ORDER NO. 31476 2010 KERB COUNTY EMPLOYEE HEALTH BENEFITS PROPOSALS Came to be heard this the 28th day of September, 2009, with a motion made by Commissioner Letz, seconded by Commissioner Oehler, the Court unanimously approved by a vote of 4-0-0 to: Open bids for the 2010 Kerr County Employee Health Benefits: IHS Datapath Administrative Services Don Wallace through American United Life and One America Company Don Wallace through Travelers Wallace and Associates through Unicare American United Life (maybe part of a prior one already named) Entrust Willis through HRH Wallace and Associates through Humana Willis through UMR Mutual Assurance Administrators, Inc. Datapath Administrative Services (may be part of one already named) Willis through ABC Company underwritten through The Principal Financial Group Texas Association of Counties And accept all bids and refer to Human Resources Department and our outside Consultant for evaluation. COMMISSIONERS' COURT AGENDA REQUEST PLEASE FURNISH ONE ORIGINAL AND ONE (1) COPY OF THIS REQUEST AND DOCUMENTS TO BE REVIEWED BY THE COURT MADE BY: Eva Hyde OFFICE: Human Resources MEETING DATE: September 28, 2009 TIME PREFERRED: SUBJECT: Open 2010 Kerr County employee health benefits proposals and refer for evaluation and recommendation. EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON) NAME OF PERSON ADDRESSING THE COURT: ESTIMATED LENGTH OF PRESENTATION: IF PERSONNEL MATTER -NAME OF EMPLOYEE: Time for submitting this request for Court to assure that the matter is posted in accordance with Title 5, Chapter S51 and 552, Government Code, is as follows: Meeting scheduled for Mondays: 5:00 PM previous Tuesday THIS REQUEST RECEIVED BY: THIS RQUEST RECEIVED ON: @ .M. All Agenda Requests will be screened by the County Judge's Office to determine if adequate information has been prepared for the Court's formal consideration and action at time of Court Meetings. Your cooperation will be appreciated and contribute towards your request being addressed at the earliest opportunity. See Agenda Request Rules Adopted by Commissioners' Court. ~~ A GROUP ~ PENSION ~ADMiNiStR,4l`ORS, /NC. P,a~r C~vbz~ 8 ~ /2770 Awe[it D~ Z"' F~oaz ~ A~t[u~ 7X 725/ ~ (9721238-7900 Proposal for: Group Health Insurance for Kerr County Agent: Wallace and Associates To be Opened: Friday, September 25, 2009 Kerr County A SELF-FUNDED EMPLOYEE BENEFIT PLAN Designed By: ~~,-~~ A r T ~' GROUP & PENSION ADMINISTRATORS, INC. Park Central 8, 12770 Merit Dr., 2"d Floor Dallas, TX 75251 972-238-7900 www.gpatpa.com Agent: Wallace and Associates To Be Effective: January 1, 2010 Proposal Date: September 24, 2009 TABLE OF CONTENTS I. Summary of Group & Pension Administrators, Inc. GPA Mission Statement Y GPA Commitment - GPA Partnerships II. Self-Funding Y Advantages and Opportunities Stop Loss Contract Y Carrier Letters Y Stop Loss Protection - Sample Disclosure Statement Y Banking Alternatives III. Costs Schedule of Costs Y GPA Spreadsheet y Assumptions IV. GPA Services Implementation Billing /Eligibility Y Customer Service Reporting Client Services Y Claims - Technology - Optional Services V. Service Partners - GPA On-Line CONEXIS (COBRA/HIPAA) HealthWatch - CAREMARK - AIG Life Transplant Program ELAP - ERISA Liability Assurance Program Y TelaDoc ~',, ' !'G~d~' ,,~ .~~, SUMMARY OF CROUP & PENSION ADMINISTRATORS, INC. - Established in 1968 and is the oldest TPA in Texas. - Ranked as the largest solely-owned TPA in Texas. - Licensed as a TPA or filed an exemption for all states that require TPA licensing. - Texas based Corporation with locations in Dallas, San Antonio and Houston. - Member of the following organizations: ^ Texas Association of Professional Benefit Administrators ^ The Self-Insurance Institute of America ^ The Society of Professional Benefit Administrators ^ National Association of Health Underwriters ^ Dallas Association of Health Underwriters - Over 150 companies and organizations which represent a broad spectrum of business throughout the Southwest with participants nationwide. Actuary on staff. Experienced, dedicated personnel to provide professional service to Employer groups to administer Life, Medical, Dental, Vision, STD, Pension and Section 125 plan designs consolidating billing of all covered benefits. - GPA utilizes: - Claim System "trade name": GBAS - System vendor: SBPA Systems, Inc. in Houston, TX -Date system put in place: March 1997 - On-line Internet accessibility for eligibility, verification, claim status and reporting. - Interactive Voice Response (IVR) capabilities for providers. - Internet access to various PPOs, Drug Vendors and GPA Customer Service. - Own and manage our system with on-site staff. - SAS 70 Internal Control Audit. - A strategy of growkh to be no more than 20% each year. - Partners Plus Consulting for auditing services. - The Phia Group for subrogation. - NCN and ELAP for Hospital bill audit. - HealthWatch for utilization review. - CONEXIS for COBRA/HIPAA Internet administration. ~''` - ELAP for Fiduciary Liability Carve-out and bill audit GPA MISSION STATEMENT Group & Pension Administrators, Inc. and its Employees: Strive to provide our clients more services than they expect with an attitude consistent with doing more than anticipated. We must meet the demands of technology and managed care, but maintain the basic values on which GPA was founded: Integrity, Quality and Personalized Service. Ensure the future of GPA so that it will prosper and continue to be a place where hard working people can make their dreams a reality. Each year our dedicated employees bring us closer to fulfilling our mission. GPA COMMITMENT ~'""' GPA is committed to providing customized, flexible, web-based health care benefits management solutions that liberate human resource professionals and empower members. For more information and a demonstration of our capabilities, please visit our website at www.gpatpa.com. We look forward to meeting with you to discuss our proposal in greater detail. GPA PARTNERSHIPS Our partnerships with some of the most recognized leaders in the health care industry enable us to offer a wide array of products and services, ranging from claims processing and stop loss insurance coverage, to membership among extensive medical provider networks offering the most advanced forms of managed care. For that reason, we are uniquely positioned to serve as your single-source solution for health care benefits management and administration. Overlay this with our revolutionary new web site, www.gpatpa.com, and your employees have the ability to manage many of the health care benefits administration services they relied on your human resources representatives to provide. And because our solution is web-based, you will see savings in dollars, time and resources through the automation of manual tasks, self-service ophions and streamlined processes. In addition, your employees will gain access to personalized health care benefits information, anytime, anywhere. We are confident GPA will offer you access to the most advanced technology, administrative infrastructure, comprehensive solutions and knowledgeable people to effectively manage your health care benefit programs. The following proposal will described those features as they relate specifically to your business and will ,,: address why GPA is uniquely qualified to serve as your health care benefit administrator of choice. '°GPd~; ~ ~' SELF-FUNDING. ADVANTAGES AND OPPORTUNITIES WHAT ALTERNATIVES ARE THERE TO PAYING EVER-INCREASING MEDICAL PREMIUMS? Many Employers have turned to self-funding their employee benefit plans to keep costs down. THE ADVANTAGES Hold Your Own Reserves - Under a fully insured plan, the insurance company charges for and keeps reserves for unreported claims. Under self-funding, the Employer establishes and controls his own reserves, improving his flexibility. No Advance Premiums -Under self-funding, claims are paid only as they are presented, not by advance premium payments. Good claims experience immediately results in positive cash flow, and the Employer will have the use of this money. Flexibility and Control of Benefit Plan Design -Self-funded plans are not as highly restricted by government regulations and state mandates asfully-insured plans, giving the Employer greater flexibility on benefit design. BUT... Self-insurance has its risks. What happens when there are several large claims? Or a catastrophic claim? Or a greater than expected number of smaller claims? An Employer's budget may not be able to handle this cost. And this risk is one of the biggest concerns an Employer has when considering self-funding. HOW DO EMPLOYERS CONTROL THEIR RISK? The key to self-funding success is limiting financial risk, which means accepting only predictable and budgetable risks. Stop Loss coverage does just that - it stops the Employer's claim expense at a certain limit. Claims above that limit are reimbursed by the stop loss carrier. And, because the Employer knows the limit of his liability up-front, he can more confidently implement aself-funded plan. BUDGET FOR THE PREDICTABLE -INSURE FOR THE UNKNOWN THE SPECIFIC COVERAGE The Specific Stop Loss coverage protects the Employer for claims on an individual in a contract year which exceed a certain limit, called the Deductible Amount. This Deductible is on a plan year rather than a calendar year basis. Deductible Amounts are available from $5,000 to $250,000. Normally, the Specific Deductible is at 5%-10% of total annual expected claims. THE AGGREGATE COVERAGE The Aggregate Stop Loss Coverage puts a limit on the Employer's liability for ALL eligible claims in a contract year. Claims above this limit, called the Attachment Point, are reimbursed by the carrier up to a maximum amount of $1,000,000. The Attachment Point is calculated by multiplying the number of employees and dependents each month by the aggregate factors determined by the stop loss carrier. The sum of the twelve-month total is the annual attachment point or the maximum Employer claim liability. AGGREGATE PROTECTION DURING THE CONTRACT YEAR Eligible - Specific = Claims Claims Reimbursed or other claims that fall outside the Aggregate contract Claims - Attachment = Aggregate Eligible Point Claims For Reimbursed Aggregate Composite Factors Group & Pension Administrators, Inc. does not recommend the use of Composite Factors for specific or aggregate stop loss coverage. If Composite Factors are quoted, it is at the request of the broker or client. Composite Factors are obtained by taking the total claim cost for all plans and benefits and dividing by the number of employees:. The entire cost is therefore allocated to the employee without regard to the number of dependents or whether there is more than one plan of benefits involved. The use of Composite Factors does not give the Plan Administrator the benefit of the stop loss carrier's expertise in allocating costs between employees and dependents or between different sets of benefits and such factors are not helpful in establishing funding rates or COBRA premiums for the plan, particularly if all employees do not have the same plan of benefits. STOP LOSS CONTRACTS ,. Specific and Aggregate Stop Loss claims are payable under reimbursement contracts. The Specific is reimbursed as it occurs, and the Aggregate is reimbursed at the end of the plan year. The plan year begins on the effective date, and ends on the last day of the contract period. Common Specific and Aggreqate Contracts 12/12 Incurred and Paid Coverage includes claims which are incurred and paid during the contract year. This usually changes to paid in the second and subsequent contract years. Paid Basis Coverage includes claims which are incurred both prior to and during the contract period and paid during the contract year. 12/15 Incurred and Extended Paid Coverage includes claims incurred during the contract period and paid within 90 days after the contract period ends. This contract renews on a 12/15 basis and protects the Employer for run-out plan liability, provided claims incurred during the contract period are reported and paid within 90 days after the contract period ends. 15/12 Incurred and Paid with 90 day run-in Coverage includes claims incurred no more than 90 days prior to the contract period and paid within the contract period. This usually changes to paid in the second and subsequent contract years. 18/12 Incurred and Paid with 180 day run-in Coverage includes claims incurred no more than 180 days prior to the contract period and paid within the contract period. This usually changes to Paid in the second and subsequent contract years. 24/12 Incurred and Paid with 365 day run-in Coverage includes claims incurred no more than 365 days prior to the contract period and paid within the contract period. This usually changes to Paid in the second and subsequent contract years. Run-in Limit '~r~ Run-in limit is the specific dollar amount the carrier limits the run-in claims in a contract period. This could be written to limit the dollar amount on specific claims and/or it could be written to limit the dollar amount on aggregate claims. TERMINAL LIABILITY Terminal Liability wording varies by carrier. The reimbursable calculated amounts can differ by carrier. It is very important that you read your policy as to how it will provide Terminal Liability if this option is ' elected. Terminal Liability Extension Option (Sample) At the Policyholder's request, the Reinsurer, if available, can provide a Terminal Liability Extension for run-out benefits during the 90-day period following termination of this policy. Such extension will be available only if: 1. The Policyholder purchased this Terminal Liability Extension option at least 12 months before the date of termination of this policy; 2. The Policyholder continues to provide the funds required to pay the benefits under the Employee Benefit Plan; 3. The Administrator shown in the Schedule continues to be the Claims Administrator with respect to run-out benefits; and 4. The Policyholder pays the Terminal Liability Extension Premium before the date of termination of this policy. The Terminal Liability Extension Premium will be adjusted at the beginning of each policy period and shown in the Schedule of Benefits. "Run-out benefits" for the purposes of this option are Eligible Benefits payable under the Policyholder's Employee Benefit Plan which are: 1. Incurred while this policy was in effect; 2. Unpaid as of the date of this policy is terminated; and 3. Paid during the Terminal Liability period. Terminal Liability Aggregate Excess Risk Extension: In lieu of the Aggregate Excess Risk Benefit described in the policy, if available, the Terminal Liability Aggregate Excess Risk Benefit described below will apply to Eligible Benefits that are paid during the final active policy period and the run-out benefits that are paid during the Terminal Liability Extension Period. Subject to any maximum reimbursement show in the Schedule, the Reinsurer will reimburse the Policyholder in an amount equal to the sum of: 1. The Eligible Benefits that are paid under the Employee Benefit Plan during the policy period immediately prior to the effective date of termination (the final active policy period); and 2. Run-out benefits that are paid during the Terminal Liability Extension Period. Less the sum of: 1. The sum of the monthly Aggregate Deductible for the three months prior to the last date the Policy ~"" Period; plus 2. The minimum Aggregate Deductible for the policy period. - Eligible benefits that have been paid on account of one or more Covered Persons in excess of the Maximum Eligible Benefits per Individual show in the Schedule; plus - Any Monthly Accumulated Cap Benefit that has been paid by the Reinsurer during the final active policy period. Terminal Liability Individual Excess Risk Extension: Subject to any maximum reimbursement shown in the Schedule, the Reinsurer, if available, will reimburse the Policyholder for any run-out benefits that are paid during the Terminal Liability Extension Period in excess of the Individual Excess Risk Benefit Level for the Terminal Liability Period. The Individual Excess Risk Benefit Level for the Terminal Period will be the same as the benefit level shown in the Schedule for the final active policy period or the specific benefit level shown in the Schedule for a named individual, if any. The Terminal Liability Extension will normally end on the earliest of: 1. 90 days after termination of this policy; 2. The date the Policyholder does not provide the funds required to pay the benefits under the Employee Benefit. Plan; 3. The due date of the Terminal Liability Extension Premium which remains unpaid; or 4. The date the Administrator shown in the Schedule ceases to be the Claims Administrator with respect to run-out benefits. The Reinsurer will have no further obligation for reimbursement following the end of the Terminal Liability Extension Period. The Terminal Liability Extension Option survives the terminal of the policy. Please refer to your contract for further details. STOP LOSS PROTECTION Disclosure Nofice -Change in Stop Loss Carrier This notice is to inform the Employer of a risk which is inherent when changing stop loss insurance carriers. It is important that this notice is read carefully so that the Employer fully understands the extent of the risk. The Employer's current stop loss insurance policy reimburses eligible claims paid under the Employee Medical Plan during the 12-month policy period. This is commonly know as a "paid" stop loss policy. When the Employer changes stop loss carriers, the new carrier (for the first policy year) generally issue what is know as an "incurred and paid" stop loss policy (or a paid policy with a "run-in" limitation). These types of policies are similar to the current policy in that they cover eligible claims paid by the medical plan during the 12-month policy period. However, there is an additional requirement and the claim be incurred during the 12-month policy period, or within a certain period (usually 90 days) prior to the policy period. A claim is considered incurred on the date the medical services are rendered. If the Employer changes from the current stop loss policy (a "paid" policy) to an "incurred and paid" policy (or a paid policy with a "run-in" limitation) it is possible that a medical claim which is paid in the new policy year will not be reimbursable under the new policy because it was incurred prior to the policy year (or prior to the "run-in" period which may be specified in the new policy). It also will not be reimbursable under the prior policy, because it was not paid in the policy year of the prior policy. To illustrate the problem, assume you change from a "paid" stop loss policy to an "incurred and paid" stop loss policy, effective May 1St. An employee was hospitalized for the month of February, incurring $50,000 in medical charges. The claim is filed in April but not processed and paid until May. The claim will not be reimbursed under the prior "paid" stop loss policy because the medical claim was paid in May, after the prior "paid" stop loss risk policy terminated. The claim will also not be reimbursable under the new "incurred and paid" stop loss policy because it was incurred in February, prior to the effective date of the new policy (May 1St) Although GPA attempts to identify possible stop loss claims being processed prior to the effective date of a change in carriers, GPA cannot guarantee that all claims will be received, identified, processed or paid prior to the end cf the policy period. Stop loss carriers may require the Employer Disclosure Statement to be completed to bind coverage or when waiving the actively-at-work rule. A sample of the Employer Disclosure Statement can be found on the next page. The language referring to the Employer Disclosure Statement and actively-at-work provisions address requirements of the stop loss carrier. HIPAA provisions are not applicable to a stop loss policy since the stop loss policy is not considered health coverage (i.e., the policy is issued to the Employer not the Health Plan). Therefore, the stop loss policy is not subject to nondiscrimination or portability requirements of H I PAA. However, if the stop .loss carrier aggress to follow the HIPAA requirements, the language referencing Employer Disclosure Statements and/or actively-at-work provisions could be eliminated. H Z w W Q F- N W v ~_ W J a U ~ ~ ~ ~ O ~ ~ L O p O ~ N p ~ ° ~ c ~3a~ N O N ~..`~ X-~ N O W N .~ O ~' N O > O .~ U O `~ ~_. 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Q ~ •C .~ Q ~ .C O ~ ~ ~ ~ O' ~ ~ ~, "_' c "a O ?' ~ to to 'C ~ ~ Y O ~.. .~ ~ fB ~ ~ ±. E ~ .~ ~ ~ N N ~ N N ~ :. O C f6 ca L . O O O ~ ,~ O O ~ , N Q. ~ ~ QQ Q UUU~22= ~ J~~ 022~~m(n (n(Afn ~l- BANKING ALTERNATIVES AND FUNDING METHODS Self-funded Plan Banking Alternatives Group & Pension Administrators, Inc. provides a number of alternative methods for clients to disburse claim payments. Banking arrangements are designed to provide a Plan holder with maximum cash flow. TWO ALTERNATIVES: No Prefunding For Claims /Employer Holds Reserves -The claims account is established by the Employer at a bank of his choice. GPA will laser print benefit checks and explanation of benefits statements, notifying the Employer of the total amount required to fund the account prior to releasing any checks. This will be fpllowed up with a printed check register and optionally, copies of the checks. Using this method the Employer is responsible for funding the claims disbursement account and reconciling the account bank statement. As an administrator GPA never has possession of the Plan funds, thus simplifying future Plan audits. Using this method, the Employer will only remit the administration fees, stop loss and life insurance premiums to us for disbursement. Prefunding For Claims -This method includes establishing a set of billing rates for the Plan participants which includes an actuarially established amount for a claims payment reserve. As the monthly funding is received, the claims reserve portion is deposited in an account and held for benefit payments. As claims are processed, funds are transferred from this account to a common claims disbursement account. Benefit checks are prepared for this account and mailed directly without Employer notification. Both of these methods include the preparation of signed checks by authorized GPA employees. If the client desires to have benefit checks signed by the Employer, checks can be prepared unsigned or with an additional charge, checks can be prepared with the Employer signatures. Self-funded Welfare Plan Funding Methods 501(c) (9) Trust -This trust has the advantages that funds contributed to the trust by the Employer are deductible when deposited to the trust to the extent of claims incurred and administrative expenses. Interest earned by the trust is tax exempt. To the extent of claims incurred but not filed, a reserve may be built up in the trust to pay those claims. Because the Employer has only a fiduciary relationship to the plan, contributions held by the trust are not subject to the claims of creditors if the corporation becomes involved in bankruptcy. The disadvantages of a 501 (c) (9) trust are that contributions, once made, may not revert to the Employer if the trust terminates. 'In that event, the assets must be distributed among participants or used to provide similar benefits. A trustee must be appointed and, in most cases, bonded and provided fiduciary coverage. Investments are subject to FRIBA's fiduciary duty rules. To obtain a tax exemption, it is necessary that an application on Form 1024 be filed with the IRS for approval. However, if there is no taxable income, the exemption is of no value. A plan audit by an independent auditor is required if there are 100 or more participants. In addition, a Form 990 and Form 5500 must be filed with the IRS each year. As a general proposition, it would seem that unless the company has reason to anticipate that there would be taxable income in the trust, there is little benefit to using a tax exempt trust. Welfare Trust - A welfare trust would operate in generally the same manner as atax-exempt trust. However, because there is no tax exemption, any taxable income earned by the trust would be subject to federal income taxation. For this reason, employee contributions would be used as soon as possible to pay life premiums, stop-loss premiums and administrative costs and claims. Employer contributions would be made to cover any additional amounts needed to fund the plan as required, but no further. This approach has many of the advantages of a General Asset Plan (discussed below), but protects the employee contributions from any claims of a creditor and bankruptcy. If the trust is terminated, assets derived from Employer contributions may revert to the Employer if the trust so provides. Similarly, the disadvantage of this trust is the cost of maintaining the trust. This includes filing an income tax return on Form 1041 and a Form 5500 Annual Report. An annual plan audit by an independent auditor would be required if the plan has 100 or more participants. The only income taxable to the trust would be the investment income earned by the trust. In the absence of a trust, this same income would be taxable to the corporation. Of course, if the trust invests in tax exempt municipal bonds, tax-exempt mutual funds or the like, there will be no taxable income. General Asset Plan -This plan has the advantages that the Employer pays claims and expenses only as incurred and out of its general assets. There is no requirement of a trustee, with the attendant bonding and fiduciary insurance. A plan audit is not required. Of course, assets set aside for employee claims but not transferred to a trust can be reached by the corporation's creditors in the event of bankruptcy. The disadvantages of this type of plan are that there can be no tax deduction until payment of the claim or administrative expense. Thus, the corporation will be unable to build any reserve or to earn tax-free investment income. Also, it is necessary to show that all employee contributions have been used to pay insurance premiums or administrative costs as soon as possible (and not more than 90 days) after being withheld from the employee's salary. Unless the employee contribution is abnormally high, this is usually not too difficult. Unless the company intends to build a reserve in the 501(c)(9) trust or wants to protect the employee contributions from creditors in the case of bankruptcy, the General Asset Plan is probably the best choice. Positive Pay -Safeguard your company against fraud and keep your funds secure with Positive Pay services. You work hard to maximize your corporate investments and contain costs. Don't let check fraud cut into your profits. Counterfeiting, check alteration and sophisticated check scams cost the business community billions of dollars each year. All companies are vulnerable to some degree. Positive Pay services can greatly reduce your exposure to risk. This simple control measure identifies discrepancies between checks presented for payment and your company's check issued information. How Your Company'Benefits from Positive Pay Services: - Anti-fraud protection. You can detect fraud and monitor your internal controls. - Control. Positive pay services gives you complete control over whether a discrepant check should be paid or returned. - Reduced risk. You reduce your risk in the disbursement process because Positive Pay Services allows for timely returns. - Convenient reporting. All your information reporting is delivered conveniently through facsimile transmissions. How Positive Pay Services Work: Positive Pay -Bank Match. This is in conjunction with an electronic transmission of your company's check information. Yaur bank will compare the checks issued to checks you've issued to checks presented for payment. Here's how it works: - We provide checks issued information via transmission on the same day or any day prior to releasing checks for payments. - The bank compares paid items (checks presented) to the issue file. This comparison identifies checks that do not match the issue file. A "Paid-No-Issue Report" of discrepancies is faxed to your for your review from your bank. - You then fax a list of your pay or no pay decision to your bank. Positive Pav Set-ups In order for GPA to provide clients with Positive Pay for their claims account, we need the following items: 1. Bank name, routing number, account number and spec sheet 2. Bank's file format for Positive Pay 3. Method to be used to send the date (i.e., via bulletin board, diskette, email, etc.) GPA would prefer to send the file to the client and allow the client to forward it to the bank. NOTE: Group & Pension Administrators, Inc. recommends that legal and/or CPA counsel be obtained ~""' before selecting a funding method. r....:~ ~ ,~, !'GPd~' COSTS -- Schedule of Costs (Based on Current or Requested Benefit Plan) Set-Up Fee $2,800 + Cost of Printing The set-up fee includes the Plan Document, Employee handouts and assistance with local Employee enrollment meetings. This fee is a one-time charge and is not included in any of the following cost calculations. This fee is based on current plan design and a monthly billing with one location or division. If additional plan designs or multiple locations and divisions are required, there may be an additional fee. If a specialized or custom-made Plan Document is required, there may be an additional fee. Printing of the Summary Plan Description/Employee Booklet is charged to the client and is not included in the set-up fee. If the claims run-in/run-out option is requested, additional set-up fee based on plan design and an additional 10% of all paid claims will be charged. The 10% fee of paid claims will be calculated and a check made payable to GPA will be included with your weekly check run. y Quote assumes GPA will receive 5% override on the Stop-loss Premium. Administration fee per Employee per month (Medical/Rx) - $17.00 Texas True Choice PPO Network access fee per Employee per month - $5.50 OPTIONAL: Network Travel Wrap - 20% of savings Y HealthWatch Utilization Review fee per Employee per month - $3.00 plus $135.00 per hour for Large Case Management. Optional HealthWatch Services: Maternity Management through HealthWatch $125.00 per hour. Disease Management through HealthWatch $125.00 per hour. Physician Review: $250 per hour. CAREMARK Prescription Plan fee - includes a $.85 per script charge:: No Dep. Names on ID Card: ID Card fee waived utilizing CAREMARK as Drug Vendor (with no color on the card) r CONEXIS COBRA / HIPAA administration fee per Employee per month - COBRA - $1.00 HIPAA - $ .85 - GPA On-line is available for: $65 per hour for programming/set-up - No per Employee per month fee. Plan changes made after Plan Benefits are entered into GPA system - $75/hour. - Fiduciary Liability Carve-out: $1.00 Per Employee Per Month - Renewal fee - $500 - Positive pay arrarngement with client's bank -one time set-up fee of $500 plus $.35 (minimum) per employee per month. Additional fees may be assessed, at the discretion of GPA, for services provided outside the scope and intent of this proposal. Y Eligibility Maintenance of products other than those being administered by GPA is $1.00 per employee per month per product (i.e. dental, vision, life, etc.). A Monthly Minimum Fee will be based on the total number of employees administration fee and dependents administration fee (if applicable) on the effective date of the plan x .75. Non-PPO negotiations and / or network access -Fraud and Abuse detection - 30% of savings Third Party Subrogation - 30% of recovery Group & Pension Administrators, Inc. Self-Funded Welfare Plan Stop-Loss Proposal Comparison Kerr Cnunty Reinsurance Carrier American Fidelity/Excess Re Setup Fee ": 2,800.00 Specific Lifetime Maximum Benefit: $2,000,000 Aggregate Plan Yeaz Maximum Benefit: $1,000,000 Run-In/Run-Out: 10 Note: These rates are not indlnded in tota/s belo~~. SWOP=LOSS BASIS :::::::.::::::::::::::::::::::: Number of Employees: 259 Number of Dependent Units: 98 Specific Deductible: $60,000 Specific Contract: t5/12 Aggregate Contract: 12/12 Aggregate Run-in: $342,196 Est. Aggregate Minimum Attachment: $2,012,916 Specific Contract Includes: Medical & RX A e ate Contract Includes: Medical Bc RX MONTHLY:F.IXED COSTS :::::::::::::::~:: ; ::::::: Specific Premium** Employee: $91.42 Dependent Unit: $120.87 Family: $212.29 Composite (for Illustrative purposes only): $137.15 Aggregate Premium Composite: $7 17 Monthly Cap: $0.00 Administration Claims Per Employee: (Medical, RX) $17.00 Administration Per HRH (Dental) $4.00 Utilization Review - HealthWatch: $3.00 GPA Texas True Choice PPO Network: $5.50 Rx Program:'*• $0.00 Total Per Employee: $128.09 Total Per Dependent Unit: $120 87 Total Per Famil Unit: $248.96 AGGRE' ATE RA . l}RS"* ' ' ' '.'.'.~.~.'.'.'.'.....:.. >. Employee: $413.16 Dependent Uni[: $619.74 Famdy: $1,032.90 Composite (for 111ustrative puryo6es only): $647.66 Attachment Points Monthly: $167,742.96 Annual: $2 012 915.52 TfITAL:ANNi7AC COSTS :::::::< :::::::::::< :::::: Stop-Loss Premium $426,276.48 Aggregate Premium $22,284.36 Administration $65,268.00 Administration as a % of Maximum Annual Costs 2.56 U PPO Rx Broker and All Other $26 418.00 .............................................. Total Fixed $540,246.84 Expected: $2,150,579.26 Maximum: $2 553 162.36 TALL CIdIT15 OVER THE AGGREGATE PLAN YEAR MAXIMUM BENEFTT ARE EXCLTJD$D FROM AGGREGATE REIMBORSMENT.. LASERS/AGGREGATING SPECIFIC ARE NOT INCLUDED IN THE EXPECTED OR MAXIMUM COST. Fiduciary Liability Carve-out: $1.00 Per Employee Per Month (See Additional Services for explanation) * Set-up fee does not include the cost of printing plan booklets, PPO directories, or the hourly pro~rammin~ fee for the on-line enrollment system. ***CVS/Caremark Prescription Plan: $ .85 per script. ID Card fee waived. (No Dep. Names on ID Card) PLEASE REFER TO CARRIER QUOTE FOR CARRIER CONTINGENCIES. IF QUOTES HAVE NOT BEEN PROVIDEll WITH TIiIS SPREADSHEET, PLEASE CONTACT GPA IMMEDIATELY FOR COPY. 9/24/2009 Prepared By: MT 3:23 PM GPA ASSUMPTIONS Quote based on the proposed effective date of January 1, 2010. * Annual Maintenance Fee does not include cost of restating the Summary Plan Description, printing plan booklets or PPO directories. GPA Tee for PBM interface is $85 per script or $1.50 pepm depending on the PBM contract selected. GPA may receive additional compensation from the carrier in the form of override commissions based upon GPA's potential volume with the carrier. The amount of such additional compensation, if any, will not be known until the end of GPA's contract date with the carrier. Amounts will never be above 3 % of premium. Due to changes in DOL Claims Regulations, GPA requires weekly check runs to be funded within 5 business days. PLEASE REFER TO CARRIER'S QUOTE AND ASSUMPTIONS, as GPA spreadsheet is only an overview and may not disclose proposal plan specifics related to any types of benefits and/or rates included in the coverage and/or applicable limitations and exclusions. The figures quoted by the Carrier and GPA are based on the information submitted. Inaccurate or incomplete representations of the information submitted may necessitate revised figures. Quote is contingent upon receipt of total paid claims, diagnosis & prognosis of large claimants up to the effective date. Quote is contingent upon receipt of Disclosure Statement. Rates will not be guaranteed until Disclosure Statement is signed and completed. Programming charges for non-standard reports $225/hour Plan changes made after Plan Benefits are entered into GPA system $125/hour -Minimum $250 Rates are based on final enrollment. Any changes in the number of participants may affect [he rates and/or administration fees quoted. GPA is not responsible for the length of time in which an aggregate claim is reimbursed. GPA's fee is based on the information provided at the time of quote and is subject to change upon disclosure of new and/or updated information. A monthly minimum fee will be based on the total number of employees admin fee and dependents admin fee (if applicable) on the effective date of the plan x .75. Plans written on an a 12/12 basis (incurred in 12 months and paid in 12 months) means that only expenses for plan benefits incurred within the 12 month plan period and paid within the same period will be eligible to apply toward stop loss coverage. GPA does NOT recommend this type of contract unless the prior contract was either on a self- funded 12/15 basis (incurred in 12 months and paid in 15 months) or a fully insured policy. ADDITIONAL SERVICES: Fiduciary Liability Carve-out (FLAP): $1.00 Per Employee Per Month -The Fiduciary Responsibility Transfer protects employers acting as sponsors of self-funded health plans. This program provides aclear-cut strategy to deal with the responsibilities of being a Plan Fiduciary. The program will make the final benefit decision at "Level II Appeal." The Plan Document would be amended to name FLAP as a co-Fiduciary. The Fiduciary Liability carve-out becomes responsible for legal defense and awards that result from their denial of a benefit (excluding the cost of the benefit itself). The limit is $1,000,000 per legal action, and no deductibles apply to you. Restatement of Summary Plan Description for medicaUdental/vision (if applicable)- $1,000 Restatement of Summary Plan Description for dental only - $500 COBRA - $300 Set-Up Fee. COBRA fee - $1.20/employee /HIPAA fee - $0.65/employee. (250.1000+ Employees) COBRA fee - $1.40/employee /HIPAA fee - $0.85/employee. (51-249 Employees) Positive pay arrangement with client's bank -one time set-up fee of $500 plus $.35 (minimum) per employee per month. Dental Administration Fee with Medical coverage $2.50 per Employee per month Vision Administration Fee with Medical coverage $1.00 per Employee per Month Den[al/Life coverage without Medical coverage is $3.50 per Employee per month Employee Life Only Coverage $1.00 per Employee per month. Monthly Aggregate -additional $1.50/employee to Admin fee to GPA, as well as additional premium to carrier. Eligibility Maintenance of products other than those being administered by GPA is $].00 per employee per month per product (i.e. dental, vision, life, etc.). The charge for Large Case Management through IealthWatch is $135,00 per hour. The charge for Maternity Management through HealthWatch $125.00 per hour. The charge for Disease/Care Management through HealthWatch $125.00 per hour. The charge for Physician Review through HealthWatch is $250 per hour. TelaDoc -$3.00/employee; No Registration Fee TTC charges 25 % of savings on run-off claims only Non-PPO negotiations and/or network access -Fraud and Abuse detection - 30"/0 of savings Third Party Subrogation-30% of recovery Optional: Network Travel Wrap - 20 % of savings HRA -Additional $4.00 pepm plus additional $1,000 set up fee HSA - $500 set up fee (additional fees may apply) If EAP is sold, GPA's Admin. Fees will increase $.50 for assisting with EAP services. Set-up fee does not include out of town travel expenses. 9/2412009 Prepared By: MT 3:23 PM Proposal Prepared For Kerr County Effective Date: 01/01/2010 TO: 'Group and Pension Administrators From: Excess Reinsurance Underwriters Agency, Inc. Underwriter: Chris Jansen Phone: (763) 241-1721 .Email: cjansen@excessre.com Marketer: Chris Jansen Phone: (763) 241-1721 Email: cjansen@excessre.com 9/23/09 Proposed Policy Term: 01/01/2010 to 12/31/2010 Proposed Carrier: American Fidelity Assurance Company Offer #1 Covered Benefits Med Rx Specific Deductible $60,000 Specific Excess Limit Per Covered Person $1,940,000 Contract Basis 15/12 Specific Rates Single $91.42 Family $212.29 Aggregating Specific Deductible $0 Commission 15.0% XS RE A;;~re;ate F,xcess Cove--a~e I, Covered Benefits Med Rx Aggregate Excess Limit $1,000,000 Contract Basis 12/12 Corridor 125% Aggregate Factors Single $413.16 Family $1,032.90 Aggregate Rate $7.17 Specific Premium $426,276 Aggregate Premium $22,284 Minimum Aggregate Attachment Point $2,012,915 Maximum Cost $2,461,476 Single Deductible (in/out): current Single Out of Pocket Max. (in/out): current Coinsurance (in/out): current Mental Nervous: current Rx: current UR/LCM: Heathwatch PPO(s): TTC Other: Proposal requires a complete copy of the inforce plan document 9/23/09 Kerr County Page 2 of 3 TERMS X S Our offers are based upon the assumptions, limitations, and requirements listed below. RE 1 Quotes are based on 161 Single, 98 Family (259 Total Employees). ~ Run in Aggregate Claims are limited to $342,195.53. Proposal requrres updated large claim details through at least 12/1/09. Proposal also requires documentation of all precertifications initiated in the last 90 days of the current policy period. Detailed APS's are required on all ongoing claimants. 4 Proposal requires updated paid claims through at least 12/1/09. g Eligible Claim Payments or Expenses incurred within the proposed run in period are limited to the Specific Deductible. 6 This proposal is based upon the accuracy and validity of the data provided by Kerr County or its representative who warrant that the data is accurate. ~ American Fidelity reserves the right to recalculate the aggregate attachment point and premium if the average of the last 2 months of claims in the Current policy period varies by more than 10% from the average monthly claims for the first 10 months of claims in the current policy period. g Kerr County represents and recognizes that any Third Pariy Administrator and/or Broker involved in any communications with Excess Reinsurance and/or American Fidelity is/are at all times acting solely as the agent(s) of Kerr County and not as the agent (s) of Excess Reinsurance or American Fidelity. 9 Your plan of benefits must be administered by an administrator approved by Excess Reinsurance. 10 This proposal is valid until the effective date shown. 11 American Fidelity reserves the right to re-evaluate this offer if the enrollment or composition of the group changes by more than 10% between the date of this proposal and any point during the policy period. 12 Within 15 days prior to the effective date American Fidelity requires execution of the attached Disclosure Statement whose terms are incorporated herein. American Fidelity reserves the right to amend the rates, deductible, terms or other conditions of this proposal upon receipt of the completed Disclosure Statement. 13 A valid signed Plan Document must be received by Excess Reinsurance within 60 days of the effective date. 14 All active full-time employees working 30 hours per week are eligible. Retirees and COBRA beneficiaries are eligible only if you have requested they be covered, and have disclosed them on the census. 15 Participation: 75% of eligible active full-time employees and 50% of their dependents must participate in the self-funded program. 16 All claims paid for a covered person by Kerr County will be deducted from the plan's lifetime maximum for such covered person. The accumulation of claims toward the plan's lifetime maximum does not restart if a participant changes to another plan '~ww offered by Kerr County or when the plan is updated or revised. 17 Under NY Health Care Reform Act reimbursement will only be based on the 9.63% surcharge. Under Massachusetts Act C.47 reimbursement will only be based on the 5.06% surcharge. These surcharges are for self-funded plans only and no other surcharges, fees or taxes will be reimbursed under these acts. lg All out of network claims in excess of $5,000 must be repriced through Quantum Care unless Kerr County or its plan utilizes another comparable repricing mechanism. Failure to utilize Quantum Care in these circumstances may jeopardize any reimbursement for claims. Offer/Plan Elected: EMPLOYER/PLAN SPONSOR ACCEPTANCE By signing below, Kerr County acknowledges acceptance of rates and factors quoted in the Proposal for the elected offer and the terms as delineated in the TERMS section and further acknowledges that all material facts and conditions as previously stated remain unchanged. Kerr County acknowledges that data provided by Kerr County or its representative is accurate and complete. Date: Officer's Signature Print Name & Title 9/23/09 Kerr County Page 3 of 3 b U~o (D O M N y .ti a'.d~' ~ ~"~'o.~.~ vi ~ w N !-moo atd ~ C/~ ~ ~ coo ~ ~, O N ~ C7 -Oi ~ c"`o v' O ~ ~'O N O CUG~~'~ I~ y O ~ OUQ ~O O O ~'O ~ dC17 O O. O '+ ~ r. ~' '-• • ~ c C ~' C ~ `O ~ C .k-' ~ C 'O ,0.. n O O O C ~'~O "?~ A CT'ti ~ ~ 0.p ~''p+ ~ '~,+ O ~•y N 0. '* ~ ~ y O ~ C ~ 0. ~ ~ ~_' N ~ ~ ~ b O. b ~ O crop O N b O ~ O a~ ~•~c'+o ~ ~ ~ '"' C. .fl co ,~~ ~ coo n o 5, o ~ ~ cc a~ ~ CD c~ ~ O p- °- 7r fD O a' y CD ~ ao n ~ O ti a^• i~t (i ~r~y.' ~ ~ fD ~ v~ ~• coo `.Y n ~ "~T O A ~cn~'~N`ticcw`Y ~' o~ ~ can., cudc.:y ., cu C -'~' n. c cc '.. '. ., ~, .Q ~ ~, c rbO~~ ,_~~'~ .n+ ~~ ~ C O 0. 0. `dam O ~' ~ @"~ wd~ a~•mZ ~ ~~`~o ~<•o ~ cr.fl o ~ ~ ~ ~ ~~ nc m Yo n ~ ~' c x~ c ~ ~~ w ^o v~~ ocra ~ ~d_.~ d ~ b y ~.~:~tacoc~c~~ %°o ~ ~'cCu ~ ~ oo c''ocn?:p~' C1 ~ cP ~ ~ c ~~ c •° c co ~ m a~ ti v,•~ ~ ~ NCJ~ °.c p O ?i ~'* ~ °- `~ c °- ~ C ~ ° Ua ~ cu ~ ~ ~ n ~ ~ ~~•. 0.N 0. c0.c n rr a~ f~i N fD A ~. N (DD '..' ~ A ~ `C N A. K O ~ ~ ~ ~ 6' `~., C tv O a ~ ~ co O p~ UU d ~ ~' m ~ ~' p ~ ~ : h cci c~'~ ~ `~ Harm ~ ~ ~°'~ is o'~ ~ ° o ~,~ ~~ ~ o~C~~cs~~~m p ~~ a ;; w act' .c~oB 0.n ~ ~ ~ .O C 'T1 C7 ~.O U4•~ n O ~~~ ~ ~'~ ~ O O O ~~ ~-e ~ ~ ~ ~t v, 0. 0. O ~ ~ ~ 'N„ 'i7 O ~ O ~ „'~ O ~' QO C O-t ~ O O ~ ~ ~ ~ X ~ ~• ~ ~ ~~ ~ N ~ ~ ~ ~• ~ ~ n O- A~ O ~' co cu ~ O ~ '* O A~ ~ "'~ W ~ v v~ N ~ ,~.~ v' N 'S' ~ Vi ~ ~ ~ ~ ?• N 0' N 7y~ (D ~! CD "w3 a '. cc O O O.~ ~O ~ C~O.~~• ~ O ~ ~ ~ n~ k ~,aUQN o ~o .t D w m ~' d`~ o `~ '+ f~ O ~ ~ C ~ C ~ '. O ^ ~t N N '•~ O (7 O co G O O C N 0~ 0.n ~ ~• ' 3 O p• ~ N~ O iu ~ A~ N ~ O ~' O "~ O ~ '~ `~ ti 0..~ ~0.~+`G vii ~C ti~ ~ N ~' ~ O z n o ~ A~ C ~n `C ~ r '+ w~•~~~~' ~o~ ~ H ~ w ~ ~ ~ ~,~~ a~ ~ ~ ~~ x~ ~ ~ ~ ~ y ~ ~ ~~~~~ ~ "~• n w ~ ~ ~ ~~ ~ ~. o'.~•o ~ ~ ~~o~~o. N'~ ~.~ ~p ~ A ~ o ~~~ ~ ~ ~~ N• o r. ~' yz C~J ~~ Hy ~o ~ a. f7 z n a~ ~. z ~O z d ~7 z ~.~n n ~ ~ ~. ~ t" ~~~~d ~, ..~ Q: ~,wooG~ ~ v,'a,rn ~ ;~ O ~' ~ ~ (~ ~ ~ '~ o C7 ~ oo~CD~~ ~ n ~v ~' ~ ~ o ~ ~ o '' rn ~ ~ ~• ~ ~" y y~ a Cw CrJ ~'~ ":~' C7 n. C7 ~' o y ~` ~ ~ C ~' ~ y trJ ~ ~ , a.~ m l~ ~ ~,~ ~ ~, ~ o^Z ~~ ~ ~ n N ~ ~, ~ ~ 0 °~~ ~ o ~`~ a v' ~ O rn -~ ~C ~ ~~ o~~ ~ ' : ~ n a' ~ ~ ~~ •~~ ~ c ` ~ ~ o c~ ~ a ~ Q; ~ 0 0 ~ r ~~~~ ~ `~~~° cv~ ~'o.~~'~~o~ .., •~~ v~ c~'. o~ ~~~~ cu ~ "'~ ~ w I C1 ~ ~ ~ ~ m ~ r. y ~ ~ ~ Z ~ ~ d ~ ~ ~ ~ ~ ~'~•y vi ~.~ ~ ~ ~ ~ ~~-C '' ~ ~ ~ ~n ~ ~ b ~ ~ ~_ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ N O ~+-, N z r y ~C f'1 z z n ASSUMPTIONS AND LIMITATIONS This proposal is based on an effective date no later than January 1, 2010. The rates assume an enrollment of 259 employees. Any changes in the number of participants may affect the rates quoted. Please refer to the carrier's proposal for plan specifics related to any types of benefits included in the coverage and/or any applicable limitations and exclusions. The figures are based on the information submitted. Inaccurate or incomplete representations of the information submitted may necessitate revised figures. Inaccurate or incomplete representations of the information submitted may necessitate revised figures. GPA is not responsible for the length of time in which an aggregate claim is reimbursed. GPA's fee is based on the information provided at the time of quote and is subject to change upon disclosure of new and/or updated information. Y Claims checks will be drawn on Bank account specifically established and maintained by Employer. Y Employer will provide initial eligibility as well as ongoing changes to eligibility in a timely fashion. Employers can work with many vendors other than the ones presented in this proposal; however, there may be additional monthly or annual administrative fees. Our pricing does not include special programming charges associated with electronic transfers of data. Special programming is billed at an hourly rate. Rates are based on final enrollment. Any changes in the number of participants may affect the rates quoted. Quote is contingent upon receipt of Disclosure Statement. Rates will not be guaranteed until Disclosure Statement is signed, completed and accepted by the stop loss carrier. Y Quote is contingent upon the review and approval of the medical diagnosis/prognosis and status of all claimants with claims in excess of $10,000 or 50% of the quoted/sold individual stop loss deductible, whichever is less, in the prior policy period. A completed employer disclosure statement providing this information is regwired prior to underwriter approval and acceptance of coverage. Actively at Work Provision Applies. - Employees who are not actively at work on the effective date will not be covered unless medically underwritten based on the EMPLOYER DISCLOSURE STATEMENT. Dependents who are unable to perform normal duties of individuals of like age and sex of the effective date will not be covered unless medically underwritten based on the EMPLOYER DISCLOSURE STATEMENT. Y Quote is contingent upon plan participation of at least 75% of all eligible employees. Y Life insurance requires Employer contributions. y The maximum aggregate stop loss reimbursement is $1,000,000 per policy period. y Monthly aggregate accommodation is provided through the eleventh (11th) month of the policy/plan year, if elected. Simultaneous reimbursement on specific claims is only available through the eleventh (11th) month of the policy/plan year (claims over $10,000 only), if available through carrier and elected. Y Premium payments based on monthly billing statements will be drawn off Employer's account on the first check run of the month in which payment is due. Payment is due as billed, any changes (i.e., credits or debits) will be reflected on the next month's billing statement. Y Quote is not a contract of insurance and does not bind coverage. ~~,,rr~~' ~' e~ !/! GPA SERVICES IMPLEMENTATION Factsheet meeting with client/broker and GPA sales rep and New Group Services personnel which consists of: ^ General information, contacts • Eligibility • Reports ^ Claims Account/Check Information ^ COBRA/HIPAA Administration • Sold Rates/Fees ^ Plan Design y Transfer of Data from Prior Administrator - Funding/Cobra Rates - Employee Handouts - Enrollment meetings (Enrollment/Change forms, claim forms and Directories) y Design and Development of ID Cards - Coordination of banking arrangements Y Vendor contracts Development of Plan Document, Summary Plan Description, employee booklets BILLING AND ELIGIBILITY Assigned a primary ongoing eligibility representative On-line self administration available - Administration kit Monthly Billings Certificates Printing of ID cards COBRA/HIPAA Services ^ Full COBRA/H'IPAA Administration ^ HIPAA Certificates only Customized Billing needs with our ability to separate cost and bill by location or group, divisions or product offering, as well as to consolidate payments for insurance products and other services. CUSTOMER SERVICE Staffed with courteous, experienced persons qualified with over 5 years experience with claims paying expertise to answer group benefit questions, eligibility and assist in obtaining new ID cards Ratio of Customer Service Representatives to covered employee lives up to 2,000 Lines open from 8:00 a.m. to 7:00 p.m. Monday through Thursday and 8:00 a.m. to 5:00 p.m. Fridays. Bi-lingual representatives Interactive Voice Response (IVR) -verification and provider status Automated Call Distribution System REPORTING (Refer to Sample reports -available upon request) Providing data for certain IRS reports (Schedules A for Form 5500) Claim lag studies and assistance with establishing reserve levels Check register Monthly claims listing Annual financial reports Annual 1099 provider submission Fund Accounting Summary of Plan operation Compilation of claims statistics in format requiring special programming (Ad hoc at an additional fee) CLIENT SERVICES - Primary GPA contact for client Y Annual statistical reviews and future cost projections, evaluate plan alternatives and renewal preparation to include plan amendments, vendor notification and ID cards - Liaison between client with carriers/vendors Available for on-site employee meetings and enrollments Reinsurance and Underwriting Recommendations - Assists with Actuarial services - Assisting in compliance with federal legislation ERISA and other federal requirements CLAIMS - Claims examiners averaging 13 years experience ~w.