Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
C2009-541 - 12/15/2009 - Approved
IUMANA [suit ranee when you need it most Group Sponsored Medicare Advantage Application Please refer to your proposal to complete this document. Print clearly in black ink, and answer all questions or indicate not applicable." Business Name City of Corpus Christi Federal Tax ID Number Location address (not a P.O. Box) City Corpus Christi 1201 Leopard St Internal Use Only Group Number: 74- 6000574 State TX Zip 78401 County Nueces Do you have more than one location? Yes x No Billing address (if different) City Corpus Christi P.O. Box 9277 Nature of business or SIC number State TX Municipality Zip 78469 Date company established Business Status: Corporation Partnership Sole Proprietorship Business Phone Number 361- 826 -3300 Fax Number 361- 844 -1730 Management Contact Pat Atkins County Other) Nueces 1852 Home -Rule city Management Contact e-mail address iministrative Contact e-mail address Requested Effective Date Plan: 079 Option: Plan: 078 Option: patat @cctexas.com Administrative Contact Christina Canales christinaca@cctexas.com March 1, 2010 526 026 Rx Option: 26 Rx Option: 26 Are any affiliations or subsidiaries to be covered? If yes,: Affiliation /subsidiary information: Name Address: Total number of Medicare eligible retirees Number of Medicare retirees to be covered No Affiliation x Yes Subsidiary 190 190 Number of Medicare eligible spouses 31 Number of Medicare eligible spouses to be covered How much will the plan sponsor contribute to premium? Retiree (% or $) 0 Spouse of Retiree (% or $) 31 0 For the plan to remain in effect, the eligibility, underwriting, and participation requirements must be maintained. Failure to maintain the plan 'Vgibility, underwriting, and participation requirements will terminate the group coverage. 2009 -541 M2009 -354 12/15/09 Humana Insurance Co. You the plan sponsor, understand, agree and represent that • You have read this document and the information you provided is accurate and complete to the best of your knowledge and belief. • You have received and reviewed a proposal and the applicable regulatory information. Neither you nor the agent/broker /producer has the authority to waive a complete answer to any question, determine coverage or insurability, alter any contract, bind us by making any promise or representation, or waive any of our other rights or requirements. Only individuals who meet the eligibility requirements of the plan are eligible to maintain coverage. Providing incomplete, inaccurate, or untimely information may void, reduce, or increase past premium, or terminate an individual's coverage or the plan coverage. The employer /union sponsor can subsidize different amounts for different classes of enrollees in a plan provided such classes are reasonable and based on objective business criteria, such as years of service, date of retirement, business location, job category, and nature of compensation (e.g., salaried vs. hourly). Different classes cannot be based on eligibility for the Part D Low - Income Subsidy. The premium cannot vary for individuals within a given class of enrollees. With regard to the Part D premium, an employer /union cannot charge an enrollee for prescription drug coverage provided under the MA plan more than the sum of his or her monthly beneficiary premium attributable to basic prescription drug coverage and 100% of the monthly beneficiary premium attributable to his or her non - Medicare Part D benefits (if any). The employer /union must pass through any direct subsidy payments received from CMS to reduce the amount that the beneficiary pays (or in those instances where the subscriber to or participant in the employer /union -only plan pays premiums on behalf of a Medicare eligible spouse or dependent, the amount the subscriber or participant . ays). Dated on: Dated at: siness Name: City of Corpus Christi By: Title: (plan sponsor ti e) Agency of Record Name (print) Tax ID Address City /State /Zip: Writing Agent/Agent of Record Name (print) Social Security Number Page 2 of 2 AUTHORIZED ST COUNCIL ...1 4f .� . SECRETA As the Writing Agent/Producer, I acknowledge that I am responsible to meet with the group submitting this application in order to fully and accurately represent the terms and conditions of the benefits and services offered by the plan. Writing Agent's Signature: Date: NO 1 ;• Sa..Q 3 al\g) °I Humana - Signature, Title U Date Incorporated by reference: GHAO5G9HH Exhibit A: Request for propsal BI- 0153 -09 as clarified via Addenda 1 and 2 Exhibit B: Proposer's Proposal HUMANA Guidance when you need it most HUMANA GROUP MEDICARE RPPO PLAN 2010 Plan 079 Option 526 This is a brief summary of services and is not intended to be a complete description of benefits, exclusions and limitations. Please refer to your Evidence of Coverage for additional information regarding covered services and limitations or any other contractual conditions. All services must be medically necessary. Coinsurance and copayments are due when services are rendered. For a complete description of benefits, exclusions and limitations please refer to the actual Evidence of Coverage. If a discrepancy arises between this information and the actual Evidence of Coverage, the Evidence of Coverage will prevail in all instances. Annual Out -Of- Pocket Maximum (1) • Network: $5,000 per individual per calendar year (excludes Pharmacy, Routine Dental, Extra Services and the Plan Premium) • Non - Network: $7,500 per individual per calendar year (excludes Pharmacy, Routine Dental, World Wide Coverage and the Plan Premium) Annual Deductible (1) • Network: None • Non - Network: None Benefit Network Coverage (1) Non Network Coverage (1) Physician Services • Primary care physician (PCP) - Surgical procedures - Diagnostic procedures and lab services - Mental health and substance abuse services - Smoking cessation (Medicare- covered services) Plan pays 100% after $15 copayment per visit Plan pays 70% • Specialist - Podiatry (Medicare - covered services) - Chiropractic (Medicare- covered services) - Surgical procedures - Diagnostic procedures and lab services - Mental health and substance abuse services - Smoking cessation (Medicare- covered services) Plan pays 100% after $35 copayment per visit Plan pays 70% • Allergy shots and injections Plan pays 100% Plan pays 70% • Drugs administered in a physician's office Plan pays 80% after $15 copayment per visit to a primary care physician; Plan pays 80% after $35 copayment per visit to a specialist Plan pays 70% Preventive Services • Bone mass measurement (one per year) • Colorectal screening (one per year) • Pap smears, pelvic exams, and prostate cancer screening (one per year) • Routine physical (one per year) • Diabetes self- management o Nutritional therapy (ESRD or diabetic patients) • Screening Mammography (one per year) Plan pays 100% in all places of treatment Plan pays 70% in all places of treatment 2010 Standard RPPO 079 -526 Humana.com 9/30/2009 HUMANAa Guidance when you need is most Preventive Services (continued) • Immunizations Plan pays 100% in all places of treatment Plan pays 100% in all places of treatment Inpatient Hospital Services • Inpatient (all authorized admissions) Plan pays 100% after $675 copayment per admission Plan pays 70% • Inpatient physician services Plan pays 100% Plan pays 70% Outpatient Hospital Services • Outpatient surgical services Plan pays 100% after $185 copayment per visit Plan pays 70% • Outpatient advanced imaging and nuclear medicine Plan pays 100% after $125 copayment per visit Plan pays 70% • Diagnostic procedures Plan pays 100% after $85 copayment per visit Plan pays 70% • Outpatient lab services Plan pays 100% Plan pays 70% • Observation Plan pays 100% after $125 copayment per visit Plan pays 70% • Outpatient physician services Plan pays 100% Plan pays 70% Emergency Services • Emergency room (2) Plan pays 100% after $50 copayment per visit (waived if admitted within 24 hours) Plan pays 100% after $50 copayment per visit (waived if admitted within 24 hours) • Emergency room physician services Plan pays 100% Plan pays 100% • Urgent care Plan pays 100% after $35 copayment at an immediate care facility Plan pays 70% at an immediate care facility • World Wide Coverage (emergency services only) N/A Plan pays 80% after annual deductible and $100 deductible up to $25,000 maximum annual benefit or 60 consecutive days, whichever is reached first • Ambulance Plan pays 100% after $100 copayment per date of service Plan pays 100% after $100 copayment per date of service Additional Medical Services • Skilled nursing facility Plan pays 100% per day (days 1- 11) — no three -day hospital stay is required; Plan pays 100% after $96 copayment per day (days 12- 100); Plan pays $0 after 100 days Plan pays 70% up to 100 days - no three -day hospital stay required; Plan pays $0 after 100 days • Skilled nursing facility physician services Plan pays 100% Plan pays 70% • Outpatient therapy (cardiac, occupational, physical, respiratory, audiology, and speech) Plan pays 100% after $35 copayment per visit to specialist