M ~} N ~p ~ N m M r H lf1 N N m o N N W N N N N :V Q~ U .~+ M .-' m N Ol O fV r~ fi U w ~ ~F V1 M N ri M M d' N ~p N N r O~ l/l O N N ~D M N ~I1 t!1 N .-~ !fl ~0 N N m Ol ~ r~ N N r N m N N N .y H a fA U `" 0 a qH zzz o00o wn.aaaa o0 zzzzzz. 00 c~ w oa c~mm ur~um mmc~uuc~ mm wmwmcnm mm ar ~~f E~fm ~wEfEf wm mcncncnmcn mcn Q F w ~d z u a Q a w w at a U w O JC a u m o a a w w a 0 a m o u ~ H H Q,' Ri H ~+ U H a z " fn H ~ w ~ w Q w c~ E U Q Information Management Reports -December 2004 s 4 h '1 v t+ ~i ~. f F a 0 a. w a w x F z H Q W a O H U Q [z F O z w F w a 77 ~r-` 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 "USC" codes in this report. Therapeutic classifications group drugs by genera( category such as antibiotics, oral contraceptives, etc. The generic code groups al! 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 I 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 W (~ N~ O /~-1 W N W ~z~ 0 ~z~ H 1 H Q w O ~~ UU~ W ~ 0 ~ `Ul V a O F-~ rein a~ a " aF 000 m . p p 01NN ~ M p V v v ~ ~\\ '~ ~ U1NN 0 0 0 ooo 0 0 0 0 r~ o 0 0 0 o o.+oOrno00oo r m 0 0 0 0 0 0 0 0 0 0 000000 0 0 0 0 0 0 0 0 0 0 O\\ a' H 0000 0000000000 ~.y ~{ z U p rN ( O O O O N O O r1 O O O O O m O~ O ~O 0 0 0 0 0 0 0 0 0 0 N 0 0 0 0 0 0 0 0 0 0 .~ .i .~ W W W •~ ~~E+ U ocH ~0 0 0 000 00 T 00 O rf 00 0 00 00 0 0 ob o o b .. 0 0 0 00 O O O O 000 0000 O O O O p0 O 00 O O O 0000 000 W F Q O c7 p ~o 0 o b o~ o o n o 0 0 00 o m h 0 0 0 0 0 0 0 0 00 o N 0 0 0 0 0 0 0 0 0 0 o °" ., ., N ~ v O N b T /~ m 0 m O~ N n b m r .+ m N rvf ~ 01 r N < ~ rf ~ N ~ .~i .1 ti IA ~ ~ O ~ N . N .-r i N ,y U1 v • N a ~ m ,~ 0 rf F ~ O ~ F W W ~ N oo m . m ., w a a .-. n ~ . P e e v .n n m r~ < N ~oryuie vm O~4 n O F Z~ O~ N ilf n r ~O O n N /~ N b W i~ C O m N ~ O N ~D N m N O~ O n N n p O ~~ n r n b 6 N Y~ N N ~ N p .i ~ b ~D b W,~ a b oo C b om ~imnrbi a ~ b n b bmmmr'n inn~m ~ N a.r eN~ mmm N N N .~ r .i .y .y ., .i r~ N .+ .a .~ .+ r ,y ~i N o N N N N N N ~ a F r, ,., m . : J F W rn ~ .. N m .~ .~ .+.-. ~n e m m ~ r.+a Nm ~ N N,-r rn.-~ b e a .. a r3 a~ a ~o Q Ha ~ .+ V N p H ~ ~ U a [-. [.. [~ [. [r W LI ~ G1 W ~ ~ fil ~ fil [r [r [r [~.+ [[.-.. fil fF+l (il G] W W fFil GI W W .q[ W [F.l N W fFil W 6' R' W W ~ ' o. a a w a a a ~ n a a a a a a .. a a a a a a a s a a a - a a UFy pd~ ~qqp ~pp ~ ~qq p { ~pp ( qq ~~pp( ( p~~ { pq FF~F FHF ¢77 p~~ W~ Qtqq ~qq Q { ~qq ~p~p ¢ pQ ~r H F F F (qq pppp d ~pp ~ ~qq ~~qq ~ [qq ¢ p~~ ( d ~pp ( f~~ a aH FFU U F F F FFF F F( [ FF -'FEFF F (: C7 ~ C7 f C f N (7 f O~ ~ ~ ~ c7 U (~ (7 o C~ z I0 0 0 C ( ( E ~ I ° N 0 0 0 0 (~C~ f Ci f I E f~ U O f C~ [~ 0 E o0 (7 C~~C9N o f f U S C~ 4 1 N O 0 ~ oo E ory ~Y o o oo ~n o a a ~' I~ .. N u~ rv ., .-.., n ui .. e n rv ., .~ n ~ N ~ .i in N ., < N W W a z ~ z c F 4 u 4 I a. N Ul 4 w V a ~ ~, ~d oU m ' a ~ ~ < m m m rv a `" ~ e ~ ~ ~ ~ e a o °o ° N M ~ ° v r n r ~~ FV~ H p m ~ ~ F b o b ~ b p O m ~C a V `vrn b F .. a.+e .. r+o yr F .. .,~ e ~ v. , . -~. +~ o o o v ~.. u+., .. a , W z ~ W' CT ~ Im mo .. N n o in b r m „ .+ rv n v ~n b n m mo .y N r~ ~ b n m e ~ w N W ~ ~ ~ ^ ~ o Z A ti W z <<'il ~ V ' n a~c°n~z o ~ I m m ° o zw aao~ w~aa aa~nu Information Management Reports -December 2004 s N 1~ J a wi ~h 4i ~-. 81 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 82 Managed Access Confirmation Report -Drug Code Modifications r The Drug Code Modification report will provide the plan sponsor with a confirmation report for any changes, deletions ar 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 Drug Code: The national drug code assigned to the prescription dispensed. Druq Name: The name of the drug. Strength: The strength of the drug. Form: The dosage form of the drug, e.g. tablet, capsule. Date Begin: 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. 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. Action: This will provide the client the action taken to the existing table entry. Information Management Reports -December 2004 83 `~iMrr'` THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 84 O w H m V' d' t!1 O O O O 61 N N O \ \ ~O H O O r'1 O \ \ H O N ~ w w w a a H a rx a F q x F a 0 N H 0 O a w q W w w U O a a Z ~_ ~_ ~ U_ ~_ ~ t1 Q z O N w ~ Q W O U U U Q ~ ~ ~ w ~ C.~ ~ Q z Q a a 0 a c~ x w a .~ ~d o U 0 (aY- t~ .. .. ~ .. w q w za' m 2 a a ~ ~ z a a o H w ~ a a a a m u M /i K W ~ ~ ~ ~ ~ •1 0. nL ~ ~ ~ •i Fl. ~ K a .~ m w m r~ r o r .r ~n o r~ •o m H w ,-. m r~ rl d' Ul !fl O O H H O N O O O O .-1 H O H N C~ w m ~o ~o ~ r r r r N m rn m m m rn m ~ m rn z H `;' 0 0 0 0 0 0 0 .-~ 0 0 0 0 0 0 0 v o 0 F O1 ~ ~ ~ N In ~ ~ ul 'n N ~ ul vl vl ul ~ In In H O H H H H H H H H .• H H ri H '-/ H H H rl F v w v v v v a o v v v w v a v w v •r ~ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 cn o 0 0 0 0 0 0 0 0 ° o 0 0 0 0 0 0 0 0 W N N N N N N N N N N N N N N N N N N N O F ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ a cn a c w v v v w v v v a c v v w vi v v a q .+ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 H o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 .~ ,~ H H H .~ .~. .~ .. ,-. H H ti H H ,-~ ~ N H rn m m m m m rn rn m m m m m m m m m m m m m m m m m m m m m m m m m rn m m m rn 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 W N N N N N N N N N N N N N N N N N N N q F \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ z a H .-' .-l H .+ .-~ ,~-~ .-~ H .-~ .-~ .-~ .a H .r .-~ H H .-~ w q r~ ri r+f r~ r~ M rn ~ rn ~ ri ri r~ r~ rn r~ ri rn m N N N N N N N N N N N N N N N N ry N N H H H H H H H H H H N H H H H H H H H V' V' V' W O' V' C C V' V d• C' a a T d' V' V' V' o ° o o ° ° o o ° o ° ° ° o o ° ° o ° z o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 H W N N N N N N N N N N ry ry N N N N N N N C7 F ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ cU q H o 0 0 0 0 0 0 0 0 0 0 0 0 0 o H o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 N ~a o~ m F d a~ w cti wo am w o aa ~ " Q F F H W ~ F ~ E+ ~ H F F F F F ~ ~ F > u ~ x v > u > i °m ~ x x ~ i x > > x x F c~ c~ u u ~ u v ~ ~ ~ r, ~ ~ M ~ ~ ~ W E ~ o 0 0 0 0 o u~i C7 ° o 0 0 CK •n O N ui o m m ~n N o 0 o N o o N ~ W a a a a s w a a a a a a s w w w w w ~ ~ ~ ~ ~ ~ ((~qqq z 2 W W [c W z a a ~ ~ Z z z z z 2 z ~ O O IK [~ a' H ~ x H H H H H a a w w w rz w w a cx a a a ~z a w w z N H N N H H H H r. [r. [y ~'+ ~ ~ ~ Q ~ ~ H H 7 ~ ~ 7 7 7 ~ H a a 5 ~ ~ t~ ~ w c~ ~ ~ :~ w m w m ~ ai m a W W W H W w [z, H H H H q o a a a a a a o w a a x x x a a o H H N u v ~ N rn m r ~ ~ N r o .~ N ri a ~ a N c7 r r r r r m N ~O m O N N N N N N r r N .7 M •0 lp ~D H N O~ O~ ~ p• N N N N N N r'1 V' X11 a' M N N N T m m Ol O O N N N N N N M ~O r q N H H H H N .i H N N N N N N N N N d' ? Information Management Reports -December 2004 ti 1j .,,. w YZ 85 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. !t 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 Type: Level of drug class (example: NDC, USC class, NDC class) Drug Name: Drug name Begin Date: The begin date of fill that will require prior approval for coverage. End Date: The date of fiU 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 & 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 By: 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 far 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 Copay Types: Identifies copay type being utilized for this record if overridden from normal copay type. Copay Amount: Identifies copay dollar amount or percentage utilized for this record if overridden from normal copay amount. MAC Penalty Copay: 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 ~irrr` Information Management Reports -December 2004 88 ~rrr~' ~r H W ~~ z zp O ~ 5Q U_ L ~ O ti ~ Z C G U Z (!7 ~ W ~ U N_ Q ~ ~ O W ~- Q z Q ~-+ a a v o 0 0 0 V1 N N H \ \ l0 r1 O O r+1 o \- \ .+ o H c7 H a a F q F a 0 0 ti 0 z 0 a w q w W U 0 a a a D O a 0 a w Laf~i N a o U 0 0 a .. .. ~ .. a d q w z H m z a ~ o a a o w \ a a a a ~ u V' o O 0 o z Z N V' \ N ~• ~ M aD Q .. r~ .i z \ N • • ~+ ~u~ °' rQ .. .. .. .. a .. .. a w ax ox~ W W 0.rl ?z q V qfA E+NC~ ~~"~/SF zzzamzF~dW~ N H O~~ Q a a Q HNFx www~ ~-,aaua 0 z H x u (-~ O cn .l a mo z ~z 0 H .................... [av' [Wil .~7 f~~~~.~aaE~E[z,7~»»m Q a~ a~~ W~ 0] Q s rma~navioFaq ~n u w a H H a q f a ~ o a ma q a a u Q~ ~ a F O r 0 r- a f q ~ qa w a q cn a a w U~ o 0 0 m o o u vzNN ~•~, VI M N \\ W to i K a F m o m x W W .-' rn ,~ q z O \ \ \ W H w O W ~N-~ W o; Z .'OL ........ ...... o .. .. o z°zm xumx z c~~aaa~~N aooo O W WFF !Az Q Q a HHa '' ~~~zqq oam~n 0 w wwxc~~ w as F mmQ~w~wmozmm Information Management Reports -December 2004 O O o r z tea"' .imr ~ p .. o ,-..-~ Z \ N •• oV~ a ~~aQ[ C~ a a .. .. .. ~ O .. .. U F O~ F W N 2 w~~ F-. oo~~azH~az~' zzz~cn W wcn HHHOO ~>+av~ f+FFx W Qa a aaaoaa~~u~~m 0 z H x u ~ O H U1 a ~n w v z ~ ~' 0 rHi .. .. .. .. .. .. .. .. .. .. N w a H >• N >• >• N W a x ~,zH~~~aw~o' Q aWaW~W~o~Q m ~mWmarno~aq w q z u > ~ as a o a a °w a a Exi a~ Q a O 0 F a A Q ~ q E+ r a W W z ~aa w w U g o o A m .-~ o o a uaNN u,a cn HO\\w~ow Q a a o o rn> x [~~7a r+o r+0 Z.7 \\ \ H w Sao°w~QZO°z H .. .. .. .. .. .. .. w .. .. z zz~m H>~p'd r >+ ~>a. H a O r] O o U U F 2 0 0 o a r` wwxo~ w~~K H mmQOm~wmozmm o O o m z N p \ .. rwN ~ O •• oin~ 2 \ r •• oqN a ••a ,~ a r, ~ rX .. .. .. ~ A .. .. U F Q~~ q U W~ F W c~uc~HazFFa'z~' zzzac~[w. W m FFF xrOA2aQaQ mcncnF .+aaua w°°aaai°v°~m 0 z N x U H p Q a W w v z aw.'' m 0 F .. .. .. .. .. .. .. .. .. .. cai w a .. ~r~~ r q a a ~aa'~a ad a~o x Hz~,~~rr~~~t~aw.FFFF,.~n Q a~ a W H W f O~ Q m ucn W mamoHOq u ~ Q z r~ a a v a aaa w w a u a~ ~ a O 0 F W F ~ a F N W R1 z as w w awvv q W U g o o H CA Hoo a uaNN v,a V] H Q\\W SOW Q a a o o~ m> x W a ry r+ .r O z W \ \ \ w •• cW~ao°.~w~ ~ °z°z F W q H .. .. .. .. .. .. .. (~ .. .. u z°zcn x~mx H >. >.HH COgO W H ~~ ~~ uu~Fa'oo ~a ~ w0 wwr~zz O cOn uNi w z2Ex-~a C~Ca xtw-~ as H mma aq mwcwng2mm ,. l+ ti ... 89 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 90 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 will be issued. Following are definitions of each field for each field on the Managed Access -Due to Expire Report. COLUMN DEFINITIONS Extended (Y!N): 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. Griginal Authorization Date: The original date of the authorization. Original Expiration Date: The original expiration date of the authorization. Information Management Reports -December 2004 91 ~r- THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 92 m ~ Q r c o •• O r N o ~ ~n o O ~ r-1 C? £ F a H a a F a N } N ~ N W /U, V ~~ W W ~~ Q d Z X CQ W G O W o ~ m 0 5 0 a 0 a w a d v 0 `. .. .. ~ .. W a ~ z a ~ ° o z w a a o H owc a ~ u w a H o H a N rOi a o OW ~ H W v ~Q o0 za N H U' O1 H x N a~ ~ O o Q ,r 0 N N .-i 0 N 0 r~ a~ Q X r~ w ~C ~ C7 ~ O z~+a r a HN am (n F. ,mooa pow pNOQU7 '.7OO~U1 w~°v>~°zz ~z°E•r°zz zox~aw ~ zcix .im ~~ oHHa~rn~• oHHa~~nr w H o0 oa H coo oa a ~nozw aka cnozw art F aaat9E~ W aaaC~E°•~ W z z°v"i`~K~. F z°u~iar o H ~ aau~ H ~ aav~ H caxc~ aQw o c~ aQw N a~a aim a~a `t~cHn H aQa m aaa co a W W Q Q a a Q m~ ro w w w m W ri co ox N F m m W a '+ ~a E+ H ~ ~ k" W r+~ N a o w w H a a a w w a H w w ~ w H as ~ ~ wa z W z H~ x ~• w- Information Management Reports -December 2004 W F a a m a w a O x a F a p a w a w 0 a W H tJ Ul r. °b 93 THIS PAGE LEFT INTENTIONALLY BLANK Information Management Reports -December 2004 94 CAREMA[~K® h all starts with care' `_^,i 9 ~f~ ,`W a. y. ?' . ~' 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 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 potenflal 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 CAREMtV~C~ the value of your specialty pharmacy program, it also puts industry trends into perspective so you ~~ ' can measure and achieve better results. 