~ - Primary & Secondary examiners Average claim turnaround is 6 to 8 days on clean claims v Non-PPO negotiated discounts y Claim processing ^ Review and validation of claims ^ Determination of benefits in accordance with the plan ^ Coordination of benefits with other plans • Subrogation-related activities ^ Preparation and mailing of laser printed claim checks and explanation of benefits forms ^ Maintaining individual benefit records ^ Verify student status Specific and Aggregate Reinsurance Filings Internal and external audits - Hospital bill audits Duplicate payment edits ,, - Existence of systems to support claims processing and payment with minimum level of manual interventions. TECHNOLOGY Electronic Claim Submission Automated Batch Adjudication - Claims Edit System (re-bundle services) Reasonable and Customary Edits Y Multiple PPO Contracts - Automated Correspondence Automated Production of EOB forms Check Payments tied to customer funding arrangements ~ Automatic Claim Hold for Quality Reviews Confidentiality and Security - Medicode -Usual & Customary (Ingenix) OPTIONAL SERVICES For acustom-designed approach to fit the Employer's unique needs, additional services may be added as desired. These include: y Section 125 administration y Pension administration including 401 (k) - COBRA administration y HIPAA administration y Claims audits - GPA On-line (online eligibility and claims status review) ~.- :~ rGPA ` ~~~ ' SERVICE PARTNERS GPA ON-LINE Online Enrollment GPA has harnessed the Internet's power to simplify employee benefits administration and dramatically reduce the cost and errors associated with today's paper-based enrollment systems. Through GPA On- line, you can eliminate time-consuming date entry and filing functions associated with processing employee benefit elections. In addition to automating this cumbersome task, GPA On-line reduces inaccurate or fraudulent enrollment errors while maintaining date integrity from initial submission of employee elections to final input into your payroll system and GPA On-line. Online enrollment through GPA On-line is an optional service that is available to all medical administration clients for maintaining accurate and complete plan eligibility. If selected, employees can take charge of their own enrollment and benefit selection. Using the Online Enrollment System, members can make elections and modifications to their benefits from any Internet-connected computer. See the following pages for sample screens of GPA On-line. $65 programming fee applies. Log aft Security a ~, u Ni~~ ~~,.r~~~ Enrollment Orm.,~ .. Cn,... inquiry C;L,u~ra _,.. sra ~:re . riL _u .ors L ir; L;y RPVIPW F+;.n..: lr,i,,~~ r Help At.;a.d G~: •rthsrds ++ ^~^ WELCOME GPA DEMO GROUP TEST CLIENT! GBAS Web Enterprise is a flexible, easy-towse, end time-saving [od that: • Allows employees to enrdl m-line • Provides an on-line Review/Transfer System that shows you to review epplice ti ms for accuracy, end submit or reject them, prior to sending [fie eppllcati ms to your TPA • Allows you a the employee to make on-line changes [o enrdlment forms, trad< these dranges, end notl fy the employee of the changes you've made through en automated a-mal system Optimal functl ms [he[ you may currently hove, or which you may be able purchase, indude: • A Cl ei ms Inquiry functim that can be con9 gured to show you view employee's dai ms information • A Coverage VeriflceUm funcdm that can be cmfigured [o allow you to view the status of an employee's wverage • A Report Function the[ can be cmfl~red [o provide different types of reports for you to review. Gurreet V~ear. F~.:~,:r Log Security i ~ P:+ ,•~r9 A 1 ris ra h~i,,, Pr,f:E Enrollment Girl Fi c+n C.hangeg pEnrellmont Management Inquiry Cl ~.f„ ~s Inawn- ,;;vc r,i i:~='JeeficaiiDn ir.~~> Vi~•e~ hep:>r1s Review Help AL„ i,t :~'~~tt?nl£ ~ `~ Enraliment Management • Enraliments Summary Page 1 of 1 It-P, ~ 6tatus Case Div Dats Submittotl~.' Status ~~ ~+ Reason GPA 450-78-2193 as1-9e-1245 644-26-2508 451-25-1065 ® DEMO COL 2125/2004 Enrollment Term Z/25/2004 ABBOTT WENDY 451-69-7000 GROUP complete I1 J View: Filtered Modify Filter Tvoa Lasi Action Emolovee Nama SSN f ® ~ DEMO 001 4/20/2004 Enrollment New l 4/20/2004 FRANK BEANS GROUP cxnp ete ® ~ GPA DEMO 001 3/10/2004 Enrol Imen[ Change l BLASCHKE 3/10/2004 DAVID A GROUP cornp ate ® GPA DEMO 001 3/tOJ2004 Enrollment Txm ABDALIA 3/1 012 0 0 4 complete ELSADIG GROUP ® GPA DEMO AI 3/8(2004 Enrollment Term DEAVERS 3/9/2004 complete f+1ARLIN GROUP GPA Page 1 of 1 ~1~ ._.....,.._.-._...____....._..._.. ,..__-,-_.._~a...m_.,.....__.. ¢ ChenpEixopm•et ~ 9, INtirEnroltmatt ~__.q~~. GROVn 8 iPF7vs~o~vAn~r/HCSnearo~es lac. Security ~r: r~, ..~.,~ t iui U' ~, ~.aa ~: ~ ~... Enrollment i)i~~I ..>n Clner:ns T Erna:: a: a (_n,l?I<.,.:. •. Inquiry r~Claims Inquiry t. _, . ra,~ e A,?nil,•.a' ~. rl I.. ifi4.; ~. . I~BVIeW ~Y ~.bt I[.J~ISf.?~ Help .,~ rrder.l= ++ ~ *,~ Claims Summary Patient Name: WENDY ABBOTT Date of Service Range: 01/27/2000 - 08/01/2001 Modity Primxy SSN: 451-69-7000 To view claims detail, click on the glasses. Log orr Viow Dato of Providor Ttl. Tll. Last Stales Documeni# Ootail Servlco Name Chg. Amk. Pd. Pmt. Dato 1/1(2001 - IS-2018750 DALLAS FT WORTH MEDICAL $I,000.OU $180.00 5/31j2001 Com plate 0114500699 1/1/2001 CENTER 1/1/2001 - 75-2018750 DALLAS FT WGRTH MEDICAL $600.00 $0.00 5/31/2001 Complete 0114500699 1/5/2001 CENTER : ~ 1/10/2001 - 63-1184833 In ~&~ 1/10/2001 HEALTHSOUTH DIAG- $4,928.55 $0.00 Progress 0125302888 CGPPELL 1 ~~~' r!a>•/' 8/1,12001 - 76-0324482 RICHARD In $1,500.00 $423.00 01260110624 8/1/2001 MADAMS progress Log Grf Security r I u e ha noni tt it ni_I= r- hA'; F'r!rflldr Enrollment Cav's?~:~:: C.~. Enrol::riu: f.?;u rnir:-~en! T.; rtninat ~e Ernpl: ~~ ea Inquiry Civil T, 1=.gmry fieview Help Cl•a ,,~rl .. ` Claim Detail Patient Nana: Date of Service Range: Primary SSN: WENDY ABBOTT 1/27/2000 - 8/1/2001 Relum to Claim Summery 451-69-7000 Dated Provfdor Tti. Tti, last Sorvico Nama Chy. Amt. Pd. Pnt. Dato Status Document# 1/1/2001 - DALLAS FT WORTH MEDICAL $1,000.00 $180.00 5/31/2001 Complete 0 1 1 4500699 1/1/2001 CENTER Status Data of Chg. Inei9. Mossage Contract Dod. Co•Pay Patient Pald Sorvico Amt. Amt. Discount Amt. An>t. Coins. Arr#. Complete 1/1/2001 $1,000.00 $0.00 217 $500.00 $300.00 $0.00 $20.00 $180.00 com piece 1/1/2001 $600.00 $300.00 err $100.00 $zoo.oo $o.oo $o.oo $o.oo * MulOple Messages CLAIMS PAYA~NTS/EOFIs Dato And. Payoe Ck.# EOB# Chack Clear Dato 5/31/2001 $180.00 DALLAS FT WORTH MEDICAL CENTER 1 20010525-1719 CONEXIS - COBRA/HIPAA ADMINISTRATION COBRA, HIPAA and state continuation services are CONEXIS' core focus. CONEXIS takes care of administrative burdens quickly and reliably through their Internet based communication system. Human Resource professionals get back to core business issues faster with CONEXIS. They consolidate COBRA administration of multiple coverage options -eliminating the administrative hassle and expense of having duplicate COBRA administrative services. They do it all, and do it faster in a single easy-to-use solution. Visit CONEXIS @ www.CONEXIS.com. Comprehensive COBRA Administration Y Initial Rights Communications to all active participants as they become effective on the insurance plan - Qualifying Event Notification of COBRA eligibility Billing and Collection of COBRA premium -bill, collect and remit COBRA premiums to the Employer - Remittance of collected premium within 10 days of the end of the month Y Rate and Benefit Change Notification -Communication of rate and carrier changes to COBRA participants - Verification of Continued COBRA Eligibility in monthly participation attestations - Weekly and monthly reports keep clients informed and up to date COBRA Compliance COBRA procedures manual kept on your company premises for review, a required element of compliance - Track, maintain and report activities for response to IRS audit requests CONEXIS mails COBRA eligibility notification via proof of mailing to all qualified beneficiaries Y Bilingual customer support to assist your COBRA eligible participants Objectively enforce election and payment receipt deadlines - Prepare and mail termination notices due to expiration or cancellation - Communicate conversion rights in termination notice - Track and respond to any COBRA inquiries, reporting pertinent activities to the Employer - 24-hour bilingual Telephonic Inquiry System HIPAA Administration - Initial Rights Communication - Certificates of Creditable Coverage, via proof of mail, including COBRA coverage periods r Track, maintain and report activities for audit support - Prepare a tailored "address needed" communication requesting employee to advise Employer of accurate address - Provide a duplicate Certificate of Coverage upon request up to 24 months from the loss of coverage Y Track and respond to HIPAA inquiries Bilingual customer support to assist participants Prepare past HIPAA Certificates of Coverage for any employee and eligible dependent losing coverage since July 1, 1996 - Prepare and distribute open enrollment, rate and carrier change communication for ACTIVE employees and eligible dependents State Continuation Many states have passed health coverage continuation laws that require Employers to extend coverage beyond the periods provided in the COBRA laws. CONEXIS can provide this service at a nominal cost in our menu of services. In connection with notification of expiration of COBRA continuation coverage, CONEXIS will mail State Continuation eligibility notification, via proof of mailing, to all qualified beneficiaries y Bilingual customer support to assist your State Continuation participants Objectively enforce election and allowable payment receipt deadlines - Prepare and mail State Continuation premium coupons - Collect and confirm timely receipt of correct State Continuation premium as well as process returned checks - Conversion rights information included in termination notice - Track and response to any State Continuation inquiries, reporting pertinent activities to the Employer v 24-hour bilingual Telephonic Inquiry System COBRA Administration &HIPAA Certificate of Creditable Coverage Fees Per Employee per month: HIPAA Certificate only .................................................................................................. $0.85 COBRA only ................................................................................................................. $1.00 COBRA plus HIPAA certificate ..................................................................................... $1.85 COBRA Set-up Fee (one-time) ......................................................... Included in Set-Up Fee See the following pages for sample CONEXIS Internet pages. COBRA billed premiums will include 2% Conexis Administrative Fee. FMo Edt Vbw FavorRas !~Took Yblp ~. ®BKk ,. i?r,~ iR!1 e~la ,yr-~75erch V ~~Favaltas h1¢dfa ~8 ,'.: {. it f•'.:f~y s~~. .. .. ... ..... ._. ...._... yi rp iii m.=; » ~'SE7 ~ Ir......•COMXk pgfMld012 IIt1111 mvwebsenrsh - - -- -- -- r Ssrch ~®' S.iey Lenlyd mss' Sassmavas ®. Cvtaor Manis 8 My ido ~ Gaw»s ~ ~ Cudaai» ('~ f~ Bueon 1 ,.. ~ ~ k h~~ ~:' f"'~iR'f1t ACCkt55 1"iaitte USER: VHunt Demo Company ^ Welcome to CONEXISI We took forward to assisting with Yoiu COBRA, HIPA4 and tNt Flexible Spend~g account needs. Should you need anything please don't hesitate to call us at 1677-452-6272 CONEXtS offers an arcay of Open Enrogment services. Please caN Client Services at 1-877-452-6272 or e~naii dientservicesaconexis.com for additional information. If you do not contract open ervngment services with CONEXIS, keep in nand that any new rates or plan changes must be communicated to COBRA continuants and those in their waiting period 'gust as x is for active employees. Released by the DOL on May 26, 2004 the Department of labor (DOL) Issued the final regulations that change C06RA's notice requirements signlflcaady. These wlFl Bo Mto effect later this year and w01 effect plans as early as December 2004. Attached Is a link to the Final Regulations - C08RA Summary .This Is a brief seminary written to help yw better understand the changes they make to the proposed rooulatlans as weN as a readmap for lmplementatlln. The attached Notice of Unavailability of COBRA Coverage is also wdiable for your convenience. Sae the Summary far details surroundlaq this notice. ® CONEXIS continuously updates tho web site and makes changes to bene(~ our diems. if you would like more training on our web site, please register tar interactive on-line training . You have logged into the Demo company. You may practice without risk ~ akering Gve data. Copyright Q 2004 CONEXIS AU Rights Reserved San,1 faaAhark M ffIHIFYiG M names t ~' ~_.__ _ .____.___n.~_.._._ ~.~_... ...__ 8_~ Intsrnst CONEX~S 1_OC,Jl~I You are entering a priv8te sedlon of the CONEXIS web site. This sedlon Is provided for sole use by customers, eroiployees, eutharized Contractors, end other assigns of CONEXIS. Unauthorized access is prohibited, and ell access is lagged. If you are having problems logging in; please contact Client Services at 877.452.6272. Please sated the a ou wish to access: please enter your llSer ID '. ~.--------- Please enter your Passwofd iiiaiY/ Tip: We recommend adding this page to your favorites for quids access to our segue web site. Return Home Copyright O 2004 CONEXIS All Rights Reserved Send usvourfeedback Fle Edt Ykwv FevorRes TT~o'~ils ~Mekl ~ `-.;,,.,:~ -~ ~-.-,a L!~J ~'~14 ,~+ 'SOarch "FavaRes Medk ~}`it - ... ;;. ® '. A.jd = i~ htkP (~www.canexis.wg/ v ®Go Links 1O ..........,._....~.o..-.....,... ..e.....~.... .-.._,..,m . '. ~ ...,...~._„_ ... .._.. ._ rA - F1e Edt Vkw FevarRes Toils tirV q~E" Back ~ ` L%~ ; ~: ~ '~~ ] ~..~ Seerdi - FevoMes ~ IAef-s ~~~ ® _.... ~ ~y _ ~.. _~.,_,,,,...__..,v. _..T._..-TT ---- A~~ir ~ hhps ~~W~wv.caxx6.orgihdlx2.htepl vl ~ fo t:ril:5 ° m •wedara ~~_,r _ , _ _ _ von . ~`---- -- l ,_.<.~d, - O sm+oy c«,rr ~ so~ara: P. Cu.or r~ ~ My Irio lQ ~». - ~c Cuslo~i~ee ,~` -~ BuMOn i .~ .,. , ~ ~,~ F~al-tici~aal~k Se~r~h Pleas• Eatsr year seardh Criteria: Sodat Security Numbert Employee Number: Last Naate: First Name: Hire Date Ranpe: Account Number: Case Number: USER: VHUM Demo Company Tip: Soaal Security Numbers can be entered with or witlwut hyphens. When searching by name, You need not enter the while name -searching for "Pt" in the last name field would return partiapants with last names b®ginnkp with "At". Copyright p 2004 CONEXIS Aq Rights Reserved Contact Your Client Services Manager ~7 Cmtact Us ~ !® Internal FIe Edt New Favarkes Tads Help t Back - '~%~ ~ `~,tl ~ a Swrh `.' Farorlbs ~ Mda '~ ~ - ~ ~. ® - ,_ ,> '. ~-~ _. _._. __T___..__ ____.__ _----._ -_ _. Ad Jr ,~ httvs.J/vnwv.conezk arq/Mex2 htmt ~ v:i ~ W Lff~il~s » of+yvrcbsearch ~ S esrrh -®' Smiw Cerad ~ Scrasneavsrs ®. Cussr Marvis ~ My.M+b: (Q Gann >~ Cube ~ My BuNan 1 .Q ~, ~; ,; _:5r , .. . ~ . . ~ . ~£ p01 t'S USER: YHawt Demo CempeeY Welcome to our reporting menu. Here you wiN find our standard reports that are available through our web site. Ellaibllity: A series of reports that allows you to view Partiapants in then- waiting period, Continuants, and Canceged participants. Scheduled Reports: A kst of reports that have been scheduled to be sent by CONEXIS. New sdheduled reporting items can be added, and history of sdheduled reports sent can be viewed, Common reports configured under this tab include eligibility reports, reinstatement notifications, and cancellation notifications. Exception: This section indudes reports that are important for mon~winq error and exception condRions. You should visit this section often to stay apprised ~ important condRions such as returned mad, ineligible dependents, or dependent coverage exceptions. Activity: This section provides a way for employers to monitor [fie activity on their account. Searches can be done by user, division, or activity type for a speafied date. Employees: This report allows you to salad the employees to indude ai the report, optionally indude addresses and dependents, and to sort by various criteria. Monthly: Axess to monthly reports inducting Statements and Carrier Remittance. as Tools for viewing diem and partidparrt case history. Export: Request a file export containing partidpant data. . ~~. 'i4. . ........ ..... m__. ,..._ y t Merry Copyright p 2004 CONEXIS All Rights Reserved Contact Your Client Services Manager _., .._,_-,. ....,.._ .. ___.__..._ .._...~-,.- ._.-___~_-. ._ _,,.._. _.... .... _..._...__._-.. -.._..~-_ ....._._......_._ ..... ._.........-_-...-m.-i1_....... --.._... _. L'-FJ ~ Interns[ Fb Edt ylew Favarkes Tolls flea ~r8 Bads - it '" ~'a~' ~~ Search Fawrtas ~`,y~ ~bde ~`4'b ~ ~ ' t,~1J iii htlps //www caneaC orv/tidsx2 howl _ _ __ .. _....._ y'::~ ~ Go lir~k~ '» n~ywebsearch - ~~-~ u ~_..._ - ~:, e lrch -rG~ Smiey Cenod l~ Saeentevets p Cuaor Mania a Mg Ma ~ Gamsa ~ CaWOie~te y~ Mr BWOn t :~ ~ > ~ ~Itt(3~O~,r~~ L ISC •• USER: YHunt Detne Campa Ay Delno Company, Employees by nam e as of 10/6/2004 .~$)Y Pa amt Name j~jYjfjaQ $jEjb,jj~ Hire OeL $@p ~ SS9LYi 982-03-6689 Acke,+man. Harry Demo Division +e 10 6/5/1941 11/1/2001 M Covered Empbyee 444-44-4495 AdaM. Amv. Demo Division J!3 3/15/1968 3/1/2001 M Non Coverod Employee 444-44-4495 Ademl Amv Derrw Division ~k3 3/15/1968 4/4/2001 M Non Covered Employee 212-33-4141 Adams. Alex Demo Division k11 5/30!1961 3/30/2000 M Covered Employee 134-76-9852 ash. earn ENROM 12/21/1963 9/27/1990 M Non Covored Empbyoe 555-26956 Bake. Justin 1/1/1970 2/1/2001 M Non Covered Employee 676-78-9786 Baxter. Anne Demo Division M10 4/8/1978 1/1/2001 F Covered Empbyee 123-12-4567 Brown. Toe COM 1/1/1921 1/1/1990 M Covered Employee 020-10-5260 Brawn. ]ohn 5/1/1980 5/1/1999 M Non Covored Employee 444-SSfa666 Case Imo Dema Division NS 1/1/1956 1/1/1986 F Covered Employee 429-41-9557 Cleot~s, Jimmy ENRCMI 6/7/1956 1/1/1990 M Covered Employee 987-45~i321 Edward. David Demo Division MS 9/14/1961 11/19/1990 M Covered Empbyoe 524-12-3456 EmDlOVee. New Demo Division p10 2/22/1978 9/1/1999 M Non Covered Employee 248-67-5386 Enrollment. Part 2/23/1978 5/1/2001 M Covered Employee 574-RA-8754 Patine, inch~dr+s 7MAl1 Q7R 1l15Mf1r11 M Cnvwrnd FmnMvnw "`' Fib Edt View FavorRas Tools ' Flab ~;# Batk ~ Lx I L'S!~ ~ ~.1. ttps !lwww.conexe.ap/irdbx2 html v; ~ Go ur~ks ~° ravwebseareh - ~ Seudi -®r SmiN Can4a1 Q Screaneavars ~- CusarMaria ~ My lrio ~ Gams ~t Cuslaraa ~ My BcAlorr 1 ~'. /~CtlVit!/i RC'(?OI't5 USER: YHuat Demo Company Shaw QToday ~,JTh15 Week Submissions. -- -. ~ This Mtlnth C? Date Range to ~ _ __ I Sort by: ~~ Date Submitted C? Err~loyae Name C~Sodal Seaxity Number i~Activity Type Fiksr _ _. , For. ~ Selected User: Alberta Seaules ~+ ^SelectedDivision COM *}; ^AdiVity Type: Address Updated Note: These reports sometimes take several minutes to generate. Copyright ~ 2004 CONEXIS All Rights Reserved Contact Your Client Services Manager Fb Eck Ybw Favortes ~ ,T~ogds 'ice '4~ Back - ~ ~ ? t i d:~} Search FavorRes ~ Meda ~<; ® ,.... ::a iiddre s -._. _.._ gJirda _. ...__. ._.. _._. _ ._.. __. _..~ ~60 tanks hops !)vwvw.canexrs d x2 hGd r __.__ mywehsenrch - ~~--~--~~~-~~-s-~~ J , each -~' Saiy CanYal ~7 Seaentavws /- Luwc Maria 8 My Mb ~ Gans - >~ Lwkmoa ~ My Otehn 1 :,~ a Rarticipant Yt~fcb USER: VHunt DemoCompsny 1}artic:itaant {[? # :561496, ;SN # ; 222-22-2220 P~rti rUant irtfyc n2rrtUn Employer name D6mo Company Locatloa Demo Division !i5 Name AAF\A, AAA A Gender Male Employee Number 123 Employee Cless Not Assigned Status ~ Continuation Pendmq ohih Date 2/23/1978 Hire Data 4/+FJ2001 WakMq Start Date 4/M/2001 Coreraga Date 7/1/2001 Current Address NA City NA State, Zip NA, NA Emaq Nut Provided Phone Not Provided fJiscri n)ination=lbesting [rijca rrriakinri KoY Empbyee No ~ SK Shareholder No ? Hlahly Cemoeasated No 7 HiaAly Camsansated No 7 intarrret Fle Edt Vbw Favorkes Tads Fialp ire ~~ Back ,,.~ i.:.: J `"'' +~ ,~r . ,' Searcfi ~',`z' Favarkss r~ Meda ~ " ` • .4dir ` ~,~ hNps /Jwww canexk.orq(Yidex2.hhd vi ~ Go Lir;ks » mywebsearch . ,- Search ~ Braley CaWal Q Sgaensavers ~ Cusar Matta ~ My hYo ~ Gaaas >~ Cwtamias ~ My Bultan 1 -_ __ ~ . R~Ike Inf+t~l~makiol~ USER: YHUnt Demo Company r Current Rates As Of 10/6/2004 CGdc here to view all rates. Click here to view subsiduzed rates. Health Pian Plan Tvoe Coveraoe Tvoe Btlll:4~ BSS EHt1 E~~ Premium + Admin. Fae (BUNDLED} Test plan* I~p~~use plan Family 1/1/1990 $12.12 $12.36 Family 8/1/2001 2300.00 #306.00 Empbyee only 8/1/2000 #12.00 $12.24 Spouse Only 1/iJ1999 $4.95 #5.05 Empbyee + Spouse 1/1/1990 $11.00 #11.22 Employee + Children 1/1/1999 $110.00 $112.20 Employee + Children 8/1/2001 $142.00 #144.84 Child Orly 1/1/1999 27.00 :7.14 72 QPOS Clearwater* ASO Fee Family 9/1/2001 $392.00 #399.84 Employee Only 9/1/21 $142.00 #144.84 Spouse Only 9/1/2001 214b.00 #148.92 Children Only 9/1/2001 2146.00 #148.92 Empbyee + Spouse 9/1/2001 $293.00 #298.86 Employee + Child 9/1/2001 $293.00 $298.86 Employe®+ Children 9/1/2001 $293.00 2298.Bb Spouse + Child 9/1/2001 2294.00 $299.88 Spouse + Children 9/1/2001 $293.00 #298.86 Child Only 9/1/2001 2150.00 #153.00 72-HMO-FL04*` Medical Family BJS/2001 2300.00 #306.00 Employee + Children 8/1/2001 2142.00 2144.84 ~,,F._~ _.~ ____,.______.... rty ..._._..__~_.,__.._,...., ...w~. __..,.._._..__--~ --~-~°_°__.__~.,..___~~~___~~. ~ .......~._ _..NS~_.~~. ~ ~ Intwnet HEALTHWATCH HealthWatch, Group and Pension Administrators (GPA) trade name for their Utilization Review and Large Case Management, was established in 2001 as an internal department closely integrated with the Claims and Customer service departments at GPA. HealthWatch is staffed with Registered Nurses who have clinical and utilization review experience. They have ready access to on-line national medical necessity review criteria and physician reviewers for medical opinion on selective cases. The nurses access the GPA software system utilized for claims examination and customer service thus providing a seamless approach to claim review and continuity in service delivery. As HealthWatch nurses office in GPA, they have daily contact with the claims and customer service personnel to facilitate review and resolution of medically related questions to expedite claims processing. Their on-line access to the summary of benefits and eligibility status promotes adherence to the plan document. HealthWatch Utilization Review Services Notification Registered nurses review the medical service provided and determine if it is a covered benefit and meets medical necessity criteria. Should a denial of notification be recommended by the nurse, a physician will review the case. The goal of notification is to promote successful health care outcomes while containing cost of case. The nurse works collaboratively with health care providers, facilities, and the covered person to assure that the services provided are within the scope of nationally accepted UR criteria and the plan document. Large Case Management Specific diagnoses are identified as "trigger diagnosis" as they are likely to be large dollar cases and involve the stop loss carriers. HealthWatch nurses collaborate closely with the stop loss nurses to promote continuity of care and coverage for the patient and group. When a large case is identified, the nurse provides on going case management with the clearly defined goal being to meet the patient's health care needs through coordination and utilization of available resources to promote quality, cost effective outcomes. The nurse maintains contact with the patient and the health care providers as well as the stop loss carriers during the case management process. The nurse negotiates cost of care with out of network facilities and monitors care delivery. Updates on patient progress and recovery are available to the claims examiners and customer service staff in the software system at GPA thus integrating the claim. Description of Services Offered by HealthWatch Notification Review and certification Concurrent Review and Discharge Planning Large Case Management Outpatient Surgical Review Negotiated discounts for Non-PPO services Physician Review coordination Appeal coordination CAREMARK '~'' CAREMARK has a state of the art prescription claim processing and drug utilization review system electronically connected with a national pharmacy provider network consisting of 47,000 pharmacies throughout the United States. This system provides our clients and their employees immediate access to our managed care network. Visit www.CAREMARK..com. Prescription Drug Card The CAREMARK Prescription Benefit Program provides employees and their family members a managed care approach to the delivery of prescriptions, while maintaining quality and cost effective results. FORMULARY MANAGEMENT: Y Cost Effective Dispensing - Generic Substitution - Maximum Allowable Cost (MAC) Three-tier Co-pay Management (single source Brand, Multi-Source Brand and Generic) Y Brand Dispensing Based on Cost Effectiveness CONCURRENT DRUG UTILIZATION REVIEW (DUR): Early refills, Stockpiling Duplicate Therapy y Drug to Drug Interactions Minimum/Maximum Dosage Y Over Utilization and Abuse Drug to Age Contraindications - Duplicate Claim Protection A PRESCRIPTION FOR SUCCESS: The CAREMARK prescription benefit program offers a full array of services specifically designed to control health care costs and deliver quality care to employees and family members. THE CUSTOM DESIGNED PRESCRIPTION DRUG BENEFIT PROGRAM INCLUDES: Custom Designed' Plastic ID Health Card on One Side, Prescription Card on the Other Negotiated Contract Pricing ~ National Pharmacy Provider Network including a Preferred Provider Network 800 Number for Customer Service On-line Real Time Claims Processing Flexible Plan Design - Concurrent Drug Utilization Review (DUR) Retrospective Drug Utilization Review Available Drug Formulary Management Integrated Mail Order Excellent Plan Reports Pharmacy Network CAREMARK's National Pharmacy Provider Network includes most pharmacy chains and many independents. We also contract with several Mail Order Pharmacies for maintenance medications. Sample Network Pharmacies Include (top five retail chains): 1. Eckerd Drugs 2. Walgreens 3. Rite Aid 4. Wal-Mart 5. American Drug Stores (Osco, Save On, Albertsons) CARD IS EASY TO USE: Simply present the CAREMARK card and prescription to a network pharmacy. The pharmacy will handle the rest of the transaction electronically with . Participant will pay only their required co-pay. CAREMARK has astate-of-the-art prescription claim processing and drug utilization review system that is electronically connected with a national pharmacy provider network consisting of 37,000 pharmacies throughout the United States. This system provides our clients and their employees immediate access to our managed care network. Controlling the ever-increasing health care costs while providing quality health care at cost effective prices is a constant challenge. The CAREMARK program provides processing controls, delivers negotiated pricing discounts and involves the pharmacies in the cost-effective delivery of prescriptions to employee's and their family members. AIG TRANSPLANT PROGRAMS The AIG Transplant Program is an excellent opportunity for aself-funded group to carve-out their financial risk associated with transplantation while ensuring their employees access to some of the leading transplant facilities in the United States. To eliminate the risk with an average cost of the four stages of transplantation (evaluation, pre-transplant, transplant admission/procedure and follow-up care) far exceeding $100,000 in the first year alone, this catastrophic event can have a direct impact on any group's stop loss or reinsurance premiums and may even lead to outright termination of coverage. A group with the Transplant Program in place not only eliminates this risk, but also may qualify for a net reduction in the premiums it pays to its stop loss or reinsurance carriers. The elimination of this risk, associated with transplantation, as well as the potential cost savings in stop loss or reinsurance premium has been received extremely well by those employer groups who wish to alleviate themselves of this potentially devastating claims experience. Access to the nation's leading transplant facilities and specialists. Their goal is to make the transplant process as easy as possible for you. An AIG registered nurse will interact on your behalf with a team of health care professionals to begin the transplant evaluation process. You'll be guided through the facility selection, testing and evaluation and assured that the recommended treatments are properly certified. As your primary contact and coordinator, your medical case manager will answer questions, help interface with your physicians, assist in the planning of treatment and recovery procedures, and provide constant support, from pre-evaluation, admission and surgery, right through an entire year of follow-up care. Covered Transplant include: Allogeneic bone marrow - Autologous bone marrow - Heart Heart/Lung Lung Kidney - Kidney/Pancreas Liver Transplants Exclusions - No benefits are paid for transplant charges resulting from: - Pancreas, include Islet Cell transplants; - Cornea; - Thymus; - All bowel sections; Skin; Liver to treat Hepatitis that is surface "e" antigen positive - Animal to human transplants; - Artificial or mechanical devices designed to replace organs permanently or temporarily; Solid organ transplants in patients with Carcinoma, except bone marrow transplants; - Benefits are limited to two (2) covered transplants per lifetime; - Cosmetic or reconstructive surgery; Y For a sickness, caused by a congenital defect, which affects a bodily function, unless the sickness begins while the insured person's covered is in force; and Y For work-related bodily injury or sickness. Benefits of a Fully Insured Transplant Program: - Elimination of all financial exposure to transplant procedures Reduce stop loss or reinsurance costs Transfer Case Management responsibilities to a dedicated unit experienced in transplant protocols and procedures Provide a more comprehensive benefit plan The fees for the AIG Transplant Program are $6.00 per Employee and $7.80 per Dependent Unit. (2 Million Max) ELAP GPA offers ELAP to Plan Sponsors for the following reasons: To transfer the Plan Sponsor's Fiduciary risk relative to benefit decisions; here is how -- Y The Plan and GPA establish two levels of appeal. The EOB-denial and the 1 Sc appeal are handled within the Plan (per DOL protocol), with GPA. If a participant makes a 2"d appeal, the Plan and GPA refer it to ELAP, Inc. These are "Referred Appeals," which are specifically defined in ELAP's contract. - You amend your Plan-Doc to name ELAP as a co-Fiduciary (or "Designated Decision Maker"), and you sign a contract to accept this service -the "DDM Service Agreement." If a plan participant brings a suit to contest a final (2"d appeal) decision by ELAP, then ELAP pays for legal defense and damages that result (excluding the cost of the benefit itself). The limit is $1,000,000 per legal action. To maximize compliance with ERISA and DOL in the decision-making process Benefit determinations will be reasonable, prudent, and unbiased -fulfilling fiduciary obligations under Federal Law. You have access to a nationally recognized and URAC certified Independent Review Organization. Using Independent Review assures compliance with the DOL Regulations regarding medical consultation and further assures that benefit decisions are based on rational medical protocol. All "medical necessity" and "experimental" appeals, for example. Y You have access to an experienced ERISA attorney. Focus areas include document review, coverage interpretations, and consultation on any legal matter relative to your health plan. Need a "real world" example? See the following court case summary. A self-funded health plan covered pregnancy-related expenses but not professionally assisted insemination. Shortly after becoming pregnant via artificial means, the plan participant began to suffer with apregnancy-related illness and entered the hospital. The TPA, after consulting with the Stop-Loss Carrier, denied the claim for the patient's hospitalization on the basis that it was not covered because it was caused by the artificial method of impregnation. The patient appealed. She included a statement from her treating physician that her illness was a result of being pregnant, and not a result of the method of fertilization. The TPA consulted with the Plan Administrator, and they denied her appeal. The patient then sued the TPA, Stop-Loss Carrier and Plan Administrator (her Employer). The Plan Administrator testified that he made the ultimate decision to deny the appeal. He further testified that he relied on the recommendations of his TPA and his Stop-Loss Carrier - he said he did no medical research, he did not seek outside advice, and he had no knowledge of the basis for conclusions of the TPA and Stop-Loss Carrier. The court held that the denial was not based on "any reasoned application of either medical facts or legal analysis." The suit settled out-of-court with the three defendants, for an amount that far exceeded the original benefit. IF THIS PLAN ADMINISTRATOR HAD ELAP: 1. When the claim reached the final appeal, the TPA and Plan Administrator would have accessed an unbiased, professional decision-maker. FLAP would have made the final ("Referred Appeal') decision. 2. The whole appeals process would be DOL-compliant, and the final decision would be independent and reasonable, thereby establishing the most defensible legal position. 3. ELAP would be liable for any damages' and legal defense that result from our decision (excluding the cost of the actual benefit), up to $1, 000, 000. Actual examples of appeals referred to ELAP (Jan-July. 20031: Bone Marrow Transplant for a cancer patient -- was the procedure experimental (and therefore excluded)? - Patient hospitalized for 10 days for infection, plan paid for only 5 days -- were extra days medically necessary? - Plan specifically excludes "obesity related treatment." Can the exclusion be upheld, even if treating physician says that agastric-bypass procedure is medically necessary because the patient is morbidly obese? Clinic split-billed for surgery in phases. Plan paid one (lesser) global fee. Which fee is appropriate, according to the provider contract and currently accepted medical practice? ~w.r ELAP Appeals Statistics (Jan 2003 thru May 2004): Issued 120+ TOTAL decisions ^ upheld denial = 88% ^ overturn/cover = 12% Issued 30+ SERIOUS decisions (these are included within the figures, above) ^ upheld denial = 69% ^ overturn/cover = 31 "SERIOUS" means that ELAP involved physician(s) BJor attorney(s) in the decision The fees for the ELAP Program is $1.00 per Employee. "Damages" as described in DDM Service Agreement, the ELAP contract. ,, TelaDoc Introducing the Future of Affordable Medical Benefits SERVICES TelaDocT"" is a network of licensed primary care physicians who diagnose individual medical problems via the telephone, recommend treatment and prescribe medication (when appropriate) over the telephone 24 hours a day, 365 days a year. You can access this service wherever you happen to be: your home, office, hotel room, or vacation campsite. Simply make a phone call and, in most cases, speak to a doctor within 30-40 minutes. TelaDocT"" is available in all 50 states. TelaDocT"" offers many benefits such as: • Physicians who diagnose medical problems and prescribe medication when appropriate • Prescriptions phoned into your local pharmacy • Patient access to medical records with HIPAA compliant secure servers ADVANTAGES TelaDocT"" is changing the way people access medical services by using modern technology to match the needs of today's fast paced workforce. Below are just a few ways you and your dependants benefit from becoming TelaDocT"" members. • On-Demand access to health care • Telephone access to a physician from any phone, 24 hours a day, 7 days a week • Access to a physician within three hours • No more waiting until next week to receive medical attention • No outrageous fees or unexpected charges • Most medical issues can be resolved from any remote location • Reduce the number of hours you spend away from work therefore increasing productivity • Easy method of payment • CMS 1500 Form for reimbursement When to Call TelaDocT"" Call TelaDocT"" whenever you need non-emergency medical assistance. Take advantage of the convenience of accessing a physician 24/7, 365 days a year. Call TelaDocT"" when: • You cannot reach your primary care physician • It is after your doctor's normal hours of operation • You are on vacation or a business trip • You need your recurring prescription filled and don't have time to go to your doctor's office • You need medical attention that might be resolved without seeing your primary care physician • You have medical questions, medical issues, or concerns • You need a second opinion *OUR GUARANTEE: Te/aDocT"" guarantees that a physician will contact you within 3 hours or your consultation is FREE! 1 -800-TelaDoc (835-2362) The fee for the Teladoc Program is a composite of $3.00 per Employee. A GROUP ~ PENSION ~I DMiNiStR~il`ORS, /NC. Paair CHVbPa 8 ~ /2770 A~7 DMt~ 2"' Fioort ~ Daces. Tx 7S2S/ ~ (9721238-7900 Kerr County Table of Contents - Required Forms Section 1 - TPA Questionnaire Section 2 - Formal Proposal Section 3 - Cost Section -Spreadsheet and Quotes - TPA License and Insurance Section 4 - GPA References Section 5 - Stop-Loss Flowchart Section 6 - GPA Sample Analysis Section 7 - CAREMARK Formulary Section 8 - CAREMARK Specialty Drugs Section 9 - Sample CAREMARK Contract Section 10 - Sample RX reports Section 11 - HealthWatch Executive Overview Section 12 ^ Wellness Product Guide ^ BeWell / Incent One ^ Interactive Health Solutions Disease Management Proposal Section 13 Teladoc Brochure Inside Front Cover Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD&D ~,,, Health Reimbursement Arrangement Cafeteria Plan (IRS code 125) Administration Prescription Benefit Management PLEASE FILL IN THE FOLLOWING INFORMATION NEEDED AND SUBMIT WITH PROPOSAL. The undersigned proposer, by signing and executing this proposal, certifies and represents to Kerr County that proposer has not offered, conferred or agreed to confer any pecuniary benefit, as defined by (1.07 (a) (6) of the Texas Penal Code, or any other thing of value as consideration for the receipt of information or any special treatment of advantage relating to this proposal; the proposer also certifies and represents that the proposer has not offered, conferred or agreed! to confer any pecuniary benefit or other thing of value as consideration for the recipient's decision, opinion, recommendation, vote or other exercise of discretion concerning this proposal, the proposer certifies and represents that proposer has neither coerced nor attempted to influence the exercise of discretion by any officer, trustee, agent or employee of Kerr County concerning this proposal on the basis of any consideration not authorized by law; the proposer also certifies and represents that proposer has not received any information not available to other proposers so as to give the undersigned a preferential advantage with respect to this proposal; the proposer further certifies and represents that proposer has not violated any state, federal, or local law, regulation or ordinance relating to bribery, improper influence, collusion or the like and that proposer will not in the future offer, confer, or agree to confer any pecuniary benefit or other thing of value of any officer, trustee, agent or employee of Kerr County in return for the person having exercised their person's official discretion, power or duty with respect to this proposal; the proposer certifies and represents that it has not now and will not in the future offer, confer, or agree to confer a pecuniary benefit or other thing of value to any officer, trustee, agent, or employee of Kerr County in connection with information regarding this proposal, the submission of this proposal, the award of this proposal or the performance, delivery or sale pursuant to this proposal. The proposer shall defend, indemnify, and hold harmless Kerr County, all of its officers, agents and employees from and against all claims, actions, suits, demands, proceeding, costs, damages, and liabilities, arising out of, connected with, or resulting from any acts or omissions of contractor or any agent, employee, subcontractor, or Supplier of contractor in the execution or performance of this RFP. I have read all of the specifications and general proposal requirements and do hereby certify that all items submitted meet specifications. COMPANY: Group & Pension Administrators. Inc. AGENT NAME: Matt McCuen AGENT SIGNATURE: ADDRESS: Park Central 8, 12770 Merit Dr., 2na Floor CITY: Dallas STATE: TX ZIP CODE: 75251 TELEPHONE: 972-744-2540 FAX: 972-587-1459 FEDERAL TIN#: 75-2148164 ANED/OR SOCIAL SECURITY #.• DEVIATIONS FROM SPECIFICATIONS IF ANY Have offered TelaDoc as an optional product Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD&D Health Reimbursement Arrangement Cafeteria Plan (IRS code 125) Administration Prescription Benefit Management CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS Name Of Entity:_Group & Pension Administrators, Inc.. The prospective participant certifies to the best of its knowledge and belief that it and its principals: a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency: b) Have not within a three year period preceding this proposal been convicted of had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State, Local) with commission of any of the offenses enumerated in paragraph (I) (b) of this certification; and d) Have not within a three year period preceding this application/proposal had one or more public transactions (Federal, State, Local) terminated for cause or default. I understand that a false statement on this certification may be grounds for rejection of this proposal or termination of the award. In addition, under 18 USC Section 1001, a false statement may result in a fine up to a $ 10,000.00 or imprisonment for up to five (5) years, or both. }~~~nnnc~~ C:Ot7 Name and Title of Authorized Representative (Typed) Signature of Authorized Representative Date I am unable to certify to the above statements. My explanation is attached. Conflict of Interest Questionnaire For Vendor or Other Person Doing Business with a Local Government Entity This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with a government entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7`h business day after the date the person becomes aware of the facts that require the statement to be filed. See section 176.006, Local Government Code. A person commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C Misdemeanor. 1. Name of person doing business with local government entity. NA 2. ^ Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which the activity described in Section 176.006(a) Local Government Code, is pending and not later than the Ts 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 alocal government officer of the local government entity with respect to expenditure of money. NA 4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local government entity that is subject of this questionnaire. NA 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) NA 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? NA ^ YES ^ 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? NA ^ YES ^ 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? NA ^ YES ^ NO D. Describe each affiliation or business relationship. NA 6. Describe any other affiliation or business relationship that might cause a conflict of interest. NA 7. Signatures NA Signature of person doing business with the Date Governmental entity Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD&D Health Reimbursement Arrangement Cafeteria Plan (IRS code 125) Administration Prescription Benefit Management CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS Name Of Entity: Group & Pension Administrators, Inc.. The prospective participant certifies to the best of its knowledge and belief that it and its principals: a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency: b) Have not within a three year period preceding this proposal been convicted of had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State, Local) with commission of any of the offenses enumerated in paragraph (I) (b) of this certification; and d) Have not within a three year period preceding this application/proposal had one or more public transactions (Federal, State, Local) terminated for cause or default. I understand that a false statement on this certification may be grounds for rejection of this proposal or termination of the award. In addition, under 18 USC Section 1001, a false statement may result in a fine up to a $ 10,000.00 or imprisonment for up to five (5) years, or both. Kathy Fnochs, (:(~(~ Name and Title of Authorized Representative (Typed) Signature of Authorized Representative Date I am unable to certify to the above statements. My explanation is attached. Page 5 of 32 Conflict of Interest Questionnaire For Vendor or Other Person Doine Business with a Local Government Entitv This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with a government entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7`h business day after the date the person becomes aware of the facts that require the statement to be filed. See section 176.006, Local Government Code. A person commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C Misdemeanor. 1. Name of person doing business with local government entity. NA 2. ^ Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which the activity described in Section 176.006(a) Local Government Code, is pending and not later than the 7°i business day 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. NA 4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local government entity that is subject of this questionnaire. NA 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) NA 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? NA ^ YES ^ 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? NA ^ YES ^ 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? NA ^ YES ^ NO D. Describe each affiliation or business relationship. NA 6. Describe any other affiliation or business relationship that might cause a conflict of interest. NA 7. Signatures NA Signature of person doing business with the Governmental entity Date Page 6 of 32 Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD&D Health Reimbwsement Arrangement Cafeteria Plan (IRS code 125) Administration Prescription Benefit Management Individual Stop Loss Insurance (ISL)/Aggregate Stop Loss Insurance (ASL) Request for Proposal Submission Form STOP/LOSS INSURANCE QUESTIONS I. Describe ISL and ASL claim payment: a. Where will claims be paid? TO BE COMPLETED UPON CHOICE OF CARRIER b. What is the definition of "paid claim" to be eligible for reimbursement? An eligible claim that has exceeded the Stop-loss Specific Deductible. c. Can KERR County's HR Director and consultant speak directly to claim examiner for questions related to payment of claim? X Yes No Comment: d. What is the normal processing time for ISL claim? 15 days e. What is normal processing time for ASL claim? 30 days f. What expenses related to investigation of claim are eligible for reimbursement (e.g. hospital audit, medical records, etc) by the stop loss carrier? Charges associated with hospital audits, medical records, cost of claim, etc. 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: Completed Disclosure Statement 2. Describe Underwriting: a Will any claimants be excluded or assigned a higher deductible (lasered)? Yes No If so, please describe: Initial quote is contingent upon completion of Disclosure Statement and if APS's are needed. The carriers with whom GPA does business have agreed not to laser at renewal unless requested by the County. 3. Did you provide a Specimen Stop Loss Contract? X Yes No 4. Does your Stop Loss insurance contract have any exclusions or limitations that are more restrictive than those used in KERR County's booklet? Yes X No If so, please describe: 5. Are the active-at-work and disabled dependent provisions waived for the effective date of the contract? X Yes No Page 1 of 28 6. 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: HealthWatch, GPA's in-house UR company accesses Centers of Excellence through networks such as URN, LifeTrac and InterLink. 7. Please state any variations to the Request for Proposal Assumptions or other qualifications for your quote: GPA is also offering TelaDoc and Interactive Health Solutions Wellness Program. Please see the enclosed information on these optional products. 8. 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? Specific claims over$10,000 will be reimbursed simultaneously. If reimbursed what is turnaround time? 9. For what period of time are quoted rates guaranteed? Stop-loss rates are guaranteed for one year. 10. Is a longer rale guarantee available? Yes No If so, please describe: 11. Are quoted rates net of agent commission? If no, please describe: 15% commissions -10% Broker/5% GPA 12. Do quoted rates include advance funding for: a. Specific Claims? If no, additional cost to provide: b. Aggregate Claims? If no, additional cost to provide: Yes X No X Yes No Yes X No 13. Is the quote based on the services of a specific provider network? X Yes No An Excel Spreadsheet titled, "Self Funded Quote Spreadsheet". is required to be completed with this RFP. This spreadsheet will be used for bid analysis. A copy is included on a CD or available via Internet from glooney@alamoinsgrp.com Page 2 of 28 Medical RX PLAN $60,000 Specific Deductible Basis for Deductible: Incurred 15 Paid 12 -Specific Incurred 12 Paid 12 Aggregate Carrier: American Fidelity /Excess Re Number of Rates Monthly Premium Annual Premium Partici ants Specific Premium: Single 161 91.42 14,718.62 426,276.48 Family 98 212.29 20,804.42 Com osite 259 137.15 Aggregate Premium Com osite 259 7.17 1,857.03 22,284.36 Aggregate Attachment Pts. Single 161 413.16 66,518.76 2,012,915.52 Family 98 1032.90 101,224.20 Composite 259 677.66 Page 3 of 28 Kerr County Third Party Administration Questionnaire TPA ORGANIZATION QUESTIONS 1. Name, Address, City, State, Zip Code and Telephone Number of Firm. Group & Pension Administrators, Inc. 2. Is your firm owned or operated by a parent company? No If yes, please identify the parent and its primary business. 3. How long has your firm been in business? How long have you done claims administration? Since 1969 4. Who are the principal officers in your firm? How long have they been in their positions? Jerry McPeters 39 Kathy Enochs 23 Neal Stanley, FSA 27 Edna Geer-Hudgins 19 Mac McIntyre 9 Clyde New 7 Beckie Ingram 23 Dawn Moore 13 Chris Reep 19 Barbara Derlein, RN 6 Randy Farrow 16 Madalyn Straughan 9 5. Is this a branch facility? If so, please identify the main office location. Dallas, TX is the home office. GPA also has offices in San Antonio and Houston. 6. How many claim processors are Full Time employees in your firm? a. How many claim processors will be appointed to service this account? One with one back-up b. Of those approximately how many years of experience does each have with medical claims processing? GPA's Claims Examiners have an average experience level of over 15 years. 7. Do you have bilingual claims personnel available to plan participants who call your office for customer service and/or claims processing? Yes 8. How many clients do you perform claim administration services for? 201 What is the average size? 350 EEs 9. Do you carry Errors & Omissions coverage? Provide a copy of your current policy. Please see the attached License and Insurance Page 4 of 28 CLAIM ADMINISTRATION QUESTIONS 1. What are your claim office performance standards for claim accuracy and turnaround time? Financial 99.0% 99.5% 100% Payment 97.0% 98.5% 100% Procedural 95.0% 97.0% 99.43% Overall 98.0% 99.0% 99.89% 2. What is your average turnaround time? Claim Turnaround -Processed Claims (14 85.0% 90.0% 96.2% Calendar Days) Claim Turnaround- Paid Claims (14 Calendar 85.0% 90.0% 89.6% Days) 3. What is your current per day production minimum expected of your claims processor? 120+ claims per day 4. What are your internal audit procedures? GPA conducts internal audits on 2% of all claims on a monthly basis in addition to monthly audits that are performed by an outside vendor. 5. What edits and controls are used to avoid duplicate payments? Edit Codes: The built-in Edit Codes alert the claims examiners to COB, possible subrogation, student status, pre-existing, duplicate claims, etc. as well as detecting unbundling of procedures and other fraudulent practices. If additional information is needed to continue with a claim the system generates a letter requesting the additional information. If the information is not received a second letter is generated. This is an automatic feature and there is no charge for this process. 