ENTRUST" 14701 St. Mary's Lane, Suite 150 Houston, TX 77079 HEALTII ENEFIT PLAN pRoposAL PREPARED FOR: -, l - -49' z 4 KERR Co UNTY PRESENTED BY: CLINT WILSON REPRESENTING ENTRUST, INC. THROUGH TCPN 2011 m .,,,,,, e•,•,, Ps a 1 Corporate Office P.O. Box 440309 Houston, TX 77244 - 0309 (281) 368 - 7878 Fax (281) 368 - 7828 8 m •4treaP Table of Contents AGENT /AGENCY QUESTIONS: 15 STOP /LOSS INSURANCE QUESTIONS 17 TPA ORGANIZATION QUESTIONS 19 CLAIM ADMINISTRATION QUESTIONS 20 Eligibility System 23 System Capabilities 24 Banking Arrangements 25 Utilization Review 26 Preferred Provider Organizations 27 Reporting 27 General Questions 28 HRA QUESTIONS 30 PRESCRIPTION BENEFIT MANAGER QUESTIONS 31 CAFETERIA PLAN QUESTIONS 50 `'"' WELLNESS AND PREVENTION QUESTIONS: 53 EXHIBITS 57 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 Optional Fully Insured Medical Plans PLEASE FILL IN THE FOLLOWING INFORMATION NEEDED AND SUBMIT WITH PROPOSAL. The undersigned proposer, by signing and executing this proposal, certifies and represents to Kerr County that proposer has not offered, conferred or agreed to confer any pecuniary benefit, as defined by (1.07 (a) (6) of the Texas Penal Code, or any other thing of value as consideration for the receipt of information or any special treatment of advantage relating to this proposal; the proposer also certifies and represents that the proposer has not offered, conferred or agreed! to confer any pecuniary benefit or other thing of value as consideration for the recipient's decision, opinion, recommendation, vote or other exercise of discretion concerning this proposal, the proposer certifies and represents that proposer has neither coerced nor attempted to influence the exercise of discretion by any officer, trustee, agent or employee of Kerr County concerning this proposal on the basis of any consideration not authorized by law; the proposer also certifies and represents that proposer has not received any information not available to other proposers so as to give the undersigned a preferential advantage with respect to this proposal; the proposer further certifies and represents that proposer has not violated any state, federal, or Local law, regulation or ordinance relating to bribery, improper influence, collusion or the like and that proposer will not in the future offer, confer, or agree to confer any pecuniary benefit or other thing of value of any officer, trustee, agent or employee of Kerr County in return for the person having exercised their person's official discretion, power or duty with respect to this proposal; the proposer certifies and represents that it has not now and will not in the future offer, confer, or agree to confer a pecuniary benefit or other thing of value to any officer, trustee, agent, or employee of Kerr County in ___ connection with information regarding this proposal, the submission of this proposal, the award of this proposal or the performance, delivery or sale pursuant to this proposal. The Proposer represents that he, his agent(s), nor any corporate employee has contacted any officer, trustee, elected County official or any other County employee with the intent to discuss, influence, or in any manner affect the outcome of the bid process. The proposer shall defend, indemnify, and hold harmless Kerr County, all of its officers, agents and employees from and against all claims, actions, suits, demands, proceeding, costs, damages, and liabilities, arising out of, connected with, or resulting from any acts or omissions of contractor or any agent, employee, subcontractor, or Supplier of contractor in the execution or performance of this RFP. I have read all of the specifications and general proposal requirements and do hereby certify that all items submitted meet specifications. COMPANY: Ent _ Qli c. AGENT NAME: . .. I i AGENT SIGNATURE: �/' ' ADDRESS: 14701 Saint Mar 's r uite 150 CITY: Houston STATE: TX Ai' CODE: 77079 TELEPHONE: (281) 368 -7878 FAX: (281) 368 -7828 %we FEDERAL TIN #: 76 03 2.32.6 AND /OR SOCIAL SECURITY #: DEVIATIONS FROM SPECIFICATIONS IF ANY Page 5 of 45 (Attach documents as necessary or state No Deviations): 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 Optional Fully Insured Medical Plans CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS Name Of Entity: Entrust, 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 — '`Irow 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. EdwalablJacobson N. ` • i • • • - • ' epresentative (Typed) ti Ai. .1 , 1_.a - o • orized Representative Date I am irto certify to the above statements. My explanation is attached. Page 6 of 45 Conflict of Interest Ouestionnaire For Vendor or Other Person Doini 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. *ow' By law this questionnaire must be filed with the records administrator of the local government not later than the 7 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. Clin t Wilson 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 the activity described in Section 176.006(a) Local Govemment Code, is pending and not later than the 7 business day after the originally filed questionnaire becomes incomplete or inaccurate.) 3. Describe each affiliation or business relationship with an employee or contractor of the local government entity who makes recommendations to a local government officer of the local government entity with respect to expenditure of money. None 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. None 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) N/A 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 additionals 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? 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? 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 1O% or more? D. Describe each affiliation or business relationship. 6. Describe any other affiliation or business relationship that might cause a conflict of interest. N one 7. Signaik- \ Il/ 1 ili!n, 4..1/4`I► Signa 7, r on omT " s with the Dat- Governmental entity Page 7 of 58 Kerr County Request for Proposal 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 Optional Fully Insured Medical Plans Kerr County will accept sealed proposals for listed items individually or corporately until 11:00 A.M. local time, October 14, 2010 County Judge Pat Tinley's office, County Courthouse 700 Main Kerrville, Texas 78028. Proposals will be opened and acknowledged publicly on October 14, 2010. This is a procurement of insurance through the competitive sealed proposal procedure outlined in the Texas Local Government Code 262 including terms and conditions specified in Sections 262.030; 262.025; 262.026; At the proposal opening, only the identity of the proposers will be disclosed by KERR COUNTY. The proposals will be forwarded to KERR COUNTY'S insurance consultant for review, tabulation and analysis. The contents of each proposal will not be disclosed in order to protect the integrity of the negotiation process. To obtain the best final offer(s), revisions by short- listed candidates may be permitted after original proposal submission, and before the contract award. All proposals will be later made available to the public for inspection after the contract is awarded. If a proposer indicates and justifies in his proposal(s) that certain information is proprietary, KERR COUNTY will not release the materials for public inspection after the contract award. Clarification of RFP may be obtained from: Gary R Looney, 3201 Cherry Ridge Rd, Suite D 405, San Antonio, Texas 78230 Ph: 210- 930 -6665 glooney @alamoinsgrp.com Please mark on the outside of the submitted envelope/box: "Insurance Proposal" and send or deliver to the attention of "County Clerk, County Courthouse 700 Main Kerrville, Texas 78028" KERR COUNTY reserves the right to reject any or all competitive sealed proposals, waive any irregularities contained therein and to accept any competitive sealed proposals deemed most advantageous to KERR COUNTY. Any competitive sealed proposal received after 11:00 am., local time, October 14, 2010, will be automatically rejected and returned to the proposer unopened. KERR COUNTY will not be responsible in the event that the U.S. Postal Service or any other carrier system fails to deliver the sealed proposal to KERR COUNTY by the given deadline above. ILO Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD &D Health Reimbursement Arrangement 'rr' Cafeteria Plan (IRS code 125) Administration Prescription Benefit Management Optional Fully Insured Medical Plans PLEASE ACKNOWLEDGE RECEIVING THIS RFP BY RETURNING THIS FORM In order to allow a fair and competitive bid process proposer will not be allowed to access markets prior to the release date of this RFP. The official date and time of release is Tuesday September 21, 10:00 AM. It is your responsibility to return this intent to bid with the proper means of contacting you or your organization. Communicating any questions, answers, or amendments to this RFPwill be made through the process you provide on this form. FAX or Mail TO: Gary Looney REBC Insurance Consultant 3201 Cherry Ridge Dr Suite D 405 San Antonio, Texas 78230 Fax: 210 -930 -1838 WILL RESPOND WILL NOT RESPOND COMMENTS: AGENT NAME: Agent Phone: Agent Email: Agent Signature Print Agent Name COMPANY NAME: COMPANY FAX COMPANY PHONE COMPANY CONTACT EMAIL: SIGNATURE 'err 2 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 Optional Fully Insured Medical Plans PLEASE FILL IN THE FOLLOWING INFORMATION NEEDED AND SUBMIT WITH PROPOSAL. The undersigned proposer, by signing and executing this proposal, certifies and represents to Kerr County that proposer has not offered, conferred or agreed to confer any pecuniary benefit, as defined by (1.07 (a) (6) of the Texas Penal Code, or any other thing of value as consideration for the receipt of information or any special treatment of advantage relating to this proposal; the proposer also certifies and represents that the proposer has not offered, conferred or agreed! to confer any pecuniary benefit or other thing of value as consideration for the recipient's decision, opinion, recommendation, vote or other exercise of discretion concerning this proposal, the proposer certifies and represents that proposer has neither coerced nor attempted to influence the exercise of discretion by any officer, trustee, agent or employee of Kerr County concerning this proposal on the basis of any consideration not authorized by law; the proposer also certifies and represents that proposer has not received any information not available to other proposers so as to give the undersigned a preferential advantage with respect to this proposal; the proposer further certifies and represents that proposer has not violated any state, federal, or local law, regulation or ordinance relating to bribery, improper influence, collusion or the like and that proposer will not in the future offer, confer, or agree to confer any pecuniary benefit or other thing of value of any officer, trustee, agent or employee of Kerr County in return for the person having exercised their person's official discretion, power or duty with respect to this proposal; the proposer certifies and represents that it has not now and will not in the future offer, confer, or agree to confer a pecuniary benefit or other thing of value to any officer, trustee, agent, or employee of Kerr County in connection with information regarding this proposal, the submission of this proposal, the award of this proposal or the performance, delivery or sale pursuant to this proposal. The Proposer represents that he, his agent(s), nor any corporate employee has contacted any officer, trustee, elected County official or any other County employee with the intent to discuss, influence, or in any manner affect the outcome of the bid process. The proposer shall defend, indemnify, and hold harmless Kerr County, all of its officers, agents and employees from and against all claims, actions, suits, demands, proceeding, costs, damages, and liabilities, arising out of, connected with, or resulting from any acts or omissions of contractor or any agent, employee, subcontractor, or Supplier of contractor in the execution or performance of this RFP. I have read all of the specifications and general proposal requirements and do hereby certify that all items submitted meet specifications. COMPANY: Entrust, Inc. AGENT NAME: Edward A. Jacobson AGENT SIGNATURE: ADDRESS: 14701 Saint Marv's Lane, Suite 150 CITY: Houston STATE: TX ZIP CODE: 77079 TELEPHONE: (281) 368 -7878 FAX: (281)368-7828 FEDERAL TIN #: AND /OR SOCIAL SECURITY #: it DEVIATIONS FROM SPECIFICATIONS IF ANY 3 (Attach documents as necessary or state No Deviations): 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 Optional Fully Insured Medical Plans CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS Name Of Entity: Entrust, 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 (1) (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 `1/'' 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. Edward A. Jacobson Name and Title of Authorized Representative (Typed) • Signature of Authorized Representative Date am unable to certify to the above statements. My explanation is attached. kid 4 Conflict of Interest Questionnaire For Vendor or Other Person Doine 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 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 sectio is a Class C Misdemeanor. 1. Name of person doing business with local government entity. Clint Wilson 2. in 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 I of th year for the activity described in Section I76.006(a) Local Government Code, is pending and not later than the 7 business day after the originally filed questionnaire becomes incomplete or inaccurate.) 3. Describe each affiliation or business relationship with an employee or contractor of the local government entity w o makes recommendations to a local government officer of the local government entity with respect to expenditure f money. None 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. None 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) N/A 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 additionals 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? 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? 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? D. Describe each affiliation or business relationship. 6. Describe any other affiliation or business relationship that might cause a conflict of interest. None • 7. Signatures • Signature of person doing business with the Date Governmental entity • 5 Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD &D i Health Reimbursement Arrangement Cafeteria Plan (IRS code 125) Administration Prescription Benefit Management Optional Fully Insured Medical Plans NOTICE TO PROPOSER Information provided in these specifications is to be used for purposes of preparing a proposal detailing costs of providing the services and insurance specified. It is further expected that each proposer will read these specifications with care, since failure to meet each condition or a combination of specified conditions may disqualify proposal. Information provided by Kerr County includes: 1. Current census 2. Plan documents 3. Rate history 4. Standard Loss Information 5. High Claim Losses • KERR COUNTY reserves the right to reject any or all proposals or any portion thereof and to accept the proposal deemed most advantageous to KERR COUNTY. Proposer is required to submit quotations on the basis of these specifications. Alternative quotations (for service on a basis different from requested in these specifications) will receive consideration if such alternatives are clearly explained. Any exceptions to coverage requested herein must be clearly noted in writing and be included as a part of the proposal. KERR COUNTY believes that the data contained in these specifications is sufficient for preparation for a proposal. The information is believed to be accurate and is based upon the latest available information, but it is not to be considered in any way as a warranty. Requests for additional information should be directed in writing to Gary Looney REBC, Insurance Consultant, 3201 Cherry Ridge Drive, Suite D 405, San Antonio, Texas, 78230, Phone (210) 930 -6665 Fax (210) 930 -1838 Email address glooney @alamoinsgrp.com 6 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 Optional Fully Insured Medical Plans GENERAL INFORMATION and INSTRUCTIONS 1. The information contained in these specifications is confidential and is to be used only in connection with preparing a proposal for all or part of the following employee benefit plans: 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 Optional Fully Insured Medical Plans 2. KERR COUNTY reserves the right to accept or reject all or any part of the proposals, waive minor technicalities, and award the proposal to best serve the interest of KERR COUNTY. KERR COUNTY also reserves the right to waive or dispense with any of the formalities contained herein. 3. Proposals are to be submitted on the basis of the specifications contained herein. Alternate proposals will also be considered, if the alternatives are clearly explained. All deviations from the specifications must be clearly identified and explained. Nft/ 4. The information contained herein is believed to be accurate and up -to -date, but is not intended to be an express or implied warranty. 5. No telephone or fax proposals will be accepted. Proposals will only be accepted if delivered by U.S. Postal Service, contract carriers, hand delivery, etc. KERR COUNTY will not be responsible for missing, lost or late mail. Any proposals received after the deadline will be returned to the proposer unopened. 6. At the proposal opening, only the identity of the proposers will be disclosed by KERR COUNTY. The contents of each proposal will not be disclosed in order to protect the integrity of the negotiation process. 7. To obtain the best final offer(s), revisions by short- listed candidates may be permitted after original proposal submission, and before contract award. 8. All proposals will later be made available to the public for inspection after the contract is awarded. If a proposer indicates and justifies in his proposal(s) that certain information in the proposal(s) is confidential or a trade secret, KERR COUNTY will review those materials with the proposer prior to releasing the materials for public inspection after the contract award. 9. Gary R Looney REBC is the independent insurance consulting agent providing technical assistance to Kerr County during the RFP process. Gary R Looney is compensated by KERR COUNTY on a fee basis, and is not compensated by the service provider. 10. Vendors are cordially invited to the proposal opening, but are not required to attend. 7 8 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 Optional Fully Insured Medical Plans TIMETABLE 1. These specifications are to be released for action at 10:00 am September 21,2010. 2. One original and three (3) copies of the proposals are to be delivered or mailed to Kerr County Courthouse, C/O County Clerk, Jannett Pieper 700 Main, Kerrville, Texas 78028 to arrive by October 14, 2010, 1 1:00 am. Mark proposal as "Proposal for Kerr County Employee Benefits" 3. Consideration and action on the Proposals will be presented to the Commissioner's Court on or about October 25 , 2010. 4. The successful proposer will be notified on or about October 25, 2010. 5. Coverage is to be effective January 1, 2011. 6. Policies or contracts are to be provided to KERR COUNTY no later than 30 days after such effective date. 7. The contract term desired is three years with years two and three subject to County Commissioner's Court approval. PREPARATION OF PROPOSAL The proposer shall prepare their proposal in one original and three (3) copies on the attached proposal form with attachments as necessary to fulfill the specifications contained herein. Unless otherwise stated, all blank spaces on the proposal or as applicable to the subject specification, must be correctly filled. A unit price must be stated for each item, either typed in or written in ink. Any exceptions or deviations from the requested services must be clearly indicated in writing and submitted with and form a part of the proposal form. Failure to follow these instructions will be grounds for disqualifications of a proposal. Complete and sign all documents provided including the Conflict of Interest Questionnaire (CIQ) CVS Caremarkch is included in the information you have received. A vendor's spreadsheet is provided in an MicroSoft Excel spreadsheet format. This spreadsheet must be completed. If you have questions or comments on the spreadsheet please request information from our consultant. 9 • • koo • • • • • • 10 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 Optional Fully Insured Medical Plans WITHDRAWAL OF PROPOSAL Proposers may withdraw their proposals anytime up to the time specified as the closing time for acceptance of proposals. However, no proposer shall withdraw or cancel their proposal for a period of 60 days after said closing date for acceptance of proposal nor shall the successful proposer withdraw or cancel or modify their proposal, except at the request of KERR COUNTY, after having been notified that KERR COUNTY has accepted the said proposal. Withdrawal or cancellation of a proposal after the closing date for acceptance of proposals shall result in the forfeiture of the bid security. CRITERIA USED IN EVALUATING PROPOSALS 1. No insurance proposals will be accepted from insurers without a Best's Rating, of at least an "A -" in the most recent edition of BEST'S KEY RATING GUIDE FOR LIFE /HEALTH,. 2. Any insurers, agents or third party administrators shall be duly licensed by the state of Texas, and comply with all applicable state insurance laws and requirements or duly constituted applicable insurance regulatory authorities. A local government self - insurance pool organized under the Texas Interlocal Cooperation Act or other state law shall also be an acceptable ‘liov 3. The proposal must be in easily understood format with coverage clearly outlined. 4. Proposals will be first evaluated on technical factors other than cost, including but not limited to coverage, benefits, services and financial stability. After a preliminary evaluation of the technical criteria, cost will be included in the evaluation process. Cost will be evaluated on an equal basis with the technical criteria. For the evaluation of cost, fixed administrative cost for a three -year period will be considered first; followed by total first year cost for stop loss insurance premiums and maximum claim cost. For aggregate stop loss insurance maximum claim cost, additional specific deductibles (lasers) will be added to maximum claim cost, if not an allowable claim expense for aggregate maximum claim cost. 11 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 Optional Fully Insured Medical Plans QUALIFICATION OF COMPANIES AND AGENTS SUBMITTING PROPOSALS. All companies and agents submitting proposals must be licensed by the state of Texas and have demonstrated level of good performance with municipalities, school districts or other public entities in Texas. The company or agent must have an Errors and Omissions (E &O) policy with a minimum limit of $1,000,000. An agent submitting a proposal must maintain a fully staffed office for the servicing of the program. The agent must have been in business for at least five years and must assign a minimum of one qualified account representative to service KERR COUNTY to include assisting with enrollment responsibilities. This representative must have a minimum of five years experience in employee benefits, or hold the CLU, CEBS and or RHU designation. DEVIATION FROM SPECIFIED COVERAGE OR SERVICE Proposals are to be submitted on the basis of the specifications contained herein. Proposer MUST include the RFP Submission Forms with its proposal. All costs to be incurred and billed to KERR COUNTY will be firm and included in these forms. Alternative proposals will also be considered, provided the alternatives are clearly explained. All deviations from the specifications must be clearly identified and explained. IWO UNDERWRITING DATA KERR COUNTY has assembled the underwriting exposure, and loss data included in these specifications. CVS Caremarkle every effort has been made to ensure the accuracy of this information, it cannot be guaranteed. It shall be the responsibility of the successful proposer to review this information and work with KERR COUNTY on an ongoing basis to ensure all relevant exposures are included in KERR County's program. If it becomes necessary to revise any part of this proposal, a written addendum will be provided to -all proposers who have submitted an "Intent to Bid Form ". KERR COUNTY is not bound by any oral representation, classifications, or changes made in the written specifications by KERR COUNTY employees, unless such classification or change is provided to proposers in a written addendum from an authorized representative of KERR COUNTY or KERR County's insurance consultant. COMPLIANCE WITH LAWS All proposers involved shall observe and comply with all regulations, laws ordinances, etc., of local, state, and federal government as they apply to this proposal process 12 Kerr County Specific and Aggregate Stop Loss Insurance Third Party Medical Claims Administration Group Term Life and AD &D Now Health Reimbursement Arrangement Cafeteria Plan (IRS code 125) Administration Prescription Benefit Management Optional Fully Insured Medical Plans TERM OF CONTRACT AND EXTENSION /RENEWAL RIGHTS The term of the contract for insurances or service shall be for not less than one year, subject to earlier termination as provided by the law and by the terms of the contract. In addition, unless otherwise specified in the proposal, the award of this proposal shall include the right at the option of KERR COUNTY, and contingent upon the agreement by both parties, to any change in premium costs or benefits to renew and extend this contract on a year to year basis as may be permitted by applicable law and Commissioner's Court approval as may be in the best interest of KERR COUNTY; if the maximum term of this contract and all renewals of it shall be not more than three years before such contract must again be offered for competitive bidding. AUTHORIZED SIGNATURE All proposal forms must be signed by persons who have legal authority to bind the insurer and administrator to the services proposed. DISQUALIFICATION AND REJECTION OF PROPOSALS Failure to comply with the requirements or the procedures set forth herein, or to satisfy the insurance and servicing criteria as set forth in the specifications, may result in disqualification. It is not intended that exceptions to the specification will, in and of themselves, result in disqualification. CONTINUITY OF COVERAGE All employees, retirees and dependents covered by the current plan are to receive immediate coverage under the new plan. Continuity of coverage for current participants is to be on a "no loss no gain" basis for all insurance coverage. In addition, proposers must waive the actively at -work provisions. In fulfilling the Continuity of Coverage requirement fair credit must be allowed for all or any part of health insurance deductibles or co- insurance satisfied, and accumulated lifetime maximum amounts before the contract effective date. 13 4 IIM' 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 Optional Fully Insured Medical Plans Individual Stop Loss Insurance (ISL) /Aggregate Stop Loss Insurance (ASL) Request for Proposal Submission Form RFP ASSUMPTIONS: I. A proposal for the duplication of the existing Plan of Benefits must be provided. Any deviations must be clearly identified and explained. All proposals will be assumed to have been submitted without any deviations unless clearly noted. We request a proposal for Stop /Loss insurance taking into consideration the elimination of all dependent coverage effective DECEMBER 31, 2010. 