and comprehensive outpatient rehabilitation facility; Plan pays 100% after $60 copayment per visit to outpatient hospital Plan pays 70% in all places of treatment • Freestanding radiological facility Plan pays 100% after $50 to $100 copayment per visit (based on services received) Plan pays 70% • Ambulatory surgical center Plan pays 100% after $150 copayment per visit Plan pays 70% 2010 Standard RPPO 079 -526 Humana.com 9/30/2009 HUMANA Guidance when you need it most Additional Medical Services (continued) • Freestanding laboratory Plan pays 100% Plan pays 70% • Chemotherapy Plan pays 80% after $35 copayment per visit to a specialist; Plan pays 100% after $50 copayment per visit to outpatient hospital Plan pays 70% in all places of treatment • Renal dialysis Plan pays 100% per visit to dialysis center; Plan pays 80% to outpatient hospital Plan pays 100% per visit to dialysis center; Plan pays 80% to outpatient hospital • Radiation therapy Plan pays 100% after $35 copayment per visit to specialist; Plan pays 100% after $50 copayment per visit at freestanding radiological facility; Plan pays 100% after $60 copayment per visit at outpatient hospital Plan pays 70% in all places of treatment • Home health care Plan pays 100% Plan pays 70% • Medicare - covered Part B drugs Plan pays 80% in all places of treatment Plan pays 80% in all places of treatment • Durable medical equipment Plan pays 80% in all places of treatment Plan pays 70% in all places of treatment • Prosthetics, orthotics, and other medical supplies Plan pays 80% in all places of treatment Plan pays 70% in all places of treatment • Diabetic monitoring supplies Plan pays 100% in all places of treatment Plan pays 70% in all place of treatment • US Travel benefit Member receives in network benefits when services are received from a participating PPO provider in another Humana PPO service area N/A Mental and Nervous Disorder Services • Inpatient psychiatric care (all authorized admissions) Plan pays 100% after $675 copayment per admission; 190- day lifetime limit Plan pays 70 %; 190 -day lifetime limit • Inpatient psychiatric physician services Plan pays 100% Plan pays 70% • Outpatient psychiatric care — partial hospitalization Plan pays 100% after $35 copayment per visit Plan pays 70% • Outpatient hospital mental health services Plan pays 100% after $85 copayment per visit Plan pays 70% Alcohol and Substance Abuse Services • Inpatient alcohol and substance abuse services (all authorized admissions) Plan pays 100% after $675 copayment per admission Plan pays 70% • Inpatient alcohol and substance abuse physician services Plan pays 100% Plan pays 70% • Outpatient hospital alcohol and substance abuse services — partial hospitalization Plan pays 100% after $35 copayment per visit Plan pays 70% 2010 Standard RPPO 079 -526 Humana.com 9/30/2009 HUMANA when you need it most Alcohol and Substance Abuse Services (continued) • Outpatient hospital alcohol and substance abuse services Plan pays 100% after $85 copayment per visit Plan pays 70% Medicare - Covered and Routine Services • Dental - Medicare- covered services • Routine DEN747 -FL / DEN749 -Non FL -One oral exam and one cleaning every 6 months; one bitewing /X -ray per calendar year - Emergency Services (includes non- surgical extraction) (unlimited) - Restorative (one per mouth every 3 calendar years) Plan pays 100% after $35 copayment per visit Plan pays 75% Plan pays 50% Plan pays 25% Plan pays 70% Plan pays 50% Plan pays 45% Plan pays 20% • Hearing Plan pays 100% after $35 copayment per visit - Medicare- covered services only, routine services not covered Plan pays 70% - Medicare - covered services only, routine services not covered • Vision • Post Cataract Surgery Plan pays 100% after $35 copayment per visit - Medicare- covered services only, routine services not covered Plan pays 100% for eyeglasses and contacts following cataract surgery Plan pays 70% - Medicare - covered services only, routine services not covered Plan pays 100% after annual deductible for eyeglasses and contacts following cataract surgery Extra Benefits • SilverSneakers® - SilverSneakers® is not available to members who reside in Arizona or Pennsylvania In most service areas members wil have free membership to a local fitness center through the SilverSneakers® Program. The SilverSneakers® Fitness Program offers your retirees free membership at a warm and friendly fitness center. Enrollment is easy and there is no initiation fee or contract. • Silver & FitTM - Silver & Fit is only available to members who reside in Arizona or Pennsylvania The Silver & FitTM Fitness Program, designed specifically for Medicare beneficiaries, is a total health and physical activity program that is beneficial for Medicare- eligible persons on all fitness levels. Eligible members receive a basic fitness center membership at a contracted fitness center that includes all the amenities offered at that location. • Humana Active Outlook`" Humana Active Outlook Program includes HAO Magazine, Life - Works- Member Assistance Program, and other health and wellness education materials. • QuitNet® A comprehensive smoking cessation service. Its features include the Customized QuitNet ®Website, telephone counseling /coaching, the QuitNet® QuitGuide, and QuitTips e-mail support. • HumanaFirst® A toll -free 24 -hour, 7 day a week medical information service staffed with specially trained registered nurses to assist in immediately answering questions on symptom related health conditions. Also available is an audio text library to access information on a variety of health topics. 2010 Standard RPPO 079 -526 Humana.com 9/30/2009 H UMA.1 ALA. Guidance when you need it most Care Management • Clinical Programs /Disease Management (3) - CHF - Congestive Heart Failure - COPD - Chronic Obstructive Pulmonary Disease - ESRD - End Stage Renal Disease - Diabetes - Rare Disease Program - this program includes the following diseases /conditions: ALS, Cystic Fibrosis, Parkinson's, Lupus, Rheumatoid Arthritis, Dermatomyositis, Myasthenia Gravis, Polymyositis, Hemophilia, Scleroderma, Sickle Cell Anemia, CIDP, Multiple Sclerosis Transplant Program CKD - Chronic Kidney Disease (this program is a pilot program offered only to members in the Kansas City market at this time, which is the site of the pilot) (1) All coinsurance percentages are based on the Medicare fee schedule and not billed charges. (2) Emergency room copayment waived if admitted or if hospital is outside the U.S. (3) We have provided examples of various Health Education and clinical programs. Actual programs may vary by market. 2010 Standard RPPO 079 -526 Humana.com 9/30/2009 HUMANA Guidance when you need it most The products and services described below are neither offered nor guaranteed under our contract with the Medicare program. They are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Humana grievance process. Extra Services • Complimentary & Alternative Medicine The American WholeHealth network provides complimentary & alternative medicine discount services for Humana members and includes more than 25,000 practitioners. • EyeMed Vision Discount EyeMed Vision Care provides all Humana members reduced rates through the discount program. Discounts include savings on eyewear, contact lenses, laser vision correction, and eye exams. The EyeMed program offers national access to over 48,000 eye care professionals, including private practice optometrists, ophthalmologists, and opticians. Humana members present their member ID card to the EyeMed provider at the time of service to receive their savings. Members can also access a printable discount card that can be presented at the time of service. There are no claims to file, no deductibles to meet, and no waiting for reimbursement. Savings are applied directly to the member's purchase. • HumanaDental Discount The HumanaDental discount is easy to use. Visit Humana.com or call HumanaDental at 1- 800 -898 -0371 (TTY: 1- 800 - 833 -3301) to find a dentist in your area. The HumanaDental dentist will charge the negotiated fee, and you make the payment right after receiving services. Members residing in Florida have a similar dental discount program through CAREINGTON. Visit www.Unified.cidental.com or call 1- 800 - 290 -0523 for more information. • Hearing Aids and Care Humana has teamed with TruHearing, HearUSA and Newport Audiology Hearing Centers to provide services and discounts that include savings of $600 to $2,700 off retail costs on state -of- the -art digital hearing aids, a free comprehensive hearing exam using the latest diagnostic equipment, and follow -up office visits. These vendors provide a return guarantee within 45 days of purchase plus a one -year warranty on lost or damaged instruments and a two -year limited product warranty. • Hearing Discount You receive discounts for hearing aids and a free hearing screening at Beltone hearing care locations. Not available to members who reside in Illinois, Nevada, and Florida. • Lifeline® Medical Alert Systems Humana has partnered with Lifeline® Medical Alert Systems to help you live a more independent, active life at home. You receive discounted rates on the installation of Lifeline CarePartners Home Communicator and lower monthly fees for monitoring services, provided 24- hours -a -day all year. • Nutritional Supplement Discount You receive discounted prices on nutritional supplements available through HumanaMail. There is no charge for shipping and handling. • Over - The - Counter Discount You receive discounted prices on over the counter health and wellness products available through HumanaMail. There is no charge for shipping and handling. 