6. What safeguards exist to protect against claims abuse and fraud? Please see question 5 7. What program do you use to unbundle claims? Please see question 5 8. What coordination of benefits (COB) procedures do you follow? Birthday method 9. What database do you use to determine Reasonable and Customary fee allowances? How frequently do you update your R&C screens? INGENIX at the 90`h percentile 10. Describe your procedures for professional Medical claims review? GPA contracts with a physician as Medical Director for Medical reviews. Page 5 of 28 11. Explain your hospital bill audit procedures. Hospital Bill audit is out-sourced to ELAP, NCN and CorVel. 12. Describe your procedures for tracking and reporting excess claims? Please see attached Stop-loss Work Flow Chart. 13. Explain how you handle subrogation and third party disbursements? GPA out-sources subrogation to The Phia Group. The fee is 30% of savings. System Edit Codes flag claims for possible subrogation. 14. List the excess carriers which you are approved with for claims administration? HM Insurance (Highmark) Symetra American United Life ING SunLife/Genworth (GE Financial) HCC AIG American Fidelity Boston Mutual American National And others....... 15. Do you provide a toll free number for claim inquiries? Yes If yes, what is the cost? NA 16. What are your normal hours of operation to answer calls for claim inquiries? Monday -Thursday Sam to 7pm Friday Sam to Spm 17. Describe your customer service process when an employee calls with a claim inquiry. Customer Service Representatives work off the same systems platform as Claims so they are able to access all claims, notes, etc needed to resolve the inquiry. 18. If you have a separate customer service unit, what are your standards for: Answer Time: Less than 1 minute Abandon Rate: Less than 2% 19. What submission rate has been assumed when calculating your fee? Does not apply to Self-funding 20. Does your fee assume a first year claim lag? If so, what is the cost to purchase mature claim year administration? Does not apply to Self-funding 21. Does your fee assume any excess loss carrier overrides? GPA receives overrides from some, but not all, of our stop-loss carriers. Page 6 of 28 Eligibility System 1. How is an insured's eligibility assigned and maintained? Each client is assigned to an Administration/Billing Representative who maintains all eligibility and billing functions for the group. Our clients may also access GPA On-line our on-line eligibility 15+service if they choose to maintain eligibility themselves. 2. How often can eligibility information be updated? Daily 3. Do you maintain information on each of the family members separately, as well as the employee? Yes 4. What is your accuracy standard and turnaround time for loading new groups, updates, and changes? System Capabilities 1. Is your claim processing system completely automated? GPA limits auto-adjudication to claims less than $500 as a cost saving measure for our client. 2. Are there any significant manual activities required to process claims? 3. Describe your claims payment system, including hardware and software? Claims Svstem• Our current claims system (GBAS) is a fully adjudicated Software Package. This system has the capability to process electronic claims and automatic claims adjudication according to the clients benefit plan. This system also has all of the HIPAA compliant codes sets and can process all code sets in an automated fashion. 4. Do you own or rent your claim payment system software? Own 5. How is a person's claim history tracked? Through system accumulator functions. 6. Can the system track number of visits by procedure? Yes 7. What percentage of your claims is currently accepted on an electronic basis? 95% Ban'ng 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. No. GPA prefers the County use their own bank. 2. Is an initial claims payment deposit required to establish banking arrangements? No. 3. Will you perform bank account reconciliations? GPA does not reconcile the bank accounts. 4. Are there any additional costs to the banking? (I.E.: -EFT charges, monthly charges, etc.) Per the arrangements the client has set-up with their bank. Page 7 of 28 Utilization Review 1. What U.R. services are performed in-house? ,- HealthWatch is GPA's in-house Utilization Review Company. Case management starts when a trigger diagnosis is identified in one of several ways; in the initial notification call to HealthWatch, in the ICD-9 report, in the CAREMARK large claim report (over $1000/week, in the 50% report, in the Medstat reports of billed charges, and also at the request of the stop loss carrier. The carriers' quotes reflect this intensity of HealthWatch providing case management and it is an expectation which has earned HealthWatch the "Elite Status" which provides maximum discounts for the groups. HealthWatch accesses Centers of Excellence through networks such as URN, LifeTrac and InterLink. HealthWatch Case Management Fees are $125.00 per hour. Most Case Management vendors' fees are assessed in increments of 15 minutes. However, HealthWatch charges a minute for minute fee rather than by the '/ hour as is the norm. GPA will make every effort possible to negotiate non network claims. However, if a outside firm needs to be used a 30% of savings fee will apply. 2. What outside U.R. services do you use? How long have you used them? NA Please see question 1. 3. Indicate which U.R. services you have assumed in your proposal? X Pre Notification X Preadmission Review X Concurrent Review - On Site or Off Site X Retrospective Review X Large Case Management X Discharge Planning 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 Page 8 of 28 Preferred Provider Organizations 1. Do you have capabilities to process PPO discounts in-house? Yes 2. Which PPOs do you have access to processing in-house? 3. Can you install PPO discounts for Direct contracts with providers? If so, what is the charge? Yes 4. How many different PPOs do you interface with currently? Who are they? Texas True Choice Texas True Choice PHCS Beechstreet First Health Interplan Devon Multiplan And others... Reporting 1. Provide a list of reports available in your standard reporting package. What is the cost of these reports? Please see attached Sample Report Package. 2. Can you generate customized reports? Yes Are reports available through Internet? No What is the charge? 3. How are paid claims reported? Please see Sample Fund Accounting Summary (FAS). 4. How does your firm report claims to Excess Loss carriers? A 50% report is run monthly and sent electronically to the Stop-loss carrier. 5. Can you report on PPO savings? Yes Page 9 of 28 GENERAL QUESTIONS 1. What is the cost for producing a plan document? Cost is included in the Sep-up fee Is it included in your cost assumptions? Please see attached Cost Spreadsheet. 2. What is the cost for producing a Summary Plan Description? GPA supplies a Summary of Benefits at no cost at implementation. Is it included in your cost assumptions? 3. What is the cost of having the Plan Document and SPDs changed due to regulatory changes? An amendment would be written to reflect the changes. Is it included in your cost assumptions? Plan Document Amendments are provided at no change. 4. What is the cost of printing the 500 Summary Plan Descriptions for the plan participants? A Summary of Benefits is included at no cost. Is it included in your cost assumptions? 5. What is the cost for printing 1000 ID cards? One ID Card without SS# and one additional ID card per Employee with dependents is included at no extra charge. Is it included in your cost assumptions? 6. What is the cost of Explanation of Benefits: No charge. Is it included in you cost assumptions? If so, how many do you assume? 7. Is there an initial set-up fee charged for the installation of our plan? Yes, please see the attached Cost spreadsheet. 8. Please disclose any additional fees or expenses that are borne by the client including but not limited to any contractual reimbursements, capitated fees or other fees paid to the TPA , e.g. Rx reimbursements . Yes, please see the attached Cost spreadsheet. 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. GPA out-sources COBRA/HIPAA Administration to CONEXIS. COBRA - $1.20 per Employee per month HIPAA - $ .65 per Employee per month 10. Do your administration fees include the following: 1. Postage (in 4 below) No, fee is postage + 10% 2. Claim forms Yes 3. ID cards, (medical/rx combo cards?) Yes 4. Mailing to participants homes No, fee is postage + 10% 5. Participating provider directories No, fee is pass through cost of printing 6. Customer service representatives specific to KERB COUNTY. Page 10 of 28 HRA QUESTIONS 1. Do you offer HRA administration in conjunction with your claims administration? Yes 2. How often do you reimburse a claimant for expenses incurred that are filed on a paper claim form? Once per week 3. Do you provide a debit card for all participants? Yes 4. Do you require the use of a specific banking institution? GPA is currently using Wells Fargo for it's HRA/HSA plans. 5. Is there a minimum funding requirement? No If so what? 6. Please describe your HRA administration in relationship to your medical claims administration. 7. Identify all costs associated with your HRA administration package to include all costs and services provided. HRA Administration - $4.00 pepm + $1,000 Set-up fee HSA Administration - $500 Set-up fee. Accounts are charged a $4.95 monthly Service Fee. 8. Do you include access to accounts via the Internet? Yes At what additional cost if any? None Page 11 of 28 Prescription Benefit Manager Questionnaire CAREMARK TRADTIONAL PLAN Please find 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). The CAREMARK National Network is our most comprehensive pharmacy network. To ensure plan sponsors are able to offer the widest possible choice of pharmacies to plan members, the network includes more than 59,000 chain and independent pharmacies nationwide. All major pharmacy chains are included in the CAREMARK National Network. We contract directly with retail pharmacies. Our contracts with network pharmacies are not based on exclusive arrangements; no leasing arrangements are involved. 2. Please confirm that prescription drugs prescribed by any licensed health care provider, including dentists, will be covered by the pharmacy program. Confirmed 3. Is the use of a formulary mandatory? We would be willing to discuss providing all services, except formulary services, for your organization. However, acting as an independent prescription benefit manger, we are unencumbered by drug manufacturer influence and believe that this approach would be counterproductive. Because we are not owned by a drug manufacturer, we approach formulary decisions from an unbiased and independent viewpoint and believe that your best cost leverage is attained through adopting one of our formularies. Please attach a copy of the formulary for review. 4. Does the retail brand discount include savings from formulary, network spread, clinical savings, DUR savings'? No 5. Is the brand discount a hard discount? The hard rate is AWP -15.5%. 6. Is the brand discount an average? Is it based on 11 digits NDC? We bill based upon actual package size dispensed using the full 11-digit NDC code to determine AWP price. 7. Is the brand discount at mail order based on 100 units or actual acquisition NDC? Our mail service prices are based upon the actual package size of the medication dispensed. 8. Is the mail discount based on 11 digit NDC? Yes. We bill based upon actual package size dispensed using the full 11-digit NDC code to determine AWP price. 9. Is pricing for retail brand and overall generic effective rate guaranteed? Yes 10. Your quote MUST include a traditional pricing model and a transparency full pass-thru model Is the pricing guaranteed? We have provided a guaranteed traditional pricing model. Please refer to the Pricing Summary tab for details. 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? Please refer to our Financial Proposal for a complete description of our proposed specialty pharmacy pricing. Charges for ancillary supplies, when needed with a specialty drug, are included in our AWP discounts. Page 12 of 28 12. Please provide your definition of "generic". Also provide a definition of the generic included in the overall generic guarantee. A generic drug is defined as a prescription drug that is designated as a generic drug by Medi-span or, if Medi- span is not available, in another nationally recognized pricing-reporting service. 13. What quantity is an AWP based on for mail order? ~ Mail service prescriptions are priced based upon the actual package size dispensed and pass on the savings through lower AWPs. Our most recent analysis estimated the additional savings to be 0.35% to 1.25% of AWP depending upon the drug mix. 14. How are manufacturer rebates handled? Will KERB COUNTY share in the rebates? If so, what percentage? Plan sponsors are eligible for savings resulting from the adoption and use of our formulary. Savings result from the selection of therapeutically equivalent formulary drugs by the prescriber and are derived from lower AWP alternatives and incentives offered by the respective manufacturers. We currently contract for 141 distinct drug products. Contracting with a pharmaceutical manufacturer is based on the following criteria: the product must have clinical efficacy; if the product is unique, formulary acceptance and contracting is dependent upon acceptance by the P&T Committee, and; if the product is not unique, the product's net cost is also taken into account. The contracting services that we provide include negotiating contracts, performing therapeutic class cost analysis, and fulfilling all manufacturer contract requirements such as sending data in NCPDP format, constructing market baskets, and maintaining eligibility lists, estimating rebates, and reconciling manufacturer payments. We estimate the rebates based on manufacturer contract terms, then allocate these rebates to the account level at the drug level. Once manufacturers pay rebates, our accounting department distributes rebates accordingly based on the rebate sharing arrangement with clients. We normally receive payments due from manufacturers by 180 days after the close of the quarter. We recognize that clients depend on the regularity of rebate payments, so in the event that manufacturers are not timely with payments, a partial rebate check will be provided based on the estimate for the quarter, within the time frame mentioned above. Our pharmaceutical relations department reconciles the manufacturer payments to our estimate. If a discrepancy is found, the department pursues resolution with the manufacturer. Rebates are guaranteed depending on plan design, 2-tier or 3-tier. Please refer to the Pricing Summary for additional details. 15. Do rebates have a minimum guarantee per claim? Per brand? Rebates have a per claim guarantee. 16. Are rebates paid quarterly? If not, when? Rebate payments will commence approximately three (3) months following the close of the first quarter of the program. Subsequent payments will be remitted on a continuing basis. 17. Under transparency pricing model, are rebates a 100% pass thru of Gross? Yes 18. Will coverage of OTC impact rebates? If so, how much? Yes, it would depend on which therapy class was impacted and the co-pay scheduled for OTC drugs 19. Do rebates survive termination? When are they paid after termination? If the client does not breach the agreement and terminates with proper notice at the end of a term, they will be entitled to rebates that accrue, based on utilization, prior to the date of termination. In addition, rebates accrued and owed will survive contract termination providing there are no outstanding balances owed by your organization. Page 13 of 28 20. Are rebates paid on specialty drugs? We are currently not offering rebates for specialty medications. 21. Do you contract directly with manufacturers for formulary rebates or do you use another PBM? If yes, who handles? We contract directly with manufacturers. 22. Please describe how the drugs for the formulary are selected, and who is responsible for the selection. One of the major responsibilities of our P&T Committee is to develop and maintain a drug formulary system. The formulary can be used as the basis for promoting optimal pharmacotherpy because it contains only those drugs judged by the P&T Committee to be in the best interest of the patient's health needs in terms of efficacy and cost. A thorough review of pharmaceutical and medical literature supports the evaluation of all drugs proposed for addition to our formulary. Comparative data associated with a drug's efficacy, therapeutic advantages and deficiencies, adverse effects, and cost are presented to the P&T Committee for an unbiased evaluation. A standardized presentation format that includes the following components has been developed: Generic name Brand name Recommendation Indications Unique advantages/deficiencies Dosage forms Identification codes (i.e., NDCs, GC3, GSN, GPI, etc.) Dosage range Adverse effects/toxicities Special precautions Cost comparison Therapeutic interchange opportunities Bioavailability and kinetics All proposed new additions to the formulary undergo this rigorous review process, without regard to the targeted disease state. 23. Do you own your own mail service? If not, who do you sub-contract with and do you retain revenue? Yes. We own and operate three primary mail service pharmacies located in Pittsburgh, Pennsylvania, Fairfield, Ohio, and Largo, Florida. Our mail service program was established in 1983 to provide a viable and cost-effective option for dispensing maintenance prescriptions, such as those used to treat high blood pressure, diabetes, ulcers, and arthritis. 24. Do you own your own Specialty Pharmacy? Or subcontract? If yes, who handles specialty pharmacy? Our specialty pharmacy services are provided by CAREMARK Specialty Services located in Pittsburgh, Pennsylvania. CAREMARK Specialty Services performs a full range of therapy management services for patients with complex and expensive chronic diseases, their physicians, and their clients. 25. What is the average turnaround time for mail order pharmacy? The turnaround time standard for "pharmacist-approved" prescriptions is an average of two business days, calculated from the date of receipt to the date shipped. However, our actual turnaround time is averaging 0.6 business days for "pharmacists-approved" prescriptions. "Pharmacist approved" prescriptions are orders for which product is available and do not require a pharmacist to contact the prescriber for clarification or consultation. 26. Can mail order pharmacy be ordered on-line? Yes. Mail service members can submit requests for new prescriptions by using the on-line Start Using Mail Service form provided on our website. In addition, our website applications allow plan participants to securely place mail service refill orders. 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 COUNTY fora 90-day network? What plan design is used? The list below is pharmacies that participate in the 90-day retail network. MAC pricing is not available for 90-day retail claims. Pricing for the 90-day retail network is not necessarily similar to mail order pricing, but is dependent upon plan design. Our proposed pricing is included in our Financial Proposal. Page 14 of 28 90-Da Retail Network Partici atin Chains Phartnac Name NAPB Count CVS 6082 Wal een's 5366 Wal-Mart 3800 Rite Aid 3457 Amerisource Ber en 2782 Eckerd Rite Aid 1651 Kro er Co Co orate 1242 Tar et Stores 1218 K-Mart Co oration 1125 Brooks Rite Aid 343 Meier, Inc 175 Fred Me er, Inc 132 Smith's Food & Dru Centers, Inc 128 F 's Food & Dru (Kro er Co ) 116 Ral h's Pharmacies 112 Kin Soo ers, Inc. 105 Dillon's Pharmac 92 CAREMARK Pharmac 45 Ci Market / Dillon Com anies, Inc 35 uali Food Centers, Inc 35 CAREMARK S ecial Pharmac 12 TOTAL 28053 23. 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. Yes. Our managed prescription care programs are designed to address and enhance both quality of life and financial issues. We provide several clinical programs and administrative services designed to assist plan sponsors in maximizing cost savings while providing a high quality prescription drug benefit program. Plan Design Administration We are able to administer a variety of plan designs that focus on the specifications desired by the plan sponsor. For example, we have extensive experience administering the increasingly popular plan design components of mandatory mail service and mandatory generic programs. Additional customizable plan design features include, but are not limited to, percentage copays, benefit maximums, drug coverage or drug class coverage, days supply, prior authorization, benefit cap limits, family or individual deductibles, split copays, and COBRA benefits. We work with plan sponsors to ensure the chosen plan design is in the best clinical and economic interest of all parties. We are prepared to provide plan design modeling to your organization. Our modeling systems are customizable to meet your unique clinical and financial objectives. Our plan design impact modeling provides projections for amulti-year time frame based upon group-specific or industry utilization data. We do not anticipate plan design limitations; if a plan design is not currently supported, we are able to program the claims system to support your unique requirements. Generic Utilization The GENesisTM Patient Program is the first program of its type to bring a generic drug sampling opportunity directly to patients in a real-time point of sale claims transaction. Through the GENesisTM Patient Program, patients receive advisory letters informing them of the option to try the generic equivalent of their current prescription at no charge. Participants may receive up to two letters per targeted drug per year until they move to the generic alternative. After receiving an intervention letter, the patient is able to receive the next refill of their medication at a local pharmacy in the generic form fora $0 copay. For subsequent fills, the participant continues to benefit from the added savings of using the generic drug rather than the brand name medication. Every generic drug dispensed under this program is processed online through our claims system and is coordinated with the patient's current pharmacy benefit plan. Page 15 of 28 Mail Service Savings As a full service prescription benefit manager, we recognize that to demonstrate significant savings, acute medication purchases must be directed through retail pharmacies while maintenance medication purchases must be dispensed through the mail service. Our mail service pharmacies serve a large customer base and are able to take advantage of large volume purchasing to provide lower prices on maintenance medications. We will work with your organization to create a plan design that provides an incentive to use the mail service pharmacy, ensuring that your organization recognizes the potential savings involved with increased mail service use. We are able to demonstrate the savings that can result from administration of certain mail service-driven plan designs. Through the review of claims data, the QuickStartTM program identifies patients, including high utilizers, who are able to purchase medications through our mail service program as part of their prescription drug plan. QuickStartTM invitation materials include apatient-specific letter that identifies the eligible prescription and details the savings available through mail service. Patient materials also include a coupon offering savings on the first mail service order, a QuickStartTM enrollment form, and a brochure describing the plan's mail service program. If a patient does not move to mail service for any drug in his or her profile, including the QuickStartTM targeted drug, the individual will continue to receive a solicitation package every 120 days. As an added benefit, CAREMARK Direct is able to obtain the required prescription from the prescriber, eliminating any extra effort on the part of the patient to convert to our mail service program. MAC Savings We use a MAC program in the retail environment to manage the pricing variability among multi-source pharmaceuticals. Plan sponsors benefit from the consistently low, electronically enforced pricing of over 800 generic products, equating to 31,301NDCs, included on the MAC list. The MAC list provides cost controls on multi-source pharmaceutical products and provides an equitable reimbursement to the pharmacy provider, thus ensuring their continued participation. Our MAC equates to approximately AWP minus 58% to 62% for MAC items. Formulary Savings Plan sponsors are eligible for savings resulting from the adoption and use of our formulary. Savings result from the selection of therapeutically equivalent formulary drugs by the prescriber and are derived from lower AWP alternatives and incentives offered by the respective manufacturers. CAREMARK TS: Increasing Formulary Utilization We developed our CAREMARK TS program to increase formulary savings by intervening on each instance of non- formulary prescribing in both the retail and mail service environments. Intervention Request Forms (IRFs) are sent to each physician who prescribes anon-formulary drug. IRFs are patient-specific forms that educate physicians about the plan sponsor's formulary preferences and offers the opportunity to change a patient prescription to a formulary drug. In fact, the IRF itself can be used as a new prescription. If the physician chooses to change the prescription, we inform the patient and the dispensing pharmacy of the prescription change in writing. The pharmacy receives a copy of the new prescription or IRF, eliminating the need for additional physician visits. Patients are able to return to the pharmacy for refill prescriptions, which are filled with the formulary product. In addition, our optional mail service therapeutic interchange component provides extra cost savings by converting patients to lower costing, therapeutic or generic equivalent medication. We document the number of prescription medications interchanged to determine the overall savings impact and provide clients with a monthly report detailing each substitution and identifying the savings associated with each interchange. PatientALERTTM: Increasing Formulary Utilization Through PatientALERTTM, participants using non-preferred drugs are identified for intervention through detailed, patient-specific letters. Each year, these participants may receive up to two letters per targeted drug until they move to the generic alternative. The PatientALERTTM program is available for three different plan design scenarios: three- tier copay plan designs, traditional differential copay plan designs, and coinsurance plan designs. Prior Authorization For select medications, a clinical review is necessary to determine whether a drug may be covered. In addition to clinical prior authorization, we offer drug-specific quantity limitation guidelines and step therapy protocol management as integral parts of the overall prior authorization management program. Our goal is to respond to prior authorization requests within one business day of receipt of all necessary documentation. When challenged, our prior authorization program typically screens out 10% to 25% of utilization as inappropriate. Page 16 of 28 Drug Utilization Review Aggressive drug utilization review is an integral part of our managed prescription benefit program. The primary goal of the DUR program is to ensure that patients receive appropriate drug therapy based on current medical guidelines. The program is designed to evoke long-term improvements in drug utilization based on the principles of safety, efficacy, and cost containment. Savings generated from the concurrent DUR system are based on the severity of the edits. Our claims processing system provides more flexibility in edit design than other leading retail pharmacy networks. Our system allows our clinical staff to work with clients to modify clinical edits and improve quality of care for participants. Agreed upon changes can be updated in the system and are effective immediately. DURNowTM retrospective DUR is conducted on every claim, every day. DURNowTM reports highlight utilization statistics that fall outside established parameters, enabling our clinical pharmacists to identify prescribing physicians, pharmacies, and patients who are candidates for clinical intervention. This program combines the following DUR capabilities: high utilization, acute frequency, high cost, high quantity, ScripCheckTM, dose optimization, drug-to-drug interaction, and therapeutic duplication. Our state-of--the-art DURNowTM interventions provide specific and detailed patient information to physicians and notifies physicians and patients of potential cost savings opportunities. Our client-specific DUR reporting package is provided monthly and includes intervention activity and cost savings reports as applicable to each intervention. DURNowTM: Identifying High Utilization Patients DURNowTM determines the existence of patients receiving a high volume of specific controlled substances or drugs of abuse in a calendar month. While, the edit's default threshold is more than three claims per month, clients are able to choose the number of prescriptions per month that comprise high utilization. The high utilization program is invaluable in highlighting specific patients who are high-cost or high-volume users and identifies potential drug abuse, poly-physician occurrences, and poly-pharmacy occurrences. High utilization interventions include a detailed prescriber communication package with explanation letter, detailed patient profile, and response form regarding the identified high utilization occurrence 24. Please explain your Drug Utilization Review process for these programs: ^ Prospective ^ Concurrent ^ Retrospective Our DUR offers three distinct advantages. Prospective DUR We realize the power of prescriber and patient communication in affecting prescribing behavior. Proper communication and intervention may have the long-term effect of preventing medication errors and patient non- compliance. We use print and web-based communications to positively alter prescribing behavior and enhance patient education. Concurrent (Point-of--Sale) DUR Concurrent review occurs at the point of service and is meant to effectively alert the pharmacist to potential prescribing errors, including serious drug interactions or costly duplicate therapies. Every prescription is checked against the patient's drug utilization history and appropriate edits or messages are sent to the prescribing pharmacist. Action is immediate so as to cause little or no disruption to the pharmacist and patient. DURNowTM Retrospective DUR All too often, errors or cost savings opportunities are not caught when a prescription is dispensed at the pharmacy. Through DURNowTM we review prescriptions within hours of dispensing, not weeks or months like many PBMs. This retrospective review occurs away from the pharmacy setting causing little or no disruption to the pharmacist or patient. When problems are found, appropriate communications are sent to the prescribing physician or dispensing pharmacist and, if necessary, to the patient as well. We act quickly so that costly and dangerous medication errors are caught in near real time, corrected, and prevented from occurring in the future. Our daily DURNowTM programs include: ^ Drug Interaction ~,r Acute Frequency ^ ScripCheckTM ^ Therapeutic Duplication Page 17 of 28 ^ Dose Optimization 25. 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. Our standard report package contains the reports listed below. Utilization Summary Summary of plan participant prescription benefit utilization providing separate and combined comparisons of network and mail service programs, YTD and most recent 12 months. Group Utilization Summary statistical information on prescription benefit utilization broken down by Summary Account and/or Group. Brand/Generic Utilization Provides a summary of generic drug substitution patterns by network and mail or a Summary specified carrier, account or group. It reflects actual savings as well as projected available savin s. Per Member Per Month Summary of plan participant prescription benefit utilization providing separate and Utilization Summary combined comparisons of network and mail service programs, YTD and most recent 12 months on a er member er month basis. Age/Sex Utilization Summary of prescription data broken down by age and sex for a carrier, account Summary and/or group using standard HEDIS age bands. Therapeutic Class Summary drug usage information within a corresponding therapeutic class by Summary account and/or group Drug Cost Ranking Summary of top drugs dispensed within the chosen time frame ranked in order o Summary benefit dollars paid. 26. 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 the attached Specialty Drug Pipeline. 27. 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? Our enrollment booklet includes a Questions and Answers about Generic Drugs section. In order to encourage generic drug utilization, we provide answers to the most commonly asked questions regarding generic drugs. In this section of our enrollment booklet, we discuss how generic drug usage offers a safe and cost-effective alternative to brand name medications. In addition, members can find information about formulary alternatives on our website. Registered members using MyBenefits can look up specific drugs to view formulary status. If anon-preferred drug is selected, the preferred alternatives will also be presented. When using our Copay Counselor feature, if a member researches anon-preferred drug, non-preferred and preferred drug copays are presented. We also take the following actions to increase generic substitution: We strongly recommend designing plan parameters that encourage the participant to use generic drugs. A split copayment with a higher charge for a brand than a generic drug will typically increase generic usage. An ancillary charge may also be imposed to encourage the selection of a generic alternative instead of a brand drug. Plan designs that require additional out-of-pocket expenses for the member typically increase generic usage. Front-end deductibles and maximum drug benefits (company stop loss) are two examples of plan designs that indirectly promote the use of generics. We attempt to adjust prescribing habits through physician education and interventions to increase cost effectiveness and quality of care to participants. Reducing the number of dispense as written (DAW) prescriptions, also known as product selection code (PSC) #I, is a priority for our clinical staff. Fewer DAWl prescriptions combined with proper plan design incentives will increase the rate of generic dispensing. The GENesisTM Patient Program is the first program of its type to bring a generic drug sampling opportunity directly to patients in a real-time point-of--sale claims transaction. Through the GENesisTM Patient Program, patients receive advisory letters informing them of the option to try the generic equivalent of their current prescription at no charge. Participants may receive up to two letters per targeted drug per year until they Page 18 of 28 move to the generic alternative. After receiving an intervention letter, the patient is able to receive the next refill of their medication at a local pharmacy in the generic form fora $0 copay. For subsequent fills, the participant continues to benefit from the additional savings of using the generic drug rather than the brand name medication. Every generic drug dispensed under this program is processed online through our claims system and is coordinated with the patient's current pharmacy benefit plan. 28. What financial advantage would KERR COUNTY gain if we limited the pharmacy network to several large chains? Could exceptions be made in outlying areas? Savings can always be achieved through lower pharmacy reimbursements when a plan sponsor decides to eliminate select pharmacies from their network. The degree of savings is entirely dependent upon the extent of the network paring, however in terms of branded ingredient cost a savings of approximately 1% of AWP is within the realm of being realistic and a reduction in dispensing fees by approximately $0.50 to $1.00 may also be achievable for both brand and generic claims. 29. Is electronic billing available? Reports on line? Is an interactive website available? Can members compare pricing of drugs on line? Yes, electronic billing is available. Drug spend charges are billed twice a month. Administrative fees are billed monthly. After receipt of an invoice, payment is due twice a month, within 48 hours, for drug charges and within 30 days for administrative fees. Reimbursement can be made through an Automatic Clearing House (ACH) debit or credit transfer or by electronic wire transfers through a bank account designated by our organization. Standard reports are also available for the client's use on our website. Like all transactions on our website, client-specific information is secure. Unique user identification and passwords are necessary to access information to ensure clients can only view their specific data. Our website, www.CAREMARK.com, provides a variety of user-friendly, secure services to clients, members, and healthcare professionals. In addition to fundamental information, the website offers the following capabilities and services. Clients ^ PharmaView®, our powerful reporting platform, serves as the hub for all standard financial, statistical, modeling, and ad hoc reporting capabilities. ^ Eligibility update capabilities are available through auser-friendly management tool. ^ iCard provides remote card printing for select eligible clients. ^ Access to various forms, including enrollment forms and ID request forms, is provided. Members ^ MyBenefits provides member-specific tools such as: ^ Co-Pay Counselor allows members to view the formulary status of a drug, brand/generic status, drug cost, and required copays at both mail service and retail specific to the member's benefit design. In addition, this information can be viewed relative to a specific pharmacy in the member's network or a default pharmacy. When selecting the medications, members can enter the specific quantity of the medication they are taking along with the specific drug strength. ^ Find a Pharmacy locates a pharmacy in the member's network based on zip code and distance. ^ Members can view a listing of the past 12 months of prescription claims, including copay amounts paid. ^ A family explanation of benefits summarizing year-to-date prescription drug spending and plan paid amounts is available. Access is limited to the head of household. ^ An online medication reference guide, RxAdvisor, provides information on drug side effects and interactions, dosage information, drug images and more. Members can download and print a mail service enrollment form or complete our online enrollment form to start using CAREMARK Direct. Page 19 of 28 ^ Existing mail service members can order refills through the website. ^ Existing mail service members can check the status of prescription orders through the site. ^ Mail service members can elect to receive email notification when prescriptions are due to be refilled, or when a new prescription must be obtained from the member's physician. CAREMARK Specialty Pharmacy customers can refill their prescriptions and check the status of their orders. ^ Members can use our secure message center to send inquiries to our customer service staff. ^ Members can also use our Ask the Pharmacist feature, located within the secure message center. ^ Members can request new ID Cards or download and print a temporary ID card through the website ^ Using the Plan Design link, members can view a description of their pharmacy benefit plan, including required copays at retail and mail service, quantity limits or restrictions, etc. ^ A variety of forms are available for members to download including HIPAA forms and direct member reimbursement forms for out-of-network claim submissions. Healthcare Professionals ^ Healthcare professionals can access CAREMARK AIertTM notifications concerning critical medical information, including product withdrawals, recalls, and other potentially serious issues. ^ Clinical News provides monthly updates on breakthrough treatments. ^ Specialty Pharmacy Vital FactsTM newsletters provide insight into clinical trial results, new drug therapies, and recently approved drugs. ^ PBM Industry PharmaPhacts quarterly newsletters feature information on new drug approvals, generic approvals, and industry and regulatory news. ^ Pharmacies are able to join the pharmacy network through the site. ^ Pipeline Summary & Report details new product releases quarterly. ^ Drug reference and disease state information is available. 30. Will the PBM provide assistance with developing a communication piece? Yes 31. Provide all materials used in marketing your product. Please see attached sample marketing materials. 32. Do your administration fees include the following: a. Postage (in D below) For no additional charge, we bulk ship identification cards for active employees to the client. We would be pleased to discuss shipping to several client locations or directly to members' homes. Retiree identification cards are mailed directly to the plan participant's home. Fees for bulk mailing services are included in the proposed pricing. b. Claim forms Direct member reimbursement (DMR) forms are provided by our company at no additional charge. DMR forms are also available on our Web site. c. ID cards, (MedicaURX combo cards? We provide two ID cards per family as part of the standard enrollment kit. d. Mailing to participants homes The cost of postage + 10% will apply. Page 20 of 28 e. Participating provider directories We provide network pharmacy directories tailored to meet individual client needs. Your benefit representatives may obtain directories in several formats. For example, we are able to provide a complete network pharmacy listing, a listing of major pharmacy chains or a network pharmacy listing by county. Directories will be provided to you at no additional cost prior to implementation. We will provide complete network directories to your organization at least quarterly through the use of electronic file transfer. Because of the size of our expansive nationwide network of pharmacies, it is neither cost-effective nor necessary to distribute pharmacy directories to plan participants. As part of our standard communication materials, we provide a list of the major pharmacies that can be used by plan participants. Currently, plan members are able to contact customer service through atoll-free telephone number for help locating a network pharmacy. Customer service representatives are able to recommend network pharmacies to plan members based on zip code information. In addition, our website lets plan participants view a list of nearby network pharmacies. Unlike the pharmacy locator services provided by other prescription benefit managers, our on-line pharmacy locator provides your plan participants with pharmacy information specific to the network chosen by your organization. f. Customer service representatives specific to Garland 1SD As your current prescription benefit manager, we are committed to providing your members with the highest quality customer service. We are proposing that you continue to use our state-of-the- art call center located in Pittsburgh, Pennsylvania. Your plan participants will continue to have toll-free access to our customer service representatives through a unique telephone number. g. Mail order forms Yes. Our proposed program includes pre-addressed, postage-paid prescription order envelopes at no additional charge. h. 1 - 800 number to call center Yes. Your plan participants will continue to have toll-free access to our customer service representatives for specific information regarding their retail and mail service programs. In addition, pharmacists are available for immediate consultation 24 hours a day, 365 days a year. Standard report packages Yes. You will continue to receive monthly utilization summary reports from our organization at no additional charge. 33. 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, after registering on our Web site, employees can have access to this information free of charge. 34. 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? No. Revenue will not be paid to a third party administrator for services, fees, disease state management or other vendor services. 35. 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? Yes. Our pharmacy auditing staff has extensive healthcare, Medicare, and financial auditing experience. The auditing staff is responsible for the auditing of network pharmacies according to our established pharmacy auditing practices and state and federal laws. The staff also prepares quarterly and annual reports of auditing activities, evaluates errors, determines penalties, and evaluates disputes and resolutions. Standard pharmacy audits are included in our proposed program. 36. Will you provide consultative modeling and forecasting annually? Yes. One of the primary goals of our integrated pharmacy benefit services is to help control your escalating ~'' prescription drug costs. Our program accomplishes this goal by working in partnership with you and your other healthcare providers to blend your prescription drug program with medical plan objectives to achieve your clinical and financial goals. Page 21 of 28 37. Will atrue-up of guarantees be performed annually? If so, when can KERB COUNTY expect payment of true-ups above guarantees under transparency model? True-ups are performed annually 45 days after the end of the calendar year. 38. Will the mail service provider provide to KERB COUNTY copies of their suppliers (wholesaler or manufacturer) invoices showing net invoice for medications? 39. Will your firm detail its total revenue from all sources for administering the KERB COUNTY pharmacy benefit plan and allow an independent audit by the KERB COUNTY? 40. The 3 finalist will be required to make a presentation to KERB COUNTY and answer questions to fully explain the specifics of the program offered. 41. 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? Attach a sample draft of the PBM contract CAREMARK PHARMACY -PROPOSED FEES BRAND .. AWP - 24.5 % + $0.00 dispensing fee GENERIC AWP - 60% + $0.00 dispensing fee ELECTRONIC CLAIM ADMINISTRATION FEE $ 0.00 per Claim ADMINISTRATOR ADDITIONAL CREDIT $0.85 per Claim BROKER ADDITIONAL CREDIT $0.00 per Claim BRAND Lower of U&C or AWP-16.5% + $1.80 dis ensin fee GENERIC Lower of U&C or AWP-16.5% + $1.80 dispensing fee or Caremark MAC + $1.80 dis ensin fee Generic effective rate guarantee of AWP-58% (MAC and non-MAC combined) ELECTRONIC CLAIM ADMINISTRATION FEE $0.00 per Claim MANUAL CLAIM ADMINISTRATION FEE $1.50 per Claim ADMINISTRATOR ADDITIONAL CREDIT $0.85 per Claim BROKER ADDITIONAL CREDIT $0.00 per Claim MAIL $11.00 per Claim RETAIL $2.35 per Claim MAIL $13.00 per Claim RETAIL $3.00 per Claim ~ • AWP -16.5% + $0.00 dispensing fee Administration Fee $0.00 Page 22 of 28 CAFETERIA PLAN QUESTIONS 1. Name, address, city, state, zip code and telephone number of home office of firm. Branch office location(s), if any. GPA also administers the Cafeteria Plans Group & Pension Administrators, Inc. Park Central 8 12770 Merit Dr., 2"d Floor Dallas, TX 75251 Randy Farrow randvf a(~,gpatpa.com 972-744-2309 www.~patpa.com 2. Is your company awholly-owned subsidiary or a division of another company? No If so, please identify the company name and address. In addition, please list all owners (if not publicly owned), and all affiliated companies. 3. Have any principals of the firm ever been named in a lawsuit dealing with the management/administration of a Section 125 Cafeteria Plan? No 4. How many clients are currently served? Please provide the largest group, the smallest group and the number of employees covered. 78 5. What is the maximum processing time that will occur between receipt of claims and reimbursements to the members? We print cafeteria checks every Thursday. If a claim is received by Tuesday, either by fax or mail, it will be processed for the following Thursday check run. Once the checks are printed, an authorization to release is faxed to the client along with a check register and a detailed claim report. The client is responsible for insuring there are sufficient funds in the checking account for the checks to be released. If so, they will send the fax back authorizing the release of the checks and upon receipt, GPA will place the in the mail; addressed to the employee's home address. 6. What guarantee will you provide to Kerr County that this function will be completed within this time frame? 7. What is the size of your staff? 6 8. List staff experience of the employees that will be handling Kerr County's account. We have a Director of Pension and Cafeteria Plan Administration who has been with GPA for 14 years administering these plans. He responsible the overall administration of the cafeteria plans. He has an administrative assistant who has been with GPA for 3 years and has 15 years of experience in employee benefit arena. Together they see that you plan documents are in accordance with current regulations and claims are paid timely. We have four individuals who pay cafeteria claims; they all have more than 15 years of experience in pay cafeteria claims. Customer service has over 10 employees with over 11 years of experience who can answer your employee's questions regarding their cafeteria issues. 9. List the office location intended to service Kerr County. Dallas, TX 10. 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? Sam to 5pm Monday through Friday 11. Does your firm perform discrimination studies as to eligibility, contributions and benefits under the plan? No If so, how frequently? 12. Does your company offer debit card services? Yes If so, please explain in detail. Page 23 of 28 Debit cards (My Benny Card) are issued through Wells Fargo. The funds are deposited to the account and are used as any other debit card with the exception that they will only work for Medical/RX/DentaWision purchases. They cannot be used at an ATM or for non health related services or products. ADMINISTRATION 1. Describe the computerized system used to collect, assimilate and integrate the data of the program. The FSA benefits are maintained on the same system as the medical benefits. If debit card is not use, most co-pays and deductibles will rollover to the FSA for payment without filing a FSA claim form. If debit card is used, rollover will be turned off. 2. Provide a sample of your Administrative Service Agreement. 3. Provide a sample of your Plan Document. 4. Describe your capabilities for Direct Deposit. Direct deposit is available and all monies are transferred via ACH into the employees accounts. 5. Provide samples of worksheets and/or any materials that will be provided to Kerr County for educational purposes. Please see the enclosed materials. 6. Describe your process for entering enrollment information into your system. Same as medical eligibility. 7. What electronic or Web-based services does your company offer? Employees can check status via our website. Can claims be filed via fax or through other electronic means? Yes Do you charge additional fees for this service? No 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. Once a month, you will receive a company statement, showing the annual election for each participating employee and detailing year to date contributions and disbursements by employee. Employees will receive a quarterly statement detailing the FSA activity. 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 Attached. 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. Please see attached TPA License. 2. Is your organization for profit or non-profit? For Profit 3. Are you an affiliate of an insurance carrier or independently owned and managed? No 4. If you are a multiple site organization, are certain services delegated to specific locations or are all services available at any location? GPA is a multiple site organization. The Dallas and San Antonio offices offer all services. The Houston location is a Claims payment site. LIABILITY PROTECTION & BANKING REFERENCE 1. Please disclose the amount of liability insurance protection currently in force. The selected Administrator must provide confirmation of coverage. Please see the attached Confirmation of Insurance. 2. Is the company and all employees bonded? If so, please provide details. Yes, through our E&O policy. 3. Are employees covered by workers compensation insurance while performing services on site at Kerr County? Page 24 of 28 a. { }Yes {XX }No GPA has opted out of Workers Comp Insurance. 