4GIS R•spig4ry SrntiEal V4uc 1,075 a1R Asthma 136 AT ROPE Nupoa CiraMlt Hormorr 105 Hemophilia 5 ~~fS Hamophilia 11 4Z',TO Hemophilia 9 BORN AO Human Gmwttt Hosn•m T8 OT ROPIN Human Growth Hormone 59 EZYME 6wcAara 6 ROFIN Human Growth Hormone 35 IOlllNE tiare0phlfa 3 f NA Psorias's 79 A4AG.WDSD Irrtrwanouatmmunoybktlin 18 OFII M H•mophiGa 7 Gaining Greater Control Over Your Entire S cialty Spend 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 be 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. s x,651,21 1ex s 1354 X42 5x ~~ Specialty Pharmacy Insight report CAREMA~iC tilpha-t Arcicrypsin Defiaency 1 2 I E 31,049 14 199... ! 51,990 S 1,364,J42 Coaqutarm 1 1 Y 93 3 2,598 poachers 3 6 3 548.178 E: 913.+.80: HemaCtpo~etics 16 18 3 65,096 3 104,729 Hem4pIMN -. 7T 100 ; .9,553.924 3>:.:1a,252~T4 HepafiCSC 14 12 Y 175.758 S 88.089 Hannne 8 9 t ..84,987: 3 147,818 Your Top Drugs i ~ tl6 5dt J ~ s° ~,wsr•s RxNavigator° Detailed information at Your Fing~rti s 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. $250,000 $200,000 ', $150,000 $100,000 $50,000 0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 Participant Age RxNavigator screen shot 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 DR[LL - INvnc•d '. From: To: ~ v..~u~Q.,.t c...d.. '. DEACIass ~ 1 Drug Dosage Name Drug List ', Drug Manufacturer Drug Strength Name ,..1 -~. , , ~~` r Unknown r Female r Male RxNavigatorscreen shot Caremark also provides full training and support to ensure that you and your staff receive the maximum benefit from using RxNavigator. Advanced Clinical Outcomes Reporting A Closer Look ~t Your Return on Invest et 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 Customized Reporting Solutions 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 Eec~~ 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. ,,, CAREMAI~K hall mur a-rN e a e' www.caremark.com 800-223-7745 ®2oob CaremarR. Ad ng~ts reseved. ~Or+ ~: r~` ~ `, i .~~~. .. ;" .."`a'"~ 'fd ^ ~ Your Prescription Benefit ~ ~e sam'P Your Logo Goes Here Prepared for ~1~~ h uA's~aris wif3i cars" 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 ~"'` ^ 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 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 thQ 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 Difference 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. ~r Your Personal Prescription Benefit Program ''` A Convenient Pull-Out Guide ~~~ h:> ~~ ~ <' rp ~- ~ ~ ~ ~zs 1 x f ~=~ +lt !ll' t . ~... ~ ;~v, d ~ ~.~F~ '~i... _ .rl ~.. ° 7. ~ '~'~'^~!~ ai a'- , ~i~ .. 4 '~'f 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. "~.r ~/ ~ °o ro ~ ~' c c }; ~ v a ~~ ~ ~ o c ca y,as ~ v ~ ~°~~ ~L~ ~~Y ~oa~ po3~,c ~, 3 c +-~ >- Q Q~ C C v ~, O a, O~~ N v o ~~ ~ ~ 3 ~~ a, ~ o ~ >,.Y >, ~ E ~o O v - a~ ~ N~ ~ UOL ~ ~ c~a0 V O ~ Q~ O~~ O-n 4I 7 - v ~ O N rp ~6 v ~ N ~ ~ N ~- Y N o ~ ~ dui r6 . ~^ c c -c a ~ } co c Y ~ ~ ~ ° a'.~ ~ s ° E.~ v c~ a o ~ ~~ `o a ~ ~ c`o ~ Q~a o°c'~o aim- ~~o~a ~~-c~cv "' co c~ I v v ~ OC ~ c p _ c °' c a.., ~, ~ c Q V 'O ~ c c V >, ~ ~ ~L ~ .}, ~ ~ ~ io Q ro O ~ ' a, L ~ L (p ++ V ~+, ' h I co ~ ro ~ C ai vi ~ Q ~ ~ ~ d7 -_ Q ~ v b4 fl. °' •}, •}, ~ £_ c ~ E °' '- Y -v c °- aci o c ~ ~ ~ ~, o ~' a a~ ~~~., ~^ v'~'~o ~•a ~ `~-° ~ ~ ~ E max, }' ~ ~ a o E ac,~ ~ ~ C>- fl.a~o cc~ n.+-.,- Vv av ~ ~ ~o~V Z ~ aa° o °V -o v; ~ ,~ ~ c o~•~~~ ~~•m co o~ Q N p~ 0 ~~.Q~ c o'er v ~ ~ o ~ v ~ ~ 4~ ~ ~ x o `° ~ v c- ~-c ~, V a ~ o ~o ~° L L v-_ ~ ''~~ Q' a~ ~ >, o ~. o ~ c-a a~ v-o- E ,y °' ~ +~ o ~., v ' v, ~ ~ v ~ aci ~ ~ v ~ v a ~ ~ ~ _° ~ v ~' ~ `6~0~0~ 3~~I a~.~ ~~c~ ~~~a C V +~ • V ~ ~ '+ .O . C - r0 OO, .Q - 'O A L ~ r6 ~ Q- T V ~ ~ 'a lL6 O '+~~ ~ vVi ~ i ~ ++ '~ ~ V ~ c O p ~ ~ ~ ,` v ~ V a. V ~ vQi v N >, ~ C ~ ~ ~ ~ ~ ~ ~ ~ ~ p ~ • ~ ~ N - U - C ~ ~J ~ '^ ~ U ~ it ~ 01 ~ p ° p L C N ~ ~ O >, ~ ~a•- V~My~ N `- ~ ~ a L O ~ Y L >, 01 C~ L ~ N ~~ oQ~~s•c~ ~'vco° o~ao O,v~nov =°_~v~>° ~ ~ a ° >'~ v ~' v ~ c ~o~u 2 a~.4 C v c.~'_' •~ c rLa ~ ~-' ~ f.~ ~ ~ ~ L' Ewe ac of ~'~~ c H ~ ~ h ~ a~ ~~•~ ~ v ~~ > °, v V ra ° c ~ t p ~ ~ o ~ p ~ . k d ~ ~ L ra ~ ~ O p ~ . ~ ~ ~ vin v a~ >,3 0>- Q>,~ a a,a~ Q a~ a>~ u>-V~ ~'~ Count on ~ , Safe and Effective. 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 money 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 DARVOC ET-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. N O v C W C O ca L it n ~ ~ ~ i ~ • ~p ~ 0 Q ~ ~ Q ~ ~ ~ J ~ r--~ O L C -i V v V ~ ~ c n N ~ ~' U ~ N ~ ~m~ a ~~ ~ vo o ~ ~ V~ ~~~ ~ i ~ /\ ° o Y X ~X ~ ~ rn o cfl ~ ~ ~ M c ~ oU r ~ ~ U ~ ~ ~ ~ ~ ~ a~ ~ ~~ m~C3 N ~ z 0 N O O W 00 ~ ~ ~ ~a~~E o X c~ ~ ~ O ~ cn ~ ~ ~ a U ~ c~ ~ a~ ~ Q ~ ~ (~ C ~ i ~ N ~ ~ ~ ~ x ~ ( ~ ~ 'O . U ~ O ~ O ~ ~ ~ ~ U X ~ Q.. .,y O ~ . 0 U X U 0 0 0 >, ~.C ~ ~ V O ~ Q ~ ~' ~ C V t~ ~ ~ -p ~ °' `~ i U O N U O ~ ~ U ~ ~ ~ (~ N ~ U V ~ ~ Q ~ ~ "-' O C ~ ~ ~ _ ~+ O LL O ~ ~ N ,~ ~ O ~ v,~~ om U ~~ c U ~ o ~U ° c '~ f~ Q O Eo '~ O U~ ~ ~ ~ ~ X ~ m UU~ CA CO N H .O C O C a c (~ C ~ v O t to :;= _ ++~,v+ ~ ~ d i V ~ ~+ +s+ C i ~ ~ ~ ~ ~ ~ ~ ~ v ~ .= Q +d+ 0 ~ Gl ~ '~ i V E~.a~3 ~ V ^~ ~ Y ~ ~ ~ .v ~ N ~ a-~+ ' j X ~ ~ L N ~ Q +-' ~ U ~ ~ ~ .~ ~ N O ~ .~ ~ Q ^O^11 ^W o ~/'\ Y.! VO O Q ~ v v .~ O c O N .~ O N i-, ~ ~ ~ ^~ W ~„~ ^L W Q O T ~> O v .i C ~ N •~ ~ ~ O C +-' o ^~ 1.! ^O ~ W ~ V 0 ~v ~ h ~~ V^ v v v a Y N d ~6 U o -~ N ~ - O 0 ~ ~~ a O ~ rp ~ o v ~ ~ i=-+ a o p v cp ~ " g c v ~*-' .}.. ~~ ~ c ~ a O~ o ~ Q~ ' ~ c~ o v ~ ~ ~ ~ a ~ o v a o ~ >, k ~ N _ _ ~ l7 'X vi ,.~ p ro c~ Z u v to ~ ~ ~ o ~ -- v ~ ~ ~ - ~ °~ rho ~ +-~U O v ~_ ~ ` ' O a~~ ~ cua p Q ` ~ ~+ 6 +~ ~' ~` v v ~ ~ E v, ~ c a~ O f~, vii ~ +-' O .'^ ~ ~ C ~ ~ ~ u ° ate.., p . u ~ ~ ~ ro ~ O ~ O v o ~ ~ ~ ~~ 'p N v .O ~ ~ ~ c ~ v o -p ~ v r`a ~ ~ _ c ~=Q ~ ~~~ ~~~ N n ~.n v ,op = ~ c ~ ~ ~ v .~ u O n. o ~ _ = c ~ a d a d d Q ~ ~ G~ a ~1 0 ` W ~ ~ ^^++ W ~ ~ ~ ~ 1 ^'~1 y ~~,~ V ~. ~..y1 ~1 0 ~ ~ O +•~+ i Y (C ~~ ~ ~ ~ ~ ~ i~ .~ ~ 0 ,V •^^V• O ~ 00 N .3 ~ 3 €.~ y 4 w, f '~ ~~* ~: y 0 0 .3~u~ric vvm ~~~Q~~ °oao ~ ~~ ~o ,. * ^' o o moo ~ ~~a >,no ~pU ~ N E pU >'~ ~, a, `~ a, E >'L o`"~ c o c ~~~ o °,v cz ~ N c ~ va a ~~ ot~ ~.3v v•~ Yo~}.~oo ~a~ a,a ~vY v c c v ~~ °1~ '_ ~Q ~ ~ ~v N f6~ E ° c~ ~Q ~~v ~ v~ ~° ~ .~e `6 ~ ~_ H v v. °1 ~ ~ -~ o ~ av o n rvo rua v ~ Q `0 c~ i x v n ~ 'v 'a:. ~ v v V ~~ N~ o >, E o ~ +. ~ o V +.' ~ ~ v?~ c ~.~-, O a ~ ,Q ~ ~ ~ c '~ -o ~ c ~ ~ a O ~ ;'p E ~ c af63-~'a.Nv =E o~~-`6>a~~o~z°~ av ~E o~~ ~o ~ ~ ~ Q ~ n ~ 4 ~ V v nQ t n na .~ ~ ~ ~ ~ ~ V v Q a d a d a d ~. v c o~ c ~ c ~' «. ~ ~ vii O c ~ ~ ~ ~.i O °'-_ O a o o ~ v o X ~~ E- Q~ v ~ ~ >, o O~ c c ~c o p~ v N ~~ c~ `6 ~ .~ o v G ~_ ~n Q v ~-, ~ ~ > ~ ax, v ~ a a a a, a~ ~ ~ lJ _ O C ~ 4J ~ N C C N vi ~ ~' ~ v ~ E ~ n -o ~o a > c ~ a a`~ `o ~ E •-• o ~o n a~ ~, C`'-U `~ ~ ro c ~+~ u ~L~s co mN- ~ ~ oT~ ~.v ~ j >' v °' c rca o v ~_ n ou co ~ E +' `v^ Y ~ ~' c v v ~ a o a, ~ v ~ n ~+ v s O ~ `° °' ~ O ~ `° ~ n v Q z~ v~ v ~, n. ~ Q~~ >, c E n~ ~ u V E ~, a Q d d d Q ~~ N ~ ~ ~,-~ o~ (p L ±-' >, ~n ~n 0 0 0 0 .~ ~ V ~ O> C C O v :+J ~O C i in Q '^ ~ O~ ~ Nis n o O c ~ ~ Q v ~ ro ~ '-^ ~' v v ~' v; c v Q ~ ~' a`~ v ~ '~ ~ i > O }' ~ U~ O ±' N ca O O C i -O v~~ ~ O ~ ~ ~ v c v >, CO ~ O a~ O v vii v p N c6 ~ v v, Q v a, ~+' +~ ~n v ~ ~ o ° ~ ~ O ai a, - ~ V ~ ~ o ~}, ~ ~ O o~o~~ v3E~~~~~.v :},vim o-ooa ~>,~ °~'o O v, a~ ~ ~ v ~ ~ c a`~ . ~ cua c0 c a vCi c c n v ~ ~ ~ ~ +~ '~ V o o~ p v U ruo ~ v~ c~~ n v~ _c °' '^ c v °~'' a~i v~ ~ r6 +--~ 4J T C ~ ~ O C O U O '..' ~ ~ C C N > . `n L 4O c c c ~ c ~ c ~ v n O ~ ~, `6 ~ ~ c O ~ .~ ~ ~ v u ~ ,C ~^ '^ v - C -Q ~ 'n N > E C v .C N> ~' v~~ N v `~ ~_ C v ~~ O OT ~ rp L Q ~ v rn a, O Q ~ O V - n ~ +-~ p ~ = F- ~ v +~ `~ c 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. 2. 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. 4. 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. 5. 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 INSURANCE MANAGEMENT SERVICES By Title Date Date 09/01/2007 THIS AGREEMENT IS SUBJECT TO THE STANDARD TERMS AND CONDITIONS ATTACHED HERETO AND MADE A PART HEREOF. By Title President '~rr- 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. ~.. -tire 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. `~Ir'' 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. 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: 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. V ~. 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 err" 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. '~r~ PLAN DOCUMENT `~..y HEALTH BENEFIT PLAN FOR THE EMPLOYEES OF: ABC COMPANY TABLE OF CONTENTS INTRODUCTION ......................................... ..................................................................... SCHEDULE OF BENEFITS ............................................................................................. DEFINITIONS .................................................................................................................. ELIGIBILITY FOR COVERAGE ....................................................................................... EFFECTIVE DATE OF COVERAGE ............................................................................... TERMINATION OF COVERAGE ..................................................................................... PRE-EXISTING CONDITIONS LIMITATIONS ................................................................ PRE-ADMISSION CERTIFICATION.......______ ...._ .................._................................. SUPPLEMENTAL PRESCRIPTION DRUG PROGRAM ................................................. THIS IS WHERE THE DRUG PLAN FROM CAREMARK WOULD BE INSERTED....... PREVENTIVE CARE BENEFIT ....................................................................................... PREFERRED PROVIDER ORGANIZATION (PPO) ....................................................... MAJOR MEDICAL EXPENSE BENEFITS ....................................................................... CASE MANAGEMENT ..................................................................................................... GENERAL PLAN EXCLUSIONS AND LIMITATIONS ..................................................... HEALTH CLAIM PROCEDURES FOR POST SERVICE CLAIMS .................................. APPEALS OF ADVERSE BENEFIT DETERMINATIONS ............................................... INTERNAL RULES, GUIDELINES OR PROTOCOL ....................................................... PRIVACY STANDARDS .................................................................................................. ~r-` COORDINATION OF BENEFITS (COB) .................. SUBROGATION, REIMBURSEMENT, AND THIRD PARTY RECOVERY PROVISION CONTINUATION OF COVERAGE .................................................................................. GENERAL PROVISIONS ................................................................................................. NOTICE OF ENROLLMENT RIGHTS ............................................................................. ERISA RIGHTS ................................................................................................................ ADMINISTRATIVE INFORMATION ................................................................................. ...1 ........................ 3 ........................ 5 ...................... 