2. Proposal is to be based on the provided census. 3. Contract effective date is to be January 1, 2011. All participants enrolled in the insurance plan as of December 31, 2010 are to be covered on a "no loss /no gain" basis. "No loss /no gain" for participants are to include credit /debit for accumulated deductible, coinsurance, and lifetime maximum benefits. 4. KERR COUNTY desires to receive proposals for a three (3) year period on one of the following basis: * to" • Fixed price for the three (3) year period, or • Two annual renewal adjustments determined by formula at the time the contract is awarded, or • One (1) year contract with two annual renewal options for rate and premiums deemed to be favorable to KERR COUNTY. Renewal rates are to be provided to KERR COUNTY by October 1 (90 days prior to anniversary date). 5. KERR COUNTY will only consider stop Toss insurance policies meeting the following: a Specific and Group Aggregate Policy on a 15/12; paid/12; 24/12 or paid /15 basis for Medical and Drug (Rx). We do not wish to see an aggregating specific. b. Medical and Drug (RX) Specific Coverage with $60,000; $70,000; $80,000 Stop loss. c. Medical and Drug Aggregate Coverage at 120% and 125% of expected claims d. Final determination on all lasers, if any, including deductible amounts and conditional lasers should be clearly identified and provided with RFP response based on provided claims data e. Insurance Company Quotation Document with all terms clearly listed f.. Waive Actively at Work Provisions g. Provide a quote for Employee only coverage, eliminate dependent eligibility. 6. Renewal rate must be received by KERR COUNTY at least 90 days prior to date of rate change. 7. Any estimated savings, performance or other guarantees should be specific, quantifiable and should include a method for validation. 14 AGENT /AGENCY QUESTIONS: Describe the Agent/Agency submitting the proposal: a. Agent/Agency Name: American National c/o Bardon Insurance Group 14 118/ b. Address: 8326 East Hartford Drive #100 Scottsdale, AZ 85255 c. Contact Person: Adam Thaler d. Telephone Number: (888) 550 — 4961 xt. 1412 e. Year Founded : 1996 f. What percentage of overall business is Health related? 100% 2. a. Has your agency or have you (Agent) been a defendant in any lawsuit in any state or federal court during the preceding five (5) years? Yes X No If yes, identify each lawsuit by party, case number, court, subject matter, and disposition: b. Does the agency or have you (Agent) had any claims filed against it CVS Caremarkch are unresolved and presently pending before any State of Texas Administrative agency? Yes X No If yes, please provide a full description of the charges 3. Financial Information: a. Has the agency or have you (Agent) filed a voluntary or involuntary petition in bankruptcy, obtained an order for relief, or received a discharge on any debt under the U.S. Bankruptcy laws during the preceding seven (7) years? Yes X No If yes, please describe: b. Has any owner, member, or partner of the business entity filed a petition in bankruptcy, obtained an order for relief, or received a discharge on any debt under the U.S. Bankruptcy laws during the preceding seven (7) years? Yes X No If yes, please describe: 4. Describe insurance coverage (include copy of Insurance Certificate): a. The Agency or Agent must provide satisfactory evidence of existing insurance coverage in the amount of $1,000,000.00 for Errors and Omissions or other fiduciary liability. If the business entity is selected to provide services it must provide evidence that such coverage will be in effect for the duration of the agreement. 5. Provide three (3) Texas client references (preferably public entities): Company Name: Hill Country Mental Health Mental Retardation Center Company Contact information: Name: David Weden Phone Number: (830)792 -3300 Company Name: City of Kingsville Company Contact information: Name: Diana Gonzalez Phone Number: (361) 595 -8017 15 Company Name: Peterson Regional Medical Center Company Contact information: Name: Buddy Volpe Phone Number: (830) 258 -7415 6. Describe the insurance company you are proposing: a. Name of Insurance Company: American National c/o Bardon Insurance Group b. Current Business Address: 8326 East Hartford Drive #100 Scottsdale, AZ 85255 c. Mailing Address: 8326 East Hartford Drive #100 Scottsdale, AZ 85255 d. Contact Person: Adam Thaler e. Telephone Number: 888 -550 -4961 f. Financial Rating Current Rating Prior Year Rating Service A.M. Best A A Standard & Poors N/A N/A Moody's N/A N/A 16 STOP /LOSS INSURANCE QUESTIONS Describe ISL and ASL claim payment: a. Where will claims be paid? Scottsdale, AZ b. What is the definition of "paid claim" to be eligible for reimbursement? PAID CLAIM means charges that are covered and payable under your Plan , that have been adjudicated and approved , with check or draft issued and placed in the US Mail , for which sufficient funds are on deposit on the date said check or draft is issued , and which said check or draft is paid upon presentation. c. Can KERR County's HR Director and consultant speak directly to claim examiner for questions related to payment of claim? Yes. Comment: Entrust would prefer Kerr County to go through the Entrust Claims Manager. d. What is the normal processing time for ISL claim? Clean Claim within 10 Business Days e. What is normal processing time for ASL claim? Aggregate claims audits generally take 30 days when an On -Site audit is required. f. What expenses related to investigation of claim are eligible for reimbursement (e.g. hospital audit, medical records, etc) by the stop Toss carrier? Hospital Bill Analysis fees with supporting documentation, Negotiated savings fees with supporting documentation, Independent physician review fees with prior approval, LCM fee with supporting invoices and reports. g. If KERR COUNTY has negotiated with providers, will these discounts be accepted, in lieu of doing a hospital or other audit? No - Negotiated savings are reviewed on a case- by-case basis. The reinsurance carrier should be consulted prior to agreeing to a negotiated discount whenever Advance Funding will be requested. h. Describe documentation needed for ISL claim reimbursement: See our Specific Stop -Loss Check List on our website www.bardon.net 2. Describe Underwriting: a. Will any claimants be excluded or assigned a higher deductible (Iasered)? The carrier will need a signed and approved carrier disclosure statement before any decision can be made as to Higher Individual Specific Deductibles. b. If so, please describe: Please refer to the Terms & Conditions in the Financial Sections of the Proposal. 3. Did you provide a Specimen Stop Loss Contract? Yes 4. Does your Stop Loss insurance contract have any exclusions or limitations that are more restrictive than those used in KERR County's booklet? No If so, please describe: 5. Are the active -at -work and disabled dependent provisions waived for the effective date of the contract? Yes (With Disclosure statement. 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: Interlink would be the Transplant Network utilized for Kerr County. The Interlink Case Rates are proprietary. 17 7. Please state any variations to the Request for Proposal Assumptions or other qualifications for your quote: Please see Terms and Conditions in the Financial Section of the Proposal. 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 Advancement has been included in the quote provided. If reimbursed what is ;tor turnaround time? N/A 9. For what period of time are quoted rates guaranteed? January 1, 2011 — December 31, 2011 10. Is a longer rate guarantee available? Yes ✓ No If so, please describe: 11. Are quoted rates net of agent commission? ✓ Yes No If no, please describe: All Stop - Loss quotes have been provided net of commissions. 12. Do quoted rates include advance funding for: a. Specific Claims? ✓ Yes No b. Aggregate Claims? Yes ✓ No If no, additional cost to provide: $2.00 Per Employee Per Month 13. Is the quote based on the services of a specific provider network? ✓ Yes No First Health was the quoted PPO Network for Kerr County. 14. Please give rate differential to use the following networks: Specific Aggregate a. PHCS No Change No Change b. Healthsmart No Change No Change c. BC /BS N/A N/A d. CCN +10% +5% e. Beechstreet +10% +5% Other (Name) N/A N/A 21. The following rate exhibit may be used for rate submission however included with the CD or available by Internet is an Excel Spreadsheet titled, "Self Funded Quote Spreadsheet ". Complete this spreadsheet as it will be used for bid analysis. An Excel Spreadsheet titled, "Self Funded Proposal Spreadsheet 2011 ". 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 An Excel Spreadsheet titled, "Self Funded Proposal Spreadsheet 2011". 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 'fir 18 Kerr County Third Party Administration Questionnaire lotiv TPA ORGANIZATION QUESTIONS 1. Name, Address, City, State, Zip Code and Telephone Number of Firm. Entrust, Inc., 14701 St. Mary's Lane, Suite 150, Houston, Texas 77079, (281) 368 -7878 or (800) 436 -8787. 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? Entrust has been in business since July 1990. How long have you done claims administration? Ed Jacobson, the Founder and President of Entrust, Inc. has administered plans for over 35 years. Full claims administration services have been performed at Entrust since its legal conception in 1990 and its predecessor administration company, IMA, back to 1975. 4. Who are the principal officers in your firm? How long have they been in their positions? Principal Officers Length of Time Edward A. Jacobson — President /Owner 40 Years + Robyn Jacobson — Chief Operating Officer 15 Years + Dixie Gunning — Chief Financial Officer 29 Years + 5. Is this a branch facility? No. If so, please identify the main office location. 6. How many claim processors are Full Time employees in your firm? There are 8 full time claim processors. 6a. How many claim processors will be appointed to service this account? The Entrust claim adjudication software auto - adjudicates approximately 60% of all claims so the traditional model of using claim processors to evaluate every claim is no longer necessary. Notwithstanding, Entrust will dedicate as many processors as it takes to adequately handle the group. We initially assign 2 processors to review and examine any edited or facility claims, and then make whatever adjustments are necessary, predicated on volume. 6b. Of those approximately how many years of experience does each have with medical claims processing? All of Entrust's claims processors /examiners are experienced, with many having over ten (10) years of medical claims processing experience. The manager of the claims department has over twenty (20) years of medical claims processing and management experience. 7. Do you have bilingual claims personnel available to plan participants who call your office for customer service and /or claims processing? Entrust has bilingual personnel in each department to enhance customer service satisfaction, including the claims department. 8. How many clients do you perform claim administration services for? What is the average size? Entrust currently provides services to approximately 83 employer organizations. The clients range from 40 to 1000 employees, with an average of 248 per organization. 9. Do you carry Errors & Omissions coverage? Yes. Provide a copy of your current policy. Please see the Request for Proposal Section. 19 CLAIM ADMINISTRATION QUESTIONS 1. What are your claim office performance standards for claim accuracy and turnaround time? The following chart illustrates our standards for both Financial Accuracy and Claim Payment Accuracy which are tracked by each group and each examiner according to industry standards. The performance standard for turn - around time for claim payment for all types of claims (see question 2) is less than 15 days which we have exceeded every year for the last nine years. Financial Accuracy Financial accuracy is considered to be the most important industry measurement of performance. It is obtained by adding over and underpayments, without regard to minus or plus application, and subtracting that total from total paid dollars audited. The result is divided by the total paid dollars audited. } e l st �/o I ndustry Standard 99.8% 99.5% or above Ate. 99.0% — 99A% UnatesititibIS Less than 99% Claim Payment Accuracy Claim payment accuracy is obtained by taking the total number of transactions handled correctly, without either a dollar error or a procedural error, divided by the total number of transactions audited , ,,> ; 3 ,= t tist'% Industry Standard 98.6% 97% or above /I, 95.0% — 96.9% U blf - Less than 94.9% *Industry standard derived from: Ea Trilogy Consulting Group, Inc. r 2. What is your average turnaround time? The average turn - around time for Entrust to adjudicate all types of claims — COB, subrogation, pended, third - party, and clean claims — is 12.69 days. This is based on when the check "went in the mail" versus when the claim was processed. This is an important distinction when evaluating the adjudication efficacy of an administrator. The average turn - around time for claim processing prior to check issuance is less than 7 calendar days depending upon how often a client funds. 3. What is your current per day production minimum expected of your claims processor? The expectation of each claims processor /examiner is approximately 600 claims per week, which equates to an expected minimum of at least 120 claims processed per day, slightly more than 17 per hour. All paper claims are converted into electronic claims which are then auto - adjudicated according to the plan provisions and edits. 4. What are your internal audit procedures? Entrust has an Auditing Department that uses the following guidelines for their quality control standard: 1. All HCFA's (provider or ancillary bills) with payments of $2,500 or greater. 2. All UB -92's (hospital bills) with payments of $5,000 or greater 3. 100% of all claims that are over the specific deductible. 4. A random 10% of all claims regardless of the paid amount. 5. In addition, once Entrust starts processing claims for a new group, 100% of all claims are audited until such time as it is determined that the % can be reduced to meet internal quality guidelines. 6. 100% of all RDE (system processed /auto adjudicated claims) are also audited for data entry accuracy. 7. 100% of all Member - direct payments over $500. 8. 100% of all claims processed by examiners within the first ninety days of hire. Auto - Adiudication of Claims: For even greater quality control, Entrust performs a 100% audit of all critical 20 fields that are entered for auto - adjudication. 5. What edits and controls are used to avoid duplicate payments? Entrust begins their edit process in the EDI (electronic data interchange) stage by applying group and name edits on the file prior to system loading. Once in the EDI module, common eligibility edits, provider edits and date of service edits are performed prior to *low release into the batch adjudication process. The Entrust claim adjudication system has a sophisticated internal auditing process which identifies common duplicate claims (same date of service for same participant with a common grouping of procedures), fraudulent claims (dates of service performed on national holidays or weekends; provider practice patterns) and workers compensation or subrogation claims (common accident procedure codes). The impacted claims are batched in a manner so an examiner must actively work through a screen prompt to continue processing (such as bundling) or return the claim for other action. Custom edits are commonly created during the plan build stage so certain plan - specific or participant- specific elements can be further reviewed by an experienced examiner. 6. What safeguards exist to protect against claims abuse and fraud? Even though Entrust recognizes that no system can eliminate 100% of all claim abuse, we maximize the system set up so we can identify potential claims and aid the processor to utilize his /her best judgment. Provider information is garnered from other sources that enable the system to flag certain providers as non -pay or audit required. As a result and previously stated, Entrust has created programming changes to flag what is identified as common duplicate claims (same date of service for same participant with a common grouping of procedures), fraudulent claims (dates of service performed on national holidays or weekends) and workers compensation or subrogation claims (common accident procedure codes). The impacted claims are batched in a manner so an examiner must actively work through a screen prompt to continue processing, review the claim for bundling or return the claim for other action. Additionally, there is security set up for each department so every employee only has access to the minimum amount of system modules to enable them to adequately complete their job. For example, employees in the eligibility department cannot access the claims data module or provider database. These security measures are maintained by one employee and reviewed by senior management for appropriateness. Each department is responsible for creating and maintaining quality control procedures. 7. What program do you use to unbundle claims? A variety of "unbundling" edits are built directly into the Entrust claim adjudication architecture (called "EnCore ") so the internal auditing process can identify common concerns, based on procedural codes, place of service, dates of service, CPT codes or diagnosis codes. \r" The impacted claims are batched in a manner so an examiner highly skilled in the specific area must actively work through a screen prompt to continue processing, audit for bundling errors or return the claim for other action. 8. What coordination of benefits (COB) procedures do you follow? Even though the Summary Plan Document will dictate the rules by which Entrust will adjudicate claims, Entrust defaults to the birthday rule for our order of benefits when coordinating with other health coverage plans. There are 5 basic steps that Entrust uses to administer the COB provision in a plan. They include 1) recognition of other coverage, 2) documentation of other coverage, 3) determination of primary /secondary status, 4) determining allowable expense for COB purposes, and 5) processing for payment. Claims received for which the spouse of the covered employee is the patient, or in which there are covered minor children and the spouse of the covered employee is employed are investigated for COB. This COB investigation also applies to stepchildren or natural children that have an address different from that of the covered employee whether there may be a court degree requiring a divorce parent to provide coverage that would be primary to the plan. 9. What database do you use to determine Reasonable and Customary fee allowances? Since the majority of all services are rendered at the in- network level of benefits, today most out -of- network claims are reimbursed at a percentage above Medicare's RBRVS fee schedule. Typically, most clients choose the allowable charge for such claims at 125% of Medicare to control costs, however, Entrust also utilizes Medical Data Research (MDR) to determine Reasonable and Customary charges when evaluating out -of- network and non -PPO claims, multiple and bilateral surgeries, and for assistant surgeon fees upon request. For in- network charges, the contracted rate is used. Entrust also has several other fee schedules that are used for clients, depending upon their need and plan design. These include other per diems, percentage of billed charges, Industry Allowable, Data Warehouse or custom created fee schedules. How frequently do you update your R &C screens? Our Reasonable and Customary allowances are updated on an annual basis based on the plan allowable amounts during the renewal and plan build stage. On a selected plan design basis, the RBRVS schedules are utilized at varied percentage rates. The Entrust system has the flexibility to put in any fee schedule(s) for any physician /provider group in the system or create a customized schedule as appropriate for the plan. 21 10. Describe your procedures for professional Medical claims review? Entrust Customer Service Representatives and Claim Analysts have been trained by Medical Helpline, Inc. — a sister - company providing Utilization Review and Case Management services -- to aid in the screening of benefit calls and claims by diagnosis, treatment and dollar amount for potential cases. Additionally, the Entrust claims adjudication system has been programmed with identification of certain CPT and DX codes that trigger further examiner review for possible case management necessity. Both have been successful in the early identification of large claims especially breast and prostate cancers, which may never require inpatient treatment. Trigger Diagnosis reports are also created to identify those patients who have incurred claims with those industry defined diagnosis and are reviewed by both Medical Helpline and Entrust staff. Furthermore, Entrust's Audit and Stop Loss department is trained to identify potential cases long before the claims surpass the customary "50% of the stop loss threshold" notification guideline required by the carrier. Once a case is identified, review of medical necessity is initiated which includes assessing cost effectiveness of the treatment plan, making recommendations and referrals, providing patient education and negotiations as necessary. The Case Managers of Medical Helpline review all opened files and refer any required medical opinions to one of three independent physician review boards, some with over 150 physicians available in multiple disciplines. Second opinions and appeals are reviewed as necessary. 1 1. Explain your hospital bill audit procedures. Hospital bills exceeding $10,000 (with no PPO discount) or charges in excess of the norm for the particular diagnosis, or categories that appear unusually high such as IV drips, medical supplies or implants /devices are referred to the Cost Containment Manager for further review or audit. The claim is reviewed for non - covered or excess charges and may be submitted to a case manager or a contracted medical specialist for further evaluation. Entrust uses several medical service organizations to audit hospital procedures for not only medical necessity but appropriateness of care or coding. On site hospital reviews are performed on a case by case basis as the need may or may not arise. 12. Describe your procedures for tracking and reporting excess claims? The Entrust Stop Loss Department has several means of knowing and notifying the stop loss carriers of potential reinsurance claims. After every check run a specific stop loss report is generated that reflects the name s of all individuals who are in excess of 50% of the specific deductible. Once an individual hits this report, a notice is sent to the carrier. If a claimant is being handled by the client's Large Case Management or Utilization Review Company the carrier as well as the Stop Loss Department is put on notice. The Stop Loss Department will also send up a report that reflects the amount of claims paid during the current contract period, if any. Occasionally there may not be anything %tw"' paid but we have a pre - certification on file or a phone call from the claimant or provider. In anticipation of a potential excess claim, hospital bills exceeding $10,000 (with no PPO discount) or charges in excess of the norm for the particular diagnosis, or categories that appear unusually high such as IV drips, medical supplies or implants are referred to the claims or cost containment manager for further review or audit. The claim is reviewed for non - covered or excess charges and may be submitted to a case manager or a contracted medical specialist for further review. 13. Explain how you handle subrogation and third party disbursements? All subrogation is monitored and managed by Entrust's in -house counsel and assisted by experienced subrogation claim reviewers. The plan will contain appropriate subrogation language, reflecting the past and recent case law, necessary to establish and protect the plan's subrogation rights. This language is written in a manner sufficient to notify any participant that such subrogation rights exist. If selected for the Contract, Entrust can include, among the annual enrollment materials already provided by Entrust, information regarding the plan's subrogation rights, which can be presented by Entrust during the annual enrollment process. Entrust also has experienced claims staff trained in identifying claims for which there is a potential for subrogation under the plan. Once identified, there is a careful investigation of the claim and, if determined to be a claim to which subrogation exists, a notice is then sent to the participant advising of the plan's subrogation rights and requesting accident information, including any Third Party involvement. Upon receipt of the requested accident information, all claims will be processed according to the plan document. Any money recovered under the subrogation rights of the plan will be documented in the Entrust system, a copy made of the submitted check and then immediately forwarded to the Client for reimbursement to the plan. 14. List the excess carriers which you are approved with for claims administration? Entrust management has been on the forefront of the self - funded industry since 1975. In this current, tight sellers market for stop loss the Entrust management's philosophy of enduring, long -term stop loss relationships has really paid off. We have been working with the same few underwriters (MGU's) or carriers, some for as long as twenty years. Some of % the carriers represented are: 1) American National 2) Pan American Life 22 3) American Fidelity 4) QBE Insurance 5) Standard Security Life 6) AIG Life 7) Gerber Life 8) Companion Life 15. Do you provide a toll free number for claim inquiries? Yes. If yes, what is the cost? There is no additional cost for Entrust toll free number. 16. What are your normal hours of operation to answer calls for claim inquiries? We receive live inquiries anytime from 8:OOam — 4:30pm Central time, Monday — Friday. Additionally, there is a Fax Back and Web Claim Portal system available 24/7 for providers and /or patients to verify claim status and benefits within seconds. We also maintain a voice mail system for handling after -hours calls, which each customer service person /claims processor is required to empty and resolve by the end of the morning of the next business day. 17. Describe your customer service process when an employee calls with a claim inquiry. Entrust is committed to the belief that the "customer comes first" and takes pride in assisting employees or their dependents in answering questions and resolving problems. The average speed of answer is Tess than 21 seconds (national average is 41 seconds) with a live, professionally trained customer service representative and the first call resolution rate is 96 %. The standard for follow up call resolution is within 24 hours and the average call abandonment rate is <1 % whereas the national average is 5 %. All calls are recorded and monitored for quality control purposes and are documented as described below. Computer system: One of the premier features of the Customer Service module on the Entrust claims adjudication system is its ability to track and record "events" that occur during routine calls. These "events" can be as specific or as broad as necessary and then reports can be generated about these events for further quality control review. Entrust currently utilizes a lengthy list of events to monitor activities, such as complaints. This sophisticated Customer Service module not only tracks, monitors, and records every call but it logs and tracks all correspondence to the claimant. Phone system: Entrust utilizes the latest telecommunication version of Intertel's telephone system which records every call received at Entrust. Furthermore, the phone system enables the Claims Manager, or other department managers, to monitor their staff for quality control purposes and it tracks every call to determine abandonment rates, hold time and average length of call per person /per department. 