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. Without Debit Card: $4.00 per account With Debit Card: $4.50 per account Set-up Fee: $1,000 Annual maintenance fee: $500 2. Are the fees due payable on the first of the month, quarterly, annually or combination of these? First of the month 3. Is a fee structure available that incorporates various levels of participation? Yes 4. Do you intend to receive any commissions from the vendors servicing Kerr County? Any commissions received are disclosed in the Administration Agreement. 5. Explain any methods to be utilized to control expense. GPA utilizes many methods for controlling claims cost for the client through identifying at risk employees through Disease Management, MedStat drill down reporting, Projective Modeling and other cost saving measures such as limiting auto adjudication to claims less than $500. 6. Provide a fee for administering the Medical and Dependent Care Spending Accounts with and without a Debit Card option. Without Debit Card: $4.00 per account With Debit Card: $4.50 per account Set-up Fee: $1,000 Annual maintenance fee: $500 HISTORY 1. Briefly explain the development of your organization and your corporate business objectives. GPA is committed to providing customized, flexible, web-based health care benefits management solutions that liberate human resource professionals and empower members. For more information and a demonstration of our capabilities, please visit our website at www.~patpa.com. We look forward to meeting with you to discuss our proposal in greater detail. Our partnerships with some of the most recognized leaders in the health care industry enable us to offer a wide array of products and services, ranging from claims processing and stop loss insurance coverage, to membership among extensive medical provider networks offering the most advanced forms of managed care. For that reason, we are uniquely positioned to serve as your single-source solution for health care benefits management and administration. Overlay this with our revolutionary new web site, www.~patpa.com, and your employees have the ability to manage many of the health care benefits administration services they relied on your human resources representatives to provide. And because our solution is web-based, you will see savings in dollars, time and resources through the automation of manual tasks, self-service options and streamlined processes. In addition, your employees will gain access to personalized health care benefits information, anytime, anywhere. We are confident GPA will offer you access to the most advanced technology, administrative infrastructure, comprehensive solutions and knowledgeable people to effectively manage your health care benefit programs. The following proposal will described those features as they relate specifically to your business and will address why GPA is uniquely qualified to serve as your health care benefit administrator of choice. 2. Explain how long you have been in business and how long you have been providing Section 125 Administration services. GPA has been in business since 1969 and has been offering Section 125 Administration services since 1980. Page 25 of 28 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? 2. Please comment on any other characteristics of your organization that are considered unique in the industry. GPA utilizes state of the art technology for reporting and identification of at risk claimants through Productive Modeling, MedStat reporting and Disease Management. With our in-house UR company, HealthWatch, accessing the same platform as Claims we are able to identify and begin the Case Management process more quickly with an ROI: of 8:1. Please also see the enclosed Disease Management proposal. GPA also offers unique services such as TelaDoc, which not only lowers the employers cost but allows Employees to attend to their health missing less time at work and allowing for a more productive employee. WELLNESS AND PREVENTION QUESTIONS: 1. Provide an executive summary of the wellness services you provide. Please see the attached HealthWatch Executive Summary 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. HEALTH RISK ASSESSMENT (HRA) SERVICES: 1. Describe the Health Risk Assessment (HRA) tool your organization offers. Please attach a sample. Please see attached Sample Assessments 2. In what languages are your HRA, website, and employee materials available? English & Spanish 3. What is the average participation rate for your clients? 50%, greater with incentives. 4. Explain your experience designing incentive systems to drive participation, including your most successfully designed incentive program. 5. Please complete the grid below with a checkmark or specific answer if your HRA includes the feature described. Please provide the grid. 6. How often do you recommend that the members have an HRA? Annually 7. Please describe turnaround time for each of the following areas: a. Providing the HRA results to individuals. 24-48 hours b. Contacting individuals for possible interventions. 6 weeks c. Providing Kerr County with a summary report of the initial HRA results. 4 weeks 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. Please see chart below. Page 26 of 28 Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6 STEPS TO Screening Screening Worksite Screening Employee Health Screening Outcome Disease Management IMPLEMENT Implementatio n Meeting Promotion & Reoistration Education Reoortina Launch OUTCOMES Schedule Drive High profile, Document Evaluate the Identify at-risk Participants & GOALS health employee high and explain health state screening program participation, the and health Pro-actively event(s) awareness and high quality participant's needs of contact and Coordinate and state of health employees provide health logistics such participation Provide the Measure the management as screening Review participant value that the resources to locations, operational with on-going health these nrnirc ann details to health screenin s fro g participants insure high employees TIMELINE - 6 weeks -4 to 0 Weeks 0 + 2 days to 2 + 4 weeks + 6 weeks weeks KEY • ACTIVITIES ~ AND ~ MATERIALS Interacbv"~\ Health Solutions r 9. Describe how your company will set and reach HRA participation goals? This can be streamlined to how the County would want to approach -through monetary incentives, benefit incentives, benefit reductions, etc. 10. Do you recommend using incentives? If so, please describe sample incentives your company might recommend. Monetary incentives such as gift cards, benefit incentives, benefit reductions, etc. 11. How is the individual's HRA record updated in working with the disease management staff? Through the annual evaluations 12. Do you monitor and report individual HRA changes from year to year? Yes 'HRA PRODUCT FEATURE Included? Web-based HRA Yes Pa er-based HRA Yes Biometric clinic based Yes 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 Yes Lifes le risks Yes Safe Yes Preventive exams Yes Page 27 of 28 Immunizations Yes Biometrics Yes Readiness to Chan 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/lifest 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 Summa re ort is available online Yes Summa re ort can be rinted Yes Links to additional health information are available Yes Provides information or links to risk reduction ro rams Yes Employer can customize messages on their URL to include references and links to internal ro rams or other vendors Yes EMPLOI"ER REPORTS Web-based/electronic re orts available - Yes 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 IMPLEMENTATION & COMMUNICATION STRATEGY: 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. Please see chart for Question #8. Please see enclosed Brochure. 2. How can employees communicate with the medical team? Via Telephone Discuss the frequency and type of communications that eligible persons will receive throughout the program period. Periodically (and with the employee's consent), we'll a-mail participants health information that is relevant to them based on their age, gender, health history, or screening results. On average, each individual gets 4 health information a-mails from us per year. 4. Provide your web address and any access codes needed to explore your services. interactivehs.com To complement the hard copy PHR, participants are given access to our private health management website that they can use to: ^ Research health topics and current health news ^ Complete on-line Health Risk Assessments ^ Create a virtual Personal Medical File that stores health screening results -including year:year comparisons ^ Consult with our medical staff to get private answers to questions on virtually any health topic 65% of our health screening participants become registered users of interactivehs.com and they use our website an average of 4 times per year. Page 28 of 28 I ~ ~~ 00 M O N ~/1 O~ Vl ~O ~O O~ V1 Vl M V1 •--~ ~D V 7 N r 7 7 r 0 •--~ T 00 O ~/1 p~ O N ~O ~p O O o O o p~ ~p O --~ O O O T N O '-+ --~ Q~ V1 O Vl O M p~ ~ ~O r O N O r ~O N O CO N 7 M 0~ ~/1 ~p ~D O y.., p r M p~ ~ ~p O ~n v1 N r -- oo M 00 p~ r o0 00 r o0 r r p~ p~ 00 O~ O V1 ~!1 p~ 00 V V p. Q. 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M O oo .-. ~D ~O O .-• 7 7 O O~ 7 N 7 0o O O 01 vi M O V l~ N O~ W O l~ .-. .--. er h N O O N vi ~D l~ M O O M m M V1 O ~--~ r~ ~ ~ Vi ~ O~~ N O~~ op b~ pp O M B 00 O~ ^ (~ T o0 ~ ~ V1 n v1 ~ 00 00 v1 ~ ~ h ~ ~ 00 00 O~ O\ Q~ Q~ O~ O o0 01 O~ O 01 T Q~ O~ O~ 00 O oo O~ 00 Q~ 00 M ~D O o0 M oo N O o0 N ~D N O~ ~O ~-• Q~ o0 7 l~ vl ~-. 00 ~D N ~ l~ `O V1 ~ 0o V o0 ~O o0 M 01 ~O ~O V ~ V h N O l~ O N N CO O~ N N M o0 ^ M vi rt ~n V'1 00 [~ N O N U [~ O~ ~D N vi v1 O~ O N N N ~O ^ M N O O M M N C O l~ n U O O~ ~--~ O 7 l~ V ~ h~~ N M o0 ~D l~ ~ O~ O~ 7 T N N l~ r~ oo ~ N r~ V1 p^ ^ V1 7 V M N Vl 7 M M V vi ~ ~ l~ N V 7 V1 V' vi ~O V Vl V1 [~ Vl ~O h ~ ~ ~ r V1 V1 ~ 00 V1 ~ Vi r V ~ ~ O ~ N N ~ M ~ ~ O ~ ~ b N M N ~ Q` ~D V1 N ~T vi O ^ O~ ~ V1 1~ ~ O~ M M l~ N v1 .-. ~ p~ M .-. M p~ M N Vl M V' .-. [~ N h ~ N M .--~ 7 ~O o0 0~o N O vl ~ r Q~ ~ M M M v? M V' V1 01 ~ .-. N O~ M Q~ r, V M r ~ ~ r N N ~ ~ O h O !~ M N ~ r ~D ~O O~ V1 p~ ry oo .-i .. N M .-. ~ .-. N ~ V1 Oi ~ .-. .-. .-. Q~ N ,-• O~ oo ~ N 7 ~ Vl M 00 T O Q~ M [~ ~D v1 M vi 7 O~ M ~O V M v1 M^ W N O M O~ N O O O~ p^^~ O~ ~D O r [~ M O O O M N ~ ~ ~ O o0 ^ M ^ ~D ~ ^ M ~ M ~p N V ~D N ^ O ~O oo d' [~ ~O ~O N ~ (~ ~ O o0 O N M 00 ~-. ,r .~ M M N ~O ~-• 7 00 .--~ M V 7 ^ .--~ l~ .-. V1 ~ M M ~ ,~ '~ ~ ^, N .~. ~^ p M l~ O~ O M O~ O~ O~ O N O~ O O O O O O O O O O O O O O O O O O O '-' O O O O 00 ~O ~ .--~ ~O N vl vl oo ~ ~ r M h N ~ M v1 01 O~ M N~ N d' ~ N N~ O N N N ^ r .~ N ~ ^ er ~ Q+ l~ r ~ ~ [~ t M ~ h O~ Q~ ~ ~ r N o0 ~ ~ M Qi V1 v1 N ~ O V l~ ~ N m ~ N o0 O V p~ O~ ~ ~O O~ N o0 ~ 00 ~ [~ r. .-. ~ ~ O~ pp ~ ~ r r O M oo N vl N O oo r, N N 7 O r ~ ~ ~ ~ oo ^ ~ M N M `~ M v1 ap M (~ 00 N ^ ~ t~ ~p ~ l~ ~ O [~ N O [~ N oo r 00 ~ ~ ~ N .-. O N O O M N N N ^ ~ M N ~--~ O N n ~ b O~ vl ^• .-• ,-. T N ^ O~ O vl ^ ~D ~ .-• ^ M N O~ 7 O~ ~O O~ V `~ ~n O~ ~ ~ ^ [~ ~O ~ O O r O [~ .-. N ~ r [~ M ~ 00 r r .-. 00 N v1 00 ~ ~ M N N V l~ r ~p O M M ~ M ^ ~ ~ ~ r 01 O N Vl oo .--~ O~ 7 v1 7 N 7 [~ N O N V N N 7~ ^• oo N O N ~O ~O ~ O O ~O o0 ^ ... ~O O vi .^. V' ~O o0 ~D ~p h M Vl M [~ O~ V ^ ~O 'cF M M V N ~ M V M V ^ N ^ N o0 M O~ N N ^ V .-. O O O O M O 0 0 ~ 0 0 0 ~ 0 0 0 ~D O ~ O o0 0 0 0 0 0 0 0 0 ~ 0 0 0 0 0 ~ 0 0 0 0 0 0 0 ~-. .r 7 M O ^ .-+ ~-.. .-. N O O~ M N^ Oi N O oo .-. oo O N E v'~ ~ ~O 7 M N V' ~O M M N r~~~ N_ N oo r N vl O V ^ ~p ~O ~ O v1 N oo N t~ 00 vi M ~ N M O~ O O .--~ ~ M V M ~O ~ ~ ~ M N .~. ~ ~ ~ M [~ ~ 00 ~ ~ 7 O O oo O~ R ~ 00 ~ ~n ^ M M 7 O~ M ~D ^ N Q~ l~ M ^ ~ ~n M ~ .-, O M O~ N ^ N ~ 7 N N o0 0o O O~ ~O ^ M .ti N ~-. .-. ~-. ~-. V M V ~O ^ ^ ~O O~ ... vi O oo M o0 N Q~ N .-. 00 M o0 00 O O~ M ~ ~ ^ .-• N ~ N N ~D O~ ~O ~ ~ 7 N ~O ~ O V ^ M V .-• ~ N .-• 00 .-~ Vt M Vl 01 O ~p .-• .-• M 00 7 M 00 ~-. 00 N ~D ~O N ^ N ^ ^ N N M N ^ ~ ~_ ~ ~ Q PO ¢ w x ~ w v w w V] O U V] r~ ~ H Q Z V] z ¢ ¢ ~ a" V] F Q O a z V] w ~[-~ U w~ H w w~Q xz¢ >-H U x~o~ H ~o ~~ Q ¢>-~ w O~~ ~~~ A~Q ~~ d ¢a~W~ w O~ AW~w¢w¢ oaa ~ za~~ ~"~'~~aF'zzw>A?¢~ x a~'`"~aa. ~ w¢ a~wxw¢°"wW Ho °7 HUSH ~ow¢x~a~W W wvwi~a¢,v,OwOF~' ~ ~ ~U ~ y, z H C7 W~~ z W U ~^ ~ z ~ Z x aa. ~" C7 z~ (7 d¢ ,~ W z 9 a z v~ w w~ F. pC ~. a U O~ O [- a s ?~ w ~ ~ w¢ U >- O O ~' v' o' ¢ a ~" ~ O O p ¢ o'~ v, w w z ~ z ~ ¢ H w 3E a >- a' U H H O O W Q ~ Q z „ate d Q ~ z ~' C¢7 O a °m w¢ z a W F~ 0 0 W Q O~ Q z Q~~~~ p z w~ ¢¢ x U w~ U z z F, °'3 O a¢ ~ Q C7 O w v, x a F C7 Z cC v'~ O Q Cw7 vwi vwi w ~ w Q Q ~ ~ ~WW ~ ~ z ~ ~ Z i U W z ~ z Q Cw7 vwi ~ W ~ z w '~ '~ z a' ~ CG W vwi ~ z W Q Q Q q w w Z ~ ~ ~ aW. ate. ~ ~ ~ ~ vii ~ v. ¢ d ~ U ~ q Q Q A w w cW7 Z ~ ~ ~ ~ z aW. a ~ a ~ ~ w N_ N bD c0 a v 0 0 N 0 w ~a -o [-- I uw_ .G .~ W O ~ 00 O M 7 vi Vl V O N O~ 01 O~ Q. ~' M ~--~ O~ ~D N ... ~-- O 7 O ~c r ~n ~o M ~ r ~-- M N pp ~ M M ~ V' O ry ~ M V O O ~. K '~ N ~ r ~ N oC .-. C ~+ .~ '~ O d CO ^^~~ I~ tom, y ~I b U O O O M ~ ~. d DD ~ ~ V 00 M r d Q M N 1! r O r a r M OC O o0 V GL a b+ .~ r -~ v- ~-. oc loo ~ o c a 00 00 00 r ~ ~ 00 ~ p~ d. v~ d ~ ~ v 7 ~ 00 ~ r O N r -- A w w Q ~~ ~F~ w ~z~ d a a CG d z a ~ ~ o v v, O v O~ O ~ p~ O O' ~n O ~' r O ~C O~ O O` ~ ~ ~ r v 00 ~ OC ~n v r ° r N C ~ O O C 00 d ~ ~ O In V ~ M ~` 7 v r N ~ N C 0 o c C V ~ c M 0o a O~ .--~ 7 Q z w w W W A O °" z a ~ a v, ..w,~ ;; z o .~ ~ ~ U ~ ~ W o O O O O lp ~p Q~ 00 a, o 0 0 0 0 0 0o r o X 0 0 0 0 0 ~A ~ O~ 00 x 0 0 0 0 0 00 0o Q. o0 M O O T ~--~ V~ r r ~O N O O M O~ O r ~O r N .-. v1 M o0 0o O O~ ^• V 7 ~O r O~ O~ ~O O h O ~ ~ O ~O r M 7 ~n N O O K O .~. O ~/'~ d' r V'1 00 ~ r M 7 `O in ~p M ~`~ N O~ N .-.. .-. V ~ O O O O O ~~ M ~ V1 •-•• « N .--. N M 0 0 0 0 0 0~ 0~ M N .-. ~C N N r o~ ON V1 O ~/1 ~ V ~ 7 00 C r M V ~p m~ M v M 01 00 .-. ,r ~L N V y~ N M oo r 0~^ M~ M A N r O M r W O N r M N l~ ~l oooooo~oo^ ~n O ~ ~p p~ ~ N r ~/1 C Vl N M 7 00 ^" ~D V' h 7 ~ .-• N •-• cr V ~C r ~O ~ O M M~ N ~n ~p N .-. ~ 7 .-. 7 ui w w w >.~aw F.~ Z a~~W ~Qw W F A A p d~~ ~z~¢Na,d,¢~z xz~~`~z~wzc? H H rn ~ v~ p O d ~ v 0 ~ W vHi `~ H~ O O d U U ~ a ~d~oAAZ~~~ 0 0 0 0 0 0 ~--~ N O r 0 0 0 0 0 o v v o v O O O O O O O M O O r r r r r r oo r r r r O M eh 7 0 r M •--~ N ~O O O N ~ ~O v1 ~n ~O r ~D O oo N O ~/1 r ~/1 ~/~ v ~o v v, vi ~n r vi v~ i, O O O O r ~--~ M G M O. O r O~ O~ oo ~ ~O o0 ~.. r r N N M O O S •-• 00 N M ~O "" 7 M M ~ r M M M ~ O O O O O O O O O O M O O O oo O~ ~ O~ O~ "" N W .-. Q~ M M O+ ~ O 01 r oo M ~ .. ~ ~O Vi 7 Q~ ~ M N O~ O o 0 0 0 0 0~ o o~ ~ ~ M M r. V1 p o0 vi r ~ V O ~ r. O o0 0o vi O .-. N M r N 00 0 V ~ ~-, ^.. N .-. .-. 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V M S ~+ O ~O N N~ O ~O ~' N pp O N~ oo N N O O N N N V' ~O O O\ y~ N M O\ O~ [~ h U1 00 Q~ W O~ ~ M 00 N ~-. 7 V'1 \O lp V 7 ~p ~p ~ y~ ~ O ,M. N ~ .-. M ~ O ~ M ~ M d' .--. .-. h ~ v? N V '~ ^ 1~ ~? M N Vl M M o0 00 M ^ M ~ N ^ V N ~ ~ ~. ~p `p ~p ~p M M ~D 01 M [~ `~ 7 O O l~ O M O~ O 7 ~O v1 p v~ ~ ~ O~ V1 W M 0 0 0 0 N N N N~ O ~p N M ~O N M 7 00 ~r1 ~ .-. N W h ~!1 ~n O N N M M^ l~ M 7 M N Vl V1 N O N O O O O O ~ 0 0 0 ~ 0 0 0 0 ~ 0 0 ~ O ~ ~~ ~ N~ ~ ~~ ~ O ~ O~ Op 0~ O O O O O O 0 0 0 0 0 N N N N V? N N N ~/1 l~ ~ 00 .-. O~ 00 M V1 p~ V .-. t l~ 01 \O Vl 00 M p .-~ O o0 00 Vl M ~ O~ \O ~O V o0 .-. O Q~ 7 ~D ~p O+ M V1 M oo O M O oo ~ ~ W W ~ ~D ~ 7 pip pip h r .N. O ~ N ~ N M ~O ~D ~ 00 `p 7 00 N ~-. 00 [~ N N ~ ~ V1 ~ N ~ 00 ~ M M W 00 M .-. M 7 N .-~ V1 ~ V1 ~ .--~ N ~ ~ ~ ~ M ~ "' O~ O O ~ ~ T oo l~ M v1 O~ [~ M ~D ~ vi M .-~ op o0 O~ O O~ ^• •-~ h N V v~ ^ O+ M V ~ O~ ~D l~ N ~O b~ M r n o0 ~ cr h .-. O O O O O O O .-. O o0 .-. 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O [~ N A M V N N h l~ V ~D N~ N N O ~D V' 00 O O~ O, ~~ O ~~ ~ V Q~ O~ N O N r O m ~ ~ 00 00 V N Vl ~O ~--~ M N .-• ^ ~p O+ O~ 01 N N Q~ O~ ~D ~O 7 N CO N M ^ ~D N ~O Vl 00 ~--~ V N '-+ 00 l0 '7 M ~D O ^ .--~ M .--~ ^ ^ ^ N ~--~ V N ~O .--~ V Vi ... .-. ~ .. z ,a d O ~ ~Ca O az ~ z ~ W `wnZ z Z d ~w w ~ U x~ o o ~ w U O H Q w U w w ~ a Q¢ Q~ ~ v~ ~ ~ U F cn F= v~ Q O Z O Q ~ Q Ca Q Z ~ Ca w w A ~ d ~ a ~ ~W V W O ~ a O ~ ~ O ~ ~ ~ ~ ~ ~ ~ W ~ Q `n y, z ~ O ~ w ~ a ~ a `~ z a vi ~ F cn d W 0.1 0.1 ~ „Z„ P7 q ~ ~ ~ a~ W od. v~ W O F ~3 O ~ F U z~ W O p A W z x z x z ~ ~ W Q vWi aa. ~ c7>•zas' ~z~w aU ~ Oz~H~ xz ~xc? wc? wc? ,.., a H ~ v~ w ~ Q E" µ~j ~ d ,~ ~^ a U O rn z '„ 0, H ~ fsi n 0.! cn W' ~ H ~ vwi ~ ~ W O ~ W z ~ z U O W [=. ~ ~ v, ~ O ~ ~ ~ O 3S ~ `i' > ~ O ~_ d ~ O z ~ Q z F" w O ~ ~ .a ~" .. vi ~ .. ~ .. ~ rn Q ~ w a a~ F" v~ ~" v z w y y v v w 'v. ~' W p O w~vwiHACZ7Q]O~'¢'z~zv3O~~cG a~wZ ~dO ~O ~O ~z a~¢HaH ~ ¢cw7~w'~¢w~3HGi!~~~ a~i~¢z iA~ ~w~ ~~~ ~~~ ~~~ '~w~~w~ Q Q Q z ~ ~ ~ ~ Z Z aw. ~ ~ ~ ~ ~ ~ Fes- ~ ri Q ~ ~ d c~i~ v~ ~ v. ~ U ~ ~ Q Q w Z ~ h I ~ H b U A .G '~ O co O O h O V O v~ ~ M M O O O O O O O V1 O O O M O N O o0 7 0 N M O O O ~O 0 0 0 0 0 0 0~ N O~ Q~ O O V O ^ W 0 0 0 0 0 h h h h h O O O 00 00 o 0 o rn rn ... .. ^ p p h h p p O N 0 0 0 V1 O O O ~O Vi 0 7 M h h h h h h h h h h h h oo h o0 0o r ~ M O O ~--~ O h h h h r O~ O~ rn rn ~ y~ \ o ~ ~ a O O O N N N o0 vl M O v 0 0 ~D ~O O O O ~--~ O~ h h ^ .--~ Vl V1 O^ O ~/1 O N O h N 7 ~--~ N co O h V O Q~ O o0 O N O N h ~--~ V'1 Vl h .^ O O M ~-+ O ~h ^ 7 ' O~ Sh ^~ 00 .-• ~O N N V ~' ~ ~ V O O O V M O T vi o0 00 h h M M 01 M M v~ M .-. M V1 O h ~n N V1 M U1 7 V~ ~O ~O M ~O 7 ~D ~O [~ ~O ~ ~D ~O V1 V ~O M ^ ^• h O M h V 1 N O ~O o0 ~O M M 7 V' V] V1 V1 V1 h Vl ~ V1 ~O ~O y V1 O .-.. ~p O~ Vl N h N ^ h ~ .. ~ ~ M N N M 7 V O~ O~ V oo ~n O h ~D ~/1 O h h N ~ ~ ~ ~ h Q~ O~ N v'1 ... N M .-. O~ .-. ~O v N ~ ~ W .-. O~ V1 p~ •-• O O 01 O~ N N l .-. M M V~ 7 N 0 ^-r ,-. ~O ~O 7 p~ ~ h O~ .-. .-. O O M M N N Vl Vl .. .-. L ~ h 0^~ M ,-. N N 0 0 0~~ ~~ O N^ O~ h 0 ~--~ O M h~ h Q' ^ h N ' O O O Q~ ~ O~ ~ O _ h Vl .N. ~ 7 V --~ r. in .-• ~D ~ V 1 O V O ^ N ~ V1 N N N M W Vl O [~ h ~ ~ ~ 7 M N N H U A O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 6> O1 h .-. h~ h~ O M~ --~ h O~ ^ d' "" M N~ M O O N N 7 .-• ~O o0 V V1 ~O O O v'i O N I O N Q` M G M ~D N ~O M V ~--~ N~ 7 h h O N b b ~O lp o0 O~ b N ~D M O p~ O h h o0 00 . ~ M 7 M M ~ ~ ~-.. ,-. .--~ 7 ~/1 vi ~ ~O M ~ V1 W 00 00 .-. O ... V O O W N N ~ ~ ^ ,,,~ O a M M~~ M O^ N V~ ~O ~O M~ 7 "" M 7~ O .-. ~O ~O M oo ~~ ~ vl N ^ ~ ~ N ~~ O O M p .M. W M N M h N N 00 00 h o0 W ~ V1 Vl M M ~ . i!1 .-. ~ . ^ N M M ~ ~ e} ~ ~ h .-+ O~ 0 0~ O O O ~O ~O O O O O O O~ 0 0 0 0 0 0 ^' O O o0 O~ o0 00 0 0~ 0~ M M ~+ G ~ ~ C ^ ^O ^ h 7 N h O N ~ ~ M 7 ~ ~ ^ ^ O~ 01 h V1 O oo h ~ O ~ O ~ W o0 00 N [~ ~ O N Vl ~ ~ ~ ~ 00 ~ .~ M O O ~r O 7 ~ M O ~ M ~ ~ N h h . . N v1 00 ~D oo Vl V' N N . . N ~ V1 v~ ~ M N N M M M h M M .--i O O ~-+ ^. ~ ~O ~ --~ N .-.. .-. .-. O+ O o0 7 N o0 N o0 .-. .-. N V h N 0 l~ M O .-. M v1 7 7 d h I~ •-• ~-• .-. N ~ .-. .. 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N O N O^ O N V1 ~A O O~ ~O O d' M O~ O O O ~p l~ oo O O O O O r~ p ~p ~p a ~--~ N O O~ M O ~n O N O ~O O ~p M O ~p O -+ o0 0o co 0 O~ M vi 0 0 0 O O M M ~p 00 00 N N N O~ O l~ p1 p~ I~ 00 p~ 00 00 00 0o O~ 00 O~ ~O o0 00 l~ ~ ~ 0o Q~ 00 ~ ~ ~ ~ ~ ~ ~ ... ~ b0 a N N M N v1 ~ O ~-^ ~ O b O ~--~ ^ N o0 O~ t~ M Q, O [~ M ~n o0 M 7 M l~ b O~~ O O O O v1 v1 1~ 00 t~ M O N O Vl ~--~ O T 00 ~--~ N l~ O n ~ O n ~ v1 ~ ~ ~ ~ 7 M O ~ p~ O O CO o0 ~n ^ o0 00 O 7 N l~ ~ O~ Q~ ~p M ~^ O V o0 0 [~ vi o0 0 0 0 O~ O O M [~ O O N N l~ [~ .-• N ~--~ V ~ ~ Vi R ~--~ 7 ~O M ~ M 7 ~O V O~ N ~D ~n ~p l~ ~p V~ M v1 O~ l~ r ~ ~ O~ T M M M N v1 00 ~ 00 0o M O~ O ~ v~ ~ ~ N .-. O M .--. O 7 .-. O~ ~ 00 V1 ~ M .. M V O O o0 00 v1 ~ ~ l~ N ~ ~ 00 ~ O V M O I~ ~ [~ ~ r Q~ op r ~ ~ r Q~ 00 h O~ ~ [~ O l~ v1 ~ 01 ~ M M N .-. ~ V pp [~ ~ V' V1 M ~ 00 V1 01 a0 ~p N M p~ M N ~D o0 .•. v1 Vl O O ~p O O .-. ~ (y O~ O ~ V1 ^ N ^ M V '^ r. 7 ~ ~ '. .-. N .-. .-+ .-. V1 ~ M M ~p o0 V N p 00 •-• ~ W O~ 00 ~ M N O M r O d' ~ oo M 7 7 V o0 ~ O l~ l~ l~ ~ O O O O h l~ V oo N r~ r~ N~ M~ N~ O O l~ 7~ O~ l~ M M~~ ^• V' V ~p M N ,-. ~O N O N ~/1 M N cf M .-. .-. ~A N ^'; .-. .-. .-. .-~ .-. .-. .-. .-. vi o0 O+ O+ l~ O~ O O~ O O O o0 0o p 0 0 0 O ~p 0 0 0 ~D O O N O~ 0 0 0 O O O O O~ O~ .~. Vl O N h vi .-.. oo ~ vl ~ V1 vl M O 7 Vl O V d' V N 7 O N N N M N~ N~ ~~ W N N ^ ^ Vl Vl ~p O ~p O ~p '"' ~ N l~ 00 V1 M Vl 00 V .-. M ~ ^ V1 W O~ 00 00 M .N-~ N N .-. O ^ !~ l~ 00 00 Yl Vl .-. M 7 ~ r~~ 01 N .--~ O pp r~ 00 ~ V1 O O M^ N Vl M 7 l~ b O r r ~~ M M O~ p~ N M ~ O~ .-. N O~ pp v'1 N oo ~ 00 00 O+ ~p M O N W h .-~ M 7 ~ ~ V ~ M ~p p1 .-• ~p ~D ~p .~-i ~--~ ... N N V1 00 7 ~ ~ Vf r. '. V1 ~ O .-. N N ^ N v1 V1 O pp M pp O+ ~p O 00 ~--~ p~ -~ M N ~ M 00 ~ ~ ~ O N V ~ .-. l~ O~ [~ [~ .-. N M l~ O~ O~ l~ ~ O ~ Vl .-. .-.. ~ ~ M .-. v1 O O O O O ~ ~ Vl ~!1 .-. ~ r ~ r V .-. ~O N N ~O O~ ~p --~ O oo l~ ~ V1 M ~ N 7 ~ .-. N N V1 p~ ~O d' ~D M vi O~ N M V1 O+ ~--~ ~--~ V V1 00 .-. .-. ~-. .--~ ~-.. M l~ l~ O O O ^ O^ 0 0 0 0 0 0 ~n ^ 0 0 0 0 0 0~ 0 0 0 0~~ O O O O O O O O N o0 N ~p O~ Vl a0 O N M~ V1 lp lp V1 1~ M ~ 00 W 7 [~ ~ ~ ~ O ~ ~ v1 b r O O ~ 7 p1 ~n .-. ~O O 7 p1 .-. ~O ~--~ O ~ v'i ~n ~O ~n M .-. p .-. l~ [~ V ~ l~ ~ M M ~O O O~ N •-• p~ O ~ V O ~O V1 N ~/1 N Vi O O~ l~ l~ [~ M .-• V N Q~ O N N ~~ V V V V M M ~D O .-. ~O M ~D O M T O oo O~ ~p M ~n O~ N ~ N N o0 00 .-. 00 ~ M oo ^ ..• ~O ~D ~ V M V O~ .-• ~D T ~-. ~p [~ N ,~. [~ .-• O p~ ~D ~p .--~ N O~ O ~ ~--~ ~--~ N M M ~--~ M M ~--~ h ^ M 00 .--~ 00 ~--~ O ~p N ~--~ ^ [~ vl V V n N ~ O ~--~ ~ ~ O ~ N ^ h ~ ^ M ^ N ~. N ~ M ~--~ ~--~ N M ~-° .r (~ V Q W C uj f-a W Q ~ W ~ ~ ~n U ~ ~ O 0. Oa z H~ a ~ rn z F a Q O d q }, ~ ~ A :a v~ w ~ O v, W Fw wow OQ xz w vim U w ~ ~ A ~U ~ Q ~ Wdr~ Q x ~„ A ~ O _~ O ~ ~ wd ~" ~ vFi d ~ A `a a ~ ~" > U ~ it o a, ? x a ~ a ~ O Ga q Ca ~ x ¢ a ~ w H ~ ~ ~ C7 ~ a P4 F, ~ W ° W W o;z W dx0 ¢E-~wx~~a~d X23 ~ HUZ, W vFiwO '' C7`i' rn ,w.l ~ Pw. > ~ r7 ~, x a ~" U Cal vi w w z d ~! z W '-~ ~^ A Z ~ vHi W z > ~ CL ~„ •• ~ v~ v~ v~ a: v~ v~ F p; a W Q p rn F cG F i~ > w O O O d ~ cn ~ H DE ?~ cL U ~. w W r~ rn cn ~ W ~ W O O ~ A Z T z U O CO H~ vi O ¢O H ~ Q H ~ W d z .Q-i W Q H [=~ vWi vWi W Q ~ ~ O O O z ~ Z ~ ~ ~ ~ a°i vWi d ~ ¢ ai cy ~ ~; ~a ~t~a. ~Q~c7~c7H~wW wx wa~~xc7a.F"'z~ad '>wz '~z >~ '> -o a~i ~ ~ w ~ m U Z w a O w d c7 v~ ~ ~ 4 w d w ~ ~ w O ~C .~'~- ~ ~ ~ ~' w a`~ w a`~ WW ~ °' U~ ~~~ V. d d W U U (~ Q Q Q Q w w ~~~ Z Z a. c~ oG v~ cn cn A U Q~ U Q U CG V ~ F .~ '~ O iI, ti ~+' b U a/ w .r I- O n. w c~ C p W J Q. O CO 0 0 0 0 0 0 0 0 (O N O O O O O O O 00 X 0 0 0 0 0 0 0 0 0 0 (O 'a O n~ 0 0 to O N O O I~ ~~ 0 0~~ 0 0 0) n 0 0 0 0 0 0 0 0 cY N r d~ n N 0 0 oD M~ tD O r O CO O O CO M O O CO O O r 0 0 0 0 0 n N M N {p ~ O) eP N b9 U3 N O N ap fA O OO Efl EA (O M EH 00 O d9 t!i fA ffl fA r r (D O ~ d ~ Q7 Eif GD n fD N a0 ~ u9 aD r 10 H3 O n W y N ~[) ~ ~ ~ n W ~ ~ 00 ~ 69 69 ER ~ EA Efl EA ~ ~ fA 69 69 EH ~ 69 2 W N GO O O O O sf CO ~ O c0 N O O O CO r O~ n n 0 0 0 0 0 0 0 00 O M r W N O O O N 00 M r O N n 0 0 0 0 M 0 0) V ~O O O O O O O O n O M N _ N 00 O O O M ~' H M O X 0 0 0 00 O7 O N~ N 0 0 0 0 0 0 0 Q~ O N 1( M N ffi b9 fA N O 01 M fiJ O) ~ b9 El9 b9 M fA b4 CO (O CO EA 69 b9 N9 69 69 V3 f0 69 O O {Q ~~ N ~ M to n M M N n n tD EH M r d rn ~ ua v3 o rn w y V) ~ ~ d4 ~ 69 b9 d~ ~ ~ y - vi Z W Nvooornvco~novvooom ovu~ o0oooooaooMn M O~ O O n 00 ~ r O O r~ 0 0~ 00 O Q1 V' M O O O O O O O n~~ M . . . . . . . . . . . . . . . . . . . . . . ~ n t0 N O O n a0 O O M tD (O O O tq N O N M O r 0 0 0 0~ CO N 1n M _ N n N fR 69 ~n O v? O to a0 69 to O ~ G9 a0 ~ M fA to to G9 t9 r a0 f0 In to d ~ r EA N O N O (O r t0 ~ fH S O N fA to 0 0 M ++ ~ O M n N CO ~ n O~ M a0 ~ ~~ M N Z W ~ to fA fA to tH ~ ~ EA to d3 ~ rtA fH to fA ~ O M O O O O O O O O O O O O O O O O O r 0 0 0 0 0 0 0 0 0 0 0 0 y ~I W WI 00 W 0 0 0~ 00 M O M~ O O O~ r O r O 0 0 0 0 0 0 0 0 M O~ r W r N r r M r n O r r r r •` N ~ .~ (A W 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o r o 0 0 0 0 0 0 0 0 0 0 0 Q W~ y v v r o o n r ~n M o r r r o o v N o N v v o r o 0 0 o r r n n d r N r O y W .~ U c0 (C y ~ N _ 7 ~. ~ C ~ O _ U 'O N ~p y N O O E C N O y N N lyp ~ V ~ C y N_ ~ y ~ f0 w y C ~ L O C ~ N U T N 'O '•y-• N L E E 'O O U y O O N O fL..) N U L C U` t r N N ~^ y E~ E C N U O_ O y N a N U N m y 'p 4. ~~ O N ~ y~ T w a ,~ a T T y ~~ O 'y N ~ N E y ~~ L N ~ C O ~` y ~` L w O L 7 E O y E L f0 y L X _ ~ C to 7 Vl f0 f6 7 d r y ~_ y N w > 0 0 •~ c .o ~ 3 E `° d= °~ = c 7 E o- m n° E m f0 - U N N~ C C y f0 L w U ~ N ~ 01 U .O N ~ O d r N ~ E N E ~ C O] y~ L Y U _~ '= C O O Q 7 U N d~ V .0. T~ d U N~ w~ L_c L_c L_ N L_cG LS ~c L 3 O C O y C N w U C f0 C N O£ f0 ~' 7 O G7 1] N 5 5~ y 5 5 5~ N y ~ O` L V 'ry--. ~ ~ 'C f0 O ~ f0 n n ld U y O N ~ ~ ~ y y to ~ y y to to ~ ~ C H~ ~ •m ~ .nL I m o a~i ~ `m c `0 3 •~ ' c o v ~~ w w w `m w w w w ,°~ w N {0 f0 ~_ E p O y L a N O) y Of O~ N d in 7 V~ U N N N U N G7 N N O~ O H E E~ m~ > E m ~ m m „a`~ °~ > E w rn m E m E E E~ E E E E c o n D O N fG U~ U N to L N N~ C N .L-. ~ 'O ~ E O E y y y > y y y y 0 'y N a c y '~ o ~ m m ~° ~ E~ ~m m i d ~' ~' a °' n m m m 3 d d m a~ v"Ei m -o ~ y~ O L C7j L O¢ L~ C C U U¢~ n n T N T~~~~ 0 0 0~ 'O N x¢~inU¢UUUU~a`~¢¢UO ~ ~cn¢~npoopoooo¢p~ m ~ m y t~ N~(~ ~) N N N N~ fD ~ N +3 O O O O O O O O O O O O O O O O O _ ~ N U r N M r r N M r r N N N M M M r r d N C N ~ ffl C L d li p a W U' Q ~ U U a o '~ C9 m ~, a a E ~ H ~ M V N M I N M n N O O O O O O O O O O O O O r r N N N N M M M M r r N C O .y y N a a~ p ,~~P"1r r~;~.~ ~~ ~ '~ Texas Department of Insurance Financial, TPAIPremium Finance, Mail Code 305-TPA/PF 333 Guadalupe • P. O. Box 149104, Austin, Texas 78714-9104 512-305-7521 {TPA) or 512-322-3579 (PF) telephone • 512-322-4380 fax www.tdi.state.tx.us STATE OF TEXAS COUNTY OF TRAVIS The Commissioner of Insurance, as the chief administrative and executive officer and custodian of records of the Texas Department of Insurance has delegated to the undersigned the authority to certify the authenticity of documents filed with or maintained by or within the custodial authority of the TPA/Premium Finance Section, Financial Program of the Texas Department of Insurance. Therefore, I hereby certify that the attached documents are true and correct copies of the documents described below. I further certify that the documents described below are filed with or maintained by or within the custodial authority of the TPAJPremium Finance Section, Financial Program of the Texas Department of Insurance. The current Certificate of Authority No. 9204, dated the 5th day of Aprit, 1990, consisting of one (1) page, issued to third party administrator: GROUP & PENSION ADMINISTRATORS, INC. DALLAS, TEXAS IN TESTIMONY WHEREOF, witness my hand and seal of office at Austin, Texas, this 28`h day of April, 2009. MIKE GEESLIN COMMISSIONER. OF INSURANCE • ...,.r...- r~ BY: DAVID MOSKOWITZ ASSISTANT CHIEF EXA R FINANCIAL PROGRAM COMMISSIONER'S ORDER NO 0$-0444 STATE OF TEXAS STATE BOARD OF INSURANCE ~''• Certificate N a 9 2 0 4 1~ ~¢, ~T Company No. 3 0- 0 0 5 0 3 2 w ..;:. CERTIFICATE OF AUTHORITY THIS IS TO CERTIFY THAT GROUP & PENSION ADMINISTRATORS, INC. DALLAS, TEXAS has complied with the laws o! the State of Texas applicable thereto and is hereby authorized to trans- act the business of li Third Party Administrator e within the State of Texas. This Certificate of Authority shall be in full force and effect until it is revoked. canceled or suspended according to law. ~.~,. , . ~~ ;,tip, . r~, - ~, r ~ ,~'; £~ }~~ ,. ~~ ~' 9 u` ~ORra 6000 IN TESTIMONY WHEREOF, witness my hand and seal of office at Austin, Texas, this .. /5/~t_\h\'.J.day of..........'Ap~;.~,~ ................. A. D...19.9.0. . . GODU1 SSIONER OF, INSURANCE ~~ ~~~ ~~ ~~~ /ldnsirt~-trMiv~1 +C?tflcos; tifNtvil+~r iria ~?0 Seavtsrv AvenuM /t7i ~j~~~_a V ~ Mil~'7/~"W'+'V 1~QIT•rsav-~ir~ . RND~~ 7'#KR.Gt4llS 1N5URANCE G~PAN F 8tatutvey t?1fi~~a-; ~T ~a~raGtfian $,r~e~-m ~p314 Easf T{h~y~y~r~[pAvesnyud~ f33Sttidr~kf 711ppiJ~q~pV57i~~++iV~~~~°~(pY~~~W {BVV~ ^7ti71T / fA+117 `t"h+t camP~nyr Prexva3inq ty~ trt8c~r~nce atiixdect by this cc-ver€rcie is intlic~ted ~t~ovc~. This #r~ura rontrect fs with an ?nearer not iic+ertsed t4 tran8act lrrsurance in this stiete artd ian ~su+~-d x~nd deiiv~^od as aurplua~ fine Gca~vgrage urKteH' tt-o Texas ix~ixrilrs+Cit atatufi-s. Thar- Tsxas t7rtrratttt crf Inaurar~c+r dears not audit ttte i~narfaes ~r n~ntAevv satvency of the rrut~plua iiraes insurer providin+8 thRs crrvar~rge, >snd tfx~ in~-urer is rtt'tt ^ nrartrtter of the property and caauatty Errstrr~rrt~a guarsnty a+sscr+~iattcrn +created under Article 21,28- C, lnsuran~+a Code. Saction 12~ ArtiCib 1,1a- 2, lrxsurancre Ccxly, rsquRraar payment of s, 4.$8 per~e-nt tax ofy ~rc~a~s pt~emluart. ~~tt~R~ ANA? C~MlSSlQNS DECI.ARA~TiQ1V'~ TMI~ I3 8©'i'Fi A Cl.AlM:3 lIAADE AND REPORTED 1N9t1RANCE FC~R.IGY, PI,I~A~i= REAQ l`P' CAR~'FI~L.LY. Pfit7~?Vi~fAR: U $ Ri6k Gi' t,t,C p©1.tCY NUNFBf,53R; MPPC)02ff7 ~' Suite 10210 NcxtM Ctrat ~r+essway t?ait~rs.1'X 75.231 l'~fit+fUGi`R ~. t?9199 f2ENlKWAR_ 4~: t~tf~Ptkp25155(~1 TNl;~3 f$ A r;f,,Afii~fl fNAQi~ Al~tl~ ftEi'QRTEIJ Pt}f.iCY, TNiB Pt}I.ICY' APl'i.il~~ QNi.Y Tr3 TH48is C1.AfMs THAT Aft f~iR$'l" fNADfz AGNliNt3T THE iM8URED AND RfPtN'tl'ED iN 1KRf'fiNG TO THE COMf~APtY DtIR~iG TM1~ POLiGY i~RIQQ. Cf,.A4JM i~XPf"sf~iBE$ ARi~ WfTNft+! AINf~ Ri DItCE THE f..ttMIT' Qi` lrffaAf3iL.fTY. FLk`.Aii;'ir R~1N 'ttii8 Pt}t.iGY GAiRkF1~tl.t,Y. teem 1. 1N~AeNiABD tNSUFt~i+>~i3: p ~* l^ ~.7r~f'! f'r~.t»~tpf\7s tt~~+. Vt«~ iwf~f~~~ti/t~t'~r~t" '~ ft(NT't ~, ACi~.I~{fRrts«:sR~V:ptq+ f i l .,............».-~«,.,,~_..,.. «....,.~..««..._... ~1477vt1fl4G ('ltfY~6 i.}f~~YC tfbrCl tiM l•Oi.fC 11 ~~fMVY; i'iFV(N ~r~f 6~r aFWir / Sf 'fE I~~~ +G{~ R1R ..-. «,.....s,...~..... _....ww.. »,,~.,.~...w......~. 12:01 A,fvf. ~t~ar-dsrd Time et the address of tip Narrtc~t! fr-aurecf ~s stated tr~trr iUarr ~4, ifMRS10~ LiN~lf,.if`Y (lnctusrve of rtsfm +~xp+tnse~r): ,...~.~._...~.~. thitC~xCSra~Nt~t,t~p ~~~rt~s> d~t2t7(1~4 Xir Atnt~riCB, irtt;. f'rizat~i ~~ i,,,t.~.A. fnsura-rf Copy ~» 8. ~Mlt11aI1; S 1015.343 pant ~'. P'RGFiR~3~tANl4t. d1~RVtC~& Th1rd party benafit ccfr~ima adminirt+a#s~' 3rwckstlir~g relattfd 819GtrtN~9 data ~cr~et-ryg sarv, atr t~ , Asma+~ corr~rrc~ ^bFn:~,~_ .._. .~.y..~..~....... ~N xx ai o7 or ~,` Im : Not#oa • r '~'._ irxkxaernent Ma(XI't-~'_ ,~ 1~. MF 9tQ4 12081NIG -XI.Sf~'A+If%'1.1t}~~ 3 ~ In Wi#rreas ~ndc~emant - Indkan 1#arbtN trt~vrs~nca Am ~rtctc~reeinun3 .__.~.,_.~..,_...,~..,~..~., ~._~ ~'~.~ ~ r~ddr#remer-t Nd. ~~ Xt_.SPMP4i~$!03„~~ Amerxf~ty rncfar°semant ,_,__.._~.~___-_ ~ Er~Otarsnrnent Pla. 4Q3 ~, ~ rxSora+a++n+srtt No XI.SPMF~1.938 ~~ XLSPMP163 ~ ~ 1A~Ar~dwide Cpveri~„rxlvr8a~t8ri# H___.._....~.,,....,,..._ i ~ tSA G' Pen~ittce ~~, , ..,.. ~..._._.__ , _.....~..._ _ Endar*emanttVr~, OS~ _.._~._ „ ~ t,?tl.~`r'XSCJ_,_,.P.~_?1g8~j._._~__,~ ..S±Frrvicet?#Pccicass _~,..._._._.....~.~.a~._........~........~......,...... ~~,~~`"~ ~,..._.~__ (i~utht7riZed Raptascmtaitva) ~~._ tt~iG-XI.SR-MP'~Pt~ jt'j Insun~l Copy ~?rirtt~ed t-1 U.S.A. ~yg i f~gFY~ ~~~ qtly ~.. "`R~'' ._ .. .. x Ash?a::%4it ANl) Itc~ih~ry_c"tr 5afc 13u~l~-rti~ Please dcr n~:rt fur);ct tc+t~r~s~•ide ass is~ttlr tfae fnllrlwin),r itrfrrrnrati~rra i~r !hc^ Prime frrnrte rusrcrt fielc,ri=: t_'i~ity i71 ~()(itt ~ F'~1 ,~~~a9it~:tl i~tt~mci<~i~; cvi7~:11 tlr~ti ~~rc rele~E~eti ;Clr~~ jv//r~n~ia,~ enct~yrrearents are ir~clNded i~7 c•avera,~e: -NI+.W- ~Ccxas C'htnt~es• l~~al rlctivrt n~c~irlct t.lc -`t'cxas C'hatt~cs- t'r~lucrticr~~ -'Texas C'ttarr~es- buss Prrturrerrt •'C ~~ F,>vK jha112(r,~gai c, cony -+}-+~~s~.crirrreinsaranre cvne GROUP " PENSION ADMiNiStR,AI`ORS, /NC. P.1R~[ CENbe4l 8 ~ /2770 M~i7 D~R1v~' 2"' fl'ogR ~ D14t4tt. TX 7S2S/ ~ (97212.38-7900 CLIENT REFERENCE LIST Group & Pension Administrators, Inc. City of Sherman Mr. Wayne Blackwell 972-892-7623 # Employees: 499 San Patricio Mr. David Wendel 361-364-9312 # Employees: 333 The Container Store Ms. Renee Moore 972-538-6861 # Employees: 550 Stop Loss Workflow Funding Form Authorizing Release of Advance Funded Checks Returned to GPA, Checks Mailed N U c v ~_ v m rn ~~ _v u c U w E U v LL C < < O U t9 ~ E c v a d 9 ° n U Y ~ N ~O 7 M ~ V i E d° E v d E u E ° O E u E ~ p ~ _v u o U~UF o o u o Ugl~T o ~ j C ° a9UV ° i = a°^UU ° „ ~ a U ~"'e .v ° 6 ~ ~'^iv d .~. ° X X ~ Y 2 iL< ~ m ZS< YJ d oS< h N m ~ O .. d C m d s ~P ~ ° ° ~ o~ = ~ O O a p- ~p d m e N N N m ~ ~~ ~^ P C m o m 1n Q N1 O O 6 0 W m p r M Y Y Y N ~ N N a m Y N N ~ h M ~ '~ v °n a z ~, LL < ~ N ~ Y u~ Y eND d ~ b o lV ~ Y < N M E i + N N o. ~~ E y~y 4 O ~ ~ N M ~~M U U ~ E LL CLL}} U qU N •h N (h } 4 5 < 6 ~ t) u U' U' E a o a o ° v d v ° U d° E N d° E v Ev E EV E V 4',5 o u '° U ~ V T+ o o u o U¢ U x o ~ ~: o ua v V U ~ ~ a v V U , ~nd ° m ~ Fwd ° ~ d p p X. ~~ Z~< ~ r 2 Q Q ° P S W ~ ° ,. 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U tq q U N N U 1-I U rn m S-I -ri ?i D U~ P+ ~ a N U U q H H -.a v do u o~ q S-i W ~ W U UM-0002A CONDITION SUMMARY REPORT 8/1/2007 - 6/17/2008 PROCEDURES ACT LENGTH Patient_ID Rel Sex Age Open_dt Closed Adm_dt Dist_dt Dx Codel Diagnosisl ICD CPT Req Cert Den Dx Code2 Diagnosisl H870353 EASTHAM ENTERPRISES INC H87035300031 SELF M 44 112007 111907 111807 111907 786.0 dyspnea/respiratory abn* 1 1 H87035300203SP F 35 091107 090807 090707 090807 276.5 hypovolemia 99223 1 1 575.0 acute cholecystitis H87035300301 SELF M 45 110107 110207 110207 110207 721.3 lumbosacral spondylosis 64483 0 0 722.10 lumbar disc displacement H87035300371 SELF M 54 051008 051208 051208 051208 211.3 benign neoplasm Ig bowel 45380 0 0 H87035300411 SELF M 75 053008 082908 052908 082908 204.1 chr lymphoid leukemia' 92 92 285.9 anemia nos H87035300491 SELF M 51 051608 062008 061708 062008 715.96 osteoarthros nos-I/leg 27447 3 3 H87035300542SP F 65 111407 010408 010408 010408 V16.0 family hx-gi malignancy 45378 0 0 H87035300622SP F 47 031908 041008 040908 041008 626.2 excessive menstruation 58550 1 1 625.3 dysmenorrhea H87035300711SELF M 54 040408 040408 040408 040408 530.81 esophagealreflux 43239 0 0 536.8 stomach function dis nec H87035300712SP F 50 121207 121307 121107 121307 436 cva 2 2 vlwr°' 414.01 curry athrscl natve vssl H87035300822SP F 56 031208 032808 032808 032808 530.81 esophagealreflux 43235 0 0 H87035300872SP F 44 122907 010208 010208 010208 611.72 lump or mass in breast 19120 0 0 H87035300932SP F 49 083107 090107 082907 090107 780.4 dizziness and giddiness 99223 3 3 436 cva H87035301112SP F 63 081007 081407 080707 081407 180.9 mal neo cervix uteri nos 7 7 H87035301142SP F 48 032808 043008 032708 043008 682.6 cellulitis of leg 99600 34 34 H87035301212SP F 65 060508 060308 625.6 fem stress incontinence H87035301271SELF M 75 022008 022008 022008 022008 188.8 malig neo bladder nec 52235 0 0 H87035301412SP F 42 052908 053008 052708 053008 296.3 deprpsych,recurepisod* 90817 3 3 H87035301644CH M 16 050808 051008 050608 051008 136.9 infect/parasite dis nos 99223 4 4 Wednesday, June 18, 2008 Page 1 of 2 Patient_ID Rel Sex Age Open_dt Closed Adm_dt Dist_dt Dx Codel Diagnosis] Dx Code2 Diagnosis2 H87035301721 SELF M 56 092207 092707 092407 092707 162.9 mal neo bronch/lung nos 191.9 malig neo brain nos H87035301721 SELF M 56 041008 041108 040808 041108 786.3 hemoptysis 191.9 malig neo brain nos H87035301721 SELF M 56 101607 101907 101607 101907 162.9 mal neo bronch/lung nos 191.9 malig neo brain nos H87035301721 SELF M 56 090107 090707 090407 090707 160.9 mal neo access sinus nos 191.9 malig neo brain nos H87035301721 SELF M 56 080907 081507 081307 081507 162.9 mal neo bronch/lung nos 157.9 malig neo pancreas nos H87035301721 SELF M 56 060408 061108 061108 061108 162.9 mal neo bronch/lung nos H87035301721SELF M 56 052408 073108 052308 073108 162.9 malneo bronch/lung nos 288.00 H87035301721 SELF M 56 042308 073108 042308 073108 162.9 mal neo bronch/lung nos H87035301721SELF M 56 041508 052708 041408 052708 162.3 malneo upper lobe lung 198.3 sec mal neo brain/spine H87035301721 SELF M 56 110307 110807 110507 110807 191.9 malig neo brain nos 162.9 mal neo bronch/lung nos H87035302532SP F 30 030808 030308 030108 030308 650 normal delivery H87035302704CH M 3 020708 020608 020508 020608 486 pneumonia, organism nos H87035303612SP F 21 092707 092807 092607 092807 654.20 prev c-delivery unspec H87035304072SP F 31 041608 041708 041508 041708 650 normal delivery H87035304352SP F 44 103107 110907 110807 110907 112.1 candidal vulvovaginitis 626.2 excessive menstruation H87035304402CH F 1 012408 053108 012108 053108 749.00 cleft palate nos H87035304441 SELF M 47 022908 030508 030508 030508 729.2 neuralgia/neuritis nos 724.2 lumbago H87035304782CH M 6 032808 032708 032608 032708 813.2 fx radius/ulna shaft-cl* Wednesday, June 18, 2008 PROCF,DURF.S ACT LENGTH ICD CPT Req Cert Den 3 3 99223 3 3 96413 3 3 96413 3 3 96412 2 2 36590 0 0 69 69 99 99 77421 43 43 99255 3 3 59410 2 2 99223 1 1 59510 2 2 59410 2 2 57288 1 1 131 131 62311 0 0 99223 1 1 Page 2 of 2 '~I ro a +~ U ~+ z O H a v . a~ rz roo U E G ro I-I E ~~ V] H az ~.i H N ~ ai ~ U .i Z w O ~.-I H U V] N Z aw m a I w v a w ~ a o ~a U U' N N N N N N N N N N N N O N H Ol OD O d' O O r O O OJ N O I \ O N H O Ol M O d' \ O r ~n o 0 moon w o 2 ~ +~ ~ U ~ ro r+ rt ~, 0o b+ N U u N sa N N~ M' ~ La a E LL O +~ I RC N N ?~ U U C ~k +~ U i~ 1~ H ro 7 .-I >a \ O Sa O H h N 'd O N C O a~ a+ u I C S1, to N Q. 3-I +~ C r~ m ~ m ro ~, a~ o ro o H o W P4 U a lt: v] a U * I O O o N O I L * I O O o 61 O I 61 * N I I * U l o M o o~ o I H N * ro I O m I W * H I u1 v I Ol I * ro I H m I rn * W I H 1 H N * I 1 b~ * I I ro * I a * l 0 0 0 0 0 1 0 * l 0 0 0 0 0 1 0 * I 1 ~ * l 0 0 0 0 0 l o W -.i I I O N I I F N U; I I ~+ U l~ I I ~ ~ ~ W I I W N d' I 1 E E M to O I O C7 ~k N w I O O O ~ O I In U H M I O O O 01 O 1~ E W I Y-I N I I W W I u~ ro v t o ch o 00 0 l rl U !x H r N 5 I c rl I lfl z W P4 t0 }i O I O m I~ U ~ D o I v7 d' I~ z U ~o I H m I m H D z W * I •-I I ~-I to H U * I I z z a * I I ~+ H r.C H * I oW d~ o\~ c7 a E+ * I o o M a o w E * I~ ~ W W H O * I z z O~ C7 * I m o rn ~ m 1 m W H\ W r~ * I M o r m o I H W U C4 U * 'O 1 I O •H E H * -.i I M M r !)D N I v1 H O O z~ x * ro i N V• M H r I N X U U H r U * w l o o ao w W I~ * I .-+ ~ o rn rn I~ •• •• •• •• •• * I W H oo m d• I H * I •-I M ~-i d• N I C * I I H ~ * I I +~ U U I N z -•i I O H r1 y I a o ~ I v a v * l 0 0 0 0 0 l o [>a rn a~ v u * l 0 0 0 0 0 l o ro v 0 o v o b +~ i o 0 0 0 o i o U H -~i ~ U ;Z r-C * -rl I I ~ +~ ro * m I I ro a s i H -a ~ v v v ~ ~ U] 3-I N -.1 -.i -.i * I I m H U C S-I N S-I 1 1 G z U -'i 11 S1 L1 I I -.i H v o ro ro ro ~ 1 N E Q P: U U U O 1 0 O O M O I M Pi ~ O 1 0 O O N O I N r-~ N Sa I I U \ N I o M o 0 o I M -.i 2 ~n > I v m I M w 0 0 0 I o m I m -.i H I u7 N I r U V] ,4 I H •-1 I N N z }~ I I a W G I I m a o I I ~ I I ~ I Ol N N M O I N I N H •H N ~o I r U W * 'O I I W 'J * -'I I W O d' O Ol I N Q+ O * ro I r O •-1 Ol M I N ~n a * a I ~ rn c m ~o I rn U C7 * I N rn r N I M * I M rl H I r * I * 1 1 1 U * I I z q I OJ H !) I O -rl I O L~ I N ?-~ ro 1 \ U` r-I 1 O C4 N 1 M -~ W p; I W W W \ ow z \ I a a a o~ o w V] I P+ a w w w o ~n m 1 cn rn ~ m ~n I O I r E i O W N k 1 N O ~ ~ O O I ~ N J~ AJ O O N 1 V' \ {v ~.' O O Ol I r N rl O O O O C I 00 Ol O~~ O N O I C' \ M ri r I •iJ r O N 0 00 I ~ w~,~ x I a ~+ I w .. .. .. .. .. .. .. rn I ~I I ~ ~+ u -.+ I o -.~ q w I w ~ ~ I vc -~+o I ~ o ff a~ I ro -rl I I +~ S-i ~ +~ U I O O~ W ~ ~ -.i N I E o atzowx~ I o I -~ o I N $..' u T3 C U q I ~ O O q m s i i a P. t h V'w ~ ~ N v v v u I •ti •~ U -.i TS TJ m rn I Mao ~oaro~aro roI H O ~4 U H C4 H H U a I SR0008-ICD CODE ICD9 CODE FOR DISCLOSURE STATEMENT 10/1/2007-5/31/2008 CASE_NLJM CERT NUM CLMT NUMICD9_CODE DATE INCURRED DATE PAID CHARGE PAID 5860050 O 1 ] 9 1 250.02 10/26/2007 2/21/2008 25.00 6.16 5860050 0119 1 250.02 10/26/2007 3/13/2008 25.00 0.00 S860050 0119 1 272.0 7/3/2007 10/25/2007 285.71 89.67 335.71 95.83 S860050 0491 1 277.7 3/18/2008 4/24/2008 266.00 137.72 S860050 0491 1 402.90 7/24/2007 11/8/2007 135.01 29.16 5860050 0491 1 402.90 7/24/2007 11/21/2007 135.01 0.00 5860050 0491 1 411.1 2/26/2008 3/13/2008 2215.00 1283.40 5860050 0491 1 414.01 3/18/2008 4/3/2008 141.00 47.84 5860050 0491 1 414.01 2/27/2008 3/20/2008 160.00 82.58 S860050 0491 1 414.01 2/26/2008 3/20/2008 1425.00 453.89 4477.02 2034.59 S860050 0015 2 110.9 3/18/2008 4/3/2008 77.00 45.04 77.00 45.04 5860050 0080 1 250.00 3/14/2008 4/24/2008 631.30 187.43 631.30 187.43 5860050 0128 3 783.40 3/17/2008 4/3/2008 428.00 370.20 428.00 370.20 S860050 0550 1 174.9 9/25/2007 11/1/2007 205.00 91.94 5860050 0550 1 174.9 9/25/2007 10/11/2007 85.00 70.00 5860050 0550 1 174.9 9/20/2007 10/25/2007 42.85 14.77 5860050 0550 1 174.9 4/10/2008 5/15/2008 318.60 79.75 5860050 0550 1 174.9 9/20/2007 10/11/2007 247.38 232.38 S860050 0550 1 174.9 9/25/2007 1/3/2008 205.00 0.00 S860050 0550 1 174.9 4/10/2008 5/1/2008 246.88 112.72 1350.71 601.56 S860050 0628 1 162.9 2/11/2008 3/20/2008 175.00 175.00 S860050 0628 I 486 2/12/2008 4/17/2008 45.00 42.75 S860050 0628 1 486 2/20/2008 4/3/2008 45.00 42.75 5860050 0628 1 486 2/9/2008 3/6/2008 914.48 295.01 5860050 0628 1 486 2/9/2008 3/13/2008 313.00 250.40 S860050 0628 1 486 2/20/2008 3/27/2008 45.00 0.00 5860050 0628 1 487.0 2/14/2008 3/13/2008 120.00 54.14 5860050 0628 1 487.0 2/13/2008 3/13/2008 120.00 54.14 S860050 0628 1 487.0 2/12/2008 3/13/2008 120.00 54.14 S860050 0628 1 487.0 2/10/2008 3/13/2008 9501.00 7160.84 5860050 0628 1 487.0 2/15/2008 3/13/2008 120.00 61.84 5860050 0628 1 487.0 2/20/2008 3/13/2008 142.00 107.92 5860050 0628 1 487.0 2/25/2008 4/17/2008 130.00 20.26 S860050 0628 1 487.0 2/20/2008 4/17/2008 130.00 20.26 11920.48 8339.45 S860050 0442 I 099.41 11/12/2007 ]2/6/2007 160.00 88.28 5860050 0442 1 281.9 2/8/2008 4/3/2008 118.00 44.00 S860050 0442 1 794.5 5/15/2008 5/29/2008 590.00 169.39 868.00 301.67 S860050 0249 4 272.2 11/2/2007 11/21/2007 105.00 49.43 105.00 49.43 S860050 0254 2 783.41 9/19/2007 11/1/2007 65.00 11.10 S860050 0254 2 783.41 9/19/2007 10/11/2007 295.00 0.00 5860050 0254 2 783.41 9/19/2007 11/8/2007 65.00 0.00 425.00 11.10 S860050 0403 4 282.9 12/31/2007 3/13/2008 150.00 105.00 150.00 105.00 S860050 0102 8 388.8 8/23/2007 10/4/2007 65.00 21.10 S860050 0102 8 388.8 8/24/2007 10/4/2007 85.00 38.10 5860050 0102 8 774.6 7/30/2007 10/4/2007 75.00 29.10 S860050 0102 8 774.6 7/30/2007 10/11/2007 75.00 0.00 300.00 88.30 S860050 0615 3 079.9 1/28/2008 3/13/2008 100.00 72.40 100.00 72.40 5860050 0145 1 388.70 1/2/2008 2/7/2008 77.00 45.04 77.00 45.04 S860050 0021 1 250.02 10/29/2007 ]2/6/2007 148.00 97.37 5860050 0021 1 250.02 3/17/2008 5/22/2008 217.76 48.2] S860050 0021 1 250.02 12/28/2007 3/13/2008 ]91.76 0.00 5860050 0021 1 250.02 12/28/2007 2/21/2008 191.76 38.44 S860050 0021 1 250.02 3/19/2008 4/17/2008 50.00 12.39 S860050 0021 1 250.02 10/29/2007 11/15/2007 251.01 59.60 5860050 0021 1 250.02 9/21/2007 11/29/2007 265.71 0.00 S860050 0021 1 250.02 9/21/2007 11/1/2007 265.71 131.53 S860050 0021 1 250.02 12/28/2007 2/28/2008 118.00 61.14 5860050 0021 1 250.50 11/6/2007 12/13/2007 215.00 157.00 5860050 0021 1 272.2 8/1/2007 11/21/2007 217.76 0.00 5860050 0021 1 272.2 8/1/2007 11/8/2007 217.76 53.58 2350.23 659.26 S860050 0230 1 110.1 4/3/2008 5/8/2008 155.00 72.62 5860050 0230 1 112.1 11/7/2007 11/21/2007 240.00 186.45 395.00 259.07 S860050 0479 1 272.2 9/14/2007 12/6/2007 135.01 0.00 S860050 0479 1 285.9 9/13/2007 12/13/2007 213.80 48.70 348.81 48.70 5860050 0340 1 272.4 12/13/2007 1/10/2008 81.00 51.75 5860050 0340 1 272.4 9/11/2007 10/25/2007 80.00 60.75 S860050 0340 1 272.4 3/12/2008 4/3/2008 100.00 70.75 261.00 183.25 S860050 0165 3 214.9 12/13/2007 1/24/2008 100.00 82.40 S860050 0166 1 414.00 3/24/2008 4/17/2008 155.00 109.09 5860050 0166 1 585 10/2/2007 11/15/2007 1573.05 1573.05 5860050 0166 1 585 4/8/2008 5/15/2008 1767.31 1767.31 S860050 0166 1 585 4/1/2008 5/8/2008 1593.51 1593.51 5860050 0166 1 585 3/17/2008 5/1/2008 3520.72 3520.72 5860050 0166 1 585 3/1/2008 4/10/2008 4169.77 4169.77 S860050 0166 1 585 2/28/2008 4/3/2008 1190.90 1190.90 5860050 0166 1 585 2/12/2008 4/3/2008 2064.73 2064.73 S860050 0166 1 585 2/7/2008 4/3/2008 2469.97 2469.97 S860050 0166 1 585 2/7/2008 3/20/2008 674.00 674.00 S860050 0166 1 585 1/22/2008 2/21/2008 1980.18 1980.18 5860050 0166 1 585 1/3/2008 2/7/2008 1688.53 1688.53 S860050 0166 1 585 4/15/2008 5/22/2008 1748.58 1748.58 5860050 0166 1 585 9/25/2007 11/1/2007 1556.78 1556.78 S860050 0]66 1 585 1/29/2008 3/13/2008 3351.43 3351.43 5860050 0166 1 585 10/9/2007 11/15/2007 1572.54 1572.54 5860050 0166 1 585 10/16/2007 11/21/2007 1670.42 1670.42 5860050 0166 1 585 10/23/2007 12/6/2007 1533.00 1533.00 S860050 0166 1 585 11/1/2007 12/6/2007 1782.22 1782.22 5860050 0166 1 585 11/8/2007 12/13/2007 1132.51 1132.51 S860050 0166 1 585 11/13/2007 12/20/2007 1740.69 1740.69 5860050 0166 1 585 11/20/2007 12/27/2007 1005.49 1005.49 S860050 0166 1 585 11/20/2007 1/10/2008 1788.22 1788.22 5860050 0166 1 585 11/29/2007 1/10/2008 1.58 1.58 5860050 0166 1 585 12/24/2007 1/31/2008 2051.06 2051.06 .N bQ O .~ ~ RS A •V .~ ~ U -' W U ~ ~ ~~ 0 W U ~ Q ~ O a e 0 z 0 a a. ~ .: p„ '+ ° a. 0 0 z w 0 ~ ~ o 0 o 0 r 00 ~ 00 0 0 0 0 0 0 0 0 o v v rn v a 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N O~ ~ N M `n ~ ~ -. v1 N N ^ O+ N O~ O~ -~ V1 ~ M ^ d'~ w w w w ~ ~ ~" Q ~ x (~ H W ~ `n ~ F ~ O C4 ~ A °' ~ w O v, H ~ v~ H W ~ w -~ o Q x ~~ a h ~ H a ~• Q Z z d a> Q~° Q o w v0, ~ (~ Cz7 .'~- H vFi '~ U CAj z ~ H a3 .~~z~z~~w~~~~z U] Q~ U A A w z~~~~~ w 0 n~i O M N O ^ O M M O 0 0 0 O N O 7 N 7 O T M ~ O ^ ~O 7 ~D O ~D [~ t~ ^ O o0 --i o0 ^ ~ O M O O^^ ~n ^ M O^ O N O O N M T O ~--~ l~ V O ~n N [~ ~D O ~O ~O ~O ~D O ~O ~n oo ~ '~ O h O O N Qi I~ O ~ O ~ O ~ O O o0 ~ 7 O h o0 ~O O o0 O ~/l 00 O o0 7 7 ~/'1 O o0 00 l~ ~ 0o vi o0 00 l~ ~O l~ r` r` r` r` r` r` r 00 r` r` r` n n ~ r C` C` [~ [~ M M O1 ~ V1 ~ [~ ~ Q. W O a+ l~ ~U T O M O ~/1 O O O ~/1 l~ h ~ N ~ ~ 7 O ^ N 7 O O~ V1 O (~ p t~ [~ [~ N p ^ ~ •~ Q. ^ vl O O~ ^. c0 M M O ^ O oo l~ ^ ~O N N O l~ v'~ 7 O N CO N CO p o0 ~O ~O ^ p M ~n [~ O ~ ~}' O ^ Q~ V ^ ~ O l~ T O~ 00 N [~ 7 M O 7 ~ ~O O oo V1 M l~ O ~ V V M p M o0 ~ l~ v} t~ o0 1~ ~ ~ V1 r` r C` ~ ~ ~ C` r r [~ N ~ ~ N r r ~ C` M M Qi 01 V ~O l~ ~O a O ~D ~ ~ 7 ~ N N '"' V1 ^ O 01 N l~ 7 N U M 7 7 N N O ~ V1 O ~O p ~O 7 V ~D O O~ V'1 ~ v1 N O~ O~ l~ N o0 7 .-. N O N O~ ,-• 7 N O l~ ~{ o0 0o N ~O O (~ ^ a0 00 Qi O. M ~ 00 ~ y M ~ N M ^ 01 ^ M ~p 7 7 M ^ ~ O 7 ^ M V1 l~ ~ N C` ~ [~ .-. Vl ~ .-. ~ O ~-. ~p M M ^ .~-i ~--~ N .M. ^ ~ M M l~ ~ R7 QI O~ ^ M T O V1 M M O ~ N ^ Q~ l~ ~ O .-. C` N V V~ .-. ~D ~ O ~ M O M O p I~ .-. l~ ~ oo ~ N O~ ~ --~ vi N ~p ~ O~ V N M ~ M N ~ ^ O o0 N ~ 7 ~ O~ Q~ ^ M O N ~ ~ M M M 7 .-. 7 M .-+ O M o0 ,-. N •.• h vi ~ o0 0o N O N V! M N ^ ^ 7 M ~ M M ri a v O ~ O O O ~ O O O O O O O O O ~ O O O O ~ ~ O N O ~ ~_ O ~_ O O ~ O N ~ ~ ® d' M Vl ^ ^; ^~ ~O 00 A ~ N ~ ~ 7 v1 h N O^ V O 7 O O ~p o0 ~O v1 ~D Vl vi vi 7 p V V 7 M p N vi O y ~ ~O ^ Q~ ~O M M ~ r` oo Q~ t~ N N o0 N V O O Qi 7 7 00 ^ ^ M O+ O+ O O ~O O M O ~ O ~O ~ ~ M N r r oo r ~} ~.. ..+ N M M N 7 00 O~ l~ oo N l~ [~ N N O~ ~ N ~ ,~ C oo .-. ~ ~ .-. p .-~ M .~. r. N O+ O~ .-. .N. N h W ~ L` ~ O^ O~~ O O N ~p ^ O O N O~ l~ O~ M O O^ "~ ~ O ~ O O ~ O~ O M V1 ~'F ^ N ~ ~ N ~--~ N d' ^ 1~ O~ v1 N O O O l~ 00 ~ h ~ ^ ^ v? N N N ~ N N ~ N r ~ M O V1 p ~ Vl ~ ~ ~ N ~ O ~ oo ~ `O V O~ Vl ~p ~ [~ ~ W O 00 ~ ~ N p ~O V1 M O oo I~ ~' 01 M W 1~ ~ ~ M N O ~ V1 ~ O a 7 V o0 `D M M 01 01 p p 7 00 M ~O v'1 7 'n M N~~ W W ~ .-. N M M M N v1 00 ~ r~ C` ~ O~ N N N vi N O ~ N [~ `~ N V1 O l~ .-+ O .-. ~O M ~O N l~ .-. 00 ~ .-. n .-• .-.• ~ r .-• ~ 00 ~ N M O 7 ~ M Gl .-. .-. oo V .-. V ^ ^ V V~ N N .-. ^ .-. .--. I.y a W ~ ~ a pa F d LO z Q' H Pw. W W ~ O ~ Z ~" y, H ~ F ~ ~ ~ ~ I A '~ O ~ vw_i ~~ Q ~ W f0A ~ q >< W ~ O H~ o c~ ~ cn a o Q~ Ll C] .~ W ,v~~ d Y W W O~~ W O 'xi ~ ,^ ~ N ~'~ v~ ~ ~ ~ ~ Z ~ ~ W ¢' {~ ,,, Q ~ ..7 ~ ~ z ~ ~n ~ O W a v] Z W ,~ ,Q.7 0 i Z , d d~ w v~ a~ w d ~?S W v, d U z w z H a, >+ [-• d V ~ \' O ~ ~ O ~ ~ w ~ z ~ z ~ ~ E- ~ d Y a ~ v O ~ ~ od.~ ~ a Ox., O v"i ^~W4 O a~i v' F, w H w O O~ ~~ w z~ z U O w H~~ w w~ F- ~ ci w Z a H [= ~ ~ W Q O ~ fa Z ~ ~ d w ~ Z ~' cQ7 p ~ °' '~ ~' °' z ni w F- ~ ~ ~ a ~ (~ C7 O W~ d d x d' H U W~ U rx z Q H ~3 O a d v~~ v F, v p ~, U 0 .o ,~~, ~ v w ~ ~ cw7 ~ ~ ~ w w w d d ~ j ~ w w O ~ ~ ~ cG a~i w ~ a~i O ~ v ~ ~ ~ ~ v~ v~ d GO U A Q Q A W w C7 ~ ~ ~ ~ Z a R' cG a: ~ ~ ~ ~ ~ A A v~ a: v~ d Ca ~ ~ F" O O~ O O V M V o0 0 0 O V V p~ ~p N O ~O O O O V V r r O h oo O O h O h O O --~ O ~n O H O N O O O 0 0~ oo N O ~--~ O O O O O ~p h N N M M v1 O V1 O O M O M O M O ~ p O O O O h N ^ O ~O O O O O O ~p ~ p~ ~ O~ ~ p~ p p~ O r~ v, ~ 0 00 0 0o r rn o o rn N rn rn oo rn r r o o v rn r~ o, a~ rn o, rn r O lp O N O l~ ^ W O O O l~ V N ~O Yl O ~O O O O V O [~ 1~ M N ~ O O [~ O (~ O O e{ O V O~ o0 7 O O O O O v1 0o N O^ 0 0 0 0 0 ~O ~/"~ N O~ N l~ r N O N O O N O 7 V1 N [~ N O O O h 0 ~ N N O ~ O O O O y-. ~p (~ r <} ~ ~ 7 h O r O l~ ~ v~ v~ I~ ~ ~ ~ r O~ T O l~ N o0 01 0o O~ l~ r O N V O~ l~ ~O o0 O~ O~ O~ O~ l~ 7 O o0 N N h .-. W ~y O O O~ O N O O~ 7 O~ oo N V1 O~ '~ N ~ N N O O l~ h ~ O ~ O\ ~ M 00 I~ V O\ ~ pp V1 .-. .-. 00 ~ ~ V1 .~-i ^ N l~ M M M ~ ~ W V1 N V o0 M ~` Q~ N ~--~ ~ M if1 N ~ M d' N N M 7 N ~; M M V tt ^ ~ ^ M N ~A M ^ N r [~ W ~ ^ N N l~ r i ~_ ~ ~ ~ O N O N ~ O O O O r O h oo O b ~ 00 ^ ~ O r r ^' N l0 ~--~ N N Vl V M ~D O O ~ M M ~ ~ Vl ~ M O M N ~ N ~? M M M M O O O O O M O M O O O O O O `n O O O O O O O O O O ^ r N O O O O O O '/~ v1 N O O l~ O N N ^ .. ~ r N l~ ~n V N O r. M y~ O O p~ O O~ V1 l~ M ~ V1 O V1 N ~ O N N r O V 7 O~ O Q~ p p1 N M ~ O N p~ ^ ~ O l~ ~ ~ h O ~ ~ M N N `D ~ O ~ ~ ~--~ O W oo ~-» ~--~ M M .-. OO M ~ O~ N N Vl M `O .--~ M N M V ^ N N N M M ~ ~ ~ V M M 00 OO N N M Vl M N ~O M .-~ M M l~ [~ 00 00 N N N h l~ ^ M O O O ~ O ~ O M O O O O O O ~ O O ~ N ~ ~ ~ ^ O ^ O O ~ O ^ O h N ~ N M ~ h N ~ ~ ~D ~O '7 V ^ ~ l~ [~ h h ~ M M W o0 h W ^ N M ~ O M M V O ~ O O b 0 ~ U1 O M M vl O ~ N O p N ^ Q~ Vl N N O O O O M O ti M p Q~ .--i .ti 7 N ~ M M ~--i 7 W ~ V1 ~ N ~D N p ~ V .--i N V' 7 00 00 00 00 M 00 [~ O M N M V N N O M M .--~ ~ O l~ l~ ~D ~O N M .r ~--~ ~ M M ~D M ~--~ .--~ M vi l~ r O O M M N 00 00 N 00 ^ .-. ~ M ~--~ N V V M O~ ~-+ V ~D Vl N n. ^ Q~ ~D N O c0 ~n ~ ^ N .--. M V V1 M N Vl .-. .-.. N M ~ 7 ~ (-~ CO w ~ H (7 ~ ~ Q z a ~ F W~ a o F~ ~ Q a~ Q z~ z~ w o w ~ x H ° Q ~~ o ~ H~ U w '~ U Q ~ v~ w~ o Ca ¢ a~ U v w o d d ~ >" x¢ r~ ~ v~ rn CG W ¢ ~ C7 C4 W Q a ~' ,,,~ O a. v~ z a vi p. W ~ °" x~ ~ x~~~ x o z x~~~ z° H u o~ H z~ W ~a a ~ a o A, z ~ A, O ~ z A, ~ ~ O O ~ z H w cxn 0. -~ ~ aUi O v ~ o. ~ v' o, F~ F. w¢ ~. F- w~ z O [=-~ w z ei O z ~ ti a~~ y w ~ ~Q .¢a ~ W Z a~~ U Q F z~ C¢7 O~ y a ~ a H y z ~ ~ F. p., ~ ~ ~ z ~ Ca O ~ ~ ~ x c7 E¢- U ~ ¢ z ~ ~ @S O aF. ¢ ~ H v F¢- ~ v c7 ~ ~ o ,~~. ~ ~ ~ ~ ~ v Q a z ~ ~ ~ ¢ w ~ w ~ w w o ~ ~ ~ ~ a~i w ~ w ~ a~i ¢ ~ z x ~ ~ U Q H ~ ¢ ¢ ¢ ¢ v Q w ~ ~ ~ z O a ~ x ~ ~ ~ O ~ q ~ q q v~ ~ d .~ W 0 ~~+ fl .Q O 6~ .n R CC L .'~ ~r ICI 1 U ~~~ =1 Ci .'~11/ w 0 M d O V V V O O O ~ ~--~ r ~--~ M V ~--~ ~--~ O O ~O N ~/1 T 01 O O~ N V V V V ~ ~ O O O O O O O M O O O ~--~ M O O O O r r O V 7 O ~O ~/1 O O O O ~ '~ O O O O O O O r. O ~--~ O W c0 O O O O 7 ~O M o0 0o O O Qi O O O O tC r o 0 o r r r ~o ~n ~o 0o r r r r v~ r ~o ~n ~ ~ ~ v, ~ vi o 0 0 o a. 0 +„i O V V V O M O O~ ~--~ N ~ ~O ~!1 O O V1 0o N O O O r V V V V •~ O O O O O O O O ~p O V O O~ N M r O O O O r M ~O O O O ~O M O O O O O O O O O r O O O O 7 O r ~D r ~ O Vl Vl N V1 r V 7 O~ r ~O O r O r O O O~ M Vl r M Vl V o0 ~O 00 ~D O M V1 Vl M Vl O O O O O ~O ~n ~n O O N -~ \O O ~ r ~O r r ~n O 7 ~n 7 ~ ~ ~n 7 ~ ~ '"" ~ ^ '"" V '""' V y v1 ,--~ r O~ .-.. O~ N O o0 r _ O~ N 7 N N ~ ~ N •.• r o0 V1 O~ ~D N O N O r 7 r o0 00 00 .~, .--~ ~ 'r •--~ •-• ~ ~ ~ O r O r ~ y ~ O O O ~n ~ O ~--~ ~O O r ~ ~ ~ ~ 7~~ r M M h N r O O O O y„ N M er o0 00 ~O ~O N N N ~O O r r r oo Vl a 7 V1 M V V 7 ~ V1 .ri b U 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Q O v1 ~ O V1 Q, N N N O V1 0o M .-• .-• O V ~O .-• •-• N N O ~O ~O o0 00 .-. .- y o0 --~ r O~ .--~ N M ~ r ~ M r --~ o0 00 ~ --+ oo h O O O ~ N r o ~ V 7 ~" o O O .N. r r W O O O O O^ O ~ O O V1 7 Q~ O O O O r~ r O O O O O O O .--~ _ N M N N ~--~ M ~ ~/~ ~O ~/1 ^+ ~O ~O O in O O N '"' N T O N N ,-. ,-. O ~' O °° M ~ O r r o0 00 ^. .-. = 00 ~ r O~ ~ ~ M r ~ 00 OO ~ Vl ~ . . 0 ~}' V M . . r N M 7 ~O ~ ~ .-. M ~ 00 0 a r r ~ ~O r N N N a V `n ~" ~ ~ A Q r Q F W ~ ~ ~ a ~ z ~ a F N W w ~ W w ~, a w w a ~" ~ d d ~, w~~ A W~ Q Q od a vii N Wi ~ v O a [-~ C ~ o v~ . z ~ ~ o . ~ ~" ° q ~ °. Z ~ w ~ z w ~ Q ~ Q H ~ ~ ww ~ x C] ce A a Q P4 cG o ~ ~ V cL w O w d z d >" d °' w U V U z j a O a Q E -~ ~ C 7 O~ a O j. a [-" F -a a F a F F a ~ z ~ z ~ w ° ~ ~ ~' O ~t ° ° a ~ A o o ~ o W ~ a w a W W d W W W d H d U~ H a ' E- O W F, F. d H U U v . ~ W ~ ~ ~ H . ~ ~ a ~ F ~ ~ ~ ai ~ Z ~ ¢ v ~ O ~ ~ ~ _ ~ W _ ~ W ~ i ~ Z ~ ~ Z ~ W W O ~ ~ ~ ~ ~"' c s Q ~ c%~ w c%~ ~ U v~ Q a' v~ c%~ Q V~ a a (~ ~ V v vi vi o0 00 V V M V v1 ,-. O O~ O~ ~-+ O~ N V M M O [~ N o0 O O O N N O O N n Vl ~ O O M O M n O~ O~~ M~ O O T O~ l~ M O O O a0 00 O O ~p ~ ~p ~p O O pp O ~p r O M O~ ~O ~--~ V O~~ O ~--~ ~ b O O O ~O iD O O o0 00 O~ O~ O O o0 O oo O~ v~ oo [~ O~ 7 00 O O~ O~ O~ T T oo vi ~n vi l~ I~ ~ ~ v1 V1 00 m V V M V Vl .-. O ~ p ~--~ ~--~ oo Q~ V M M O l~ N a O O O N N M M l~ [~ M v1 O O M O M r O n O M r O ~ O O O+ O ~ l~ W O O O 00 0o O~ O~ ~D ~D ~O ~O O O o0 O ~p l~ O O O ~ ~D 7 O~ O ~ `p O ^ ~O M O O O ~O ~O o0 00 00 00 01 O~ O O o0 O oo O~ ~n oo ~O O~ M l~ O O~ O~ T T O~ oo vi vl vl l O O ~ ~ 7 V Vl M 7 7 N Vl O V1 O O~ O V'1 O~ .