2010 Standard RPPO 079 -526 Humana.com 9/30/2009 HUM ANA Guidance when you need it most Extra Services (continued) • Weight Management Discount (NutriSystem SilverTM) The goal of the NutriSystem Silver program is to help older Americans lose weight simply so they can enjoy vibrant, healthy lives. You get free membership and counseling, as well as free access to the NutriSystem community through our Website. When you sign up for the 28 -Day NutriSystem Silver program, you get a free 30 -day supply of Nutrihance® multivitamins and $30 off every order you place through the program. • eHarmony.com Discount The eHarmony environment is designed to help you meet compatible singles. After getting to know you through a detailed questionnaire, eHarmony does the searching for you and only presents you with matches that are pre- screened for compatibility with you. As a Humana Medicare member, you save 20% on a six - month eHarmony membership. • Roadside Assistance Discount Through the Auto Assist Plus® 24 -Hour Roadside Assistance Service, you and your spouse get comprehensive roadside assistance coverage in any owned vehicle you drive. Services include help with towing, flat tires, battery failure, lock -outs, and more at the Humana member -only price of $49.90 per year -- a retail value of $89. You can also enjoy savings on hotels, car rentals, and automotive services, at no additional cost. • Pharmacy Discount - This is optional for all employers in 2010. Certain types of prescription drugs often are not covered by prescription drug plans. But if your doctor prescribes any of these drugs to you, the pharmacy discount service can make them more affordable. This discount program can save you an average of 20% or more for prescription medicines. These include drugs for weight loss, impotence, hair loss, and many other conditions. To see if a drug qualifies for the discount program, go to Humana.com and use the "prescription tools" section of MyHumana, or check your evidence of coverage booklet. All major pharmacy chains participate in this discount program, as well as many independent pharmacies, so it's easy to find a participating pharmacy near you. 2010 Standard RPPO 079 -526 Humana.com 9/30/2009 HUMA rA Guidance when you need it most GENERAL LIMITATIONS AND EXCLUSIONS OF MEDICAL BENEFITS Your benefits do not include the following, except as otherwise noted: Abortions, except in cases of rape, incest or for life- endangering medical reasons. Acupuncture Ambulance service for nonemergency care to a physician's office, ambulance service for routine maintenance dialysis (unless medically necessary), ambulance service when another means of transportation could be used without endangering your health, or cost of air ambulance in excess of the amount payable for land ambulance when land ambulance would have sufficed. Assisted suicide Chiropractic services, except manual manipulation of the spine to correct a subluxation. Clinical Trials are not covered under the Humana Group Medicare Plan, but are covered under Medicare. If you choose to be part of a Medicare - qualifying clinical trial, you may continue to receive any care unrelated to the clinical trial through the Humana Group Medicare Plan. Custodial care /non- skilled nursing home care Emergency services (as part of the emergency room benefit) that are non- authorized, and routine conditions that do not appear to a prudent lay person to be based on an emergency medical condition. Experimental or investigational procedures, items and medications, as determined by Medicare; or Phase I and Phase II investigational treatments as outlined by the National Cancer Institute. When there is no Medicare national coverage policy or determination, we will, at our sole discretion, determine if a treatment is experimental or investigational. =ood allergy testing and treatment Hearing Care, except what is covered under Medicare. Medicare - covered services are limited to diagnostic hearing exams and treatment when a medical problem is present. Home health care services, including home health care blood transfusions, homemaker services, meals delivered to your home and nursing care on a full -time basis in your home, drugs and biologicals not covered by Medicare. Hospice services in a Medicare - participating hospice are not covered under the Humana Group Medicare Plan, but are covered under Medicare. If you become eligible to enroll in a hospice program, you may continue to receive care unrelated to the terminal condition through the Humana Group Medicare Plan and you may also use a network physician as your hospice attending physician. Hospital services for care and supplies not ordered by a physician, if such care and supplies would not be paid for under Medicare guidelines; convenience and personal care items which are billed separately such as telephone, television or radio; private duty nurses and a private room in a hospital, unless medically necessary. Immunizations, except as outlined as a preventive care benefit. Kidney dialysis • Home dialysis services not covered include: dialysis aides services to assist in home dialysis; home dialysis blood or packed red cells unless administered by a network physician or a network physician personally directs its administration or it is needed to prime your dialysis equipment and wages lost to you and your dialysis assistant during self- training. • Inpatient dialysis services not covered include inpatient hospital and skilled nursing facility costs when the stay is solely for maintenance dialysis. • Outpatient dialysis services not covered include expenses for ambulance or other transportation from your home to a physician's office or a medical facility for routine maintenance dialysis and lodging costs during outpatient dialysis treatment. Naturopath's services Nursing care on a full -time basis in your home or private duty nurses 2010 Standard RPPO 079 -526 Humana.com 9/30/2009 HUMANA:. Guidance when you need it most Jrthopedic and therapeutic shoes, except if they are part of a leg brace or are for individuals with severe diabetic foot disease. Orthotics and custom - fitted inserts in shoes are not covered unless they are for individuals with severe diabetic foot disease. Plastic, cosmetic, or reconstructive surgery, except when medically necessary as the result of an injury or tumor. Such surgery will also be covered if an objective physical impairment is present, which is defined as a direct measurable reduction of physical performance of an organ or body part. The presence of a psychological condition will not entitle you to coverage for plastic, cosmetic, or reconstructive surgery unless all other conditions are met. Breast reconstruction is only covered following a mastectomy. Religious aspects of care provided in Religious non - medical healthcare institutions Services for which you have other coverage, including military service - connected conditions as defined by the Veterans Administration for which care is received from the Veterans Administration by you or paid for you by the Veterans Administration. If you have Veterans Administration benefits, you may decide whether you will use those or the Humana Group Medicare Plan. However, the Humana Group Medicare Plan will not pay for services received from the Veterans Administration, services covered by another government program other than Medicare or Medicaid and services paid by workers' compensation, automobile liability insurance, employer group health plans, or any other type of insurance. The Humana Group Medicare Plan will become the secondary payer in cases such as workers' compensation, automobile liability, or other types of insurance. Services performed by immediate relatives or members of your household, or services for which neither you nor another party acting on your behalf has a legal obligation to pay. Skilled nursing facility if rehabilitation services or skilled nursing care are only required occasionally; or an inpatient stay is not necessary to receive the skilled rehabilitation services required; or the rehabilitation services no longer improve a condition or could be carried out by someone other than a skilled therapist; or care is custodial. Surgical treatment of morbid obesity, except when determined medically necessary. Therapeutic wigs i ransportation other than ambulance transportation Vision Care, except what is covered under Medicare. Medicare - covered vision care is limited to one pair of standard eyeglasses or contact lenses after each cataract surgery, annual glaucoma screening if you are determined to be at high risk for glaucoma, and diagnosis and treatment of diseases and conditions of the eye. HUMANA. Guidance when you need it most A Medicare - approved PPO available to anyone enrolled in both Part A and Part B of Medicare through age or disability. Copayment, service area, and benefit limitations may apply. 