21 ...................... 23 ...................... 24 ...................... 26 ...... ............... 28 ...................... 31 ...................... 32 ............... ....... 33 ...................... 33 ...................... 34 ...................... 39 ...................... 40 ...................... 43 ...................... 46 ...................... 50 ...................... 51 ...................... 54 ...................... 58 ...................... 60 ...................... 63 ...................... 64 ...................... 66 ...................... 67 INTRODUCTION '~r® 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. PARTICIPATING EMPLOYERS - A complete list of the employers sponsoring this Plan maybe 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: ~irr' ABC Company ~1r' SCHEDULE OF BENEFITS Effective Date: October T , 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 will 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 InpatienUOutpatient: 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 e Intensive Care Inpatient and Outpatient charges for emergency room, radiology, anesthesiology and pathology services rendered by a Non-PPO Physician will be paid the same as Covered Expenses for a PPO Physician if such services are performed at a PPO facility. ~~ SCHEDULE OF BENEFITS (Cont'd) Ma'or Medical Ex ense Benefit PPO "Non-PPO Outpatient Rehabilitation, Speech, & Occupational Thera g0% 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 Maternit Expense 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 Outpatient Visits Per Cal Year 30 Char es will never a I toward satisf 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 and s rin es 80% Covered expenses 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: Procedures which cannot be performed by a PPO Provider. Hospital Admission or treatment in a Non-PPO Facility or by a Non-PPO Provider due to an Emergency. 'ii~- Non-PPO charges will be reimbursed by the Plan based on Usual & Customary. 4 DEFINITIONS '~lrr' 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 agreementwith 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 shalt 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, either free 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: Must be a Physician or other health care professional who is licensed, accredited or certified to perform specified health services under state law; Must have appropriate training and experience in the field of medicine involved in the decision; and 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 `~r-" of Benefits. Such Benefit Period will terminate on the earliest of the following dates: The last day of the one year period so established; or The day the Plan Benefit Maximum applicable to the Covered Person becomes payable; or 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. DEFINITIONS (Cont'd) CASE MANAGER -The term "Case Manager" means an entity or person that reviews the cost effectiveness or prescribed courses of treatment for the 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" means 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: Such Confinement must commence within fourteen (14) days of being discharged from a Hospital; and 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. ~r' DEPENDENT -The term "Dependent" means 1. 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. 2. 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 than twenty-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 (OMCSO) 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. ~rlr' 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, Coflege, 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 of Full-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 for the 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 P-an 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 rrrr" 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 for the same or related condition for which 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. fir' 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 maybe 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, or wing within the Hospital which is separated from other facilities and: 1. Is operated exclusively for the purpose of providing professional medical treatment for critically ill patients; 2. 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 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: 1. 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 w community property law); or 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 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; fir' 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. 'fir 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. r-' 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 under{ying 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 overa-I 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, 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. ~rr~ 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 Administrator to 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 taw 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 for which a Participant or Dependent is entitled under this Plan. In order for such order to be a QMCSO, it must clearly specify the following: 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; 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; The period of coverage to which the order pertains; and The name of this Plan. In addition, a National Medical Support Notice shall be deemed a QMCSO if it: 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 types} of coverage or all available coverage, the Company and the Plan Administrator will assume that all are designated; or `'~r+ 17 DEFINITIONS (Cont'd) QUALIFIED 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 heath 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 be taken 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 or speech-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 ~r 19 DEFINITIONS (Cont'd) rr+ 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. ~iir` 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 ~ 2. 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. 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. fir' 21 ELIGIBILITY FOR COVERAGE (Cont'd) 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 under the 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 (other than 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: 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" below. 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 under the 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 covera e 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 `fir 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 may be maintained during certain leaves of absence at the level and under the 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 other than 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 `fir 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 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 P-an 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 vi~,,- 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 Company within 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. fir' 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 - 1. 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 orTermination - 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 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: 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); 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) rte; This is where the Drug Plan from Caremark would be inserted. 32 PREVENTIVE CARE BENEFIT Syr All charges incurred by a Covered Person in connection with routine Tests, X-Ray and Lab will be eligible for reimbursement up to the Calendar Year 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 r 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 $1,000.00 Whichever is less. rr-` 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 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. b. 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. 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 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) stir' 2. 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 forwhich the Covered Person is confined will be eligible for benefits. These expenses include: 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- private charges or an average semi-private rate made by a representative cross section of similar institutions in the area; 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. 3. 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 visitslexams, 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 in Audiology) or Speech-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 for females age thirty-five (35} or older, microscopic tests, and laboratory tests, which shall include one routine annual fir' 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, or the purchase of this equipment if economically justified, 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 orgqan from a cadaver or tissue bank, including the surgeon's chargge for removal of the organ and a Flospital's charge for storage or transportation of ~ the organ, will 6e 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. fir` 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 Ferson 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 afull-time Inpatient in a Drug Dependency Center for 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 MentallNervous 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. `~r-' 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 physica- 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 asset forth in the Plan or are provided only as a convenience to the Covered Person, the Covered Person's Family or the 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 -ess 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. r~' 39 GENERAL PLAN EXCLUSIONS AND LIMITATIONS r~r The following exclusions and limitations apply to expenses incurred by all Covered Persons: Charges incurred prior to the effective date of coverage under the Plan or after coverage is terminated. 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. 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, or while engaging in an illegal occupation or act, or aggravated assault by the Covered Person, including, without limitation, illega-ly driving by the Covered Person while under the 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 for treatment 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 or tests 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), donor sperm, 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, over the 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 e-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). ~rlrrz' 42 HEALTH CLAIM PROCEDURES FOR POST SERVICE CLAIMS `r`,+ 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 Pfan 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. 2. 