-. ~O p O ~ N V1 O~ M p l~ [~ OO 00 ~ W W 00 M M lp ~D ~ O\ ^ V ~D ~A ~-. V1 00 OO N N pp pp ~-., ,-. N nr O 00 N O~ M h ~ vii ~ ~ \p W O O ~ ,N. C V1 ~ ~ M N M ~--~ l~ N ~O ~D M N M ^ ~ .--~ 7 Q` ~ N N O O N O GO O O ~ O M r ^ ~ O ~ ~ ~ ~ ~ ~' O ~ ~ O O O O M M o0 -+ 01 ~D ~ M Vl O O W 00 01 0o M N N M V V ^ .-. M ~ N V1 ~. ~O O .-. N ~ .-. a' vl O O O O O O M M O O O O O O O O O O M O O O O O O O O M O O O Vl O ~/1 vl l~ ~/1 O r N ~/l N N N N ~ O~ O~ ~D ~D O~ O~ O O 7 V C V~ 00 vl O o0 O O O~ ..• d' O ~n O ~p Qi ~ ^ ~ ~ ~ ~ ^ ^ ~ ~ ~ O ~ N M N ~ O o0 V1 h ~ N ~ M N ^ O ~ M l~ N N N N O O h M U V1 e{ ~--~ 01 V r a r r p~ M ~--~ M N m O ^ V V ^ M N M N O~ M ~O ~--~ l~ M N M ~--~ <{ N M h O O N N_ O O O O O O O O O O O ~ O ~ O O O O O O O O ~ O O O Vl V1 M V1 M ~ ~ O~ Q~ 00 00 O~ O~ O O 7 V V V1 m h O m O O U M ~ O ~ O ~ a ~ N O ~ ~ ~ ~ ~ ~ ^ ^ ~ ~ ~p ~p O p~ N M N V1 O 00 ~O N ~ N l~ N N l~ N O O .. ,-. !~ ,-, M T v1 00 ~O O~ l~ N Q~ t~ ~ ~ M r. ~ N oo O ^ V 7 ^ M N M N Q~ M ~D ^ W M N M ~--~ V1 N M Vt ~ V1 M ~--~ 7 ^ N Vl 00 N V Vl W O V M N M ~--~ M Vl .--~ M N N EE-- ,.. ,__, G Q Q z Q ¢ w w Q w A C7 O F~S Q ~F Q F A C7 O A ~ ~ w~ F w v 0 U w~ z F~ d ¢ a~ O Q w y W w O d a G7 a ~ a c~., vi a w ~ w v~ U W ~ v' m ~ ~ w x~ ¢ -? ~ ~ z a ~ ~ v' FO ri p w¢ H x~¢~ ~ z w ~ O a ~ vi ~ ~ ri ~ vAi W ~ Z H a ~ ~ F" C7 W a ~- ~ z ~ ~ F ~ ~ F ~ ~ ~ ~ ~ ~ ~ ~ a ~ ~ Q z ~ z ~ ~ ° ~ o o z ° w ~ ¢ ~ y ~ ~ ~ OF ~ ¢ ~ OF ~ ~ ~ `a ~ A ~ cz7 ~ ¢ ~ `i' ~ ~ F" z cG z @i O ~ ~ °~ d z '~ ¢ ~ U F w ¢ U ~ C7 a. F" PS P. ¢¢ `~ F, ¢ v ~ ~ w ~ ~ ~ ~ ~ w ~ v z w x w ~ ~ y ~ ~ a w o ~ ~ ~ a ~ w ~ ~ ~ ~ ~ A v~ v, v~ ~ ~ w ~ ¢ ¢ oa U A Q A w ~ z a. a cG v~ v, ~ A ~ ~ O ~ G ', O L a IN b U A b+ .~ y ri a w 0 d o0 00 0 o v v v v o 0 0 0 0 0 0 0 o r v o 0 0 o M v, .n .~ rn o o '. ~ O O O O O O O O O O O O O O O O O ~n oo O O ~O ~n N M r 0 0 ~ '~ O~ Q~ O O O O O O O O O O O O O O O m ~ O O N N M O~ 7 r O O ~ ~ ~ 00 0o O .-. O O .-. O r r r r r r r ~D ~O O~ O~ oo O~ O~ O~ Q~ Qi ~ ~+ w +.+ ~ ~ O O c.~ c~ v v O O O O N CO O O O V M O O O~ O~ 00 r ~D .-. N O O •~ O O O O O O O O O O O O 7 7 O O O ~n o0 O O ^ ^! ~ O N M r O O O~ Q. O O O O O O p p O O r r O O O o0 0o p p Yl Vl M ~O oo d' r O O ~ v v o0 00 0 0 0 o r r ~o ~o r r r~ ~o v v o0 0o rn rn rn rn rn ~ ._ ~. \° e O O ~/1 ~ O O O O ~p O~ ~ ~ M o0 ~ r O O M M O r ~O M O~ 7 O y N o0 N 0o r M r M r o0 r 0o O O O O r r .-. N 7 r. ~ M M . . 7 M N M N N r r N O~ er O~ N M .-» ~ O ~p O~ ^~ .-. O O .--~ .--~ M N d' GC C~ a d N N M M O O O O O O M M E ~ ~ r~~ O~ O O O O Q~ V ~O ~O N N O yy V1 V~ O~ O~ M r r ~ N ~ m N N M V vl V V r ~--~ M M M 7 ~. N •--~ .--~ .-. Vi ri 7 7 1 O U 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ^- o 0 0 o ~ o ~ ~n M M M M V1 v1 O O O O p~ M ~ O ~ O N O~ ~O O O M M ~ ^' N O~ .~ ~ O y [~ C' ~p ~D r r O O O V' T v7 .-. O+ •-• oo O V1 v1 ~/1 N M ~O O~ .-. O ~ ~~ ~ ~ 7 V o0 00 O O .-. N ~ O~ 7 7 ~p N N ~ N vl ^ r .-. M N V W O O O O O O O O "r r '~ r O O ~ ~ O O O O O ~ ~ M ~ M M ~ O O M O O ~] ~ ~ y~ vl y~ Vl N N D N ~O N r ([~j~T~` N N M M M M ~ ~ O O ^~ ^+ 01 M ~ W 01 O ~ \O 00 W ~O ~D ^ O N O~ ~ b O r r ~p ~p r r O O r r O ~ V~ O p~ oo . . ~ O N N ~0 0 M ~O O~ O ~" ~ W 7 7 00 0o O O ~/1 ~n ,-. N ^ V? 7 ~ ~ v1 7 ~D N ~/1 ~--~ r ~--~ .-. N N ~ .~.. ~+ ^.. M N V ~--~ ~ 7 ^ N M 01 ~--~ 00 M ^+ 7 ^ M N ~ O r '7 Vl M M --• Cr .-. N N M O ~ 7 ~ N a a v ~ w z z k w N w U z Z w v i a . w ~ ~ w V w x w z z ~ ~~ z d w d Q ~.~~ d ca O x H w O O p F., w p A a z O O ~ V A w A A v~ ~ ~ U v , _~ ~ ~ ~' a s o a a W a > w ~ Q ~ Z x x oa O L1 ~ q ~ N Z . a. W ' a" Z Z a A a' ~ U U vAi ~ H A A o a ~z az a z ~~ cd ~ ¢ a¢d a a ~z a~xo¢ F 4 d ~ V '`-~ U ~ a~ U W W (~ a O x a G C7 C7 d C7 . , . , ~ ~ 7 ~ 3 3 ~„ 7 ~ ~ w ~ ~ ~, ~ ~, ~ ~, > w w ~ ~ c w ; z F a ~; a c O ~ ~ ~ w ~ w ~ ~ w ~ O O F ,~ vi z w y 0 y 0 y 0 w y z d w w ei 0.1 Z W d w w ei F w z w ei Z ei w Z z d z w ti w d z a F. >; A ~ ~ ~ a ~ a ~ F Z, ~ x F, F, Z o w x H ~, ~ F ~ F w ~ A ~ c7 q~ w ro b ~ _ ~ ~ ~ ~ _ ~ ~ ~ q _ ~ uS A A ~ d w A ~ ~ a ~ A ~ U Q w z ~ z ¢ ~ q v >. ~ >. a~ ~ a~ O a~ ~• O O a~ Y 0 0 a~ O ~ O a~ U z w O F, ~ v~ v, v~ v~ v] v~ ~ x v~ w rx rx v~ L w a x v~ u: cn cG v~ ¢ Q d c0 U U Q .~ W O W .~ .G a \° 0 V1 00 ~ M oo O o0 O~ ~D v1 O ~O N ~O O v M o0 01 O~ V T o0 O O M d' O~ O V 00 00 ~ [~ h O h W ^ '~F V ^ 00 O ~O N 7 ~/1 M O ~O V O Q~ of ~O O M O 01 O~ 00 00 00 T T T 00 00 01 01 00 O~ T 00 O~ 00 O O~ 01 l~ oo ~ M o0 O 00 M .--~ O vi O^ ~O 7 ~O O ~D O M M Qi O~ ~A O~ 00 O O O ~O M ... O 7 00 M Vl l~ b O ~ W O 7 00 ~--~ oo O ~O V1 M ~--~ M O ~O ~t [~ T ~ v1 v~ M o0 0o rn t~ o0 0o rn rn o0 00 0o rn rn oo rn m oo rn oo r rn o0 .G ce ?r L ri ICI O~ r. ~ 7 N M M iD N ~ O N ^ O~ 00 ~ d' Q~ ~ N Vl M N r~ M .-. i!1 r. ~O l~ ~ V 7 r. M O~ ~p O H O M N o r .-. ~ O O N^ N N 01 ~ O l~ ~~ V O '. vi Vt 00 M 1~ V M V1 00 00 N 00 M 7 N O ^ ~O ^ V ^ N ~ O~ O [~ N O~ N O O+ O •--~ ~ v A O O O N O O O O O O O O O N O O O O O O ~ ^ ^ ~ N N ~ Q~ oo M 1~ ~ 00 ~ O ~ .-. ~ r ~-• M .--~ M O. ~ T O N N .-. ~. M N M ^ oo .--~ ~ M M ,-. N ~O l~ ~ O+ ~D O [~ O~ N ~ ^ N N ^ M ~ oo N co M ~ V V1 ~p .-. ^. V ~ ~-+ ~ ^ r. ~.j .-. p '-. ~ _N O ~ O O O O O ~~ O O O O M O O N ~ O T oo '. .-. ~ .~~+i+ G ra '~ O O~ l~ M n ~ 00 .~ V ~ r. ~ t~ .-• ~ .-• M N ~p O~ I~ V ~ ap .-. M N ~ l~ O~ N ~ ^ N N ^ ~ M ~ V M ~ N oo ~ ~ '7 O+ y d C a M ~ r 00 M oo ~ M V1 O ^ ~D O 1~ V ~' O Vt M .-. .--. ~p N ~D ^ N 'ch o0 M .--. M ~-. .-. 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CC CG v~ ~ ~ d Q ~ ~ rn rn v~ Performance Drug list The CVS Caremark Performance Drug List is a guide within select therapeutic categories for clients, plan participants and health care providers. 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. This is not anall-inclusive Iist.This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN PARTICIPANT Your benefit plan provides you with a prescription benefit program administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor. 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 copay' information, please visit www.caremark.com or contact a CVS Caremark Customer Care representative. • CVS 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. • Any brand drug for which a generic product becomes available may be designated as anon-preferred product. ANTIBACTERIALS § CEPHALOSPORINS cefaclor cefdinir cepha/exin SUPRAX § ERYTHROMYCIN51 MACROLIDES azithromycin clarithromycin clarithromycin ext-rel erythromycins § FLUOROQl11NOLONES ciprof/oxacin ext-rel ciprofloxacin tablet AVELOX CIPRO SUSPENSION LEVAQUIN § PENICILLINS amoxicillin amoxicillin-clavulanate dicloxacillin penicillin VK § TETRACYCLINES doxycycline hyclate `' minocydine tetracycline § MISCELLANEOUS metronidazole sulfamethoxazole- trimethoprim § ANTIFUNGALS fluconazole itraconazole terbinafine tablet ANTIVIRALS § HERPES AGENTS acyclovir VALTREX § INFLUENZA AGENTS amaniadine rimantadine RELENZA TAMIFLU § ACE INFIIBITOR5 fosinopril lisinopril quinapri! ramipril HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe abrand-name product is necessary, consider prescribing a brand name on this list. Please note: • Generics should be considered the first line of prescribing. • This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. • The plan participant's specific prescription benefit plan may have a different copay for specific products on the list. • Unless specifically indicated, drug list products will include all dosage forms. • Log into www.caremark.com to check coverage and copay information for a specific medicine. § ACE INHIBITOR/ DIURETIC COMBINATIONS fosinopril- hydrochlorothiazide lisinopril- hydrochlorothiazide quinapril- hydrochlorothiazide § ACE INHIBITOR/CALCIUM CHANNEL BLOCKERS TARKA ANGIOTENSIN II RECEPTOR ANTAGONISTS! COMBINATIONS AVAPRO/AVALIDE BENICAR/BENICAR HCT MICARDIS/MICARDIS HCT ANTILIPEMICS § BILE ACID RESINS cho/estyramine WELCHOL CHOLESTEROL ABSORPTION INHIBITORS ZETIA § FIBRATES fenoflbrate TRICOR TRILIPIX § HMG-CoA REDUCTASE INHIBITORS pravastatin simvastatin CRESTOR LIPITOR NIACINS/COMBINATIONS ADVICOR NIASPAN SIMCOR § BETA-BLOCKERS ateno/oI carvedilol metoprolol metoprolol succinate ext-rel nadolol propranolo! SYSTOLIC COREG CR § CALCIUM CHANNEL BLOCKERS amlodipine diltiazem ext-rel nifedipine ext-rel verapamil ext-rel Your specific presc•iption benefit plan design may not cover certain categories, regardless of their appearance in this document. For specific information, visit www.caremark.com or contact a CVS Caremark Customer Care representative. CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS CADUET DIGITALIS GLYCOSIDES digoxin § DIURETICS furosemide hydrochlorothiazide metolazone spironolactone- hydrochlorothiazide torsemide triamterene- hydrochlorothiazide ANTIDEPRESSANTS § MISCELLANEOUS AGENTS bupropion bupropion ext-rel mirtazapine CAEZEMAi,~~K. § 5ELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) citalopram fluoxetine paroxetine paroxetine ext-rel sertraline LEXAPRO § SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs) Z venlafaxine CYMBALTA EFFEXOR XR PRISTIQ HYPNOTIC5, NONBENZODIAZEPINES zol pidem AMBIEN CR MIGRAINE § SELECTIVE SEROTONIN AGONISTS sumatriptan MAXALT ZOMIG SELECTIVE SEROTONIN AGONIST/NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) COMBINATIONS TREXIMET ANDROGENS ANDRODERM ANDROGEL ANTIDIABETICS § BIGUANIDES metformin metformin ext-rel DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORI BIGUANIDE COMBINATIONS JANUMET INCRETIN MIMETIC AGENTS BYETTA INSULINS APIDRA HUMALOG HUMULIN LANTUS LEVEMIR NOVOLIN NOVOLOG INSULIN SENSITIZERS ACTOS INSULIN SENSITIZER/ BIGUANIDE COMBINATIONS ACTOPLUS MET INSULIN SENSITIZER/ SULFONYLUREA COMBINATIONS DUETACT MEGLITINIDES PRANDIN § SULFONYLUREAS glimepiride glipizide glipizide ext-rel § SULFONYLUREA/ BIGUANIDE COMBINATIONS glipizide-metformin SUPPLIES ACCU-CHEK STRIPS AND KITS° BD INSULIN SYRINGES AND NEEDLES ONETOUCH STRIPS AND KITS° CALCIUM REGULATORS § BISPHOSPHONATES alendronate ACTONEL § CALCITONINS Fortical PARATHYROID HORMONES FORTEO CONTRACEPTIVES § MONOPHASIC ethinyl estradiol- drospirenone YAZ § TRIPHASIC ORTHOTRI-CYCLEN LO § EXTENDED CYCLE ethinyl estradiol- levonorgestrel LOSEASONIQUE SEASONIQUE CONTINUOUS LYBREL TRANSDERMAL ORTHO EVRA VAGINAL NUVARING ESTROGENS § ORAL estradiol estropipate ENJUVIA PREMARIN § TRANSDERMAL, ESTROGENS estradiol CLIMARA ESTRADERM VIVELLE-DOT § ORAL ESTROGEN/ PROGESTINS estradiol-norethindrone PREMPHASE PREMPRO § PROGESTINS medroxyprogesterone PROMETRIUM SELECTIVE ESTROGEN RECEPTOR MODULATORS EVISTA § THYROID SUPPLEMENTS levothyroxine SYNTHROID § H~ RECEPTOR ANTAGONISTS ranitidine § PROTON PUMP INHIBITORS omeprazole KAPIDEX NEXIUM § BENIGN PROSTATIC NYPERPLASIA doxazosin finasteride terazosin AVODART FLOMAX § URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel DETROL DETROL LA ENABLEX OXYTROL SANCTURA XR VESICARE § ANTICOAGULANTS warfarin COUMADIN ANAPHYLAXIS TREATMENT AGENTS EPIPEN EPIPEN JR § ANTICHOLINERGICS SPIRIVA § ANTICWULINERGICI BETA AGONISTS ipratropium-albuterol inhalation solution COMBIVENT § ANTIHISTAMINES, NONSEDATING fexofenadine § ANTIHISTAMINE! DECONGESTANTS ALLEGRA-D3 BETA AGONI5T5 § SHORT ACTING albuterol PROAIR HFA PROVENTIL HFA LONG ACTING FORADIL SEREVENT LEUKOTRIENE RECEPTOR ANTAGONISTS SINGULAIR NASAL ANTIHISTAMINES ASTELIN ASTEPRO § NASAL STEROIDS fluticasone NASACORT AQ NASONEX RHINOCORT AQUA VERAMYST STEROID/BETA AGONIST5 ADVAIR SYMBICORT STEROID INHALANTS ASMANEX FLOVENT PULMICORT QVAR DERMATOLOGY § ACNE clindamycin solution erythromycin solution erythromycin- benzoylperoxide tretinoin BENZACLIN DIFFERIN DUAC CS RETIN-A MICRO ZIANA OPHTHALMIC § BETA-BLOCKERS, NONSELECTIVE timolol maleate solution BETIMOL BETA-BLOCKERS, SELECTIVE BETOPTIC S PROSTAGLANDINS LUMIGAN TRAVATAN XALATAN § SYMPATHOMIMETICS brimonidine 0.285 ALPHAGANP Your specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document For specific information, visit www.caremark.com or contact a CVS Caremark Customer Care representative. Z '` A ACCU-CHEK STRIPS AND KITS` ACTON EL ACTOPLUS MET ACTOS acyclovir ADVAIR ADVICOR albuterol alendronate ALLEGRA-D' ALPHAGANP amantadine AMBIEN CR amlodipine amoxicillin amoxicillin-clavulanate ANDRODERM ANDROGEL APIDRA ASMANEX ASTELIN ASTEPRO atenolol AVALIDE AVAPRO AVELOX AVODART ~~,: azithromycin B BD INSULIN SYRINGES AND NEEDLES BENICAR BENICAR HCT BENZACLIN BETIMOL BETOPTIC S brimonidine 0.296 bupropion bupropion ext-rel BYETTA SYSTOLIC C CADUET carvedilol cefaclor cefdinir cephalexin cholestyramine CIPRO SUSPENSION ciprofloxacin ext-rel ciprofloxacin tablet citalopram clarithromycin clarithromycin ext-rel CLIMARA clindamycin solution COMBIVENT COREG CR COUMADIN CRESTOR CYMBALTA p DETROL DETROL LA dicloxacillin DIFFERIN digoxin diltiazem ext-rel doxazosin doxycycline hyclate DUAC CS DUETACT E EFFEXOR XR ENABLEX ENJUVIA EPIPEN EPIPEN 1R erythromycin solution erythromycin- benzoyl peroxide erythromycins ESTRADERM estradiol estradiol-norethindrone estropipate ethinyl estradiol- drospirenone ethinyl estradiol- levonorgestrel EVISTA F fenofibrate fexofenadine finasteride FLOMAX FLOVENT fluconazole fluoxetine fluticasone FORADIL FORTEO Fortical fosinopril fosinopril- hydrochlorothiazide furosemide G glimepiride glipizide glipizide ext-rel glipizide-metformin H HUMALOG HUMULIN hydrochlorothiazide 1 ipratropium-albuterol inhalation solution itraconazole J JANUMET JANUVIA K KAPIDEX L LANTUS LEVAQUIN LEVEMIR levothyroxine LEXAPRO LIPITOR lisinopril lisinopril- hydroch/orothiazide LOSEASONIQUE LUMIGAN LYBREL M MAXALT medroxyprogesterone metformin metformin ext-rel metolazone metoprolol metoprolol succinate exi-rel metronidazole MICARDIS MICARDIS HCT minocycline mirtazapine N nadolol NASACORT AQ NASONEX NEXIUM NIASPAN nifedipine ext-rel NOVOLIN NOVOLOG NUVARING O omeprazole ONETOUCH STRIPS AND KITS` ORTHO EVRA ORTHO TRI-CYCLEN LO oxybutynin oxybutynin ext-rel OXYTROL P paroxetine paroxetine ext-rel penicillin VK PRANDIN pravastatin PREMARIN PREMPHASE PREMPRO PRISTIQ PROAIR HFA PROMETRIUM propranolol PROVENTIL HFA PULMICORT Q quinapri! quinapril- hydrochlorothiazide QVAR R ramipril raniiidine RELENZA RETIN-A MICRO RHINOCORT AQUA rimantadine 5 SANCTURA XR SEASONIQUE SEREVENT sertraline SIMCOR simvastatin SINGULAIR SPIRIVA spironolactone- hydrochlorothiazide sulfamethoxazole- trimethoprim sumatriptan SUPRAX SYMBICORT SYNTHROID T TAMIFLU TARKA terazosin terbinafine tablet tetracycline timolo/ maleate solution torsemide TRAVATAN tretinoin TREXIMET triamterene- hydrochlorothiazide TRICOR TRILIPIX V VALTREX venlafaxine VERAMYST verapamil ext-rel VESICARE VIVELLE-DOT W warfarin WELCHOL X XALATAN Y YAZ Z ZETIA ZIANA zolpidem ZOMIG Your specific prescription benefit plan design may not cover certain rateyories, reyardless of their appearance in this document. For specific information, visit www.caremark.com or contact a CVS Carernark Customer Care representative. 3 ACCOLATE SINGULAIR ACIPHEX ameprazofe ACTONELW/CALCIUM afendronate AEROBID, AEROBID M ASMANEX, FLOVENT, PULMICORT, QVAR ALORA estradiol, CLIMARA, ESTRADERM, VIVELLE-DOT ALTOPREV pravastatin, simvastatin, CRESTOR, LIPITOR ALVESCO ASMANEX, FLOVENT, PULMICORT, QVAR AMERGE sumatriptan, MAXALT, ZOMIG ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO ARMOUR THYROID levothyroxine, SYNTHROID ASCENSIA STRIPS AND KITS ACCU-CHEK STRIPS AND KITS`, ONETOUCH STRIPS AND KITS` ATACAND, ATACAND HCT BENICAR, BENICAR HCT ATRALIN tretinoin ATROVENT HFA SPIRIVA AXERT sumatriptan, MAXALT, ZOMIG AZELEX erythromycin solution AZMACORT ASMANEX, FLOVENT, PULMICORT, QVAR BECONASE AQ fluticasone BENZAC AC, BENZAC W clindamycin solution, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, BENZACLIN, DIFFERIN, DUAC CS,RETIN-A MICRO, ZIANA BENZAGEL clindamycin solution, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, BENZACLIN, DIFFERIN, DUAC CS,RETIN-A MICRO, ZIANA BENZIQ clindamycin solution, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, BENZACLIN, DIFFERIN, DUAC CS, RETIN-A MICRO, ZIANA BREVOXYL clindamycin solution, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, BENZACLIN, DIFFERIN, DUAC CS, RETIN-A MICRO, ZIANA CARDIZEM LA diltiazem ext-ref CARDURA XL doxazosin, terazosin, FLOMAX CENESTIN estradiol, estrapipate, ENJUVIA, PREMARIN CLARINEX fexofenadine CLARINEX D ALLEGRA-D' CLINDAGEL erythromycin solution DESQUAM E, DESQUAM X clindamycin solution, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, BENZACLIN, DIFFERIN, DUAC CS,RETIN-A MICRO, ZIANA DORAL zolpidem, AMBIEN CR DYNACIRC CR amlodipine, nifedipine ext-ref EPIDUO tretinoin ESTRASORB estradiol, CLIMARA, ESTRADERM, VIVELLE-DOT ESTROGEL estradiol, CLIMARA, ESTRADERM, VIVELLE-DOT EVOCLIN FOAM clindamycin solution, erythromycin solution FEMHRT estradiol-norethindrone, PREMPHASE, PREMPRO FEMTRACE estradiol, estropfpate, EN)UVIA, PREMARIN FENOGLIDE fenofibrate, TRICOR, TRILIPIX FIRSTTESTOSTERONE ANDRODERM,ANDROGEL FORTAMET metformin, metformin ext-ref FOSAMAX PLUS D afendronate FREESTYLE STRIPS AND KITS ACCU-CHEK STRIPS AND KITS', ONETOUCH STRIPS AND KITS' GELNIQUE oxybutynin ext-ref INNOPRAN XL atenolol, propranolal ext-ref ISTALOL timololmaleatesolutioq BETIMOL KLARON LOTION erythromycin solution LUNESTA zolpidem 'nMlw~ MAXAIR PROAIR HFA MENEST estradiol, estropipate, ENIUVIA, PREMARIN MENOSTAR estradiol, CLIMARA, ESTRADERM, VIVELLE-DOT OMNARIS Buticasone PATANASE ASTELIN, ASTEPRO PEXEVA citalopram, Nuoxetine, paroxetine, paroxetine ext-ref, sertraline, LEXAPRO PRECISION XTRA STRIPS AND KITS ACCU-CHEK STRIPS AND KITS', ONETOUCH STRIPS AND KITS' PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO RAPAFLO doxazosin, terazosin, FLOMAX REIION INSULIN HUMULIN INSULIN, NOVOLIN INSULIN RELPAX sumatriptan, MAXALT, ZOMIG SKELID afendronate, ACTONEL STARLIX PRANDIN STRIANT ANDRODERM, ANDROGEL SULAR amlodipine, nifedipine ext-ref SURE-TEST STRIPS AND KITS ACCU-CHEK STRIPS AND KITS', ONETOUCH STRIPS AND KITS' * The preferred alternative products in this list are a broad representation within therapeutic categories of available ueatment options and do not necessarily represent clinical eyuivalenry. Your specifc prescription benefit plan design may not cover certain products, regardless of their appearance in this document For specific inforrnation, visit www.caremark.com or contact a CVS Caremark Customer Care representative, 4 TEKTURNA,TEKTURNA HCT TEVETEN,TEVETENHOT TOVIAZ TRIAZ TRIGLIDE TRUE CARE STRIPS AND KITS, TRUETEST STRIPS AND KITS, TRUETRACK STRIPS AND KITS BENICAR, BENICAR HCT BENICAR, BENICAR HCT oxybutynin ext-rel clindamycinsolution, erythromycinsolution, erythromycin-benzoyl peroxide, tretinoin, BENZACLIN, DIFFERIN, DUAC CS,RETIN-A MICRO, ZIANA fenofibrate, TRICOR, TRILIPIX ACCU-CHEK STRIPS AND KITS', ONETOUCH STRIPS AND KITS' TWINJECT EPIPEN, EPIPEN 1R UROXATRAL doxazosin, terazosin, FLOMAX XOPENEX HFA PROAIR HFA ZODERM clindamycinsolution, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, BENZACLIN, DIFFERIN, DUAC CS, RETIN-A MICRO, ZIANA ZYFLO, ZYFLO CR SINGULAIR "The preferred alternative products in this list are a broad representation within therapeutic categories of available treatment options and du not necessarily represent clinical equivalency. FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. a is not inclusive and does rn~t guarantee coverage. Any brand drug for which a generic product becomes available may be designated as anon-preferred product. Specific prescription beneft 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 copay for specific products on the list Unless specifically indicated, drug list products will incude all dosage forms.This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generic: listed in therapeutic categories are for representational purposes only. This is not anall-inclusive list. Listed products may be ava~Jable generically in certain strengths or dosage forms. Dosage `orms on this list will be consistent with the category and use where listed. Log in to www.caremark.com to check coverage and copay information for a specific medicine. § Generics are available in this class and should be considered the f rst line of prescribing. Copayment, copay yr coinsurance means the amount a plan partiripant is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fxed amount or other charge, with the balanre, if any, paid by a Plan. 2 Indicates the proposed mechanism of action, based on the American Psychiatric Association Summary ofTreatment Recommendations. 3 I liyher copays may apply depending on the plan participant's specific prescription benefit plan. Log in to www.caremark.com to Find the copay under a specific plan. 4 An Aecu-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: 1-800-588-4456. Plan participants rnus[ have CVS Caremark Mail Service Pharmacy benefits [o qualify. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers fvr certain listed products. r This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical ~[ ~~~ manufacturers that are not affiliated with CVS Caremark. ~~~~~1111~~~ Lisi'ed products are for Informational purposes only and are not intended to replace the clinical judgment of the prescribes Ilt\[(~j~ ©2009 Caremark Rx,L.L.C.All rights reserved. 15045-1-1009 wwW. ~ E ~ ~ ~ d ~ ~~~~~.~ ~w~ ~~ a c'~ c ~~ ~,~ yoo a~ ~ °_'~~ ~ v ~~ o m o 0 3 ~~ ~ >.nmoz C L ~o~~~~ ~. ~~~ ~•-a v~~~j~ ~o~O~v E a~ N C m~vU DE ~~ roc ~ a mtQ/~~a U ~ ~ ~ ~ ~ w 'O ~ u y p o~~~~o~ ~ m` ~ ~ ~ E ~ Um~ Cam'., C =O U ~-' as ~~ ~ 30 0 ~ a~ ,9i ~ U a'~n~m`oa ~~~~~`° _._.. ~.~ _ _ m.......~ _g~g N d O 7 .-i t 01 ~ a Y I ~~ i W z a M N ., II L tp~ V V Q Oo' 0 rn o c ~o E °o o I o { v 7 I N i ~ d +~ p 0 O N M N ti 0 ~Y .~ N_ ~_ .V L ML W ~_ L.~ t~ V 0 N M C O ~ 'i ~ ~ a _ ~ ~ a a N v c a ~ K V i O\ ~ Q ~ ~ i d a~.+ C ~ ~ L7 ~' 'C C • L ~ m c~ a~ .~ T ? 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I~ O O IMl1 y~y~ Lf1 tOR 01 M C' V' ~. o V' M N O~ n N ~ N ~ ~ ~ ~.~ I ~ N N cY N u v ~ c ~ V m (~ '~ i ~ L C ~ N N ~ C m C7 i'! O O Q O ~ f ~ ~ .~ U H a~°i v .~ Yn cg H c O .~ .~ U U N f`00 ui Z Q H w ry m ~ d Y V 3 3 3 N W Z ~ M I N r ( ~ m I Q ll N i ~, `. ~ N. 0 €4 O { ( ( C ( ~ I O N .-i O O C N v 3 ~ ~ G y ~., p ~ v ~_ 0 O N M N_ O N M 0~0 .~-~ CQ'n O .--i iPr ~ ti ~ ~ .--~ O N m a V Y L co m u 3 ~V O~ M M lfl O M O M O M M N N N V d' N i0 M O .-~ ~ i~ N ~ .~ fPr i~ tPr Vt ~ • (A N ~ H O ~ M H ~ ~ a~.r ~ N ~ ~ M a z _ ~ Oi I: ri ~ ~ = ~ v a -~ a o ~ .~ ~ .R .~ C Q C N Q ~ N ` ~~ N TI ~ a o ~ 0 ~ _ ~ m a ~ ~ 0 0 0 0 0 L ~ 00 ., O ? v1 N • N ~N tpp t V' ~N M L }1 U ~ 3 N L,i.i OD ~ ( O I p~ 01 Q ~ O H H ry r-1 H y o~ 7 L ~ ~ ~ U L C D a u d C C U .` ~ V .i C c C c 0 ~ ~ 1 ~ N ~ ~ N ~ m ~ Z m ~, o n o+ v n 500 lives: $2500 culture. Each program is uniquely designed to meet your needs and has online GPA Covered Employees and Spouses points and incentive tracking capabilities. The result equals lower healthcare Level I: $1.50 PMPM costs, increased productivity and healthier populations. See below for the Level II: $2.00 PMPM description and components of each program level. Level III: $2.50 PMPM Our BeWell Packages are designed to assist our clients in the Program that is a Non GPA Covered Employees and Spouses right for them based on desired outcomes, budget and resources. All Levels: $4.00 PMPM Cost of Incentives Cost of shipping and handling (if any) HealthMedia ''. HealthMedia, online wellness web site, provides individualization, support and information to empower all individuals to lead healthier lives. It includes a Health Included for GPA covered members Risk Assessment, four online lifestyle management programs, online tools and resources, and a detailed end of plan year report. $4.00/month for non-GPA covered members Lifestyle Management Lifestyle management targets high-risk individuals. This intervention focuses on tailored educational materials and an outreach to stop the progression of the condition and help the employee return to a better health status. Conditions Covered: $100/ hour - Pre-Diabetes -Obesity (billed by the minute, six minute minimum) - Metabolic Syndrome -Smoking Cessation - Hypertension -Back Pain Disease Management Disease management targets groups of individuals with chronic diseases that have evidence of being costly and that can be significantly improved in both cost and quality of life through early intervention, coordination among service providers, and through educational programs. Our Care Coaches proactively contact patients telephonically to monitor their progress and ensure they are $1251 hour following their plan of care. (billed by the minute, six minute minimum) Conditions Covered: - Congestive Heart Failure -Asthma - Coronary Artery Disease (CAD) -Diabetes - Chronic Obstructive Pulmonary Disease (COPD) -Depression Maternity Management ~ Maternity management is a telephonic education program. Expecting Moms $125/ hour receive monthly follow up calls from obstetric nurses as well as targeted, trimester appropriate educational materials. Through on-going assessment the (billed by the minute, six minute minimum) nurse is able to assess risks for the pregnancy and serve as a resource for maternity and delivery related questions. Reward $50 Babies-R-Us gift card (included) IHS Onsite Screenings Health screenings goals is to check whether you are healthy or if you are developing or suffering from an illness. The IHS analysis consists of 34 different $200/screening tests. Results are seamlessly integrated into our HealthWatch Programs. Onsite Health Seminars I We offer professional, fun, and interactive onsite seminars to increase awareness and education on a variety of wellness topics. Presentations can be tailored to $350/1-hour Presentation + travel expense the unique needs of your population. Confidential and Proprietary Information of GPA Page 3 BeWell Program Package Guides - ~.. BeWell Level This level is geared towards employers that might not have onsite support staff or senior management buy-in. This is the start; of creating a culture of wellness,,health risk reduction, and recognizing that employees perform their best. when they are healthy. - Wellness Consulting and Program Design - Wellness Coordinator Support - Custom Online Points and Incentive Tracking - Program Integrates with elected HealthWatch Services Annual Implementation Fee - HealthMedia Programs for Covered Members (including an online Health Risk Assessment) GPA Covered Members $1.50 PMPM - Monthly Wellness Online Seminars Non GPA Covered Members $4.00 PMPM - Monthly HealthWatch Newsletters (posted on employer administrator gpatpa.com site) Cost of Incentives - uarterl Communications, including development (max home 2) Cost of shipping and handling (if any) - Annual Detailed Aggregate and Participant-Identified Reports - 1 Health Challenge - Annual Health Awareness Fair (travel expense not included) BeWell Level 11 This level is designed to promote behavior change and create a supportive environment that can encourage improvements in the health and lifestyle areas that are driving your costs. It is intended. to meet the needs of your; organization and goals. ' Level I Plus: Annual Implementation Fee - Bimonthly Communications, including development (max home 4) GPA Covered Members $2.00 PMPM - 2 Corporate Health Challenges - Annual Health Awareness and Education Fair (travel expense not Non GPA Covered Members $4.00 PMPM included) Cost of Incentives - Health Activities Promotion Cost of shipping and handling (if any) BeWell Level III This level will design an intelligent. approach to incentives and a program designed to maximize behavior change that will result in health risk reduction. This level has the ability to transform the culture' of an organisation and lead to ;~ healthier, more productive employees. Level II Plus: - Monthly Communications, including development (max home 6) Annual Implementation Fee - 4 (maximum) Health Challenges GPA Covered Members $2.50 PMPM - Semi-Annual & Annual Detailed Aggregate & Participant Identified Reports Non GPA Covered Members $4.00 PMPM - Annual Health and Benefits Fair (travel expense not included) Cost of Incentives - "Ask a Care Coach" (online support for everyday health issues) Cost of shipping and handling (if any) - Establish & Support Wellness Committee Meetings (quarterly) Confidential and Proprietary Information of GPA Page 4 Yau r Li n k ~o Hea Ith ier Resu its ,,, Customized Health Benefit Planning for Employers and Brokers Who Want Solutions .... I you're facing the enormous challenge of choosing and partnering with a benefit plan administrator, consider this: At GPA, we embrace our entire healthcare community with unflinching standards and atime-tested commitment. For 40 years, GPA has offered a uniquely customized approach to benefit planning for employers and brokers who want solutions. We provide the highest-quality information, resources and service to employees and providers. If you demand the healthiest employees -- and the "healthiest" bottom line -demand GPA. "We look for a partner that has a solid reputation; core values and a work ethic that closely matches ours; and reasonable pricing. GPA has all ~f these qualities and much more." -GPA Client ................................................................................................ EMBRACING OUR ENTIRE HEALTHCARE COMMUNITY Employers We provide our employer clients with the creative and custom benefit solutions they require. Add to that unrivaled customer service, transparent reporting, total claim management system and employee-targeted programs. In this way, GPA clients receive the best-managed, most-efficient benefits plan. With easy access to enrollment, claim information and online wellness resources, our clients' employees become more accountable for their healthcare. Results include improved health and reduced absenteeism for employees and reduced claims costs and a better bottom line for you. Brokers but their reputation on the line every time they recommend a plan administrator. Brokers choose GPA because we deliver what we say we will, providing responsive service, a flexible offering and reporting -not to mention results. Providers Providers are part of our team, too. We give them easy access to valuable benefit information in a timely manner, making the claims process seamless. u,.. ~~.r,, ~~t~ +e~w '~~t` 'ti' About GPA Largest independently owned TPA in Southwest 40 years of high-quality service More than 100,000 U.S. participants Flexible and comprehensive services. Cost-containment focus Personal and responsive approach Different from the Rest Custom Benefit Plans for every employer Management of ALL claims, small and large Simplified, custom wellness & disease management programs Total claims management solution Personalized service backed by latest technology Stringent focus on management of cost ~~~ ~~li • Group & Pension Administrators, Inc. Park Central 8, 12770 Merit Drive, 2nd Floor, Callas TX 75251 PHONE (972) 238-7900 • TOLD FREE (800) 827-7223 • FAX: (972) 669-8155 • gpatpa.com © 2007 Group & Pension Administrators, Inc. Delivering the Healthiest Employees & the "Healthiest" Bottom Line Our solutions include the highest-quality healthcare plan development, claims processing and management, personal customer support, and wellness and disease management services. Easily accessed through BenefitWatc_hs^"~ asingle-access Web portal, we effectively manage claim expense while improving the long-term health of your employees. Administrative Services and Marketing & Sales -The Personal Touch We offer the highest-quality Administrative and Marketing & Sales services. While we have all the latest technology needed to support you, it's our personal service that delivers results that set us apart. Specialty Services - We Have a Plan for You We offer an array of solutions to meet the needs of employers of any size (US Health and Life, MiniMed, HRAs, HSAs), to offer convenience (TelaDoc'""), manage risk (Fiduciary Liability Transfer and Regulatory Compliance) and to deliver peace of mind °Due to GPA's diligence in coordination of benefits oral eligibility management, vue have seen an immediate savings in claims costs from otar prior administrator." - GPA Client ~~~'~ k }~ t~ { ~t ~} n 1, S h ~ I 'j'l:' .r3,.. ~1 ~ ,Vk b~' 0 i 4 IraE~ TS 4N s ~ ~ Y ~'~~~~ ~ ~ , ~ ~~ { i'~ ` -per Er .1. ~ 3ic]~ ' s ~ k' ~fr \. ~'. ~ ~ , s Y.` ~ ~ ~ ~ k ~ MM .' >r ~' u~.1 C: ! ~ j, I ~ ~N.. ~~~ fi, ~ ~, ~iY~, ~ ~ ~~ !y` > _ For more information, please visit gpatpa.com or contact: Jeff McPeters, CPA, CLU, ChFc, REE3C Sr. Sales Executive 1-972-744-2447 jeffm@gpatpa.com Matt McCuen Sr. Sales Executive 1-972-744-2540 mattm@gpatpa.com i~IIIIIINi Group & Pension Administrators, Inc. Park Central 8, 12770 Merit Drive, 2nd Floor, Dallas TX 75251 PHONE (97Z) Z38-7900 • TOLL-FREE (800) 8Z7-7223 FAX: (972) 669-8155 • gpatpa.com 2007 Group & Pension Administrators, Inc. ~-° ~~' ~~~ ._ .c . ~;- ~~~~ ~ ~ ~ *~ ' ~`~ `~ 1 ~~. ,~~ a ~ ~: ~ ~,. ~~ , , , R ~: r: ,y ^; ? ~ J' The goal: a healthier lifestyle. The key to success: a program tailored specifically to you. The answer: HealthMedia. The information and guidance you need to improve your health is here. Your HealthMedia program begins when you complete the questionnaire that becomes the basis for your personalized roadmap to a healthier lifestyle. A breakthrough in health improve- ment programs, HealthMedia provides individualization, support and information to empower individuals to lead healthier lives. '~~~~~~ I ~- -: c°"GPA ' "~ , dlHeta't/t~,~M~epd{i~a' ~, ~l.t l.l..C. C.. ~ Over 50% of premature death and disease is caused by unhealthy behaviors that can be changed. Leaming to make healthy lifestyle choices is a key to living a longer, healthier, happier life. HealthMedia Succeed®, a health behavior assessment and care plan, will introduce you to the relationship between your behavior and your health. The program will begin by assessing your health- related behaviors such as nutrition, weight, physical activity, stress, and skin protection. According to your unique makeup, a customized action plan will be created just for you. The plan will recommend healthy behavior choices and offer guidance and support toward making positive lifestyle changes. d HYe tam l 1 t h M Y e dC i a• t t V ~! 1 J ~~Poor nutrition is one of the nation's top health risks leading to premature death and disease. Leaming to make healthy eating choices is an important part of illness prevention. HealthMedia Nourish®, a nutrition program, will help you simplify the complex task of making healthy eating decisions. Nourish offers smart and creative strategies for improving eating habits over time, both in terms of food selection and methods for handling challenging situations. By participating in the Nourish program, you will receive a customized action plan and three follow-up newsletters that include techniques for making healthy choices when dining out, shopping, and preparing meals. The program is designed to reinforce changes, deal with trouble spots, and help you develop long-term healthy eating habits. OHfealt/hMedia• tJal a~~eTMOverweight and obesity are major contributors to many preventable causes of death and disease. High blood pressure, high cholesterol, heart disease, and cancer are among the myriad of illnesses associated with higherbody weights. HealthMedia Balance®, a weight management program, will teach you about the critical elements of successful weight loss and maintenance: nutritional habits (food); physical activity patterns (body); and the psychological, emotional, and behavioral patterns (mind) that influence them. By participating in the Balance program, you will be provided with a customized action plan and three follow-up newsletters that include personalized weight management information and self-monitoring activities. The program is designed to help you achieve and maintain a healthy body mass index by giving you the tools to make healthier food choices, increase your physical activity levels, and break the negative patterns between emotions and eating. ~lHea/lthMedia• del Q~'~ Forty-three percent of all adults suffer adverse health affects from stress. Over 50 percent of all lost workdays are due to stress, and 75 to 90 percent of all physician visits are stress-related. Stress is associated with six of the leading causes of premature death-heart disease, cancer, lung ailments, accidents, cirrhosis of the liver, and suicide. HealthMedia Relax®, a stress management program, will teach you how to deal with your daily stress. Relax assesses your sources of stress; your physical, emotional, and behavioral symptoms of stress; and your current healthy and unhealthy stress-management solutions. By participating in the Relax program, you will be provided with a customized action plan that includes important stress-reduction techniques such as muscle relaxation, time management, and physical activity. The program is designed to help you modify your attitudes and behaviors so you can avoid future relapse and lead a less stressful life. . ' C! ealthMe ia• `~ ~reat~ There are 430, 000 tobacco-related deaths each year in the United States. That's 1200 people per day. We don't want you to become a statistic. HealthMedia Breathe®, a smoking cessation program, will provide you with a personalized program to meet your individual quitting needs. The program targets smokers who feel ready to quit and identifies their primary motivations for giving it up, the factors favoring their success, and their barriers to quitting. If you choose to participate in the Breathe program, you will receive a customized action plan and three follow-up newsletters to help you stay strong throughout your quitting process. The program is designed to increase your confidence and motivation, while providing the tools you need to stay quit for good. '! .,~- ";', A Suter w,ty to Belles ffc i~ • ~. .~~ .~._,. #, .Smoke-Free Fos Life Lifestydes~ fear Succes'sfi~I Weight toss >By exp[oevtg differectt quit techniques, learn to apply VWeekly telep~ha~ t with a peofessiortal the best option for ycxt, Special emphasis ~ pieced on expericttced in helping people to lose weight and keep eeuatiott aids and ttse prevention, Work with alt it otL Ixarn a pertttaneni new way of eating that expetienoed profesrional, who has he~od a-~!' etttphasizes a ba3atrced, tt~t-diex app. 'I'ra oottree ~tIIP.lS b ~ snwktttg Su'?! ~ t~'te. w~ guide yon to reshape your habits whtle support you neetd atxi bemrne stake-free fix' Vie! yatrse}f and fe~~ gt'+CSt! Diabetes Prevention and Control Managing Chalestero! Levels !f vvn have diabeaes, or have freest at risk, I)evtlop ~ ' pica fvr bad 1.Ui. learn to snake the right citaiees frx eourd or ~ ratstaa the $caod fIDt, a bwetutg prcvetttioa. You stay also tie to be wozkia6 ~~ t your ~ maY;~iU with yav doAor. Nttlritional and exercise optioru are be but it miry be taediaoet} or trt~ttiderl ~e reviewed in a apExoac3t to help yar erxtect diet aed excrtsse dt0ioes. make die t ehoicea tt3 i~tprove your healtA. Managing a~u1 Preventing Higl: BI©od Pressure Learn the latest proven metttc~i kx redtta~ blood pressure through lifestyle changes. Medication firottt Your phys+csatt may still be required, but ~ y be reduced ar avoided with the axretx diet attd exereise clxtices. •. HeskH~rcna a tare ceded w~h tie IHS Het Erswa~--at too east to yon. (over) €" 1'C~tt Better Nutrition Preventing and Managing. Back Pain Bvahraee ~ earr~trrt eat i~abits awd set Ttas cro~s~se w+ll aaerver y of year q~cio~ abeaat gook Yea w~ ie>vn serateaies for meal- what aunes hoick Aran. iadudes sic ta P ~lrysical acterity aot! a~kx for a fix Figoy tba beaux d ~ . You may be regais~,d Oo atop anere energy and be1ler MealEh kx life. t+c ~ wig Controlling Your Asthma Achieving f3alunce V~th the hrlli of a profesaiorsal, yvW wiY receiut "Itec txhaviixal dime t~acpuc~s w+~ yea icrformat+on, gmidar+ce wind scrpporl you need to; reduce xtre~, ad+ievc balaece aad irwproae !i'+C ' e~t+o) ~ Prey moat act+te asEltrrsa at y~r lik. Year prraoaa! coach ~ help yon ai~ss aad reauatarier poor desirE~ #Ai+rity lewd. Yua sreas ®f need, iwd prix~ide tecl+aw~res !o exec art r+oquired to also be rrit~t yeirr d©ctoc strtac and ma~k~ i eve changes. Penonali~ecl Fitness A Pnrfeaaiowal wtiK hdP yea dcsegn and oacariboir s 6Rness robtinc to hdp Y'~ b*x aAd ~ ~ Addrtias aneh as lilac ~ anJ ata~, i;4 . I lilll{~ ~"" F nfptl~ N4 rawer what G~r'r6ert 1Crrsl. ~ + MN111 fCe~ gadst and become , Ate, ,+ . ~.. jr~ HFottta co~rsea sre w#It ~e ills H Eralus~tion--ot ne eel to ~o~. '~:~ A ~~ ~~A~' ,~ Group & Pension Administrators, Inc. Disease Management Components Health Plans utilize nursing case management and notification to meet the demand for high quality, cost effective health care. Case management's role is to make sure that individuals receive quality health care in a timely manner and in the appropriate setting. While case management has proven to be a valuable service for cost containment, disease management is the next step. Disease management focuses on individuals with chronic conditions using a care coordination concept. Educators work closely with individuals to anticipate their needs and coach on how to manage their lifetime condition. Disease management targets groups of individuals with chronic diagnoses that have evidence of being costly and that can be significantly improved in both cost and quality of life through early intervention, coordination among service providers, and through educational programs. Having disease management services with GPA provides a solution for every level of health. Our HealthWatch programs come together to create a seamless integration to ensure continuous care and cost containment. Disease Management Care Model Participant Identification Enrollment Physician and Case Manager Feedback Initial Assessment and Stratification and Intervention Participant Intervention and Plan Development Ongoing Assessment Outcome Analysis and Reporting 4/24/2007 GPA Disease Management Components Page 2 Our Care Model: 1. Participant Identification: The participants are identified through many different systems, including: a. Notification event from HealthWatch Utilization Review Department -Care Coaches are notified when someone with a chronic diagnosis goes in for a procedure (ie: EKG, stress test, and many others). b. Referral from HealthWatch Case Management to Care Coordination/Disease Management - Once a participant in case management with a chronic diagnosis becomes stable and at home on their own, they are referred to disease management services. Care Coaches are then able to work with the participant to create a care plan that will prevent future episodes that would require case management. c. Completion of an online Health Risk Assessment (HRA) -Employees are encouraged to complete an online HRA to provide both the employee and HealthWatch a complete picture of their health. Those found to have a chronic diagnosis will be referred to a Care Coach. This outlet helps identify those employees who do not actively see their physician about their condition. d. Results of on-site health screening -Results from screenings conducted at the worksite also help identify those employees who may not be controlling their condition or those who were not aware that they have a chronic condition. e. Through Medstat claims statistical information -Medstat reporting provides up-to-date information based on claims data. Reports generated by Medstat show cost of care, co-morbidities, treating physicians, as well as pharmacy data so that we can determine those individuals who would most benefit from working with a Care Coach. Because HealthWatch and its various components are in-house at GPA, the communication systems are very strong. Through our various identification methods, every individual in need can be identified and assisted through every level of health. Once a participant has been identified, their information is thoroughly reviewed to assess co-morbidities, pharmacy use, and current YTD claim amounts. Our goal is first assist those participants who are in a higher disease stage and could potentially have a costly claim in the near future. 2. Enrollment: A physician statement of condition is sent to the participant's primary care doctor as well as any specialist that may be seeing them. The document returned from the physicians includes diagnoses, prescriptions, compliance concerns, and prognosis. A list of prescriptions filled in the last year is requested from the participant's pharmacy provider to ensure compliance with the physician and to assist with care plan development. Participants are then mailed an introductory letter that introduces our Care Coordination program and gives an explanation of the services we offer. (PHI is a priority through every step of the process. The letter will not disclose the participant's diagnoses.) The letter also contains our toll-free number so that the participant can call with questions upon receipt of the letter. 4/24/2007 GPA Disease Management Components Page 3 3. Assessment: A week after the letter is mailed, the participant's Care Coach will contact them to better explain the program and benefits of participation. Once the individual ~,,,.~ commits to participation, the Care Coach will complete a Health Risk Assessment (HRA) with them to better target areas for improvement. 4. Intervention: After the introductory phone call, participants are mailed a welcome kit. The kit typically includes health education materials specific to the participant's diagnoses, as well any areas identified during completion of the HRA. The kit also contains a release for records that the participant is requested to sign and return. If the participant reports that they are not currently tracking their condition or they don't have the equipment necessary, we can send them the supplies at no charge. We have items such as glucometers for diabetes to test their blood sugar, and peak flow meters for asthmatics. 5. Ongoing Assessment: On the next phone call with the participant, the Care Coach completes a disease specific assessment. The assessment focuses on the participants understanding of their condition(s) and the effect they feel it has on their daily life. Prescriptions are discussed and the participant is asked to describe their drug schedule and any problems with taking their medication at the scheduled times. From the questions asked on the disease assessment, the Care Coach is able to assess the participant's knowledge and understanding of their condition, as well as set a treatment plan for them. The participant is asked to set a goal to reach before the next meeting, and the Care coach will mail materials to help the participant reach those goals. Participants are typically contacted monthly depending on their need and requested level of involvement. With each phone conversation, the Care Coach and participant get deeper into the conditions the participant is dealing with and continue setting small goals to step them towards better health. ;~, 6. Outcome: Once the Care Coach or participant feel that the disease is completely under control, and that the participant has obtained their goals, the case can be closed. Participants may be referred to wellness programs or seminars so that they can continue to be active in their healthcare. Should the participant have an episode, they will be referred to case management until their condition becomes stable once again. Participants can stay enrolled in the Care Coordination program for up to one year. Diagnoses Targeted in Care Coordination: Conditions Covered: o Asthma o Diabetes o Coronary Artery Disease o Chronic Obstructive Pulmonary Disease o Depression o Congestive Heart Failure Optional Conditions: o Obesity o Multiple Sclerosis o Hypertension o Rheumatoid Arthritis o Crohn's Disease o High Cholesterol 4/24/2007 GPA Disease Management Components Page 4 Care Coordination Components • Risk Assessment: Individuals can participate in Winning Habits online Health Risk Assessment. The website includes activity and calorie tracking systems, as well as a very comprehensive questionnaire. The results of the questionnaire are submitted to GPA and if the individual has consented, they can be contacted by a Care Coach. • Milliman Care Guidelines: All care plans and assessments are developed using Milliman Guidelines. All information is researched and peer reviewed. • On-site wellness seminars and newsletters: Seminars can be disease specific or more general (ie: obesity, smoking cessation, or diabetes management.) • Educational materials: Participants are provided with workbooks, videos, recipes, pamphlets, and log books to control their conditions. • Supplies: Home monitoring systems are available for dangerously uncontrolled conditions and include scales for heart failure, blood pressure machines, blood sugar, lung capacity, or heart rate. Blood glucose monitors are free for all participants with diabetes, as well as peak flow meters for asthmatics. Ensuring Participation: Because anyone with a chronic diagnosis can benefit from every intervention level, we offer a tiered approach. If a participant is initially reluctant to participate, we can approach it from several different areas. For some, the assurance that this is a free service for them through their employer encourages them to participate. Others don't want to be bothered on the phone. If that is the case, the Care Coach can offer mainly mailed materials with periodic follow-up. If the participant denies their diagnosis or need for intervention, the Care Coach can approach them from an overall wellness standpoint. The physician statement of condition is a helpful tool as well. If a physician reports that their participant is having a difficult time staying with a diet, we can share that with the participant and use it to show them their need for an intervention. It is very rare for a participant to completely decline services. However, if they do, they are put on a periodic follow-up list. We will watch their claim information for any new developments and call the participants just to let them know we are still to here to help if they desire. Quality Assurance: We have a formal quality management program. Our policies are reviewed and approved annually by the Director, C.O.O of GPA, and the VP of Information Technology. - Care Coaches are educated on policies and procedures at orientation, following revisions, and annually. Each coach is provided with a copy of the procedures. - On a monthly basis, 3 cases are reviewed with each Care Coach based on a standard list of guidelines. Corrective action plans will be implemented if it is indicated that a procedure was not adhered to. - Communication of quality improvement outcomes or concerns is made during monthly staff meetings. - Participant satisfaction is assessed through an evaluation form administered at the end of the program or as needed. A physician satisfaction survey is also randomly submitted. - Outside review companies provide services required to maintain URAC credentialing and Texas Department of Insurance Certification. - Care Coaches use Milliman Care Guidelines to assess participant needs, to determine standards of care, and to tailor education. Detailed notes are 4/24/2007 GPA Disease Management Components Page 5 maintained on each participant to serve as a communication tool between coaches and as a monitoring process. - Coaches are provided with continuing education opportunities and educational materials are reviewed annually for content and up-to-date peer-reviewed research information. Enrollment: Approximately 10% of a population will be identified as having a diagnosis for disease management. Of that 10%, around 30% are active participants in the Care Coordination program. Another 10-20% will become involved on a mail only basis with periodic follow-up. Cost Involved: Interaction with participants in the Disease Management Program is billed to the minute at a rate of $125 per hour. Threshold intervention levels exist to determine cost effective candidates for enrollment. Example thresholds include cost of care for the chronic diagnosis to date, presence of co-morbidities, or patterns of non-compliance. 