2010 Standard RPPO 079 -526 Humana.com 9/30/2009 HUMAN. Guidance when you need it most HUMANA GROUP MEDICARE PFFS PLAN 2010 Plan 078 Option 026 This is a brief summary of services and is not intended to be a complete description of benefits, exclusions and limitations. Please refer to your Evidence of Coverage for additional information regarding covered services and limitations or any other contractual conditions. All services must be medically necessary. Coinsurance and copayments are due when services are rendered. For a complete description of benefits, exclusions and limitations please refer to the actual Evidence of Coverage. If a discrepancy arises between this information and the actual Evidence of Coverage, the Evidence of Coverage will prevail in all instances. Annual Out -Of- Pocket Maximum (1) $6,000 per individual per calendar year (excludes Pharmacy, World Wide Coverage, Extra Services, and the Plan Premium) Annual Deductible (1) None Benefit Plan Coverage Physician Services • Primary care physician (PCP) - Diagnostic procedures and lab services - Surgical procedures - Allergy shots and injections - Mental health and substance abuse services - Smoking Cessation (Medicare - covered services) Plan pays 100% after $15 copayment per visit • Specialist - Diagnostic procedures and lab services - Surgical procedures - Podiatry (Medicare- covered services) - Chiropractic (Medicare - covered services) - Allergy shots and injections - Mental health and substance abuse services - Smoking Cessation (Medicare - covered services) Plan pays 100% after $35 copayment per visit • Drugs administered in a physician's office Plan pays 80% Preventive Services • Bone mass measurement (one per year) • Colorectal screening (one per year) • Pap smears, pelvic exams, and prostate Cancer screening (one per year) • Routine physical (one per year) • Mammography screening (one per year) • Diabetes self - management • Nutritional therapy (diabetic or ESRD patients) • Immunizations Plan pays 100% in all places of treatment Inpatient Hospital Services • Inpatient Plan pays 100% after $225 copayment per day (days 1 -7) per admission • Inpatient physician services Plan pays 100% Outpatient Hospital Services • Outpatient surgical services Plan pays 80% • Outpatient advanced imaging, nuclear medicine, diagnostic procedures, and radiation therapy Plan pays 75% • Outpatient lab services Plan pays 100% • Observation Plan pays 75% • Outpatient physician services Plan pays 100% Emergency Services • Emergency room Plan pays 100% after $50 copayment per visit (not waived if admitted) 2010 Standard PFFS 078 -026 Humana.com 10/23/2009 HUMANA.o: uic>ance when you need k most Emergency Services (continued) • Emergency room physician services Plan pays 100% • Urgent care Plan pays 100% after $35 copayment per visit at an immediate care facility • World Wide Coverage Plan pays 80% after $250 deductible up to $25,000 maximum annual benefit or 60 consecutive days, whichever is reached first • Ambulance Plan pays 80% Additional Medical Services • Skilled nursing facility Plan pays 100% from days 1 -14 — no three - day hospital stay is required; Plan pays 100% after $100 copayment per day (days 15 -100); Plan pays $0 after 100 days • Skilled nursing facility physician services Plan pays 100% • Outpatient therapy (cardiac, occupational, physical, respiratory, audiology, and speech) Plan pays 80% to a specialist office or comprehensive outpatient rehab facility; Plan pays 75% to a outpatient hospital • Freestanding radiological facility Plan pays 80% • Ambulatory surgical center Plan pays 75% • Freestanding laboratory Plan pays 100% • Chemotherapy Plan pays 80% in all places of treatment • Renal Dialysis Plan pays 80% in all places of treatment • Home health care Plan pays 100% • Medicare - covered Part B drugs Plan pays 80% in all places of treatment • Durable medical equipment Plan pays 80% in all places of treatment • Prosthetics, orthotics, and other medical supplies Plan pays 80% in all places of treatment • Diabetic monitoring supplies Plan pays 100% in all places of treatment Mental and Nervous Disorder Services • Inpatient psychiatric care Plan pays 100% after $225 copayment per day (days 1 -7) per admission; 190 -day lifetime limit • Inpatient psychiatric physician services Plan pays 100% • Outpatient psychiatric care — partial hospitalization Plan pays 80% • Outpatient hospital mental health services Plan pays 75% Alcohol and Drug Abuse Services • Inpatient alcohol and substance abuse services Plan pays 100% after $225 copayment per day (days 1 -7) per admission • Inpatient alcohol and substance abuse physician services Plan pays 100% • Outpatient alcohol and substance abuse services — partial hospitalization Plan pays 80% • Outpatient hospital alcohol and substance abuse services Plan pays 75% 2010 Standard PFFS 078 -026 Humana.com 10/23/2009 HUMANL3 C.rui once when you need it most Medicare - Covered Services • Dental Plan pays 100% after $35 copayment per visit, Medicare - covered services only, routine services not covered • Hearing Plan pays 100% after $35 copayment per visit, Medicare - covered services only, routine services not covered • Vision • Post - cataract surgery Plan pays 100% after $35 copayment per visit, Medicare - covered services only, routine services not covered Plan pays 100% for eyeglasses and contacts following cataract surgery Extra Benefits • SilverSneakers® - SilverSneakers' is not available to members who reside in Arizona or Pennsylvania In most service areas members will have free membership to a local fitness center through the SilverSneakers® Program. The SilverSneakers® Fitness Program offers your retirees free membership at a warm and friendly fitness center. Enrollment is easy and there is no initiation fee or contract. • Silver & FitTM - Silver & FitTM is only available to members who reside in Arizona or Pennsylvania The Silver & FitT"" Fitness Program, designed specifically for Medicare beneficiaries, is a total health and physical activity program that is beneficial for Medicare - eligible persons on all fitness levels. Eligible members receive a basic fitness center membership at a contracted fitness center that includes all the amenities offered at that location. • Humana Active Outlook® Humana Active Outlook Program includes HAO Magazine, Life - Works- Member Assistance Program, and other health and wellness education materials. • QuitNet A comprehensive smoking cessation service. Its features include the Customized QuitNet® Website, telephone counseling /coaching, the QuitNet® QuitGuide, and QuitTips e-mail support. • HumanaFirst® A toll -free 24 -hour, seven day a week medical information service staffed with specially trained registered nurses to assist in immediately answering questions on symptom related health conditions. Also available is an audio text library to access information on a variety of health topics. 2010 Standard PFFS 078 -026 Humana.com 10/23/2009 HUMANA Guidance when you need it most Care Management • Clinical Programs /Disease Management (2) - CHF - Congestive Heart Failure - COPD - Chronic Obstructive Pulmonary Disease - ESRD - End Stage Renal Disease - Diabetes - Rare Disease Program - this program includes the following diseases /conditions: ALS, Cystic Fibrosis, Parkinson's, Lupus, Rheumatoid Arthritis, Dermatomyositis, Myasthenia Gravis, Polymyositis, Hemophilia, Scleroderma, Sickle Cell Anemia, CIDP, Multiple Sclerosis - Transplant Program - CKD - Chronic Kidney Disease (this program is a pilot program offered only to members in the Kansas City market at this time, which is the site of the pilot) (1) All coinsurance percentages are based on the Medicare fee schedule and not billed charges. (2) We have provided examples of various Health Education and clinical programs. Actual programs may vary by market. 