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. ~r 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 Pian 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 reified 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}; fir/ 44 HEALTH CLAIM PROCEDURES FOR POST SERVICE CLAIMS (Cont'd) 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. `~rw' 45 APPEALS OF ADVERSE BENEFIT DETERMINATIONS `r 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 for the 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: The specific reason or reasons for the denial; Reference to the specific portion(s) of the Plan Document or Summary Plan Description on which the denial is based; 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 of the 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 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: 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 second appeal. 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. err 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 InterOual 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, InterOual 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 providerjudgment; 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 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 PPOPROVIDERS -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 includes two-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 8 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. ~1rr-' 50 PRIVACY STANDARDS rv~ 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. 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 Plan 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 err' 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 et seq); i. ff 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) j. 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. 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. 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 r+ 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 for a claim under this Plan and under another plan, this Plan is a "Secondary Plan" which has its benefits determined after benefits of the other plan, unless: The other plan has rules coordinating its benefits with Benefits under this Plan; and 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: 1. 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 ,r' Dependent. 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. 3. 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; '~rr~ 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. 4. 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. 6. 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: 1. The Covered Person to whom, or on whose behalf, payment was made; 55 COORDINATION OF BENEFITS (Cont'd) ~tir- 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 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 ~irr- 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. 3. 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. If 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 P-an 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 under this 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 col{ectability 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 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 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 maybe 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. `err 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 under this Plan that arise out of any Injury or Illness that provides or may provide the Plan subrogation rights under this 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 Administrator of a payment received from a third party or insurance carrier that 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 r 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. "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). "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. 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: The date that the Employer ceases to provide a group health plan to any Employee; or 2. The date that the qualified beneficiary first becomes, after the date of election, (a) covered under any other group hea-th 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 Plan 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 ~„r 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 OF CLAIMS -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 OF RECOVERY -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 OF PHYSICIAN -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. stir' 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 identica- 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: Reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 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 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. ~1rr'` ~rr+' 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: 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 bylaw 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 andlor 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. 66 ADMINISTRATIVE INFORMATION NAME OF PLAN: Health Benefits Plan for the Employees of ABC Company '~/ 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 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.imstpa.com PLAN SUPERVISOR'S TELEPHONE NUMBER: (806) 373-5944 or (800) 687-5944 67 Don't Think A lexible Spending Account is Right For You? 1~{~NK 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 and want to keep as much of it as you can. en participating in an FSA, your annual ~itribution 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 '~ 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 $1,601) on expenses like office visits, prescription co-pays, dental work and new glasses - or an unexpected hospital stay. And, if that $),600 were put into an FSA, the family could save over $400. EVOLUTION Benny'" can be a Debit MasterCard'° Card or a Debit Visa' Card ~-~ .VISA i 02005 Evolution Benefits, Inc. Use Your Health Care Flexible `'Spending Accounts (FBAs) Wisely... 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). Take a look at the many ways your FSA can work for you. ~r+ EVOLUTION Dental Services Physical Exam Prosthesis - Dental X-Rays (not employment related) Splints/Casts or Support Hose Dentures Physical Therapy (if medically necessary) Exams/Teeth Cleaning - Reconstructive Surgery Syringes Extractions (if medically necessary due to Transportation Expenses Fillings congenital defect or accident) (essential to medical care) Gum Treatment Rolling Tuition Fee at Special School for Oral Surgery Speech Therapy Disabled Child Orthodontia/Braces Sterilization Weight Loss Drugs Transplants (to treat specific disease) Lab Exams/Tests (including organ donor) Wheelchair Vaccinations/Immunizations Wigs (hair loss due to disease) Blood Tests Vasectomy and X-Rays Vasectomy Reversal Medication Cardiographs Weight Loss Programs Insulin Laboratory Fees Metabolism Tests (as prescribed by your doctor) Prescribed Birth Control Spinal Fluid Tests Well Bab Care Y and Vitamins Urine/Stool Analyses Medical Equipment Prescription Drugs Vision Services Supplies and Services Obstetric Services Eye Examinations Abdominal/Back Supports Ambulance Services Lamaze Class Midwife Expenses E e lasses Y 9 Contact Lenses Arches/Orthopedic Shoes OB/GYN Exams Laser Eye Surgeries Contraceptive, prescribed Counselin g OB/GYN Prepaid Maternity Fees Artificial Eyes Crutches (reimbursable after date of birth) Prescription Sunglasses Guide Dog (for visually/ Pre and Postnatal Treatments Radial Keratotomy/LASIK hearin im aired 9 p 1 Practitioners Medical Treatments/ Hearing Devices and Batteries Hospital Bed Allergist Procedures Lead Paint Removal Chiropractor Acupuncture (if not capital expense and Christian Science Alcoholism (inpatient treatment) incurred for a child poisoned) Dermatologist Drug Addiction Learning Disability Homeopath Naturopath Hearing Exams (special school/teacher) Osteopath Hospital Services Medic Alert Bracelet or Necklace Physician Infertility Oxygen Equipment Psychiatrist In Vitro Fertilization Prescribed Medical and Psychologist Norplant Insertion or Removal Exercise Equipment „~v L C <- or J{ Eligible Expenses -Over-The-Counter Items Use Your Health Care Flexible Spending Accounts ~llor" (FBAs) Wisely... Thls document is confidential [o Evolution Benefits, Inc. and may not be used, copied or disclosed except with express prior written consent of Evolution Benefits, Inc. ©Copyright Evolution Benefits, Inc. 2005 -All rights reserved. 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. Here is a brief listing of some of the OTCs covered by FBAs: ii 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) 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 FBAs: EVOLUTION Beery" can be a Debit MasterCarda Card or a Debit Visa® Card. `' ~"i 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 4 Baby-sitting and Child Care Contact Lens or Eyeglass Insurance r. Cosmetic Surgery/Procedures +. Dancing/Exercise/Fitness Programs Diaper Service ,, Electrolysis Personal Trainers or Exercise Equipment Hair Loss Medication ~ Hair Transplant 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. w Health Club Dues 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. tiy~ ~ ~; EB CHC010 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 Peroxid e • Antibiotic Ointments This list is just a few of the commonly covered items. Consult your Summary Plan Description for details. ~~ Paperless FSA Capabi I ity 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 PH Start shopping NOW. What could be easier? For more information, call your administrator at the number on the back of your Card. EVOLUTION .. ~il~ ~~ CC-036 110205 >y/A~ ~~A~ I'n Bill 5. Thank yw !or shoving me to serve you today. 517 LO 1438 00005 001 RFHB 0123-4567-8901-2345-6789 F 7YLHNOL 1A 3.99 CRAGKHRS 1 .89 F WALFHHD lA 2.99 SUBTOTAL 7.87 A=St SALH5 TAX .39 70TAL 8.26 ACCT/****xxxw+: 4403 CRHDIT CARD 7.37 CASH •89 CHA119GB .00 TOTAL FSA ITBF6: 6.98 TOTAL FSA Il8H5 7AX: .39 ~~~~~~~~~~~~~~~~~~~~~~I~~~~~~~~~~~~~~~~~~~~~~~~ 555 Hain St, Deer Pield, IL ~~I~~~~~~II~~~~~~) STORB: (3331 555-1212 F•FLHXIBLE SPHNDIHdG ACCOLNT ITIH IFSA) rw~aBC YDv FOR FASTBR SYRYICE, CALL 7H YOUR OR DLACB IT C1! HOURS 7H ADVAIiCB 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 ~,nanufacturer 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. 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 (FSAs). 4 , ~~ 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 manage your health care needs. 