4/24/2007 GPA Disease Management Components Page 6 e a oc• MEDICAL SERVICES TelaDoc is a network of state licensed, board certified primary care physicians providing cross coverage consultations 24 hours a day, 7 days a week, and 365 days a year. TelaDoc physicians diagnose routine, non-emergency medical problems via telephone, recommend treatment and prescribe medication' when appropriate. You can access this service from anywhere! Simply logon to your TelaDoc account or make a phone call to our 800 number and, in most cases, speak to a doctor in less than an thirty minutes. TelaDoc SERVICES TelaDoc consulting physicians treat illnesses that arise quickly and tend to run a brief course, typically 5 -10 days. Consulting physicians address acute, episodic, self-limited and minor illnesses as opposed to chronic (always present) conditions such as hyperten- sion, epilepsy, or diabetes. Remember TelaDoc for: Respiratory Infections Bronchitis Gastroenteritis Allergies Urinary Tract Infections Pharyngitis Sinusitis Rx Refill (short term only) TelaDoc BENEFITS TelaDoc is changing the way people access medical services by using modern technology to match the needs of today's fast paced workforce. Below are just a few ways you and your dependents (aged 10 years and older) benefit from becoming TelaDoc members. *On-Demand access to health care 24/7 -members request consults online or by calling 1-800-TelaDoc (835-2362). *Consult with physicians who diagnose medical problems and prescribe medication' when appropriate *Access to a physician within three hours or the consultation is free! *No outrageous fees or unexpected charges *Retrieve prescriptions from local pharmacy *Ability to maintain personal medical history and account profile using HIPAA compliant secure servers *CMS 1500 Form for filing or reimbursement (when applicable) WHEN TO USE TelaDoc Call TelaDoc whenever you need non-emergency medical assistance. Take advantage of the convenience of accessing a physician 24/7, 365 days a year. Call TelaDoc when: *You cannot reach your primary care physician. (TelaDoc physicians do not replace your primary care physician) *Your primary care physician's office is closed *You are on vacation or a business trip *You need your recurring prescription filled and don't have time to go to your doctor's office (short term refills only) *You need medical attention that might be resolved without seeing your primary care physician *You have medical questions, medical issues, or concerns and would like to discuss these with a physician *You need a second opinion TelaDoc guarantees that a physician will contact you within 3 hours or your consultation is FREE! Note: 'TelaDoc consulting physicians do not prescribe DEA controlled substances. Members must be at least 10 years of age to use the service. Not available in OK. TelaDoc is not an insurance product or a prescription fulfillment warehouse. 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N 3 N D W CA ~ C Q o d N d d ~•' Z c a~i O C C N '- U C7 Q O X Z ~ Z ~ a O Q ~ w J O_ J o ^ ~ ^ ^ o a ~~o ~ o ^ ^ ^ o o ~:o ^ ~ o 0 G~' Group & Pension Administrators, Inc. o Annual Clinical Analysis Report Prepared For ~' o ^ o o ~, SAMPLE CLIENT ~, February, 2009 ~~~~,~~,~~~~~~~~~~~~~~d~~ ~. ~.. ~.. r.. ~ ~ ~ ~~ a Group & Pension Administrators, Inc. Table of Contents -~ a - Executive Summary - Medical Cost Driver Analysis - Episode Group Report - Pharmacy Cost Driver Analysis - Provider Utilization Analysis ~' -~ - Emergency Room Report -~. - Chronic Condition Status - Preventive Care Analysis -~. AU data is reported on an Incurred Claim basis with a three month lag. The results fl h l f ll re ect t e tota o a claims incurred, regardless ofmagnitude, and indicators or totals are not adjusted for large claimants or for any amount the client might receive back from a Stop Loss vendor. Episodic data is reported ui the period when the first diagnosis indicator for the condition was present. - ~' Executive Summar J' ~~~' .. .~ L ~ ~.~. ...~ ~ The data included In this analysis is presented from a Clinical perspective to ~~ help ascertain the types of medical conditions that are inherent within the ~~~ organization. A review of the Clinical data will help to identify the historical ~' ~. expenditure of benefit dollars for health care and to assist in determining ~1 , , ~ how to allocate future expenditures. The data will also show what is driving ~,-1 ~'~ ~ ~` cost in key areas and if there are opportunities to better manage the use of - - ... ^ benefit resources and capital expense. >' ,,l ... .. Ma 'or Observations ~1 i ~ ~. ~:.I "~~ 1. Gross Medical Claim cost is 25% to 30% below most of the comparable Medstat Benchmarks and that is even with five individuals who account for 23.9% of the claims ~', 1', r~ ~. ~ ~~ -,.I ~ 2. Emergency Room cost is 125% higher than the normative data with utilization more than 11% of total cost and an increasing number of visits, especially in the age 30-34 demographic, and many of the visits appear to be for relatively minor events 3. Almost all the Key Indicators from Utilization Statistics are negative which is a very favorable sign of good health status with the organization `'~~,,~' `' -_,_ ~ ~~~ ~._,._ ,r ~+ ,~ ~ 4. 5. Cardiac-related claims are a serious concern with utilization increasing over the periods and Cardiac related cost currently almost 25% of total plan cost In addition to the Cardiac issues there are also concerns about a new Prostate Cancer, the frequency of Gallbladder issues, the jump in the number of Mental Health patients, the high cost for Pancreatic patients, and the increase in Diabetic patients ~' ~~' ~', ~?~~ ~.n r~ 6. The Pharmacy cost per member is relatively low and script pricing is below the Benchmark with high Generic usage, but the Mail Order utilization is almost non-existent ~~~ k =~ ~ ~ id ~ ~ D ~ 7. 8. . In-Network utilization is at a favorable level although one person incurred a significant hospital claim Out-of-Network, skewing some results The number of individuals with manageable Chronic Conditions is high and increasing and this should be an area of focus The number of Preventive Care visits appears very low as a percent of the covered membership and this is another area that needs attention ~~~ ;~ ~ ~I ~.....~ ... ... -1' ^' -1 ^', ^' -l ^ ^ -I' ~' ~ ~' -1 ^ ^' -I' -l -I' -I' ~' ~'', r ~P~ SAMPLE CLIENT Medical Cost Driver Analysis All data in the Analysis is based upon INCURRED CLAIMS for the periods identified and Medstat utilizes athree- month Lag from paid claims for incurred reporting ..~ .. ~. .. rr ~~ l~ ..r r/ ~M ..r ,>~ ..r Illll~ ~w Ir .... Medical Cost Driver Analysis Executive Summary SAMPLE CLIENT WHAT IS DRIVING COST? 1. Is the number of employee and/or dependents stable over the periods or has there been a significant change? 2. Has there been any change in the average age demographics within the organization? 3. What portion of the membership is in rural locations and how is the population distributed? 4. How do key claim cost value indicators and utilization indicators compare with the Medstat Benchmark? 5. What has been the trend of the key claims cost value indicators and utilization indicators over the periods? 6. Is there any particular indicator that "stands out" because it is well off the normative average; and why does it stand out? 7. How are large claims impacting some results? 8. What is the condition of the large claimants and is their condition ongoing? AI $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 257 $8,863 $8 $8 327 $8 018 $~3 , $6 074 , ; , - $4,904 Large Claims excludes all individua _,<:,; ls with net paid claims in excess o f $50,000. CLIENT CLIENT Net GPA Block of United States Southern U.S. Texas United States The threshold is a of Large Business Average PPO Only set factor across Claims the entire GPA block of business. Client compared to National Industry Benchmark Standards to\ec° ~`na~ce & R•E' Hea\thcaSeN`ce todUSttllRe`at\ tndMfg urabte GpOMfg.No~~~urabt .tryosP°~at~or GOVer~meot 'Allowed Amount is the Expense after application of all Claim Reduction Provisions (ineligible, discount, etc.) but before the application of plan design provisions (copays, deductible or coinsurance) Distribution of Total Allowed Amount paid by the Client for Key Service Areas, and owed by the Member as their share of Out- of-Pocket Expense Client -Outside Ring Benchmark -Inside Ring (c) 2009 Group and Pension Administrators, Inc. 2% 18% ^ IP Expense 28% 15% 23% _ _ ^ OP Expense ~s, ^ Pharmacy 49% Member Cost 42% 2 Medical Cost Driver Analysis Demographic Review SAMPLE CLIENT Results Based on Incurred Dates Initial Previous Current Of: Oct 2005 -Sep Oct 2006 -Sep Oct 2007 -Sep 2006 2007 2008 Employee Distribution Average Number of Female Employees 13 Average Number of Male Employees 192 Average Number of Total Employees 205 Male % of Total Employees 93.7% Change in Number of Employees from Prior Period Change in Female % from Prior Period Dependent Distribution KEY STAT 14 17 Avg. Change in Employees 15.88% 213 263 Clients that are experiencing GROWTH 227 280 will have Claim Cost Values that tend to be 93.8% 94.0% LOWER than the Benchmark norms 11.01% 23.24% -0.19% -0.12% Average Number of Spouses 67 71 94 Average Number of Children 92 95 128 Average Number of Members 363 393 502 Average Contract Size 1.77 1.73 1.79 Benchmark Avg. Contract Size 2.08 2.04 ~ 2.03 Variance From Benchmark -14.5% -15.2% -11.8% Change in Contract Size from Prior Period -5.74% 8.45% Average Age of Covered Individuals Average Employee Age 45.07 44.83 44.14 Average Spouse Age 45.25 45.08 43.74 Average Child Age 9.82 10.38 9.74 Average Member Age 36.22 36.57 ~ 35.33 Benchmark Avg. Member Age Variance From Benchmark 32.09 12 9% 32.38 13 0% 32.49 8 7% Change in Employee Age from Prior Period . . -1.0% . -2.8% Change in Member Age from Prior Period -0.7% -5.3% Number of Employees by Age KEY STAT Avg. Change in Contract Size -1.78% Clients that are experiencing STABILITY will have Claim Cost Values that tend to be COMPARABLE with the Benchmark norms KEY STAT Avg. Change in Employee Age -1.04% Clients that are experiencing STABILITY will have Claim Cost Values that tend to be COMPARABLE with the Benchmark norms 50 37 38 38 40 29 28 28 30 _ 21 20 - - - ~5 18 - - ---- 7 6 8 10 0 4 - - - - - 0 0 0 0 Ages 18- Ages 20- Ages 25- Ages 30- Ages 35- Ages 40- Ages 45- Ages 50- Ages 55- Ages 60- Ages 65- Ages 75- Ages 85+ 19 24 29 34 39 44 49 54 59 64 74 84 ^ Prior Period ^ Current Period On average, the highest cost age demographics (for active Male Employees, Age 40-64 employees and their families) are the Male Employee, Age 40-64 Percent of Membership INTERESTING category and the Female Dependent, Age 20-39 category. If more Benchmark Percentage FACT than 35°/ of the membership is in these two categories combined Female Dependents, Age 18-39 then it is likely the Claim Cost Values will be HIGHER than the percent of Membership Benchmark norms. 163 32.5% 44 8.7% (c) 2009 Group and Pension Administrators, Inc. 3 Medical Cost Driver Analysis Location of Membership SAMPLE CLIENT The RURAL QUOTIENT is a methodology of weighting the distribution of members between major metropolitan areas, cities, towns and rural locations. The lower the RURAL QUOTIENT, the greater the likelihood the average cost per member will be KEY STAT below Benchmark norms since healthcare costs are the highest in major metropolitan areas. The members locations are stratified based upon the Metropolitan Service Area size. The closer to zero the RURAL QUOTIENT, the more rural the demographic mix. RURAL QUOTIENT Members Population of Locations for Weighting 437.0 Over 1,500,000 residents 14.9 0.0 700,000 to 1,500,000 residents 11.63 2.0 500,000 to 700,000 residents 23.7 300,000 to 500,000 residents 0 3 6 9 12 15 18 0.0 100,000 to 300,000 residents 46.7 Less than 100,000 residents RURAL URBAN 509.4 TOTAL RESIDENTS If the Rural Quotient is ABOVE the Benchmark average then the Client can expect their costs, on average, to be above comparable Benchmarks. For example, if the client has a Rural Quotient of 13 then the average cost of care for the urban members will be 13% higher than the average cost of care for the rural members. Distribution of Members by RURAL QUOTIENT (size of cities/towns where members residel Less than 100,000 100,000 to 300,000 300,000 to 500,000 500,000 to 700,000 700,000 to 1,500,000 Over 1,500,000 Top Employee Locations (Average Number of Employees) Results Based on Incurred Dates Initial Previous Current Location Of' Oct 2005 - Oct 2006 - Oct 2007 • Percent of Sep 2006 Sep 2007 Sep 2008 Total 1 Houston-Sugar Land-Baytown, TX TX 152.8 160.2 168.2 59.11% 2 Dallas-Plano-Irving, TX TX 4.9 14.2 28.4 9.99% 3 San Antonio, TX TX 15.4 18.5 26.5 9.32% 4 Fort Worth-Arlington, TX TX 9.1 9.8 13.3 4.69% 5 -RURAL TX 12.0 12.7 12.4 4.36% 6 Austin-Round Rock, TX TX 7.2 8.1 10.4 3.66% 7 -RURAL NV 0.0 0.0 8.8 3.10% 8 Reno-Sparks, NV NV 1.0 1.0 7.4 2.61% 9 Little Rock-North Little Rock-Conway, AR AR 0.0 2.0 2.0 0.70% 10 Cambridge-Newton-Framingham, MA MA 1.0 1.0 1.0 0.35% 11 Carson City, NV NV 0.0 0.0 1.0 0.35% 12 Beaumont-Port Arthur, TX TX 0.0 1.0 1.0 0.35% 13 Boston-Quincy, MA MA 1.0 1.0 1.0 0.35% 14 Las Vegas-Paradise, NV NV 0.0 0.0 1.0 0.35% 15 -RURAL ID 0.0 0.0 1,0 0.35% (c) 2009 Group and Pension Administrators, Inc. 4 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of Members Medical Cost Driver Analysis Key Claim Cost Value Indicators (based upon avowed Amount*) SAMPLE CLIENT Results Based on Incurred Initial Previous current Current Period Current Period Oct 2005 - Oct 2006 - Oct 2007 - MedStat variance from variance from Dates Of: Benchmark Benchmark Average Sep 2006 Sep 2007 Sep 2008 * Allowed Amount is the Expense after application of all Claim Reduction Provisions (ineligible, discount, etc.) but before the application of plan design provisions (copays, deductible or coinsurance) Per Member, Per Month (PMPM) Claim Cost Value Breakdow n Medical Expense $284.43 $267.04 $232.58 $275.65 -15.6% -11.0% Pharmacy Expense $41.47 $51.07 $49.97 $73.02 -31.6% 5.2% Medicalln-Patient $123.91 $58.32 $81.32 $85.40 -4.8% -7.4% Mental Health In-Patient $0.00 $0.00 $0.01 $1.92 -99.4% 200.0% Emergency Room $20.17 $31.45 $26.00 $11.46 126.9% 0.5% Out-Patient Facility $57.26 $117.28 $78.41 $79.80 -1.7% -7.0% Physician Office Visit $56.57 $45.86 $39.97 $71.46 -44.1% -15.8% Out-Patient Mental Health $0.21 $0.32 $0.74 $4.81 -84.7% 73.1% Out-Patient Laboratory $16.24 $13.39 $10.68 $14.33 -25.5% -20.5% Out-Patient Radiology $26.57 $24.06 $20.01 $28.47 -29.7% -15.0% Large Claim Impact on PMPM Claim Cost Value Breakdown (Patients with MORE than $50,000 in Net Paid are ENTIRELY removed) Medical Expense $179.03 $203.01 $177.76 Pharmacy Expense $40.90 $49.21 $49.02 Medicalln-Patient $33.23 $24.22 $38.57 Emergency Room $18.71 $25.79 $25.17 Out-Patient Facility $51.31 $91.54 $68.30 Physician Office Visit $56.71 $44.35 $39.03 Large Claims encompass 19.7% of Current Period expense Large Claims encompass 20.7% of Prior Period expense Large Claims encompass 32.5% of Initial Period expense If medical claims in excess of $50,000 are present within an organization's data there will be a trend for Allowed Amount factors KEY to be higher than the Benchmark normative averages. The impact STAT of large claims on the Benchmark is minimal but for an individual client the impact can be significant since these high dollar claims make up a larger portion of the total cost. Variance from Benchmark --Allowed Amount Indicators 150% 100% 50% 0% -50% -100% -150% i ~c eoi_ Impact of Large Claims ot:t zoo? - Sep 2008 oct 2oas - Sep 2007 oct zoos - Sep 2006 ^ Net of Large Claims Expense ^ Gross Total Claim Expense -4.8% -1.7% -44.1 % ° ° -99.4% -84.7% ^ Medical In-Patient ^ Mental Health In-Patient ^ Emergency Room ^Ovt-Patient Facility ^Physician Office Visit ^Out-Patient Mental Health 90ut-Patient Laboratory ^Out-Patient Radiology (c) 2009 Group and Pension Administrators, Inc. 5 $0 $100 $200 $300 $400 Medical Cost Driver Analysis Key Indicators from Utilization Statistics SAMPLE CLIENT Results Based on Incurred Initial Previous current Current Period Current Period Dates Of: Oct 2005 - Oct 2006 - Oct 2007 - MedStat % variance from variance from Sep 2006 Sep 2007 Sep 2008 Benchmark Benchmark Average Patients Total Patients 288 343 424 20.6% Patients per 1000 Members 645.7 638.7 625.4 736.4 -15.1% -1.8% Avg. Allowed per Patient $ 3,232 $ 3,674 $ 3,304 $ 3,502 -5.7% -2.9% In-Patient Utilization Total Admissions 21 19 20 0.0% Admits per 1000 Members 76.99 48.32 39.85 63.96 -37.7% -27.6% Average Length of Stay 5.38 2.79 5.30 4.40 20.4% 18.0% Days per 1000 Members 414.3 134.8 211.2 255.5 -17.4% -16.7% Avg. Allowed per Day $ 3,589 $ 5,193 $ 4,621 $ 3,511 31.6% 3.4% Out-Patient Visit Utilization Total Out-Patient Visits 1,479 2,044 2,245 16.8% OP Facility Visits per 1000 509.6 602.7 532.0 1037.7 -48.7% -2.9% Avg. Allowed per OP Facility Visit $ 1,348 $ 2,335 $ 1,769 $ 1,578 12.1% -2.7% Office Visits per 1000 3780.0 4030.5 3506.6 5618.6 -37.6% -7.0% Avg. Allowed per Office Visit $ 180 $ 137 $ 137 $ 162 -15.5% -9.4°/a Visits per Patient 5.14 5.96 5.29 6.26 -15.4% -3.1% Services Provided Total Services 5,926 7,519 8,580 16.9% Total Services per 1000 Members 21,727 19,120 17,094 23,139 -26.1% -11.5% Avg. Allowed per Service $ 157 $ 168 $ 163 $ 169 -3.4°/a 0.4% Physician Services per 1000 19,956 18,100 16,116 16,357 -1.5% -10.8% Laboratory Services per 1000 5,921 5,844 5,326 5,302 0.4% -6.5% Radiology Services per 1000 1,261 1,330 1,050 1,612 -34.8% -13.5% Services per Patient 20.58 21.92 20.24 22.43 -9.8% -3.2% In-Patient Admissions are the biggest utilization cost driver and variances from the Benchmark normative average tell most of the story. But some of the In-Patient Utilization KEY indicators are co-dependent. For example, if the average length of stay is below the STAT Benchmark then the Average Allowed per Day will almost certainly be above the Benchmark. This is because the first day at a facility is always the most expensive and the cost is spread over a shorter period of time. Variance from Benchmark -- Key Utilization Indicators (c) 2009 Group and Pension Administrators, Inc. 6 ^ Admits/1000 ^ ALOS ^ Days/1000 ~ OP Fac11000 ^Phy Visit/1000 ^Phy Serv/1000 ~ Lab Serv/1000 ^ Rad Serv/1000 Medical Cost Driver Analysis Top 40 Highest Cost Claimants -- Current Period (paid above $10,000 only) SAMPLE CLIENT Claims Incurred for Period of: Oct 2007 -Sep 2008 1o.s2% Patient rimary Diagnosis In-Patient Aut- Physician Drug All Other Total Out of Identifier (highest cost service) Patient Claims Network 1 H87034103541 Pancreat Cyst/Pseudocyst $ 82,551 $ 1,675 $ - $ - $ - $ 84,225 $ 6,241 2 H87034103071 Crnry Athrscl Natve Vssl $ 41 $ 63,553 $ 2,399 $ 899 $ - $ 66,892 $ 3 H87034102701 AMI Inferior Wall, Init $ 61,350 $ 67 $ 575 $ 2,050 $ - $ 64,043 $ 4 H87034104152 Single LB In-Hosp w Cs $ 62,840 $ - $ 57 $ 189 $ - $ 63,086 $ 7,671 5 H87034104481 Ocl Crtd Art wo Infrct $ 44,842 $ 3,975 $ 2,693 $ 2,448 $ - S 53,958 $ 6 H87034101721 Malignant Neoplasm Cecum $ 38,186 $ 4,432 $ 3,986 $ 1,136 $ - $ 47,740 $ 2,679 7 H87034100461 Crnry Athrscl Natve Vssl $ 38,430 $ 1,652 $ 3,509 $ 1,909 $ - $ 45,501 $ 37,734 8 H87034104972 Int Derangement Knee NEC $ 32,510 $ 1,850 $ 404 $ 1,499 $ - $ 36,263 $ 9 H87034104151 Placenta Prev Hem-Deliv $ 28,666 $ 589 $ 773 $ 38 $ - $ 30,065 $ 651 10 H87034104382 Acute Pancreatitis $ 23,432 $ 1,411 $ - $ 165 $ 270 $ 25,279 $ 1,613 11 H87034104132 Uterine Leiomyoma NOS $ 4,691 $ 13,850 $ 276 $ 511 $ - $ 19,328 $ 867 12 H87034102801 Lower Nephron Nephrosis $ 11,937 $ 2,597 $ 591 $ 3,083 $ - $ 18,207 $ 13 H87034104612 Torsion of Testis NOS $ - $ 16,360 $ 714 $ 135 $ - $ 17,209 $ 5,332 14 H87034100992 Postop Vaginal Prolapse $ 12,432 $ 4,232 $ 369 $ 44 $ 50 $ 17,127 $ 1,679 15 H87034101331 Corneal Opacity NOS $ - $ 13,083 $ 897 $ 2,488 $ - $ 16,467 $ 16 H87034102891 Cataract NOS $ - $ 14,286 $ 458 $ 1,442 $ - $ 16,186 $ 5,118 17 H87034103622 Cholelith w Cholecys NEC $ - $ 13,143 $ 567 $ 1,473 $ - $ 15,183 $ 18 H87034103901 Loc Osteoarth NOS-Shlder $ - $ 13,893 $ 408 $ 152 $ - $ 14,453 $ 1,960 19 H87034105162 Cholelith w Cholecys NEC $ 94 $ 12,803 $ 457 $ 419 $ - $ 13,773 $ 1,573 20 H87034103792 Dis of Gallbladder NEC $ - $ 11,886 $ 1,150 $ 449 $ 50 $ 13,535 $ 394 21 H87034100611 Chrnc Hpt C wo Hpat Coma $ - $ 1,503 $ 2,437 $ 9,200 $ - $ 13,140 $ 22 H87034100363 Hered Prog Musc Dystrphy $ - $ 12,325 $ 506 $ 23 $ - $ 12,854 $ 9,724 23 H87034100532 Unc Beh Neo Brain/Spinal $ - $ 11,345 $ 175 $ 561 $ - $ 12,081 $ 24 H87034101094 Unilat Inguinal Hernia $ - $ 11,581 $ 217 $ 15 $ - $ 11,814 $ 861 25 H87034101722 Cataract NEC $ - $ 7,290 $ 884 $ 3,486 $ - $ 11,660 $ 26 H87034100671 Carpal Tunnel Syndrome $ 100 $ 8,918 $ 2,073 $ 303 $ - $ 11,394 $ 27 H87034105021 Lumbar Disc Displacement $ - $ 10,358 $ 170 $ 51 $ - $ 10,579 $ 366 28 H87034105001 Convulsions NEC $ - $ 5,285 $ 4,868 $ 330 $ - $ 10,483 $ 502 29 H87034104311 Chest Pain NEC $ 88 $ 9,354 $ 862 $ - $ - $ 10,304 $ 550 30 31 32 33 34 35 36 37 38 39 40 23-9°l0 15.5% ~ 37.1 °/ Top Individual Top 2 Individuals Top 3 Individuals Top 5 Individuals lop 10 Individuals Top 20 Individuals Top 40 Individuals (c) 2009 Group and Pension Administrators, Inc. 7 GPA )]' SAMPLE CLIENT Episode Group Clinical Analysis All data in the Analysis is based upon INCURRED CLAIMS for the periods identified and Medstat utilizes athree- month Lag from paid claims for incurred reporting ---T-- r.. Clinical Condition Cost Driver Analysis Episodic Group Summary SAMPLE CLIENT WHAT IS DRIVING COST? ilr 1 How do Episodic Groups compare to the Benchmark norms with regard to total expense and percentage utilization? ~ 2 Is EENT a high dollar expense Episodic Group, which is considered very positive? 3 Are Episodic Groups impacted by individual patient high cost episodes? i 4 Is there any trend in the number of patients in an Episodic Group? 5 How do Clinical Episodes compare in both utilization and cost against the ._ normative data? 6 Is the frequency of Episodes in line with Benchmarks? 7 Is the average cost per Episode consistent with the Benchmark? ~ 8 Are any of the Cost Saving Suggestions being utilized current or viable? tplsoae group I otais ~ (Incurred Dates) i~ Client's Total Medical Episodes Client's Total Medical Episodic Cost r^s^ All Episodes Average Cost per Patient I WHAT IS AN EPISODE? An Episode of Care is a summary record of all care for a course of treatment for a disease or condition. It includes inpatient, outpatient and prescription drug claims. If there is no treatment for an identified episode over a 60 day period then a recurrence of the same condition will be classified as a new episode. Initial Period Previous Period Current Period 3-Year Totals/Avera e Oct 2005 -Sep 2006 Oct 2006 -Sep 2007 Oct 2007 -Sep 2008 g 773 1,012 1,148 2,933 $ 904,488 $ 1,201,026 $ 1,151,380 $ 3,256,894 $ 1,170 $ 1,187 $ 1,003 $ 1,110 Episode Groups attribute all treatment costs to the time period in which the condition initially begins I WHAT IS AN EPISODIC GROUP? I An Episodic Group is a compilation of all individual episodes into groupings based upon either Major Organ Systems, Regional Groups of the Human Body, or Disease Specific incidences. There are ten Episodic Groups with Cancer the only category that is entirely Disease Specific. The tenth category, All Other Serious Conditions, consists of episodes not easily classified into one of the previous groupings. Eye, Ears, Nose 8 Throat and Preventive Care is the category with most of the lower cost type of services and ideally a client should strive to have the highest percentage of claims in this category. s, EPISODIC GROUP WITH HIGHEST DOLLAR COST IN THE CURRENT PERIOD r~ 1 CARDIAC CONDITIONS rli~r 2 MUSCULOSKELETAL EPISODIC GROUP WITH HIGHEST DOLLAR COST OVER ALL PERIODS ~a 1 CARDIAC CONDITIONS l~ 2 EYE, EAR, NOSE, THROAT & PREVENTIVE EPISODIC GROUP WITH LARGEST DOLLAR liillii~ INCREASE: PREVIOUS TO CURRENT 1 MATERNITY /NEWBORN 2 CARDIAC CONDITIONS 1~ EPISODIC GROUP WITH BIGGEST % INCREASE: liili~^ PREVIOUS TO CURRENT 1 MATERNITY /NEWBORN ~ 2 NERVOUS SYSTEM DISORDERS liiiiiii~ (c) 2009 Group and Pension Administrators, Inc. ~~ Current Period Change from Previous Period ^Client's Total Medical Episodes ®Client's Total Medical Episodic Cost ^All Episodes Average Cost per Patient EPISODIC GROUP WITH LARGEST INCREASE IN # OF PATIENTS: PREVIOUS TO CURRENT 1 MUSCULOSKELETAL 2 EYE, EAR, NOSE, THROAT & PREVENTIVE EPISODIC GROUP WITH BIGGEST % JUMP IN # OF PATIENTS: PREVIOUS TO CURRENT 1 NERVOUS SYSTEM DISORDERS 2 MUSCULOSKELETAL EPISODIC GROUP WITH BIGGEST % VARIANCE ABOVE BENCHMARK IN CURRENT PERIOD 1 CARDIAC CONDITIONS 2 HEPATOBILIARY 8 REPRODUCTIVE EPISODIC GROUP WITH BIGGEST ABOVE BENCHMARK OVER ALL F 1 CARDIAC CONDITIONS 2 HEPATOBILIARY 8 REPRODI 2 Clinical Condition Cost Driver Analysis Episodic Group Summary SAMPLE CLIENT Each Episode Group Patients & Cost Totals CARDIAC CONDITIONS CANCER TREATMENT EYE, EAR, NOSE, THROAT & PREVENTIVE DIGESTIVE & ABDOMINAL CONDITIONS MATERNITY /NEWBORN NERVOUS SYSTEM DISORDERS MUSCULOSKELETAL HEPATOBILIARY & REPRODUCTIVE RESPIRATORY CONDITIONS OTHER SERIOUS CONDITIONS Each Episode Group Cost as a Percentage of Total Cost CARDIAC CONDITIONS CANCER TREATMENT EYE, EAR, NOSE, THROAT & PREVENTIVE DIGESTIVE 8 ABDOMINAL CONDITIONS MATERNITY/NEWBORN NERVOUS SYSTEM DISORDERS MUSCULOSKELETAL HEPATOBILIARY 8 REPRODUCTIVE RESPIRATORY CONDITIONS OTHER SERIOUS CONDITIONS Benchmark Current Period Previous Period Initial Period Initial Period Previous Period Current Period 3-Year Totals/Avg Patient ~ Net Paid by Episodes Client Patient I Net Paid by Episodes Client Patient Episodes 'Net Paid by Client Patient 'Net Paid by Episodes Client 88 _ - 46 - 278 $ 178,131 - $ 147,301 $ 167,124 112 _ 50 370 $ 254,426 -- ! $ 116,985 $ 177,230 111 - 1, 40 - 406 $ 284,948 'i $ 106,446 $ 149,504 311 i $ 2,307 136 I $ 2,726 -~ --- 1054 $ 469 65 $ 34,188 102 $ 164,697 96 $ 111,383 263 $ 1,180 6 $ 14,918 8 $ 33,484 10 $ 79,336 24 $ 5,322 16 $ 2,056 22 $ 8,2401 39 $ 17,675 77 ! $ 363 134 53 ~ $ 137,66 $ 136,002' 159 $ 155,788'1 239 ~ ~ 65 ', $ 184,992 80 $ 166,155 - $ 119,911 532 i 198 $ 864 $ 2,227 46 $ 42,255 58 I $ 44,689 63 $ 53,543 167 $ 841 41 ~ $ 44,846 66 $ 60,495 64 $ 62,478 171 $ 981 Initial Period Previous Period Current Period 3-Year Totals/Avg Client MedStat Benchmark Client MedStat Benchmark Client ' MedStat Benchmark Client MedStat Benchmark 19.69% ' 15.76% 16.29% 12.47% 21.18% 15.51 % 9.74% 12.40% 24.75% 9.25% 13.99% 11.42% 22.03% 11.38% 14.97% 12.03% 18.48% 12.30% 14.76% 12.73% 12.98% 14.01% 15.16% 13.13% 3.78% 9.35% 13.71% 9.70% 9.67°/ 10.66% 9.53% 9.99% 1.65% 7.47% 2.79% 7.57% 6.89% 6.42% 3.92% 7.09% 0.23% 2.98% 0.69% 2.64% 1.54% 2.98% 0.86% 2.86%- 15.22% 19.05% 12.97% 19.27% 14.43% ~ 19.17°/a 14.11% ~ 19.18% 15.04% 8.46% --- 15.40% 7.86% 10.41% - 8.05% 13.54% 08 8% 4.67% 4.21% - 3.72% 4.59% 4.65% 5.53% .- - 4.31% 4.87% 4.96% 7.96% 5.04% % 7.72% 5.43% ~.76`%, 5.15% 7.80% 15.0% 12.0% 13.1% 10.0% 7.1% .9° 19.2% 8.1% 4.9% 7.8% 9.7% 6.9% 1 5 ° 14.4% 10.4% 5.4% 21.2% 9.7% 14.8% 13.7% .» % t 15.4% 5.0% 19.7% 16.3 % 18.5% 8 15.2% 15.0% 5.0% I (C) 2009 Group and Pension Administrators, Inc. 0 Cardiac OCancer EENT ^ Digestive O Maternity ^ Nervous ®Musculoskeletal ^ Heptobiliary ®Respiratory ^ Other 3 Clinical Condition Cost Driver Analysis Top 50 Highest Cost Clinical Episodes SAMPLE CLIENT TOP COST EPISODES Bench- M lti P i d Multi-Period Average Cost Benchmark Expected Frequency mark u - er o Number of Per Patient Average Cost Frequency within Ranking Total Cost Patient Episode Per Patient population within Based on Multi-Period Cost Episodes Epis. Population 1 Angina Pectoris, Chronic Maintenance 3 $ 255,346 29 $ 8,805 $ 5,531 2.30%I 2.03% 2 Encounter for Preventive Health Services 1 $ 137,444 327 $ 420 $ 422 25.98%'! 36.35% 3 Essential Hypertension, Chronic Maintenance 4 $ 124,890 200 $ 624 $ 704 15.89%!, 11.48% 4 Diabetes Mellitus Type 2 Maintenance 7 $ 115,297 102 $ 1,130 $ 1,351 8.10%I, 4.77% 5 Pancreatitis ~ -- - 51 $ 115,084 6 $ 19,181 - - -- $ 16,605 - 0.48% 0.10% 6 Cholecystitis and Cholelithiasis 11 $ 97,241 10 $ 9,724 $ 8,904 0.79%j 0.56% 7 Cerebrovascular Disease with Stroke 23 $ 94,914 4 $ 23,728 $ 11,596 0.32%~ 0.26% 8 Other Pancreatic Disorders 277 $ 94,253 1 $ 94,253 $ 6,394 0.08% 0.02% 9 Factors Influencing Health Status 83 $ 87,429 16 $ 5,464 $ 399 1.27% 2.27% 10 Neoplasm: Eyelid -- -- -- 284 - -- $ 73,877 _ - _ 1 _ $ 73,877 - $ 4,944 --- _ _ 0.08% 0.02% - - ----- - - 11 Neo lasm, Mali Want: Prostate P 9 40 $ 67,956 11 $ 6,178 $ 5,127 ° ; 0.87/0, 0.40% 12 Other Respiratory Symptoms 19 $ 67,255 49 $ 1,373 $ 1,053 3.89%i 3.27% 13 Neoplasm, Benign: Adenomatous Polyps, Colon 29 $ 67,081 28 $ 2,396 $ 2,196 2.22% 1.14% 14 Uterovaginal Prolapse 77 $ 64,034 6 $ 10,672 $ 5,289 0.48% 0.19% 15 Acute Myocardial Infarction 6 $ 63,376 I, 5 $ 12,675 $ 28,289 0.40% 0.23% 16 Prematurity, Low Birthweight 52 $ 62,869 1 $ 62,869 $ 17,525 0.08% 0.10% 17 Tibial, Iliac, Femoral, or Popliteal Artery Dis 50 $ 52,429 '~ 2 $ 26,215 $ 5,404 0.16% 0.34% 18 Osteoarthritis 2 $ 51,759 31 $ 1,670 $ 4,693 2.46% 2.81% ! 19 Neoplasm, Malignant: Colon and Rectum 17 $ 41,606 1 $ 41,606 $ 28,870 0.08% 0.12% 20 Urinary Tract Infections 37 $ 38,814 36 $ 1,078 $ 658 2.86% 3.12% 21 Other Atherosclerosis 290 $ 38,577 2 $ 19,289 $ 698 0.16% 0.12% 22 Bursitis 33 $ 38,573 13 $ 2,967 $ 1,085 1.03% 2.21 23 Asthma, Chronic Maintenance 21 $ 38,157 40 $ 954 $ 1,079 3.18%~ 2.88% 24 Other Arthropathies, Bone and Joint Disorders 12 $ 37,637 84 $ 448 $ 529 6.67%' 9.15% 25 Herniated Intervertebral Disc 5 $ 36,360 12 $ 3,030 $ 6,148 0.95% 1.08% 26 Neoplasm, Benign: Uterus (Leiomyomas) 55 $ 36,248 5 $ 7,250 $ 4,330 0.40% 0.37% 27 Hernia, External 36 $ 35,451 ', 7 $ 5,064 $ 4,313 0.56% 0.48% 28 Injury: Knee, Ligamentous ! 60 $ 35,230 ~ ' 9 $ 3,914 ~ $ 1,713 0.71% 0.82% 29 Sinusitis I 25 $ 33,607 87 $ 386 ' $ 329 6.91% 8.54% 30 Cataract 64 $ 32,478 'I 13 $ 2,498 $ 1,175 1.03% 1.07% 31 Pharyngitis, Non-Streptococcal 31 $ 31,583 69 $ 458 $ 316 5.48% 7.72% 32 Hernia, Hiatal or Reflux Esophagitis 32 $ 31,159 42 $ 742 $ 1,034 3.34% 2.35% 33 Other Gastrointestinal or Abdominal Symptoms 27 $ 30,817 50 $ 616 $ 670 3.97%' 3.92% 34 Arrhythmias 20 $ 29,736 20 $ 1,487 $ 2,595 1.59% 1.21% 35 Delivery, Cesarean Section 13 $ 29,700 1 $ 29,700 $ 12,776 0.08% 0.38% 36 DiverticularDisease 45 $ 29,511 i! 9 $ 3,279 $ 2,906 0.71%i 0.68% 37 Muscular Dystrophy 392 $ 28,107 ~ 3 $ 9,369 ! $ 2,089 0.24%'~ 0.01% 38 Rhino, Adeno, and Corona Virus Infections 38 $ 26,071 83 $ 314 $ 255 6.59% 8.02% 39 Infections of Skin and Subcutaneous Tissue 30 $ 25,926 41 $ 632 $ 707 3.26% 3.46% 40 Rheumatoid Arthritis 41 $ 25,415 7 $ 3,631 $ 4,965 0.56% 0.41 41 Dysfunctional Uterine Bleeding 22 $ 24,015 29 $ 828 $ 1,258 2.30% 2.43% 42 Headache 24 $ 22,427 29 $ 773 $ 862 2.30% 3.37% 43 Mitral Stenosis 58 $ 22,294 13 $ 1,715 $ 2,074 1.03% 0.69% 44 Otitis Media 47 $ 22,289 I 74 $ 301 $ 366 5.88% 5.23% 45 Appendicitis 46 $ 20,752 3 $ 6,917 $ 11,070 0.24% 0.17% 46 Neoplasm: Central Nervous System 75 $ 19,876 4 $ 4,969 $ 15,578 0.32% 0.07% 47 Other Ear, Nose, and Throat Infections 61 $ 19,229 95 $ 202 I, $ 177 7.55% 7.68% 48 Other Spinal and Back Disorders 16 $ 19,138 55 $ 348 $ 652 4.37% 5.62% 49 Fracture, Dislocation, or Sprain: Humerus/Shoulder 44 $ 18,103 !, 7 $ 2,586 $ 2,518 0.56% 0.79% 50 Delivery, Vaginal 8 $ 17,499 3 $ 5,833 $ 7,264 0.24% I 0.84% (c) 2008 Group and Pension Administrators, Inc. 4 Clinical Condition Cost Driver Analysis Top Highest Cost Individual Episodes -- Current Period SAMPLE CLIENT TOp 4U EpISOdeS by Patient (patients highlighted have more than one episode) Claims Incurred for Period of: Oct 2007 -Sep 2008 Patient Episode Group Detail Episode Group Net Paid High Cost Identifier Position' 1 H87034103071 Angina Pectoris, Chronic Maintenance Cardiac Conditions $ 64,690 2 2 H87034104152 Prematurity, Low Birthweight Maternity /Newborn $ 62,869 4 3 H87034102701 Acute Myocardial Infarction Cardiac Conditions $ 61,794 3 4 H87034104481 Cerebrovascular Disease with Stroke Cardiac Conditions $ 44,910 5 5 H87034100461 Angina Pectoris, Chronic Maintenance Cardiac Conditions $ 42,389 7 6 H87034101721 Neoplasm, Malignant: Colon and Rectum Cancer Treatment $ 41,606 6 7 H87034104972 Injury: Knee, Ligamentous Musculoskeletal $ 32,510 8 8 H87034104382 Pancreatitis Heptobiliary $ 24,199 10 9 H87034104132 Neoplasm, Benign: Uterus (Leiomyomas) Cancer Treatment $ 18,850 11 10 H87034100992 Uterovaginal Prolapse Heptobiliary $ 16,275 14 11 H87034102891 Cataract EENT /Preventive $ 14,608 16 12 H87034103622 Cholecystitis and Cholelithiasis Gastric $ 13,205 17 13 H87034102801 Renal Failure Heptobiliary $ 12,103 12 14 H87034103901 Osteoarthritis Musculoskeletal $ 11,851 18 15 H87034101094 Hemia, External Musculoskeletal $ 11,735 24 16 H87034105021 Herniated Intervertebral Disc Musculoskeletal $ 10,170 27 17 H87034104311 Other Respiratory Symptoms Respiratory $ 9,341 29 18 H87034105162 Cholecystitis and Cholelithiasis Gastric $ 9,285 19 19 H87034101132 Dysfunctional Uterine Bleeding Heptobiliary $ 8,841 #N/A 20 H87034101071 Angina Pectoris, Chronic Maintenance Cardiac Conditions $ 8,691 #N/A 21 H87034100611 Anemia Other , 22 H87034100303 Ectopic Pregnancy Maternity /Newborn $ 8,462 #N/A 23 H87034100611 He atitis C p 24 H87034100921 Rheumatoid Arthritis Musculoskeletal $ 7,997 #N/A 25 H87034100532 Neoplasm: Central Nervous System Cancer Treatment $ 7,718 23 26 H87034100671 Carpal Tunnel Syndrome Musculoskeletal $ 7,488 26 27 H87034100363 Muscular Dystrophy Musculoskeletal $ 7,286 22 28 H87034105551 Calculus of the Urinary Tract Heptobiliary $ 6,893 #N/A 29 H87034104761 Fracture, Dislocation, or Sprain: Foot Musculoskeletal $ 6,663 #N/A 30 H87034105714 Foreign Body: Nasopharynx, Throat or Bronchus EENT /Preventive $ 6,648 #N/A 31 H87034104612 Cryptorchidism Heptobiliary $ 6,537 13 32 H87034103792 Other Biliary Disorders Heptobiliary $ 6,351 20 33 H87034102102 Neoplasm, Benign: Adenomatous Polyps, Colon Cancer Treatment $ 6,269 #NIA 34 H87034105271 Other Respiratory Symptoms Respiratory $ 6,139 #N/A 35 H87034103841 Pneumonia, Bacterial Respiratory $ 5,987 #N/A 36 H87034101162 Dysfunctional Uterine Bleeding Heptobiliary $ 5,785 #N/A 37 H87034104913 Rhino, Adeno, and Corona Virus Infections EENT /Preventive $ 5,726 #N/A 38 H87034100652 Hernia, Hiatal or Reflux Esophagitis Gastric $ 5,708 #N/A 39 H87034103072 Headache EENT /Preventive $ 5,650 #N/A 40 H87034105732 Delivery, Vaginal Maternity I Newborn $ 5,641 #N/A "High Cost Position is the corresponding location from the High Cost Claimant Section of the Medical Cost Driver Report #N/A --Individual does not appear in the High Cost Claimant Section of the Medical Cost Driver Report Each High Cost Episode Group as a Percentage of All High Cost Episodes ®Cardiac Conditions ^ Cancer Treatment ^ EENT I Preventive ^ Gastric 8 Maternity /Newborn ©MHSA ^Musculoskeletal O Heptobiliary ~ Respiratory ^ Other Serious Conditions (c) 2009 Group and Pension Administrators, Inc. 5 rF o` 0e Clinical Condition Cost Driver Analysis Cardiac Episodic Group CARDIAC CONDITIONS Includes circulatory system and blood-related organs and issues) SAMPLE CLIENT Client is % ofTotal Benchmark ABOVE 24.75% 13.99% The most commonly occurring Cardiac Condition nationally is routine High Blood Pressure, which occurs on average in 11.48% population each year with an average cost of $704 per patient episode; 17.36% of Cardiac total cost Common High Frequency Cardiac Conditions Essential Hypertension, Chronic Maintenance Angina Pectoris, Chronic Maintenance Arrhythmias Other Cardiovascular Symptoms Mural Stenosis Treatments Frequency Total Cost Avg. Cost per Patient 200 15.89% 11.48% 17.41% 17.36% $ 624 $ 704 29 2.30% 2.03% 35.59% 24.13% $ 8,805 $ 5,531 20 1.59% 1.21% 4.14% 6.75% $ 1,487 $ 2,595 10 0.79% 0.94% 0.18% 1.70% $ 129 $ 840 13 1.03 % 0.69% 3.11 % 3.09% $ 1,715 $ 2,074 client Cost NORMAL REVIEW GREAT GREAT NORMAL There are several very high cost procedures that occur in the Cardiac Category, some frequently like Heart Attack (Acute Myocardial Infarction) or Stroke, and other less common such as Transposition of Great Arteries (fetal heart defect), Hemophilia or Infective Endocarditis Normal Highest Cost Cardiac Conditions Angina Pectoris, Chronic Maintenance Essential Hypertension, Chronic Maintenance Acute Myocardial Infarction Arrhythr~ias Cerebrovascular Disease with Stroke Treatments Frequency Total Cost Avg. Cost per Patient 29 2.30% 2.03% 35.59% 24.13% $ 8,805 $ 5,531 200 15.89% 11.48% 17.41% 17.36% $ 624 $ T04 5 0.40% 0.23% 8.83% 14.16% $ 12,875 $ 28,289 20 1.59% 1.21% 4.14% 6.75% $ 1,487 $ 2,595 4 0.32% 0.26% 13.23% 6.42% $ 23,728 $ 11,596 Client Cost REVIEW NORMAL GREAT GREAT REVIEW ACCORDING TO I Heart Disease is the #1 cause of death in the U.S. among adults and is the primary diagnosis for 11 % of all patient seeking treatment each year. Although the death rate is declining, costs are increasing due to socioeconomic THE CDC or NIH: status, obesity and physical inactivity. Top 15 Episode Group Detail Oct 200 5 -Sep Zoos Oct 200 6 -Sep 2007 Oct 200 7 -Sep 2008 Total Patient Total Cost Avg. Cost er Patient (based on claims incurred during period) Patient Client Cost Patient Client Cost Patient Client Cost Episodes p Episode Epis. Epis Epis Angina Pectoris, Chronic Maintenance 11 $ 25,330 10 $ 109,731 8 $ 120,285 29 $ 255,346 $ 8,805 Essential Hypertension, Chronic Maintenance 60 $ 38,736 69 $ 45,716 71 $ 40,438 200 $ 124,890 $ 624 Acute Myocardial Infarction 0 $ - 2 $ 1,306 3 $ 62,069 5 $ 63,376 $ 12,675 Tibial, Iliac, Femoral, or Popliteal Artery Dis 1 $ 51,660 1 $ 769 0 $ - 2 $ 52,429 $ 26,215 Other Atherosclerosis 0 $ - 2 $ 38,577 0 $ 2 $ 38,577 $ 19,289 Mitral Stenosis 3 $ 1,608 5 $ 18,902 5 $ 1,784 13 $ 22,294 $ 1,715 Congestive Heart Failure 0 $ - 4 $ 16,877 0 $ 4 $ 16,877 $ 4,219 Aortic Stenosis 1 $ 512 2 $ 3,831 1 $ 2,777 4 $ 7,120 $ 1,780 Cerebrovascular Disease with TIA 0 $ - 2 $ 302 5 $ 5,784 7 $ 6,086 $ 869 Cerebrovascular Disease, Chronic Maintenance 0 $ - 0 $ - 1 $ 2,193 1 $ 2,193 $ 2,193 Other Disorders of Blood and Blood-Forming Organs 0 $ - 1 $ 1,675 1 $ 86 2 $ 1,761 S 881 Other Cardiovascular Symptoms 3 $ 81 3 $ 629 4 $ 578 10 $ 1,288 $ 129 Varicose Veins of Lower Extremities 0 $ - 1 $ 46 2 $ 302 3 $ 348 $ 116 Anomaly: Ventricular Septal Defects 1 $ 150 0 $ - 0 $ 1 $ 150 $ 150 Other Diseases of Veins 0 $ - 1 $ 61 0 $ - 1 $ 61 $ 61 The biggest change in Cardiac care in recent history is the focus on prevention through the use of drugs to reduce COST SAVINGS high serum cholesterol. The number of patients with high serum cholesterol has been declining over the last SUGGESTIONS couple of years (mainly due to the new drugs) but the need for testing and the usage of cholesterol-lowering drug: is recommended as research has proven these drugs help lower the risk of Heart Disease. (c) 2009 Group and Pension Administrators, Inc. 6 Clinical Condition Cost Driver Analysis Cancer Episodic Group SAMPLE CLIENT CANCER TREATMENT Includes benign and malignant tumors, bone marrow and lymph gland disorders Client is % ofTotal Benchmark BELOW 9.25% 11.42° The most commonly occurring Cancer Treatment nationally is Atypical Nevus, an unusual spot or mole on the skin, which occurs on average in 1.70% of the population each year with an average cost of $318 per patient episode; 1.44% of Cancer Treatment total cost Common High Frequency Cancer Treatments Neoplasm: Atypical Nevus Neoplasm, Malignant: Carcinoma, Squamous Cell Neoplasm, Benign: Adenomatous Polyps, Colon Neoplasm, Benign: Skin or Subcutaneous Tissue Neoplasm, Benign: Breast Treatments Fre quency Tot al Cost Avg. Cost per Patient 10 0.79 % 1.70% 0.34% 1.44% $ 126 $ 318 12 0.95% 1.38% 1.41 % 1.48% $ 437 $ 400 28 2.22% 1.14% 18.09 % 6.70% $ 2,396 $ 2,196 17 1.35% 1.10% 3.74 % 1.07% $ 815 $ 364 13 1.03 % 0.78% 2.39% 3.03% $ 681 $ 1,452 Client Cost GREAT NORMAL NORMAL REVIEW GREAT Although it occurs less frequently, the Cancer with the highest average cost is Leukemia (Acute and Nonacute Lymphoma) which will likely have an average cost per patient in excess of $50,000 per episode. Normal Highest Cost Cancer Treatments Neoplasm, Malignant: Breast, Female Neoplasm, Malignant: Colon and Rectum Neoplasm, Mal: Lungs, Bronchi, or Mediastinum Neoplasm, Benign: Adenomatous Polyps, Colon Neoplasm, Malignant: Prostate Treatments ~ Fre ~ quency Tot al Cost Avg. Cost per Patient 2 0.16% 0.38% 1.06% 11.20% $ 1,965 $ 11,051 1 0.08% 0.12% 11.22% ~ 9.54% $ 41,606 $ 28,870 #N/A #NIA 0.08% #N/A. 7.41% #N/A $ 34,894 28 2.22% 1.14% 18.09 % 6.70% $ 2,396 $ 2,196 11 0.87% 0.40% 18.33% 5.42% $ 6,178 $ 5,127 Client Cost GREAT REVIEW #N/A NORMAL REVIEW ACCORDING TO Skin Cancer is the most commonly occurring Cancer and an Atypical Nevus is how most of these cancers are found. Skin Cancer is also the easiest to treat and has the lowest morbidity of any Cancer, but is still very THE CDC or NIH: dangerous if undiagnosed or untreated. Top 15 Episode Group Detail Oct 2005 -Sep 2006 Oct 2006 -Sep 2007 Oct 200 7 -Sep 2008 Total Avg. Cost (based on claims incurred during period Patient Epis. Client Cost Patient Epis Client Cost Patient Epis Client Cost Patient Episodes Total Cost per Patient Episode Neoplasm: Eyelid 1 $ 73,877 0 $ - 0 $ - 1 $ 73,877 $ 73,877 Neoplasm, Malignant: Prostate 4 $ 22,370 4 $ 41,063 3 $ 4,523 11 $ 67,956 $ 6,178 Neoplasm, Malignant: Colon and Rectum 0 $ 0 $ - 1 $ 41,606 1 ! $ 41,606 $ 41,606 Neoplasm, Benign: Uterus (Leiomyomas) 0 i $ - 3 $ 17,118 2 $ 19,130 5 $ 36,248 $ 7,250 Neoplasm: Central Nervous System 2 $ 7,108 1 $ 5,050 1 $ 7,718 4 $ 19,876 $ 4,969 Neoplasm, Benign: Breast 6 $ 1,983 3 ~ $ 1,753 4 $ 5,121 13 $ 8,858 $ 681 Neoplasm, Malignant: Carcinoma, Basal Cell 4 $ 8,768 0 $ - 0 $ - 4 $ 8,768 $ 2,192 Neoplasm, Malignant: Carcinoma, Squamous Cell 4 $ 405 2 $ 3,702 6 $ 1,131 12 $ 5,238 $ 437 Neoplasm, Benign: Other Sites 2 $ 4,049 0 ' $ - 1 $ 43 3 $ 4,092 $ 1,364 Neoplasm, Malignant: Breast, Female 0 $ 1 $ 850 1 $ 3,081 2 $ 3,931 $ 1,965 Neoplasm, Benign: Sinuses 1 $ 57 3 $ 3,585 0 $ - 4 $ 3,642 $ 911 Neoplasm, Malignant: Cervix Uteri 1 $ 2,398 1 $ - 2 ! $ 785 4 $ 3,183 $ 796 Neoplasm, Malignant: Primary Bone 0 $ - 0 $ - 1 $ 2,914 1 i $ 2,914 $ 2,914 Neoplasm, Benign: Pterygium 1 ~ $ 2,571 2 $ 165 0 $ - 3 ~ $ 2,736 $ 912 Neoplasm, Benign: Musculoskeletal Sys/Connect Tis 0 $ 1 $ 1,506 0 ' $ - 1 $ 1,506 $ 1,506 Many of the common Cancers are preventable and less costly to treat with early diagnosis. We recommend you COST SAVINGS encourage (and cover under your plan) individuals to seek preventive Colonoscopies (Colon), Mammograms SUGGESTIONS (Breast), Pap Smears (Cervical), PSA (Prostate) tests at the recommended time frames and ages; and to stop smoking (Lung) or chewing (Tongue and Throat). It is also important to wear proper clothing when outside and to avoid excessive sun exposure (Skin). (c) 2009 Group and Pension Administrators, Inc. ~ Clinical Condition Cost Driver Analysis EENT Episodic Group EYE, EAR, NOSE, THROAT AND PREVENTIVE CARE (EENT) Includes all care related to common conditions in the Head and Esophagus SAMPLE CLIENT Client is % of Total Benchmark NEAR 12.98% 14.01% The most commonly occurring EENT Condition nationally is Preventive Care, routine visits (including immunizations), which occurs on average in 36.35% of the population each year with an average cost of $422 per patient episode; 35.57% of EENT total cost Common High Frequency EENT Conditions Encounter for Preventive Health Services Sinusitis Rhino, Adeno, and Corona Virus Infections Other Ear, Nose, and Throat Infections Pharyngitis, Non-Streptococcal Treatments Frequency Total Cost Avg. Cost per Patient 327 25.98% 36.35% 27.83 % 37.57% $ 420 $ 422 87 6.91% 8.54% 6.80°/ ~ 6.87% $ 386 $ 329 83 5.59% 8.02% 5.28 % ~ 5.00% $ 314 $ 255 95 7.55 % ~I 7.68% 3.89% 3.32% $ 202 $ 177 89 5.48% 7.72% 6.40 % 5.98% $ 458 $ 315 Client Cost NORMAL NORMAL REVIEW NORMAL REVIEW Almost every condition in this category is relatively low cost with only certain problems, like an Orbital Blow Out or a Cholesteatoma (an inner ear problem) or a Deviated Nasal Septum; each of which will likely cost a few thousand dollars Normal Highest Cost EENT Conditions Encounter for Preventive Health Services Headache Sinusitis Pharyngitis, Non-Streptococcal Rhino, Adeno, and Corona Virus Infections Treatments Frequency Total Cost Avg. Cost per Patient -- - 327 25.98%~ 35.35% 27.83% 37.57% $ 420 $ 422 29 2.30% 3.37% 4.54% 7.12% $ 773 $ 862 67 8.91 % 8.54% s.80% 6.87% $ 385 $ 329 69 5.48 % ', 7.72% 6.40% 5.98% $ 458 $ 316 83 6.59 % 8.02% 5.28% 5.00% $ 314 $ 255 Client Cost NORMAL NORMAL NORMAL REVIEW REVIEW ACCORDING TO Colds, flu, most sore throats and bronchitis are caused by viruses and not bacteria and antibiotics should not be THE CDC or NIH: used. The more an antibiotic is used the more likely the individual will become resistant to the curative effects. Top 15 Episode Group Detail oct zoos -sep zoos oct Zoos -sep zoo? oct 200 7 -sep 2008 Total Patient Total Cost Avg. cost er Patient (based on claims incurred during period) Patient Client Cost Patient Client Cost Patient ' Client Cost Episodes p Episode Epis. Epis. Epis Encounter for Preventive Health Services 86 $ 37,496 114 ~ $ 55,929 127 $ 44,019 327 $ 137,444 $ 420 Factors InFluencing Health Status 6 $ 84,003 5 $ 35 5 ! $ 3,391 16 $ 87,429 $ 5,464 Sinusitis 19 $ 4,015 33 $ 19,275 35 $ 10,317 87 $ 33,607 $ 385 Cataract 2 $ 7,211 4 $ 4,497 7 $ 20,770 13 $ 32,478 $ 2,498 Pharyngitis, Non-Streptococcal 19 ~ $ 4,935 31 $ 23,941 19 $ 2,706 69 $ 31,583 $ 458 Rhino, Adeno, and Corona Virus Infections 24 $ 3,685 27 $ 7,520 32 $ 14,865 83 $ 26,071 5 314 Headache 9 $ 7,660 8 $ 5,071 12 $ 9,697 29 $ 22,427 $ 773 Otitis Media 22 ', $ 6,620 26 $ 12,099 26 i $ 3,570 74 $ 22,289 $ 301 Other Ear, Nose, and Throat Infections 16 $ 1,724 43 $ 11,934 36 ' , $ 5,572 95 $ 19,229 $ 202 Macular Degeneration 0 $ - 3 $ 14,057 0 $ - 3 ~ $ 14,057 $ 4,686 Other Ear, Nose, and Throat Disorders 21 $ 1,819 22 $ 2,341 35 $ 8,758 78 $ 12,918 $ 166 Other Nutritional and Metabolic Disorders 12 ~ $ 4,198 2 $ 1,003 12 $ 5,970 26 $ 11,171 $ 430 Pharyngitis, Streptococcal 10 $ 981 4 $ 4,173 10 $ 4,157 24 $ 9,311 $ 388 Foreign Body: Nasopharynx, Throat or Bronchus 0 $ - 1 $ 149 1 $ 6,648 2 $ 6,797 $ 3,398 Deviated Nasal Septum 0 $ - 1 i $ 6,408 0 $ - 1 $ 6,408 $ 6,408 COST SAVINGS I Recent studies have shown there is a high correlation between dental health and some chronic cor SUGGESTIONS cardiovascular disease and diabetes. Encouraging members to get twice annual dental preventive cleanings can have as much of an Impact on preventing some chronic conditions as costly medics such as ps and air (c) 2009 Group and Pension Administrators, Inc. 8 Clinical Condition Cost Driver Analysis Gastric Episodic Group SAMPLE CLIENT DIGESTIVE & ABDOMINAL CONDITIONS Includes esophageal, stomach, intestine, bowel, rectum and thyroid Cllent IS % of Total Benchmark NEAR 9.67% 10.66°0 The most commonly occurring Gastric Condition nationally is general Stomach and Intestinal Problems, which occurs on average in 3.92% of the population each year with an average cost of $670 per patient episode; 8.43% of Gastric total cost Common High Frequency Gastric Conditions Other Gastrointestinal or Abdominal Symptoms Hernia, Hiatal or Reflux Esophagitis Hypothyroidism Gastroenteritis Functional Digestive Disorders Treatments Fre quency Tot al Cost Avg. Cost per Patient 50 3.97% 3.92% 9.93% 8.43% $ 616 $ 670 42 3.34% 2.35% 10.04% 7.83% $ 742 $ 1,034 27 2.14% 2.35% 2.16% 2.57% $ 248 $ 340 21 1.67°/ ~ 2.02% 1.70 % 2.74% $ 251 $ 421 13 1.03% 1.10% 2.26% 2.96% $ 540 $ 838 Client Cost NORMAL GREAT GREAT GREAT GREAT t~ 'i a.r~ I ~~ ~i Outside of several congenital conditions that rarely occur, Appendicitis is the most common high cost episode in the category occurring ! in about two out of every 1000 adults at a cost of about $10,000 ~ ~ Normal Highest Cost Gastric Conditions Cholecystitis and Cholelithiasis Other Gastrointestinal orAbdominal Symptoms Hernia, Hiatal or Reflux Esophagitis Hernia, External Overweight and Obesity Treatments - - Fre - - quency _ _ Tot al Cost _ Avg. Cost per Patient - 10 0.79% 0.56% 31.34% 15.93% $ 9,724 $ 8,904 50 3.97% 3.92% 9.93% 8.43% $ 616 $ 670 42 3.34% 2.35% 10.04% 7.83% $ 742 $ 1,034 7 0.56 % 0.48% 11.43 % 6.66% $ 5,064 $ 4,313 8 0.64% 0.70% 0.30% 6.44% $ 117 $ 2,865 Client Cost NORMAL NORMAL GREAT NORMAL GREAT ACCORDING TO Two-thirds of adults are overweight and one-third are obese. Obesity leads to many gastric problems as well as elevated risk of heart disease, diabetes and some cancers; and increases the severity of disease associated with THE CDC or NIH: hypertension, arthritis and other musculoskeletal problems. Top 15 Episode Group Detail oct 200 5 -Sep zoos oct zoos -Sep 2007 oct 2007 - sep zoos Total Avg. cost based on claims incurred Burin ) ( g period Patient ' Patient Patient Patient Total Cost per Patient Epis. Client Cost Epis. Client Cost Epis. Cl ient Cost Episodes Episode Cholecystitis and Cholelithiasis 0 $ - 5 $ 70,820 5 $ 26,420 10 $ 97,241 $ 9,724 Hernia, External 0 ~ $ - 4 $ 21,483 3 $ 13,968 7 $ 35,451 $ 5,064 Hernia, Hiatal or Reflux Esophagitis 11 $ 3,185 14 $ 5,599 17 $ 22,375 42 ' $ 31,159 $ 742 Other Gastrointestinal or Abdominal Symptoms 12 $ 1,602 21 $ 10,773 17 $ 18,442 50 $ 30,817 $ 616 Diverticular Disease 2 $ 1,679 6 $ 24,505 1 ; $ 3,327 9 $ 29,511 $ 3,279 Appendicitis 1 $ 5,447 2 $ 15,305 0 $ - 3 $ 20,752 $ 6,917 Gastritis 8 $ 8,310 8 $ 1,692 8 $ 4,165 24 $ 14,167 $ 590 Ulcerative Colitis 1 $ 6,253 0 , $ - 1 ! $ 1,799 2 $ 8,052 $ 4,026 Functional Digestive Disorders 2 $ 59 6 $ 555 5 $ 6,404 13 ! $ 7,019 $ 540 Hypothyroidism 7 $ 2,428 7 $ 1,043 13 $ 3,230 27 $ 6,701 $ 248 Other Diseases of Esophagus, Stomach, and Duodenum 1 $ 301 2 $ 5,667 2 $ 600 5 $ 6,568 $ 1,314 Gastroenteritis 5 $ 1,270 10 ~ $ 633 6 ! $ 3,363 21 $ 5,266 $ 251 Foreign Body: Esophagus 0 $ - 0 $ - 1 $ 4,100 1 $ 4,100 $ 4,100 Hemorrhoids 2 $ 624 3 $ 2,070 7 $ 1,313 12 $ 4,007 $ 334 Anal Fissure 3 $ 825 3 $ 1,882 0 $ - 6 $ 2,707 $ 451 In the last 40 years, the spending on food at restaurants has almost DOUBLED to over 42% of total food COST SAVINGS expenditure. Restaurant meals tend to be higher in calories, fat, saturated fat and sodium and tend to be larger SUGGESTIONS than home portion sizes. This trend has contributed significantly to the increase in obesity as well as other gastrointestinal problems. Encouraging individuals to eat more home-cooked meals is certain to lower the incidence of certain gastric problems and help reduce the trend towards more obesity. (c) 2009 Group and Pension Administrators, Inc. g Clinical Condition Cost Driver Analysis Maternity Episodic Group SAMPLE CLIENT Includes all treatment related to pre-natal, delivery and newborn care Client is % of Total Benchmark NEAR 6.89% 6.42% The most commonly occurring Maternity /Newborn event nationally is normal, healthy Newborn Babies, which occurs on average in 0.84% of the female population each year with an average cost of $1,995 per patient episode; 7.58% of Maternity /Newborn total cost Common High Frequency Maternity I Newborn Live Newborns Delivery, Vaginal Ante- and Postpartum Complications Abortion, Spontaneous Delivery, Cesarean Section Treatments Frequency Tot al Cost Avg. Cost per Patient 3 0.24% 0.84% 3.11 % 7.58% $ 1,324 $ 1,995 3 0.24% 0.84% 13.70% 27.79% $ 5,833 $ 7,264 9 0.71 % 0.78% 3.06 % 3.06% $ 435 $ 860 #NIA #NIA 0.41% #NIA 3.09% #NIA $ 1,643 1 0.08%I 0.38% 23.25% 21.85% $ 29,700 $ 12,776 i Besides Prematurity, there are several other infrequent but very costly neonate procedures like Hyaline Membrane Distress (respiratory ~i distress), Meconium Aspiration Syndrome (feces in lungs) or Cytomegalovirus Disease (severe infection); each of which will cost $10,000+ ~ Normal Highest Cost Maternity I Newborn Delivery, Vaginal _s Delivery, Cesarean Section Prematurity, Extremely Low Birthweight s Prematurity, Low Birthweight Live Newborns t~llll ~r ~r ww ~w r .. iir tr Treatments Frequency Total Cost Avg. Cost per Patient 3 0.24% 0.84% 13.70% 27.79% $ 5,833 $ 7,264 1 0.08% 0.38% 23.25% 21.85% $ 29,700 $ 12,776 #NIA #N/A, 0.01% #N/A 11.73% #NIA $ 317,206 1 0.08% 0.10% 49.22%. 7.64% $ 62,869 $ 17,525 3 0.24% 0.84% 3.11% 7.58% $ 1,324 $ 1,995 Client Cost GREAT NORMAL GREAT #NIA REVIEW Client Cost NORMAL REVIEW #NIA REVIEW GREAT ACCORDING TO Now more than 30°.0 of all deliveries are by Cesarean Section and the percentage continues to increase each year. THE CDC or NIH: The number of pre-term deliveries (less than 37 weeks gestation) has risen to 12.7% of all births, up 25% in the last 15 years (adjusted for the change in multiple births). Top 15 Episode Group Detail Oct 2005 -Sep 2006 Oct 20 06 -S ep 2007 Oct 200 7 -S ep 2008 Total Patient Total Cost Avg. Cost per Patient (based on claims incurred during period) Client Cost ~ Client Cost Client Cost Episodes ~ Episode Prematurity, Low Birthweight 0 $ - 0 $ - 1 $ 62,869 1 $ 62,869 $ 62,869 Delivery, Cesarean Section 0 $ - 1 $ 29,700 0 $ - 1 $ 29,700 $ 29,700 Delivery, Vaginal 2 $ 11,858 0 $ - 1 $ 5,641 3 ~ $ 17,499 $ 5,833 Ectopic Pregnancy 0 $ - 0 $ - 1 $ 8,462 1 $ 8,462 $ 8,462 Live Newborns 2 $ 2,406 1 $ 1,565 0 $ - 3 $ 3,971 S 1,324 Ante- and Postpartum Complications 0 $ - 5 $ 1,823 4 $ 2,090 9 ~ $ 3,913 $ 435 Other Neonatal Conditions 2 i $ 655 0 ~~ $ - 1 $ 183 3 $ 837 489 $ 279 244 Hemolytic Disease of the Newborn 0 $ - 1 $ 397 1 $ 92 2 $ $ Abortion, Elective 0 $ - 0 $ I - 1 $ - 1 $ - $ The cost of premature delivery is well documented but what is causing as much of the problem is the dr amatic COST SAVINGS increase in the number of low Birthweight babies. The number of newborns below 5.5 pounds has incre ased to 8.2% of all births (up from 7% just 5 years ago). The primary cause for low Birthweight is due to poor E ARLY SUGGESTIONS prenatal care. Pregnant women are encouraged to get high quality prenatal care as soon as they becom e pregnant and not wait until the second or third trimester. (c) 2009 Group and Pension Administrators, Inc. 10 Clinical Condition Cost Driver Analysis Nervous System Episodic Group SAMPLE CLIENT NERVOUS SYSTEM DISORDERS Includes nerve disorders and issues, mental health and substance abuse Client is % ofTotal , Benchmark BELOW 1.54% 2.98°'0 The most commonly occurring Nervous Condition nationally is Depression, which occurs on average in 2.88% of the population each year with an average cost of $791 per patient episode; 25.60% of Nervous total cost Common High Frequency MHSA Depression Other Neuroses Generalized Anxiety Disorder Other Peripheral Nerve Disorders Bipolar Disorder, Manic Episode Treatments Fre - quency _ Total Cost - Avg. Cost per Patient 11 0.87 % ~ 2.88% 2.93%~ 25.60% $ 75 $ 791 20 1.59 % I 1.77% 12.13% 7.04% $ 170 $ 354 18 1.43% 1.29% 10.14% ~ 5.21% $ 158 $ 359 3 0.24 % 0.52% 2.34% 5.59% $ 218 $ 960 3 0.24% 0.40% 23.39% 10.71% $ 2,181 $ 2,363 Client Cost GREAT GREAT GREAT GREAT NORMAL ..ice .