18. If you have a separate customer service unit, what are your standards for: The average length of time for a call to be answered: 00:00:21 seconds (nat'l average speed to answer >40 sec) Abandonment Rate: 00:00:01 seconds, 0.01 % (nat'! average is >5 %) Hold Time: 00:00:02 seconds Return Calls: Messages left in the morning are returned in the afternoon and messages left in the afternoon are returned the following morning if they are unable to return the same day as the initial inquiry. The customer service standard is to return the calls the same day as received or within 24 hours, whichever is less, unless instructed otherwise. (nat'! average is 48 -72 hours) 19. What submission rate has been assumed when calculating your fee? The claims submission rate assumed when calculating fees is .7 claims per member per month. 20. Does your fee assume a first year claim lag? If so, what is the cost to purchase mature claim year administration? No 21. Does your fee assume any excess loss carrier overrides? No, the fee does not assume any excess loss carrier overrides or commissions. Eligibility System 1. How is an insured's eligibility assigned and maintained? NNW Eligibility is maintained using the EnCore Claims Administration System. Eligibility records are updated "real time" on the system so Customer Service Representatives or claim examiners can access this 23 information as soon as it becomes available. After the initial enrollment, enrollment information is entered into the system within 24 hours of receipt. Each group is configured by the specific eligibility classes, sub- groups, locations or other delineations of each type of plan offered for the group. Member elections and information are entered by trained and experienced Member Services Staff and cannot be changed by unauthorized personnel. Controls are set at the group /plan level and maintained by management staff. %Ow Entrust strongly recommends a meeting between Entrust Member Services and the Human Resources staff to ensure the procedures are properly defined. 2. How often can eligibility information be updated? After the initial enrollment, eligibility information is updated "real time" as it is received and entered into the eligibility module by Entrust. Furthermore, monthly billings are mailed to our clients for verification of enrollment. Enrollment information received prior to the 15 of the month will be reflected in the next month's billing. Information received after the 15` will be reflected in the following month's billing. Invoices are to be paid as rendered so adjustments can be properly reflected. Once the correct enrollment is received in our office, we process within 24 -48 hours of receipt. 3. Do you maintain information on each of the family members separately, as well as the employee? Yes, Entrust maintains full information on each of the family members separately, as well as the family unit, and it can be cross - retrieved by the customer service professional as needed. 4. What is your accuracy standard and turnaround time for loading new groups, updates, and changes? After initial enrollment, Entrust's standard turnaround time for updates and changes is within 24 -48 hours of receipt, assuming the information on the enrollment form is complete. The initial enrollment turn - around time is subject to the manner in which Entrust receives the eligibility data, typically this is within two weeks of receipt of completed forms. Commonly, groups that have been with a carrier for more than 1 year want a full eligibility audit performed to assist in identifying any potential errors. A recent Wall Street article indicated such audits have yielded as much as 20% changes in enrollment. Entrust recently performed such an audit on a fairly large Austin group which yielded such a change. Entrust reviews all initial enrollment materials for accuracy and completion before submission into the eligibility module. System Capabilities 1. Is your claim processing system completely automated? The principals of Entrust own and operate the EnCore Claims Administration System, formerly known as BeneSys, www.encoresyspros.COm, a state -of -the -art computer claims processing system operating on the HP platform considered by technicians as one of the most comprehensive and efficient systems on the market today. This is an on -line direct access system specifically designed for managed care plans and complex plan designs. The computer system automatically adjudicates claims according to the benefit and pricing structure customized by each client /plan. Co- payments, deductible, eligibility, premium paid - through dates, validated diagnosis, procedure payment and location of service codes are fully automated thereby facilitating a cost effective and accurate adjudication of claims. Data is ether received electronically or turned into an electronic claim through scanning and 100% audit of any data entry. Auto - adjudication of claims can account from 50- 94% of all eligible claim payments, subject to plan design. 2. Are there any significant manual activities required to process claims? In the event that claims are received in a paper format, then Entrust will convert that claim into an electronic claim through scanning wherein 100% of all data is audited and verified prior to release for adjudication. Any claims that edit out based on plan parameters or have attachments are reviewed by experienced claim examiners for evaluation and completion. 3. Describe your claims payment system, including hardware and software? The principals of Entrust own EnCore System Professionals, formerly known as BeneSys, www.encoresyspros.com, a state -of -the -art computer claims processing system operating on the HP and windows platform, considered by technicians as one of the most comprehensive and efficient systems on the market today. With over 2.2 million participants using this system nationwide, it has proven itself as a quality leader in the industry today. This is an on -line direct access system specifically designed for managed care %✓ plans and complex plan designs. The computer system automatically adjudicates claims according to the benefit and pricing structure customized by each client /plan. Co- payments, deductible, eligibility, premium 24 paid- through dates, validated diagnosis, procedure payment and location of service codes are fully automated thereby facilitating a cost effective and accurate adjudication of claims. Data is ether received electronically or turned into an electronic claim through scanning and 100% audit of any data entry. Auto - adjudication of claims can account from 50 -94% of all eligible claim payments, subject to plan design. Entrust operates on the most recent upgrade of the EnCore Claims Administration System which enhanced the system reporting, data base analytics and created even more flexible plan building (design) options. The modules include claims administration, eligibility, customer service, consolidated billing, capitation, EDI, Reporting, COBRA and Trust Accounting. Since the principals of Entrust own and operate the EnCore Company, Entrust has a direct line of communication with EnCore and has the ability to institute necessary changes and/or upgrades as needed. The benefit to the District is that the typical TPA does not have the luxury of being the owner of the claim software company so they are victim to the priorities that their software company sets. This is not true for Entrust. Entrust is in control of the development and future enhancements of the software to ensure they best reflect what is mirrored in the health market industry today. To our knowledge, Entrust is the only independent third party administrator that owns a claim adjudication software company not only in Texas, but nationally. With over 2.2 million participants on the EnCore system, Entrust believes they are in the best position to maximize the benefits any claim system can bring to a client in today's marketplace. 4. Do you own or rent your claim payment system software? As stated above, the principals of Entrust own and operate the EnCore System, formerly known as BeneSys, www.encoresyspros.com, a state -of- the -art computer claims processing system with over 2.2 million participants nationwide. So, Entrust not only owns the software, but the entire software company so enhancements and special projects are customized to fit the needs of Entrust's clients, as needed. 5. How is a person's claim history tracked? Employee and family history is tracked in the claims payment module and accumulated as events occur. Every verification of benefits, status of claims or member inquiry is attached to the member's file and is easily retrievable by the customer service staff. History of claim data can be kept and tracked as long as ten years. Plan participants can access their claim history through the claim web portal as desired. 'hlr' 6. Can the system track number of visits by procedure? Yes. 7. What percentage of your claims is currently accepted on EDI? Approximately 50% of all claims are now sent electronic. However, claims can be either delivered to Entrust as paper or in a HIPAA compliant EDI Format. Any paper claims are converted into an electronic claim by scanning wherein 100% audit of any data fields is completed prior to system release. All paper claims are received, and begin processing in Entrust's mailroom. Compliant electronic claims, if available, are captured through the state -of -the -art EDI system in "EnCore" and are translated directly into the auto - adjudication system. In anticipation of HIPAA eight years ago, Entrust created a batch - adjudication and auto -entry process that edits and electronically adjudicates anywhere from 50- 94% of all claims , subject to the various plan design elements. Whether the claim is received in paper or electronically, Entrust translates the claims into an electronic format and applies the customized edits required for the specific plan design. It is this type of capability that has yielded such extraordinary accuracy rates which is virtually unsurpassed in the industry. Banking Arrangements 1 . Do you require the use of a specific bank f o r claim accounts? No. I f so, please provide the name, address, and phone number of the bank. There are several banking options available to be considered by the client. One option is for the client of to use their own bank; however we will need to set up a new Trust Account for Entrust to process payments. Subject to the financial institution, the bank may allow for a zero pay or other electronic means of transmitting transactions. Entrust is happy to discuss the various options to assist the client in selecting the method that would satisfy both their financial departments and budget goals. We suggest that the client establish their benefit account at a bank of their choice (Entrust can assist with this process) and that this account be funded and used to track all plan expenditures; i.e., all claims, administration fees, premium payments for stop loss coverage, other vendor payments (e.g., PPO access fees, 25 Rx transaction fees, capitated services, pre - certification /utilization review or case management fees, etc.), stop loss reimbursements and any other plan income and expense. Entrust has a fully staffed administration and accounting department, which will perform the monthly reconciliation of the account and provide the client with the plan sponsor with completed financial statements, each month. Obviously, this complete financial reporting would be further augmented by claim and utilization reporting. We find that over the past 30 years of providing TPA services, most clients want to minimize their staffs involvement in the day -to -day plan activities. This approach minimizes plan sponsor involvement; yet, provides maximum reporting and accountability. However, Entrust systems are more flexible than most TPA's and all insurers that provide ASO services. Clients may choose to fund one of three ways; a) to maximum, b) to expected or c) as needed. Entrust recommends the group fund to maximum (premium + fees + maximum claims) for the l year. This should allow a claims reserve to develop over the length of the plan. The reserve may then be used to help offset future increases and claims cost the plan may incur. If the group considers the reserve to be a sufficient amount the group may want to alter their funding to the "expected" (premiums + fees + expected claims) level in future years. Entrust does not recommend the group "fund as needed ". No reserve will be established when utilizing this funding method. Regardless of the funding mechanism chosen by the group, all premiums and vendor fees must be paid each month in full. Other options that may be considered to mitigate the risk on a plan include capitating certain types of risks. Entrust has a unique capitated generic drug program that limits the risk on all generic drugs to a per - member- per -month basis by carving it out of the self - funded risk. This is an excellent tool to control costs and bring budget ability to a plan. Entrust also has an outstanding capitated EAP /behavior health program that is also carved out of the risk and brings an excellent value to the plan. A commonly- requested option is for an independent RX audit program, uniquely offered through Entrust as "Rx Watch Dog" which can be reported back to the group for further fiduciary review. This is just a sample of the type of programs that are uniquely available through Entrust, Inc. It is important to remember that any employer, when taking on the responsibility of sponsoring an employee benefit plan, whether fully insured of self insured, is adding a new line of "business" to their primary "business" purpose. A plan that functions using prudent business principals has a greater chance to become a successful, long -term endeavor. Entrust staff has "managed" thousands of plans over the past 30 years, `iln►' including school districts, and once our systems plan design concepts and procedures have been put in place, these health plans outperform others for years. 2. Is an initial claims payment deposit required to establish banking arrangements? Depending on the bank of choice, there may be a minimal deposit requirement but this not an Entrust requirement. 3. Will you perform bank account reconciliations? Entrust provides as part of their comprehensive service administrative services, full trust accounting for every client. This includes monthly Income & Expense statements, as well as a Balance Sheet. 4. Are there any additional costs to the banking? (I.E.: — EFT charges, monthly charges, etc.) This will be subject to the bank and their banking fees and services requested on a pass- through basis. Utilization Review 1. What U.R. services are performed in- house? All U.R. services will be performed by Medical Helpline, Inc. , a sister- company, which has on -line access directly into the Entrust system to update any authorizations and notes. 2. What outside U.R. services do you use? Entrust primarily utilizes the services of Medical Helpline, Inc. located in Orange, CA', a sister company, to provide Utilization Review, Concurrent /Retrospective Review, Case Management, Special Claim Negotiation and Large Case Management. How long have you used them? Entrust has utilized Medical Helpline since its inception in 1998. 3. Indicate which U.R. services you have assumed in your proposal? Pre Notification 26 Preadmission Review Concurrent Review — On Site or Off Site Retrospective Review Large Case Management Discharge Planning Medical Helpline will provide all the services listed above. These services are included in the price of our inpatient utilization management fee. Concurrent review is performed off -site telephonically. A second surgical opinion program is an option available to the employer should they choose to incorporate that language into the plan document. The identification and notification to the plan administrator of potentially high dollar claims and large case management cases is included in this fee. Once a case is opened, however an hourly rate is applied for management and interventions provided on that case. 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 Medical Helpline can, for an additional fee, provide review for any or all the outpatient services listed above. The needs, costs and benefits for such a program would be reviewed with the client individually to develop a customized plan. Inpatient surgical procedures, inpatient mental health and substance abuse are included in Medical Helpline's inpatient utilization management fees as addressed in question #3. In the event the group decides to utilize the services of a Behavioral Health /EAP program, then Entrust utilizes Interface EAP to perform these type of specific certifications. N r' 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? First Health Network, SPOHN Health Network, Texas True Choice, Galaxy Health Network, HealthSmart, Best Care, various Mississippi networks, Evolutions, Southeast Texas Health Network and miscellaneous other regional networks. 3. Can you install PPO discounts for Direct contracts with providers? Yes. If so, what is the charge? In a typical environment, this is included in the administration fee. If there is extensive custom contracting required, Entrust has experienced Provider Relations Contractors to negotiate fee structures. Without knowing the extent of this request, a fee specific is unknown. 4. How many different PPOs do you interface with currently? Approximately 10. Even though the Entrust is fully capable of loading and adjudicating fee schedules for networks "on the fly ", we find most networks are not interested in releasing their proprietary fee schedules. Who are they? Entrust directly accesses the networks listed in question #2 above as well as some regional networks in Louisiana, Wyoming and South Texas. Reporting l . Provide a list of reports available in your standard reporting package. What is the cost of these reports? The reporting capacity of the Entrust claim adjudication system as well as the sophistication of their proprietary data warehouse "Mindset" is one of the foremost features of this proposal. Entrust feels so strongly about sophisticated analytics that they hired a Ph.d. in Business Management & Logistics to head up their research 14kir department. Reports are generated as follows: 1) system generated reports, 2) ad hoc reports, 3) data warehouse customized reports, and 4) stand alone financial reports. Attached please find sample reports in 27 the Report Section, which are normally provided on a monthly or quarterly basis, depending upon the type of report. 2. Can you generate customized reports? Are reports available through Internet? What is the charge? Ad Hoc reports and other customized special reports are available upon written request and will be delivered No/ no later that the agreed upon due date and price. Report delivery and content are customized to fit the needs of the client. 3. How are paid claims reported? Paid claims are reported in various different analyses as demonstrated in the sample reporting package. 4. How does your firm report claims to Excess Loss carriers? The Entrust Stop Loss Department has several means of knowing and notifying the stop loss carriers of potential reinsurance claims. After every check run a specific stop loss report is generated that reflects the name s of all individuals who are in excess of 50% of the specific deductible. Once an individual hits this reports, a notice is sent to the carrier. If a claimant is being handled by the client's Large Case Management or Utilization Review Company the carrier as well as the Stop Loss Department is put on notice. The Stop Loss Department will also send up a report that reflects the amount of claims paid during the current contract period, if any. Occasionally there may not be anything paid but we have a pre - authorization on file or a phone call from the claimant or provider which is then transmitted to the carrier for their proper notification. 5. Can you report on PPO savings? Yes. Data Warehouse Analysis and Plan Forecasting Entrust believes so strongly in empirical decision- making that they hired a PhD. on staff in Business Management & Logistics that is available to assist in extensive forecasting and plan analysis. Based on the needs of the client and extent of the research desired, there may an additional fee for these services. Dr. Pong Chopichitiar heads up the Research Department at Entrust and utilizes star schema logic to access and analyze data on a warehouse of five years of accumulated health information. Trends can be identified in areas and normative comparisons to group utilization can be made. If extensive plan design changes are contemplated then a new plan can be built within the EnCore system to forecast the potential impact to the group and thereafter such data can be brought over to the warehouse for comparison analysis. The fees for r such reports are quoted upon request. General Questions I. What is the cost for producing a plan document? The cost for producing one plan document is included in the Implementation Fee.Is it included in your cost assumptions? Yes, this is included in the Terms & Conditions in the Financial Section. 2. What is the cost for producing a Summary Plan Description? Entrust incorporates the Summary Plan Description and Plan Document into one document, the cost of which is included in the Implementation Fee. Is it included in your cost assumptions? Yes, this is included in the Terms & Conditions in the Financial Section. 3. What is the cost of having the Plan Document and SPDs changed due to regulatory changes? None. Is it included in your cost assumptions? Yes. 4. What is the cost of printing the 500 Summary Plan Descriptions for the plan participants? The cost of the Summary Plan Descriptions is borne by the group; however, Entrust will create a sample document for approval and arrange for printing as requested by the group. Is it included in your cost assumptions? nia 5. What is the cost for printing 500 ID cards? Entrust produces customized, integrated ID cards on hard mil plastic and as their standard, produces 1 card per employee coverage, 2 cards per employee + family coverage and 1 card per full time student (if applicable to the Plan) if living at a different address and Entrust is notified. The cost of producing standard cards is included in the administration fees. Is it included in your cost assumptions? Yes. 28 6. What is the cost of Explanation of Benefits: This is included in the administration fees. Is it included in you cost assumptions? Yes. If so, how many do you assume? Even though this answer is dependent upon the actual utilization, the assumption is .7 per member per month. 7. Is there an initial set -up fee charged for the installation of our plan? The Implementation Fee is $1500 and the Annual Maintenance Fee is $3000 as disclosed in the Financial Section. • 8. Please disclose any additional fees or expenses that are borne by the client. Please see Terms & Conditions in the Financial Section. 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. Entrust has two attorneys on staff and provides full Compliance Services overseen by Entrust General Counsel which includes COBRA administration, HIPAA, Medicare Part D, WHCHR, SCHIPS, Newborns, Pre - Existing and now PPACA administration. All of these employer required services are offered for $3.95 per employee per month as disclosed in the Financial Section. 10. Do your administration fees include the following: 1. Postage (in 4 below) Yes. 2. Claim forms Yes. 3. ID cards, (medical /rx combo cards ?) Yes. 4. Mailing to participants homes Yes. 5. Participating provider directories These are available on -line or on a pass- through basis. 6. Customer service representatives specific to KERR COUNTY CSR's are located in the Houston and Corpus Christi offices but are bi- lingual and familiar with Kerr County due to the other groups Entrust administers in the local area. k ir j 29 HRA QUESTIONS 1. Do you offer HRA administration in conjunction with your claims administration? Kerr County can retain their current vendor or Entrust will coordinate with the vendor of their choice. 2. How often do you reimburse a claimant for expenses incurred that are filed on a paper claim form? Kerr County can retain their current vendor or Entrust will coordinate with the vendor of their choice. 3. Do you provide a debit card for all participants? Kerr County can retain their current vendor or Entrust will coordinate with the vendor of their choice. 4. Do you require the use of a specific banking institution? Kerr County can retain their current vendor or Entrust will coordinate with the vendor of their choice. 5. Is there a minimum funding requirement? If so what? Kerr County can retain their current vendor or Entrust will coordinate with the vendor of their choice. 6. Please describe your HRA administration in relationship to your medical claims administration. Kerr County can retain their current vendor or Entrust will coordinate with the vendor of their choice and provide such reports as needed to assist in smooth administration. 7. Identify all costs associated with your HRA administration package to include all costs and services provided. Kerr County can retain their current vendor or Entrust will coordinate with the vendor of their choice. 8. Do you include access to accounts via the internet? At what additional cost if any? Kerr County can retain their current vendor or Entrust will coordinate with the vendor of their choice. NNW `ere 30 Prescription Benefit Manager Questionnaire 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). Designed to provide maximum geographic coverage at marketplace- competitive rates and fees, our comprehensive National Network currently consists of more than 65,000 stores in the mainland United States, Puerto Rico and the Virgin Islands. The CVS Caremark National Network currently consists of 96% of all walk -in pharmacies located within the United States, thereby providing clients with maximum geographic coverage and offering their members greater choice and maximum convenience. Additions to the existing network are made as new stores open, or at the request of Kerr County and your members. All major chains participate in the CVS Caremark National Network. Our comprehensive National Network currently consists of approximately 25,000 independent and 40,000 chain pharmacies, in the mainland United States, Puerto Rico and the Virgin Islands. 2. Please confirm that prescription drugs prescribed by any licensed health care provider, including dentists, will be covered by the pharmacy program. Yes. CVS Caremark confirms. 