2010 Standard PFFS 078 -026 Humana.com 10/23/2009 HUMANA, Guidance when you need it most The products and services described below are neither offered nor guaranteed under our contract with the Medicare program. They are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Humana grievance process. Extra Services • Complimentary & Alternative Medicine The American WholeHealth network provides complimentary & alternative medicine discount services for Humana members and includes more than 25,000 practitioners. • EyeMed Vision Discount EyeMed Vision Care provides all Humana members reduced rates through the discount program. Discounts include savings on eyewear, contact lenses, laser vision correction, and eye exams. The EyeMed program offers national access to over 48,000 eye care professionals, including private practice optometrists, ophthalmologists, and opticians. Humana members present their member ID card to the EyeMed provider at the time of service to receive their savings. Members can also access a printable discount card that can be presented at the time of service. There are no claims to file, no deductibles to meet, and no waiting for reimbursement. Savings are applied directly to the member's purchase. • HumanaDental Discount The HumanaDental discount is easy to use. Visit Humana.com or call HumanaDental at 1- 800 -898 -0371 (TTY: 1- 800 - 833 -3301) to find a dentist in your area. The HumanaDental dentist will charge the negotiated fee, and you make the payment right after receiving services. Members residing in Florida have a similar dental discount program through CAREINGTON. Visit www.Unified.cidental.com or call 1 -800- 290 -0523 for more information. Not available in Puerto Rico. • Hearing Aids and Care Humana has teamed with TruHearing, HearUSA and Newport Audiology Hearing Centers to provide services and discounts that include savings of $600 to $2,700 off retail costs on state -of- the -art digital hearing aids, a free comprehensive hearing exam using the latest diagnostic equipment, and follow -up office visits. These vendors provide a return guarantee within 45 days of purchase plus a one -year warranty on lost or damaged instruments and a two -year limited product warranty. • Hearing Discount You receive discounts for hearing aids and a free hearing screening at Beltone hearing care locations. Not available to members who reside in Illinois, Nevada, and Florida. 2010 Standard PFFS 078 -026 Humana.com 10/23/2009 HUMANA Guidance when you need it mow.. Extra Services (continued) • Lifeline® Medical Alert Systems Humana has partnered with Lifeline® Medical Alert Systems to help you live a more independent, active life at home. You receive discounted rates on the installation of Lifeline CarePartners Home Communicator and lower monthly fees for monitoring services, provided 24- hours -a -day all year. Not available to members who reside in Puerto Rico. • Nutritional Supplement Discount You receive discounted prices on nutritional supplements available through HumanaMail. There is no charge for shipping and handling. • Over - The - Counter Discount You receive discounted prices on over the counter health and wellness products available through HumanaMail. There is no charge for shipping and handling. • Weight Management Discount (NutriSystem SilverTM) The goal of the NutriSystem SilverTM program is to help older Americans lose weight simply so they can enjoy vibrant, healthy lives. You get free membership and counseling, as well as free access to the NutriSystem community through our Website. When you sign up for the 28 -Day NutriSystem SilverTM program, you get a free 30-day supply of Nutrihance® multivitamins and $30 off every order you place through the program. • eHarmony.com Discount The eHarmony environment is designed to help you meet compatible singles. After getting to know you through a detailed questionnaire, eHarmony does the searching for you and only presents you with matches that are pre- screened for compatibility with you. As a Humana Medicare member, you save 20% on a six - month eHarmony membership. Not available to members who reside in Puerto Rico. • Roadside Assistance Discount Through the Auto Assist Plus® 24 -Hour Roadside Assistance Service, you and your spouse get comprehensive roadside assistance coverage in any owned vehicle you drive. Services include help with towing, flat tires, battery failure, lock -outs, and more at the Humana member -only price of $49.90 per year -- a retail value of $89. You can also enjoy savings on hotels, car rentals, and automotive services, at no additional cost. Not available to members who reside in Puerto Rico. 2010 Standard PFFS 078 -026 Humana.com 10/23/2009 HUMANA Guidance when you need it most Extra Services (continued) • Pharmacy Discount - This is optional for employers in 2010. Certain types of prescription drugs often are not covered by prescription drug plans. But if your doctor prescribes any of these drugs to you, the pharmacy discount service can make them more affordable. This discount program can save you an average of 20% or more for prescription medicines. These include drugs for weight loss, impotence, hair loss, and many other conditions. To see if a drug qualifies for the discount program, go to Humana.com and use the "prescription tools" section of MyHumana, or check your evidence of coverage booklet. All major pharmacy chains participate in this discount program, as well as many independent pharmacies, so it's easy to find a participating pharmacy near you. 2010 Standard PFFS 078 -026 Humana.com 10/23/2009 HUMANA when you need it most GENERAL LIMITATIONS AND EXCLUSIONS OF MEDICAL BENEFITS Your benefits do not include the following, except as otherwise noted: Abortions, except in cases of rape, incest or for life- endangering medical reasons. Acupuncture Ambulance service for nonemergency care to a physician's office, ambulance service for routine maintenance dialysis (unless medically necessary), ambulance service when another means of transportation could be used without endangering your health, or cost of air ambulance in excess of the amount payable for land ambulance when land ambulance would have sufficed. Assisted suicide Chiropractic services, except manual manipulation of the spine to correct a subluxation. Clinical Trials are not covered under the Humana Group Medicare Plan, but are covered under Medicare. If you choose to be part of a Medicare - qualifying clinical trial, you may continue to receive any care unrelated to the clinical trial through the Humana Group Medicare Plan. Custodial care /non - skilled nursing home care Dental care, except what is covered under Medicare. Medicare- covered services are limited to medically necessary surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease, or services that would be covered when provided by a doctor. Emergency services (as part of the emergency room benefit) for routine conditions that do not appear to a prudent lay person to be based on an emergency medical condition. ' xperimental or investigational procedures, items and medications, as determined by Medicare; or Phase I and Phase II investigational Lreatments as outlined by the National Cancer Institute. When there is no Medicare national coverage policy or determination, we will, at our sole discretion, determine if a treatment is experimental or investigational. Food allergy testing and treatment Hearing Care, except what is covered under Medicare. Medicare- covered services are limited to diagnostic hearing exams and treatment when a medical problem is present. Home health care services, including home health care blood transfusions, homemaker services, meals delivered to your home and nursing care on a full -time basis in your home, drugs and biologicals not covered by Medicare. Hospice services in a Medicare- participating hospice are not covered under the Humana Group Medicare Plan, but are covered under Medicare. If you become eligible to enroll in a hospice program, you may continue to receive care unrelated to the terminal condition through the Humana Group Medicare Plan. Hospital services for care and supplies not ordered by a physician, if such care and supplies would not be paid for under Medicare guidelines; convenience and personal care items which are billed separately such as telephone, television or radio; private duty nurses and a private room in a hospital, unless medically necessary. Immunizations, except as outlined as a preventive care benefit. Kidney dialysis • Home dialysis services not covered include: dialysis aides services to assist in home dialysis; home dialysis blood or packed red cells unless administered by a network physician or a network physician personally directs its administration or it is needed to prime your dialysis equipment and wages lost to you and your dialysis assistant during self- training. • Inpatient dialysis services not covered include inpatient hospital and skilled nursing facility costs when the stay is solely for maintenance dialysis. • Outpatient dialysis services not covered include expenses for ambulance or other transportation from your home to a physician's office or a medical facility for routine maintenance dialysis and lodging costs during outpatient dialysis treatment. 