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. -' .. .. '- ' ~ 'k~'UF a ppI LS. ~..,. ,. ,.. ~.., ..._ - ~_ „ ArACUVU~ ~j~ °~ anvnniaf pyoclo~'~ -- . . , :'':~ ~;N,~ FKes n~~nG T, ,i,q~, ge. • 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 will 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! Fast, easy and convenient -Contact Lens shopping with no paperwork hassle. i Special Savings For ~ BennyTM Cardholders ~ Introductory Offer ~ For a limited time, get ~ 1 1 10% 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 I 1 ~ call 1.800.VisionDirect (847.4663). ~ 1 ~ Offer expires 1.31.06 ' I ' r ~ Start saving today. Log on to www.VisionDirect.com and see for yourself. ~r.r ' ~ i :• EVOLUTION ViSiOnDireat com P~,...a o, ~,;C1Y'l1bStOTY'-(~~Ytt. Company Statement Page: 1 Case: SABC123-001 P.eporting Period: 06/Di/2007-06/O1J20Ub ABC GROUP Pay Cycle: W A@C I.P.DtE Print Date: OS-Sep-2007 ABC TX 79101 'err/ Benefit: HEALTH REIhffiURSEMENT ACCOUNT Ann. **+*+ M.onth aa+aa aa+ra++ Year To Date a+++•a+• Pending Unreimb Advan Employee Name Certtt Employee ID Elec Cont Reimb Cont Reimb Ealance Claims Elec Reimb DQ£,JDHPI 0002 SOO.DO 0.00 0.00 500.00 D.DO 500.00 0.00 500.00 @enefit Totals 5DD_DO D.00 0.00 504.00 0.00 500.DD 0.00 500.00 Total Contributions for Cycle W: SOG.00 Total Distributions for Cycle iv: O.OD account Balance for Cycle W: 500.00 Division Totals SOD.DD O.DO 0.00 500.00 D.00 500.D0 0.00 500.60 0.0[ ~r '~~/ Ccmpany Statement Paae: 2 Case: SAbC123-G03 Reporting Period: 06/01/2067-D6/O1/2006 ABC GROUP Pay Cycle: W ABC I.PNE Print Date: 05-Sep-2007 ABC TX 79101 Benefit: HEALTH REIMBURSEMENT ACCDIINT Ann. **'** M.anth **•** "`**** Year To Date ******** Pending Unreimh Advan Employee Name Certt; Employ-ee ID Elec Cont Reimb Cont Reimb Balance Claims Elec Reimb DOE,JANE 4003 SOO.OD 0.40 4.00 500.00 4.00 500.00 O.DD 500.00 Benefit Totals 504.00 0.00 0.00 SOD.00 0.00 500.00 0.00 500.00 Total Contributions for Cycle W: 504.DD Total Distributions for Cycle W: 0.00 Accoc:nt Balance for Cycle w: 540.4e Diviaion Totals 500.00 O.DO 0.00 500.04 0.00 500.00 0.00 500.GO 0.4C Case Totals 1000.00 0.00 D.00 100D.D0 0.00 1040.00 0.00 lOG0.G0 O.OC ABC GROUP Statement of Account For Period Ending 06/41J2007 ~/ IGk FYE 06/01/2060 CC;; &ABC123D042 Div 4D1 SOHId DOE Code Benefit Descriptior, Annual Elect Contributions Payments Balance --------------------------------------------------------------------- FiRAl }iEALTH REIMi3UFiSc.MEh'T A SCO.C4 SDD.D4 O.OD SD4.OC Totals 504.06 0.60 540.40 ~I/ ABC GROUP sta[ement e€ Acccunt For Period Ending p6/O1jZ007 ID# FYE 06/D1/200B CCft SABC1230003 Div 003 JANE DDE Code Benefit Description Annual Elect Contributions Payments Balance ------------------------------------------------------------------- Fll2A1 ucr,LTI: REIMBUBSEMEh"T A 500.DD 500.00 0.00 5D0.00 Totals 500.00 D_00 500.00 I ~` INSU NCE MANAGEMENT SERVICES REFERENCES CURRENT GROUPS Amarillo ISD Dan Slaughter 7200 I-40 West (g06) 326-1498 Amarillo, TX 79106 ~tr+ Potter County Janie Brown 900 S. 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M a C ~ d O W V ` '~ ~ O d v N C O ~' ~ N ii '> > w ~ a ' ~ ~ N ~ a ~ ~+ (If ~ C O O O~ O O ON N ''"i O O ~ O O ~ O O O O N ~ iPr O O O O 00 d' ~ O d' ~ o 0 O 0 D 0 ~ o 0 ~ 0 o 0 0 lr~ 0 to ~ X 0 0 ~} 0 0 O L(7 ~} 0 0 O O N i~ ~ ~ O a:+ ~ ~ ~ ~ ~ ~ ~ N > W ~ E ~, O O ~ C ~ ~ cn O y ~ ~ ~ ~ ~ ~ N ~ ~ ~ ~ ~ N O a L N ~ ~ O O O L L O ~ w ~ ~ N ~ ~ y L L ~ a..+ L O L O ~ ~ O (1t ~ ~ ~ ~ 4 ~ ~ ~ N ' y L ~ ~ . ~ ~ V i ~ Q ~ ~ O ~ ~ U ~ U •] N > ~ • cn ` a~ > N o 4 w ~ w w ~ > ~ ~'~ > ~ , = ra ~ 0 0 ~ o ~ o w v r> ~ _ ~ ~ ~ ~, ~ w w ro N ~ ~ O ~ ~ c ~- o w w w w o (n c d L rs • > _ _ ~ ' > L cn cn ~ N ~ L ~a LL L o ~ ~ ;~ ° o °' ~ ~ o ~ ~ cn cn a cn ~ ~ O 0 0 °' ~ ~ ~ ~ _ o ~ O O ~ ~ w a w a ~ O w 4 O a~ i > r0 > ~ ~ E O Q (O O C w W O . ~p ~O O = _ ~ w m V # # > Q a d ~ # # o # o 0 0 # > Q !4 ~1 3 0 0 0 0 0 0 V/ N N O L N N O L U •L a~ ~ X ~ ~ ~ ~ C C ~ N ~ N U ~ .~ L 0 U ~ ~ ~ °~ o ~ N c~ . ~ ~ O (~ ~ , R ._ ~ O O JQ ~ 1 Y J ~ \ , A W O ~ O ~ 'On _ • ~ O 0 O O M O '~' 0 M ~M ~ Q 0 p O p ~ ,O .1.+ ~ 0 a .~ a °"~ a .+ tfi ~< ~ #~ c ~ ~ ~ ~ ~ t ~n > cUV ~ ~ ~ U ~ ~ a +, Q : ~ ~ ~ ~ ~ ea ~' ~ ~ a ~ -° ~ a~ = = U ~ ~ ~ ~ - ~ i- R W ~ ,~ ~ ~ C o v ca ~ V 'Q ~ Q Q ~ U ~ O V 1- r~ 4a{ 0 0 0 0 0 0 0 0 N M r 0 0 N M O W .~ U c O .~ i+ .~ C Z C O •N .~ C_ m O v. V ~o N e !yr ~ C O N o U O K b ~ o O O v1 0.. Q\ h r M M N N ~O v~ O O 69 69 69 69 69 V N O O M Y1 U ~O ~O ~D O Q~ 4~ C 6A 6A b9 b9 69 5I~ 7 V1 V1 O M O O O~ M M N 69 6A 69 6A EA y RCy ~--~ 00 00 N M ~ M N N N N y. 69 6R 69 69 6A v° y + (~,' 0 0 0 0 0 i v O O O O O •~+ tA. d' v1 V ~ r. Q M v~ c~ N ~ ~ (}. 6A 69 69 69 6A Q O O O O O MO O O O O O ~" lJ 69 69 69 69 69 O rn oq ~, ~ ~ oo c~ 00 ~~~oavo~rn ., p`.°oov~ ["'+ V 69 69 69 6A 69 0 ~',~„~ 0 0 0 0 0 oo O N ~ h N y 7 ~ ~ M ~ l~ N O O~ ~ .-. C. O ~ f~ ~ ~i ~ ~ W H ~ ~ ~ F. z ~ ~~~~~w ~~~oWa ~,wz~~c~ ~QO~-xo "H°°~~ ~~aa~x C 0 U O .~ .V. N T N+ ~ C a~ y ~ O O Q, O w. ~ X ~ h ~ ~ ~ ~ ~ o ~„o ,~ s ~ c .~ r o ~ O ~ ~ o ~ U_ ~ ~ ~ ~ M ~ y ~ Q ~ ~ k 'fl h .-. ,°-~ ~ ,n U ~ O . ^~i V' ~ O CG P. ,.. G X O .~ y ~ ~_ O .a .. , b^^-0 U ~ ~ 'v '~ T ~ ~U... C b ai a~ U ~ ~~ ~ ~ a R O ~, ~ ~ ~ ~ X v E -° ~~ N ~o o~ ~ ~ ~~ '~ y .o ~ ~ ~~ a a a r ~/^O ~/~ V i. +'. ;;~, U F O i.i a W F~ a .. o ~ ~, o N M CL ~ s p., o O ~ ~ ~ ice. O a ~ ~ N M o cw~., E N •~ ~~ V •~ ~ o .., U A O o < N N ^-~ O ~ 0 0 0 0< 69 69 69 69 6 o rh M N ~ < O ~ ~ O O O O< Qy 69 &9 ff3 b9 6 C.. U H U N ti 0 N N U N O a \° O u7 ~+ r` o0 0o t~ c y ~ ~ N ~ < p 0 0 0 0< 69 69 69 69 6 ~rY N O a" p" ~ O O O < ~ Q o °o °o °o °o < 0 ~~ N N N N f O r~/f 69 6R 69 69 6 ¢ a c~ A '~' ~ .--~ 00 01 V7 ~ ~.. '~ l/7 ~ .~ V7 < ~ p 69 6R 6A 69 6 u Q o C7 ++ O ~ ~ 00 .~ ~ M ~ ~ 00 &1 ~. l~ ~O ~O M y ~ 00 ~ N ~ ~} N ~ N 01 f _VL" M O ~ O O- ~ 69 69 69 6 H ' t~ O N V7 ~ V7 C e ~ ~ c o0 0 ~ ~ v ~ (~} ~ fV N ~--~ V Q O x Q W~F"aa Z a a Q a W O U + ~ O ~ .~ o U ~ ~ ~ .-r ~ ~ ~ ~ 0.1 ~ ~ s.. ~ ; N k i"~ Q O /"~ • C~ ti ~r ~ .~ o '~ .~ ~ N ~ ~ U .Ur y ~ 0. ~ k U ~ II .O , i" a ~, ~ U ~ k U ~ ~ .~ U ~ U 'o `~ a N U ~~ a ,.~ < a i~~' ~~;;~ 4.: ~^ ,;` ~; } ~~ j~_., o 9ii {' t ;: ~:y:._ 1,,~ , t:_' r.~.; ,.M j a w ~' .y ~ O •~ N C ~ 6~ rr (~ M w ~ i S 3 ~ ~ ~¢. 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U . U . U . ~ C ~ C ~ C ~ C ~ •~ U ~ •~ U ~ •~ C7 N •~ U c U ~ c U ~ c U ~ c U ~ m`C7~ ~ mC~~ = m`C~~ ~ m`C)~ L 6~ '~ . . R .~ ~ L L CC N a ~,,~ ~-° 0 0 0 ~ ~ ti ~ ~ ~°~~ O i ~ i a O M N M 00 N ';~. N M ~ ~ M N M O ~ ~ r 6F? N '' ~' : _ ~ ~ i: to ,`::~~'r N O O _.. ~ ~ ~ N I~ r rA; M Efl i~i~ ~ . i:' (~--~ :a`^ e_ O O M a0 ~ M l M N ~ ;r ~ , U .~ i= N C U ~ ~ ~ U r M t ,. 0. - ' ! 3 !:`,; ~1r' ~rW 0 V U r.Gi w W a W ~ O ~ V d m F G 0 U Q Q Lt1 ^~ G L o 0 0 ~a 0 0 0 0 0 ~~o o ~a ~e e ~e e e ~~e ~o ~o 0 0 ~ ~ M a ~n Pv v~ M r oo v ~ 80 ~ ~o M & r F~ oo .., b n M ~ 8 e b ... 8~ N N ("~ 06 ~ .d ~ o co ~ o~ a; a e ~ o a: ~ a ~n ~o a o ~ a: e ~ 06 -0 ~ N N N N N ~ ~ N N O~. N N ~ N N ~ ~ q r r ~ N 00 00 N N N ~ N N N~~ O b O P 00 O O O 0 0 0 0 0 0 0 0 0 0 0 0 O O N O O S d' ~ .+ O~ V O N N~~ N ~D V V V N '+ ~O a N r V V O A Q~ r vi t~ O~ V h N N O~ a 0 vi N O~ O. 00 .-~ M O. h N 00 ~ 69 N b 69 fA 69 N N~ '+ N ~--~ 00 69 N h .-. N 4h N 69 fA ~ fA ~ fA fA fA fA N fA FA 69 69 69 ~ 69 69 Vi (9 69 69 (A ~ 69 Ni N 69 p~ 3{§ (/~J PV ON l~ r p~p W W O 00 ~ O M T U vii 00 n 00 M M ~ ~ tVy~~ V ~ ~ OVOyi ~VD V O 00 ON ~D p V W vii ~ M ~D ti ~ ~~. 69 ~~.W ~ ~ .N-~ ~ ~ ~ 6~9 69 ~ fA N .~-~ 6N9 V o0 ~ Nv+ 6N9 y fA (A fA ~ fA d3 43 fA fA (A 69 fA N 69 fA 69 69 cV ~ O O~ O~ O~ O~ P O~ O~ O~ O~ O~ O~ O~ O~ O~ O, O~ O~ O~ O+ O~ 0~ O~ O~ O~ O~ O~ O~ Q~ O~ O~ Q~ O~ ~O 69 69 FA fA fA 69 69 69 fA 69 Vi b9 (A 69 fA 69 fA (A 69 69 69 69 69 69 69 G9 69 69 V9 fH 69 H c es ~ vi ~ O~ ~D o0 O V O~ O O~ O O, ~ M O M M N vi N n ~D vi N `:.5', ~D h l~ h O h N O N 00 00 00 ~D 00 N ~ O M O l~ --~ b 00 O. ~D N M V ~O M O. O M ~D ~D a ~D .. ^ .--~ h O ~O M ~ ~D ~D ~D l~ R V a Ni b Yl ~ Vf '. .-. F9 69N .-. ~ .. ~ Ni .-. Yi N .~ FA H3 OO .. N .-• 69 V ="~• l~ fA 69 69 MW fA fi9 fA (A iA 69 69 (A (A Vf Y3 d3 N (A 69 69 (A .'., ~p 69 ~S~.T:i. b F.-i 3:. U U U ~ 'C 'C ~~ '~ 'v '~ 'C '~ ~~ 'C '.. '~ '~ 'v '.. 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U U ~ U Rt A, ~ ~ ~ ~ ~ ~ O O p 0 ~ ~ ~ ;~-~ .R ee y w y 'y ~ a ~ ~ H ~ ~ ~, h ~ ~ ee Z ~--i N M a a a a ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ O ~' N o0 O M N o0 ~O O O~ ~, ri N ~ 5R 6N~9 o ~ o ~O O O ~ ~ o ~ o ~ ~ ~ M C\ 00 ~--~ V1 ~ i i ~ ~O N r!' O M N M 00 ~ ~--~ M N .m-i 6~9 N_ ~ 69 N O O~ M N ~ ~ ~ ~ N [~ ~ ~ ~ ~ ~ M 69 6A O ~ O~ M 0~0 ~ M M ri N ~O ~ ~ N M ~ ~ N V .D ~ ~ ~ i! V C R .~ E-~ ~ ~.° r' ,~ ~ ~ ,~ ... Sponsored by 1MS Managed Care, Inc. Powered by WoridDoc Wellness is the human process of being aware and actively working toward better health and a healthier Lifestyle. Organizational WeNness 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' ~aling with the health needs of their spouses, children, parents, or other family members. WorldDoc ips consumers make better healthcare decisions. As a result, employees and employers save casts through healthcare education, prevention and individually tailored wellness initiatives. At l~I~e/Iness~Ilorks, 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 toots. 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 far health care- VVonrl~yD~c. WCrRLDC1C SUPPORT ~ COMMUNtCATtON - A KEY TO SUCCESSFUL POPULATION HF~-LTH MANAGEMENT This section is devoted to the employee communication tactics. After alE, 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 aver the next year. Our experience shows that the more you communicate with your employees/members, the more positive results and increased portal utilization you are likely to see. Frequent use of the member health portal means that your organization's members will become more healfh educated and likely to spend less money on healthcare. Considering the importance of communicating effectively with your members, establishing a cornmunications 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. HOW TO RUItJ A SUCCE55FU! COMMUMiCATtON CAMPA1GtU 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 far their departments' participation} III. Execute the campaign -stay committed to the dates IV_ Report results - {et your members know hour many of their colleagues participate; share the success stories V. Plan for next year`s campaign err' 1NDRLDDDC-ADPoi{NiSTRATIVE BINDER ~Vo rld Dec. Health Management System WORLDOC SUPPORT Designing a campaign When you are working on preparing your campaign, try to answer the following questions: 1. When do !want to officially launch the program? 2. fn the past, what methods of communication have we used to comrnunicafe 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 ail that appy. W e used: ^ Posters ^ Information included in D Word of mouth paycheck envelope (paycheck D Speech by a manager stuffers} D E-mails ^ Brochures in mailboxes ^ 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 ^ Speech by a manager stuffers) ^ E-mails ^ Brochures in mailboxes ^ Newsletters ^ Table tents in common areas © Flyers ^ Other Every company is different -different people, different industry, in short a different culture. As the WoridDoc Champion, it is important for you to identify some of the fac#ors 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) for every one of the "wanted" methods (desired neev communication me#hods}_ 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, VIQALDDOC-ADr~IINISTRATfVE B1rJd£H 2 World Dec. Health A7anagemrn[Syatem0 CaMMtJNICA71(7NS 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: "I need to get in better shape. l need to exercise. I am going to change my behavior - it wit! 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. Now that you have defined how to communicate this great, new benefit to your co-workers, it is time to answer the question "What do I communicate?" 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 benefits of the program to your team members. If 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 wi#h management campaign (prior to the official launch} -use Why WorldDoc 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 ii for me"; make sure that the "How to use" materials are available far a{I 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: onsite training and demonstrations are great ways of presenting the program- ~wr VVORlDDOC - COf~9~AUNtCAT10N5 orldD~c. Hralth Management System C O M M u N t C A 710 N S C A L E N D A R ~Ir' rr-. Once your members know what the program is ail about and what purpose does it serve you can start focusing more an the specifc features that are directly linked to your particular goals_ Health Risk Assessment are the great mean to start, they allow to collect base information on your population and ad}ust 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 health news letters, season specific health tips and Did You Knoav 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. 