~ ...~ ..~ .t !~ I The highest cost Nervous System Disorder is Guillain-Barre Syndrome, an extreme muscle weakness in extremities brought on by some infectious diseases, which occurs on average in only 0.004% of the population but has an average cost of $15,000 to $20,000 per episode. Normal Highest Cost MHSA Depression Bipolar Disorder, Manic Episode Drug Abuse, Dependence, Intoxication: Alcohol Other Neuroses Other CNS Inflammation, Infection, or Disorder Treatments Fre quency -- - Tot - al Cost --- Avg. Cost per Patient 11 0.87%~ 2.88% 2.93 % - 25.60% $ 75 $ 791 3 0.24% 0.40% 23.39% 10.71% $ 2,181 $ 2,363 #N/A #N/A 0.17% #NIA 8.29% #N/A $ 4,245 20 1.59 % 1.77% 12.13% 7.04% $ 170 $ 354 2 0.16%i 0.34% 1.92%~ 6.08% $ 268 $ 1,592 Client Cost GREAT NORMAL #N/A GREAT GREAT ACCORDING TO Antidepressant Drug use for diagnosed depressive conditions has increased to 10.6% of the adult U.S. population THE CDC Or NIH: with women twice as likely as men to take antidepressants. There has been a substantial increase in the "off-label" use of such drugs indicating even higher utilization in all demographic groups. Top 15 Episode Group Detail Oct 200 5 -Sep 2006 Oct Zoos -Sep 2007 Oct 2007 -sep 2008 Total I Avg, cost based on claims incurred Burin ) ( g period Patient Cli Patient Patient Patient Total Cost per Patient Epis. ent Cost Epis. Cli ent Cost Epis. Client Cost Episodes Episode Bipolar Disorder, Manic Episode 1 I $ 20 0 $ - 2 $ 6,523 3 $ 6,543 $ 2,181 Poisoning: Drugs Not Antidepressants Tranquilizers 0 $ - 0 I $ - 2 i $ 4,552 2 $ 4,552 $ 2,276 Antisocial Personality Disorder 1 ! $ 706 1 $ 2,087 1 $ 904 3 $ 3,697 $ 1,232 Other Neuroses 5 I $ 175 6 $ 2,254 9 $ 965 20 $ 3,394 $ 170 Generalized Anxiety Disorder 4 $ 546 4 $ 1,734 10 ~ $ 556 18 $ 2,837 $ 158 Other Neurological Conditions 1 $ 80 3 $ 1,679 1 $ 70 5 $ 1,830 $ 366 Other Psychoses 1 $ - 1 $ - 1 $ 1,610 3 $ 1,610 $ 537 Adverse Drug Reactions 0 $ - 3 $ 186 1 $ 1,092 4 ~ $ 1,277 $ 319 Depression 1 $ - 3 $ 61 7 $ 760 11 $ 821 $ 75 Other Peripheral Nerve Disorders 0 $ 1 $ 240 2 ~ $ 415 3 $ 655 $ 218 Other CNS Inflammation, Infection, or Disorder 1 $ 478 0 $ - 1 $ 58 2 $ 536 $ 268 Other Cranial Nerve Disorders 0 $ - 0 $ - 1 $ 169 1 $ 169 $ 169 Conduction Disorders 1 $ 50 0 $ - 1 $ - 2 $ 50 $ 25 Prescriptions for antidepressants have been rising, associated with the introduction in 1988 of a new class of drugs COST SAVINGS known as selective serotonin reuptake inhibitors (SSRIs). These antidepressants have been marketed for many "of SUGGESTIONS label" uses for a variety of other mental health and physical disorders. It is recommended that clients cross reference the antidepressant prescriptions with actual mental health provider utilization in order to minimize the "off-Zabel" use of such prescriptions. ~i (c) 2009 Group and Pension Administrators, Inc. 11 Clinical Condition Cost Driver Analysis Musculoskeletal Episodic Group Common High Frequency Musculoskeletal Other Arthropathies, Bone and Joint Disorders Oth Inflam and Infect of Skin and Subcutaneous Tis Other Spinal and Back Disorders Infections of Skin and Subcutaneous Tissue Osteoarthritis Client is % of Total Benchmark BELOW 14.43% 19.17% The most commonly occurring Musculoskeletal Condition nationally is non-serious, general Bone and Joint Disorders, which occurs on average in 9.15% of the population each year with an average cost of $529 per patient episode; 8.12% of Musculoskeletal total cost Treatments Frequency Tot al Cost Avg. Cost per Patient 84 6.67% 9.15% 8.19% 8.12% $ 448 $ 529 82 6.51%' 9.09% 2.13% 3.08% $ 119 $ 202 55 4.37%i 5.62% 4.16%~ 6.14% $ 348 $ 652 41 3.26 % 3.46% 5.64% 4.10% $ 632 $ 707 31 2.46% 2.81% 11.26% 22.12% $ 1,670 $ 4,693 Client Cost NORMAL GREAT GREAT NORMAL GREAT A broken femur bone is one of the highest cost Musculoskeletal conditions (skull fractures are the most costly but occur very rarely) and even though it occurs on average in only 0.7% of the population, it has an average cost of $6,000 to $12,000 per episode. Normal Highest Cost Musculoskeletal Osteoarthritis ~ Herniated Intervertebral Disc t Other Arthropathies, Bone and Joint Disorders Other Spinal and Back Disorders ~ Infections of Skin and Subcutaneous Tissue MUSCULOSKELETAL CONDITIONS Includes skin, muscles & skeleton SAMPLE CLIENT Client Cost GREAT GREAT NORMAL GREAT NORMAL t#t ~~ ~s ~~ a~iwM ~r r~ ~~ Treatments Frequency Tot al Cost Avg. Cost per Patient 31 2.46% 2.81% 11.26% 22.12% $ 1,670 $ 4,693 12 0.95% 1.08% 7.91% 11.16% $ 3,030 $ 6,148 84 6.67% 9.15% 8.19% 8.12% $ 448 $ 529 55 4.37% 5.62% 4.16% 6.14% $ 348 $ 652 41 3.26%' 3.46% 5.64% 4.10% $ 632 $ 707 ACCORDING TO I Some type of an arthritic-related condition (osteoarthritis, rheumatoid arthritis, gout, lupus or fibromyalgia) affects 22% of adults, with osteoarthritis the most common impacting 9% of adults in their lifetime; and 5% of those THE CDC Or NIH: diagnosed each year will have some type of work limitation. Top 15 Episode Group Detail oct zoos -sep zoos oct Zoo s -sep 2007 Oct 200 7 -Sep 2008 Total Patient Total Cost Avg. cost er Patient (based on claims incurred during period) Patient '~i Client Cost Patient ' Client Cost Patient Client Cost Episodes p Episode Epis. Epis. Epis Osteoarthritis 8 $ 21,044 10 $ 9,088 13 $ 21,626 31 $ 51,759 $ 1,670 Bursitis 2 $ 2,089 4 $ 33,303 7 ~ $ 3,181 13 ~~ $ 38,573 $ 2,967 Other Arthropathies, Bone and Joint Disorders 15 i $ 11,222 32 $ 12,582 37 $ 13,834 84 $ 37,637 $ 448 Herniated Intervertebral Disc 6 $ 5,932 3 $ 18,731 3 $ 11,697 12 $ 36,360 $ 3,030 Injury: Knee, Ligamentous 3 $ 920 1 $ 499 5 $ 33,811 9 $ 35,230 $ 3,914 Muscular Dystrophy 1 ~ $ 11,972 1 $ 8,849 1 $ 7,286 3 $ 28,107 $ 9,369 Infections of Skin and Subcutaneous Tissue 11 $ 21,186 8 $ 1,186 22 $ 3,555 41 $ 25,926 $ 632 Rheumatoid Arthritis 4 $ 4,659 1 $ 11,862 2 $ 8,894 7 i $ 25,415 $ 3,631 Other Spinal and Back Disorders 14 $ 4,644 16 $ 4,613 25 $ 9,881 55 $ 19,138 $ 348 Fracture, Dislocation, or Sprain: Humerus/Shoulder 1 $ 11,899 3 $ 5,093 3 $ 1,111 7 $ 18,103 $ 2,586 Fracture: Acetabulum 1 $ 13,641 0 $ 0 $ - 1 $ 13,641 $ 13,641 Carpal Tunnel Syndrome 2 $ 4,021 6 $ 1,274 2 $ 7,661 10 $ 12,956 $ 1,296 Injury: Knee, Semilunar Cartilages 2 $ 2,583 5 ~ $ 5,488 3 $ 4,824 10 $ 12,895 $ 1,290 Fracture, Dislocation, or Sprain: Wrist Hand 2 $ 3,674 2 $ 7,843 4 $ 458 8 $ 11,975 $ 1,497 Fracture, Dislocation, or Sprain: Foot 2 i $ 1,487 2 $ 12 4 $ 8,318 8 $ 9,818 $ 1,227 Musculoskeletal costs are driven higher by the increase in cost of imaging. The cost of high-tech imaging (MRI, COST SAVINGS PET and CAT Scans) has exploded with a 50% increase in cost in just the last five years. Specialty imaging SUGGESTIONS networks have been developed across the nation and there is significant savings to be derived by utilization of these special contracted imaging networks. (c) 2009 Group and Pension Administrators, Inc. 12 Clinical Condition Cost Driver Analysis Hepatobiliary Episodic Group SAMPLE CLIENT HEPATOBILIARY 8 REPRODUCTIVE CONDITIONS Includes reproductive organs, liver, kidney, pancreas, prostate, gall bladder and urinary tract Client is % of Total Benchmark ABOVE 10.41% 8.05°0 The most commonly occurring Hepatobiliary Condition nationally is general Urinary Tract Infections, which occurs on average in 3.12% of the population each year with an average cost of $658 per patient episode; 8.15% of Hepatobiliary total cost Common High Frequency Hepatobiliary Urinary Tract Infections Other Disorders of Female Genital System Dysfunctional Uterine Bleeding Other Urinary Symptoms Vulvovaginitis Treatments Fre - quency Tot - al Cost -- Avg. Cost per Patient -- - 36 2.86% 3.12% 8.80% 8.15% ~ $ 1,078 $ 658 23 1.83% 2.8T% 2.31% 8.11% $ 443 $ 711 29 2.30% 2.43% 5.45% 12.17% $ 828 $ 1,258 16 1.27% 1.37% 0.76% 1.73% $ 209 $ 317 7 0.56%~ 1.14% 0.22% 1.26% $ 141 $ 278 Client Cost REVIEW GREAT GREAT GREAT GREAT Renal Failure and Pancreatitis are the most common high cost episodes in this category, both costing on average $15,000 or more, but there are also high claims associated with Endometriosis, Kidney Stones (Calculus of the Urinary Tract) and Hysterectomy (Uterovaginal Prolapse) Normal Highest Cost Hepatobiliary Renal Failure Calculus of the Urinary Tract Dysfunctional Uterine Bleeding Urinary Tract Infections Other Disorders of Female Genital System Treatments Fre quency Tot al Cost Avg. Cost per Patient 2 0.16% I 0.30% 2.85% 20.45% $ 6,283 $ 16,871 7 0.56%' 0.64% 3.69% 14.11% $ 2,326 $ 5,559 29 2.30% 2.43% 5.45% 12.17% $ 828 $ 1,258 36 2.86% 3.12% 8.80% 8.15% $ 1,078 $ 658 23 1.83 % 2.87% 2.31 % 8.11 % $ 443 $ 711 Client Cost GREAT GREAT GREAT REVIEW GREAT ACCORDING TO Kidney Disease impacts 1.5% of the adult population and those with End Stage Renal Disease is up 300% in the last 20 years. In the U.S., 40% of all new ESRD cases develop in individuals with a primary diagnosis of diabetes while THE CDC or NIH: another 25% arise from patients with a primary diagnosis of hypertension. Top 15 Episode Group Detail Oct 200 5 -Sep 2006 Oct 200 6 -Sep 2007 Oct 2007 -Sep 2008 Total i Avg. cost based on claims incurred Burin ) ( g period Patient Patient Patient Patient Total Cost per Patient Epis. Client Cost Epis. Client Cost Epis. ' Cl ' ient Cost Episodes t Episode Pancreatitis 1 $ 86,040 2 $ 3,780 3 $ 25,265 6 $ 115,084 $ 19,181 Other Pancreatic Disorders 0 $ - 1 $ 94,253 0 $ - 1 $ 94,253 $ 94,253 Uterovaginal Prolapse 2 $ 11,015 2 I $ 36,329 2 $ 16,690 6 $ 64,034 $ 10,672 Urinary Tract Infections 13 $ 24,719 13 $ 10,243 10 $ 3,851 36 ' $ 38,814 $ 1,078 Dysfunctional Uterine Bleeding 10 $ 5,905 8 $ 2,313 11 $ 15,797 29 $ 24,015 $ 828 Calculus of the Urinary Tract 0 $ - 3 $ 6,522 4 $ 9,758 7 $ 16,280 $ 2,326 Renal Failure 1 $ 463 0 ~ $ - 1 ' $ 12,103 2 I $ 12,565 $ 6,283 Other Disorders of Male Genital System 2 $ 385 5 $ 933 9 $ 10,445 16 $ 11,763 $ 735 Pelvic Inflammatory Disease 2 $ 986 1 $ 10,128 0 $ - 3 $ 11,114 $ 3,705 Other Disorders of Female Genital System 5 $ 728 8 ~ $ 6,456 10 ~ $ 3,013 23 $ 10,198 $ 443 Other Biliary Disorders 0 $ - 0 ~ $ - 2 $ 7,301 2 $ 7,301 $ 3,651 Cirrhosis of the Liver 1 $ 338 2 $ 6,815 0 $ - 3 $ 7,154 $ 2,385 Cryptorchidism 0 $ - 0 $ - 1 $ 6,537 1 $ 6,537 $ 6,537 Bladder Disorders 2 I $ 2,026 3 $ 1,929 2 ' $ 1,809 7 'i $ 5,765 $ 824 Other Disorders of Kidney or Ureter 1 $ 63 1 $ 94 4 $ 3,906 6 $ 4,062 $ 677 COST SAVINGS It goes without saying, anything that can be done to avoid End Stage Renal Disease will provide substantial SUGGESTIONS savings. The supply of kidneys available for people with ESRD is not keeping up with demand. A strong focus on diabetes and hypertension avoidance and maintenance will certainly return favorable results. (c) 2009 Group and Pension Administrators, Inc. 13 Clinical Condition Cost Driver Analysis Respiratory Episodic Group SAMPLE CLIENT RESPIRATORY CONDITIONS Includes respiratory, viral and bacterial infections and diseases Common High Frequency Respiratory Other Respiratory Symptoms Asthma, Chronic Maintenance Other Viral Infections Influenza Pneumonia, Bacterial Client is % ofTotal Benchmark F3ELOW 4.65% 5.53% The most commonly occurring Respiratory Condition nationally is non-serious, general Respiratory issues, which occurs on average in 3.27% of the population each year with an average cost of $1,053 per patient episode; 22.76% of Respiratory total cost Treatments Frequency Tot al Cost Avg. Cost per Patient - 49 3.89%I --- 3.27% 47.87% 22.76% $ 1,373 $ 1,053 40 3.18 % ' 2.88% 27.16 % 20.50% $ 954 $ 1,079 16 1.27 % ' 1.92% 1.67% 2.22% $ 147 $ 175 11 0.87%' 1.41 % 0.91 % 1.81 % $ 116 $ 194 10 0.79% 1.03% 8.52% 28.04% $ 1,197 $ 4,107 Client Cost REVIEW NORMAL NORMAL GREAT GREAT Cystic Fibrosis is a hereditary disease that causes chronic respiratory infections, usually starting at infancy (impacts about one out of every 2500 children), and will significantly shorten the lifespan of an individual at a cost in excess of $15,000 per episode Normal Highest Cost Respiratory Pneumonia, Bacterial Other Respiratory Symptoms ~ Asthma, Chronic Maintenance Chronic Obstructive Pulmonary Disease e+ Other Disorders of Respiratory System ~i ~y ~I ~~ ~~ l~ rlti A ~M ~~ Treatments Frequency Tot al Cost Avg. Cost per Patient 10 0.79% 1.03% 8.52% 28.04% $ 1,197 $ 4,107 49 3.89 % 3.27% 47.87% 22.76% $ 1,373 $ 1,053 40 3.18 % 2.88% 27.16% 20.50% $ 954 $ 1,079 16 1.27%~ 0.69% 5.27% 8.14% $ 463 $ 1,791 6 0.48% 0.40% 0.69% 4.06% $ 161 $ 1,530 Client Cost GREAT REVIEW NORMAL GREAT GREAT ACCORDING TO I Just over 11% of the population will have an asthma attack some time during their lifetime, with 55% of those II THE CDC Or NIH: individuals having more than one attack. Children are more likely to have an attack than adults and female adults have a 50% higher chance of having an attack than adult males. Top 15 Episode Group Detail oct zoos -sep Zoos Oct 2006 -Sep 2007 Oct zoo? -sep zoos total P ti t Total Cost Avg. Cost er Patient (based on claims incurred during period) Patient Client Cost Patient Client Cost Patient Client Cost a en Episodes p Episode I Epis. Epis. Epis. Other Respiratory Symptoms 13 $ 15,140 19 $ 31,156 17 $ 20,960 49 $ 67,255 $ 1,373 Asthma, Chronic Maintenance 14 $ 20,081 11 I $ 7,598 15 $ 10,478 40 $ 38,157 $ 954 Pneumonia, Bacterial 2 $ 123 3 $ 189 5 $ 11,661 10 $ 11,973 $ 1,197 Chronic Obstructive Pulmonary Disease 6 $ 3,304 4 $ 2,145 6 $ 1,960 16 $ 7,409 $ 463 Emphysema 0 $ - 0 $ - 1 $ 3,823 1 $ 3,823 $ 3,823 Tuberculosis 0 $ - 2 $ 34 1 $ 2,368 3 $ 2,402 $ 801 Other Viral Infections 3 ! $ 1,231 7 $ 433 6 $ 681 16 $ 2,346 $ 147 Respiratory Syncytial Virus Infections 0 $ - 4 ~~ $ 2,156 0 $ - 4 $ 2,156 $ 539 Alpha 1-Antitrypsin Deficiency 1 $ 1,276 1 $ 393 0 $ - 2 $ 1,669 $ 835 Influenza 1 $ 30 2 $ 398 8 i $ 853 11 $ 1,280 $ 116 Other Disorders of Respiratory System 2 $ 291 1 $ - 3 $ 674 6 $ 964 $ 161 Coxsackie and ECHO Infections 3 $ 431 0 $ - 0 $ - 3 $ 431 $ 144 Cystic Fibrosis 1 $ 348 0 ~~ $ - 0 $ - 1 $ 348 $ 348 Other Infectious and Parasitic Infections 0 $ 0 $ - 1 ! $ 86 1 $ S6 $ 86 Mycoplasma pneumoniae Infection 0 ' $ - 1 ~I $ 76 0 $ - 1 $ 76 $ 76 Chronic Obstructive Pulmonary Disorder (COPD) is the fourth leading cause of death in the U.S. More than 90% of COST SAVINGS these deaths are related to smoking. Female smokers are 13 times more likely to die from COPD as non-smokers SUGGESTIONS and male smokers are 12 time more likely. Smokers also have more upper and lower respiratory infections becaus smoking suppresses immune functions. Encourage smoking prevention! (c) 2009 Group and Pension Administrators, Inc. 14 Clinical Condition Cost Driver Analysis Other Serious Conditions Episodic Group SAMPLE CLIENT OTHER SERIOUS CONDITIONS Includes endocrine and immune systems, diabetes, anemia, and other unclassified disorders Client is % of Total I Benchmark BELOW 5.43% 7.76% The most commonly occurring Other Serious Condition nationally is Type 2 (Adult Onset) Diabetes, which occurs on average in 4.77% of the population each year with an average cost of $1,351 per patient episode; 26.55% of Other Serious Condition total cost Common High Frequency Other Serious Conditiot Diabetes Mellitus Type 2 Maintenance Injury: Other Injury: Craniocerebral Anemia, Other Diabetes Mellitus Type 1 Maintenance Treatments - _ Fre quency Tot al Cost Avg. Cost per Patient 102 8.10%' _ 4.77% 68.70% ~ _ 26.55% $ 1,130 $ 1,351 13 1.03% 1.37% 4.39% 2.27% $ 567 $ 402 6 0.48% 0.61% 0.84% 6.55% $ 236 $ 2,586 5 0.40% 0.60% 5.28% 1.96% $ 1,771 $ 786 5 0.40% 0.59% 1.24% 4.48% $ 416 $ 1,842 Client Cost NORMAL REVIEW GREAT REVIEW GREAT Asa "catch all" category for other conditions there are several extremely high cost episodes that could occur but one common condition, Anemia, occurs in some form in 1.2% of the population and the cost of treatment ranges from $200 to upwards of $15,000 per episode Normal Highest Cost Other Serious Conditions Diabetes Mellitus Type 2 Maintenance Complications of Surgical and Medical Care Injury: Craniocerebral Multiple Sclerosis Epilepsy Treatments Fre -- quency Tot al Cost Avg. Cost per Patient 102 8.10% ~ 4.77% 68.70 % ~i i 26.55% $ 1,130 $ 1,351 1 0.08% 0.54% 0.00% 23.18% $ - $ 10,340 6 0.48% 0.61% 0.84% 6.55% $ 236 $ 2,586 #N/A #N/A 0.11% #NIA 4.82% #N/A $ 10,299 5 0.40% 0.31% 6.00%I 4.56% $ 2,015 $ 3,603 Client Cost NORMAL GREAT GREAT #N/A GREAT ACCORDING TO Current estimates indicate that 25% of all Caucasian adults, 40% of Black and Hispanic adults and 50% of Hispanic THE CDC Or NIH: women alive today are either currently diabetic or pre-diabetic (will develop diabetes in their lifetime). Top 15 Episode Group Detail Oct 2005 -Sep 2006 Oct 2006 -sep 2007 Oct 2007 -Sep 2008 Total Avg. cost based on claims incurred Burin ( g period) Patient ' Patient Patient Patient Total Cost per Patient Epis. Client Cost Epis ~ Client Cost Epis. Cl ient Cost Episodes Episode Diabetes Mellitus Type 2 Maintenance 28 $ 39,429 35 $ 41,083 39 ~ $ 34,785 102 $ 115,297 $ 1,130 Hepatitis C 1 $ 8 1 $ 2,570 1 $ 8,030 3 $ 10,608 $ 3,536 Epilepsy 1 $ 3,948 2 $ 2,627 2 $ 3,498 5 $ 10,073 $ 2,015 Anemia, Other 2 $ 158 0 $ - 3 $ 8,699 5 $ 8,857 $ 1,771 Injury: Other 2 $ 94 7 $ 3,821 4 $ 3,452 13 $ 7,367 $ 567 Rheumatic Fever 0 $ - 3 $ 6,677 0 $ - 3 $ 6,677 $ 2,226 Diabetes Mellitus Type 1 Maintenance 1 $ 114 2 $ 512 2 $ 1,454 5 $ 2,079 $ 416 Hepatitis B 0 $ - 1 j $ 873 2 $ 690 3 $ 1,564 $ 521 Injury: Craniocerebral 1 I $ 708 2 $ - 3 $ 707 6 $ 1,415 $ 236 Other Electrolyte Disorders 2 $ 382 0 $ - 1 $ 929 3 ~ $ 1,311 $ 437 Eosinophilia Myalgia Syndrome 0 $ - 1 $ 518 0 $ - 1 $ 518 $ 518 Abnormal Lab, X-ray and Clinical Findings 0 $ - 1 i $ 487 0 $ - 1 $ 487 $ 487 Other Disorders of Connective Tissue 0 $ - 1 $ 356 0 ~ $ - 1 $ 356 $ 356 Anemia, Iron Deficiency 1 $ - 4 $ 334 0 $ - 5 $ 334 $ 67 Burns 0 $ - 1 ~ $ 287 1 $ - 2 $ 287 $ 144 Medicare has recently implemented legislation that will no longer allow for the coverage of "never events". These COST SAVINGS are sometimes complications of surgical or medical care and it is now recommended that benefit plans adopt SUGGESTIONS similar wording. "Never events" include such conditions as wrong site surgeries, wrong blood type, bedsores, falls or trauma, and hospital-acquired infections. (c) 2009 Group and Pension Administrators, Inc. 15 ~p~ SAMPLE CLIENT Pharmacy Cost Driver Analysis All data in the Analysis is based upon INCURRED CLAIMS for the periods identified and Medstat utilizes athree- month Lag from paid claims for incurred reporting Pharmacy Cost Driver Analysis Summary of Condition i=requency SAiVIPLE CLIENT WHAT IS DRIVING COST? 1. What is the Prescription Drug activity trend? 2. What is the relationship between Brand Name and Generic Scripts? 3. Is there good Mail Order utilization efficiency? 4. Is there consistent and reasonable cost sharing with the member? 5. Is the average cost per day fair for all delivery types? 6. Will Therapeutic Exchange work for some drugs? 7. Is the frequency and cost of the drugs comparable with the National averages for the most common drugs? 8. Are drugs reasonably priced for 30 day supply? 9. Is any individual over-utilizing the program? 10. Are members maximizing Generic efficiency? Results Based on Incurred Dates of: Total Scripts Retail Scripts Mail Order Scripts Total Drug Cost Amount Paid by Client Amount Paid by Member Average Cost / 30 Day Supply Client Average Cost Member Avg. Cost Results Based on Incurred Dates of: Total Scripts Retail Scripts Mail Order Scripts Total Drug Cost Amount Paid by Client Amount Paid by Member Average Cost / 30 Day Supply Client Average Cost Member Avg. Cost Total All Scripts Oct 2005 - Oct 2006 - Oct 2007 - Sep 2006 Sep 2007 Sep 2008 2,582 3,885 4,870 2,567 3,789 4,780 15 96 90 $ 133,848 $ 237,521 $ 295,744 $ 96,289 $ 169,877 $ 203,874 $ 37,559 $ 67,644 $ 91,870 $ 62.63 $ 71.11 $ 70.20 $ 45.06 $ 50.86 $ 48.39 $ 17.57 $ 20.25 $ 21.81 Singl e S ource Brand Multi -S ource B ra nd G eneric Oct 2005 - O ct 2006 - Oct 2007 - Oct 2005 - Oct 2006 - Oct 2007 - O ct 2005 - Oct 2006 - O ct 2007 - Se p 2006 S ep 2007 Sep 2008 Se p 2006 Sep 2007 Sep 2008 Sep 2006 Sep 2007 S ep 2008 995 1,394 1,564 185 207 313 1,402 2,284 2,993 984 1,356 1,531 185 199 311 1,398 2,234 2,938 11 38 33 0 8 2 4 50 55 $ 94,353 $ 165,049 $ 191,653 $ 7,307 $ 11,285 $ 29,019 $ 32,189 $ 61,187 $ 75,073 $ 66,055 $ 115,540 $ 134,273 $ 4,981 $ 7,710 $ 20,087 $ 25,254 $ 46,626 $ 49,514 $ 28,298 $ 49,509 $ 57,380 $ 2,326 $ 3,575 $ 8,932 $ 6,935 $ 14,560 $ 25,559 $ 101.73 $ 123.92 $ 127.04 $ 44.20 $ 59.45 $ 97.54 $ 30.82 $ 33.65 $ 31.19 $ 71.22 $ 86.75 $ 89.01 $ 30.13 $ 40.62 $ 67.52 $ 24.18 $ 25.64 $ 20.57 $ 30.51 $ 37.17 $ 38.04 $ 14.07 $ 18.83 $ 30.02 $ 6.64 $ 8.01 $ 10.62 Total Number of Scripts by Type 6,000 - i 5,000 4,000 61.5% 3,000 - 58,8% 2,000 54.3% r.... 0 1,000 ""' o i Oct 2005 -Sep Oct 2006 -Sep Oct 2007 -Sep iir..~ 2006 2007 2008 '` ^ Single Source Brand ^Muiti-Source Brand ^ Generic (c) 2009 Group and Pension Administrators, Inc. Average Cost for 30 Day Supply by Type of Generic Mult-Source Brand Single Source Brand $0 $50 ^ Oct 2005 -Sep 2006 ^ Oct 2007 -Sep 2008 $112 - $98 $ 41 $127 $124 $102 $100 $150 ^ Oct 2006 -Sep 2007 ^ Benchmark 2 Pharmacy Cost Driver Analysis Key Claim Cost Value Indicators (based upon Avowed Amount*) SAMPLE CLIENT Results Based on Incurred Initial Previous Current Current Period Current Period MedStat Oct 2005 -Sep Oct 2006 -Sep Oct 2007 -Sep Variance from variance from Dates of: zoos 2007 2008 Benchmark Benchmark Average `Allowed Amount is the Expense after application of all Claim Reduction Provisions (ineligible, discount, etc.) but before the application of plan design provisions (copays, deductible or coinsurance) Per Member, Per Month (PMPM) Claim Cost Value Breakdown Total Pharmacy Allowed Amount $ 53.04 $ 65.56 Retail $ 52.00 $ 59.18 Mail Order $ 1.04 $ 6.38 Ingredient Cost $ 39.66 $ 49.22 Retail $ 38.87 $ 44.16 Mail Order $ 0.79 $ 5.06 Dispensing Fee $ 1.80 $ 1.85 Retail $ 1.80 $ 1.84 Mail Order $ 0.00 $ 0.02 Client Pharmacy Cost $ 41.47 $ 51.07 Retail $ 40.67 $ 46.00 Mail Order $ 0.80 $ 5.07 Member Share $ 11.57 $ 14.48 Retail $ 11.33 $ 13.18 Mail Order $ 0.24 $ 1.31 Other Claim Cost Value Breakdown Allowed Amount per Patient Retail Mail Order Allowed Amount per Script Retail Mail Order Allowed Amount per Day Supply Retail Mail Order Retail vs Mail Order Utilization Benchmark Oa 2007 -Sep 2008 Oct 200fi -Sep 2007 Oct 2005-Sep 2006 0% 50% 100% 150% ^ Retail ^ Mail Order $ 65.44 $ 60.84 $ 4.60 $ 48.30 $ 44.75 $ 3.55 $ 1.67 $ 1.66 $ 0.01 $ 49.97 $ 46.41 $ 3.56 $ 15.47 $ 14.42 $ 1.04 $ 1,172.64 $ 2,710.17 $ 2,854.97 $ 519.61 $ 715.95 ~ $ 714.61 $ 653.03 $ 1,994.22 $ 2,140.36 $ 205.09 $ 303.41 $ 292.74 $ 51.44 $ 56.70 $ 57.54 $ 153.65 $ 246.71 $ 235.20 $ 4.22 $ 5.95 $ 5.14 $ 2.10 $ 2.29 $ 2.31 $ 2.12 $ 3.66 $ 2.83 Retail Drug Cost Share $ 52.75 $ 40.56 $ 12.18 $ 50.29 $ 35.76 $ 14.53 $ 1.13 $ 1.11 $ 0.02 $ 42.07 $ 31.87 $ 10.20 $ 10.68 $ 8.69 $ 1.98 24.1 °/p 6.7°/p -4.0% 5.6% 48.5°/p -5.9°/p 18.8% 5.2% 44.8% 11.7% $ 1,666.58 71.3% 27.1% $ 576.12 $ 1,090.47 $ 308.85 -5.2°/p 9.6% $ 64.42 $ 244.43 $ 4.20 22.3°/p 0.7°/p $ 2.49 $ 1.71 Mail Order Cost Share 76.3% Oct 2005 -Sep Oct 2006 -Sep Oct 2007 -Sep Benchmark 2006 2007 2008 D Client Cost O Member Cost Od 2005 -Sep Oct 2006 -Sep Oct 2007 -Sep Benchmark 2006 2007 2006 Client Cost 17 Member Cost (c) 2009 Group and Pension Administrators, Inc. 3 Pharmacy Cost Driver Analysis Key Indicators from Utilization Statistics SAMPLE CLIENT Results Based on Incurred Initial Previous Current Dates of: opt zoos - oct zoos - ot:t zoo? - Medstat Sep 200s Sep 2007 Sep 2008 Benchmark Patients Total Patients 256 305 391 Scripts 2,603 3,923 4,947 Scripts per Patient 10.2 12.9 12.7 Type of Prescriptions Retail Scripts 2,586 3,826 4,856 Mail Order Scripts 17 97 91 Mail Order Efficiency 0.7% 2.5% 1.8% Single Source Brand Scripts 995 1,394 1,564 Multi Source Brand Scripts 185 207 313 Generic Scripts 1,402 2,284 2,993 Other Scripts 21 38 77 Generic Utilization 53.9% 58.2% 60.5% Generic Potential 1,553 2,444 3,202 Generic Efficiency 90.3% 93.5% 93.5% Maintenance Drug Scripts 1,839 2,879 3,562 Maintenance Scripts -- Mail Order 17 97 88 Maintenance Drug Mail Order Efficiency 0.9% 3.4% 2.5% Days Supply of Prescriptions 13.3 8.0% 59.3% 92.6% 11.0% Current Period % Current Period Variance from Variance from Benchmark Average 23.2% 29.4°/a -5.0% 6.4% -77.0% 11.1% 18.7% 33.2% 34.4% 69.9% 2.1 % 5.2% 33.4% 0.9% 1.2% 29.1 30.7% -77.s% 9.s% Days Supply 64,699 101,189 128,470 30.9% Days Supply per Script 24.9 25.8 26.0 34.0 -23.s% 1.7% Days Supply Retail 63,469 94,647 120,896 30.0% Days Supply per Retail Script 24.5 24.7 24.9 28•s -13.0% 0.7% Days Supply Mail Order 1,230 6,542 7,574 48.1% Days Supply per Mail Order Script 72.4 67.4 83.2 89.4 -7.0% 12.0% Key Indicators Utilization Variance from Benchmark Script Utilization Script Efficiency 20°i° 2.1 °i° o.9°i° o°i° -20% -ao°i° -so°ie - •80% _- -77.0% -77 -100% -- --- ^Generic Utilization ~ Generic Efficier ^ Mail Order Efficiency ^ Main. M.O. Effic POSITIVE PERCENTAGES ARE FAVORABLEI (c) 2009 Group and Pension Administrators, Inc. 4 ^ Retail Days/Script ^ M.O. DayslScript NE(,A I IVE PERCENTAGES ARE FAVORABLE! Pharmacy Cost Driver Analysis Top Therapeutic Groups SAMPLE CLIENT All pharmecutical drugs are classified into one of 26 Therapeutic Groups. The drugs are distributed into the group which most appropriately defines the drug's primary therapeutic focus. The largest Therapeutic Group is Central Nervous System which includes all depression and anti-anxiety medication. Approximately 7% of drugs are Unclassified Agents and are grouped together. Drugs in Therapeutic Groups are not always interchangeable because they are not Therapeutic Equivalents (exact same active ingredients), but sometimes a more cost effective option is available within the group. Members should consult their physician to explore these options. Based on Incurred Date from: Oct 2007 -Sep 2008 Therapeutic Group Total Amount patients Scripts Days / Avg. Cost I Avg. Cost / Paid by Client Script Script Day TOTAL OF ALL SCRIPTS $ 206,931 1,196 4,947 26.0 $ 41.83 $ 1.61 COMBINED TOTAL Therapeutic Group Percent of Total Cost 1 .3% Cardiovascular Agents Central 21 Nervous System 1 60~ 13. Hormones & synthetic Subst 1 .4°/ 1 Cardiovascular Agents $ 51,303 126 1,383 31.8 $ 37.10 $ 1.17 ~ Gastrointestinal •8% 2 Central Nervous System $ 34,340 175 926 22.8 $ 37.08 $ 1.63 Drugs 6% 3 Hormones & Synthetic Subst $ 33,833 124 836 29.6 $ 40.47 $ 1.37 4 Gastrointestinal Drugs $ 17,711 62 190 30.0 $ 93.21 $ 3.11 5 Anti-Infective Agents $ 15,837 243 487 10.4 $ 32.52 $ 3.14 ~ 9 3% 6 Unclassified Agents $ 13,243 28 105 28.9 $ 126.12 $ 4.36 ~ Antl•Inrective 7 Autonomic Drugs $ 9,092 79 211 24.0 $ 43.09 $ 1.79 Agents •7% 8 Blood Form/Coagul Agents $ 8,465 14 91 30.5 $ 93.03 $ 3.05 91 165 17 5 $ 30 82 $ 1 76 9 Skin & Mucous Membrane $ 5,085 . . . 10 Eye, Ear, Nose Throat $ 4,894 71 104 19.1 $ 47.06 $ 2.46 ~ unclassltied 6 9% I Agents 6. RETAIL Cardiovascular Agents $ 47,994 119 1,344 30.2 $ 35.71 $ 1.18 Central Nervous System $ 34,188 174 925 22.7 $ 36.96 $ 1.63 4.4 /0 Hormones & Synthetic Subst $ 33,245 120 821 28.7 $ 40.49 $ 1.41 Autonomic Drugs Gastrointestinal Drugs $ 15,659 60 183 27.7 $ 85.57 $ 3.09 4.4 /0 Anti-Infective Agents $ 15,837 243 487 10.4 $ 32.52 $ 3.14 Unclassified Agents $ 5,280 27 97 29.0 $ 54.44 $ 1.88 Autonomic Drugs $ 8,370 78 208 23.1 $ 40.24 $ 1.74 Blood 2.1°/ Blood FormlCoagul Agents $ 8,448 13 90 29.9 $ 93.87 $ 3.14 ForAmle tggul 9 ; 4.1 i/o Skin & Mucous Membrane $ 4,991 90 164 17.1 $ 30.43 $ 1.78 Eye, Ear, Nose Throat $ 4,894 71 104 19.1 $ 47.06 $ 2.46 2 8° MAIL ORDER Skin&MUCOUa Cardiovascular Agents $ 3,310 7 39 90.0 $ 84.86 $ 0.94 Membrane 2.5°/ Central Nervous System $ 151 1 1 90.0 $ 151.37 $ 1.68 , Hormones & Synthetic Subst $ 588 4 15 82.0 $ 39.20 $ 0.48 Gastrointestinal Drugs $ 2,051 2 7 90.0 $ 293.05 $ 3.26 Eye, Ear, Nose 2.6° Anti-Infective Agents $ - 0 0 #DIV/0! #DIV/0! #DIV/0! it rnroat 2 4°/ Unclassified Agents $ 7,963 1 8 28.0 $ 995.34 $ 35.55 Autonomic Drugs $ 722 1 3 90.0 $ 240.67 $ 2.67 Blood Form/Coagul Agents $ 17 1 1 90.0 $ 16.98 $ 0.19 Skin & Mucous Membrane $ 94 1 1 90.0 $ 94.26 $ 1.05 ' ~ i Bench mark Eye, Ear, Nose Throat $ - 0 0 #DIVIO! #DIV/0! #DIV/0! ^ Client Total (c) 2009 Group and Pension Administrators, Inc. 5 Pharmacy Cost Driver Analysis Most Commonly Prescribed Drugs Nationally SAMPLE CLIENT e1~ t~ llr w BRAND NAME DRUGS Client Results Drug Name Therapeutic Class Avg. Cost / 30 Day Supply Avg. Cost / 30 Day Supply Patients Scripts Total Client Cost Client Rank 1 LIPITOR Cardiovascular Agents $ 106.27 $ 97.37 20 123 $ 8,354 1 2 NEXIUM Gastrointestinal Drugs $ 163.65 $ 135.89 14 54 $ 7,624 5 3 LEXAPRO Central Nervous System $ 89.78 $ 87.43 6 29 $ 1,780 13 4 SINGULAIR Unclassified Agents $ 104.79 $ 102.38 12 43 $ 3,112 8 5 SYNTHROID Hormones & Synthetic Subst $ 32.31 $ 38.90 4 29 $ 258 14 6 VYTORIN Cardiovascular Agents $ 96.34 $ 95.98 10 52 $ 3,431 6 7 CRESTOR Cardiovascular Agents $ 97.17 $ 95.52 10 55 $ 4,208 4 8 EFFEXOR-XR Central Nervous System $ 151.14 $ 113.02 5 16 $ 1,328 30 9 LEVAQUIN Anti-Infective Agents $ 328.25 $ 273.33 21 30 $ 2,206 11 10 DIOVAN HCT Cardiovascular Agents $ 83.17 $ 90.90 11 78 $ 5,116 2 11 TRICOR Cardiovascular Agents $ 104.95 $ 107.08 9 27 $ 2,030 15 12 ZYRTEC Antihistamines & Comb. $ 75.47 $ 79.86 7 11 $ 449 48 13 NASONEX Eye, Ear, Nose Throat $ 86.77 $ 88.80 12 12 $ 696 42 14 PREVACID Gastrointestinal Drugs $ 166.19 $ 134.34 9 25 $ 2,657 17 15 PREMARIN Hormones & Synthetic Subst $ 52.58 $ 59.40 3 10 $ 412 58 16 CYMBALTA Central Nervous System $ 143.34 $ 106.69 5 29 $ 2,298 12 17 PLAVIX Blood Form/Coagul Agents $ 131.95 $ 120.95 9 72 $ 6,660 3 18 YAZ Hormones 8 Synthetic Subst $ 59.43 $ 68.74 5 20 $ 723 22 19 YASMIN Hormones & Synthetic Subst $ 62.82 $ 73.06 3 19 $ 764 23 20 ACTOS Hormones & Synthetic Subst $ 170.96 $ 138.25 7 33 $ 3,680 10 21 BENICAR HCT Cardiovascular Agents $ 77.38 $ 85.04 7 26 $ 1,431 16 22 VALTREX Anti-Infective Agents $ 272.85 $ 280.43 5 4 $ 559 98 23 DIOVAN Cardiovascular Agents $ 71.77 $ 90.73 4 43 $ 2,612 9 24 ZETIA Cardiovascular Agents $ 94.60 $ 92.22 3 17 $ 1,307 28 25 AMBIEN CR Central Nervous System $ 115.75 $ 115.76 4 7 $ 577 73 28 PROAIR HFA Autonomic Drugs $ 49.57 $ 58.42 4 5 $ 118 97 27 TAMIFLU Anti-Infective Agents $ 276.70 $ 276.14 12 11 $ 574 47 28 CELEBREX Central Nervous System $ 130.58 $ 104.70 2 5 $ 373 91 29 ORTHO TRI-CYCLEN LO Hormones 8 Synthetic Subst $ 58.09 $ 63.55 1 7 $ 251 76 30 ADDERALL XR Central Nervous System $ 162.92 $ 117.46 4 18 $ 1,574 25 31 LUNESTA Central Nervous System $ 133.84 $ 126.14 3 12 $ 1,154 39 32 BENICAR Cardiovascular Agents $ 64.21 $ 71.84 3 10 $ 418 57 33 LANTUS Hormones & Synthetic Subst $ 142.57 $ 118.12 5 7 $ 617 72 34 LYRICA Central Nervous System $ 143.38 $ 113.97 3 4 $ 336 102 35 NUVARING Hormones & Synthetic Subst $ 54.78 #N/A #N/A #N/A #N/A #N/A 36 ADVAIR DISKUS 250/50 Hormones & Synthetic Subst $ 180.89 $ 162.21 2 2 $ 264 131 37 TUSSIONEX PENNKINETIC Antituss/Expector/Mucolytic $ 103.49 $ 121.24 4 6 $ 332 83 38 TOPAMAX Central Nervous System $ 242.48 $ 119.75 2 4 $ 359 101 39 FLOMAX Unclassified Agents $ 92.04 $ 86.75 6 17 $ 946 29 40 ALLEGRA-D 12 HOUR Autonomic Drugs $ 96.26 $ 94.33 7 15 $ 933 32 41 BUDEPRION XL Central Nervous System $ 118.33 $ 98.03 1 1 $ 48 205 42 WELLBUTRIN XL Central Nervous System $ 165.14 $ 115.30 1 1 $ 85 191 43 ACIPHEX Gastrointestinal Drugs $ 154.86 $ 149.47 5 22 $ 2,628 20 44 NIASPAN Cardiovascular Agents $ 111.96 $ 73.41 2 14 $ 608 34 45 LOESTRIN 24 FE Hormones & Synthetic Subst $ 53.18 $ 70.14 1 7 $ 262 75 46 HYZAAR Cardiovascular Agents $ 75.74 #N/A #N/A #N/A #N/A #N/A 47 ALTACE Cardiovascular Agents $ 72.27 $ 75.74 1 10 $ 457 55 48 ARMOUR THYROID Hormones & Synthetic Subst $ 30.99 $ 35.62 2 25 $ 140 19 49 CONCERTA Central Nervous System $ 128.83 $ 130.35 1 5 $ 502 89 50 JANUVIA Hormones & Synthetic Subst $ 162.31 $ 139.68 12 48 $ 5,594 7 (c) 2009 Group and Pension Administrators, Inc. 6 Pharmacy Cost Driver Analysis Most Commonly Prescribed Drugs Nationally SAMPLE CLIENT GENERIC DRUGS Client Results Dru Name g Thera eutic Class P Avg• Cost 130 Avg. Cost 130 patients Scripts Total Client Client Day Supply Day Supply Cost Rank 1 APAPIHYDROCODONE BITARTRATE Central Nervous System $ 56.17 $ 38.65 75 164 $ 1,446 1 2 AZITHROMYCIN Anti-Infective Agents $ 172.40 $ 196.75 66 80 $ 1,914 4 3 AMOXICILLIN Anti-Infective Agents $ 41.52 $ 28.22 44 48 $ 82 14 4 LEVOTHYROXINE SODIUM Hormones & Synthetic Subst $ 34.07 $ 9.89 7 30 $ 19 24 5 LISINOPRIL Cardiovascular Agents $ 37.52 $ 12.73 21 135 $ 610 2 6 METOPROLOL SUCCINATE Cardiovascular Agents $ 49.75 $ 26.29 5 32 $ 508 20 7 SIMVASTATIN Cardiovascular Agents $ 55.15 $ 34.91 12 61 $ 1,531 8 8 ALPRAZOLAM Central Nervous System $ 36.51 $ 9.40 14 55 $ 42 9 9 HYDROCHLOROTHIAZIDE Electrolytic, Caloric, Water $ 31.80 $ 4.65 13 63 $ 13 7 10 SERTRALINE HYDROCHLORIDE Central Nervous System $ 57.84 $ 28.32 6 32 $ 667 19 11 AMLODIPINE BESYLATE Cardiovascular Agents $ 49.94 $ 27.46 6 21 $ 571 35 12 AMOXICILLIN/CLAVULANATE POTAS Anti-Infective Agents $ 164.12 $ 177.36 18 18 $ 837 46 13 METFORMIN HYDROCHLORIDE Hormones $ Synthetic Subst $ 45.40 $ 20.38 18 87 $ 1,041 3 14 ATENOLOL Cardiovascular Agents $ 33.05 $ 4.89 8 68 $ 14 5 15 ZOLPIDEM TARTRATE Central Nervous System $ 67.94 $ 60.82 6 17 $ 819 48 18 APAPIPROPOXYPHENE NAPSYLATE Central Nervous System $ 44.57 $ 26.63 23 53 $ 28 11 17 FLUTICASONE PROPIONATE Eye, Ear, Nose Throat $ 69.66 $ 57.79 7 10 $ 478 77 18 PREDNISONE Hormones & Synthetic Subst $ 32.69 $ 10.48 10 10 $ - 82 19 METHYLPREDNISOLONE Hormones & Synthetic Subst $ 42.95 $ 30.75 18 21 $ - 37 20 CEFDINIR Anti-Infective Agents $ 229.98 $ 189.42 22 28 $ 1,728 26 21 CIPROFLOXACIN Anti-Infective Agents $ 47.01 $ 31.93 19 20 $ 25 42 22 CEPHALEXIN Anti-Infective Agents $ 54.28 $ 46.13 27 28 $ 103 27 23 IBUPROFEN Central Nervous System $ 34.11 $ 9.89 20 32 $ - 21 24 AMLODIPINE BESYLATE AND BENAZ Cardiovascular Agents $ 97.63 $ 75.20 6 24 $ 1,565 31 25 OMEPRAZOLE Gastrointestinal Drugs $ 71.72 $ 45.54 5 7 $ 225 99 26 HCTZILISINOPRIL Cardiovascular Agents $ 43.83 $ 21.75 7 41 $ 487 18 27 FLUOXETINE HCL Central Nervous System $ 47.53 $ 11.96 3 13 $ 30 64 28 CYCLOBENZAPRINE HCL Autonomic Drugs $ 36.91 $ 13.51 12 16 $ 33 52 29 METFORMIN HCL Hormones & Synthetic Subst $ 41.48 $ 17.75 10 42 $ 416 17 30 FEXOFENADINE HYDROCHLORIDE Antihistamines & Comb. $ 70.73 $ 49.78 8 18 $ 811 47 31 FUROSEMIDE Electrolytic, Caloric, Water $ 31.65 $ 1.88 1 3 $ - 164 32 CLONAZEPAM Central Nervous System $ 36.80 $ 7.24 4 11 $ 6 75 33 FLUCONAZOLE Anti-Infective Agents $ 53.68 $ 89.53 10 15 $ 90 54 34 MELOXICAM Central Nervous System $ 58.09 $ 32.30 9 20 $ 423 39 35 HCTZITRIAMTERENE Electrolytic, Caloric, Water $ 32.78 $ 5.89 5 46 $ 23 16 36 METOPROLOL TARTRATE Cardiovascular Agents $ 32.80 $ 5.32 7 31 $ - 23 37 DOXYCYCLINE HYCLATE Anti-Infective Agents $ 38.19 $ 10.98 11 14 $ 11 58 38 ESTRADIOL Hormones & Synthetic Subst $ 35.98 $ 5.67 4 11 $ 6 74 39 FEXOFENADINE HCL Antihistamines & Comb. $ 73.64 $ 58.50 4 16 $ 776 51 40 CITALOPRAM HYDROBROMIDE Central Nervous System $ 41.29 $ 16.33 4 5 $ 53 120 41 NAPROXEN Central Nervous System $ 36.98 $ 11.32 16 21 $ 18 36 42 PRAVASTATINSODIUM Cardiovascular Agents $ 63.80 $ 46.10 9 47 $ 2,033 15 43 ALBUTEROL Autonomic Drugs $ 48.80 $ 26.77 6 6 $ 51 112 44 PROMETHAZINE HCL Antihistamines & Comb. $ 64.01 $ 73.12 10 10 $ 15 80 45 GLIPIZIDE Hormones 8 Synthetic Subst $ 39.48 $ 9.11 10 63 $ 127 6 46 PANTOPRAZOLE SODIUM Gastrointestinal Drugs $ 124.96 $ 105.65 3 7 $ 599 98 47 ALLOPURINOL Unclassified Agents $ 32.47 $ 7.25 1 10 $ 3 81 48 CARISOPRODOL Autonomic Drugs $ 42.10 $ 17.46 13 54 $ 281 10 49 LORAZEPAM Central Nervous System $ 40.26 $ 27.16 2 2 $ 26 194 50 GABAPENTIN Central Nervous System $ 72.54 $ 35.59 4 19 $ 510 44 (c) 2009 Group and Pension Administrators, Inc. 7 Pharmacy Cost Driver Analysis Top 50 Individual Utilizers SAMPLE CLIENT Based on Incurred Dates from: Oct 2007 - Sep 2008 Patient ID Total Amount Retail Scripts Mail Order Generic Generic Client Cost / 30 Member Cost / 3 paid b Client Y Scri is P Utilization % Efficient /° Y° Da Su I Y PPY Da Su I Y PPY 1 H87034100921 $ 9,735 55 8 82.5% 100.0% $ 157.96 $ 63.89 2 H87034100611 $ 9,200 27 0 51.9% 93.3% $ 372.46 $ 114.99 3 H87034102371 $ 4,000 113 0 58.4% 88.0% $ 35.65 $ 16.35 4 H87034103903 $ 3,841 37 0 29.7% 100.0% $ 98.65 $ 36.79 5 H87034101161 $ 3,540 53 0 28.3% 100.0% $ 71.14 $ 32.15 6 H87034101722 $ 3,486 44 0 27.3% 75.0% $ 85.44 $ 38.78 7 H87034104411 $ 3,401 13 0 0.0% 0.0% $ 278.78 $ 119.48 8 H87034102131 $ 3,293 60 0 38.3% 100.0% $ 54.88 $ 25.21 9 H87034102801 $ 3,083 45 0 37.8% 100.0% $ 74.10 $ 33.91 10 H87034105032 $ 3,041 20 0 40.0% 100.0% $ 152.04 $ 44.59 11 H87034103262 $ 2,912 103 0 53.4% 82.1% $ 30.01 $ 14.24 12 H87034103212 $ 2,892 91 0 57.1 % 100.0% $ 44.44 $ 24.50 13 H87034103141 $ 2,832 61 0 41.0% 78.1% $ 47.82 $ 23.31 14 H87034101162 $ 2,757 44 0 29.5% 100.0% $ 66.65 $ 29.41 15 H87034100541 $ 2,527 29 0 20.7% 54.5% $ 98.46 $ 44.18 16 H87034101331 $ 2,488 67 0 56.7% 76.0% $ 40.28 $ 20.04 17 H87034104481 $ 2,448 52 0 46.2% 68.6% $ 47.08 $ 21.27 18 H87034104981 $ 2,431 9 25 61.8% 100.0% $ 32.60 $ 12.55 19 H87034101311 $ 2,382 33 0 39.4% 100.0% $ 76.35 $ 31.93 20 H87034102102 $ 2,349 52 0 55.8% 78.4% $ 46.64 $ 22.16 21 H87034100731 $ 2,213 40 0 60.0% 100.0% $ 58.69 $ 28.57 22 H87034100652 $ 2,117 38 0 63.2% 96.0% $ 59.01 $ 21.91 23 H87034103271 $ 2,063 36 0 52.8% 95.0% $ 59.50 $ 25.88 24 H87034103832 $ 2,062 29 0 34.5% 76.9% $ 94.57 $ 42.12 25 H87034102701 $ 2,050 46 0 47.8% 68.8% $ 46.25 $ 23.27 26 H87034102562 $ 2,038 44 0 56.8% 100.0% $ 46.48 $ 21.38 27 H87034100791 $ 1,995 56 0 62.5% 100.0% $ 34.40 $ 19.09 28 H87034104831 $ 1,915 28 0 28.6% 100.0% $ 68.38 $ 27.11 29 H87034100461 $ 1,909 27 20 72.3% 79.1% $ 23.42 $ 12.97 30 H87034103701 $ 1,896 40 0 30.0% 100.0% $ 51.33 $ 24.24 31 H87034102242 $ 1,843 49 0 73.5% 100.0% $ 38.90 $ 18.06 32 H87034102171 $ 1,783 39 0 53.8% 95.5% $ 59.77 $ 27.55 33 H87034101271 $ 1,755 28 0 50.0% 100.0% $ 64.59 $ 24.51 34 H87034103472 $ 1,747 37 0 32.4% 100.0% $ 49.40 $ 23.69 35 H87034100771 $ 1,690 23 6 55.2% 88.9% $ 41.98 $ 12.93 36 H87034100542 $ 1,560 50 0 16.0% 40.0% $ 34.22 $ 18.05 37 H87034101272 $ 1,543 37 0 27.0% 43.5% $ 49.39 $ 21.98 38 H87034102401 $ 1,526 28 0 39.3% 100.0% $ 50.86 $ 23.18 39 H87034104972 $ 1,499 27 0 70.4% 100.0% $ 68.02 $ 21.86 40 H87034103622 $ 1,473 11 12 73.9% 100.0% $ 37.13 $ 17.02 41 H87034100051 $ 1,453 29 0 55.2% 100.0% $ 55.68 $ 20.27 42 H87034102891 $ 1,442 40 0 65.0% 100.0% $ 38.80 $ 15.91 43 H87034104541 $ 1,436 52 0 61.5% 100.0% $ 29.66 $ 14.38 44 H87034103935 $ 1,408 21 0 28.6% 100.0% $ 84.14 $ 34.13 45 H87034102641 $ 1,356 40 0 77.5% 100.0% $ 38.38 $ 21.42 46 H87034101091 $ 1,328 43 0 58.1% 100.0% $ 38.20 $ 20.46 47 H87034104331 $ 1,290 26 0 53.8% 100.0% $ 49.62 $ 26.14 48 H87034103161 $ 1,285 36 0 66.7% 100.0% $ 35.70 $ 18.30 49 H87034102222 $ 1,257 17 0 35.3% 100.0% $ 89.38 $ 29.61 50 H87034102761 $ 1,193 20 0 60.0% 100.0% $ 60.66 $ 26.65 (c) 2009 Group and Pension Administrators, Inc. g r ~. ~~ SAMPLE CLIENT Provider Utilization Analysis All data in the Analysis is based upon INCURRED CLAIMS for the periods identified and Medstat utilizes athree- month Lag from paid claims for incurred reporting llllrtl .~ Provider Utilization Analysis Summary of Utilization SAMPLE CLIENT WHAT IS DRIVING COST? 1 How is In-Network versus Out-of-Network utilization by Inpatient, Outpatient and Physician? 2 What type of providers are being utilized frequently? 3 Is there favorable utilization of Primary Care Physicians? 4 Is there high out-of-network utilization with certain types of providers? 5 Are certain types of Specialists costly? 6 How is the utilization in each of the Managed Care markets and are there any problem areas? 7 Is the Place of Service utilization comparable with the Benchmark norms? 8 Why do certain individuals have high dollars expended out-of-network? Provider Type Utilization Weighting Results Based on initial Previous Current Incurred Dates of: opt Zoos - occ zoos - opt zoo7 - Sep 2006 Sep 2007 Sep 2008 In-Network Allowed Amount In-Patient Facility $ 115.14 $ 46.41 $ 68.30 Out-Patient Facility $ 43.82 $ 93.22 $ 60.42 Out-Patient Physician $ 36.29 $ 31.23 $ 27.09 Out-of-Network Allowed Amount In-Patient Facility $ 5.63 $ 3.71 $ 9.89 Out-Patient Facility $ 2.50 $ 8.20 $ 4.03 Out-Patient Physician $ 4.79 $ 2.99 $ 2.49 In-Network Percentage In-Patient Facility 95.3% 92.6% 87.3% Out-Patient Facility 94.6% 91.9% 93.7% Out-Patient Physician 88.3% 91.3% 91.6% In-Patient Facility Out-Patient Facility Physician ~~ KEY STAT ~~ The target In-Network Percentage forth three service areas is 90% but the level is influenced by the percentage of members in a rural location. A high concentration of members in major metropolitan locations should bring the In-Network Percentage up to at least 93% for all service areas. In-Network Utilization by Service Area ^ Oct 2005 -Sep 2006 ^ Oct 2006 -Sep 2007 ^ Oct 2007 -Sep 2008 ^ Benchmark Number of Provider Visits by Network Utilization Results Based on Inc rred Dates f Oct 2005 - sep zoos Oct 2006 - sep zoo7 Oct 2007 - sep zoos u : o In-Net. Hosp. Providers 16 27 25 OON Hosp. Providers 17 26 26 In-Net. OP Fac Providers 121 204 214 OON OP Fac Providers 39 63 76 In-Net. Phy. Providers 879 1,320 1,504 OON Phy. Providers 299 412 454 In-Network ER Providers 35 52 68 OON ER Providers 12 19 25 (c) 2009 Group and Pension Administrators, Inc. 0 In-Patient Out-Patient Facility Facility ~~Oct 2005 -Sep 2006 'Oct 2007 -Sep 2008 100 /o 98% 96% - 94% 92% - so°i° 88% 86% 84% - 82% 80% Physician fOct 2006 -Sep 2007 Benchmark 2 0% 20% 40% 60% 80% Provider Utilization Analysis Top Utilization by Provider Type SAMPLE CLIENT Report based on Incurred Claim Data for the Period: Oct 2007 -Sep 2008 Provider Type In-Network Amount Out-of-Network Amount Total Allowed Amount % Out-of- Network (1) Faculties (2) PCP's Specialists (3) ERAP Providers Non-Physicians $ L86,U99 $ 16,603 $ 302,703 5.5% $ 116,795 $ 7,634 $ 124,429 6.1% $ 139,350 $ 4,819 $ 144,168 3.3% $ 44,733 $ 33,726 $ 78,458 43.0% $ 7,786 $ 6,348 $ 14,134 44.9% Report based on Incurred Claim Data for the Period: Oct 2006 -Sep 2007 Provider Type In-Network Amount Out-of-Network Amount Total Allowed Amount % Out-of- Network Current Period Distribution 0 12% ° I 45% 22% O 19% ^ Facilities ^ PCP's ^ Specialists ^ ERAP Providers ^Non-Physicians (1) Facilities $ 453,801 $ 13,470 $ 467,271 2.9% 9% 2% (2) PCP's $ 84,760 $ 1,938 $ 86,697 2.2% Specialists $ 139,350 $ 6,345 $ 145,694 4.4% 19%~ ®I (3) ERAP Providers $ 38,534 $ 28,504 $ 67,037 42.5% Non-Physicians $ 10,719 $ 3,412 $ 14,131 24.1% 59% 11% (1) Inpatient $ Outpatient Hospital, Ambulatory Surgical Centers, Urgent Care Centers, etc. (2) Family Practice, Internal Medicine, Pediatrician and Ob/Gyn (3) Emergency Room Physicians, Radiologists, Anesthesiologists and Pathologists Report based on Incurred Claim Data for B OTH PER IO DS COMB INE D Provider Type In-Network Out-of-Network Total Allowed Amount Amount Amount 1 -Missing $ 992,540 $ 245,944 $ 1,238,484 2 Acute Care Hospital $ 697,872 $ 11,811 $ 709,683 3 Family Practice $ 77,871 $ 708 $ 78,579 4 Radiology $ 37,473 $ 22,429 $ 59,902 5 Pediatrician (NEC) $ 50,465 $ 8,603 $ 59,068 6 Geriatric Medicine $ 52,091 $ - $ 52,091 7 Anesthesiology $ 27,999 $ 21,679 $ 49,678 8 Cardiovascular DislCardiology $ 47,815 $ 90 $ 47,905 9 Internal Medicine (NEC) $ 45,585 $ - $ 45,585 10 Laboratory $ 36,737 $ 8,541 $ 45,278 11 Obstetrics & Gynecology $ 27,632 $ 261 $ 27,893 12 Pathology $ 15,602 $ 6,017 $ 21,619 13 Gastroenterology $ 21,582 $ - $ 21,582 14 Otolaryngology $ 20,382 $ - $ 20,382 15 Surgeon (NEC) $ 16,248 $ 2,078 $ 18,326 16 Ophthalmology $ 16,020 $ - $ 16,020 17 Orthopaedic Surgery $ 14,119 $ 696 $ 14,815 18 Emergency Medicine $ 2,192 $ 12,104 $ 14,297 19 Podiatry $ 13,301 $ 170 $ 13,470 20 Ambulatory Surgery Centers $ 3,677 $ 9,193 $ 12,870 21 Supply Center $ 8,662 $ 4,118 $ 12,780 22 Urology $ 12,224 $ 554 $ 12,778 23 Neurology $ 7,747 $ 3,190 $ 10,937 24 Allergy & Immunology $ 8,895 $ - $ 8,895 25 ChiropractorlDCM $ 4,922 $ 300 $ 5,222 Previous Period Distribution Provider % of Benchmark % % Out-of- Benchmark Total Claims of Total Network Out-of- Claims Network 46.5% 44.5% 19.9% 18.7% 26.7% 27.1% 1.7% 4.1% 3.0% 3.1 % 0.9% 2.0% 2.3% 2.3% 37.4% 12.7% 2.2% 1.7% 14.6% 3.0% 2.0% 0.2% 0.0% 0.5% 1.9% 1.8% 43.6% 38.4% 1.8% 1.1% 0.2% 3.5% 1.7% 1.6% 0.0% 3.0% 1.7% 1.5% 18.9% 5.8% 1.0% 2.1 % 0.9% 1.3% 0.8% 0.6% 27.8% 19.5% 0.8% 0.5% 0.0% 3.2% 0.8% 0.5% 0.0% 2.8% 0.7% 0.8% 11.3% 10.3% 0.6% 0.5% 0.0% 3.0% 0.6% 1.2% 4.7% 5.6% 0.5% 0.6% 84.7% 66.0% 0.5% 0.3% 1.3% 3.4% 0.5% 0.5% 71.4% 9.3% 0.5% 0.3% 32.2% 18.0% 0.5% 0.4% 4.3% 3.8% 0.4% 0.5% 29.2% 4.0% 0.3% 0.3% 0.0% 2.4% 0.2% 0.7% 5.7% 20.3% Missing refers to providers that do not indicate their field of specialty at time of claim submission (c) 2009 Group and Pension Administrators, Inc. 3 Provider Utilization Analysis Top Utilization by Location & Place of Service SAMPLE CLIENT Report based on Incurred Claim Oata for the Period of: Oct 2007 -Sep 2008 Metropolitan Statistical In-Network Out-of-Network Total Allowed Area Amount Amount Amount ~ Out-of-Network 1 Houston-Sugar Land-Baytown, TX $ 732,936 $ 110,559 $ 843,494 13.1 2 Dallas-Plano-Irving, TX $ 138,768 $ 10,239 ' $ 149,007 6.9% 3 -RURAL $ 95,778 $ 52,856 $ 148,634 35.6% 4 Austin-Round Rock, TX $ 85,886 $ 1,610 $ 87,496 1.8% 5 San Antonio, TX $ 66,131 $ 8,752 $ 74,883 11.7% 6 Fort Worth-Arlington, TX $ 43,093 $ 960 $ 44,053 2.2% 7 Reno-Sparks, NV $ 27,324 $ 6,815 $ 34,139 20.0% $ Cambridge-Newton-Framingham, M $ 8,721 $ 4,150 $ 12,871 32.2% 9 Boston-quincy, MA $ 3,413 $ 104 $ 3,517 3.0% 10 Las Vegas-Paradise, NV $ 2,175 $ - $ 2,175 0.0% 11 Beaumont-Port Arthur, TX $ 558 $ - $ 558 0.0% 12 13 14 15 Place of Service 1 Inpatient Hospital 2 Office 3 Outpatient Hospital 4 Ambulatory Surgical Center 5 Emergency Room -Hospital 6 Independent Laboratory 7 Patient Home 8 Ambulance (land) 9 -Missing/Other 10 Urgent Care Facility 11 12 13 14 15 for PROVIDER TYPE OR PLACE OF SERVICE Provider Type refers to the specialty of the physician or the primary purpose of the facility whereas Place of Service indicates the location where the member seeks treatment. Place of Service is a better indication of how resources are being utilized and if plan design can influence the decision process. Place of Service is more useful in detailing the types of services members need. 'eriod of: Oct 2007 - S In-Network Out-of-Network Amount Amount $ 434,854 $ 62,291 216,548 $ 24,165 196,762 $ 30,494 172,254 $ 23,642 135,926 $ 20,974 43,125 $ 12,515 4,699 $ 18,574 - $ 3,388 403 $ - 213 $ - Top Location C Totals 6.2% 5.3% 0% 20% 40% ^ Houston-Sugar Land-ea ^Dollas-Plano-Irving, TX O-RURAL ^Austin-Round Rock, TX ®San Antonio, TX 80 TX p 2008 Provider % of Benchmark Total Allowed Total Claims of Total Claim Amount $ 497,145 35.5% 33.5% $ 240,713 17.2% 21.8% $ 227,256 16.2% 15.7% $ 195,895 14.0% 14.3% $ 156,901 11.2% 8.5% $ 55,640 4.0% 2.5% $ 23,273 1.7% 1.3% $ 3,388 0.2% 0.4% $ 403 0.0% 0.4% $ 213 0.0% 0.2% Distribution by Place of Service ^ Inpatient Hospital ^ Office ^ Outpatient Hospital ^Ambulatory Surgical Center ^ Emergency Room -Hospital ^ ALL OTHER TYPES 36% 6%~ 11%. 17% 14% 16% (C) 2009 Group and Pension Administrators, Inc. 4 Provider Utilization Analysis Individual Out-of-Network Detail (up to 50) SAMPLE CLIENT Report based on Incurred Claim Data for the Period of: Oct 2007 -Sep 2008 Patient Identifier Place of Service Out-of-Network Provider Metropolitan Service Area (of Member) 1 H87034100461 2 H87034100363 3 H87034100951 4 H87034104152 5 H87034104761 6 H87034102891 7 H87034103541 8 H87034103162 9 H87034104612 10 H87034101162 11 H87034104461 12 H87034102161 13 H87034101072 14 H87034105714 15 H87034103541 16 H87034103901 17 H87034100772 18 H87034103181 19 H87034101721 20 H87034100992 21 H87034101091 22 H87034103211 23 H87034105162 24 H87034104152 25 H87034104132 26 H87034102801 27 H87034102701 28 H87034100652 29 H87034102242 30 H87034104612 31 H87034101132 32 H87034101722 33 H87034102891 34 H87034102631 35 H87034101094 36 H87034104092 37 H87034104382 38 H87034104735 39 H87034102161 40 H87034103212 41 H87034105744 42 H87034105194 43 H87034104151 44 H87034101172 45 H87034104612 46 H87034100601 47 H87034101721 48 H87034101721 49 H87034100231 50 H87034103671 Inpatient Hospital Patient Home Independent Laboratory Inpatient Hospital Office Ambulatory Surgical Center Inpatient Hospital Office Outpatient Hospital Ambulatory Surgical Center Outpatient Hospital Outpatient Hospital Patient Home Emergency Room -Hospital Inpatient Hospital Ambulatory Surgical Center Ambulatory Surgical Center Office Inpatient Hospital Inpatient Hospital Emergency Room -Hospital Outpatient Hospital Outpatient Hospital Inpatient Hospital Inpatient Hospital Outpatient Hospital Inpatient Hospital Office Ambulatory Surgical Center Outpatient Hospital Outpatient Hospital Ambulatory Surgical Center Outpatient Hospital Outpatient Hospital Outpatient Hospital Outpatient Hospital Outpatient Hospital Outpatient Hospital Outpatient Hospital Ambulatory Surgical Center Ambulance (land) Emergency Room -Hospital Inpatient Hospital Ambulatory Surgical Center Emergency Room -Hospital Ambulatory Surgical Center Inpatient Hospital Outpatient Hospital Outpatient Hospital Emergency Room -Hospital (c) 2009 Group and Pension Administrators, Inc. EAST TEXAS MEDICAL CENTER THE CARE GROUP OF TEXAS PENN IMAGING OF HUMBLE LAK RAJAGOPALAN MICHAEL HARPER DOCTORS OUTPATIENT SURG CTR KENNETH HILLER MASS GENERAL PHYSICIANS ORG JEFFREY HORWITZ METHODIST ASC MEDICAL CENTER UTMB AT GALVESTON MMC OF EAST TEXAS HOUSTON STAT MED SUPPLY & RENOWN REGIONAL MEDICAL CENTER METROWEST ANESTHESIA CARE ALAN CARRUTH MEDCENTER AMBULATORY SURGERY GREATER HOUSTON SLEEP & RESERC ARMAND MARTEL GREATER HOUSTON ANESTHESIOLOG' 2920 ER VA MEDICAL CENTER NORTH HOUSTON ANESTHESIOLOGIS RENE RAMIREZ MARTIN EASON COPPERWOOD MED CENTER DANIEL HUANG TERESA ATKINSON SAN ANTONIO GASTRO ENDOSCOPY JEFFEREY KLEIN HADEN STEFFEK KELLY BOURGEOIS SYED GHYASUDDIN NORTH CYPRESS MEDICAL CENTER ALLAN CONDE STEVEN SAX RAY ORTIZ CHRISTOPHER MEGGYESY TERESA TODD MARK SAVRICK REMSA NORTH CYPRESS MEDICAL CENTER FELIX RAMIREZ RPK ANESTHESIA LESLIE POER MAR10 VILLAFANI PATRICK CURLING NORTH HOUSTON ANESTHESIOLOGIS J. B. ASKEW,JR. MD TOPS SURG SPEC HOSP -RURAL Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Cambridge-Newton-Framingham, MA Houston-Sugar Land-Baytown, TX San Antonio, TX Houston-Sugar Land-Baytown, TX RURAL -RURAL Reno-Sparks, NV Houston-Sugar Land-Baytown, TX Dallas-Plano-Irving, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Dallas-Plano-Irving, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX San Antonio, TX Houston-Sugar Land-Baytown, TX Dallas-Plano-Irving, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Bay[own, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Dallas-Plano-Irving, TX Dallas-Plano-Irving, TX -RURAL Houston-Sugar Land-Baytown, TX Reno-Sparks, NV Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX Houston-Sugar Land-Baytown, TX ...rld Ill ..~ I~ Amount Paid Amount Paid by Client by Member $ 38,297 $ 1,416 $ 9,700 $ 4,756 $ 6,280 $ 2,816 $ 5,720 $ - $ 5,390 $ 1,348 $ 4,398 $ 2,932 $ 3,135 $ - $ 3,106 $ 872 $ 2,865 $ - $ 2,674 $ 200 $ 2,465 $ 816 $ 2,424 $ 606 $ 2,375 $ 1,743 $ 2,294 $ 773 $ 2,280 $ - $ 2,100 $ - $ 2,044 $ 1,363 $ 2,011 $ 1,540 $ 1,750 $ - $ 1,575 $ - $ 1,342 $ 536 $ 1,325 $ 785 $ 1,230 $ 3 $ 1,216 $ - $ $ 1,100 1,094 $ $ 277 274 $ 1,032 $ 688 $ 984 $ 264 $ 945 $ 630 $ 941 $ - $ 918 $ 42 $ 904 $ 21 $ 899 $ - $ 879 $ 786 $ 877 $ 323 $ 855 $ 641 $ 834 $ - $ 761 $ 190 $ 756 $ 508 $ 743 $ 17 $ 698 $ 175 $ 664 $ 366 $ 651 $ - $ 649 $ 162 $ 629 $ - $ 619 $ 155 $ 612 $ - $ 612 $ - $ 606 $ 91 $ 582 $ 218 5 ^... r.. ~,,, ~GPA Y~. ~ ~ ~~ .