2010 Standard PFFS 078 -026 Humana.com 10/23/2009 HUMANA Guidance • when you need it most Naturopath's services Nursing care on a full -time basis in your home or private duty nurses Orthopedic and therapeutic shoes, except if they are part of a leg brace or are for individuals with severe diabetic foot disease. Orthotics and custom -fitted inserts in shoes are not covered unless they are for individuals with severe diabetic foot disease. Plastic, cosmetic, or reconstructive surgery, except when medically necessary as the result of an injury or tumor. Such surgery will also be covered if an objective physical impairment is present, which is defined as a direct measurable reduction of physical performance of an organ or body part. The presence of a psychological condition will not entitle you to coverage for plastic, cosmetic, or reconstructive surgery unless all other conditions are met. Breast reconstruction is only covered following a mastectomy. Religious aspects of care provided in Religious non - medical healthcare institutions Services for which you have other coverage, including military service - connected conditions as defined by the Veterans Administration for which care is received from the Veterans Administration by you or paid for you by the Veterans Administration. If you have Veterans Administration benefits, you may decide whether you will use those or the Humana Group Medicare Plan. However, the Humana Group Medicare Plan will not pay for services received from the Veterans Administration, services covered by another government program other than Medicare or Medicaid and services paid by workers' compensation, automobile liability insurance, employer group health plans, or any other type of insurance. The Humana Group Medicare Plan will become the secondary payer in cases such as workers' compensation, automobile liability, or other types of insurance. Services performed by immediate relatives or members of your household, or services for which neither you nor another party acting on your behalf has a legal obligation to pay. Skilled nursing facility if rehabilitation services or skilled nursing care are only required occasionally; or an inpatient stay is not necessary to receive the skilled rehabilitation services required; or the rehabilitation services no longer improve a condition or could be carried out by someone other than a skilled therapist; or care is custodial. Surgical treatment of morbid obesity, except when determined medically necessary. Therapeutic wigs Transportation other than ambulance transportation Vision Care, except what is covered under Medicare. Medicare - covered vision care is limited to one pair of standard eyeglasses or contact lenses after each cataract surgery, annual glaucoma screening if you are determined to be at high risk for glaucoma, and diagnosis and treatment of diseases and conditions of the eye. HUMANA Guidance when you need it most A Medicare - approved PFFS available to anyone enrolled in both Part A and Part B of Medicare through age or disability. Copayment, service area, and benefit limitations may apply. 2010 Standard PFFS 078 -026 Humana.com 10/23/2009 30 Day Home Infusion Drugs (3) a Is F, o o M M M co" F O Ea N E i- N a to r • 0) i- co to Out of Pocket that triggers Catastrophic (2) $4,550 30 Day Retail Cost Sharing from Catastrophic (2) to Unlimited Greater of $2.50 for generic/multiple source drugs ($6.30 for all others) or 5% coinsurance 30 Day Retail from ICL (1) to Catastrophic (2) "Coverage Gap" v L H o O o C., E o O N s- 0 H e' 0 O — r m F (3 30 Day Retail from $0 to ICL (1) v m i- o M M m o N I" H 3 s C) H co CA L ixx w E C 3 O Z co N 1 Plan /Option 078/026 079/526 Out of Pocket that triggers Catastrophic (2) coo Cf) CA 30 Day Mail Order Cost Sharing from Catastrophic (2) to Unlimited Greater of $2.50 for generic/multiple source drugs ($6.30 for all others) or 5% coinsurance 30 Day Mail Order from ICL (1) to Catastrophic (2) "Coverage Gap" a L Is H e C 0 M L. 4f c O N m F e O r m f 0 69 30 Day Mail Order from $0 to ICL (1) a F o M M m U, co N m F s r m U, L re w E OZ cm x IX Plan /Option 078/026 079/526 Y O C) C c N r C C CO U 'c O. E L o t a v C SC CO O c C C1 C) T co N ` Q CA U € O N c G t w c o a c E Vim Y N N to oA T l0 V C1 N O C) C oi .c CO co = C) C d E a) 7 C.) O N C6 I N w o c 76 C> O to' N f6 C) Jo a a) cfO0 3 w C E a = N m 1- C L CO O O V O. d C ` 4 69 d 2 3 0 p t E C m N V 11 O O CO C 0 N U CO N CO L t0 N O C '-' O W > N C�.0 CO CL o_ 6. E Ca CL E O , N N CO CO ('1 c L > N O H w O- L N f.. m O 7 'C O X y O ) 3a o C 3 O ,4 Q N O 7 'O O .G =O N N o O0 = w C aL E " 60 r t6 9 2 at ` = 7 O O p c (n O 2 C) N Ed v )uf)N N t C J E~ Gl f00-- L O m O) U T T C L o E o as c uJ a == U m 0 ° c o m d d t eh 76 CI � Q w G+e_ 2 E N C) V 0—t 0 N w WEE m C : a E O C C) N E p V U 2 3 t w L u..- N 09 O CO -0 a 2010 Standard Rx Option 26 REQUEST FOR PROPOSAL ADDENDUM CITY OF CORPUS CHRISTI PURCHASING DIVISION Request for Proposal No.: BI- 0153 -09 Addendum No.: 2 April 9, 2009 Prospective Proposers are hereby notified of the following modifications to Request for Proposal No. BI- 0153-09. All terms, conditions and specifications of the original Request for Proposal not in conflict with this addendum remain unchanged and continue in full force and effect. I. The following are questions submitted by prospective proposers and the City's responses thereto: 1. QUESTION: What does the City contribute to the post 65 health plan? ANSWER: Currently, retiree rates and contributions, both pre and post 65, are blended with active employees. Please see the attached rate and "contribution schedule ". 2. QUESTION: On the plan design for the post 65 employees we NOT being ask to match their current benefits is that correct? Union plan be the same? ANSWER: The City is asking that you model your proposed benefit offer on the Citicare Civilian benefit plan design to be offered to all retirees, both the pre and post 65. 3. QUESTION: On the pre -65 retirees what is the City Contribute? ANSWER: Currently, retiree rates and contributions, both pre and post 65, are blended with active employees. Please see the attached rate and "contribution schedule ". 4. QUESTION: Are all Medicare eligible retirees on the plan. Are 100% of the retirees on the plan. ANSWER: Only retirees who have elected to participate are currently enrolled. 5. QUESTION: Please provide current rates for retirees. ANSWER: Please see Exhibit J as published in Addendum 1. 6. QUESTION: Is the City of Corpus Christi asking for an agent on the case? ANSWER: Quotes shall be provided net of fees and taxes. The City will not pay commissions and/or fees to an agent or broker working on behalf of Contractor. Any commission/fees must be paid to the agent/broker by the Proposer at Proposer's expense. Any such fees paid or to be paid must be fully disclosed including specific amounts /percentages and the name and address of the individual or organization to whom said fees are paid. 7. QUESTION: Is Corpus Christi a member of PEBA? ANSWER: No. 8. QUESTION: Please provide paid claims and covered subscribers /employee data by month separated by Fire, Police and Civilian plans from 8 -1 -06 through the most current month (February, 2009). ANSWER: See attached spreadsheet for claims data from 2007 to February 2009. 9. QUESTION: Please provide a census key to understand the codes reflected in each column of the census file. ANSWER: Please see applicable attachment. 10. QUESTION: We understand that the City is offering 4 plans to members: Citicare, Fire, Public Safety, & Police. Are Police and Public Safety the same group of employees? If not, please elaborate. ANSWER: The City has four plans offered to three categories of employees / retirees currently. Civilians (Citicare PPO, Citicare Alternate), Fire, and Public Safety. Police and Public Safety are the same group of employees. 11. QUESTION: Please confirm the pharmacy plan design for Police. For Public Safety if a separate group. ANSWER: The pharmacy plan designs for each segment are summarized in the benefit booklet descriptions. 12. QUESTION: Does the City offer Rx mail order benefits to members? If so, what are the co -pays for each tier for mail order; for each specific plan design? ANSWER: Yes, mail order provides 90 -day supply at cost equal to 60 -day retail. Mail order not applicable to Fire and Public Safety plans. 13. QUESTION: Please provide a current eligible census including gender, date of birth, home zip code, tier and current enrolled plan (if any); the preferred format is a subscriber -based census for pre -65 (non- Medicare eligible) and a member -based census for post -65 (Medicare eligible). ANSWER: This information is contained in the Exhibits (Excel file) already published with the RFP. 14. QUESTION: Please provide Pre -65 and post -65 monthly Medical claims and enrollment for past 24 months (specify if paid/incurred). ANSWER: See attached spreadsheet for claims data from 2007 to February 2009. 15. QUESTION: Please provide Pre -65 and post -65 monthly Pharmacy claims and enrollment for past 24 months (specify if paid/incurred and if rebates are included/excluded). ANSWER: See attached spreadsheet for claims data from 2007 to February 2009. 16. QUESTION: Please describe any value -added services included in each plan design (for example, disease management programs, high - performance networks, patient safety programs, etc.). ANSWER: Incentivized wellness program from Virgin Life, Nurse advice line which provides nurse triage and general health care information, Humana Beginnings services for expectant mothers which assists in identifying high -risk pregnancies for individual case management services, Neonatal Intensive Care Unit Support provided to premature and sick newborns admitted to the Neonatal Intensive Care Unit and Disease management programs that provide education and assistance to members for specified diseases. 