4h'ORLDDOC - CGMP~AUNICATIONS 4 Cdsing ~X/orldDoc to Improve and Manage Health User Training Guide or1dD ~ Health Support Systems 6 tril~-" Using WorldDoc to Improve and Managc Health 1( 9(o rl~ D~c, }ip,Tl~h Man, Dement Sysrcm b ~rrr `~rr~ Table of Contents Welcome to Wor(dDoc ......................................................................•----....................._.. 2 About Wor(dDoc ................................................•-•---•------...........-----........_...-------.............. 3 Healthcare Consumerism .........................................•---._........................--•--................... 3 !'rivacy and Securit}r ........................................•---............................................................ 4 Navigation -Finding Your Way on the WorldDoc Site ............................................. 5 WorldDoc Features ..........................•--•-•-•-----..._._..----•---...._..........................................--- ~ When to Use WorfdDot ......--• ................................................................................•-----22 Troub(eshoating ..................•------..._..----•--•---......----•---......._...........................................24 Summary ......................................................................................................................... 25 WorldDoc Inc., Confidential I Using WorldDoc to Improve and i~ianaee health Y Y~ rld Dec, Health Rt:+nagemrnt Svitem Welcome to WorldDoc Welcome to Wor]dDoc Health Management System! WorldDoc'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. VVorldDoc, 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 on haw to set up their personal account; haw 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 WorldDoc, Inc_ wor]dDoc Inc., Confidential Using WorldDoc to lmprove and Manage Health The Company About WorldDoc Wor1dD~C. Heatth t,4?rtanem^nt SVSSCm 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-certifed physicians to help consumers make more informed health decisions. Today, WorldDoc offers the solutions MyHealth 24/7, a Personal Health Management. System; WorldDoc Rx~~, a Pharmacy Benefits Manager; and WorldDoc Tx=A~, a Care Gap Management tool. Together these products consolidate and communicate information throughout the entire hcaIthcare continuum. !-Iealt~tcare 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 Eo 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 far uninsured and at-risk popuIatians. 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 personal health and wellness decision-making. The Health Management Systems benefit patients, providers and payers of healthcare. WorldDoc Inc., Confidential Using WaridDoc to lcnprove and A4anage Health Vilarld keatlh RSancocment S Privacy and Security Our users trust us with sensitive, personal information. We are aware of the responsibility ~ that comes with their trust. Therefore, WorldDoc uses the same Internet security tools that ma}or 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 traff c is protected with industry-leading encryption technology. WorldDoc uses VeriSign® for encryption, server authentication and eCornmerce services. VeriSign is the leading provider of digital trust services and the parent company of the world's largest domain administrator, Network Solutionsa. More importantly, we use the encryption throughout a WorldDoc user's entire site visit (not just on the login page}. In addition, WorldDoc 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 wi1_l 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. WorldDoc 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 share ii with healthcare providers, family members or caregivers. WorldDoc does produce aggregated usage reports to evaluate the effectiveness of our services. No individual users are identified Gom these reports. WorldDoc conducts user satisfaction surveys, in which your participation is totally voluntary. WorldDoc regards you, the user, as our most important customer. We work hard to maintain your trust and conf dence. WortdDoc Inc., Confidential Using Woridlloc to Improve and Manage Health [/~ f~ r~~ Health hSanaycnreN S~ Navigation -Finding Your tXlay on the WoridDoc Site There are several ways of navigating the WorldDoc site_ You may use the Navigation Buttons, Tabs, Drop-down Menu, Utility Bar and Footprints. In the picture below, you can see where these tools are located. ''1d D~C Sisalth Managemsnt Sysicm t~ t ~' ph,.b..~y t >~ h atth I ~ Thast ire ab9. YOU tUC them t0 t h.aleh navigatrwlthln a main saetion of hel n tha Wt)tIdDDGS1T9_ [iltking on the toga and taglfna always sakes you back tatha homepaga_ haslth f symptom tY6tilJilQft ~~ p~ msdlceE ubr ~ ° (t's Those arQ tha Plavfgailon 8uttans. a°ti ~.ituim4 l psrts~i e~dua a?r nr+~+ th_ s .~. , SUe wide sQareh Dar .. _ err : teals & •e_bpcY! : i -~na.~*X~i: ~.s.c 1: 71r~.c. ~J'T«3ra T---~,~-.--,~ _ _ _ _ t :~ This {s the uti!!ry bar_ tt you tt{tk cn iha [are ht2Yigat6T, yDUwlli get options io contact s nu-s:. ! ay cllcktngon a Navigation Sutton, ""'s•~OT1"" a you wl11 get to a main section (content cammunlcatbns ntagory) of tha kfortdaoC site. -. oataesspagcsyauhavcpTavlous4ysav¢d, cAck on MyFavoritcs. in My FocusATeas you rill rind speclatty topics. To saw a link Io a pagQ to ytrut Favorites, Click Sava l0 FavoTftas. !t you ctkk on Print Paga, you wilt gat a prfntet-friendly vs-ston of the pogo. r '• s I Thefaotprlntnavigatfanh¢ips you backtrack how you arrived ata page. ; 1 C, WorldDoc Inc., Confidential S Using tivorldDoc to Improve and Manage Health WorldDoc Features V11o old D~c~ Nezlttt Man.~gemenl System Ttte 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 S 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 }reu may have. The Assessment area contains Health Risk Assessments (HRAs) to evaluate _vaur health and nsk factors. The HRAs will be described later in this guide. Personal Evaluation System Step I : Choose area of concern Click an a part of the Body. ~ y.yQrL~Q ~, He~lib lNanayement System . ~ ~ - ! - , (.a'-t,l~ health a symprom evatuanon 3 ? ~rn ^3~ : r.~c° c:,wo~^ ~ ~r,~T n R r+n~:nn mm,*: v . -. ' , hr, rymptetn ..tt ~ - - - ------ - IVrlLLe1100 I - mrdic.l bbsery - 5~ep 1; Cnoase area of mncsm ~ --- --_. -... _.--- ~ 2 CarNim sYmplein ~ `~ 3 Ansner rueskans ~ ~ ~~ J Renew resLlt - _ --- -- -- ! kretrh ~~~ , `~ A6daminetMass 1 L todr aahnNan AbdominelPaininChild l[pper AbdaminalPain V ~1e ~°J i r _ _ _ _ -. •~:~ , AbdominalPain~Hioating !m! o~..,, i AbnormalHaartbeat V mp h.Jtk fdel ~ r.,,y,= ~ ~ Aches/P01ns in [hi!dren t - r..., Anal Bleeding C ners,)rn,lmra O ,rn,..~um.,coa+,le, Ank4eProbtems [nnrrta,nkdlnrs M~du.i..tmar.at~r.. '~ Arntiety/Fear ' o,,,,t~.,,~ ArmlYeakness *m~imnarw __ ay„„r ` Armpit pain 1 - - - _ ( s .. r , Back Pain. Lower i ~ ss,. r,zn~ Had Hreatp _ } ' .- _' . 4 tt Blisters ' i ~-- ~ - i_ i .. .- . vte 8tood in Ur 'rrY ~armlirs _ k _ --- '--- _ E ~ i > ~___. t esa, ~ N +~iP rtn~v Statmtnct Fc.c~nck t~:5 ramaC "' ' ... :z+~at rie '.-~-- Worldf}~c ~~~ . ~ - 41855 ='a5 vpyiw~+s r .~.~ . u Or, choose a symptom area. Or, choose a specific symptom in the `~ drop-down menu. -_ WorldDoc lnc., Confidential 6 Using WorldDoc to Improve and Manage NeaIth Wo rtd Q~c. Hea![h Mantgemen[ System Step ~: Confirm symptom a a~}t't.QU ~ .Health Management Sytltm' - r . ~. -r_ eaz~.^ ~~ (,{-t,Z{ health 6 rympSOm e~alual{on ~' ^~^t^ ILi~"^^' L"x'+xxn ~ pncxd r.~tm sy~em IIL~J// ®uvs. ..~.~.y.~<< ®>=,. r. a.r r Efl~r»~ hf,llht ~~ ~~ fymglom Mlu,tlan 1 madlc,t - Gieo t~ Choose area otconcern 7 Conhtm symDtam '~ 3~ Wtswer goes«ons -'- i Feview msutl t ®hanlth h.lp,rs CorrQlt - pharm •`7' . you hale lntlicatetl your symptom to De Cdup0. ThlS is a bast tortefLt clearing at oir and mucus Nmugh the mau7t. I ', Pl olontted ca>Utl of tlaal»esenca dtDbod-7tnDed sylntun deserves tnelticai annnion „r k.alih (un { Fn t afir,~ f mr¢n. t n u O 11 ~ .. r com " "" Tak¢ ne to thv 'y Chl!dtrn'f vrrslan~ f - _ i i - - tRthe aL)Q Ctfp. yOll vd! artSWH fIPIh~C-Cho{Ct fgltfi{Mtf M~iM by a {It 1 SPt4}.'~St Ta t{tgry011 ~tnTnW dcteltnkte ilea catrse of yea goblem. Step 3: Answer questions M~ 7 ,{ ~l^ D tvt~. N attAMenfg.mmlSyftem W~rLU (,ttitthulthtry LOn syften W mplom rvf Juarlcn LFS' ~Pnh 3~mvlcT r~o~eton . perssrmm~. ~~~~ff~~ / ~ ®tv. ...fig ~u v Q4^"('+Y h.f u he -- _- _ t~'s.. ------- mm pp .~ i I - . _. -_ u¢. Ju 1 ___ ®hh'di~l !jSeo t'LTnose~aresetconc~~.~;?Cmtmri srmzlom.-1 •r._we+nuesCnns a. tie,~iew r~sa:t _--___. _ 1 61d1h h`l~" Pteaso answer tnetaaowlnp Pu~amts mthat we may Detter M~PYau wrm your twNdr Tfis la for. phrrmfcy 1 .How long have you lead s cauph7 ®mr 6.dlh pln ~ O1-3days.. 1 O .M.1»~•t O 1 to 2 r2ahs 02laB wrelcs cvnnurYCfllma OMmr than 2 mond;s r±~y ~/D~~Q_~V~~`~~ 1 r ^ _ ~ How many yeen here you smoked dpareuea2 '""~- ~ .-~ ONone, Pm anon-smoker ! O Between 1 and 70 years '"° - OBetwarn 14 and 25 years .'"--r-t°'-1O1~r'f ~- 4 O More Ntn TS years - ) ' f Doyol! cough upalry spunrm ~muau)7 .. - O tJo, it's m¢sdy dry 1 ~- tM+eea i>a:m O p , O Groan ui yclic» spµtum OBiooa Dnged (same Diood) ~ OB(may-apattlm, .. , - Hew you I.nd a fever {n the pml 2 drys] O rfd O hlo (wee, Dot sweating a la OFe~r bsYwaert 7{I>I and t01-5 Cegrees f OFctiar mare than 101.5 F Do you how airy of tDa foifowing~ Confu~n that the symptom you chase is correct. Click on "Next Step". FiII in the questionnaire and click "Next Step" at ~~ the bottom of the form {button not displayed). ~tVorlcll?oc Inc-, Confidential 7 Using WorldDoc to Improve and Manske Health Step 4: Review results .,a:„r:. r~an~, ~c, Hrelth.-iR~em~,~trm Wor1dD _ ~ health d ryt rrpiom evatwttan to rc"t,r~n a svrrcAprn r~E~`ax' ~S0"'tcrab~3ar ~~` ~ l`1~:/1- ~uwArnnar;ru ~:x.cwu.nn:: (~yn:eox~. ~yG~g:.~'.n ` AeaEth t ~ ~=: O ~ ~ ~ rriluatfon ~ . n,.dlcat O hhrruY 'r5te¢t'Cho¢seerea~cftancem ~~2G~'Ftmsrtri¢S¢m >3'MSwerailastl¢ns 4:Reriewresuris - __,--- I ,,ril brxltt PtaHla for. Jae Smlth Fe:prn 1 Y¢u indicvt¢d a Cough. ~ (.~,! phunary LJ ~itis is n¢t a subsututa ice a medal evaEualmn 6Y s Eit eased phrsinan Y¢ur pruF.Ie suggests [he fdi¢..ing t p¢ssibihties. Cfiek on the possibilities and rzad the ¢aplanptian and treatment ¢ptipns We hope this helps ® r,y h,anh ptra y~cu vrth your health d2ci;ior=_. { n,va,lan:r:at P¢~36ifMtae: cannlrhatkro Nurtxe Sevatlty level mttdera>r - ryp,Dq,amx - - _ t.'PPFF RESPIP.ATORY TRACT R~FEC710N t7 .a„a BRONCtiITiS.ACUrE p~~tet~o~ _ - ' mc.~. S~lU5Fn5 ACUTE ~ ~,~ a7 tom'>,::a, - _zctet» . - I ~~ (~ -xiM [~ Sav: en mY M,Ith fife Q tegtn mY eVFait WorldD~c, keN{h bSanagcment System By clicking on a condition, you will be transferred to the Medico] Library. Step 1: Review info WortclC}~c, NoltarAanag ~nrrtiyaxtn ,•"• n.e;cat 116r £~ arY .cases t ccnanc. ~~ ~-, .F. ,., . - ,. 'CY ^ymptrv '- -- -- ^.i. t ~'a!Slurm{¢~rlp~Gl air ccetrrutre cmduwlkt5 o hbr,q i 9rDrPe+ew Fh -: SkoS CrKCt Pra'.rr~'{ syylWreRrawck- Irlpara .w,..,.,~r,,.w ..,,.