3. Is the use of a formulary mandatory? Please attach a copy of the formulary for review. Yes. CVS Caremark's Drug Lists are sets of cost - effective drugs in selected therapeutic categories that represent the majority of the prescription costs of our average client. They are not complete formularies and purposely omit many categories. Within the categories represented, however, CVS Caremark's Drug Lists enable physicians to identify products that optimize clinical results and economic value for our clients and their members. As we work to assist clients choose the plan design that best fits their needs, the following issues are fundamental to the decision- making process: • Understanding plan design options (open, three -tier and closed) • Understanding three - tiered copay plans and their impact • Clarifying copay differentials • Considering plan disruption and member acceptance. , I l)12i I. - I 1 011) i t)SFI) Ili 'N14 AS The following variables should be considered when choosing a plan design: Open Plan Design: Incentivized Plan Design: Closed Plan Design: Two - Tiered Copay Three - Tiered Copay Two - Tiered Copay • Voluntary program. • Physicians are encouraged to • This is the most aggressive prescribe generics and plan, but it also provides the • Physicians are preferred brand products. highest level of savings for encouraged to prescribe the plan sponsor. generic and preferred • Financial incentives are used ,otaw brand products. to encourage members to • Physicians are encouraged to request generics and prescribe generics and 31 • Members are asked to preferred drugs when their preferred brand products. have their physicians physicians prescribe consider prescribing medications. • Requires members to receive preferred brands. preferred brand products for • CVS Caremark recommends the plan to provide coverage. , • Members can receive any a greater than $15 copay covered drug, regardless differential between • Exceptions can be made of whether the brand preferred brands and non- through a formal prior product is included in the preferred brands. authorization process. drug list. Please refer to the attachments for a copy of the preferred drug list. 4. Does the retail brand discount include savings from formulary, network spread, clinical savings, DUR savings? Under the Traditional pricing model, the discounts are guaranteed. Under the transparent model, the client receives the actual contracted discount. 5. is the brand discount a hard discount? Yes. The discount is guaranteed for the length of the agreement. 6. Is the brand discount an average? Is it based on 11 digits NDC? The brand discount is a guaranteed discount. Adjudication is based on the full 11 -digit NDC number. Now 7. Is the brand discount at mail order based on 100 units or actual acquisition NDC? Acquisition cost at mail is confidential and proprietary information and is not subject to disclosure. CVS Caremark Mail Service will guarantee that the facilities will dispense prescriptions and price those prescriptions using the actual package size of the dispensed medication. 8. Is the mail discount based on 11 digit NDC? The AWP used in adjudication of mail order claims is based on the 11 -digit NDC number of the original medication. CVS Caremark obtains average wholesale prices from First DataBank, Medi - Span, or any other nationally available reporting service of pharmaceutical prices as selected by CVS Caremark. CVS Caremark uses a single data reporting source for determining a Client's AWP pricing. The data reporting source used is dependent on the service platform utilized by the client. 9. Is pricing for retail brand and overall generic effective rate guaranteed? Yes. Both retail brand discounts and an overall generic effective rate are guaranteed. 10. Your quote MUST include a traditional pricing model and a transparency full pass -thru model. Is the pricing guaranteed? The proposed pricing reflects that of traditional and transparent pricing. While the traditional carries guaranteed discounts, the transparent model includes minimum guarantees. 32 11. What is the discount for specialty drugs? What is the dispensing fee? Is the specialty drug program a pass -thru under a transparency model? Are supplies included in the pricing? The discount for Specialty medications is AWP- 16.5% for either traditional or transparent models. There is no dispensing fee and, at the clients directive, supplies are included. Included in our specialty program is a l "aur unique program that reaches out to the member to ensure delivery, respond to questions, ensure compliance, make certain the medication is properly aligned with the FDA approved indications and take steps not to overfill the prescriptions. 12. Please provide your definition of "generic ". Also provide a definition of the generic included in the overall generic guarantee. "Generic Claims" are defined as all claims that adjudicate at a generic member cost share logic. All Generic Claim financial guarantees will include all Generic Claims, except claims for single source generics, new to market generics, generics subject to patent litigation, or generics subject to limited supply, all of which shall be excluded from all financial guarantees. In no case will claims for Generic Claims, single source generics, new to market generics, patent litigation, and / or limited supply generics be reclassified as a Brand Claim for purposes of calculating "Brand Claim" financial guarantees. 13. What quantity is an AWP based on for mail order? CVS Caremark Mail Service will guarantee that the facilities will dispense prescriptions and price those prescriptions using the actual package size of the dispensed medication. 14. How are manufacturer rebates handled? Will KERR COUNTY share in the rebates? If so, what percentage? Under the traditional pricing model (ie, reinvested), rebates are retained by Caremark in exchange for a deeper brand discount at the point of sale. This strategy maximizes cash flow. With the Transparent model, Ntree rebates can be returned to the client. 15. Do rebates have a minimum guarantee per claim? Per brand? With the reinvested model, rebates are retained by Caremark on in exchange for a deeper discount at the point of sale. With regard to transparent, yes, there are minimum rebate guarantees. Rebates are based on per claim. 16. Are rebates paid quarterly? If not, when? Yes, rebates are paid quarterly within 180 days of the quarter in which they are earned. 17. Under transparency pricing model, are rebates a 100% pass thru of Gross? Yes. 18. Will coverage of OTC drugs impact rebates? If so, how much? No. 19. Do rebates survive termination? When are they paid after termination? Yes. The run -out and final reconciliation of rebates after termination is approximately 180 days. This applies if termination is within the contract terms. In the case of termination for cause or termination outside of the allowable termination terms occurs, there is no rebate run -out. 33 20. Are rebates paid on specialty drugs? No. All Specialty Rx rebates are retained by CVS Caremark. 21. Do you contract directly with manufacturers for formulary rebates or do you use another PBM? If yes, who handles? CVS Caremark contracts directly with manufacturers and administers its own formulary program. 22. Please describe how the drugs for the formulary are selected, and who is responsible for the selection. CVS Caremark's National Pharmacy and Therapeutics (P &T) Committee selects drugs that will deliver high quality clinical outcomes for members. We look at many key factors when evaluating new and existing drugs for inclusion on the CVS Caremark Drug Lists. Some of these factors include: • Safety relative to other drugs with the same indication(s) and therapeutic action(s) • Efficacy relative to other drugs with the same FDA - approved indication(s) • Available dosage forms of the drug and the dosing interval for each approved indication. New products must meet all drug admission criteria to be considered for addition to the CVS Caremark Drug Lists. As the standards of practice change and new information becomes available, products that currently reside on CVS Caremark's Drug Lists will be reevaluated for continued inclusion or removal. \11 1)1( 11I(rS 11ONt)t,ll Medication Monographs and Therapeutic Class Reviews are prepared by clinical pharmacists in the Clinical Formulary department to support the CVS Caremark P &T committee functions. These monographs and therapeutic class reviews are prepared following a comprehensive review of the available clinical literature. Numerous references and information resources are used to assist in evaluation and review of the medications under consideration for formulary addition. These peer - reviewed resources - selected on the basis of their reputation among health care professionals as being accurate, reliable, current, comprehensive, and respected - are considered by many as representing an villw industry standard. The following criteria are included in each medication monograph and therapeutic class review. • Disease state background information • FDA review designation /category • FDA - approved indications • Mechanism(s) of action • Pharmacokinetics - Onset of action - Absorption /distribution - Metabolism /excretion - Duration of action /dosage regimen • Efficacy - a summary of evidence -based clinical studies • Warnings/Precautions • Adverse reaction profile • Significant drug interactions • Product availability • Dosage and administration • Approach to treatment • Formulary consideration • References. Other information that may be provided includes but is not limited to: 'Illim' • Drug pipeline information • Investigational or off -label use 34 • Comparison of therapeutic alternatives • Pharmacoeconomic data • Comparisons with other forms of medication therapy currently being used • Compliance issues. tirrr► 23. Do you own your own mail service? If not, who do you sub - contract with and do you retain revenue? Mail service is provided through CVS Caremark Mail Service. 24. Do you own your own Specialty Pharmacy? Or subcontract? If yes, who handles specialty pharmacy? Yes. CVS Caremark will administer the specialty pharmacy benefit through CVS Caremark Special Pharmacy. 25. What is the average turnaround time for mail order pharmacy? In 2009, CVS Caremark's average turnaround for all prescriptions was 1.30 Days. CVS Caremark's processing system is designed to separate clean (prescriptions with no intervention such as a PA or other MD call) and diverted (requires the prescription to stop for the MD call, etc.). In 2009, 74% of all prescriptions were considered clean and were processed and shipped within an average of 0.86 Days. Twenty -six percent of prescriptions were diverted and were processed and shipped within an average of 2.53 days. 26. Can mail order pharmacy be ordered on -line? Yes. CVS Caremark accommodates members by increasing access to mail service fulfillment options. Members can obtain their maintenance medication from CVS Caremark in the following ways: 4.1 MAI L Members complete an Order Form and send it, along with their new or refill prescription and copay, to one of CVS Caremark's regional inbound mail processing centers (Regional Order Creation Centers or ROCC). All correspondence will be electronically imaged and will route to our network of mail service pharmacies for further processing. INTERNET In continuing our commitment to provide members with convenient access to our mail service, we have developed Web -based mail service solutions at Caremark.com. Members can use our Web site to order refills or check the status of mail service prescriptions at any time. Members may also access our FastStarf program where they can request CVS Caremark to contact their prescriber and obtain a new prescription. Additionally, members can register for our electronic check or Bill Me Later" payments options. CVS Caremark offers co- branding and single sign -on services to simplify access for members. CUSTOMER CARE CENTER Members can contact our Customer Care Center to order a new prescription, obtain a refill, or request that a prescription transfer from a retail pharmacy to our mail service pharmacy. At the member's request, we contact the prescribing physician to obtain the prescription information, eliminating the need for the member to visit the physician. A verification form is faxed to the physician, who confirms the prescription information, signs the form, and faxes it back. In addition, we offer a toll -free number for physicians who wish to contact us on behalf of the member to order a prescription. INTERACTIVE VOICE RESPONSE SYSTEM 35 For added convenience, 24 hours a day, 7 days a week, CVS Caremark provides toll -free Touch -Tone and voice integration telephone access to prescription services. PHYSICIAN SUBMITTED — Physicians may submit prescriptions to CVS Caremark mail pharmacies via electronic prescribing, phone, and solicited or un- solicited fax. 27. Does the PBM allow 90 -day fills at retail in addition to mail order? If so, what contracted pharmacies participate? What is the discount to KERR COUNTY for a 90 -day network? What plan design is used? Yes. CVS CAREMARK provides the industries most comprehensive 90 Day Retail program. Designed for members utilizing maintenance medications, the Retail 90 program has proven to be a viable alternative for members. For many people using maintenance medications to treat long -term health conditions, their only choice is to get prescriptions filled via mail. CVS Caremark mail has proven to be an effective and convenient approach for some, others favor the comfort and familiarity they enjoy with their neighborhood pharmacy. To address both preferences, Retail 90 offers members the freedom to obtain a 90 -day supply of maintenance medication from over 39,000 retail locations. Mail service remains an option for members who prefer home delivery. The following is a list of the top 10 participating Retail 90 pharmacies in the State of Texas: ♦ CVS Caremark ♦ CVS Pharmacy ♦ Wal -Mart ♦ Walgreens ♦ Kroger ♦ Albertsons • Target • Randalls ♦ Tom Thumb ♦ Sam's Club • Brookshire Brothers Pharmacy The discounts available for 90 -day retail prescriptions approaches those available through mail service, and represents a significant savings opportunity over savings available through multiple 30 -day supplies. 28. Do you offer alternatives in the pharmacy program that can help control or reduce the plan costs? If so, please provide details and approximate savings for each feature. CVS Caremark's online adjudication system monitors retail pharmacies to ensure that they are dispensing prescriptions according to Kerr County's plan, which has been designed to help Kerr County significantly improve savings. Through electronic messaging, we are able to send the pharmacy information that enables it to dispense the most cost - effective medication possible. In addition, the pharmacist is able to substitute generics, as appropriate, with the member's permission. Pharmacies must use their best efforts to carry out CVS Caremark and our clients' mandatory generic programs. In doing so, pharmacies must contact the physician to encourage a generic substitution when the prescription contains a "dispense as written" signature for a multisource brand medication. Pharmacies must stock a sufficient amount of drugs under their generic name coinciding with the habits of local physicians, the CVS Caremark and /or local plan sponsor drug list(s) as indicated by the claims system response and other correspondence, or the generic drug list of the State in which the pharmacy resides. When a multisource brand medication is dispensed, the physician must submit the correct "dispense as written" code. 36 29. Please explain your Drug Utilization Review process for these programs: a. Prospective Nov CVS Caremark's prospective DUR programs include Prior Authorization, Step Therapy, and Quantity Limits. CVS Caremark's Prior Authorization program offers several benefits, including: • Promotes appropriate prescribing of drugs by ensuring adherence to approved treatment protocols • Decreases expenses by shifting utilization to less expensive, clinically appropriate drugs • Promotes member safety. CVS Caremark's Step Therapy program ensures that members utilize the most therapeutically appropriate and cost - effective drugs first. Step therapy protocols optimize appropriate drug therapy while controlling costs by defining how and when a particular drug or drug class should be used, based on a member's drug history. Post -step prior authorization is also available to allow coverage for clinically appropriate situations that do not meet the initial step therapy protocol. Quantity Limits are available as an alternative or a supplement to CVS Caremark's Prior Authorization program. Clients that wish to maintain control over drugs with the potential for abuse, misuse, or safety concerns — without eliminating coverage — can do so by means of the Quantity Limits program. b. Concurrent The CVS Caremark Concurrent (POS) DUR program is an automatic, system- driven drug utilization review program performed for all clients on all prescriptions, at both mail and retail. No *Ialw extra charge is made for this standard service. CVS Caremark's concurrent DUR program is implemented through their single - platform information systems, which power CVS Caremark's online national retail pharmacy network, which currently consists of over 65,000 points of sale as well as their mail service pharmacy facilities. The system can perform up to 500 edits on every prescription to ensure that prescriptions meet administrative, plan- design, and member safety criteria. c. Retrospective CVS Caremark's Safety and Monitoring Solution evaluates pharmacy claims for patterns of potential overuse or misuse. On a quarterly basis, CVS Caremark clinical pharmacists evaluate controlled- substance and other select drug claims (along with supporting medical data, if available) to identify potential medication abuse and fraudulent claims for appropriate intervention. This program uses utilization -based clinical rules designed specifically to identify cases of potentially excessive or abusive use. There is also a monthly review of claims for the most egregious cases of overutilization /high cost, in addition to the standard quarterly review. Monthly reviews give CVS Caremark the opportunity to spot egregious claims much sooner, and intervene for better outcomes for both members and clients. The Retrospective Safety Review solution acts as a safety net for serious drug interactions. This solution reviews both mail and retail prescriptions within 72 hours after the claim adjudicates for potential safety issues not addressed at point -of- dispensing, and messages the prescriber with an actionable member - specific communication identifying the clinical issue and suggestions for improving medication therapy. This early retrospective intervention may allow for a change in the prescription before the member picks up the original prescription, resulting in increased member `‘111✓ safety, less member disruption, and earlier savings capture for Kerr County. 37 30. Please submit a sample of your standard reporting package. Attach samples of your standard reporting package that is included in your quote. Please note if your paid claims numbers are based on paid or incurred claims figures. CVS CAREMARK has included a sample reporting package as an attachment. All reported figures are based on true paid claims. 31. Include in your response a PPI report, a specialty drug report, and a net cost per day for mail or retail report w/ specialty and acute meds removed. CVS CAREMARK has included a sample of its standard reporting package as an attachment. Detailed reports specific to certain therapeutic categories (i.e. PPI report) or cost metrics (i.e. cost per days supply) can be made available as an ad -hoc report. 32. How do you propose getting members to look at alternative brands that have generics available and do your manufacturer contracts preclude you from providing this type of information to members? A therapeutic interchange is defined as the substitution of a therapeutically equivalent prescription brand drug for another brand drug in the same class. It also includes the substitution of a generic drug that is not the chemical equivalent for that brand. The determination of whether a therapeutic interchange is appropriate may be impacted by a client's plan design, safety and drug availability. All therapeutic interchanges are reviewed and approved by our independent P &T committee. Each interchange is based on sound clinical evidence and must be determined to be appropriate by the Committee. All therapeutic interchanges must be authorized by a member's physician. Therapeutic interchanges may be performed with the goal of helping to reduce a client's overall health care costs. We strive to provide our client with a low- net -cost strategy at the therapeutic class level. In that regard, we look for opportunities to communicate with physicians about clinically appropriate, cost effective prescribing options. Specifically, our goal is to maximize dispensing of generics and where appropriate, to maximize dispensing of preferred brands instead of non - preferred brands, which helps reduce the overall cost of a therapeutic category. In instances where the non - preferred target brand has a lower AWP than the preferred brand, we evaluate discounts, rebates and other factors that impact Niousf client costs to determine whether they offset the higher AWP of the preferred brand in a manner that drives the overall lower cost at the therapeutic class level. All therapeutic interchanges must be authorized by a member's physician. All proposed interchanges are reviewed in the development stage to confirm that neither the client plan nor the member is negatively impacted financially. We routinely monitor interchanges to identify the impact of market and price changes and discontinue interchanges that negatively impact either the client or the member. When considering a therapeutic class for therapeutic intervention, our P &T Committee evaluates many criteria. In addition to cost, these criteria include the following: • The conversion must meet member treatment needs. • The conversion must be clinically safe. • The conversion must be clinically effective. • The conversion must have therapeutic merit compared to other effective drug therapies. • The conversion must facilitate appropriate drug use, in addition to helping to reduce cost. CVS Caremark will intervene when prescriptions written for non - formulary products meet program - specific screening criteria. The prescriber is contacted, via phone or fax, and CVS Caremark submits a request to use the generic or preferred product. CVS Caremark also provides physicians with a toll -free number that will connect them directly to a registered pharmacist who is available to answer any questions regarding the preferred product or the CVS Caremark Preferred Drug List or Prescribing Guide. 38 If the prescriber agrees to use the preferred alternate, it is dispensed to the member replacing the original, non - formulary product. A letter explaining that the member's physician was contacted and agreed to the change will accompany the preferred medication when shipped. A toll -free number is also provided so that the member can call to ask questions or obtain additional `__ information. If after the consultation with the Clinical Program Support Pharmacist, the member is does not want to accept the conversion, the conversion can be reversed and the original prescription sent to the member. 33. What financial advantage would KERR COUNTY gain if we limited the pharmacy network to several large chains? Could exceptions be made in outlying areas? CVS Caremark is currently offering access to their National Network only. Should Kerr County have additional network needs, CVS Caremark and Entrust would be happy to discuss those needs and work to provide solutions to fit your objectives. 34. Is electronic billing available? Reports on line? Is an interactive website available? Can members compare pricing of drugs on line? Billing /Invoicing Currently CVS CAREMARK does not offer electronic billing. We invoice pharmacy claims twice each month. Administration fees are invoiced once per month. We strongly prefer payment be made via wire transfer to enable timely payment to participating pharmacies. For wire or ACH payment, a fax or e-mail containing invoice numbers and amounts should be sent at the same time as the transfer to CVS CAREMARK. Online Reporting Our online information management capabilities will provide Kerr County with information to support: • Geographic intelligence: Prescriber profiles - Member demographic insight Dosing patterns Impact validation. • Member information: Member profiling - High -risk members - Therapeutic interchange programs - Noncompliance Case management. • Evaluation of pharmaceutical claims at various levels: Disease state - Drug class - Line of business - Geography - Physician - Pharmacy - Member. %N W RXNAVIGATOR` REPORTING 39 Our suite of Web -based and ad hoc reporting tools will enable Entrust to obtain desired information on behalf of Kerr County, while expediting and facilitating the decision - making processes that depend on this valuable information. Because these tools are available to report on all data elements maintained by CVS Caremark, they will provide Kerr County with a great deal of flexibility. For example, data elements can be added or removed, sorting sequences can be changed, and new processes or reports can be created. Our Web -based reporting tools provide a direct interface with our Information Warehouse — a technologically advanced repository that facilitates the storage, linkage, and rapid retrieval of prescription information and other health data. With access to both summary data and detailed Kerr County- specific claims data from our Information Warehouse, designated Kerr County personnel will be able to conduct analyses that are as simple or sophisticated as desired. CLIENT MANAGEMENT REPORTING CVS Caremark offers an online report viewing tool called Client Management Reporting (CMR). This easy -to -use, Internet -based application will enable Entrust's staff to conveniently access production reports to manage plan performance for Kerr County. Following are some of the benefits of our CMR system: • Convenient Internet access to documents • No delay in paper production and delivery • Ability for multiple users to view the same document, each using an assigned logon ID and password • Search capabilities that help the user find specific information • Ability to zoom in on areas of the report for easier viewing • Full printing capabilities • Ability to copy pages to file • Ease of learning and use. fir• In order to access documents that reside on our computer system through CMR, Kerr County will be assigned a valid logon ID and password. In the case of multiple users, each individual user will be required to have his or her own logon ID and password. We will provide initial logon IDs and passwords to individuals specified by Kerr County. In order to access documents that reside on our computer system through OnDemand Reporting, Kerr County will be assigned a valid logon ID and password. In the case of multiple users, each individual user will be required to have his or her own logon ID and password. We will provide initial logon IDs and passwords to individuals specified by Kerr County. Interactive Website and Member Cost Compare Prescription and benefit information is personalized for users at the plan level. This means that members who log onto the site are provided with accurate information specific to their plan, such as drug costs and coverage information. Members are able to: • Order mail service refills online • Learn how to start a new prescription with CVS Caremark Mail Service • Check drug coverage and price, including therapeutic alternatives • View online drug list • View benefit information • Check mail service status • Check drug interactions (Gold Standard Multimedia) • Search drug information (Gold Standard Multimedia) • View 24 -month drug history • Find a local pharmacy (client network - specific) and access maps /driving directions 40 • Download forms (claim and mail order forms) • Access CaremarkDirect"' (purchase non - covered prescriptions through CVS Caremark Mail Service) • Gain e-mail access to Customer Care Center • View secured member messaging via the member's online Message Center • Read e-mail alerts regarding available refills, expiring refills, and shipped prescription refills • Print ID cards • Set e-mail alerts • Access our Interactive Savings tools, including the Savings Center and Check Drug Options solutions, to identify savings opportunities and price and compare brand -name drugs, preferred drugs, and generic drugs. • View the Caremark.com Site Tour. By accessing the Web site, members benefit from: • Enhanced personalization • Enhanced single sign -on • Service -based eAlerts with embedded savings messages Health and Drug Information CVS Caremark offers members a comprehensive health and wellness section on Caremark.com, including content produced in -house as well as content aggregated from best -in -class third -party vendors. This award - winning offering provides members with valuable information to help them better manage their own health and conditions in addition to their medication regimens. Readers interested in learning more about managing their health will be able to: • Utilize 27 self -care centers and dozens more condition centers to find valuable information quickly • Access CVS Caremark's "Ask A Pharmacist" interactive feature • Access hundreds of frequently asked questions '`r • Access interactive tools, quizzes, animated guides, calculators, videos, and podcasts • Read more than 30,000 health and wellness articles provided by outside vendors • Find answers in a comprehensive Drug Center that provides information on the safe use of medications, questions to ask your doctor, and understanding potential risks and side effects of medications. 