17. QUESTION: Please provide large claims (over $50,000) for the most recent 12 -month period with diagnosis, current course of treatment, claimant status and claims activity for this individual for the last three months; for each claimant, identify the plan and status (active, pre- or post -65). ANSWER: This information is provided in the Exhibits (Excel file) published with the original RFP. The City will not provide prognosis information. 18. QUESTION: What is the current Medicare integration method (MOB, COB, etc.) for post -65 claims experience? ANSWER: COB. 19. QUESTION: Please confirm of whether part time or seasonal rehires are eligible for the program; if applicable, an estimate of the eligible number, as well as how they are paid (for example, W -2 form). ANSWER: Part-time and seasonal hires are not eligible. 20. QUESTION: Please provide claims of $100,000 or more for past three years by eligibility class, including the prognosis and diagnosis? ANSWER: See attached spreadsheet for claims data from 2007 to February 2009. 21. QUESTION: Need claims experience broken out by plan for both the medical and Rx for past 3yrs. ANSWER: See attached spreadsheet for claims data from 2007 to February 2009. 22. QUESTION: In Exhibit H (census), there are various Benefit Codes (column N). Are CCFIR & FIRE the same plan and are CCPOL & PUBSTY the same plan as well? If not, please provide a key as which plan summaries belong to each specific benefit code within the census. ANSWER: Yes, CCFIR and Fire are the same plan as are CCPOL and PUBSTY. 23. QUESTION: What are the current premium rate equivalents for the Medical & Rx plans from the past 3yrs? ANSWER: Please see Addendum 1. The City does not separate the funding rates into medical and Rx. 24. QUESTION: We will need the blended and unblended rates for the past 3yrs for the post 65 retirees. ANSWER: The City has only used blended rates, therefore, there is no unblended rate history. 25. QUESTION: Is it possible to provide the following for each plan offered so that we may quote an Rx solution as well: a) copy of the formulary b) exclusions c) the non - Medicare Part D drugs that are covered d) do you pool all plans together or separately e) clinical edits: Prior Authorization, Quantity Limits and Step Therapy. f) Need claims experience for the post 65 retiree's broken out by plan for Rx. Number of scripts by month, broken down by generic, preferred and non preferred brand and total claims cost by month. ANSWER: a) View formulary on Humana.com website. b) Please refer to the SPDs that were released with the RFP c) Please refer to the SPDs that were released with the RFP d) The existing plans are pooled separately in order to determine the blended rates. e) Please refer to the SPDs that were released with the RFP. f) See attached spreadsheet for claims data from 2007 to February 2009. 26. QUESTION: Need the RFP in Word, un- protected, so we can address the questions by sections making the RFP easier to read and evaluate for the City. ANSWER: This document is unprotected. 27. QUESTION: Have you been advised by legal counsel that you can provide one plan for all your post 65 retirees? ANSWER: The City may provide one fully insured plan for all post -65 retirees. 28. QUESTION: Regarding the Police & Fire Trust Fund -Can you provide the estimated dollar or percentage amounts that subsidize the retiree's monthly premiums? ANSWER: See Addendum 1. 29. QUESTION: Does the City currently take the RDS subsidy? Do they plan to continue to do so? ANSWER: The City does currently take the RDS subsidy and plans to continue to do so. Reports are not currently available. 30. QUESTION: Are all Post 65 retirees eligible for both Medicare parts A & B? ANSWER: Yes. 31. QUESTION: Please confirm that this will be list billed to the City and not direct billed to each retiree. ANSWER: Please provide your standard process for handling billing and collection. 32. QUESTION: Provide a copy of the CMS Retiree Drug Subsidy (RDS) annual report for Plan Year 2007, Plan year 2008 and Plan year 2009 if applicable. ANSWER: Annual report currently unavailable. 33. QUESTION: Provide prescription drug Paid Claims by month, for each group of Medicare covered retiree's for the period 8/1/07 - 2/1/09. ANSWER: See attached spreadsheet for claims data from 2007 to February 2009. 34. QUESTION: What is the city's total contribution, per retiree, to the Public Safety & Fire funds for plan years 81/07 & 8/1/08? ANSWER: See Addendum 1. 35. QUESTION: Has the city implemented a "Plan" to address their unfunded OPEB Liability? (Defined Contribution, Defined Benefit or a Combination of each ?) If yes, Please provide a copy of the Plan. ANSWER: The City is currently gathering information to formulate a plan and strategy. 36. QUESTION: What is the current Self Funded Plan Administrative Fee per employee, per month? ANSWER: The City declines to respond. 37. QUESTION: Can the City provide a copy of the PBM's Administrative Contract for the current plan year? ANSWER: The City declines to respond. 38. QUESTION: Does the City have Excess of Loss coverage on a Specific and Aggregate basis or just a Specific Basis? What is the cost per employee, per month for contracted coverage. ANSWER: The City declines to respond. 39. QUESTION: Can verification be provided that Texas Statutes will allow the City to "Carve Out" Retiree health coverage prior to the RFP due date? ANSWER: Yes, the City has concluded that a fully insured plan is permissible. 40. QUESTION: Please provide a current eligible census including gender, date of birth, home zip code, tier and current enrolled plan (if any); the preferred format is a subscriber -based census for pre -65 (non- Medicare eligible) and a member -based census for post -65 (Medicare eligible). ANSWER: See Addendum 1. 41. QUESTION: Please provide Pre -65 and post -65 monthly Medical claims and enrollment for past 24 months (specify if paid/incurred). ANSWER: See attached spreadsheet for claims data from 2007 to February 2009. 42. QUESTION: Please provide Pre -65 and post -65 monthly Pharmacy claims and enrollment for past 24 months (specify if paid /incurred and if rebates are included/excluded). ANSWER: See attached spreadsheet for claims data from 2007 to February 2009. 43. QUESTION: Please describe any value -added services included in each plan design (for example, disease management programs, high - performance networks, patient safety programs, etc.). ANSWER: The City enjoys the following value -added services: 1. Incentivized wellness program from Virgin Life. 2. Nurse advice line which provides nurse triage and general health care information. 3. Humana Beginnings services for expectant mothers which assists in identifying high -risk pregnancies for individual case management services. 4. Neonatal Intensive Care Unit Support provided to premature and sick newborns admitted to the Neonatal Intensive Care Unit. 5. Disease management programs which provide education and assistance to members for specified diseases. 44. QUESTION: Please provide large claims (over $50,000) for the most recent 12 -month period with diagnosis, current course of treatment, claimant status and claims activity for this individual for the last three months; for each claimant, identify the plan and status (active, pre- or post -65) ANSWER: This information is provided in the Exhibits (Excel file) published with the original RFP. Also see large claims data attached hereto. The City will not provide prognosis information. 45. QUESTION: What is the current Medicare integration method (MOB, COB, etc.) for post -65 claims experience? ANSWER: COB. 46. QUESTION: Please confirm whether part time or seasonal rehires are eligible for the program; if applicable, an estimate of the eligible number, as well as how they are paid (for example, W -2 form) ANSWER: Part -time and seasonal hires are not eligible. 47. QUESTION: Does the post -65 experience provided in Exhibit I reflect all benefit plans (i.e., Fire, Public Safety, etc)? Can you provide monthly experience /counts for each separate benefit plan? ANSWER: See attached spreadsheet for claims data from 2007 to February 2009. 48. QUESTION: Exhibit I shows that the # of post -65 claimants averaged 386 during the experience period. The current census in Exhibit H references 353 post -65 members. Please confirm that the City is experiencing declining enrollment. ANSWER: Due to increases in premium, the City is experiencing declining enrollment. 49. QUESTION: Per the census there are 353 post -65 members (214 CCare, 5 CCFire, 10 CCPo1, 75 Fire and 49 Pubsty). Please confirm. ANSWER: Correct. 50. QUESTION: The Citicare Plan Summary provided reflects a policy period of 08/01/08 - 07/31/09. The Citicare Plan Document illustrates an effective date of 08/01/04. The Plan Summary and Plan Document benefits differ. Please provide the Citicare Plan Document that took effect 8/1/08. ANSWER: The fiscal and benefit contract year cycle is 8/1 — 7/31. The document dated 8/1/04 is current for 8/1/08. 