- ._ ._. -.. _., O GA•'^'-" a~a, alnuclPe Is a sw,111np Df W82on at are 6lnusri talaa (mown ab a ! ~ r Thus Miet]Ipn~fiestnu:as an > i T1: madaDq sin.nra ere lc[at,n ti Prr theeYDOnr unaer tar err er N : -e filwet ~ov:k+e svc w[' ~ - ~ a C q . Tnr rPrmolO alfu96a me totalM arf en a , w ~ -- - . The tt-nbl Gnufea ate (afatea M cn! tSenra 1 .Yru,ty refa as pe4 t% - O . Tier aPn[no~a 3llm Sri drrlap:rn NL7l Eatk M. Pfr naSr ?r•r~' ~ wr rteatnn. Slnuntin lr cna ata~e most cpmmpn hev!In pmtrtrtna, nltednp ` ~itma c-str hn mt. ~ U s¢mlalrnpcaPiepnr rear ana taueanQtn :S m>wPn aoCnr rf;ps Per YOU. j a£ok~p.o~.,~+.. ' .Y.~.;ny~;. ~ . ~ _ __-.___.- ~ 1.tan. rfntrslsl, tlwdW,wMnltr Dprrirq a7 ihr dntsn (onWytemaaa . ~~ ( ~ p+octeQ t{~tJamaPt,lnr elnxv Pnan arrapen Theaax annaln¢ves ~ Onaxdec,Aeer - t eraete mutnc.sfirmucawbaammryve4twr PnP Cta!rs ntprorn r i l CIIP[u}a 9maU aazla t~31e0fAr-LPS era r.Dne 6nQ Slnuer6 ana erra^ - Click on the possible conditions to get more details. Read the info and see if it fits your symptoms. If ---~°~°~' noi, hit the back button of your Internet browser. If the info fits your symptoms, click "Next Step" at the bottom of the page (button not displayed. ~'~ worldDoc Inc., Confidential Using WorldDoc to Improve and Manage Health >~O r~~ U~~, Ftral[h Slanagemcnt Sysicm ~'rrrs Step 2: Check Treatment ldD Wor ~c xvitR,~~[,g~;nat,tS,ts~,; _ - ~. ~ _ -. ~~:.~~~'Ti_~ '. 4,~~~~~':^~ ~..:42~'.^.~.}4~ t i~yF,..c~~CjC:C:is]!.Y'T..:G...'v-... ~ ~YS- ~~'C..1i medical ldarary hoc.!: rndca!ebrerv:teah EE frenlMnh - 1 ` ®I:m_ftca*e ns.gnrr ®~s~e t.~ hriNCai ppir~ r ,E health t _.__ ~ P :;;* ~;-r_^a^~t °s`.L'ryr'"w istlon A # .- f[IStniti.,; ivah i';_ m,dleal O 1a~~re+Cai 4.aaGYt aver fhcCm.nte }pia~y~Qfmn tatfica tmafinC+t })i>m•rv -- _ _ __ ~- hb.~y __ _ __ __ _ _ Stto i-j~r,n y+'[u: ': :~stepr Urck trratmen[ ~~y1_(iF+c rExdCact: _ 'p- _ s _„ ~/ modemtetoseVere ~ ,J t.t .n p ® meat a 1 ph•[r'n+~r uuta sfnuslCs Is oJlen a baCe[tai tntedian ot6ie slnuses_Mtlbiotics may ,~~j~~ { ' hasp to aeaithe Intec}ons and prcyentcampll~BOns.tn addfilon, other i a,~g ~ . ' '- ® my h,ilih }fir. medirw orts [ke Hasa! sprays and de3bngastants ma/ 6e used to decease ? not tk3pC~I - very AehtW tissue swelr!np and open the astfo tw betler drainaue. - d O O O O- nrn, JorumrL _ ! ~r~3:a6a9tIIET .'rtil~*b. ~~'..w-.s.~62a5fDf~au~ r _ I t 2 3 4;-~ ~ 5 '. coma rrtrc,twrf . (kink pteniy of Aulds Run acool-misihumtdtfler orraRorirEr fn tlta bedreem atnlRtit to Increase _ . i t71C lltpr:rlehSn jFi,fl{iGd r1tlC _ ; ; ' mytocuaara::--_ thomolstureteve[Inlhenose. .,~ ~ -" - ~"'~ ~- j :. _ . . ! ~. O MtP n'c avod a~ unm~-nry . - 1 _ ~-" ~ , #t -•- tu'kb'4tt4 f ~"`'{ ! O rntrvar= me b xr a d;u5r ~. r i ~- 1 ^7 Ito _-. ~ _ , Thee are seven} ever-fie-totmter medicalfons that are helpful Nasal ! der~npesLints prays (1~ whlrit shrink swollen mamas membtane53n fhe , ~ ~ a;,.,~ ,;,~ r~ ~~ a,~.,z ~' ~ - .. rc.-~~~ ~ , nose.car[Ceusedfa[three TD four days.LongerusecanresutUnNenose ' .,,~,_no,.p~,.wMV.y. ~ - -- - - to the spray. They bernme less eRedve Nasal blood ~ bemrnfing'addided ~-. d r;,.,.,.,;,x, ~L9 _ ... + t vessels Lnen'rebaund' and swell up t[nless the demnpestant Ls present. F ~ h ~~~ ~ pu,. x 42_ _ _ ._ ,- ~, O ~~ a~u+ . E~rnmplesatnnsntdecanQ[!stnntsprayshrdude .:.... - .. Q.narr a(tv Cia+c away rtasat spray . A[r!n ~ Breathe Free • Elrtstan nild aOAAwiei vyr.+ents-.-- • tteo-sprephnne S;neL f - - Step 3: Give Feedback_ 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 "Next Step" (button not displayed}. 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". WortdDoc 7nc., Confidential Using lvorldDoc to Improve and Manage Health er.01e~ • .+D,~~rl Wor1dD~ Naa116Nansganmliy2am `~ . ~_ medial lib ~ t rary ~t.: r~'mer R.mv ~ smrnrta»r ....n>. a .'. rn ®u, ...,» f~.: ., ~rn: ear ©af.,«ta b.airh ~ ~L t f._a.archxrwllr;,. j d,cJ r3 _. - _ ... .. ... ._. _......._. __ _.. _ _. _ r.. _. _:_ 7 ~ 1ibinir r The toilowinp mayow sear[h rewtla estedwlCr the closaat maim hlgRest ~_~ Mlpan py¢¢dons sae wRatyouT9 bolanpfar anawaWd tka ad¢Atonal help, S!lfh L~^.tt _ Irtaa Fn.,,,.v ~ r,Dae.c mdd, ~v ct>nt+:. , a ~Ta,r;~'~s~~~~itIn. a Is ina second mos: common r¢tsan f¢r aameaneta vtsda ¢ortar. NOre ® Esaonaceal than RaH at ad yeeCla rhil_ 1„ttn~ It ~~- I a.eiui renr.'~nns ..~, t o ^tSa r t~ ~_~S_ L~4Shi§I ~ Q-rlecdbl. [~.Pr~a /Lledica/ 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. Hea/th He/pens VUo rld D~,c, }tcatrh rtuna emerlt S •stem 5 ) --- 1. Enter your search word, for example "low back pain". 2. Click on "Search". 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 over time (based on the information you provide in the Health Risk Assessments}. ~ Worldl7nc Inc., Confidential Jfl Using WarldDoc to Improve and Manage Health ~d r,~~ ~~~, Hcaith Pdanagement Synem Et~S^ .k~nlrarer~:wsvre++ t®hullA helpers er 11 .r r'. n. rev r t ' Y 6111th t ~oyq~'~ mrdcsl O Heats kelpers are a suUe of Wols de5lpnea to w ~ I~I~~s 4~.r°~„y~. liMsry ~ haFj you manepeyour hsalN. 6alBCt arty tool hom jy ~.Y~~rc~ - 1 ~ Ne stxnmanes hattnv ar Rbm Ne rnmrspbnfllnp ~ - ®~.elih Wb above. ~ 1 - _.. - ~.ra /r-~ Asrm z - i lry V p i /~~t tF=t m~ hsdth jtln ~ }. { _. f I nl.n,(mvreat t7adt~..;-~ -; i~-.~ .Y7.~a~ZCf::Y ~ _ ~~ ~~3' :~~~ w t _ O emnrmcNClriarn l~IntttlDrs O es 7estyour kealN lO wilh Calculate yotu bory ~ - - ~ ~,(owslrw '- ~ Nis cedes of qutIIe s. mass aslwell as , - recammeraed calede - t__.__._-_.. _.. WarldDac Inc., Confidential Using WorldDoc to Improve and Manage 13ealth World Dr~~ Ncatth Atanagcmen[ Systrm 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. Fh-~+rY cg ~: >= Lju..n ta7v .r.. ~rnrnn.,.rt G$c~r ian ~r hrillh t I ® symptom ---- t i _ _ ~ _ _ mrdtut 0 ~ ~_ .__ __ _. .._. _.._.._ _.. _.. ____-. -.:.-_.._._ '•i6rarY ~~ I ThaFhnrmac7 seW¢nof¢te WOddOOC Hgsbll Minsbemsnt 6}slem [onto ns _ ~ 1 O h,•lth tnfdrmib¢nm help you compare aft aspects ¢f, and team mvrg a¢vvt more 009medtratlvns. Usg Aetatrsabpvemtinks be'aw to aaess tool :dean 1Y '~pk~°~~ hrlp.n ~ ph•rmaty , andirtvrmabvn _ PI.~.R'fTR.1;'!A ~C~+t attarmCya and ~~ t.M}+ekrta tory`[rr cx4~dv~: I ® my hrdtb (drs •~trC¢ce Pninkitle7s M[reasa H¢ad Aga[k Risk Zn[vr ti s F __' __ ___ . ~...It=d Lei rn ~n~tU` ~~~" I~ -=1Pr~ ~ 89118 1 nrrn.(mumst ~ ~ Z!llQf Q151H n~rr... r mar ..-. - . Ql@ij(P7ILD t... (trtnmuttlc•rlam ~, ~a4~1 }mss 1M (ua:rsnrr ~ ~ •BI¢pd Crasstr&F1dnt'f siting tt5h f{nhgd L^ ~~2ii1! ~2!DGS CeteCrer ' s4 ~ .. -,. 89118 'i _-.. t__ - ~ meuW Neuum _ . RndPhamacy jygnlsanS ~ Rrr (lMdttL .._._- 1~^1,,^ I~ m,nrr i ... Prera~l tt ~ n.. ~ ~ - !tx Comparison Step I :Enter drag phamacy fit=.: n_~~ n rnrztit-m To compare ..alu•tlan ~~~;~,-:. ___ medications, click on ~ m.dka7 OsE nutaxr wcnnsidur taldngtt n mev~ca¢en Ltiat d b the tab named " IZX `+? I y : ¢nG msc The R•C¢mpans¢nls i6pieehtG¢Ihelps you and ln lIIBapi7Ch786d1t5W91d16Diaylnlunnib¢nsndDd[eGan[OmpafaaleavpL.le,d'.ISWi7,y¢UCinmal¢I era9ap18 ,i comparison" lJ ® h""Ith hd n , , ! an Inr¢rrred Chal[a Cehwen Wino name LMagf, DBriFRC ref6lGnG and mer7rroun:Fr rM~Clc iL'Cn6 pe I^ V phrm.+cy ~ D[ap t: Ln:er drop . Btap 1 sgte[t svenbfn 91ep 3: enter quanmy S1cD +"mew resurs l QeeR h•ilth (dn __ H77ER ZP CODE 99118 _~ ~ L ~ (U•etl to da:grmins madi[sbin prices l¢callo'/aUr aoea} Enter the name of O C~.(nvms m+n+cntan. ~ EflTBt TiE wA+E Op 7FE DRUG TO SEARCH (er sntsr)ust tnel!rLtfew teeare Mhe medication) the drug you want to compare. _. ~ ~. Thel¢IIOMnQ inr¢rmaL¢n 3s Oresenfedl¢DIa+M1de You Mdt DGSSih:e rtort inemidl'e treaL'rterd¢Gp¢nS 3lM eslltnated DnClnp lM¢mla¢¢7i for a~.~pnta ~ Bd'J[abnnat¢arpsSeb¢nfy MyC7lanpCa to y¢df pTet:Cr:D¢¢n TUGS 6e _ _ __ itt7i¢rfZPd D7'yGttr Gn,slclan " "I~j S ¢~ tep . ext Click ', ~ rPregtt¢pb~fRr Resources dTCCls ~~ WorldDac lac., Confidential I2 Using WorldDoc to Improve and Manage Health VVo rld Health btdnaoQmdnl S Step 2: Select strength 1 D W ~4 Hnnlbbaeagamrntsyat>rJ mr'ltL1EDtL1 Below ar8 ttre tesu¢s La pur zaaaA. ~ ph.r:nkT ,Please sNtctyQta muditabon RDrrl the GSl anO tack ine'n a#SIe~t2lrQan t ®mt brrlfb pl•. ~ ~ACIFGHA ~D(OFENADPIE HCTS - ,.-1BU110 ~. ...... -rTABLEF L n..n<.tnr..mti Ocanrn.nrauorn AIlE afRA (FDfOFFNa[)RfE HCU 30x18 TA6LET j O ~ QAL[EGM (FEXOFEfUDWEHCU ~. 60610 TA8tt7 QAIiFi.7tlW ~•FPHED HCIhDfQFEtJADWF HCU tIDEDYO TAH BR I2H cry f w.s ar.u i Asst. ! i ,~. Step 3: Enter quantity pAafmacy O `..Ith a n Wlinn 1 t..~ nrdlc.l ~ `~ Ilburi I Q hnltb Mlp.n yh.rmacy 1 ® ref h.Jlh t,4r 1 ® `~ n:. a ^'nxf N.d,am ~ toa..ar*~ n.°rr m.,; ~-,r~z. rs LL.~~n ~61eQ 1'efICf CNQ -~SiCR2-:~I.~f~nQ'1 E1r03 enNf quanCy ..~~SIfQ J; rQyieN rcSU'[S YDUR HgII1CATi01t tL1.E0RA (FE%GFEfL1f ~N£M~U, SBD+a0, 7A-LFT BtTT3T ~ju'DDRliiRY 1'D ~TADIEFE ADD TOYOLJR FFALTHpFC ^ (Cnec¢bQ. tQ aro t~+s meQl: Qllcr. tG ycur Heats Flre,l BEtQCt 171Q mBClLaI CUnChUGn filet yQU 6fE UCd7nU w^I t7:6 Q,UC an Q CI:Ck'nes: step' t0 CGn[f.L'e: Q At1FRGiC ptBCDS NCCLI7EG U tovFSNaTICAIUAt [.~.~1_?v O DiHMi'T 1010YY QR ttoTLtsTHlt erg i .s 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., Conf dential 13 Using ~~~orldDoc io Improve and Manage Health IiVorld Dec. Hralth M1landgrrnrnt Syrlcm-.. __ _-_ Step 4. Review results. Compare your current medication with alternatives including prices {before copays}. ~/ cue.*~c.rrom ~ Al t FORAIa a 4ranbrrvme mvdlcavon (Mich In vtlen gWte B~vnsive.lM1ntle mere Is no gerrenc yarsinn arapitin, Utere are corer Ceavnant vpvonc mat mlpht overa much Cevar nive.tsk your vcctarwaemar arty of +veu 5 me rerommerrtletl ahermuws mlpnt 6e ngh!(oryvu r _ ...._._ _.. ._. .._._. { Ndh Sev:Onq anbRlsbminac era useCt mr cgcrpyproDlemc sntl av not make peopFe sleepy.Tttey are now t__ _- _ { anitatrla Irrer-ltto-cevnter. NtatCfc fhlrtillc lc the muctcomman Ctuonic cvnaroon In me l7nttev 6bRC. R tc ~~°- ~ trailcaity an WlnrykCeadton orcurtr.9 In Ne nasa to av alleryk reacflan,achemlcal tilled htctaminek Current -slpwmre ra!easetl bylna 6oCr. ArltWstamineswork trY btocldnq Cleacltanalhiitamine on thetlesues h,veheC In the 1 t i allergk respertre. - Medication -____ -- , -- - ~ A ~ N; ~L7~DAD - ~,~ t~~ ~' .. 'PL RA(YDL?R CUFz4EHTD rG; R, lncalPnarmary(i morY.h svppt~ S1 g0.9q ' 1 Tl+ere an'rltlmettR medcvanna ivr rC!.LEORA. Tnesemetl!CDUahs mar vveramvCR teherva!ue In CE4Mgyvur r cnnolllnn Wetacanmend aski.~q your tlormrntroutmeiveowinp memcavnnstn seevmet mlpni tre rppmpnrta ` Alternative ~ : (ar.~LL di i cat ons Me ipE7kCA710N - 3 ^ ; - ~ _ cosP, _ .. . : ..._.._ _ ._ _ r-~a ---- uSFDA7tNG ANip357ALNE5 FROAtFI}UZiNE NCL ~FOLIET}tRZINE HCL} SZ0.60 D!PH£tvtryDP.N71itE NCL (DIPl4EN!{Y[?RJJrINE HC4.I (D7 C) Gi O. L'G ~ , kl DRCXYPROOE3iz.RDNE ACG7ATpEDRCAKPRDDE*37Ef21}tJf ADEN Z7U.OQ ~VaridDnc: tnc., Con!~idential ~`~ Using WorldDoc to Improve and Manage Health 11, fO ~n~~ ~}~~e Health A'.anagemrnt System My Hea/th Fi/es ,;. WorldDoc helps you build a collection of personal health data and stores 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 r ( ~ -~ j 11eS _ : ~ health Iles: overview hom e «~ . /J t~ 2 ~Id1ERCtl C3fE n]VIpd10f ~'3~~E IG f~jiU[IIP` ®pnat paps a t)2Qa~ F~ISiI health 6 ~a symptom l ti „a . ~Y!!f i 1 ua on eva 3 ~ ... - , mrdlcal , .- t. _ .. .. - , . l ~ , Etbrary -tea pyar,~~, glues a summsry cf key Irttarmaifon. C{1ck on arr,~ flrtk or iaG to gt:t mara GBtalled ~nto- health ~,,f helpers ~ ' °~ harms P oY Wane: L[nda VNtson No medladiotls on file i i3c3aleme." L7ntye ~ - ~~~t~-~~. ~~~-r 4rr:'rFx'+^,•~. ~ ~~ ,T~,~wsr~~+ F4'~=! my hralth (flan f ~p~ lwlson~yahoo corn ~ ~9t~ k p~ nrws,farumsS ` Caest Casinos t .t~ ~. ~rs:.':.