~ r... .. i ~ `' ~~ $~ Emer enc Room g Y Utilization Anal sis y ,~ All data in the Analysis is based upon INCURRED CLAIMS ~ for the periods identified and Medstat utilizes athree- ~.. month Lag from paid claims for incurred reporting ~.. ~. ~. Emergency Room Utilization Report Visit Summary SAMPLE CLIENT WHAT IS DRIVING COST? 1. Is there high ER Utilization as compared to norm? 2. Does the plan design impact utilization? 3. Is the average cost/visit comparable to norm? 4. Is the ER being utilized for routine issues? 5. Are your employees the biggest utilizers? 6. Is a lack of providers or lack of other options in a geographic area influencing utilization? 7. Why are individuals seeking treatment? 8. Are any individuals frequent utilizers? ER Visit Freauencv Time Period Number of patients Number of Visits ER Visits/1000 Members Benchmark Visits11000 Oct 2007 -Sep 2008 83 88 175.33 190.55 Oct 2006 -Sep 2007 63 66 167.83 190.30 Oct 2005 -Sep 2006 49 42 153.99 192.72 ER Client Cost Benchmark Total Allowed Amount per Visit for following Places of Service (includes Facility & Physician cost only): Emergency Room $ 927 Urgent Care Facility S 366 Primary Care Physician $ 132 KEY STAT Client ER CostNisit versus Benchmark Client is 92.3% HIGHER ER utilization and cost in Texas is among the highest average in the Country. On a National Average, an Urgent Care Center is three times more expensive than a Primary Care Physician and an ER is three times more expensive than an Urgent Care Center. Utilization is increasing so ER is becoming a bigger piece of the Medical cost and employers are encouraged to promote PCP and Urgent Care Centers to save expense. ER Visits by Day of Week 20 15 10 5 0~ ~ ~ ~ ~ , Mon Tues Wed Thurs Frl Sat Sun t Oct 2007 -Sep 2008 f Oct 2006 -Sep 2007 -~-Oct 2005 -Sep 2006 (c) 2009 Group and Pension Administrators, Inc. FR AVP_ranP Cnct nPr Vicit Time Period Net PayNisit by Client Net PayNisit by Em to ee Total CosWisit Oct 2007 -Sep 2008 $ 1,381 $ 402 $ 1,783 Oct 2006 -Sep 2007 $ 1,918 $ 331 $ 2,248 Oct 2005 -Sep 2006 $ 1,222 $ 350 $ 1,572 Number of Visits is a count of the number of unique ER facility bills processed during the reporting period. Number of Patients is a count of every person that incurred either a facility or physician bill from an ER (even if admitted) during the reporting period. 14% 12% 10% 8% 6% 4% 2% 0% ER Cost as a Percent of Cost Time Period Total Paid by Client Total Paid by Member Percent Paid by Client Benchmark Paid b Client Oct 2007 -Sep 2008 $ 121,541 $ 35,359 77.5% 77.4% Oct 2006 -Sep 2007 $ 126,564 $ 21,825 85.3% 77.5% Oct 2005 -Sep 2006 $ 51,308 $ 14,718 77.7% 75.3% Total Visits Mon Tues Wed Thur i Fri Oct 2007 -Sep 2008 13 17 17 I 10 i 9 Oct 2006 -Sep 2007 6 13 6 9 8 Oct 2005 -Sep 2006 5 5 I 5 9 7 Total Visits Sat Sun Total AveragelWeek Oct 2007 -Sep 2008 13 9 88 1.E39 Oct 2006 -Sep 2007 15 ~ , 9 66 1.1 / Oct 2005 • Sep 2006 7 i 4 42 0. (S 1 Visits cannot be tracked by time of Day i 2 Oct 2005 -Sep Oct 2006 -Sep Oct 2007 -Sep 2006 2007 2008 ^Client ^Benchmark Emergency Room Utilization Report Demographic Distribution SAMPLE CLIENT ER Claim Expense Distribution Membership Distribution 25% 56% 19% ^ Employee ^ Spouse ^ Child ER Visit Distribution 57% 25% 18% ^ Employee ^ Spouse ^ Child 22% 61% 17% ^ Employee ^ Spouse ^ Child Demograp hic Detail A e Ran e Emp loyee Spouse Child Total g g # of Visits Net Pay # of Visits Net Pay # of Visits Net Pay # of Visits Net Pay <1 0 $ - 0 $ - 1 $ 518 1 $ 518 1 -4 0 $ - 0 $ - 7 $ 11,926 7 $ 11,926 5 - 9 0 $ - 0 $ - 9 $ 9,403 9 $ 9,403 10-14 0 $ - 0 $ - 3 $ 2,188 3 $ 2,188 15-17 0 $ - 0 $ - 0 $ - 0 $ - 18-19 0 $ - 0 $ - 0 $ - 0 $ - 20 - 24 0 $ - 0 $ - 2 $ 2,534 2 $ 2,534 25 - 29 3 $ 3,653 1 $ 2,362 0 $ - 4 $ 6,015 30 - 34 11 $ 18,674 4 $ 1,470 0 $ - 15 $ 20,143 35 - 39 11 $ 16,178 0 $ 129 0 $ - 11 $ 16,307 40-44 7 $ 11,500 2 $ 1,676 0 $ - 9 $ 13,176 45 - 49 6 $ 6,872 2 $ 4,280 0 $ - 8 $ 11,152 50 - 54 6 $ 10,675 3 $ 6,675 0 $ - 9 $ 17,350 55 - 59 5 $ 6,711 1 $ 1,605 0 $ - 6 $ 8,316 60 - 64 1 $ 171 1 $ 255 0 $ - 2 $ 426 65 + 0 $ - 2 $ 2,089 0 $ - 2 $ 2,089 TOTALS 50 $ 74,433 16 $ 20,540 22 i $ 26,568 88 $ 121,541 Avg. Cost per Visit $ 1,489 $ 1,284 $ 1,208 $ 1.381 i orals mciuae -zero ray- visits tnotnmg is owes by either the Client or the Member) ER Visits Compared to Percentage Membership zo.o°i° 5.0% 0.0% Ages Ages Ages Ages Ages Ages Ages Ages Ages Ages Ages Ages Ages Ages Ages Ages <1 1-4 5-9 10-14 15-17 18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-84 65+ -^-Membership ~-tgll- ER Visits (c) 2009 Group and Pension Administrators, Inc. 3 Emergency Room Utilization Report Summary of Facility Cost by Location SAMPLE CLIENT Report based on Incurred Claim Data for the Period of: Oct 2007 -Sep 2008 Service Facility Billing Zip Facility Location State Number of Total Allowed Average Client Average Member Code Visits Amount CosWisit CostNisit A Facility Name may appear more than once due to different Tax ID Numbers & Totals include "Zero Pay" visits 1 SOUTHWEST GENERAL HOSP DALLAS TX ~~ 75284 4 $ 6,636 $ 1,207 I $ 452 2 MHHS NORTHEAST HOSPITAL ~ HOUSTON j TX 77216 3 $ 4,098 $ 1,041 $ 325 3 WEST HOUSTON MEDICAL CENTER ~i ATLANTA GA 30384 I 3 $ 2,211 ~ $ 599 $ 138 4 MHHS NORTHWEST HOSPITAL HOUSTON TX 77216 3 $ 1,557 $ 366 $ 153 5 DELL CHILDRENS SAN ANTONIO TX 78298 3 $ 973 $ 220 $ 105 6 TEXAS MEDICAID HEALTHCARE AUSTIN TX 78720 ' 3 $ - $ - ~ $ - 7 TEXAS MEDICAID TMHP AUSTIN TX 78720 3 $ $ $ - 8 BAYLOR MEDICAL CENTER/IRVING ~ Irving TX I 75284 2 $ 12,543 $ 4,977 $ 1,294 9 ST LUKES COMM MC ~ HOUSTON TX 77210 2 $ 11,171 $ 4,329 $ 1,257 10 ST LUKES EPISCOPAL HOSPITAL Houston TX 77210 2 $ 6,753 $ 2,541 $ 835 11 HOUSTON NORTH WEST MC HOUSTON TX 77090 2 $ 5,636 $ 2,310 $ 508 12 CENTRAL TEXAS MEDICAL CENTER DALLAS TX 75395 ~ 2 $ 4,406 $ 1,821 $ 382 13 HOUSTON NORTH WEST MC DALLAS ~ TX 75284 'I 2 $ 4,211 $ 1,524 i $ 581 14 MHHS MEMORIAL CITY HOSPITAL Houston TX 77216 ~ 2 $ 3,713 $ 1,425 $ 431 15 CLEVELAND REGIONAL MED DALLAS TX 75284 2 $ 3,198 $ 1,335 $ 264 16 CHRISTUS SANTA ROSA HEALTH i SAN ANTONIO j TX ~ 78291 2 $ 3,676 $ 1,320 $ 519 17 KINGWOOD MEDICAL CENTER Kingwood TX ~ 77339 2 $ 2,077 ' $ 766 $ 272 18 NORTH CYPRESS MEDICAL CENTER HOUSTON TX 77210 2 $ 1,031 I $ 332 $ 183 19 HARRIS METHODIS NORTHWEST FORT WORTH TX 76191 2 $ 707 $ 237 $ 117 20 MEDINA COMMUNIT Y HOSPITAL HONDO TX 78861 2 $ 750 $ 220 $ 155 21 METHODIST SUGAR LAND HOSP HOUSTON TX 77210 2 ~~ $ - $ - $ - 22 NORTH AUSTIN MEDICAL CENTER ATLANTA GA 30384 1 ~ $ 4,070 $ 4,070 $ - 23 LAKESIDE HOSP AT BASTROP BASTROP TX 78602 I 1 I $ 4,658 $ 3,566 $ 1,092 24 CLEAR LAKE REG MED CTR ATLANTA GA 30384 ~ 1 $ 4,319 $ 3,495 $ 824 25 TOMBALL REGIONAL HOSPITAL TOMBALL TX 77377 ! ~ 1 $ 4,125 $ 3,180 $ 945 26 CHILDRENS MEDICAL CTR Dallas TX 75235 1 $ 3,951 $ 3,041 ~ $ 910 27 CENTENNIAL MEDICAL CTR DALLAS i TX 78284 1 $ 3,706 $ 2,804 $ 901 28 MEDICAL CENTER OF MCKINNEY I Nashville ~ TN ~i 30384 1 $ 3,431 $ 2,745 I $ 686 29 RENOWN REGIONAL MEDICAL CENTER ~ RENO NV ~ 89502 1 $ 3,067 $ 2,294 $ 773 30 CONROE REGIONAL MEDICAL ii ATLANTA i GA j 30384 1 $ 2,585 $ 2,112 $ 473 31 HUGULEY MEMORIA L HOSPITAL BURLESON !I TX i 76028 1 $ 2,468 $ 1,854 $ 614 32 GULF COAST MEDICAL CENTR DALLAS ii TX 75284 1 $ 2,401 $ 1,801 $ 600 33 METHODIST HOSPITAL San Antonio TX 30384 1 $ 2,201 $ 1,641 $ 560 34 BANNER CHURCHIL COMM HOSPITAL PHOENIX AZ 85062 1 $ 2,250 $ 1,640 $ 610 35 BAYSHORE MEDICAL CENTER I ATLANTA GA 30384 1 $ 2,198 $ 1,639 $ 560 36 2920 ER DALLAS TX 75395 1 j $ 1,878 $ 1,342 $ 536 37 NORTHEAST BAPTIST DALLAS TX 75284 1 i $ 1,494 $ 1,219 $ 275 38 CHURCHILL COMMUNITY HOSPITAL FALCON NV 89406 ! 1 ~ $ 1,256 $ 885 $ 371 39 SHASTA REGIONAL MEDICAL CENTER REDDING CA 96001 1 I $ 1,225 ~ $ 820 $ 405 40 MAINLAND MEDICAL CTR ATLANTA GA 30384 I 1 $ 894 I $ 596 $ 299 41 TOPS SURG SPEC HOSP Houston I TX 77216 1 $ 800 $ 582 $ 218 42 MHHS KATY HOSPITAL Houston ~ TX 77216 1 $ 847 $ 558 $ 289 43 SOUTH AUSTIN HOSPITAL AUSTIN TX 78704 1 $ 636 $ 500 $ 136 44 SOUTH TEXAS REG MEDICAL CTR DALLAS TX 75284 1 $ 618 $ 500 $ 118 45 TEXAS CHILDRENS HOSP ACUTE HOUSTON TX 77210 1 i $ 582 $ 500 $ 82 46 RICHARDSON REGIONAL MEDICAL CT Richardson i TX 75284 1 $ 764 $ 451 $ 313 47 METHODIST DALLAS MEDICAL DALLAS TX 75391 1 $ 426 $ 351 $ 75 48 SAINT MARYS REGIONAL MED Reno NV ~ 89520 1 $ 539 $ 271 $ 268 (c) 2009 Group and Pension Administrators, Inc. q Emergency Room Utilization Report Summary of Facility Cost by Location SAMPLE CLIENT Report based on Incurred Claim Data for the Period of: Oct 2007 -Sep 2008 Billi Zi r f N b Average t ~ T t l All d A Cli Service Facility ~ Facility Location State ng p Code um e o Visits I o a owe verage en Member Amount CosWisit CosWisit A Facility Name may appear more than once due to different Tax ID Numb ers 8 Totals include "Zero Pay" visits 49 EMERSON HOSPITAL 50 TYLER COUNTY HOSPITAL 51 MEMORIAL HERMANN HOSPITAL SYST 52 DENTON REGIONAL MEDICAL CTR 53 TEXAS CHILDRENS HOSPITAL 54 UNIVERSITY GENERAL HOSP 55 BAYLOR REGIONAL MED PLAN 56 CYPRESS FAIR BANKS MED CTR 57 MHHS SUGAR LAND HOSPITAL 58 RENAISSANCE HOSPITALS 59 TEXAS EMERG CARE SPECIALIST 60 OAKBEND MEDICAL CENTER 61 METROPOLITAN METHODIST HOSP 62 HUNTSVILLE MEMORIAL HOSP Concord Woodville HOUSTON Denton Houston HOUSTON DALLAS DALLAS HOUSTON HOUSTON HOUSTON Richmond San Antonio HUNTSVILLE MA TX TX TX TX TX TX TX TX TX TX TX TX TX 01742 75979 77216 30384 77210 77210 75284 75284 77216 77293 77253 77469 30384 77342 1 $ 267 $ 267 $ 1 $ 246 $ 246 $ 1 it $ 238 $ 163 $ 1 $ 194 $ 153 $ 1 $ 200 $ 125 $ 1 $ 190 $ 115 $ 1 $ -~ $ - $ 1 $ $ -, $ 1 $ $ -i $ 1 $ - $ -~ $ 1 $ - $ - $ 1 ~ $ - $ - $ 1 ~ $ - $ - $ 1 ~~ $ - $ - $ 75 41 75 75 (c) 2009 Group and Pension Administrators, Inc. 5 Emergency Room Utilization Report Top Diagnosis Summary SAMPLE CLIENT Report based on Incurred Claim Data for the Period of: Oct 2007 -Sep 2008 # of Average Total # of I Average Total Disease Category I, Provider Disease Category Provider Codes CosWisit CosUVisit Codes Results includes diagnoses from both the Facility and the Physicians, which may be different. As such, the number of Visits Field may be exaggerated. Diagnoses from Laboratory and Radiological providers are also included and these providers commonly will use the generic diagnosis of EMPLOYEE ER VISITS 1 Gastroint Disord, NEC 2 Respiratory Disord, NEC 3 Signs/SymptomslOth Cond, NEC 4 Pneumonia, Bacterial 5 Urinary Tract Calculus 6 Infections -ENT Ex Otitis Med 7 ENT Disorders, NEC 8 Immunodeficiency Disorders 9 Functional Digest Disord, NEC 10 Injury -Head/Spinal Cord 11 Effects of External Conditions 12 Injury, NEC 13 Injury -Musculoskeletal, NEC 14 Hernia/Reflux Esophagitis 15 Infec/Inflam -Skin/Subcu Tiss i6 Spinal/Back Disorders, NEC 17 Fracture/Disloc -Upper Extrem 18 Injury -Knee 19 FracturelDisloc - AnklelFoot 20 Injury - AbdomenlTrunk 21 Nutritional Disorders, NEC 22 Hepatobiliary Disord, NEC 23 Otitis Media 24 Adverse Drug Reactions 25 Diabetes 28 Tumors -Eye, Benign 27 Arthropathies/Joint Disord NEC 28 Cerebrovascular Disease 29 Infections -Eye 30 Infections -Respiratory, NEC 31 Infections -Urinary Tract 32 Injury -Eye 33 Male Genital Disorders, NEC 34 PrevenUAdmin Hlth Encounters 35 36 37 36 39 40 SPOUSE ER VISITS 4 ~ $ 4,918 1 Headache, MigrainelMuscle Tens '~ 3 $ 2,624 4 ~ $ 4,674 2 Renal/Urinary Disord, NEC 1 $ 4,351 4 $ 2,442 3 Cholecystitis/Cholelithiasis 1 $ 3,145 1 $ 7,879 4 Injury, NEC 1 $ 2,271 2 $ 3,386 5 Pneumonia, Bacterial 1 $ 1,910 1 $ 4,125 6 Gastritis/Gastroenteritis 1 $ 1,609 3 $ 1,315 7 Gastroint Disord, NEC 2 $ 691 1 $ 3,713 8 Otitis Media 1 $ 771 1 $ 2,401 9 Injury -Musculoskeletal, NEC 2 $ 335 1 $ 2,250 10 Injury -Knee 1 $ 549 2 $ 963 11 ENT Disorders, NEC 1 $ 439 2 $ 954 12 Respiratory Disord, NEC 1 $ 346 1 $ 1,878 13 Infections -Urinary Tract 1 $ 330 1 $ 1,754 14 Spinal/Back Disorders, NEC 1 $ 204 3 $ 499 15 ArthropathieslJoint Disord NEC 1 $ - 1 $ 1,288 i6 Urinary Tract Calculus 1 $ - 1 $ 1,232 17 2 $ 578 18 1 $ 1,046 19 1 $ 926 20 1 $ 666 1 $ 596 1 $ 333 CHILD ER VISITS 1 $ 314 1 Functional Digest Disord, NEC 1 $ 4,658 1 $ 238 2 Foreign Body -Gastroint 1 $ 4,281 1 $ 39 3 Gastritis/Gastroenteritis 1 $ 3,994 1 ~ $ 34 4 Injury -Musculoskeletal, NEC 3 $ 1,324 1 $ - 5 Gastroint Disord, NEC 2 $ 1,866 1 i $ - 6 Infections -ENT Ex Otitis Med 3 ~ $ 1,119 1 I $ - 7 ENT Disorders, NEC 1 $ 3,067 1 $ - 8 Spinal/Back Disorders, NEC 1 $ 1,842 1 $ - 9 Nutritional Disorders, NEC 1 $ 1,208 1 ~ $ - 10 Signs/Symptoms/Oth Cond, NEC 1 $ 971 1 ~ $ - 11 Toxic Effects of Substances 1 $ 871 12 Infections -Respiratory, NEC 1 $ 809 13 Injury, NEC 1 $ 679 i 14 Headache, MigrainelMuscle Tens 1 $ 525 15 Fracture/Disloc -Upper Extrem 2 $ 171 i6 Condition Rel to Tx -Med/Burg 1 $ 340 17 Infections, NEC 1 $ 200 18 Injury -Head/Spinal Cord 1 $ 108 19 Musculosk Disord, Congenital 1 $ 32 20 Cardiovasc Disord, NEC 1 $ 10 (c) 2009 Group and Pension Administrators, Inc. 6 Emergency Room Utilization Report Individual Detail (up to 100) SAMPLE CLIENT Report based on Incurred Claim Data for the Period of: Oct 2007 -Sep 2008 Patient Identifier Relationship ~ Number of I Number of Facility Prof. Amount Paid I Amount Paid Average Total Visits Providers Services Services by Client by Member Cost per Visit Results include "Zero Pay" visits. In addition, a "0" in the Number of Visits column indicates a Physician bill was nrocesserl durinr7 the> rehortinn period but a Facility bill was not processed durir:c; tl:; 1 H87034104311 2 H87034103841 3 H87034101291 4 H87034104612 5 H87034103701 6 H87034105551 7 H87034103952 8 H87034103071 9 H87034103311 10 H87034104735 11 H87034105191 12 H87034100925 13 H87034105501 14 H87034100735 15 H87034103622 16 H87034104642 17 H87034105714 18 H87034102201 19 H87034104181 20 H87034103491 21 H87034103072 22 H87034105001 23 H87034102873 24 H87034100363 25 H87034104821 26 H87034101722 27 H87034105162 28 H87034104951 29 H87034100242 30 H87034101091 31 H87034101161 32 H87034101141 33 H87034103935 34 H87034100611 35 H87034103671 36 H87034104541 37 H87034104874 38 H87034105011 39 H87034103273 40 H87034102371 41 H87034105194 42 H87034103921 43 H87034102491 44 H87034102391 45 H87034104481 46 H87034103122 47 H87034102872 48 H87034104032 49 H87034105021 50 H87034104532 Employee/Self 1 2 1 1 $ 9,041 $ 2,273 $ 11,313 Employee/Self 1 1 1 0 II $ 5,987 $ 1,647 $ 7,633 Employee/Self ~I 1 4 1 '~ 18 i $ 4,925 $ 1,431 $ 6,357 Child/Other Dependent 1 4 1 4 $ 4,818 $ 1,092 $ 5,910 Employee/Self II 1 4 1 6 $ 4,518 $ 1,079 $ 5,597 Employee/Self 1 2 1 i 1 i$ 3,860 $ 1,165 $ 5,025 Spouse/Partner 1 4 1 7 I $ 3,916 $ 1,023 $ 4,938 Employee/Self 1 5 1 12 I $ 4,710 $ - $ 4,710 Employee/Self I 1 ~~ 2 1 2 $ 3,413 $ 1,003 $ 4,416 Child/Other Dependent 1 4 1 li 4 , $ 3,305 $ 976 $ 4,281 Employee/Self 1 2 1 3 $ 3,191 $ 948 $ 4,138 Child/Other Dependent 1 ! 3 1 I 4 $ 3,129 $ 994 $ 4,122 Employee/Self 1 3 1 ~ 4 I$ 2,804 $ 901 $ 3,706 Child/Other Dependent 1 5 1 5 ~ $ 2,850 $ 475 $ 3,325 Spouse/Partner 1 I 4 ! 1 i 7 $ 2,396 $ 749 $ 3,145 Spouse/Partner 1 3 I 1 3 I$ 2,362 $ 741 $ 3,103 Child/Other Dependent 1 3 1 2 $ 2,294 $ 773 $ 3,067 Employee/Self 1 3 1 7 $ 2,438 $ 623 $ 3,060 Employee/Self 1 3 I 1 3 $ 2,161 $ 690 $ 2,851 Employee/Self 1 4 i 1 8 $ 2,007 $ 665 $ 2,672 Spouse/Partner 2 4 t 2 4 $ 4,279 $ 837 $ 2,558 Employee/Self 2 6 2 7 $ 3,850 $ 1,163 $ 2,506 Child/Other Dependent 1 3 II 1 6 $ 1,775 $ 594 $ 2,368 Child/Other Dependent 1 5 ' 1 6 $ 2,049 $ 275 $ 2,324 Employee/Self 1 2 1 1 $ 1,685 $ 621 $ 2,307 Spouse/Partner 1 1 1 0 $ 2,089 $ 183 $ 2,271 Spouse/Partner 1 3 ~ 1 6 $ 1,676 $ 482 $ 2,158 Employee/Self 2 6 ' 2 9 $ 3,102 $ 1,175 $ 2,139 Spouse/Partner 1 3 ', 1 5 $ 1,408 $ 502 $ 1,910 Employee/Self 1 1 1 0 $ 1,342 $ 536 $ 1,878 Employee/Self 1 4 1 4 $ 1,498 $ 275 $ 1,773 Employee/Self 1 3 ! 1 5 $ 1,283 $ 471 $ 1,754 Child/Other Dependent 1 3 1 3 $ 1,228 $ 457 $ 1,685 Employee/Self 1 3 ~~ 1 6 $ 1,069 $ 467 $ 1,537 Employee/Self 1 2 ~I 2 2 $ 1,142 $ 358 $ 1,500 Employee/Self 3 7 !i 5 14 $ 3,092 $ 852 $ 1,315 Child/Other Dependent 1 1 1 0 $ 885 $ 371 $ 1,256 Employee/Self 1 3 1 3 $ 826 $ 406 $ 1,232 Child/Other Dependent 1 3 1 7 $ 846 $ 362 $ 1,208 Employee/Self 1 4 1 3 $ 832 $ 358 $ 1,190 Child/Other Dependent 1 I 3 I 1 2 $ 664 $ 366 $ 1,031 Employee/Self 1 1 1 0 $ 659 $ 315 $ 973 Employee/Self 1 3 1 3 $ 612 $ 353 $ 965 Employee/Self 3 3 !i 3 I 3 $ 1,765 $ 841 $ 869 Employee/Self 1 3 I 1 3 $ 556 $ 275 $ 831 Child/Other Dependent 1 3 I 1 2 $ 518 $ 291 $ 809 Spouse/Partner 1 2 1 1 $ 577 $ 194 $ 771 Spouse/Partner 1 2 1 2 $ 419 $ 251 $ 670 Employee/Self ! 2 4 i 2 I~ 5 $ 825 $ 406 $ 616 Spouse/Partner ~ 1 3 1 2 $ 474 $ 75 $ 549 (c) 2009 Group and Pension Administrators, Inc. 7 Emergency Room Utilization Report Individual Detail (up to 100) SAMPLE CLIENT Report based on Incurred Claim Data for the Period of: Oct 2007 -Sep 2008 Pa tient Identifier Relationship Number of Number of Facility ~ Prof. Amount Paid Amount Paid Average Total Visits II Providers Services Services by Client by Member Cost per Visit Results include "Zero Pay" visits. In addition, a "0" in the Number of Visits column indicates a Physician bill was processed during the reporting 57 H87034105744 Child/Other Dependent II 1 1 ~ 1 0 $ 271 ! $ 268 $ 539 52 H87034100926 Child/Other Dependent 1 2 1 1 $ 260 j $ 265 $ 525 53 H87034103904 Child/Other Dependent 1 2 1 4 $ 396 ~ $ 116 $ 512 54 H87034103162 Spouse/Partner 1 2 ~ 1 1 $ 364 $ 75 $ 439 55 H87034102673 Child/Other Dependent 2 3 ~ 2 1 $ 681 $ 172 $ 426 56 H87034105215 Child/Other Dependent 1 2 1 3 ; $ 113 $ 228 $ 342 57 H87034100772 Child/Other Dependent 1 i 2 2 I 1 ', $ 265 $ 75 $ 340 58 H87034102562 Spouse/Partner j 1 2 1 ~ 1 $ 255 $ 75 $ 330 59 H87034102791 Employee/Self 1 1 1 ~ 0 $ 163 $ 75 $ 238 60 H87034104533 Child/Other Dependent 1 ~ 1 1 0 $ - $ 158 $ 158 61 H87034103581 Employee/Self 3 8 3 ~ 11 $ 239 $ 94 $ 111 82 H87034102984 Child/Other Dependent 3 ': 2 9 i 4 $ - $ - $ - 63 H87034102102 ', Spouse/Partner 2 j 6 2 j 14 $ - $ - $ - 64 H87034103924 I Child/Other Dependent 2 j 2 2 I 4 $ - $ - $ - 65 H87034104421 ii Employee/Self 2 'i 4 2 ~ 3 $ - $ - $ - 86 H87034103263 I Child/Other Dependent 1 3 1 5 $ - $ - $ - 67 H87034104111 Employee/Self 1 2 1 I 1 $ - $ - $ - 88 H87034104171 I Employee/Self 1 ~ 1 1 ~ 0 $ - $ - $ - 89 H87034104321 Employee/Self 1 j 6 1 13 $ - $ - $ - 70 H87034104552 ~, Spouse/Partner 1 ' 2 1 1 $ - $ - $ - 71 H87034104721 Employee/Self 1 1 1 0 $ - $ - $ - 72 H87034105061 I, Employee/Self 1 3 1 2 $ - $ - $ - 73 H87034103541 ', Employee/Self 0 3 0 4 $ 668 $ 75 #DIV/0! 74 H87034101163 Child/Other Dependent 0 I 1 0 4 i $ 219 $ 55 #DIV/0! 75 H87034101302 Spouse/Partner ~, 0 1 0 1 ~$ 197 $ 49 #DIV/0! 78 H87034102801 Employee/Self ~ 0 1 0 2 $ 171 $ 75 #DIV/0! 77 H87034103922 Spouse/Partner 0 1 0 2 'i$ 129 $ 75 #DIV/0! 78 H87034105163 ! Child/Other Dependent 0 1 0 1 I $ - $ 68 #DIV/0! 79 H87034100303 Child/Other Dependent 0 3 0 11 i $ - $ - #DIV/0! 80 H87034103612 Spouse/Partner I 0 1 i 0 2 $ - $ - #DIV/0! 81 H87034103881 Employee/Self 0 1 0 2 $ - $ - #DIV/0! 82 H87034104152 Child/Other Dependent 0 1 0 2 $ - $ - #DIV/0! 83 H87034105271 I Employee/Self 0 1 ' 0 4 $ - $ - #DIV/0! (c) 2009 Group and Pension Administrators, Inc. 8 GPA )j' ~~r SAMPLE CLIENT Chronic Condition Analysis All data in the Analysis is based upon INCURRED CLAIMS for the periods identified and Medstat utilizes athree- month Lag from paid claims for incurred reporting Chronic Condition Utilization Report Summary of Condition Frequency SAMPLE CLIENT Percentage Growth from Period to Period Membership Asthmatic Cardiac Diabetic Mental Health F P i P i d Growth Conditions Conditions Conditions Conditions rom r or er o to Current Period 27.6% 29.4% -3.6% 11.1 % 142.9% From Initial Period to Prior Period 8.1% -15.0% 18.3% 24.1% 40.0% What is Driving Cost? 1. Are the number of patients with chronic conditions increasing faster than client growth? 2. Are the patients utilizing their primary care physician for care or is it the ER or Hospital? 3. Has there been any increase in the number of "acute flare up" episodes (sudden serious onset)? 4. What is the disease stage code of the individual patients? 5. Has there been an increase in the number of patients at the highest disease stage code (3's)? 6. Has there been any change in the dollar expense for individuals at the highest disease stage code? # of Patients with Chronic Conditions ~~ 80 71 60 40 36 20 17 ~ ~ 17 0 Asthmatic Cardiac Diabetic Mental Health Conditions Conditions Conditions Conditions ^ Oct 2005 -Sep 2006 ^ Oct 2006 -Sep 2007 ^ Oct 2007 -Sep 2008 Percent of Membership with Chronic Conditions zs.o°i° 20.0% 15.0% 10.0% 5.0°/ 0.0% 19.5% 21.4% 16. o 13.6% 8 0% 9.2% 8 0°/ 0 5.5 /0 4.3% 4.4% 3.7% 5.0% 40/-_1.80/_ 3.4% 4.2% Asthmatic Conditions Cardiac Conditions Diabetic Conditions Mental Health Conditions ^ Oct 2005 -Sep 2006 ^ Oct 2006 -Sep 2007 ^ Oct 2007 -Sep 2008 ^ Benchmark According to the CDC, the percentage of adults with THREE OR MORE chronic conditions is less than 1% for adults under age 45 but as individuals get older the percentage increases dramatically. For adults 45-54, approximately 7% have THREE OR MORE chronic conditions and the percentage is two to three times higher for the 55-64 age demographic (the lower the income the greater the likelihood of multiple conditions). Cost Drivers--Admissions 1.8% I 1.63% 1.4% 1.6% - 1.4% .45 % L2% 1.2% .I _ 1.0% 1.0% - 0.8% 0.8% 0.6% 0.6% 0.44% 0.4% ~ 0.31% 0.4% 0.2% 0.00°/ - 0.00°/ 0.2% o.o°i o.o°i° Asthmatic Cardiac Diabetic Conditions Conditions Conditions ^ Total Admissions ^ Benchmark (c) 2009 Group and Ponslon Administrators, Inc. 2 Conditions Conditions Conditions ;~ ^ Total ER Visits ^ Benchmark ': Chronic Condition Utilization Report Patient Utilization & Cost Summary SAMPLE CLIENT An Acute Flare-up Episode is the sudden onset of a previously diagnosed chronic condition. This indicates a KEY STAT problem with chronic conditions thought to be under control by the member. When the percentage of Flare-ups is higher than the Benchmark, there is a need for enhanced care coaching. Asthma Summary Patients Episodes In-Patient ER Visits Physician !Amount Paid Am ount Paid M b '. Amount Paid ' i t P Admits Visits by Client by er em en per at Oct 2007 -Sep 2008 15 I 15 0 1 31 $ 10,478 ~I $ 3,907 $ 69~ Oct 2006 -Sep 2007 13 ~ 13 ~ 0 I 0 25 $ 7,648 ~ $ 3,017 $ 588 14 14 0 Oct 2005 -Sep 2006 4 25 $ 20,081 $ 4,172 ~ $ 1,43 Chronic Obstructive Pulm Patients i Episodes In-Patient ER Visits Physician Amount Paid Amount Paid Amount Paid Disorder (COPD) Summary Admits Visits by Client by Member per Patient Oct 2007 -Sep 2008 7 7 ~ 0 i I 0 18 $ 5,783 $ 2,147 $ 826 Oct 2006 -Sep 2007 4 ~ 4 0 0 4 ii $ 2,145 $ 764 i $ 536 pct 2005 -Sep 2006 6 6 0 0 ii 21 $ 3,304 $ 953 $ 551 Congestive Heart Failure Summary Patients Episodes In-Patient Admits ER Visits ~ Physician Visits ,Amount Paid by Client i Amount Paid by Member Amount Paid per Patient Oct 2007 -Sep 2008 0 0 0 0 I 0 $ - I $ - $ - Oct 2006 -Sep 2007 4 ~ 4 ~ 1 0 14 $ 16,877 $ 3,049 I $ 4,219 ~cA 7005. - yep 2006 0 ~, 0 0 0 0 $ - i $ - $ - Coronary Artery patients Episodes In-Patient ER Visits Physician 'Amount Paid Amount Paid Amount Paid Disease Summary Admits Visits by Client i by Member '. per Patient Oct 2007 -Sep 2008 10 11 2 1 36 $ 182,354 $ 11,318 ' $ 16,578 Oct 2006 -Sep 2007 11 ~ 12 ~ 4 1 29 $ 111,038 $ 12,156 $ 9,253 I FJct 2005 -Sep 2006 11 11 0 0 38 $ 25,330 $ 7,324 $ 2,303 Hypertension Summary Patients Episodes In-Patient Admits li ER Visits '', Physician Amount Paid Visits by Client Amount Paid ~ by Member Amount Paid per Patient Oct 2007 -Sep 2008 71 71 ~ 0 0 ~ 206 $ 40,438 I $ 18,325 $ 570 Oct 2006 -Sep 2007 69 72 ~ 0 1 ~ 244 $ 45,716 ' $ 18,189 $ 635 Oct 2005 -Sep 2006 60 60 0 0 195 $ 38,736 ', $ 18,251 $ 646 Anxiety Disorder In-Patient ' Physician Amount Paid Amount Paid Amount Paid Summary Patients Episodes I Admits ER Visits Visits by Client ~ by Member per Patient Oct 2007 -Sep 2008 10 10 0 0 18 ! $ 556 I $ 294 $ 56 Oct 2006 -Sep 2007 4 5 0 I 1 14 $ 1,734 II $ 848 ' $ 347 ~,,, ~~;,i~ - Sei~ 2°706 4 4 0 0 5 $ 546 $ 93 $ 137 ~ In-Patient ' Physician ,Amount Paid Amount Paid ~ Amount Paid Depression Summary Patients Episodes Admits ER Visits Visits by Client I by Member per Patient Oct 2007 -Sep 2008 7 8 ', 1 ~ 0 10 $ 760 $ 378 $ 95 Oct 2006 -Sep 2007 3 ', 3 0 0 9 I $ 61 $ 30 $ 20 ' tact 2005 -Sep 2006 1 1 ' 0 1 0 $ - $ - ~' $ - Acute Flare• up Episode Benchmark 0.0% 15.4% 6.9% 0.0% Acute Flare- up Episode Benchmark 27.3% 16.7% 10.6% 0.0% Acute Flare- up Episode Benchmark 0.0% 0.0% 0.2% 0.0% Acute Flare- up Episode Benchmark 0.0% 2.4% 2.7% 0.0% (c) 2009 Group and Pension Administrators, Inc. 3 ^.. itl~ Chronic Condition Utilization Report Summary of Potential Disease Stages SAMPLE CLIENT 8.0% 6.0% 4.0% 2.0% 0.0% iIGH RISK EPISODES (3's) MODERATE RISK EPISODES (2'S) LOW RISK EPISODES (1's) _ 30 0% 82.0% - - -- . 25 0% 80.0% - 78 0% - . 20 0% . _ . 15.0% 10 0% - - 76.0% 74.0% 72 0% -- . 5 0% . 70 0% - . . Oct 2005 - Oct 2006 - Oct 2007 - Sep 2006 Sep 2007 Sep 2008 ~ tClient Benchmark 0.0% Oct 2005 - Oct 2006 - Oct 2007 - Sep 2006 Sep 2007 Sep 2008 tClient Benchmark 68.0% Oct 2005 - Oct 2006 - Oct 2007 - Sep 2006 Sep 2007 Sep 2008 tClient Benchmark Based on Incurred Date from: occ zoos - sep zoos Oct 2006 -Sep 2007 Oct zoo? -Sep zoos Combined Totals Disease Stage Disease Stage # of Total Allowed # of Total Allowed # of Total Allowed # of Total Allowed Code Epis. Amount Epis. Amount Epis. Amount Epis. Amount Con estive Heart Failure 0 $ 4 $ 19,926 0 $ 4 5 19,926 3.01 Congestive heart failure 0 $ - 2 $ 4,433 0 $ - 2 $ 4,433 3.02 Congestive heart failure with azotemia or hyponatremia 0 $ 1 $ 112 0 $ 1 $ 112 3.04 Congestive heart failure with respiratory failure 0 $ - 1 $ 15,381 0 ', $ - 1 $ 15,381 Corona Arte Disease 11 $ 32,653 12 $ 123,194 11 $ 193,672 34 $ 349,520 1.01 CAD/asymptomatic chronic ischemic heart disease or old MI 8 $ 21,706 5 $ 12,859 3 $ 2,453 16 $ 37,018 1.02 Chr stable exertional anginalchr ischemic heart disease 3 $ 10,947 3 $ 36,070 3 $ 70,608 9 $ 117,625 2.01 Progressing angina pectoris/exertional myoc ischemia at low work; old MI w/ 2.02 Prinzmetals variant angina 2.03 Angina w/ hypertrophy/akinesia/dyskinesia/S3 or S4 gallop 0 $ 0 $ - 1 $ 9,774 1 $ 9,774 2.04 Unstable angina pectoris 0 $ - 2 $ 72,669 1 $ 45,385 3 $ 118,054 3.01 Acute inferior or posterior wall myocardial infarction 3.02 Acute IWMI or post wall MI with heart block or pericarditis 0 $ 1 $ 117 1 $ 76 2 $ 193 3.05 Acute IWMI or post wall myocardial infarction with CHF 0 $ 0 $ - 1 $ 268 1 $ 268 3.06 Acute anterior wall myocardial infarction 3.08 Acute ant wall MI with heart block or pericarditis 3.11 Acute anterior wall myocardial infarction with CHF 3.12 4cute myocardial infarction with pulmonary embolism 3.13 Acute myocardial infarction with cerebrovascular accident 3.15 CAD with ventricular fibrillation or shock 0 $ - 0 $ - 1 $ 65,108 1 $ 65,108 3.16 Coronary artery disease with cardiac arrest 0 $ - 1 $ 1,479 0 $ - 1 $ 1,479 H ertension Essential 60 $ 56,987 72 $ 63,905 71 $ 58,763 203 $ 179,655 1.01 Hypertension, minimal 53 $ 49,255 66 $ 52,708 63 ~ $ 47,334 182 $ 149,296 1.02 Hypertension, moderate 2.01 Hypertension, very severe 2 $ 1,120 1 $ 872 4 $ 8,049 7 $ 10,041 2.02 Hypertensive retinopathy, grade I or II of Keith and Wagener 2.03 Hypertensive retinopathy, grade III or IV of Keith and Wagener 2.04 Hypertensive cardiomegaly, arrhythmias, or wall motion abnor 5 $ 6,612 3 $ 8,123 3 $ 758 11 $ 15,492 3.01 Hypertensive renal failure 3.02 Hypertensive congestive heart failure 0 $ - 2 $ 2,203 1 $ 2,623 3 $ 4,826 3.03 Hypertensive CVA or hypertensive encephalopathy 3.04 Hypertensive CVA with cranial nerve involvement 3.06 Hypertensive CVA with hemiparesis or hemiplegia 3.09 Essential hypertension with coma (c) 2009 Group and Ponsion Administrators, Inc. 4 Chronic Condition Utilization Report Summary of Potential Disease Stages SAMPLE CLIENT Based on Incurred Date from: occ zoos - sep zoos Oct 2006 -Sep 2007 Oct 2007 -Sep 2008 Combined Totals Disease Stage Code Disease Stage # of Epis. Total Allowed Amount # of Epis. Total Allowed Amount # of Epis. Total Allowed Amount # of Epis. Total Allowed Amount Asthma 14 $ 24,254 13 $ 10,665 15 $ 14,385 42 $ 49,304 1.01 Asymptomatic bronchial asthma 9 $ 1,860 10 $ 7,001 12 $ 11,757 31 $ 20,617 2.01 Mild intermittent bronchial asthma 5 $ 22,394 1 $ 3,494 3 $ 2,628 9 $ 28,516 3.02 Status asthmaticus or severe asthma 0 $ 2 $ 171 0 $ - 2 $ 171 3.03 Asthma with respiratory failure Chronic Obstruc Pulm Dis COPD s $ a,257 a $ 2,606 7 $ 7,930 17 $ 16,066 1.01 Chronic bronchitis 0 $ - 0 $ - 1 $ 72 1 $ 72 1.01 Emphysema 0 $ - 0 $ - 1 $ 5,210 1 $ 5,210 1.02 Acute exacerbation of chronic bronchitis 1 $ 345 0 $ - 1 $ - 2 $ 345 2.01 Chronic obstructive pulmonary disease, mild 4 $ 2,783 4 $ 2,909 4 $ 2,648 12 $ 8,340 3.01 Chronic obstructive pulmonary disease with pulmonary hyperte 1 $ 1,129 0 $ - 0 $ - 1 $ 1,129 3.02 Chronic obstructive pulmonary disease with cor pulmonal 3.02 Emphysema with acute respiratory failure 3.03 Chronic obstructive pulmonary disease with acute respiratory fa ilure 1.01 Diabetes mellitus type 1 1 $ 144 2 $ 608 1 $ 1,298 4 $ 2,050 1.01 Impaired fasting glucose 1 $ 144 0 $ - 0 $ - 1 $ 144 1.02 Impaired glucose tolerance 1 $ 234 0 $ - 0 $ - 1 $ 234 1.02 Symptomatic diabetes mellitus type 1 0 $ - 0 $ - 1 $ 685 1 $ 685 1.03 Asymptomatic diabetes mellitus type 2 8 $ 14,045 15 $ 21,338 16 $ 16,741 39 $ 52,123 1.04 Symptomatic diabetes mellitus type 2 5 $ 11,058 5 $ 3,770 9 $ 8,270 19 $ 23,098 2.01 DM type 1 w/ retinopathy 2.01 DM type 2 w/ retinopathy 0 $ - 1 $ 1,387 0 $ - 1 $ 1,387 2.02 DM type 1 wl neuropathy 2.02 DM type 2 w/ neuropathy 1 $ 5,035 1 $ 2,300 1 $ 3 $ 7,335 2.03 DM type 1 w/glomerulosclerosis 2.03 DM type 2 w/glomerulosclerosis 0 $ - 0 $ - 1 $ 1,947 1 $ 1,947 2.04 DM type 1 w/ vascular disease (peripheral, cardiovascular, or c 0 $ - 1 $ 412 0 $ - 1 $ 412 2.04 DM type 2 wl vascular disease (peripheral, cardiovascular, or c 12 $ 22,229 15 $ 27,493 14 $ 21,530 41 $ 71,252 2.05 Diabetes mellitus with cellulitis 0 $ - 1 $ 55 0 $ - 1 $ 55 2.06 Diabetes mellitus with pyelonephritis 2.07 Diabetes mellitus with gangrenous infection 2.08 Diabetes mellitus with osteomyelitis 3.01 DM Type 1 w! renal failure 3.01 DM Type 2 w/ renal failure 3.02 Diabetes mellitus with hyperosmolar state 3.03 Diabetes mellitus with ketoacidosis 3.05 Diabetes mellitus with acute cerebral vascular accident 3.06 Diabetes mellitus with sepsis 3.07 Diabetes mellitus with coma 3.09 Diabetes mellitus with shock (c) 2009 Group and Pension Administrators, Inc. 5 Chronic Condition Utilization Report Summary of Individual Disease Stage (up to 200) SAMPLE CLIENT Based on Incurred Date from: oct 2005 - oct Zoos - oct zoo? - Se 2006 Se 2007 Se 2008 Patient # of Chronic Chronic Disease Disease Amount Paid by Amount Paid by Amount Paid by Total for All Conditions Stage Client Client Client Periods 1 H87034102T01 3 Coronary Artery Disease 3.15 $ - $ - $ 61,296 $ 61,296 2 H87034100951 3 Asthma 3.02 $ 14,442 $ - $ - $ 14,442 3 H87034104491 3 Congestive Heart Failure 3.04 $ - $ 13,157 $ - $ 13,157 4 H87034101071 3 Coronary Artery Disease 3.05 $ - $ - $ 8,730 $ 8,730 5 H8T034103211 2 Coronary Artery Disease 3.02 $ - $ 6,174 $ 61 $ 6,235 6 H87034102371 4 Congestive Heart Failure 3.01 $ - $ 1,807 $ - $ 1,807 7 H87034104491 3 Coronary Artery Disease 3.16 $ - $ 1,204 $ - $ 1,204 8 H87034100611 3 Hypertension, Essential 3.02 $ - $ 927 $ 238 $ 1,165 9 H87034101722 4 Congestive Heart Failure 3.01 $ - $ 1,128 $ - $ 1,128 10 H87034101722 4 Hypertension, Essential 3.02 $ 530 $ 304 $ 4 $ 837 11 H87034100281 4 Chronic Obstruc Pulm Dis(COPD) 3.01 $ 683 $ - $ - $ 683 12 H87034102371 4 Hypertension, Essential 3.02 $ - $ 408 $ 134 $ 542 13 H87034100611 3 Congestive Heart Failure 3.02 $ - $ 97 $ - $ g7 14 H87034100371 1 Asthma 3.02 $ - $ 46 $ - $ 46 15 H87034102371 4 Coronary Artery Disease 2.04 $ - $ 57,442 $ - $ 57,442 16 H87034100461 3 Coronary Artery Disease 2.04 $ - $ - $ 41,619 $ 41,619 17 H87034101722 4 Coronary Artery Disease 2.04 $ 2,349 $ 9,865 $ - $ 12,215 18 H87034102561 3 Diabetes 2.04 $ 246 $ 2,009 $ 1,554 $ 3,809 19 H87034102002 2 Diabetes 2.04 $ 2,883 $ 412 $ 85 $ 3,380 20 H87034102801 2 Chronic Obstruc Pulm Dis(COPD) 2.01 $ 372 $ 209 $ 2,508 $ 3,089 21 H87034104481 2 Hypertension, Essential 2.04 $ - $ 1,488 $ 1,281 $ 2,769 22 H87034102102 2 Hypertension, Essential 2.04 $ 2,016 $ 366 $ 100 $ 2,482 23 H87034100251 2 Hypertension, Essential 2.04 $ 117 $ 1,633 $ 262 $ 2,011 24 H87034102371 4 Diabetes 2.04 $ - $ 603 $ 1,141 $ 1,744 25 H87034101161 2 Diabetes 2.04 $ - $ 975 $ 557 $ 1,533 26 H87034100202 2 Diabetes 2.04 $ 345 $ 592 $ 578 $ 1,516 27 H8T034101162 2 Asthma 2.01 $ 638 $ 491 $ 300 $ 1,429 28 H87034102562 2 Diabetes 2.04 $ 380 $ 207 $ 839 $ 1,427 29 H87034100461 3 Diabetes 2.04 $ - $ 484 $ 934 $ 1,418 30 H87034101722 4 Diabetes 2.04 $ 177 $ 967 $ 236 $ 1,379 31 H87034104481 2 Diabetes 2.04 $ - $ - $ 1,296 $ 1,296 32 H87034103271 2 Diabetes 2.04 $ 884 $ 317 $ - $ 1,201 33 H87034101311 2 Diabetes 2.04 $ 76 $ 168 $ 927 $ 1,171 34 H87034103141 3 Diabetes 2.05 $ 437 $ 259 $ 426 S 1,122 35 H87034100911 2 Asthma 2.01 $ - $ - $ 1,093 $ 1,093 36 H8T034100791 2 Diabetes 2.03 $ - $ 755 $ 292 $ 1,047 37 H8T034104571 2 Diabetes 2.04 $ 538 $ 498 $ - $ 1,036 38 H87034100912 1 Hypertension, Essential 2.01 $ - $ 775 $ 257 $ 1,032 39 H87034101721 2 Diabetes 2.04 $ - $ 694 $ 337 $ 1,032 40 H87034103701 2 Diabetes 2.02 $ - $ 772 $ 234 $ 1,006 41 H87034103041 1 Chronic Obstruc Pulm Dis(COPD) 2.01 $ 946 $ - $ - $ 946 42 H87034102361 2 Diabetes 2.04 $ 406 $ 236 $ 287 $ 929 43 H87034101591 1 Diabetes 2.04 $ 460 $ 452 $ - $ 912 44 H87034100471 2 Diabetes 2.04 $ 348 $ 141 $ 417 $ 905 45 H87034100201 2 Diabetes 2.04 $ 310 $ 213 $ 273 $ 796 46 H87034100362 1 Hypertension, Essential 2.04 $ 207 $ 420 $ 165 $ 792 47 H87034101471 2 Diabetes 2.04 $ 343 $ 267 $ 147 $ 757 48 H87034101331 3 Diabetes 2.04 $ 141 $ 181 $ 348 $ 670 49 H87034100251 2 Chronic Obstruc Pulm Dis(COPD) 2-01 $ - $ - $ 596 $ 596 50 H87034102242 3 Hypertension, Essential 2.01 $ - $ 520 $ 67 E 586 (c) 2009 Group and Pension Administrators, Inc. 6 Chronic Condition Utilization Report Summary of Individual Disease Stage (up to 200) SAMPLE CLIENT Based on Incurred Date from: opt zoos - oct zoos - opt 2007 - Se 2006 Se 2007 Se 2008 Patient # of Chronic Chronic Disease Disease Amount Paid b Amount Paid by Amount Paid b Total for All Conditions Stage Client Client Client Periods 51 H87034102171 4 Diabetes 2.04 $ 341 $ 241 $ - $ 582 52 H87034103242 1 Hypertension, Essential 2.04 $ 566 $ - $ - $ 566 53 H87034100041 2 Diabetes 2.04 $ 188 $ 99 $ 279 $ 566 54 H87034102222 1 Asthma 2.01 $ 170 $ 235 $ 117 $ 523 55 H87034102701 3 Chronic Obstruc Pulm Dis(COPD) 2.01 $ - $ - $ 458 $ 458 56 H87034105031 1 Chronic Obstruc Pulm Dis(COPD) 2.01 $ - $ - $ 380 $ 380 57 H87034101801 2 Diabetes 2.04 $ 334 $ - $ - $ 334 58 H87034104831 1 Hypertension, Essential 2.01 $ - $ - $ 315 $ 315 59 H87034100991 2 Diabetes 2.04 $ - $ - $ 309 $ 309 60 H87034100761 2 Diabetes 2.04 $ - $ 307 $ - $ 307 61 H87034100041 2 Hypertension, Essential 2.01 $ - $ - $ 277 $ 277 62 H87034101981 1 Hypertension, Essential 2.01 $ 210 $ 48 $ - $ 258 63 H87034104491 3 Chronic Obstruc Pulm Dis(COPD) 2.01 $ - $ 220 $ - $ 220 64 H87034102001 2 Diabetes 2.04 $ - $ - $ 211 $ 211 65 H87034102171 4 Hypertension, Essential 2.04 $ - $ 129 $ 78 $ 207 66 H87034103832 1 Chronic Obstruc Pulm Dis(COPD) 2.01 $ - $ 61 $ 117 $ 178 67 H87034103273 1 Asthma 2.01 $ - $ 163 $ - $ 163 68 H87034101071 3 Chronic Obstruc Pulm Dis(COPD) 2.01 $ 75 $ 61 $ - $ 136 69 H87034100281 4 Hypertension, Essential 2.01 $ 135 $ - $ - $ 135 70 H87034101134 1 Asthma 2.01 $ - $ - $ 69 $ 69 71 H87034100952 1 Chronic Obstruc Pulm Dis(COPD) 2.01 $ 64 $ - $ - $ 64 72 H87034101163 1 Mental Hlth -Depression 2.01 $ - $ - $ 52 $ 52 73 H87034102952 1 Hypertension, Essential 2.04 $ - $ - $ 48 $ 48 74 H87034104571 2 Hypertension, Essential 2.04 $ 44 $ - $ - $ 44 75 H87034103511 1 Diabetes 2.04 $ - $ - $ 42 $ 42 76 H87034103241 2 Hypertension, Essential 2.04 $ 31 $ - $ - $ 31 77 H87034103491 2 Hypertension, Essential 2.04 $ - $ - $ 5 $ 5 78 H87034105501 1 Diabetes 2.02 $ - $ - $ - $ - 79 H87034100676 2 Mental Hlth -Depression 2.01 $ - $ - $ - $ - 80 H87034101162 2 Mental Hlth -Depression 2.01 $ - $ - $ - $ - 81 H87034102973 1 Asthma 2.01 $ - $ - $ - $ - 82 H87034102984 1 Asthma 2.01 $ - $ - $ - $ - 83 H87034104821 1 Mental Hlth -Depression 2.01 $ - $ - $ - $ - 84 H87034103071 2 Coronary Artery Disease 1.02 $ - $ - $ 63,977 $ 63,977 85 H87034103161 1 Coronary Artery Disease 1.02 $ 161 $ 29,274 $ 1,370 $ 30,806 86 H87034100281 4 Coronary Artery Disease 1.01 $ 11,168 $ - $ - $ 11,168 87 H87034100901 1 Diabetes 1.04 $ 4,700 $ - $ - $ 4,700 88 H87034103162 1 Hypertension, Essential 1.01 $ 215 $ 4,306 $ - $ 4,521 89 H87034100381 2 Coronary Artery Disease 1.02 $ 2,657 $ - $ - $ 2,657 90 H87034102341 1 Coronary Artery Disease 1.02 $ 2,539 $ - $ - $ 2,539 91 H87034100951 3 Coronary Artery Disease 1.02 $ 1,339 $ 1,164 $ - $ 2,503 92 H87034101271 1 Hypertension, Essential 1.01 $ 2,175 $ 88 $ 106 $ 2,369 93 H87034103071 2 Hypertension, Essential 1.01 $ 173 $ - $ 1,598 $ 1,771 94 H87034100731 2 Hypertension, Essential 1.01 $ 1,461 $ - $ 28 $ 1,489 95 H87034101331 3 Coronary Artery Disease 1.02 $ 770 $ 656 $ - $ 1,426 96 H87034100951 3 Hypertension, Essential 1.01 $ 528 $ 500 $ 396 $ 1,424 97 H87034102102 2 Coronary Artery Disease 1.01 $ 150 $ 1,270 $ - $ 1,420 98 H87034100281 4 Diabetes 1.04 $ 1,181 $ - $ - $ 1,181 99 H87034102131 2 Diabetes 1.03 $ 249 $ 713 $ 204 $ 1,167 100 H87034100231 2 Diabetes 1.04 $ 185 $ 444 $ 528 $ 1,156 (c) 2009 Group and Pension Administrators, Inc. 7 Chronic Condition Utilization Report Summary of Individual Disease Stage (up to 200) SAMPLE CLIENT Based on Incurred Date from: opt zoos - opt Zoos - oct 2007 - Se 2006 Se 2007 Se 2008 Patient # of Chronic Chronic Disease Disease Amount Paid b Amount Paid b Amount Paid b Total for All Conditions Stage Client Client Client Periods iui H87034101721 2 Hypertension, Essential 1.01 $ 214 $ 7 $ 891 $ 1,112 102 H87034100761 2 Hypertension, Essential 1.01 $ - $ - $ 1,077 $ 1,077 103 H87034103211 2 Hypertension, Essential 1.01 $ - $ 452 $ 574 $ 1,026 104 H87034100741 1 Hypertension, Essential 1.01 $ - $ 895 $ 117 $ 1,012 105 H87034100671 1 Diabetes 1.03 $ - $ 974 $ - $ 974 106 H87034101072 2 Hypertension, Essential 1.01 $ - $ 955 $ - $ 955 107 H87034103792 1 Hypertension, Essential 1.01 $ - $ 306 $ 592 $ 898 108 H87034101311 2 Hypertension, Essential 1.01 $ 201 $ 360 $ 287 $ 849 109 H87034103101 1 Hypertension, Essential 1.01 $ 758 $ - $ - $ 758 110 H87034100831 1 Hypertension, Essential 1.01 $ 343 $ 211 $ 187 $ 740 111 H87034100731 2 Diabetes 1.03 $ 144 $ 289 $ 279 $ 711 112 H87034100061 1 Diabetes 1.04 $ 154 $ 554 $ - $ 708 113 H87034100911 2 Hypertension, Essential 1.01 $ - $ - $ 662 $ 662 114 H87034103212 2 Hypertension, Essential 1.01 $ 128 $ 85 $ 434 $ 647 115 H87034102562 2 Hypertension, Essential 1.01 $ 358 $ 144 $ 141 $ 643 116 H87034100431 1 Hypertension, Essential 1.01 $ - $ 642 $ - $ 642 117 H87034103931 2 Hypertension, Essential 1.01 $ - $ 260 $ 368 $ 627 118 H87034102242 3 Diabetes 1.03 $ 139 $ - $ 476 $ 615 119 H87034102171 4 Coronary Artery Disease 1.01 $ - $ - $ 610 $ 610 120 H87034100752 1 Hypertension, Essential 1.01 $ 118 $ 487 $ - $ 606 121 H87034100652 2 Hypertension, Essential 1.01 $ 89 $ 489 $ - $ 579 122 H87034102641 2 Diabetes 1.03 $ - $ 297 $ 256 $ 553 123 H87034103701 2 Hypertension, Essential 1.01 $ - $ 259 $ 286 $ 545 124 H87034101651 1 Hypertension, Essential 1.01 $ 187 $ 182 $ 165 $ 534 125 H87034102761 1 Diabetes 1.04 $ 214 $ - $ 299 $ 513 126 H87034102491 1 Hypertension, Essential 1.01 $ 155 $ 176 $ 159 $ 489 127 H87034105571 1 Diabetes 1.02 $ - $ - $ 482 $ 482 128 H87034100461 3 Hypertension, Essential 1.01 $ 255 $ - $ 222 $ 478 129 H87034101302 1 Hypertension, Essential 1.01 $ - $ 460 $ - $ 460 130 H87034102801 2 Hypertension, Essential 1.01 $ 354 $ 97 $ 9 $ 459 131 H87034103661 1 Hypertension, Essential 1.01 $ - $ 453 $ - $ 453 132 H87034102201 2 Hypertension, Essential 1.01 $ 196 $ 251 $ - $ 447 133 H87034100791 2 Hypertension, Essential 1.01 $ 131 $ 284 $ - $ 416 134 H87034102701 3 Hypertension, Essential 1.01 $ - $ - $ 408 $ 408 135 H87034101161 2 Hypertension, Essential 1.01 $ - $ 308 $ 95 $ 403 136 H87034103491 2 Diabetes 1.04 $ - $ - $ 392 $ 392 137 H87034101301 1 Hypertension, Essential 1.01 $ - $ 382 $ - $ 382 138 H87034100542 1 Hypertension, Essential 1.01 $ 45 $ 97 $ 208 $ 351 139 H87034100721 1 Chronic Obstruc Pulm Dis(COPD) 1.02 $ 345 $ - $ - $ 345 140 H87034102651 1 Hypertension, Essential 1.01 $ 343 $ - $ - $ 343 141 H87034100472 2 Hypertension, Essential 1.01 $ - $ 91 $ 248 $ 339 142 H87034103181 1 Hypertension, Essential 1.01 $ 334 $ - $ - $ 334 143 H87034101222 1 Hypertension, Essential 1.01 $ 317 $ - $ - $ 317 144 H87034103952 1 Hypertension, Essential 1.01 $ - $ 300 $ - $ 300 145 H87034104981 2 Asthma 1.01 $ - $ - $ 291 $ 291 146 H87034100291 1 Hypertension, Essential 1.01 $ - $ 153 $ 127 $ 280 147 H87034101091 2 Hypertension, Essential 1.01 $ - $ - $ 276 $ 276 148 H87034101792 1 Hypertension, Essential 1.01 $ - $ - $ 272 $ 272 149 H87034104981 2 Coronary Artery Disease 1.01 $ - $ - $ 272 $ 272 150 H87034103411 1 Hypertension, Essential 1.01 $ 258 $ - $ - $ 258 (c) 2009 Group and Pension Administrators, Inc. g Chronic Condition Utilization Report Summary of Individual Disease Stage (up to 200) SAMPLE CLIENT Based on Incurred Date from: opt Zoos - oct zoos - opt 2007 - Se 2006 Se 2007 Se 2008 # of Chronic Disease Amount Paid b Amount Paid by Amount Paid b Total for All Patient Conditions Chronic Disease Stage Client Client Client Periods 151 H87034100471 2 Hypertension, Essential 1.01 $ 51 $ 9 $ 183 $ 242 152 H87034101331 3 Hypertension, Essential 1.01 $ 220 $ - $ 14 $ 234 153 H87034103711 2 Hypertension, Essential 1.01 $ - $ 228 $ - $ 228 154 H87034104381 1 Hypertension, Essential 1.01 $ - $ - $ 214 $ 214 155 H87034100231 2 Hypertension, Essential 1.01 $ - $ - $ 214 $ 214 156 H87034102401 2 Hypertension, Essential 1.01 $ - $ 213 $ - $ 213 157 H87034101291 2 Hypertension, Essential 1.01 $ 181 $ - $ 33 $ 213 158 H87034103051 1 Hypertension, Essential 1.01 $ 213 $ - $ - $ 213 159 H87034104541 1 Hypertension, Essential 1.01 $ - $ 206 $ - $ 206 160 H87034103141 3 Asthma 1.01 $ 26 $ - $ 170 $ 197 161 H87034100301 1 Hypertension, Essential 1.01 $ 71 $ - $ 126 $ 197 162 H87034104441 1 Hypertension, Essential 1.01 $ - $ - $ 194 $ 194 163 H87034103481 1 Hypertension, Essential 1.01 $ - $ - $ 189 $ 189 164 H87034103262 1 Hypertension, Essential 1.01 $ - $ 183 $ - $ 183 165 H87034103531 1 Hypertension, Essential 1.01 $ - $ 180 $ - $ 180 166 H87034101931 1 Hypertension, Essential 1.01 $ 173 $ - $ - $ 173 187 H87034100472 2 Coronary Artery Disease 1.02 $ - $ 168 $ - $ 168 168 H87034100381 2 Hypertension, Essential 1.01 $ - $ 168 $ - $ 168 169 H87034102131 2 Hypertension, Essential 1.01 $ 30 $ 26 $ 111 $ 166 170 H87034102101 1 Diabetes 1.03 $ - $ - $ 163 $ 163 171 H87034102791 1 Diabetes 1.03 $ - $ - $ 163 $ 163 172 H87034102051 1 Hypertension, Essential 1.01 $ 161 $ - $ - $ 161 173 H87034100771 1 Coronary Artery Disease 1.01 $ 156 $ - $ - $ 156 174 H87034100675 1 Diabetes 1.03 $ - $ 155 $ - $ 155 175 H87034102872 1 Hypertension, Essential 1.01 $ 120 $ 34 $ - $ 154 176 H87034103271 2 Hypertension, Essential 1.01 $ 122 $ 29 $ - $ 151 177 H87034102002 2 Hypertension, Essential 1.01 $ - $ 151 $ - $ 151 178 H87034101291 2 Coronary Artery Disease 1.01 $ - $ 150 $ - $ 150 179 H87034103112 1 Asthma 1.01 $ 150 $ - $ - $ 150 180 H87034101132 1 Hypertension, Essential 1.01 $ - $ - $ 149 $ 149 181 H87034103472 2 Diabetes 1.03 $ - $ 135 $ - $ 135 182 H87034101072 2 Diabetes 1.03 $ - $ - $ 134 $ 134 183 H87034102641 2 Hypertension, Essential 1.01 $ - $ 125 $ 10 $ 134 184 H87034104632 1 Diabetes 1.04 $ - $ - $ 133 $ 133 185 H87034103535 1 Asthma 1.01 $ - $ 133 $ - $ 133 186 H87034103931 2 Asthma 1.01 $ - $ - $ 132 $ 132 187 H87034100111 1 Hypertension, Essential 1.01 $ 129 $ - $ - $ 129 188 H87034105761 1 Hypertension, Essential 1.01 $ - $ - $ 128 $ 128 189 H87034103791 1 Hypertension, Essential 1.01 $ - $ 128 $ - $ 128 190 H87034102874 1 Asthma 1.01 $ - $ - $ 126 $ 126 191 H87034100891 1 Diabetes 1.01 $ 114 $ - $ - $ 114 192 H87034102361 2 Hypertension, Essential 1.01 $ - $ 114 $ - $ 114 193 H87034102461 1 Diabetes 1.01 $ 114 $ - $ - $ 114 194 H87034102931 1 Asthma 1.01 $ 110 $ - $ - $ 110 195 H87034103471 1 Hypertension, Essential 1.01 $ - $ 108 $ - $ 108 196 H87034100611 3 Diabetes 1.03 $ - $ - $ 107 $ 107 197 H87034102001 2 Hypertension, Essential 1.01 $ - $ - $ 106 $ 106 198 H87034103241 2 Coronary Artery Disease 1.01 $ 100 $ - $ - $ 100 199 H87034100473 1 Asthma 1.01 $ 97 $ - $ - $ 97 200 H87034100042 1 Hypertension, Essential 1.01 $ - $ 26 $ 69 $ 95 (c) 2009 Group and Pension Administrators, Inc. 9 ~. A., ''- _x L PA ..~ ~ .r ~. fi.. r ~- Preventive Care Anal sis Y ~. ~. ~. i,,,, All data in the Analysis is based upon INCURRED CLAIMS ~ for the periods identified and Medstat utilizes athree- month Lag from paid claims for incurred reporting ~.. ~. Preventive Care Utilization Report Visit & Cost Summary SAMPLE CLIENT PreVentlVe Care Total for All Number of Number of Visits Total Allowed Average Total % of Cost Paid by Benchmark SefVICeS Patients Amount Cost per Visit Client Paid by Client Oct 2007 -Sep 2008 99 ~ 115 I $ 11,484 i $ 100 88.3% 86.0% Oct 2008 -Sep 2007 89 i 104 $ 10,263 ' $ 99 I 89.0% 86.1 Oct 2005 -Sep 2006 62 73 $ 7,670 '~ $ 105 88.3% 85.4% rrevennve .are i ocais ao nor mciuae mrant weimess visas 25% 20% 15% 10% 5% 0% Percent of Eligible Members with a Preventive Care Visit during the Reporting Period 20.1 16.6% 14.6% MedStat Oct 2005 -Sep Oct 2006 -Sep Oct 2007 -Sep Benchmark 2006 2007 2008 Eligibility for Percent of Eligible Members with a Preventive Care Visit during the Reporting Period is based upon a persons coverage at any lime during the reporting period so some individuals may be eligible in more than one distribution range. For example, if a covered person is only covered for the first month of the Cunent Period and for only the last month of the Prior Period, they count for eligibility purposes in both periods. If they have a preventive care visit it is recorded based upon the date of service. Eligibility also includes any person covered at any point during the reporting period and does not require twelve months of continuous enrollment. Preventive Care Utilization by Agl Infant 54% a7°i° Age 1 - 4 45% 44% Age 5 - 17 100/1 Age 18 - 39 11 14 0 11 °/ Age 40 - 64 19% Age 85 + 0% 'n, Eligibility for Preventive Care Utilization by Age is based upon a persons age al any time during the reporting period so some individuals may be eligible in more than one distribution range. For example, it a covered person is age 4 at the start of the reporting period and turns 5 during the reporting period then they count for eligibility purposes in both categories. If they have a preventive care visit it is recorded based upon their age at dale of service. Eligibility also includes any person covered al any point during the reporting period and does not require twelve months of continuous enrollment. Report based on Incurred Claim Data for the Period of: Oct 2007 -Sep 2008 Preventive Service Type # of Patients i i Number of Visits Client Cost per ' 'I Visit Member Cost per Visit Percent of Patients Percent of Cost 99381 Init Pm E/M, New Pat, Inf 0 ' 0 #DIV/0! #DIV/0! 0.0% #DIV/0! 99382 Init Pm E/M, New Pat 1-4 Yrs 2 2 ', $ 102.11 I , $ 15.00 1.9% 1.8% 99383 Prev Visit, New, Age 5-11 1 i 1 I $ 119.00 $ 15.00 1.0% 1.0% 99384 Prev Visit, New, Age 12-17 0 ' 0 ~ #DIV/0! #DIV/0! ~ i 0.0% #DIV/0! 99385 Prev Visit, New, Age 18-39 11 i 11 $ 126.89 $ 10.91 ~ I 10.6% 12.2% 99386 Prev Visit, New, Age 40-64 8 j 9 $ 144.83 ' $ 13.33 ~I 7.7% 11.3% 99387 Init Pm E/M, New Pat 65+Yrs 0 ~ 0 ! #DIV/0! #DIV/0! 0.0% #DIV/0! 99391 Per Pm Reeval, Est Pat, Inf 7 11 ~ $ 72.96 $ 12.27 ~ 6.7% 7.0% 99392 Prev Visit, Est, Age 1-4 18 22 I $ 82.00 ' $ 16.71 17.3% 15.7% 99393 Prev Visit, Est, Age 5-11 10 10 $ 77.61 $ 13.50 9.6% 6.8% 99394 Prev Visit, Est, Age 12-17 3 3 $ 87.66 $ 15.00 2.9% 2.3% 99395 Prev Visit, Est, Age 18-39 ~ 16 16 $ 88.30 $ 14.06 15.4% 12.3% 99398 Prev Visit, Est, Age 40-64 28 30 $ 113.44 $ 11.02 26.9% 29.6% 99397 Per Pm Reeval Est Pat 65+ Yr 0 0 #DIV/0! #DIV/0! 0.0% #DIV/0! Total Preventive Care Visits 104 115 $ 99.86 $ 13.24 (c) 2009 Group and Pension Administrators, Inc. 2 Preventive Care Utilization Report Healthy People 2010 SAMPLE CLIENT What is Healthy People 2010? Healthy People 2010 challenges individuals, communities, and professionals-indeed, all of us- to take specific steps to ensure that good health, as well as long life, are enjoyed by all. Health People 2010 provides a framework for prevention for the Nation. It is a statement of national health objectives designed to identify the most significant preventable threats to health and establish national goals to reduce these threats during the first decade of the new century. Incurre d Claim Utilizatio n Data Key Indicators Oct 2005 -Sep Oct 2006 -Sep Oct 2007 -Sep 2006 2007 2008 Cholesterol Screening Rate 80 87 104 Cholesterol Screening Rate 41.31% 41.59% 41.57% National Average for Calendar Year 32.14% 38.70% 39.95% Healthy People 2010 Target 80.00% 80.00% 80.00% Mammogram Screening Rate 15 17 17 Mammogram Screening Rate 30.47% 32.18% 26.15% National Average for Calendar Year 28.46% 35.12% 34.21% Healthy People 2010 Target 70.00% 70.00% 70.00% Cervical Cancer Screening Rate 25 39 39 Cervical Cancer Screening Rate 31.73% 47.27% 36.53% National Average for Calendar Year 33.12% 42.00% 41.72% Healthy People 2010 Target 90.00% 90.00% 90.00% Colon Cancer Screening Rate 13 18 14 Colon Cancer Screening Rate 12.46% 15.96% 10.49% National Average for Calendar Year 14.93% 18.82% 18.80% Healthy People 2010 Target 50.00% 50.00% 50.00% PSA Screening Rate 20 33 31 PSA Screening Rate 26.87% 39.76% 31.16% National Average for Calendar Year 26.32% 33.99% 34.10% Healthy People 2010 Target 90.00% 90.00% 90.00% HEALTHY PEOPLE 2010 COMPARISON TO NATIONAL AVERAGES FOR KEY SCREENINGS Results reflect only those screenings that are adjudicated by GPA as covered by the Benefit Plan C t Y C urren ear urrent Year Compared to Compared to Prior National Average Year 4.06% -0.05% -23.56% -18.72% -12.44% -22.72% -44.22% -34.31 -8.64% -21.64% (c) 2009 Group and Pension Administrators, Inc. 3 ~~ ~~ ^Cholesterol Screening Rate ^Mammogram Screening Rate ^ Cervical Cancer Screening Rate m Colon Cancer Screening Rate ^PSA Screening Rate Preventive Care Utilization Report Age-appropriate Preventive Care Chart SAMPLE CLIENT Health Activity Physical Exam Ages 18-39 annually Ages 40-49 annually Ages 50-64 annually Age 65+ annually as needed with health demands Blood Pressure/Pulse every other year every year every year every year more often with family history Eye & Ear Exam baseline by 39 every 2-4 years every 2-4 years yearly more frequent visits with problems and yearly after age 60+ Dental Exam twice a year twice a year twice a year twice a year as needed with changes in dental health Skin Exam every 2 years every year every year every year as needed with changes in skin Tetanus/Diphtheria every 10 years every 10 years every 10 years every 10 years Influenza (Flu) per risk per risk yearly yearly pregnancy, lung disease and heart disease require immunization prior to age 50 Measles/Mumps/Rubella up to date usually not needed usually not needed usually not needed immunity desired prior to pregnancy Pneumonia Vaccine usually not needed usually not needed usually not needed at age 65 booster may be required in 5 years Cholesterol/Triglycerides at age 20 every 5 years every 5 years every 5 years more frequent if abnormality detected Blood Sugar Evaluation (Diabetes) usually not needed every 3 years at 45 every 3 years every 3 years 'more frequent and earlier depending on risk level and family history Bone Density for Osteoporosis usually not needed usually not needed baseline if at risk age 65 'may screen earlier with risk factors BREAST CANCER SCREENING Breast Self-Exam teach BSE by age 20 monthly monthly monthly always call physician with concerns Mammography usually not needed annually annually annually risk level may require higher frequency Breast Exam by Physician every 1-3 years annually annually annually 'risk level may require higher frequency CERVICAL CA NCER SCREENING Pap Test annually annually annually annually 'some doctors feel that after three or more consecutive normal results, Pap smears may be performed every 2-3 yea rs on certain low-risk women Pelvic Exam by Physician annually annually annually annually COLON CAN CER SCREENING Fecal Occult Blood Test and/or; usually not needed usually not needed annually annually 'colon screening may be performed earlier and more frequently with certain risk factors and family history Flexible Sigmoidoscopy or; usually not needed usually not needed every 3-5 years every 3-5 years Colonoscopy or; usually not needed usually not needed every 5 years every 5 years Double Contrast Barium Enema usually not needed usually not needed every 5 years every 5 years As recommended by the National Institute for Health, 2007 (c) 2009 Group and Pension Administrators, Inc. 4