35. Will the PBM provide assistance with developing a communication piece? Yes. 36. Provide all materials used in marketing your product. Please see Exhibits. 37. Do your administration fees include the following: a. Postage (in D below) For standard mail service prescription delivery, yes. For additional member materials mailed directly to members' homes, no. b. Claim forms Direct Member Reimbursement (DMR) claim forms (paper claim forms) are available at no charge. DMR claims are processed at $1.75 per claim. `e c. ID cards, (medical /rx combo cards ?) Yes. 41 d. Mailing to participants homes No. e. Participating provider directories N/A f. Customer service representatives specific to KERR COUNTY. No. Please note that customer service representatives are not designated only to Kerr County. g. Mail order forms Yes. h. 1 — 800 number to call center Yes. i. Standard report packages Yes. 38. Does your plan currently offer on -line access to claims and eligibility information for employees? Is there a separate charge for this to the plan? Yes. At no additional cost, CVS CAREMARK provides connectivity to our claim processing system to Entrust via the Internet to view eligibility, add /change /terminate eligibility, view adjudicated claims, and enter prior authorizations. Utilizing this tool provides complete control of member eligibility, eliminates paper additions and deletes, allows for online, real -time authorization of designated drugs, and provides access to member claim history and drug profiles. 39. Will any revenue be paid to a third party administrator for services, fees, disease state management or other vendor services by the PBM? No Will all compensation to third parties be disclosed? Yes, if there are any third parties to receive compensation. Is an implementation allowance paid to the payor? Yes If so, how much per member or head of household? 54.00 40. Will you audit the pharmacy data? Specifically, as a payor, what independent source will audit claims? What are the fees associated with an independent audit? Yes. CVS Caremark features a comprehensive pharmacy audit program based on both concurrent and retrospective auditing. Our pharmacy audit department, Pharmacy Performance, is one of the most experienced in the industry, with over 40 dedicated audit staff that includes on -site auditors, investigative auditors, and departmental claims analysts performing a daily review of high dollar and outlier claims, claims analysts specializing in the review of compound claims, and a member - submitted paper claims analyst. CVS Caremark's comprehensive audit process is designed to identify discrepancies; prevent and detect fraud, waste, and abuse; and provide a deterrence message to pharmacies. When fraud, waste, or abuse involving a network pharmacy is identified, CVS Caremark works closely with the impacted clients to communicate the issues and provides the necessary support to correct any future problems. In addition, Pharmacy Performance provides standard audit reporting to clients as requested. The typical reporting schedule is a quarterly audit report which includes audits performed, audits in process, audits closed, and the resulting recovery /savings identified. CVS Caremark's pharmacy audit process involves both on -site and off -site procedures: • On -site procedures are designed to verify the accuracy of claims submitted through observation of �1r► original records including, among other things, prescription hard copies and patient signature logs. On -site auditors provide education to the pharmacy staff on CVS Caremark initiatives and proper 42 billing methods. The on -site process also includes a review of the pharmacy for appropriate adherence to other contractual requirements, i.e., review pharmacy computer DUR/Medication allergy screening, drug stock review, partial and return -to -stock procedures, compliance with Medicare Part D requirements, etc. %, • Off -site procedures include Investigational and Desk audits. Investigational audits are based on utilization and cost data obtained from reports designed to identify erroneous billings. An investigational audit is a close scrutiny of pharmacy records that may include its purchases, documentation of records, and confirmation of prescriptions from prescribers. Desk audits for erroneous billings including three off -site teams —Daily Review, Compound Review, and member submitted Paper Claims Review each has processes to confirm that claims are properly submitted by the pharmacy or member. AUDIT TOOLS Pharmacy Audit utilizes several tools and processes to evaluate provider pharmacies to determine if further in -depth analysis is warranted. The audit process encompasses retrospective, concurrent, and prospective elements which include: • Pharmacy Exceptional Activity Report (PEAR) • Daily Review and Compound Review • Member - Submitted Review - Tracking and Escalations • Payment trending analysis • Late night claims analysis • Aberrant dosing reviews • Member tracking • Pharmacy data mining for fraudulent pattern recognition • Education efforts • External tips and follow -up. fir' In addition to these tools /processes, Pharmacy Performance incorporates Medicare Part D fraud, waste, and abuse requirements, specific guidelines regarding long -term care audits, and medication error program. Statistical Auditing via the PEAR Pharmacy Performance analyzes all claims submitted to CVS Caremark by pharmacies for the entire book of business. A quarterly statistical review is performed to analyze the utilization of every pharmacy that has submitted claims totaling $1,000 or more and /or processed more than 100 claims in the previous quarter. The purpose of this analysis is to identify pharmacies with claim activities indicating unusual trending and noncompliance to the client's program parameters. The quarterly report used for this statistical analysis is the Pharmacy Exceptional Activity Report (PEAR). The PEAR statistically measures certain criteria and evaluates pharmacies on the basis of their actual claim activity within the parameters of an expected norm for a provider's peer group. The pharmacy's peer group is based on their MSA (Metropolitan Statistical Area), which allows dispensing patterns to be analyzed to regional variations, yet still be able to identify outliers requiring further examination. Audits for mail service pharmacies, Long Term Care, and Specialty are distinct peer groups that are analyzed as separate groupings. The report summarizes pharmacy trends that indicate any pharmacy deviation in areas such as: • Percentage of claims for less than 15 NDC numbers • Percentage of claims that are refilled • Total number of claims • Percentage of high dollar claims • Average prescriptions per member per month. 43 The content of the PEAR is reviewed annually to evaluate utilization, cost changes, market changes, and the results of CVS Caremark monitoring efforts. Daily Review and Compound Review Processes °Ione Pharmacy Performance performs a daily review of high dollar and claims submitted with abnormal quantities or dosages. The daily review is designed to supplement the system edit processes and focuses on the reasonableness of quantity and dosage form. Keying errors are usually the source of incorrect quantity, days' supply, dosage form, or NDC numbers. When an error is suspected, a telephone call is placed to the pharmacy. More than 70 percent of calls placed to pharmacies result in a reversal of an incorrect claim. Most reversals occur within cycle before the plan sponsor pays the claim, with the remainder adjusted out of cycle. Pharmacies that have recurring or substantial billing errors are more likely to be selected for an on -site audit. The same high dollar review is performed for compound medication claims. This review ensures compound claims are paid per the contracted rates and meet the plan design requirements of the plan sponsor. Member concerns identified through the daily review of high dollar claims or on -site audits are referred to our Clinical Services team for referral to the client. RETROSPECTIVE AUDITS CVS Caremark is committed to identifying and eliminating drug diversion and insurance fraud. Our retrospective audit analysis, including on -site audit and investigational audits, helps identify eliminate fraud, waste, and abuse. On -Site Audit Process No/ In addition to the auditing and monitoring techniques discussed above, our Pharmacy Performance team conducts over 3,000 on -site pharmacy audits annually. Our on -site auditing process uses a proprietary program that performs a systematic review of the claims history and automatically flags claims meeting specific criteria. The entire claim record, as transmitted by the pharmacy and adjudicated by CVS Caremark, is made available at the audit site allowing the auditor to deviate from the original audit plan as the situation dictates. The audit function is also educational. Auditors answer questions about CVS Caremark, inform pharmacists about CVS Caremark programs and policies, and relay pharmacists' concerns back to CVS Caremark. Educational material is provided to all pharmacies to assist in improved program performance and to prevent future point -of- service and submission issues. Approximately one week after an on -site or investigational audit is completed the pharmacy is sent a report listing all of the audit discrepancies and guidelines for documenting these discrepancies. The pharmacy is required to respond to CVS Caremark, in writing, with proper verification and documentation to support the claims in question. If the documentation is not submitted within the allowable time period or is deemed unacceptable, CVS Caremark withholds funds available up to the amount of the discrepant claims and /or requests payment by check from the pharmacy pursuant to the CVS Caremark Provider Agreement. These collected funds are returned to the client as a credit on the client's invoice or through the correction of the claim transaction. Claims selected for review must be supported by: 1. A valid physician's order authorizing the dispensing of the medication, and 4tor 2. Evidence that the medication was dispensed in accordance with the prescriber's order, state and federal guidelines, contractual requirements, and within the benefit plan guidelines. 44 CVS Caremark's on -site auditing process includes a systematic review of the pharmacy's claims history. Specific claims to be reviewed are selected by algorithms, which identify claims that meet specific criteria. Claims may also be selected subjectively by the auditor for any number of reasons including the presence of unusual trends. Claims may be chosen for audit based on, but not limited to, the following % criteria: • High dollar claims • Quantity change within a prescription number • High volume of claims per member • High volume of controlled substances • Unusual or unlikely drug combinations • Apparent high dose • "Doctor DAW" code claim submissions • Compliance with FDA Risk Management Program requirements • Quantity dispensed is within plan limits • High number of refills • Compliance with State and Federal laws and rules • Amount paid for compounds is appropriate • Random Claims Discrepancies identified during the audit include, but are not limited to: • Insufficient directions (e.g. UAD) • Missing prescription • Overbilled quantity • Generic dispensed, brand billed • Different drug billed • No Signature Log Nov • Cut quantity • Inaccurately billed compound • Invalid prescription • Wrong directions on dispensed prescription • Invalid use of DAW codes In addition to validating the legitimacy of claims, CVS Caremark on -site audits also review general pharmacy procedures including, but not limited to: • Return -to -stock procedures (procedures for reversing claim billings for prescriptions not picked up) • Medicare D program requirements: - Patient profiles are reviewed, typically in the pharmacy's computer, to verify pharmacy can record and store information such as patient demographics and allergies to medications. - Verify CMS -10147 notice to enrollees is provided to Med D enrollees either as a posted notice or as a hand -out. - If CMS -10147 notice to enrollees is posted as a notice, the auditor reviews for the posted notice; if the notice is not posted, auditor provides a copy to the pharmacy. - The pharmacy is educated on the CMS requirement that any documents, records, or reports related to Med D must be maintained for a minimum of 10 years. - Reviews of requirements surrounding disclosure and confidentiality of the Med D contracted pricing. Investigational Audits *kw Investigational audits are much more complex. Pharmacies may be selected for an investigational audit if the Pharmacy Performance department's analysis indicates irregularities, upon receipt of a client 45 referral, upon receipt of a tip from a regulatory agency, member /enrollee, provider /client, or cases referred from other audit processes. CVS Caremark Pharmacy Performance management then determines which of the following actions may be appropriate: • Review of purchase invoices tar • Contacting the prescriber -of- record for validation • Contacting the patient for validation of receipt of medications Proactive Education and Reporting Efforts CVS Caremark employs an educational, informative approach and incorporates positive interaction between audit staff and retail pharmacy staff. Whether the audit - related event is conducted face -to -face (on- site), through the mail (investigative) or via telephone (Daily Review or Compound Review), all audit staff are required to complete audit interactions with an educational component. This consistent interactive closure to an audit review, regardless of audit type, provides a professional, proactive ending, allowing retail pharmacy staff and CVS Caremark audit staff to discuss preventive measures for future issues and situations. This non - confrontational approach is a positive reflection for both CVS Caremark and its plan sponsors and assists in achieving longer -term audit goals, such as improving the "sentinel effect" to avoid similar discrepancies from occurring in the future with the same pharmacies. The sentinel effect, or the overall outcomes due to initial pharmacy audits /recoveries /education that trigger corrective behavior in pharmacies for future claims' submission and behavior, are difficult to measure. While some organizations tout a 1 percent increase due to the sentinel effect, CVS Caremark is confident in outpacing this initial estimate. Other educational efforts incorporated by Pharmacy Performance audit staff include: • Written Education - Quarterly distribution of proactive audit tips based on retrospective patterns to retail chains/PSAOs /independent pharmacies 4111"' • Face -to -Face Education - Participation in: - Wholesaler /independent trade shows - 1:1 reports; conduct audit presentations to pharmacy owners - Retail chain shows - 1:1 reports to all tiers (store, district, and regional) pharmacists - Annual industry conferences - 1:1 meetings providing data and educational information to corporate contacts of pharmacy toward the shared goal of eliminating fraud, waste, and abuse • Misfill identification and reporting - Reports to corporate contacts to partner toward eliminating clinical dispensing issues to improve overall patient care. 41. Will you provide consultative modeling and forecasting annually? Yes. CVS Caremark has a benefit modeling tool available that aids Kerr County in designing and rating benefits. FORECASTING TOOLS Your experienced account services team will utilize advanced tools to provide plan recommendations including benefit design and analysis support. This level of support and these unique benefit design tools are unmatched by any other pharmacy benefit manager. Plan Design Model 46 The Plan Design Model is a consultative tool that enables our sales personnel to measure the financial impact of various plan design changes and assess clients' plan performance. Through its automated data retrieval system, it provides quick answers to complex plan design questions. The model was designed with the intention of matching client goals with CVS Caremark's products and services. _ The Plan Design Model feature forecasts client - specific savings for individual or combinations of plan design changes for both retail and mail service claims. As a supplement to the PDM, the Plan Performance Summary reporting tool enables CVS Caremark sales personnel to capture the client's key statistics and compare them to the client's previous performance or to that of their peer clients. eTools Plan Design Model The CVS Caremark eTools Plan Design Model (PDM) is a Web -based consultative modeling tool designed to help meet Kerr County's self - service plan design modeling needs. Using client - specific claims data, the tool can model client savings /cost as well as member impact. This user - friendly tool will allow Kerr County to: • Structure a future plan design that is conducive to improving economic outcomes • Make adjustments to individual aspects of a current plan design and determine the overall effect that such changes will likely have on the overall spending as well as the impact to your members. The PDM can support most, if not all, plan design changes and/or combinations. Generic Dispensing Rate Forecast Model The Generic Dispensing Rate (GDR) Forecast Model provides a three -year forecast of your generic dispensing rate based on current utilization of prescription drugs and changes in the prescription drug market place (e.g. the introduction of new generic medications to the marketplace). The GDR Forecast Model provides you with an opportunity to discuss the various CVS Caremark programs designed to promote generics. Remember: increasing generic utilization is the fastest and most effective way to reduce drug trend and maximize outcomes. Your account services team provides this model to you upon request. Health Risk Index The goal of the Health Risk Index (HRI) is to make meaningful cost comparisons across clients. There are a variety of characteristics which make your population unique and each characteristic is assigned a value based on its estimated contribution to future pharmaceutical cost. Some of the characteristics include: • Age • Gender • Diseases receiving pharmacotherapy. The sum of all these values for each member in your population provides an estimate of your predicted pharmacological burden. Your predicted burden is viewed in terms of your peer group to determine its relative relationship among all clients within its peer group. It is this relative relationship that becomes the Health Risk Index. Your pharmacy costs are correlated with a health risk and a higher score than the book of business and /or a peer group demonstrates that a client has more health risk than the group(s). Certain clinical conditions and therapies may contribute disproportionately to pharmacy cost risk as measured by the HRI. CVS Caremark offers many solutions designed to better mitigate pharmacy cost risk associated ‘1Nof with both chronic and acute conditions. HRI sets CVS Caremark apart from competitors because they have adopted an industry standard set of 47 algorithms to determine Pharmacy Risk Group (PRG) and HRI scores through a company called Symmetry. Symmetry has one of the most well -known set of clinical algorithms on the market today and are widely recognized, well- adopted and widely applied. Symmetry Pharmacy Risk Groups is a pharmacy -based health risk assessment system that uses prescription data and proprietary classification systems to help organizations better understand and measure member health risk by: w • Calculating relative health risk scores for individual members • Developing markers that describe each member's pharmaceutical treatments • Determining the key factors driving relative risk for each member Your account services team provides this model to you upon request. Additional Resources Kerr County can also take full advantage of CVS Caremark's diverse professional staff, which includes a large Trend Management unit that stands ready to support Kerr County. This group will support Kerr County's account services team in developing recommendations for program improvements and savings opportunities. Staffed by teams of individuals highly skilled in key areas of business planning (e.g., marketing, finance, communications) as well as pharmacy benefit management, this unit will apply its analytical expertise to help define your pharmacy and health benefit management services program expectations and objectives. Elements of the business plan will include the following: • An economic analysis utilizing models and consideration of Kerr County's needs and current situation • An analysis of our performance -based products and services and their projected impact on your plan design • A comprehensive impact analyses of various business and prescription benefit scenarios, including financial- and member- impact projections. These additional services are available to Kerr County at no additional cost. 42. Will a true -up of guarantees be performed annually? If so, when can KERR COUNTY expect payment of true -ups above guarantees under transparency model? Yes. CVS CAREMARK will perform a year -end audit and, if necessary, make appropriate compensation within the first six months of the following plan year. 43. Will the mail service provider provide to KERR COUNTY copies of their suppliers (wholesaler or manufacturer) invoices showing net invoice for medications? No. 44. Will your firm detail its total revenue from all sources for administering the KERR COUNTY pharmacy benefit plan and allow an independent audit by the KERR COUNTY? Under the proposed arrangement, audit rights are held by Entrust on behalf of its clients, including Kerr County. Entrust , or a designee reasonably acceptable to CVS Caremark, on behalf of Entrust clients may conduct an annual claims audit to ensure accuracy by CVS Caremark in processing claims and compliance with Entrust - specific performance guarantees. The annual claims audit is offered at no additional cost. If Entrust requires any additional audits or audits requiring more than one year of data, these may be conducted at CVS Caremark's standard audit cost per audit basis. CVS Caremark retains claims data for at least seven years from the date of occurrence. CVS Caremark requires 60 days advance written notice for an audit. We also require a detailed scope document, and a complete claims sample 30 days before the audit start date. 48 Entrust's designee, reasonably acceptable to CVS Caremark, may conduct an annual Rebate audit to validate the accuracy of the Rebates paid by CVS Caremark to Entrust. The annual audit is offered at no additional cost. If Entrust requires any additional audits or audits requiring more than one year of data, these may be conducted at CVS Caremark's standard audit cost per audit basis. CVS Caremark retains claims data for at least seven years from the date of occurrence. To allow for an efficient audit, and the collection of the appropriate information, CVS Caremark requires 60 days advance notice of an audit. We also require a detailed scope document, and a complete claims sample 30 days before the audit start date. 45. The 3 finalists will be required to make a presentation to KERR COUNTY and answer questions to fully explain the specifics of the program offered. Entrust will be able to attend finalist meetings to answer questions and to fully explain specifics to the pharmacy benefit program offered. 46. Will your firm contractually guarantee that the amount you reimburse to pharmacy providers is the exact same amount that is billed to the plan sponsor? For the traditional retail network offer, the proposed retail rates do not necessarily reflect the pharmacy contracted rates, and CVS Caremark may retain the difference. For the transparent retail network, the amount billed to the client will be equal to the amount paid to the pharmacies. ATTACH A SAMPLE DRAFT OF THE PBM CONTRACT lour 49 CAFETERIA PLAN QUESTIONS 1. Name, address, city, state, zip code and telephone number of home office of firm. Branch office location(s), if any. Kerr County can retain their current vendor or Entrust outsources these services to: Pension 411roe Concepts and Administration, Inc., 281 l -a 74` Street, Lubbock, TX 79464, 806 - 745 -9781 x2 2. Is your company a wholly -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? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 4. How many clients are currently served? Please provide the largest group, the smallest group and the number of employees covered. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 5. What is the maximum processing time that will occur between receipt of claims and reimbursements to the members? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 6. What guarantee will you provide to Kerr County that this function will be completed within this time frame? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 7. What is the size of your staff? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. ` 8. List staff experience of the employees that will be handling Kerr County's account. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 9. List the office location intended to service Kerr County. Pension Concepts and Administration, Inc., 2811 - 74 Street, Lubbock, TX 79464 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? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 11. Does your firm perform discrimination studies as to eligibility, contributions and benefits under the plan? If so, how frequently? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 12. Does your company offer debit card services? If so, please explain in detail. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. ADMINISTRATION 1. Describe the computerized system used to collect, assimilate and integrate the data of the program. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and `�► Administration, Inc. and such information can be attained. 50 2. Provide a sample of your Administrative Service Agreement. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. A sample administrative service agreement is attached as Exhibit 3. Provide a sample of your Plan Document. Kerr County can retain their current vendor or Entrust '4%.* attained. these services to: Pension Concepts and Administration, Inc. and such information can be attained. A sample Plan Document checklist is attached as Exhibit 4. Describe your capabilities for Direct Deposit. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 5. Provide samples of worksheets and /or any materials that will be provided to Kerr County for educational purposes. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 6. Describe your process for entering enrollment information into your system. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 7. What electronic or Web -based services does your company offer? Can claims be filed via fax or through other electronic means? Do you charge additional fees for this service? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 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. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 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 '`rr► that would be utilized for bank reconciliation. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 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. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 2. Is your organization for profit or non - profit? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 3. Are you an affiliate of an insurance carrier or independently owned and managed? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 4. If you are a multiple site organization, are certain services delegated to specific locations or are all services available at any location? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. LIABILITY PROTECTION & BANKING REFERENCE 1. Please disclose the amount of liability insurance protection currently in force. The selected Administrator must provide confirmation of coverage. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 51 2. Is the company and all employees bonded? If so, please provide details. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 3. Are employees covered by workers compensation insurance CVS Caremarkle performing services on site at Kerr County? a. { }Yes { }No Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. PRICES /FEES I. 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 CVS Caremarkch the products would be sold. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 2. Are the fees due payable on the first of the month, quarterly, annually or combination of these? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 3. Is a fee structure available that incorporates various levels of participation? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 4. Do you intend to receive any commissions from the vendors servicing Kerr County? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 5. Explain any methods to be utilized to control expense. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 6. Provide a fee for administering the Medical and Dependent Care Spending Accounts with and without a Debit Card option. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. HISTORY 1. Briefly explain the development of your organization and your corporate business objectives. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 2. Explain how long you have been in business and how long you have been providing Section 125 Administration services. Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 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? Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 2. Please comment on any other characteristics of your organization that are considered unique in the industry. %o/ Kerr County can retain their current vendor or Entrust outsources these services to: Pension Concepts and Administration, Inc. and such information can be attained. 52 WELLNESS AND PREVENTION QUESTIONS: 1. Provide an executive summary of the wellness services you provide. Entrust has been offering core wellness programs to their clients for 10 years. Conventionally, these services have been centered on routine health fairs where the Medical Helpline nursing staff assists in education and other customized employer programs, such as incentivized walking programs. As the last several years have expanded the interest in this area, Entrust has utilizing several different specialized companies that provide a full array of wellness and preventive services, including state -of -the -art web tools as well as nurse coaching. After on -site evaluation and due diligence, Entrust has teamed up with what they consider the best -in -class to provide exceptional wellness options at reasonable fees, through WorldDoc. The WorldDoc 24/7 personal health management system is an intuitive, interactive wellness solution that provides employers with the resources needed to help their organization better manage care and to help their employees and beneficiaries to make better healthcare decisions. WorldDoc 24/7 empowers users to evaluate symptoms, understand their health issues, assess health risks and take steps to decrease those risks. The WorldDoc solution engages and builds trust with individuals in a comprehensive manner to manage their health throughout the care continuum. For an entire employer population, WorldDoc helps individuals to identify, understand and achieve personal health goals. For higher risk individuals, the WorldDoc solution tracks and promotes medication compliance and adherence in order to improve medical management. By engaging 100% of a population, WorldDoc helps to improve health, increase benefits satisfaction and lower costs. WorldDoc collects, analyzes and integrates an individual's medical, prescription and personal health data to provide a comprehensive care management solution that includes personalized medical goals, care gap identification and personalized, actionable wellness programs and communications. WorldDoc's integration of health information provides a more personalized solution to health management. Employer Benefits • Engagement of members through personalized programs and communications • Integration of all health related information gives more complete picture of a population's health • Identification and communication based on risk and condition • Robust aggregated reporting showing measurable outcomes Key Components of the WorldDoc Solution include: Health & Symptom Evaluation • Assess overall health and receive personalized recommendations m:," through a dynamic, intuitive NCQA certified Health Risk Assessment(HRA) o_ " "_•,._� • Evaluate symptoms through the interactive self - triage tool, Personal Evaluation System, to avoid unnecessary doctor visits Medical Library = • Increase knowledge through access to board - certified physician `_ w crafted information covering more than 95% of reasons people seek medical advice • Health Helpers • Participate in a 12 -week behavior change program, Healthy Living Program, to influence positive lifestyle habits and changes • Create trackers based on personal goals and follow development of health over time Pharmacy • Evaluate current and potential drug prescriptions and compare costs with alternative and generic medications My Health Files 53 • Conveniently and securely store health data for easy retrieval in the Personal Health Record News & Communications • Search for healthcare news Marketing Communication Support %re • Launch your wellness program with materials to engage your employees into taking the Health Risk Assessment and becoming active informed participants in their own healthcare Wo rld D MEDICAL HlLrLIN! c e Consumer Care Management 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. In addition to the description above, Entrust custom designs health plans to integrate with the wellness and prevention programs for each employer to address the needs of the participants and goals of the employer. Experience has found that employer's wellness objectives are unique and can include a small, medium or large amount of tools to satisfy their program goals. These tools can include, but are not limited to, monthly email campaigns, incentivized points /rewards program, HRA's, posters, health fairs, on -site visits, disease - specific drives, and many more. Entrust stands ready to assist in reviewing the options to meet the employer's objectives. HEALTH RISK ASSESSMENT (HRA) SERVICES: 1. Describe the Health Risk Assessment (HRA) tool your organization offers. Please attach a sample. See the attached 10 page powerpoint Exhibit on the HRA tools and a description. 2. In what languages are your HRA, website, and employee materials available? Spanish and English. 3. What is the average participation rate for your clients? 60% of our clients participate 4. Explain your experience designing incentive systems to drive participation, including your most successfully designed incentive program. As described above, Entrust experience spans over 10 years of successfully implementing wellness and prevention programs that range from health fairs to monthly campaigns. A recently designed incentive program gave employer -paid gym memberships to those employees who completed an HRA with all the biometric information and maintained records monthly. Experience has found that those that are healthy and want to remain healthy participate but those that commonly need the most help still do not participate. These individuals are best served by one -on -one counseling or case management nurses. 5. Please complete the grid below with a checkmark or specific answer if your HRA includes the feature described. In addition to the grid, the attached powerpoint Exhibit on I-IRA's reviews the features of the HRA. 6. How often do you recommend that the members have an HRA? Initially and updated as deemed appropriate for the individual and the employer. When teamed with CVS as the PBM, all Rx data is then uploaded into the WorldDoc system for further management of their prescriptions. 7. Please describe turnaround time for each of the following areas: a. Providing the HRA results to individuals. Instant. b. Contacting individuals for possible interventions. TBD based on employer goals. c. Providing Kerr County with a summary report of the initial HRA results. Activity reports hire without personal health information are reported monthly or quarterly so the employer can drive participation as they deem appropriate. 54 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. This is customized for the employer using professionally generated tools such as email campaigns, posters, flyers, brochures, powerpoint presentations, etc. See Exhibit 9. Describe how your company will set and reach HRA participation goals? The key to any wellness program is motivation, company endorsement, champions, employee types and incentive programs. HRA's are only one tool that is available for employees and their families to use to better management their health. Entrust works with the employer to determine their participation goals and molds the communication campaign around such goals. 10. Do you recommend using incentives? If so, please describe sample incentives your company might recommend. Incentives can be excellent tools if used in compliance with the law as rewards and if it serves to meet the goals of the employer. A recent incentive program described above included a gym membership if they completed an HRA and maintained it monthly. 11. How is the individual's HRA record updated in working with the disease management staff? The disease management nurses at Medical Helpline work collaboratively with WorldDoc and the Entrust system to better evaluate the on -going medical needs of certain participants. 12. Do you monitor and report individual HRA changes from year to year? The changes to a plan participant's health risk assessment are self- reported or integrated from Microsoft Health vault or *4111" direct from the PBM vendor so changes are available to them on -line. %r e 55 HRA PRODUCT FEATURE Included Web -based HRA x Paper -based HRA x % or Biometric clinic based x Provides information on confidentiality x Provides information on how data will be used x DATA COLLECTED Health status x Chronic conditions x Family health history x Medications x Lifestyle risks x Safety x Preventive exams x Immunizations x Biometrics x Readiness to change x IIWDIVIDUAL RESULTS High -risk clinical situations are identified and appropriate steps can be taken for immediate intervention. x Score communicated x Focus /priority of individual's health/lifestyle areas are communicated x Health improvement recommendations are made x Action steps provided x Can go to specific topics within web site x Summary report is available online x Summary report can be printed x Links to additional health information are available x ' Provides information or links to risk reduction programs x Employer can customize messages on their URL to include references and links to internal programs or other vendors x F MPLOYER REPORTS Web - based/electronic reports available x Reports can be printed x Lifestyle risks are reported Confidential Health status are reported Confidential Chronic conditions are reported — These are confidential IMPLEMENTATION & COMMUNICATION STRATEGY: 1. Please provide a proposed communication plan for introducing an onsite wellness program and reference the ongoing communication process. Outline your company's responsibilities in these processes. Please include copies of your educational materials and timelines for distribution. Entrust is recommending the on -line web self- triage program through WorldDoc as described at length above. The communication program includes, but is not limited to the following tools: monthly email campaigns, incentivized points /rewards program, HRA's, posters, health fairs, on -site visits, disease - specific drives, and many more. Entrust stands ready to assist in reviewing the options to meet the employer's objectives. % 2. How can employees communicate with the medical team? Through Medical Helpline, there is 24/7 access to nurses for questions that may arise. 56 3. Discuss the frequency and type of communications that eligible persons will receive throughout the program period. These are customized to meet the goals of the employer as described above. 4. Provide your web address and any access codes needed to explore your services. General S web information can be found at www.worlddoc.com 5. How would you suggest reaching spouses? The on -line tool is perfect for spouses or any other family member to access since the fee is based on a per employee per month basis. The family member information can be self - reported to maintain their personal health records as desired. 57 i EXHIBIT A SUMMARY SCHEDULE OF BENEFITS • • Kerr County $1,500 FMD 100/60 In- Network Non - Network Routine Medical Expenses - Convenience Care Visit $10 Copay to a max of $100 Per Visit 60% after Deductible - Office Visit $25 Copay to a max of $350 Per Visit 60% after Deductible - Specialist Office Visit $25 Copay to a max of $350 Per Visit 60% after Deductible - Diagnostic X -Ray and Lab $25 Copay to a max of $350 Per Visit 60% after Deductible - Urgent Care Facility Visit $50 Copay to a max of $500 Per Visit 60% after Deductible Hospital Services - In Patient Services 100% after Deductible 60% after Deductible - Out Patient Services 100% after Deductible 60% after Deductible - Emergency Room Visit 100% after Deductible 60% after Deductible Deductible (Family Monthly Deductible) Per Covered Family Per Calendar Month $1,500 FMD (Limited to $4,500 in Deductible Exposure) Coinsurance Out -of- Pocket Limit (Does Not Include Deductibles or Copays) - Per Covered Family Per Plan Year $0 $4,000 Other Medical Services - All other Medical Services 100% after Deductible 60% after Deductible - Wellness Benefit Covered at 100% 60% after Deductible - Childhood Immunizations Covered at 100% 60% after Deductible Medical Helpline (Ask - A - Nurse) Registered Nurses are available 24 Hours a day, 365 day a year, to answer your healthcare questions and offer advise of various treatment options and cost .... AVAILABLE AT NO ADDITIONAL COST TO YOU! Prescription Drugs - Generic Drugs $10 Copay for a 30 - Day Supply - Formulary Brand Names > of $30 or 30% Copay for a 30 - Day Supply - Non - Formulary Brand Names > of $30 or 30% Copay for a 30 - Day Supply Lifetime Maximum Benefit - Plan Year Maximum Benefit Per Plan Participant $1,000,000 - Lifetime Maximum Benefit Per Plan Participant Unlimited ENTRUST° KerrCounty $1,000 FMD 80/60 In- Network Non- Network Routine Medical Expenses - Convenience Care Visit $10 Copay to a max of $100 Per Visit 60% after Deductible - Office Visit $25 Copay to a max of $350 Per Visit 60% after Deductible " Specialist Office Visit $25 Copay to a max of $350 Per Visit 60% after Deductible - Diagnostic X -Ray and Lab $25 Copay to a max of $350 Per Visit 60% after Deductible - Urgent Care Facility Visit $50 Copay to a max of $500 Per Visit 60% after Deductible Hospital Services - In Patient Services 80% after Deductible 60% after Deductible - Out Patient Services 80% after Deductible 60% after Deductible - Emergency Room Visit $250 Copay to a max of $1,000 per visit 60% after Deductible Deductible (Family Monthly Deductible) Per Covered Family Per Calendar Month $1,000 FMD (Limited to $4,000 in Deductible Exposure) Mnsurance Out -of- Pocket Limit (Does Not Include Deductibles or Copays) - Per Covered Family Per Plan Year $2,000 $4,000 Other Medical Services - All other Medical Services 80% after Deductible 60% after Deductible - Wellness Benefit Covered at 100% 60% after Deductible - Childhood Immunizations Covered at 100% 60% after Deductible Medical Helpline (Ask - A - Nurse) Registered Nurses are available 24 Hours a day, 365 day a year, to answer your healthcare questions and offer advise of various treatment options and cost .... AVAILABLE AT NO ADDITIONAL COST TO YOU! Prescription Drugs - Generic Drugs $10 Copay for a 30 - Day Supply - Formulary Brand Names > of $30 or 30% Copay for a 30 - Day Supply - Non - Formulary Brand Names > of $30 or 30% Copay for a 30 - Day Supply Lifetime Maximum Benefit Plan Year Maximum Benefit Per Plan Participant $1,000,000 - Lifetime Maximum Benefit Per Plan Participant Unlimited ENTRUST° i n YL w Bu PR wc& a Kerr County Self- Funded Welfare Plan Stop -Loss Proposal Comparison Current Plan of Benefits -- With & without Dependent Coverage Current Benefits Current Benefits '"uip- Currrent Benefits Currrent Benefits without Dependent without Dependent Coverage Coverage 2011 2011 2011 2011 Insurance Carrier - Third Party Administrator Entrust, Inc. Entrust, Inc. Entrust, Inc. Entrust, Inc. American American American American Reinsurance Carrier National National National National Setup Fee *: $ 1,500.00 $ 1,500.00 $ 1,500.00 $ 1,500.00 Annual Plan Cost: $ 3,000.00 $ 3,000.00 $ 3,000.00 $ 3,000.00 Run -In /Run -Out: Administration Fee 3 Months of Admin 3 Months of Admin 3 Months of Admin 3 Months of Admin Estimated run out claim liabililty Specific Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Aggregate Plan Year Annual Maximum $ 1,000,000 $ 1,000,000 $ 1,000,000 $ 1,000,000 * Note: These rates are not included in totals below. STOP -LOSS BASIS 1 1 1 1 Number of Employees: 272 272 272 272 Number of Spouse Only 35 35 35 35 N. of Child(ren) only 41 41 41 41 I,,,,,.ber of Family Units 27 27 27 27 Number of Dependent Units: 103 103 103 103 Specific Deductible: $ 60,000 $ 60,000 $ 75,000 $ 75,000 Specific Contract: 15/12 15/12 15/12 15/12 Specific Contract Includes Med & Rx Med & Rx Med & Rx Med & Rx Aggregate Contract: 12/12 12/12 12/12 12/12 Maximum Aggregate Run In N/A N/A N/A N/A Aggregate Contract Includes Med & Rx Med & Rx Med & Rx Med & Rx MONTHLY FIXED COSTS I 11 II Specific Premium I Composite: $ 146.47 $ 107.66 $ 124.53 $ 91.61 Aggregate Premium 1 I 1 Composite: I $ 4.17 $ 2.67 $ 4.17 $ 2.77 Monthly Cap $2.00 Optional $2.00 Optional $2.00 Optional $2.00 Optional Administration( all fees per unit per month) 1 1 I I Claims Cost Per Employee : $ 27.50 $ 27.50 $ 27.50 $ 27.50 Claims Cost Per Dependent : $ - $ - $ $ Utilization Review per EE $ 3.00 $ 3.00 $ 3.00 $ 3.00 PPO Network Per EE: $ 4.50 $ 4.50 $ 4.50 $ 4.50 - Rx Program Fees(Describe) $ - $ $ $ Cr 'A per EE $ 3.95 $ 3.95 $ 3.95 $ 3.95 HII A Per EE Included Above Included Above Included Above Included Above Fiduciary Liability Fee N/A N/A N/A N/A Transplant Benefit 1 I 1 Employee /Mth N/A 1 N/A 1 N/A I N/A Dependent Unit /Mth: N/A N/A N/A N/A Cafeteria Plan I FSA Account Per Participant N/A N/A N/A N/A Child Care Per Participant N/A N/A N/A N/A r hit card expense N/A N/A N/A N/A S ant up expense N/A N/A N/A N/A Other Cafeteria Plan Fees: N/A N/A N/A N/A HRA 1 1 Start up expense N/A N/A N/A N/A Per Account Fee N/A N/A N/A N/A Debit card expense N/A N/A N/A N/A Other HRA Plan fees: N/A N/A I N/A N/A Wellness Plan Cost Per EE /Mth 1 1 1 1 Entrust is Proposing World Doc $3.95 $3.95 $3.95 $3.95 Optional RX WatchDog Program I $1.00 $1.00 $1.00 $1.00 Disease Management * I Included Included Included Included Banking System Notes 1 1 1 Positive Pay /EE /Mth N/A N/A N/A N/A Positive Pay Set up Fee (One time set up fee) N/A N/A N/A N/A Broker Fee: 1 1 Fee $ - 1$ - $ - 1$ - AGGREGATE FACTORS 1 1 Composite: $ 846.32 I $ 541.40 1 $ 873.73 1 $ 561.46 Attachment Points 1 1 M 'hly: $ 230,199 $ 147,261 $ 237,655 $ 152,717 Ar` PItal: I $ 2,762,388 $ 1,767,130 $ 2,851,855 $ 1,832,605 TOTAL ANNUAL COSTS 1 1 1 1 Specfic Stop Loss Premium 478,078 351,402 406,466 299,015 Aggregate Premium 13,611 8,715 13,611 9,041 Administration 89,760 89,760 89,760 89,760 Administration as % of Maximum Annual Cost 2.65% 3.98% 2.64% 3.96% UR, PPO, Rx, Broker, and all other 37,373 37,373 37,373 37,373 1 1 1 1 Total Fixed 618,822 487,250 547,210 435,189 Expected: 2,828,733 1,900,954 2,828,693 1,901,273 Maximum: _ 3,381,210 2,254,380 3,399,064 2,267,795 Total Fixed Increase in Cost as percent of current Expected Maximum Notes: *This Spreadsheet is for Illustrative Purposes only. Please refer to the financial pages and proposal terms and conditions for a complete understanding of the proposed financial options. w Kerr County Self- Funded Welfare Plan Stop -Loss Proposal Comparison All Employees and Dependents with Major Medical Coverage Entrust $1,000 FMD Entrust $1,500 FMD Entrust $1,000 FMD Entrust $1,500 FMD 80% Plan w/ Copay 100% Plan w/ 80% Plan w/ Copay 100% Plan w/ Structure Copay Structure Structure Copay Structure 2011 2011 2011 2011 Insurance Carrier - Third Party Administrator Entrust, Inc. Entrust, Inc. Entrust, Inc. Entrust, Inc. American American American American Reinsurance Carrier National National National National Setup Fee *: $ 1,500.00 $ 1,500.00 $ 1,500.00 $ 1,500.00 Annual Plan Cost: $ 3,000.00 $ 3,000.00 $ 3,000.00 $ 3,000.00 Run -In /Run -Out: Administration Fee 3 Months of Admin 3 Months of Admin 3 Months of Admin 3 Months of Admin Estimated run out claim Iiabililty Specific Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Aggregate Plan Year Annual Maximum $ 1,000,000 $ 1,000,000 $ 1,000,000 $ 1,000,000 * Note: These rates are not included in totals below. STOP -LOSS BASIS 1 Number of Employees: 272 272 272 272 Number of Spouse Only 35 35 35 35 Number of Child(ren) only 41 41 41 41 F\ ,ber of Family Units 27 27 27 27 Number of Dependent Units: 103 103 103 103 Specific Deductible: $ 60,000 $ 60,000 $ 75,000 $ 75,000 Specific Contract: 15/12 15/12 15/12 15/12 Specific Contract Includes Med & Rx Med & Rx Med & Rx Med & Rx Aggregate Contract: 12/12 12/12 12/12 12/12 Maximum Aggregate Run In N/A N/A N/A N/A Aggregate Contract Includes Med & Rx Med & Rx Med & Rx Med & Rx MONTHLY FIXED COSTS IL Specific Premium Composite: I $ 142.02 $ 142.02 $ 120.92 $ 120.92 Aggregate Premium 1 1 I Composite: I $ 3.22 $ 3.22 $ 3.22 $ 3.22 Monthly Cap $2.00 Optional $2.00 Optional $2.00 Optional $2.00 Optional Administration( all fees per unit per month) 1 1 1 Claims Cost Per Employee : $ 27.50 $ 27.50 $ 27.50 $ 27.50 Claims Cost Per Dependent : $ - $ - $ $ Utilization Review per EE $ 3.00 $ 3.00 $ 3.00 $ 3.00 PPO Network Per EE: $ 4.50 $ 4.50 $ 4.50 $ 4.50 - Rx Program Fees(Describe) $ - $ $ $ CC '4 per EE $ 3.95 $ 3.95 $ 3.95 $ 3.95 HALM Per EE Included Above Included Above Included Above Included Above Fiduciary Liability Fee N/A N/A N/A _ N/A Transplant Benefit 1 1 1 I Employee /Mth I N/A I N/A N/A N/A ___-1.._+ .,: + rnn +I,- N/A N/A N/A N/A Cafeteria Plan 1 1 I I FSA Account Per Participant N/A N/A N/A N/A Child Care Per Participant N/A N/A N/A N/A Debit card expense N/A N/A N/A N/A ` . rt up expense N/A N/A N/A N/A *wrier Cafeteria Plan Fees: N/A N/A N/A N/A HRA 1 1 I I Start up expense N/A N/A N/A N/A Per Account Fee N/A N/A N/A N/A Debit card expense N/A N/A N/A N/A Other HRA Plan fees: N/A N/A N/A N/A Wellness Plan Cost Per EE /Mth 1 1 I I Entrust is Proposing World Doc $3.95 $3.95 $3.95 $3.95 Optional RX WatchDog Program $1.00 $1.00 $1.00 $1.00 Disease Management * 1 Included I Included I Included I Included Banking System Notes 1 I I I Positive Pay /EE /Mth N/A N/A N/A N/A Positive Pay Set up Fee (One time set up fee) l N/A N/A N/A N/A Broker Fee: 1 I I Fee I$ - I$ - I$ - I$ - AGGREGATE FACTORS 1 I I I Composite: 1 $ 620.33 I $ 612.581 $ 646.45 I $ 642.88 (Attachment Points 1 I 1 Monthly: $ 168,731 $ 166,622 $ 175,834 $ 174,864 A 'al: I $ 2,024,770 $ 1,999,466 $ 2,110,013 $ 2,098,368 TOTAL ANNUAL COSTS 1 I 1 Specfic Stop Loss Premium 463,553 463,553 394,683 394,683 Aggregate Premium 10,510 10,510 10,510 10,510 Administration 89,760 89,760 89,760 89,760 Administration as % of Maximum Annual Cost 3.42% 3.45% 3.40% 3.41% UR, PPO, Rx, Broker, and all other 37,373 37,373 37,373 37,373 1 1 1 1 Total Fixed 601,196 601,196 532,326 532,326 Expected: 2,221,012 2,200,769 2,220,337 2,211,020 Maximum: 2,625,966 2,600,662 2,642,339 2,630,694 I Total Fixed Increase in Cost as percent of current Expected Maximum Notes: *This Spreadsheet is for Illustrative Purposes only. Please refer to the financial pages and proposal terms and conditions for a complete understanding of the proposed financial options. illMr 1 Kerr County Self- Funded Welfare Plan Stop -Loss Proposal Comparison Employee Only Coverage Entrust $1,000 FMD Entrust $1,500 FMD Entrust $1,000 FMD Entrust $1,500 FMD 80% Plan 100% Plan 80% Plan 100% Plan 2011 2011 2011 2011 Insurance Carrier - Third Party Administrator Entrust, Inc. Entrust, Inc. Entrust, Inc. Entrust, Inc. American American American American Reinsurance Carrier National National National National Setup Fee *: $ 1,500.00 $ 1,500.00 $ 1,500.00 $ 1,500.00 Annual Plan Cost: $ 3,000.00 $ 3,000.00 $ 3,000.00 $ 3,000.00 Run -In /Run -Out: Administration Fee 3 Months of Admin 3 Months of Admin 3 Months of Admin 3 Months of Admin Estimated run out claim Iiabililty Specific Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Aggregate Plan Year Annual Maximum $ 1,000,000 $ 1,000,000 $ 1,000,000 $ 1,000,000 I * Note: These rates are not included in totals below. STOP -LOSS BASIS 1 1 1 Number of Employees: 272 272 272 272 Number of Spouse Only 35 35 35 35 Number of Child(ren) only 41 41 41 41 N'-mber of Family Units 27 27 27 27 (Ns,,,...oer of Dependent Units: 103 103 103 103 Specific Deductible: $ 60,000 $ 60,000 $ 75,000 $ 75,000 Specific Contract: 15/12 15/12 15/12 15/12 Specific Contract Includes Med & Rx Med & Rx Med & Rx Med & Rx Aggregate Contract: 12/12 12/12 12/12 12/12 Maximum Aggregate Run In N/A N/A N/A N/A Aggregate Contract Includes Med & Rx Med & Rx Med & Rx Med & Rx MONTHLY FIXED COSTS Q 1 11 Specific Premium Composite: I $ 104.41 _ $ 104.41 $ 90.61 $ 90.61 Aggregate Premium 1 1 1 Composite: $ 2.05 $ 2.05 $ 2.39 $ 2.39 Monthly Cap I $2.00 Optional $2.00 Optional $2.00 Optional $2.00 Optional Administration( all fees per unit per month) 1 1 1 Claims Cost Per Employee : $ 27.50 $ 27.50 $ 27.50 $ 27.50 Claims Cost Per Dependent : $ - $ - $ - $ Utilization Review per EE $ 3.00 $ 3.00 $ 3.00 $ 3.00 PPO Network Per EE: $ 4.50 $ 4.50 $ 4.50 $ 4.50 Rx Program Fees(Describe) $ - $ - $ $ COBRA per EE $ 3.95 $ 3.95 $ 3.95 $ 3.95 HI Per EE Included Above Included Above Included Above Included Above Fidtrary Liability Fee N/A N/A N/A N/A Transplant Benefit 1 1 1 Employee /Mth I N/A N/A N/A N/A Dependent Unit/Mth: N/A N/A N/A N/A / Mth: Cafeteria Plan 1 I 1 1 FSA Account Per Participant N/A N/A N/A N/A 'Child Care Per Participant N/A N/A N/A N/A Debit card expense N/A N/A N/A N/A c'' -rt up expense N/A N/A N/A N/A ...,er Cafeteria Plan Fees: N/A N/A N/A N/A HRA 1 I 1 Start up expense N/A N/A N/A N/A Per Account Fee N/A N/A N/A N/A Debit card expense N/A N/A N/A N/A Other HRA Plan fees: N/A N/A N/A N/A Wellness Plan Cost Per EE /Mth 1 1 1 1 Entrust is Proposing World