[ves~~ ~'~a:>.,r.~~:m~~. $~ communlcatfons i dependenLr. BbodPresstuc 13ai83 ra~r• ~~' IFs `~f ~"^» ~~t c f•'~ *~ e m Triglysettde Level edd date ~I my focusareas -r;3~ .~rsas._. ~.~~,r~ } .,~ eletfonshi l l dd d t Ch t p t ttan>~ r ~ ero a a e o es L-- -- - - - ~ ! pht?ne: ~ ~ieigtt 1551bs. Height 5 feet 4 inches ,Body Mess: 26 _- ! ;~ .~•,<: _... r e ..~,_fr~ }.a;~.~„ri~~ "~ksfdntsd~oit~ r-:..e~..~>.,:.r....~...-~..i Age: 35 HeaBhAge:3B HeaRhScorG .2 mot e... ~ E ~ Sex Female my favorites -- - ~ - phones 1Vevvs, Forums & Communications News, Forums & Communications is the place to ga to contact fellow site members. In the forums, you can respond to questions and comments or start your own discussion topics. In this section, you will also find archives with health tips, as well as transcripts from your chats using the Care Navigator. WorldDoc .Inc., Con6deotial ]5 Using WorldDoc to Improve and Manage Health UVorld~~e, Hearth Managemem System Get StartedI How to Set up Your Account To get started with WorldDoc, users need to register on the site. This is haw it works: l . Go to www_zmstpa.com 2. Click on the "Online Services" at the bottom of the left hand menu WorldDoc Inc., Confidential 16 _. _ . ~ _.. __., ., . , , , ,-. ._., a ~,.., ~ T~ ray, ~ .:. Using WorldDoe to Improve and R4anaee Health V11o rld Dec. Ne,~t(h 6tanagement System ~Mr-, 3. If you are a First time user of the ONLINE services at www.imstpa.com, click on "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 WorldDac Inc., Confidential I7 ~ Ed[ tYw Fardl6 Toms FrU _ -. __- ..... Using WorldDoc to Improve and Manage Health kilo rld Dec, Hcal~h Alanaoemern Sgstem 6. Click on the "I agree" button if you agree to the statements contained in the authorization_ ~ WorldDoc lnc_, Confidential I8 FC Eec lte~ (draRii Todz . • ' .• - w Using WortdDoc to Improve and Manage Health V11o rld Dec. Health;dnnanement SVStern 7. To access WorldDoc, click on "My WorldDac Center" on the menu located on the Ieft side of your screen. Select your name from the list of dependents on your plan. Pease read the disclaimer, and select `tenter." WorldDoc Inc., Confidential l9 ~,. ~..o>ss Ta. „~ Using WorldDoc to Improve and Manage Health ~. You are ready to begin using the features in WorldDoc! VIlo rtd D~c~ Fleal[h 1412itlvemefil SV.•IL'm ~ WorldDoc Inc., Confidential 20 aE~~,~.~T~~ ~ C'~ E" ~ ' ~ L~- ~J psm.°' ti tarotrs ~} t So'' ~ $ - [J I¢i =3 . _._.. _ .------_..__.._.,_-- ' - ~: El r.C-' [nom ' i ~ceic{~ - ~i?S] O~m4: Using WorldDoc to Improve and Manage Health ~o rld D~~, HcaRh btanagemcrtt System )Next Step - Health Risk Assessment A good way of making 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 time you log in. `~~'' You maybe asked some questions for which you don't have the information. That's ok. Skip that question and come back to it at a future time when you have the information requested. For example, if you don't know the exact cholesterol level, skip ahead to the general questio^ about your cholesterol_ We recommend that you retake the Assessment every b months. To take the Health Risk Assessment: 1. CIick on the button on the left side of the screen that says Health & Symptom Evaluation. 2. Anew page will display. On that page, click "Go to Assessments". 3. Now you have the choice of a genera] Health Risk Assessment (recommended for everyone); a Geriatric Assessment {generally for people over 75); and condition maintenance assessments for diabetes, congestive heart failure and coronary artery disease. CIick on "Take Assessment" for the type of assessment you want view. 4. A form with questions will display. Answer the questions and click "Next Step". S. The Health Risk Assessment now generates a Report Card that provides you a "Health Age"_ )3ased on the information you entered, the risk meter shows if you are in a "Healthy Zone", "Moderate Risk Zone" or "High Risk Zone" for certain conditions. In addition, the Report Card makes suggestions for lifestyle improvement, and you can opt in to receive monthly health tips from WorldDoc. r- .._ .. _ ._. _, 1 t'9' bnallb Jurs brJra t e,tnple¢. sed~rJ nb.r, MJrb b.ro-.. y)a s, )+Jr) lee ,.n.e.,a.ndy impoe yow han:Jr and lower ywa rink dldpthmtlxerp doeasea hY makutg HestYie rhanpea arW trtlm9 rerammvndea screanvq esams tw commm aericrs dsawes N the U5. most demhs nm caused by n tew types of disassse. Screeneig utts and L!eatyla ctungee ra adach2 tared 6ownmrQ ym:r nsk d eya~q Som one d Ume final d~xsua Ta kam mere ahauf slime Ise to take sM rltsn, Eck an tine M the dauan fared on the lelL Th~n es eapecisf!f rKt!!nmarded d ymr vs is Um 76gA' ta'ModarNa mkinne to a particrLar disease Ruk Ye2r a•+a^r err. net m s•.• WortdDoc Inc., Confidential Scar a® C91 Zl Using WorldDoc to lmprove and Manage Health Wor1dD~~. Health Alanagement System _ When to tJse WorldDoc ~r WorldDoc'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 fmd some examples of situations when it would be useful to consult WorldDoc. When You Are Experiencing Symptoms of !!!Hess Before making the trip to a doctor, go to the WorldDoc 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 an "Print Page" in the upper right corner 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 look up 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 located in the section MyHe~tlth 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 over time as well a_s the medications you are taking. Evaluate Overall Health and Risks By taking WorldDac'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 [o get better health. ~~ WorldDoc Inc., ConCtdeniral 22 Using ~'Var]dDoc to Improve and Manage Health 1~o rld U~~, Health Marugcmrnt Sysicm 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. ... find 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 feld once in the Drug Search tool. ._/earn more about pain or an it/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 search box. Choose from the search results. You can also click on the Health & Symptom Evaluation button on the left side, and then click an the Personal Evaluation System to go through a process of evaluating a specific pain or illness that you may have. __.get m touch with a nurse: 3ust 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 or search result that you wou/d /ike to easily find again.• l~'herever 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 left corner of the page. Sometimes, you may go through several steps to evaluate a condition and arrive at a page with suggesied [reatmenis. 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 that is easy to read. I may be a good idea to bring it to your doctor! ~VortdDoc Inc., Confidenrial ?_3 Using WorldDoe to Improve and Manage Health Vlfo rld Dec. HcaHh Managcmen[Synem Troubleshooting ~r Below we have listed a few things you can do if you have problems using the WorldDoe 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 "Launch Care Navigator", the window you see in the picture below opens- It asks you Itow you want to contact a nurse. Click on the preferred option -chat or email. Welcarne to the Cate Mavilyatot i am your personal assistant in managing your health- ~j -~ ~ , f,=-> Choose the method by which you'd like to communtcaie: We can message in real lime betweenihe hours oE: gam to Ypm pacific standard tine Send me a description ofwhere I can hetp and 111 gat back to you within 24 hours. Lost Passwords if you cannot think of your password, click on "Forgot your Password?" on the WorldDoe Login page in the Members' Area. A window asking for your email address will pop up; fill in the email address and click on "Go". A password will be emailed to you_ Technical problems If you are experiencing technical problems, you can email WorldDoe at info@worlddoc.com. WorldDoe Inc-, Conf denLial 24 Using WorldDoc to Improve and Manage Health ~~ rld Dec. Health b7anagement System Summary ~/ WorldDoc's Personal I~ealth 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 he. Naturally, individual goals may vary. Some WorldDoc users have chronic diseases for which they need to see a specialist regularly. WorldDoc can help them keep track of medications and lab results, and they can learn mare about their specific conditions and treatments. Other WorldDoc users are generally healthy and just need occasional medical assistance. Reg~u-dless of your situation, WorldDoc it~il] be there to support you in all your health issues. ~/ ~'Vor]dDoc Inc., Confidential ~5 UVo r1d D~~, Nealth Management System b GOAL WORKSHEET Setting and retarding 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 "WoridDoc Champion"' wilt be conscious to keep encouraging members to use WarldDoc 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 1MPLEMENTATlON POPULATION SfZE POPULATION SIZE NUMBER OF REGISTERED USERS NUMBER OF REGISTERED USERS ADOPTION 4~b ADOPTION UTILIZATION °!o UTILIZATION °/a NUMBER OF COMPLETED HRAs NUMBER OF COMPLETED HIZAs HEALTH GOALS Suggestions- 1. Decrease Number of Doctor's Visiu 2. Decrease the number of members taking a brand name medkation 3. Arrange Employee Heal[hfair 4. etc. MARKETING GOALS Suggestion.~- I _ Distribute three WorldDoc communication pieces monthly 2. 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Nc.thr+Man.:gt•Rtml S}'snmi GET TC$ K1V®1~U !~lC4RLDD®C - AOtNT 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 of health. Basic Rutes: This program allows for flexibility and adjustment of the point rules to client's needs. For completing certain activities on the ~VorldDoc's persanaI health management system site, program participants are rewarded with points. Collected points (once reach qualifying minimum) maybe redeemed to receive prizes or/and 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 6 months and is designed to provide reoccurring encounters with the site, each introducing different features and tools. On a bi-monthly ~1r-. 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 comple~ity of a task an employee may collect between 20 and 250 points_ Logistics WorldDoc will prepare email and ready-to-print communication templates promoting the program as well 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. tt~a r~ld Dec. He.~t[n !,tinarJCncnt S~.rrmt At the end of the program client will receive report detailing number of participants and the amount of points they have collected_ `~rr+ "FleaOfh lats6c'_~ssessrren~ .. - _ . , " ,,_ complete HRA 250 . _ .Personal Evaluat>ton System-: - ~,_ ~ ~ , .;, _, . _ complete a specific symptom evaluation 200 lily Health` Flies _~==. '. .. ' . _ ~ ..~.~~;' _~ , _ _'~. ~. - update personal info (including email address} 100 visit My chart 20 visit My medications 20 visit Preferences 20 visit } tealth analysis 20 visit Wellness plan 20 visit Points & rewards 20 visit Favorites 20 visit Saved files 20 visit Claims' 20 vlstt Ellgtbrltty{ 20 "' .:Rx Comparison Tool -, ~;_ . ... ~ t ` : : _ . ... ,. , . _, ., ,... ~ .... . . _~ ...:. . . ~, complete specific Rx . comparison 200 t - _ _ Medca! Likr_ary - . - t ~- .~~ ~ ~ _ ..- . ~ - - - review specific condition 20 review specific treatment 20 review all sections of a specific focus area ("evaluate", "research", "treat", "next step"} 80 (20x4} review Frequently Asked Questions 20 Nealth Helpers _ > ~~: ~ ..,. ... VtSit gUIZZeS 20 visit calculators 20 visit trackers 20 visit treatment reviews 20 visit 1