Doc $3.95 $3.95 $3.95 $3.95 Optional RX WatchDog Program $1.00 $1.00 $1.00 $1.00 Disease Management * Included I Included 1 Included 1 Included Banking System Notes 1 1 1 1 Positive Pay /EE /Mth N/A N/A N/A N/A Positive Pay Set up Fee (One time set up fee) N/A N/A N/A N/A Broker Fee: 1 1 1 Fee $ - I $ - I $ - I $ - AGGREGATE FACTORS 1 1 Composite: $ 397.71 1 $ 394.48 1 $ 417.01 1 $ 412.80 Attachment Points Monthly: $ 108,177 $ 107,299 $ 113,427 $ 112,282 A . a l : $ 1,298,125 $ 1,287,583 $ 1,361,121 $ 1,347,379 TbTAL ANNUAL COSTS 1 I 1 I Specfic Stop Loss Premium 340,794 340,794 295,751 295,751 Aggregate Premium 6,691 6,691 7,801 7,801 Administration 89,760 89,760 89,760 89,760 Administration as % of Maximum Annual Cost 5.06% 5.09% 5.01% 5.05% UR, PPO, Rx, Broker, and all other _ 37,373 37,373 37,373 37,373 1 1 1 I Total Fixed 474,618 474,618 430,685 430,685 Expected: 1,513,119 1,504,684 1,519,581 1,508,588 Maximum: 1,772,744 1,762,201 1,791,805 1,778,064 Total Fixed Increase in Cost as percent of current Expected Maximum Notes: *This Spreadsheet is for Illustrative Purposes only. Please refer to the financial pages and proposal terms and conditions for a complete understanding of the proposed financial options. Kerr County Self- Funded Welfare Plan Stop -Loss Proposal Comparison Employee on PPO Plan / Dependents on PRMC Plan Only Entrust $1,000 FMD Entrust $1,500 FMD Entrust $1,000 FMD Entrust $1,500 FMD 80% Plan 100% Plan 80% Plan 100% Plan 2011 2011 2011 2011 Insurance Carrier - Third Party Administrator Entrust, Inc. Entrust, Inc. Entrust, Inc. Entrust, Inc. American American American American Reinsurance Carrier National National National National Setup Fee *: $ 1,500.00 $ 1,500.00 $ 1,500.00 $ 1,500.00 Annual Plan Cost: $ 3,000.00 $ 3,000.00 $ 3,000.00 $ 3,000.00 Run -In /Run -Out: Administration Fee 3 Months of Admin 3 Months of Admin 3 Months of Admin 3 Months of Admin Estimated run out claim liabililty Specific Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Aggregate Plan Year Annual Maximum $ 1,000,000 $ 1,000,000 $ 1,000,000 $ 1,000,000 * Note: These rates are not included in totals below. STOP -LOSS BASIS 1 1 1 1 Number of Employees: 272 272 272 272 Number of Spouse Only 35 35 35 35 Number of Child(ren) only 41 41 41 41 Nt'~'ber of Family Units 27 27 27 27 Nm,,,,oer of Dependent Units: 103 103 103 103 Specific Deductible: $ 60,000 $ 60,000 $ 75,000 $ 75,000 Specific Contract: 15/12 15/12 15/12 15/12 Specific Contract Includes Med & Rx Med & Rx Med & Rx Med & Rx Aggregate Contract: 12/12 12/12 12/12 12/12 Maximum Aggregate Run In N/A N/A N/A N/A Aggregate Contract Includes Med & Rx Med & Rx Med & Rx Med & Rx MONTHLY FIXED COSTS f f Specific Premium Composite: I $ 134.92 $ 134.92 $ 114.87 $ 114.87 Aggregate Premium 1 1 1 1 Composite: $ 3.22 $ 3.22 $ 3.22 $ 3.22 Monthly Cap I $2.00 Optional $2.00 Optional $2.00 Optional $2.00 Optional Administration( all fees per unit per month) 1 1 1 1 Claims Cost Per Employee : $ 27.50 $ 27.50 $ 27.50 $ 27.50 - Claims Cost Per Dependent : $ - $ - $ $ Utilization Review per EE $ 3.00 $ 3.00 $ 3.00 $ 3.00 PPO Network Per EE: $ 4.50 $ 4.50 $ 4.50 $ 4.50 - Rx Program Fees(Describe) $ - $ $ $ COBRA per EE $ 3.95 $ 3.95 $ 3.95 $ 3.95 HIF Per EE Included Above Included Above Included Above Included Above - Fidi 'lary Liability Fee N/A N/A N/A N/A Transplant Benefit 1 1 1 1 Employee /Mth N/A N/A N/A N/A p De endent Unit /Mth: I N/A N/A N/A N/A Cafeteria Plan 1 1 I I FSA Account Per Participant N/A N/A N/A N/A Child Care Per Participant N/A N/A N/A N/A Debit card expense N/A N/A N/A N/A -rt up expense N/A N/A N/A N/A N...ler Cafeteria Plan Fees: N/A N/A N/A N/A HRA 1 1 1 I Start up expense N/A N/A N/A N/A Per Account Fee N/A N/A N/A N/A Debit card expense N/A N/A N/A N/A Other HRA Plan fees: N/A N/A N/A N/A Wellness Plan Cost Per EE /Mth 1 1 I Entrust is Proposing World Doc $3.95 $3.95 $3.95 $3.95 Optional RX WatchDog Program $1.00 $1.00 $1.00 $1.00 Disease Management * 1 Included I Included I Included I Included Banking System Notes 1 1 1 Positive Pay /EE /Mth N/A N/A N/A N/A Positive Pay Set up Fee (One time set up fee) N/A N/A N/A N/A Broker Fee: 1 1 Fee $ - I$ - I$ - I$ - AGGREGATE FACTORS 1 1 Composite: $ 563.94 I $ 574.92 1 $ 587.68 1 $ 603.35 (Attachment Points I 1 1 Monthly: $ 153,392 $ 156,378 $ 159,849 $ 164,111 A 'al: I $ 1,840,700 $ 1,876,539 $ 1,918,188 $ 1,969,334 Ttl1L ANNUAL COSTS 1 1 1 Specfic Stop Loss Premium 440,379 440,379 374,936 374,936 Aggregate Premium 10,510 10,510 10,510 10,510 Administration 89,760 89,760 89,760 89,760 Administration as % of Maximum Annual Cost 3.71% 3.66% 3.69% 3.62% UR, PPO, Rx, Broker, and all other 37,373 37,373 37,373 37,373 1 1 1 Total Fixed 578,022 578,022 512,579 512,579 Expected: 2,050,582 2,079,253 2,047,129 2,088,046 Maximum: 2,418,722 2,454,561 2,430,766 2,481,913 I Total Fixed Increase in Cost as percent of current Expected Maximum Notes: *This Spreadsheet is for Illustrative Purposes only. Please refer to the financial pages and proposal terms and conditions for a complete understanding of the proposed financial options. EXHIBIT B SAMPLE SERVICE AGREEMENT FOR CAFETERIA PLAN • • PENSION CONCEPTS AND ADMINISTRATION, INC. P.O. BOX 64233, LUBBOCK, TEXAS 79464 SERVICE AGREEMENT FOR CAFETERIA PLANS This Agreement is executed this day of , 20 , by and between hereinafter referred to as "Employer" and Pension Concepts and Administration, Inc. hereinafter referred to as "Consultants ". WHEREAS, the Employer intends to investigate the feasibility of installing a Cafeteria Compensation Plan designed to comply with Section 125 and other applicable sections of the Internal Revenue Code; and WHEREAS, the Consultants are making available a Cafeteria Compensation Plan, to be established by the Employer; and WHEREAS, the Cafeteria Compensation Plan incorporates professional material, and internally developed corporate information. NOW, THEREFORE, in consideration of the mutual promises and agreements herein contained, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: PART A (1) Consultants agree to make available the Cafeteria Compensation Plan to be used as the Employer's Plan. (2) Employer agrees to restrict the use of the Cafeteria Compensation Plan for its own Employer's Cafeteria Compensation Plan only. _ _ (3) Employer designates and appoints Consultants to be the Plan Agent of its Employer's Cafeteria Compensation Plan and authorizes the Consultants to perform the functions and duties necessary to prepare, implement and operate the Employer's Cafeteria Compensation Plan. (4) Consultants agree to perform all of the functions and duties essential in the implementation of the Employer's Cafeteria Compensation Plan. (5) Consultants agree to perform all of the functions and duties essential to continue operation of the Employer's Cafeteria Compensation Plan after its implementation, which will include monthly statements and reimbursement checks to the Plan's participants, Annual Report required by the Internal Revenue Service (Form 5500 Series), and annual program review. (6) Employer agrees to furnish Consultants with all data requested by Consultants in order to expedite the work flow process. (7) Consultants may rely on any data furnished by Employer, and Consultants shall incur no liability for reliance on such data. (8) Employer may terminate this Agreement on written notice mailed to Consultants at least 30 days prior to the anniversary date of the Plan, to be effective on such anniversary %No date. (9) Consultants may terminate this Agreement on written notice mailed to Employer at least 30 days prior to the anniversary date of the Plan, to be effective on such anniversary date. (10) Consultants shall not perform the duties of a plan administrator, nor shall Consultants exercise any discretionary authority or control over the Plan or the administration of the Plan's assets. (11) Consultants shall have the right to retain outside services at its cost wherever necessary. (12) Nothing contained herein shall obligate Employer to utilize Consultants as their agents or brokers in providing fringe benefits to employees. (13) Consultants shall be entitled to a fee for services described in Part A based on the schedule set forth in Part B. PART B Name of Plan Effective Date of Plan : Plan Anniversary : Month Day Service Agreement to be effective for the Plan Year Beginning (1) IMPLEMENTATION. A one -time fee to implement the Cafeteria Compensation Plan. The fee shall be (2) MONTHLY ADMINISTRATION FEES. Monthly fee to continue operation of the Cafeteria Compensation Plan. The fee shall be $ per month per eligible employee to be paid by the Employer, plus $ per month per eligible employee to be paid by each participating Employee. These fees are based on a twelve (12) month Plan Year as defined in the Plan. There will be a fee of $75.00 per hour (one hour minimum) for additional work required due to inaccurate or untimely reporting by the employer. Fees are guaranteed by Consultants for plan year(s). Pension Concepts and Employer Administration, Inc. PENSION CONCEPTS & ADMINISTRATION, INC. CAFETERIA PLAN DOCUMENT SYSTEM CHECKLIST «< Plan Definition »> [1] Plan Type: (1) CAFETERIA PLAN (2) MEDICAL REIMBURSEMENT PLAN (3) DEPENDENT CARE REIMBURSEMENT PLAN (4) PREMIUM CONVERSION (POP) PLAN [2] Tied to a Cafeteria Plan : (YES) (NO) If this is a Medical Reimbursement Plan or a Dependent Care Reimbursement Plan, and it is tied to a Cafeteria Plan, answer YES. [3] Funding Type: (1) SALARY REDUCTION (2) SPENDING CREDITS (3) COMBINATION If this is (a) a Premium Conversion (Pop) Plan, or (b) a Medical Reimbursement Plan not tied to a Cafeteria Plan or (c) a Dependent Care Plan not tied to a Cafeteria Plan then this question does not apply. [4] Trusteed Plan : (YES) (NO) If this is a non - Premium Conversion (Pop) Plan, and a trust will be established for this Plan, answer YES. [5] Plan subject to ERISA : (YES) (NO) [6] Church or Government Plan : (YES) (NO) [7] Plan Name: 1 If this is a Cafeteria Plan or a Reimbursement Plan tied to a Cafeteria Plan, then enter the Cafeteria Plans name. «< Basic Plan Information (Page 1) »> [8] Three Digit Plan Number: [9] Employer Information: Name: Address: City: ST: ZIP: Phone: ( ) - Tax ID#: Nor [10] State of Legal Construction: The State of Legal Construction is the name of the State that the Plan's provisions will be governed by. This is normally the same as the Employer's place of business. [11] Form of Business: Form of business is the legal form of the business entity. Forms of business include: C = Corporation P = Partnership D = Sub Chapter S Corp N = Not for Profit F = Personal Service S = Sole Proprietorship Z = Other - Describe [12] The Benefits Coordinator is the individual that can assist employees with further information about the Plan. It can be either an individual or a job title, such as 'The Office Manager' Benefits Coordinator: 2 «< Basic Plan Information (Page 2) »> ''r"' [13] The Document Provider is the name of the company or law firm providing the document. Document Provider: [14] Plan Administrator: Name: Address: City: ST: ZIP: Phone: ( ) - [15] Legal Representative: This is the person designated to be served with legal notice, generally an officer of the Employer. %sr Name: Address: City: ST: ZIP: Phone: ( ) - «< Signature Page Information 1 »> [16] Employer Representatives: 1 Name: Title: 2 Name: *tor 3 Title: ` 3 Name: Title: 4 Name: Title: «< Signature Page Information 2 »> [17] Affiliated Companies: Company 1: Name: Title: Company 2: Name: Title: Company 3: Name: Title: Company 4: Name: Title: Company 5: Name: Title: Company 6: ''r Name: 4 Title: If there are additional affiliated companies, use a separate page to list them. «< Trustee Information »> [18] Trustee Information: (if trusteed) Name: If there are additional trustee names, use a separate page to list them. Address: ■"' City: ST: ZIP: Phone: ( ) - [19] Trust Name: (if trusteed) «< Plan Choices 1 »> [20] Plan Dates: Original Effective Date: Effective Date: Plan Year Begin: 5 I Plan Year End: / Sr • Short Year Begin: / / The Original Effective Date is only required if the Plan is being amended or restated. The Effective Date is the date that the provisions of this Plan become effective. [21] SPD Plan Type References: (1) "CAFETERIA" PLAN (2) "FLEXIBLE BENEFITS" PLAN (9) OTHER - «< Plan Choices 2 »> [22] Allow for all applicable Change in Status options. : (YES) (NO) If you are not allowing all applicable change events, then select from the following list which events, if any, you allow. If no change in status is to be allowed, answer all questions "No ". "r Marriage or divorce of the Participant :(YES) (NO) Adoption, Birth, Death or Child or :(YES) (NO) Dependent Coming of Age of Child or Dependent :(YES) (NO) A Employment of the Participant or :(YES) (NO) Participant's Spouse Change in the Participant's residence :(YES) (NO) Participant beginning or ending adoption :(YES) (NO) proceedings Automatic changes upon cost increases :(YES) (NO) or decreases Significant cost increases :(YES) (NO) Significant curtailment of coverage :(YES) (NO) Addition or elimination of similar benefit :(YES) (NO) package option Change in coverage under employer plan of spouse or dependent Changes in 401(k) contributions :(YES) (NO) Medicare or Medicaid entitlement :(YES) (NO) [23] Will Plan limit number of Change in Status elections per : (YES) (NO) Year? 6 Y Answer "Y" if you wish to limit the number of times election changes are allowed on account of J Change in Status. If limiting the number of times, enter that number below Maximum Number of Changes: [24]Status Change Limitation : (YES) (NO) Answer "Y" if you wish to limit benefit election changes on account of "Status Change" to increases only. Answer "N" if there will be no limit to benefit election changes on account of "Status Change" «< Administrative Plan Selections 1 »> [25] (D) DAYS (W) WEEKS (M) MONTHS until Forfeiture: . Enter the number of days /weeks /months after the last day of the Plan Year (or the last day of participation in the plan, if earlier) that a participant's benefits are forfeited, if an amount is unclaimed. [26] Days until Denial Notice: Enter the number of days the Plan Administrator has to notify Participants of a denied claim. Must be 30 days or less. % ow [27] Days to Return Additional Information: . Enter the number of days the Participant has to provide additional information. Must be 45 days or greater. [28] Days Employee has to Request Review: . Enter the number of days the Participant has to appeal a denied claim. Must be 180 days or greater. [29] Additional days to Process Claim: . Enter the number of days the Plan Administrator may require to continue processing the claim after additional information is supplied. Must be 15 days or less. [30] Days until Review Decision: . Enter the number of days the Plan Administrator has to notify the Participant of the results of an appealed claim review. Must be 60 days or less. [31] Cash Conversion Allowed : (YES) (NO) If this is a Spending Credits or Combination Plan, answer 'YES' if credits can be converted to 1 7 cash. la"" [32] Maximum Conversion $ If Cash Conversion is permitted, enter the maximum dollar amount, if any. [33] Credit /Cash is Paid: (P) Each pay period (M) Monthly (Q) Quarterly (S) Semi - annually (A) Annually, (B) Annually, end of Plan Year beginning of Plan Year [34] Failure to File Result: (1) EXCLUSION (2) SAME CHOICES Failure to file an Agreement to Participate can result in either exclusion from the plan or selection of the same benefit choices. [35] Excess Credits: (1) FORFEIT (2) CONVERT TO CASH If this is a Spending Credits Plan, and 'Same Choices' was selected what happens to any excess credits, if any, after benefits are selected. "ft, [36] First Plan Year Failure to file results in: (1) Exclusion from the Cafeteria Plan for the initial Plan Year. (2) The same benefit choices, but with Cafeteria Plan contribution provisions. [37] Benefit Termination Date: (1) DATE OF TERMINATION (2) END OF PLAN YEAR The Benefit Termination Date is the date the employee may no longer receive benefits under the plan if he ceases to be a participant during the Plan Year. [38] Employer Contributes to Benefits : (YES) (NO) If this is a Premium Conversion (Pop) Plan, or a Salary Reduction Plan, and the Employer contributes to the cost of benefits in Salary Reduction -type plans answer 'YES'. If the answer is 'YES', then answer the following questions: 'fir Employer's Discretionary Premium Holiday :(YES) (NO) 8 If the Employer would like the opportunity to temporarily throughout the Plan Year increase the ... Employers' share of any Participant premium answer 'YES'. Employer's Option to increase Participant's :(YES) (NO) Cost If the Employer would like the opportunity to temporarily throughout the Plan Year increase the Participants' cost of any Participant premium. This no longer needs to be in relation to any premium increase by a third party answer 'YES'. [39] Trust Fund expenses paid by: (1) EMPLOYER (2) TRUST FUND Trust Fund expenses can be paid either directly by the employer, or from Trust Fund assets. (Trusteed Plans Only) [40] Maximum Employee Contribution: [SALARY REDUCTION & COMBINATION PLANS] (1) Fixed dollar amount: $ (2) Percent of Salary: cyo Now (3) Sum of Costs (9) Other - Describe on a separate page The limit for employee contributions to Salary Reduction Plans can be a fixed dollar amount, a percent of salary, the sum of benefit costs, or you may specify your own formula. [41] Compensation Definition: (1) Gross compensation (2) Base compensation (Bonuses, overtime not included) (9) Other - Describe on a separate page This definition is used for purposes of determining the amount of contributions to the plan. Note: Alternatives 1 and 2 include employee contributions to cafeteria, 401(k) and other plans. «< Administrative Plan Selections 2 »> [42] COBRA Continuation Coverage 9 Coverage Regardless of Employee Count : (YES) (NO) 'wow [43] Continuation of Coverage under the Family Medical Leave Act Coverage Regardless of Employee Count : (YES) (NO) Employer Pays 100% of FMLA Costs : (YES) (NO) If the above is NO, then: Prepay with Salary Reduction : (YES) (NO) Pay -As- You -Go : (YES) (NO) (The above must be selected if Pay -As- You -Go is offered to those on non -FMLA leave) Catch Up Option : (YES) (NO) [44] Treatment of rehires. ' If terminated and Rehired in less than 30 days (1) AIIow Participant to elect new Benefit. (2) Allow Participant only to elect new benefits under a Change in Status. (2) Prohibit Participant from rejoining until following Plan Year unless an applicable Change in Status. If Terminated and Rehired after 30 days or more (1) AIIow Participant to Reenter immediately and elect new benefits. (2) Prohibit reentry until first day of next Plan Year unless Change of Status. (2) Prohibit reentry until first day of next Plan Year even if Change of Status «< Spending Credits Formula »> [45] Spending Credit Formula: [SPENDING CREDITS & COMBINATION PLANS] (1) All Employees receive an equal number. `'w (2) Based on X credits per $ Salary: 10 Credits Per $ Salary, Air not to exceed Credits. (3) Based on Compensation Ranges: Compensation: From To Credits Now (9) Other - Specify on a separate page. «< Eligibility, Exclusions & Entry Dates »> [46] Eligibility Requirements: (1) No eligibility requirements (2) Based on Health Care Plan (3) Specific Requirements Minimum Age: years; (May not exceed 25) `rrr Minimum Service: 11 (D) DAYS (W) WEEKS (M) MONTHS; Other - Specify on a separate page : (YES) (NO) Employees can be eligible on their date of hire; When they are eligible for any health plan offered by the Employer; After any combination of age, service, etc. Exception for First Plan Year : (YES) (NO) Yes means that Employees are eligible to Participate as of the Effective Date. No means that the Plan's eligibility requirements apply in first Plan Year. [47] Exclusions: Part -time Employees - Min. Hours for eligibility per week; Seasonal Employees - Min. Months for eligibility per year; [Circle all that apply] Collective Bargaining Employees Excluded : (YES) (NO) Non- resident Aliens Excluded : (YES) (NO) Now Other Exclusions : (YES) (NO) Describe on a separate page) [48] Entry Date: (1) Date of Eligibility (2) First Day of Month (9) Other - Date an employee may join the Plan may be on the day all eligibility requirements are met; on the first day of the month coincident with or following eligibility; or you may specify an alternate formula. «< Premium -type Benefit Selections 1 »> [CAFETERIA PLANS ONLY] [49] Health Insurance Benefits Offered : (YES) (NO) * i v [50] Basic Health offered : (YES) (NO) 12 Dependent Coverage : (YES) (NO) (ONLY) litor Multiple Deductibles offered : (YES) (NO) Specify Deductibles & Co- payments : (YES) (NO) Deductible $ • Co- payment Maximum Co- payment $ [51] HMO offered : (YES) (NO) [52] PPO offered : (YES) (NO) [53] POS offered : (YES) (NO) Dependent Coverage : (YES) (NO) (ONLY) [54] Dental Care Plan : (YES) (NO) Dependent Coverage : (YES) (NO) Nor Multiple Dental Plan Deductibles : (YES) (NO) Orthodontic Coverage : (YES) (NO) «< Premium -type Benefit Selections 2 »> [55] Group Term Life Insurance : (YES) (NO) Multiple Coverages : (YES) (NO) [56] Disability Benefits : (YES) (NO) Multiple Coverages : (YES) (NO) [57] Other Premium -Type Programs : (YES) (NO) Benefit Title #1 (describe on a separate page) Provisions described in another Plan Document : (YES) (NO) Provisions described in another SPD Document : (YES) (NO) 13 r Document Name law Benefit Title #2 (describe on a separate page) Provisions described in another Plan Document : (YES) (NO) Provisions described in another SPD Document : (YES) (NO) Document Name «< Reimbursement -type Benefit Selections 1 »> [58] Medical Reimbursement Plan : (YES) (NO) Plan Name: Maximum Deferral $ (if any) Are eligibility requirements different : (YES) (NO) If yes, list specific requirements. Minimum Age: years; (May not exceed 25) Minimum Service: (D) DAYS (W) WEEKS (M) MONTHS; Other - Specify on a separate page : (YES) (NO) Are failure to file results different : (YES) (NO) Failure to File Result: (1) EXCLUSION (2) SAME CHOICES Failure to file an Agreement to Participate can result in either exclusion from the plan or selection of the same benefit choices. 14 Excess Credits: (1) FORFEIT (2) CONVERT TO CASH r... If this is a Spending Credits Plan, and 'Same Choices' was selected what happens to any excess credits, if any, after benefits are selected. First Plan Year Failure to file results in: (1) Exclusion from the Reimbursement Plan for the initial Plan Year. (2) The same benefit choices, but with Cafeteria Plan contribution provisions. Allow for all applicable Change in Status options for Reimbursement Plan. : (YES) (NO) If you are not allowing all applicable change events, then select from the following list which events, if any, you allow. If no change in status is to be allowed, answer all questions "No ". Marriage or divorce of the Participant :(YES) (NO) Adoption, Birth, Death or Child or Dependent :(YES) (NO) low Coming of Age of Child or Dependent :(YES) (NO) Employment of the Participant or Participant's:(YES) (NO) Spouse Change in the Participant's residence :(YES) (NO) Participant beginning or ending adoption :(YES) (NO) proceedings Medicare or Medicaid entitlement :(YES) (NO) «< Reimbursement -type Benefit Selections 2 »> [59] Dependent Care Assistance Plan : (YES) (NO) Plan Name: Maximum Deferral $ (Max. $5000.00) r '''r'' Are eligibility requirements different : (YES) (NO) 15 If yes, list specific requirements. Minimum Age: years; (May not exceed 25) Minimum Service: (D) DAYS (W) WEEKS (M) MONTHS; Other - Specify on a separate page : (YES) (NO) Are failure to file results different : (YES) (NO) Failure to File Result: (1) EXCLUSION (2) SAME CHOICES Failure to file an Agreement to Participate can result in either exclusion from the plan or selection of the same benefit choices. Excess Credits: (1) FORFEIT (2) CONVERT TO CASH If this is a Spending Credits Plan, and 'Same Choices' was selected what happens to any excess credits, if any, after benefits are selected. First Plan Year Failure to file results in: (1) Exclusion from the Reimbursement Plan for the initial Plan Year. (2) The same benefit choices, but with Cafeteria Plan contribution provisions. «< Reimbursement -type Benefit Selections 3 »> [60] Other Reimbursement -type Programs : (YES) (NO) Benefit Title #1 (describe on a separate page) Provisions described in another Plan Document : (YES) (NO) Provisions described in another SPD Document : (YES) (NO) Document Name Are eligibility requirements different : (YES) (NO) %" If yes, list specific requirements. 16 Minimum Age: years; +r. (May not exceed 25) Minimum Service: (D) DAYS (W) WEEKS (M) MONTHS; Other - Specify on a separate page : (YES) (NO) Benefit Title #2 (describe on a separate page) Provisions described in another Plan Document : (YES) (NO) Provisions described in another SPD Document : (YES) (NO) Document Name Are eligibility requirements different : (YES) (NO) If yes, list specific requirements. Minimum Age: years; (May not exceed 25) Minimum Service: (D) DAYS (W) WEEKS (M) MONTHS; Other - Specify on a separate page : (YES) (NO) Now 17 1 1" ,00000 HIBIT C MEDICAL HELPLINE • - - , • MEDICAL HELPLINE low Overview Medical Helpline Services Medical Helpline has combined several medical • 24 hour Ask -A -Nurse Program management programs into one unique service. Medical Helpline expands the typical role of • Maternity Helpline utilization review programs by integrating claims processing and medical management expertise. • Comprehensive Utilization Review This combination provides a pro- active and Services aggressive approach to medical cost control. The most costly medical procedures under any • Case Management health care plan are those involving surgery and /or hospitalization. Medical Helpline's services are • Peer Review designed to reduce costs in these areas to have the greatest impact on a health care plan without • Fee Negotiations sacrificing quality healthcare. The primary focus of Medical Helpline's • Managed Care Networks , is the level of care provided to the patient while implementing the best in medical • Benefit Plan Administration management expertise. Our team is concerned with under - utilization and inadequate medical treatment • International Claims Management as well as over - utilization and excessive medical care. We constantly and scrupulously compare treatment plans in order to maximize benefits to • Provider Network Repricing both our clients and patients. • Actuarial Services Medical Helpline has a profound understanding of managed healthcare through direct involvement • Underwriting Services in the field and by the extensive experience of our quality staff. We have assembled the most customer specific healthcare management services • Re - insurance Facilities available in the market today. Other administrators and medical management companies offer only a few in -house capabilities. This leaves clients with Medical Helpline partial healthcare management or forces them to `is committed to providing quality seek other vendors at a greater cost and loss of managed care concepts and solutions efficiency. Medical Helpline delivers complete flexible healthcare management and benefit plan which are beneficial to both administration as a cost effective and efficient individuals accessing health care �, actice. and the payor of those services." MEDICAL HELPLINE — INNI•11111 Ask -A -Nurse Maternity Helpline Our nurses are available around the clock to answer Maternity costs can account for as much as 49% of medical questions and concerns. This innovative health care expenditures. One in five women will approach enhances medical care by assisting experience a medical complication during their consumers in making the right health care decisions pregnancy. before they seek medical treatment. Medical Helpline is an easy -to- access resource and benefit When a premature birth can represent hundreds of enhancement that will reduce medical costs by thousands of dollars, the personal and financial promoting the appropriate use of healthcare. responsibility is daunting. This is why Maternity Helpline was developed. Studies show that when healthcare consumers are fully informed about the risks, benefits, and The program offers a telephone interviews during alternatives of a particular treatment plan, they are each trimester as well as healthy educational more likely to make choices that are less risky and information. The screening questionnaire was less costly. Our members report improved health designed for early detection of maternal /fetal risk status, improved communication with their factors. At -risk participants are assigned a nurse physician, and confidence in making medical case manager for early intervention. decisions. %11r Our 24 -hour availability enhances the ability to Our nurses are trained to assist in: intervene in high -risk cases that may never come to the Utilization Review staff's attention due to the • Directing the patient to the appropriate level of ban on mandatory pre - certification for pregnant care. members. Employers often increase the participation in the program by offering incentives • Providing health information and decision to those who complete the program. making tools. Maternity Helpline offers early intervention and • Improving patient health care outcomes. education for a healthy delivery. • Network steerage in most cases. • Empowering plan members by providing health Medical Helpline care options and education. 1- 877- 463 -3435 • Answering general benefit concerns with client approval. "Personal Attention Professional Assistance" • Identifying "at risk" members. 2 MEDICAL HELPLINE Air Utilization Review is the tool by which we ensure the Concurrent Review consists of a telephonic evaluation to participants receive the appropriate care in a cost - effective determine the medical need for continued hospitalization or setting. Utilization Review occurs prior to services rendered, specialty care unit confinement. Using established medical thereby: criteria and length of stay standards, the Utilization Review staff performs evaluations for: • Establishing coverage for proposed treatments under the health benefit plan whenever possible. • Medical necessity. • Directing participants to contracted plan providers. • Level of care is consistent with severity of illness. • Verifying appropriateness of care. • Appropriateness of continued hospitalization. • Avoiding unnecessary procedures. • Reducing the probability of claim disputes. In order to provide our clients with the most effective, quality oriented, and patient focused Concurrent Review Program, we In- patient Utilization Review only use highly skilled, professional nurses and medical specialists. One of the key components to the program is our After receiving all pertinent medical information, our Board Certified Medical Director and consulting physician Utilization Review Department immediately confirms panel. This resource is available to the nurses in assessing appropriateness of the proposed treatment, level of care, and medical necessity. length of stay in accordance with clinical guidelines. These guidelines are established and maintained by a board of Discharge Planning both before and during the patient's experts from every medical specialty. In- patient Utilization hospitalization, enables our staff to identify opportunities to Review occurs in three stages: reduce the length of hospital confinement. Coordinating and facilitating the patient's transition to a less expensive • Pre - admission verification of medical necessity. alternative setting meet treatment goals met without • Concurrent review. sacrificing quality of care. The discharge planning process • Discharge Planning. ensures that the acute stay will continue as long as it is medically necessary and transition will occur as soon as Iftsv Pre- admission Verification commences upon alternative environments will adequately serve the patient's notification that an employee has requested an elective surgery needs. or procedure. A nurse then contacts the physician for a treatment plan. We will assess whether the proposed The nurses use a variety of services to meet the discharge treatment plan can be performed in a more cost - effective needs of the patient including: setting (i.e., out - patient or alternative care setting) and whether • Home Health Care a second opinion is required. • Skilled Nursing Facilities Decisions are based upon medically accepted criteria which • Hospice Care ensure that the proposed treatment is customary for the • Durable Medical Equipment diagnosis and that only patients meeting these criteria are • Physical, Speech and Occupational Therapy approved. This process also provides early identification of potential Case Management and Fee Negotiations situations. Out- patient Utilization Review All certifications for elective admissions are based upon Hospitals are moving as many services as possible to out - documentation from the attending physician. An initial length patient settings. Approximately 60% of the cost of a benefit of stay is approved at the time of notification. If the plan consists of out - patient care. Out - patient pre - certification information presented were ambiguous or non - supportive, the provides control over a widely used and rapidly growing area nurse would request additional documentation and/or refer the of a health plan. We provide prior authorization of proposed case to our qualified physician staff for medical review. elective procedures and we will: • Assess if an alternate form of treatment that is equally effective is available. Medical Helpline • Recommend second opinions from impartial providers 1- 877 - 463 -3435 when medical necessity cannot be determined. "Personal Attention • Identify contracted providers, directing patients to the most appropriate and cost effective healthcare settings. " Professional Assistance" • Authorize only those treatments that are medically necessary and appropriate. 3 MEDICAL HELPLINE iftpr Case Management Fee Negotiation According to the Academy of Actuaries, only 14% of Medical Helpline negotiates provider service fees plan members account for nearly 80% of all health care prior to or after services have been rendered. Our fee claims. Industry experts estimate that a full 85% of negotiators have extensive claims knowledge and have disease management activities are in the realm of self- worked as senior claims analysts in the insurance management. industry. By working closely with the medical management staff, the negotiators are able to identify and Our case managers review serious illnesses and question charges and procedures for more effective fee catastrophic injuries, which traditionally result in negotiation. repeated and/or high cost treatment. Early identification of these high profile cases provides the opportunity for Fee negotiation can be added to any plan by simply the case manager to become an influential and visible directing claims to our cost management team. No member of the health care team, thus encouraging cost- change is required in present benefit structures, effective, quality health care. employee communications or network affiliations. Early case management intervention is the key to long- No fee will be charged unless the negotiation term cost containment. Patients in Case Management are successfully reduces our clients cost. frequently associated with high costs and/or long -term treatment or rehabilitation. Potential cases are identified Managed Care Networks through AAN, Maternity Helpline, Utilization Review, the claims department, and employer notification. When Managed Care Networks are used in conjunction with Utilization Review, the cost effectiveness of the Case identification criteria include: plan is maximized. We access managed care networks whose providers offer discounted fees and adhere to `r ❖ Specific Diagnoses recognized practice guidelines. Medical Helpline • Multiple and/or frequent usage of plan benefits offers a managed care network which: • Hospitalizations • Maintains a database of all licensed and accredited • Multiple surgeries facilities and all AMA licensed physicians in the • Physicians visits United States. • Physical therapy • Verifies and monitors practice patterns of all • Chiropractic treatments physicians for credentialing. • Durable medical equipment and pharmacy • Identifies contracted providers by specialty and Claims in excess of $10,000 per member per plan location. • • Has established case rates and provides discounts on year professional and facility fees. • Multiple health care providers treating the same • Reduces cost and improves the quality of care. condition The case manager assures that: • Plan of care is necessary & treatment is warranted Medical Helpline ❖ High quality, cost - effective vendors are selected • Provider fees are negotiated 1- 877 - 463 -3435 ❖ Medical benefit dollars are conservatively used • Quality, goal - oriented medical care is received "Personal Attention Through knowledge comes improved compliance. Professional Assistance" Chronically ill patients can reduce the severity and 1411, number of complications, as well as delay the onset of more serious symptoms thereby improving the quality of their lives. 4 • • • EXHIBIT D „. WORLD DOC Y ; s L 11Y T _ u 'e h _ a QJ Iffli ft I / - , ,,,,,,, ..„ s - , , t, ,„-,.:„..: J t , vi. II s ._ 4 .1) (1 DI mic C 4-0 •- LI - faH:. p a) u mio 0 a C - 0 E u 1 0 f z -J To W n• s 4.1 • r6 f w C O o CU C VI D ( En 4J � r0 VI u - 0 r E 0) ro 7 , VI CX L N I � O Nip 'NZ •C -C IA L V 0 .N U'1 C ` -0 N •L - D Z C CD L) -c > °' .N u ;- L) S O N cu N _ V Q ©43 i 0 VI (0 d) Q • - < v 'C5 Q • • • L 0 I 1 ( Y u Cl.) > ("0 ) ++ 0 f o s r` • >, i ro V aJ a) � r0 4-1 E ? 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By completing the confidential WorldDc 2 4/7 Health Risk Assessment you will get an instant health report that shows your approximate Health Age and provides you with detailed recommendations to lower :;;: your health risks and improve i'. .A ,, . the quality of your life. 3o . Print your Health Risk s Assessment report and share it with your physician. Together, you and your doctor can create a personalized health improvement plan that works for you. .,; ','4.3 ' 'Keducinj risk y 4e9" h p • Login at www.enformed.com l ilanoT 1 j care' • 1 time user - register and then enter your a r User ID and Password • Click on the IVledical Helpline / World Doc logo WortdD c 41 "" All information entered into WorldDoc is '"∎" 17;"[ confidential and Protected Health Information as defined by federal law (45 CFR 1.64.5oi). low I IT You aren t getting anyyounger or are you? l ey 4,14 . Complete the WortdDoc 2! /7 Mi Health Risk ar Assessment to find out if your health age ACCESS WORLDDOC 24; 77M is lower than your actual age. 1. Login at www.enformed. 2. 1 time user - register and then Your personalized HRA Report Card includes: enter your User ID and Password • Your Health Age 3. Click on the Medical Helpline / World Doc logo • Your Disease Risks • Your Important Risk Factors ". . �z • What you al . e doing well • What you need to work on ;"., • And more... - -- 411 � r vse the infer in your HRA Report Card to find out flow you can lower your health age. Then, update your HRA every six months to see how your health age improves as you make WorldD CZ4f1 changes to your health habits. A benefit (rom �•:. V EXHIBIT E R x WATCHDOG s i • a) "t:3 ii .N A-, • •^, to ' p r"0 N c O 0 0 a; i E -cs ct3 O - c '7) '7) al N ct i_, • iii; , CU $ , ,� �' ' Owl cd 4"-e cC3 ct M U� C) N 0 U ' t, o cu 17- u rS F. ... c, ct E A L.T. - a , ,.., a, o . � ct � 0 � 5 ! •.= CD i..=4 _C M Z p., • 1 •,..r cid 0 al O 78 c .) Cl) Q., j E 7:, M - r cd E � d eg 8 o . � a E r: P 11 N 4g lila i till. " 45 4 E ,i,"" W CI) cc3 43 `. +1 ° O v, O • ' ¢, Ct N aA•Gj '. at • vl c� 1 1 1 �.° t cA O - N i—+ by c� = cil t. a., #c2 -- ! ;:4 o c..) cd (A-, L -6 cl) - p a) U .� ) > = U O O � U N N N 4' O CI, +J c • ✓. 4 E mi � pp 4J O y f..-. '4 N = U X • • • P i‘iit . --,4- alma EXHIBIT F CVS CAREMARK • • J P Performance Drug List January 2010 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 riot an all- inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN PARTICIPANT HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered administered by CVS Caremark. Ask your doctor to consider prescribing, by CVS Caremark. As a way to help manage health care costs, authorize when medically appropriate, a preferred medicine from this list. Take this generic substitution whenever possible. If you believe a brand -name list along when you or a covered family member sees a doctor. product is necessary, consider prescribing a brand name on this list. Please note: Please note: • Your specific prescription benefit plan design may not cover certain • Generics should be considered the first line of prescribing. categories, regardless of their appearance in this document. • This drug list represents a summary of prescription coverage. It is • For specific information regarding your prescription benefit coverage not inclusive and does not guarantee coverage. and copay' information, please visit www.caremark.com or contact a • The plan participant's specific prescription benefit plan may have CVS Caremark Customer Care representative. a different copay for specific products on the list. • CVS Caremark may contact your doctor after receiving your prescription • Unless specifically indicated, drug list products will include all to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, dosage forms. a different brand -name product or generic equivalent in place of your • Log in to www.caremark.com to check coverage and copay original prescription. information for a specific medicine. • Any brand drug for which a generic product becomes available may be 141ree designated as a non - preferred product. ANTI - INFECTIVES § MISCELLANEOUS § FIBRATES 5 ACE INHIBITOR/ CALCIUM CHANNEL metronidazole DIURETIC COMBINATIONS fenofibrat ;LOCKER`ArNTILIPEMIC ,ANTIBACTERIAL5 sulfamethoxazole- TRICOR § CEPHALOSPORINS trimethoprim fosinopril TRILIPIX 2OPABiNATI0N5 cefaclor hydrochlorothiazide CADUET i ANTIFUNGALS iisinopril § HMG CoA REDUCTASE cefdinir INHIBITORS i DIGITALIS GLYCOSIDES y cephalexin fluconazole hydrochlorothiazide ce P ravastatin digoxin SUPRAX itraconazole quinapril- pravastatin hydrochlorothiazide simvastatin § ERYTHROMYCINS/ terbinafine tablet -- __. _ CRESTOR z DIURETICS MACROLIDES , f IVIR. 3 .ACE INHIBITOR /CAL_II li'1 LIPITOR furosemide azithromycin CHANNEL BL0CKERS hydrochlorothiazide § HERPES AGENTS NIACINS /COMBINATIONS metolazone clarithromycin ac cfovir TARKA ADVICOR clarithromycin ext-rel y spironolactone- y VALTREX ANGIOTENSI J 11 NIASPAN erythromycins hydrochlorothiazide § INFLUENZA AGENTS RECEPTOR rANT. Nl5 F i SIMCOR torsemide § FLUOROQUINOLONES amantadine CONIBINATi'ON5 j ; =T, L,�r; E .; triamterene- ciprofloxacin ext -rel rimantadine AVAPRO /AVALIDE hydrochlorothiazide ciprofloxacin tablet RELENZA BENICAR/BENICAR HCT carve it AVELOX TAMIFLU MICARDIS /MICARDIS HCT metoproloi ilol CENTRAL NERVOUS CIPRO SUSPENSION eto SYSTEM LEVAQUIN CARDIOVASCULAR 1'N i lLlPEWI'. ' metoprolol succinate ext-rel nadolol 1 ?i ■.),_.- _ A'IT § PENICILLINS : N § BILE ACID RESINS ro ranolo! ' ":.� l� li',I i �f.; p p § MISCELLANEOUS AGENTS amoxicillin cholestyramine fosinopril SYSTOLIC bupropion amoxicillin- clavulanate WELCHOL lisinopril COREG CR bupropion ext -rel dicloxacillin quinapril CHOLESTEROL ABSORPTIO penicillin VK ramipril INHIBITORS i \i_ :' ,:�: ?iiiEi_ miriazapine § TETRACYCLINES ZETIA , ' 1 - ' ".• •' - ±' "ixycycline hyclate amlodipine 41.100nocycline diltiazem ext-rel tetracycline nifedipine ext -rel verapamil ext -rel CVS Your specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. T �,- " �' F For specific information, visit www.caremark.com or contact a CVS Caremark Customer Care representative . /�UIl�IEM/puI,j��t(` § SELECTIVE SEROTONIN INCRETIN MIMETIC §TRIPHASIC GENITOURINARY i-EUKOTRIENE RECEPTOR REUPTAKE INHIBITORS AGENTS ORTHOTRI - CYCLEN LO ANTAGONISTS BYETTA § EXTENDED CYCLE i BEi9'a i1 ?i I'• AT citalopram INSULINS ethinyl estradiol- -fY?E ;PL A;I.\ SINGULAIR ■,.► fluoxetine APIDRA levonorgestrel doxazosin NASAL ANTIHISTAMINES paroxetine HUMALOG LOSEASONIQUE finasteride ASTELIN paroxetineext -rel HUMULIN SEASONIQUE terazosin ASTEPRO sertraline LANTUS AVODART LEXAPRO CONTINUOUS LEVEMIR LYBREL FLOMAX 5 NASAL ;TE°OIO § SEROTONIN NOVOLIN l , fluticasone TRANSDERMAL ) ir ' , ' ' NASACORT AQ NOREPINEPHRINE NOVOLOG ORTHO EVRA AN I ISPA3Mk.. . ' REUPTAKE INHIBITORS NASONEX INSULIN SENSITIZERS oxybutynin (SNRIs)? ACTOS VAGINAL oxybutynin ext rel VERAMYST venlafaxine INSULIN SENSITIZER/ NUVARING DETROL STEROID /BETA AGONISTS CYMBALTA BIGUANIDE ESTROGENS DETROL LA ADVAIR EFFEXOR XR ENABLEX SYMBICORT PRISTIQ COMBINATIONS § ORAL GELNIQUE ACTOPLUS MET estradiol STEROID INHAL ANTS 5 HYPNOTIC INSULIN SENSITIZER/ estropipate OXYTROL ASMANEX NONSENZODI,1ZBPINES SULFONYLUREA ENJUVIA SANCTURA XR FLOVENT zolpidem COMBINATIONS PREMARIN VESICARE PULMICORT AMBIEN CR DUETACT § TRANSDERMAL, HEMATOLOGIC QVAR MIGRAINE MEGLITINIDES ESTROGENS ) PRANDIN estradiol >>1TC ;'"11L'1' IT' TOPICAL § SELECTIVE SEROTONIN warfarin AGONISTS § SULFONYLUREAS CLIMARA COUMADIN !DERPAATOLOGY • • sumatriptan glimepiride ESTRADER § ACNE MAXALT glipizide VIVELLE DO RESPIRATORY clindamycin solution ZOMIG glipizideext -rel § ORAL ESTROGEN/ ANAPHYLAXIS erythromycin solution SELECTIVE SEROTONIN § SULFONYLUREA/ PROGESTINS TREATMENT AGENTC erythromycin AGONIST /NONSTEROIDAL BIGUANIDE estradiol- norethindrone EPIPEN benzoyl peroxide ANTI- INFLAMMATORY COMBINATIONS PREMPHASE EPIPEN JR tretinoin • DRUG (NSAID) glipizide-metformin PREMPR BENZACLIN " OMBINATIONS SUPPLIES 5 PROGESTINS 1 A, ITIiHOLINEi1GIC5 DIFFERIN 'lila/ TREXIMET ACCU -CHEK STRIPS medroxyprogesterone SPIRIVA DUAC CS AND KITS° PROMETRIUM N m RETIN -A MICRO i 1NTI�:Hf?L!i ItRGI�' ENDOCRINE AND BD INSULIN SYRINGES - BETA AGONISTS ZIANA METABOLIC AND NEEDLES SELECTIVE EST ROGEI`l f ratro ium albutero! OPHTHALMIC RECEPTOR MODULATORS P P ANDROGENS ONETOUCH STRIPS inhalation solution ANDRODERM AND KITS° EVISTA COMBIVENT § BETA ERS, NONSELECTIVE ANDROGEL CALCIUM REGULATORS 5 THYROID SUPPLEMENTS j,1NTHISTVIINE ;. timolol maleate solution AN TIDIABE TIC 3 § BISPHOSPHONATES levothyroxine NON SEDATING BETIMOL alendronate SYNTHROID a § BIGUANIDES fexofenadine BETA - BLOCKERS, metformin ACTONEL GASTROINTESTINAL SELECTIVE 4 AN111- 1!STAMINr' BONIV BETOPTIC S metformin ext-rel § CALCITONINS 5 H, RECEPTOR !DECONGES IAN f i DIPEPTIDYL PEPTIDASE -4 ANTAGONIST; ALLEGRA -D3 PROSTAGLANDINS (DPP -4) INHIBITORS Fortical LUMIGAN JANUVIA PARATHYROID HORMONES ranitidine SE f -1 ,A3 +3A1! ;T; TRAVATAN ONGLYZA FORTEO 5 PROTON PUMP § SHORT ACTING XALATAN DIPEPTIDYL PEPTIDASE -4 GDPJTt;ACEPTIVES INHIBITORS albuterol § SYMPATHOMIMETICS (DPP -4) INHIBITOR/ omeprazole PROAIR HFA brimonidine0.2% BIGUANIDE § MONOPHASIC KAPIDEX PROVENTIL HFA ALPHAGAN P COMBINATIONS ethinyl estradi NEXIUM LONG ACTING JANUMET drospirenone YAZ FORADIL SEREVENT • %r/ 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. 2 p QUICK REFERENCE DRUG LIST A ciprofloxacin ext -rel Fortical N sertraline ACCU-CHEK STRIPS ciprofloxacin tablet fosinopril nadolol SIMCOR AND KITS° citalopram fosinopril NASACORT AQ simvasiatin ACTONEL clarithromycin hydrochlorothiazide NASONEX SINGULAIR ACTOPLUS MET clarithromycin ext -rel furosemide NEXIUM SPIRIVA CLIMARA NIASPAN ACTOS spironolactone acyclovir clindamycln solution hydrochlorothiazide COMBIVENT GELNIQUE nifedipine ext-rel ADVAIR NOVOLIN sulfameihoxazole ADVICOR COREG CR glimepirid trimethoprim COUMADIN glipizide NOVOLOG albuterol NUVARING sumatriptan CRESTOR glipizide ext-rel alendronate SUPRAX ALLEGRA-D3 CYMBALTA glipizide-mefformin O SYMBICORT ALPHAGAN P D H omeprazole SYNTHROID • • amantadine DETROL HUMALOG ONETOUCH STRIPS T AMBIEN CR DETROL LA HUMULIN AND KITS' amlodipine ONGLYZA TAMIFLU amoxicillin dicloxacillin hydrochlorothiazide ORTHO EVRA TARKA amoxicillin clavulanate DIFFERIN terazosin digoxin 1 ORTHO TRI- CYCLEN LO ANDRODERM dlitiazem ext-rel ipratropium-albuterol oxybutynin terbinafine tablet ANDROGEL doxazosin inhalation solution oxybutynin ext-rel tetracycline APIDRA doxycycline hyclate Jtraconazole OXYTROL timolol maleate solution ASMANEX DUAC CS torsemide ASTELIN J P TRAVATAN ASTEPRO DUETACT JANUMET paroxetine tretinoin atenolol E JANUVIA paroxetine ext -rel TREXIMET AVALIDE penicillin VK triamterene EFFEXOR XR hydrochlorothiazide AVAPRO K PRANDIN Y ENABLEX TRICOR AVELOX KAPIDEX pravastatin AVODART ENJUVIA PREMARIN TRILIPIX azithromycin EPIPEN L PREMPHASE �, EPIPEN JR LANTUS PREMPRO B erythromycin solution LEVAQUIN PRISTIQ VALTREX BD INSULIN SYRINGES erythromycin LEVEMIR PROAIR HFA venlafaxine AND NEEDLES benzoyl peroxide levothyroxine PROMETRIUM VERAMYST • BENICAR erythromycins LEXAPRO propranolol verapamil ext-rel BENICAR HCT ESTRADERM LIPITOR PROVENTIL HFA VESICARE BENZACLIN estradiol lisinopril PULMICORT VIVELLE-DOT estradiol- norethindrone BETIMOL estro i ate lisinopril- w BETOPTIC S p p hydrochlorothiazide Q ethinyl estradiol- ulna r warfarin BONIVA LOSEASONIQUE q p it drospirenone WELCHOL brimonidine 0.2% LUMIGAN quinapril- ethinyl estradiol- bupropion LYBREL hydrochlorothiazide bupropion ext -rel levonorgestre! QVAR X BYETTA EVISTA M XALATAN BYSTOLIC F MAXALT R Y C medroxyprogesterone ramipril fenofibrate YAZ • fexofenadine metformin ranitidine CADUET finasteride metformin ext-rel RELENZA Z carvedilol metolazone RETIN -A MICRO ZETIA cefaclor FLOMAX metoprolol rimantadine FLOVENT ZIANA cefdinir metoprolol succinate ext -rel fluconazole 5 zolpidem cephalexin metronidazole ZOMIG cholestyramine fluoxetine MICARDIS SANCTURA XR • CIPRO SUSPENSION fluticasone MICARDIS HCT SEASONIQUE FORADIL minocycline SEREVENT FORTED mirtazapine 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. 3 PREFERRED ALTERNATIVES LIST DRUG NAME PREFERRED ALTERNATIVE(S)* DRUG NAME PREFERRED ALTERNATIVE(S)* ACCOLATE SINGULAIR DORAL zolpidem, AMBIEN CR ACIPHEX omeprazole DYNACIRC CR amlodipine, nifedipineext -rel ACTONELW /CALCIUM alendronate EPIDUO tretinoin AEROBID, AEROBID M ASMANEX, FLOVENT, PULMICORT, QVAR ESTRASORB estradiol, CLIMARA, ESTRADERM, VIVELLE -DOT • ALOHA estradiol, CLIMARA, ESTRADERM, VIVELLE -DOT ESTROGEL estradiol, CLIMARA, ESTRADERM, VIVELLE -DOT ALTOPREV pravastatin, simvostatin, CRESTOR, LIPITOR EVOCLIN FOAM clindamycin solution, erythromycin solution ALVESCO ASMANEX, FLOVENT, PULMICORT, QVAR FEMHRT estradiol - norethindrone, PREMPHASE, PREMPRO AMERGE sumatriptan, MAXALT, ZOMIG FEMTRACE estradiol, estropipate, ENJUVIA, PREMARIN ANGELIQ estradiol - norethindrone, PREMPHASE, PREMPRO FENOGLIDE fenofrbrate, TRICOR,TRILIPIX ARMOUR THYROID levothyroxine, SYNTHROID FIRST TESTOSTERONE ANDRODERM, ANDROGEL ASCENSIA STRIPS AND KITS ACCU -CHEK STRIPS AND KITS', ONETOUCH STRIPS FORTAMET metformin, metformin ext -rel AND KITS' • FOSAMAX PLUS D alendronate ATACAND, ATACAND HCT BENICAR, BENICAR HCT FREESTYLE STRIPS AND KITS ACCU -CHEK STRIPS AND KITS', ONETOUCH STRIPS ATRALIN tretinoin AND KITS' ATROVENT HFA SPIRIVA INNOPRAN XL atenolol, propranolol ext -rel AXERT sumatriptan, MAXALT, ZOMIG ISTALOL timolol maleate solution, BETIMOL AZELEX erythromycin solution KLARON LOTION erythromycin solution AZMACORT ASMANEX, FLOVENT, PULMICORT, QVAR LUNESTA zolpidem BECONASE AQ fluticasane MAXAIR PROAIR HFA `41.10 BENZAC AC, BENZAC W clindamycin solution, erythromycin solution, MENEST estradiol, estropipate, ENJUVIA, PREMARIN erythromycin benzoyl peroxide, tretinoin, BENZACLIN, MENOSTAR estradiol, CLIMARA, ESTRADERM, VIVELLE -DOT DIFFERIN, DUAL CS, RETIN-A MICRO, ZIANA BENZAGEL clindamycin solution, erythromycin solution, OMNARIS fluticosone erythromycin - benzoyl peroxide, tretinoin, BENZACLIN, PATANASE ASTELIN, ASTEPRO DIFFERIN, DUAC CS, RETIN -A MICRO, ZIANA PEXEVA citalopram, fluoxetine, paroxetine, paroxetine ext -rel, BENZIQ clindamycin solution, erythromycin solution, sertraliae, LEXAPRO erythromycin - benzoyl peroxide, tretinoin, BENZACLIN, DIFFERIN, DUAL (S, RETIN-A MICRO, ZIANA PRECISION XTRA STRIPS AND KITS ACLU -CHEK STRIPS AND KITS', ONETOUCH STRIPS AND KITS' BREVOXYL clindamycin solution, erythromycin solution, erythromycin- benzoyl peroxide, tretinoin, BENZACLIN, PREFEST estradiol norethindrone, PREMPHASE, PREMPRO DIFFERIN, DUAC CS, RETIN -A MICRO, ZIANA RAPAFLO doxazosin, terazosin, FLOMAX CARDIZEM LA diltiazem ext -rel RELION INSULIN HUMULIN INSULIN, NOVOLIN INSULIN CARDURA XL doxazosin, terazosin, FLOMAX RELPAX sumatriptan, MAXALT, ZOMIG CENESTIN estradiol, estropipate, ENJUVIA, PREMARIN RHINOCORT AQUA fluticasone CLARINEX fexofenadine SKELID alendronate, ACTONEL CLARINEX-D ALLEGRA -D3 STARLIX PRANDIN CLINDAGEL erythromycin solution STRIANT ANDRODERM, ANDROGEL DESQUAM E, DESQUAM X clindamycin solution, erythromycin solution, SULAR amlodipine, nifedipine ext -rel erythromycin - benzoyl peroxide, tretinoin, BENZACLIN, DIFFERIN, DUAC (5, RETIN -A MICRO, ZIANA • `rr, "The preferred alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information, visit www.caremark.com or contact a CVS Caremark Customer Care representative. 4 DRUG NAME PREFERRED ALTERNATIVE(S)* DRUG NAME PREFERRED ALTERNATIVE(S)* SURE -TEST STRIPS AND KITS ACCU -CHEK STRIPS AND KITS', ONETOUCH STRIPS TRUE CARE STRIPS AND KITS, ACCU -CHEK STRIPS AND KITS', ONETOUCH STRIPS *trire AND KITS' TRUETEST STRIPS AND KITS, AND KITS' • TEKTURNA, TEKTURNA HCT BENICAR, BENICAR HCT TRUETRACK STRIPS AND KITS TESTIM ANDROGEL TWINJECT EPIPEN, EPIPEN JR TEVETEN, TEVETEN HCT BENICAR, BENICAR HCT UROXATRAL doxazosin, terazosin, FLDMAX • TOVIAZ oxybutynin ext -re! XOPENEX HFA PROAIR HFA ZODERM cl indamycinso lution,erythromycinsolution, TRIAZ cl indamycinsolution ,erythromycinsolution, erythromycin - benzoyl peroxide, tretinoin, BENZACLIN, erythromycin benzoyl peroxide tretinain, BENZACLIN, • DIFFERIN, DUAC CS, RETIN -A MICRO, ZIANA DIFFERIN, DUAC CS, RETIN A MICRO, ZIANA TRIGLIDE fenofibrate, TRICOR, TRILIPIX ZYFLO, ZYFLO CR SINGULAIR The preferred alternative products in this list are a broad representation within therapeutic categories of available treatment options and do 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, It is not inclusive and does not guarantee coverage. Any brand drug For which a generic product becomes available may be designated as a non - preferred product. Specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. The plan participant's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products wit include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes onlyThis is not an all- inclusive list. Listed products may be available gener cally in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to www.caremark.com to check coverage and copay information for a specific medicine. § Generics are available in this class and should be considered the first line of prescribing. 1 Copayment, copay or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 Indicates the proposed mechanism of action, based on the American Psychiatric Association Summary of Treatment Recommendations. 3 Higher copays may apply depending on the plan participant's specific prescription benefit plan. Login to www.caremark.com TO find the copay under a specific plan. 4 An Accu -Chek or OneTouch blood glucose meter will be provided at no charge by the manufacturer to those individuals currently using a meter other than Accu -Chek or OneTouch. For more information on how to obtain a blood glucose meter, call toll -free: 1- 800 -588 -4456, Plan participants must have CVS Caremark Mail Service Pharmacy benefits to qualify. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. document contains references to brand -name prescription drugs that are trademarks or registered trademarks of pharmaceutical � [ � u manufacturers that are riot affiliated with CVS Caremark. ' � ^� _ ^ _ _ Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. I7 ( Q `l K ][ .J[ ` ©2010 Caremark Rx, L.LC. 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