51. QUESTION: Did the City make any benefit plan changes between PYE 8/07 and PYE 8/08? If so, please provide us with the PYE 8/07 benefit plan designs. ANSWER: See attached document. 52. QUESTION: Please provide current administration fees if possible. ANSWER: The City declines to respond. 53. QUESTION: Which of the current plans exclude a formulary? ANSWER: Formulary for Fire and Public Safety is excluded. 54. QUESTION: Please explain the subsidy policy as it relates to the Citicare Civilian and City Alternate Choice plans retirees. ANSWER: See Addendum 1. 55. QUESTION: Please explain 3.3, question 32 and its relevance to the retiree population. Waive actively -at -work clause on new entrants into the plan. ANSWER: Confirm that your policy will not exclude benefits that are commonly captured in any "actively -at- work" provision as it might apply to employees who retire and their dependents on the date coverage is effective. 56. QUESTION: Concerning section 3.5 Technical Solution, A. Provider / Network Access and Administration Question #1, Please clarify how you would like the data requested? Our GeoAccess reports are only available in read -only files. We need clarification as to whether you would like the Excel spreadsheet data used to generate the GeoAccess report in a read /write format or if the full GeoAccess finished report needs to be in a read/write format? ANSWER: The finished report may be provided in a read -only format. Citicare Basic Plan Changes for Plan Year 8 -1 -07 to 7 -31 -08 Benefit Current Plan Approved Changes 06/07 07/08 Co -pays Physician services In & Out Patient Specialist Emergency Room Urgent Care Vision Exam (routine or other) $22 Co -pay PCP $22 Co -pay $17 Co -pay $22 Co -pay $22 Co -pay $15 Co -pay PCP (Family, General, Pediatrician, Internal, NP, PA, RN, OB -GYN $30 Co -pay $30 Co -pay $30 Co -pay $30 Co -pay HPV Vaccination Not covered Cover at Co- pay /100% Females ages 12 -26 Therapy Services: Chiropractic Manipulations/Therapy Physical Occupational Speech Cognitive $22 $30 Preventive (formerly called Wellness) $300 max None $500 max for; routine; exams, x- ray, PSA, blood work, mammogram, pap smear, colonoscopy, sigmoidoscopy, proctosignoindoscopy. Elig. expenses over $500 max will then go to Ded/Co- Insurance Routine Pap Routine Mammogram Routine PSA Up to $100 Up to $100 Up to $75 Included in Preventive benefit as stated above Diagnostic - Outpatient Co -pay $17 Co -pay $20 Lab, X -ray, & Allergy Testing Co -pay $50; MRI, CAT, PET, SPECT Scans. All Acupuncture Co -pay $22 Excluded from Coverage Family Planning Injections/Implants System (Norplant) Co -pay $22 Co -pay $30 The plan changes as approved for plan year 8 -1 -07 to 7 -31 -08 become part of the plan document by reference. All Plan changes are still subject to the $5,000 Maximum Annual Plan Benefit per individual paid by plan. Rev. 05/07 Citicare and Alternate Choice Plan Changes for Plan Year 8 -1 -08 to 7 -31 -09 (This does not include the Public Safety or Fire Plans) Benefit Current Plan Proposed Changes 07/08 08/09 Lap band procedure for Obesity as medically necessary Not covered Cover as regular plan benefits for surgery Chiropractic Services No limitations Limit visits to no more than 52 in a plan year. The plan changes as approved for plan year 8 -1 -08 to 7 -31 -09 become part of the plan document by reference. verage Code Benefit Plan I Retiree Only under 65 J Retiree under 65 & Spouse Only K Retiree under 65 & Children L Retiree under 65 & family M Retiree Spouse Only N Retiree Children Only 0 Retiree's Spouse & Children P Retiree Only.65+ Q Retirees Spouse 65+ R Retiree & Spouse 65+ S Retiree65+ & Spouse 65- T Retiree 65- & Spouse 6.5+ U Retiree 65+ & Children V Spouse over 65 & Children. X Retiree65+ &Family under 65 Y Retiree- 65 &Spouse65+ &Children Z Retiree65 + &Sp65+ &Children "ALL OTHER ITEMS AND CONDITIONS REMAIN UNCHANGED" Paul Pierce Procurement Manager ACKNOWLEDGED BY: FIRM NAME AUTHORIZED SIGNATURE DATE ONE ORIGINAL SIGNED AND DATED ADDENDUM 2 AND TWELVE COPIES OF THIS ORIGINAL SIGNED AND DATED ADDENDUM 2 MUST BE RETURNED TO THE PURCHASING DIVISION WITH YOUR PROPOSAL. CITY OF CORPUS CHRISTI GROUP #675908 CLAIMS - RETIREE DIVISION ONLY by CLUSTERS by PROCESSED MONTH REPORTING PERIOD: 8/1 /2007 - 1/31/2009 INCURRED BASIS Report Cluster Processed Month Pre65 / Post65 # of Claimants Medical Claim Dollars Pharamcy Claim Dollars Total Net Paid Amount Citicare 200708 POST65 168 $0.00 $30,457.07 $30,457.07 Citicare 200708 PRE65 126 $0.00 $16,745.26 $16,745.26 Citicare 200709 POST65 162 $39.72 $27,014.13 $27,053.85 Citicare 200709 PRE65 152 $43,487.71 $15,098.13 $58,585.84 Citicare 200710 POST65 184 $16,987.33 $41,624.91 $58,612.24 Citicare 200710 PRE65 162 $130,581.93 $21,700.37 $152,282.30 Citicare 200711 POST65 196 $56,035.22 $29,583.45 $85,618.67 Citicare 200711 PRE65 186 $162,246.99 $17,421.74 $179,668.73 Citicare 200712 POST65 194 $63,946.64 $31,933.08 $95,879.72 Citicare 200712 PRE65 168 $112,580.69 $16,644.94 $129,225.63 Citicare 200801 POST65 201 $46,228.08 $38,361.62 $84,589.70 Citicare 200801 PRE65 178 $101,521.01 $19,281.96 $120,802.97 Citicare 200802 POST65 198 $71,821.56 $34,459.29 $106,280.85 Citicare 200802 PRE65 166 $134,912.56 $22,863.11 $157,775.67 Citicare 200803 POST65 205 $30,382.96 $33,910.67 $64,293.63 Citicare 200803 PRE65 169 $95,843.71 $21,015.14 $116,858.85 Citicare 200804 POST65 209 $56,879.15 $45,747.34 $102,626.49 Citicare 200804 PRE65 173 $150,660.56 $18,590.30 $169,250.86 Citicare 200805 POST65 200 $53,384.29 $40,899.11 $94,283.40 Citicare 200805 PRE65 174 $122,641.51 $21,319.25 $143,960.76 Citicare 200806 POST65 198 $56,250.29 $35,207.03 $91,457.32 Citicare 200806 PRE65 180 $319,415.86 $27,631.89 $347,047.75 Citicare 200807 POST65 208 $61,592.53 $44,799.24 $106,391.77 Citicare 200807 PRE65 170 $91,433.16 $19,137.24 $110,570.40 Citicare 200808 POST65 197 $43,323.58 $36,855.96 $80,179.54 Citicare 200808 PRE65 198 $94,002.68 $20,267.27 $114,269.95 Citicare 200809 POST65 204 $39,944.80 $38,702.30 $78,647.10 Citicare 200809 PRE65 190 $84,707.05 $16,111.74 $100,818.79 Citicare 200810 POST65 215 $62,320.87 $38,790.71 $101,111.58 Citicare 200810 PRE65 192 $128,855.94 $20,313.19 $149,169.13 Citicare 200811 POST65 200 $74,913.11 $40,879.17 $115,792.28 Citicare 200811 PRE65 166 $118,026.82 $21,487.01 $139,513.83 Citicare 200812 POST65 195 $31,642.40 $39,757.96 $71,400.36 Citicare 200812 PRE65 163 $110,356.14 $20,644.38 $131,000.52 Citicare 200901 POST65 203 $15,571.04 $37,915.19 $53,486.23 Citicare 200901 PRE65 176 $88,173.62 $27,869.74 $116,043.36 Citicare 200902 POST65 11 $0.00 $1,562.21 $1,562.21 Citicare 200902 PRE65 6 $0.00 $313.73 $313.73 Citicare Fire 200708 POST65 53 $0.00 $17,150.37 $17,150.37 Citicare Fire 200708 PRE65 86 $0.00 $32,099.56 $32,099.56 Citicare Fire 200709 POST65 52 $1,821.88 $14,739.58 $16,561.46 Citicare Fire 200709 PRE65 101 $50,519.79 $27,512.84 $78,032.63 Citicare Fire 200710 POST65 59 $3,505.05 $19,512.57 $23,017.62 Citicare Fire 200710 PRE65 97 $50,137.96 $32,467.76 $82,605.72 Citicare Fire 200711 POST65 59 $6,578.94 $17,043.75 $23,622.69 Citicare Fire 200711 PRE65 96 $62,815.59 $35,167.87 $97,983.46 Citicare Fire 200712 POST65 56 $5,622.99 $14,662.06 $20,285.05 Citicare Fire 200712 PRE65 97 $18,515.94 $29,040.93 $47,556.87 Citicare Fire 200801 POST65 60 $17,958.51 $21,099.78 $39,058.29 Citicare Fire 200801 PRE65 97 $63,969.85 $32,682.09 $96,651.94 Citicare Fire 200802 POST65 60 $8,537.46 $21,991.90 $30,529.36 Citicare Fire 200802 PRE65 97 $53,712.03 $26,533.18 $80,245.21 Citicare Fire 200803 POST65 60 $14,695.06 $22,460.68 $37,155.74 Citicare Fire 200803 PRE65 96 $62,882.96 $28,170.39 $91,053.35 Citicare Fire 200804 POST65 62 $10,107.10 $18,329.32 $28,436.42 Citicare Fire 200804 PRE65 98 $24,974.87 $32,364.28 $57,339.15 Citicare Fire 200805 POST65 60 $11,096.10 $19,060.57 $30,156.67 Citicare Fire 200805 PRE65 99 $31,176.94 $24,675.51 $55,852.45 Citicare Fire 200806 POST65 60 $10,590.76 $21,565.85 $32,156.61 Citicare Fire 200806 PRE65 94 $45,356.35 $28,111.80 $73,468.15 Citicare Fire 200807 POST65 61 $8,249.57 $19,227.85 $27,477.42 Citicare Fire 200807 PRE65 101 $43,605.34 $30,363.22 $73,968.56 Citicare Fire 200808 POST65 61 $7,754.81 $19,986.47 $27,741.28 Citicare Fire 200808 PRE65 90 $88,348.08 $32,278.04 $120,626.12 Citicare Fire 200809 POST65 62 $989.06 $25,345.98 $26,335.04 Citicare Fire 200809 PRE65 94 $47,922.22 $31,570.36 $79,492.58 Citicare Fire 200810 POST65 61 $9,671.57 $19,477.18 $29,148.75 Citicare Fire 200810 PRE65 84 $15,393.75 $25,191.19 $40,584.94 Citicare Fire 200811 POST65 65 $13,008.33 $20,053.14 $33,061.47 Citicare Fire 200811 PRE65 93 $36,328.02 $30,529.33 $66,857.35 Citicare Fire 200812 POST65 63 $7,805.52 $26,290.06 $34,095.58 Citicare Fire 200812 PRE65 89 $59,255.59 $32,756.57 $92,012.16 Citicare Fire 200901 POST65 65 $7,814.33 $19,004.75 $26,819.08 Citicare Fire 200901 PRE65 90 $38,282.09 $34,018.37 $72,300.46 Citicare Fire 200902 POST65 4 $0.00 $568.02 $568.02 Citicare Fire 200902 PRE65 6 $0.00 $700.02 $700.02 Citicare Public Safety 200708 POST65 35 $0.00 $7,849.58 $7,849.58 Citicare Public Safety 200708 PRE65 90 $0.00 $23,196.15 $23,196.15 Citicare Public Safety 200709 POST65 38 $271.85 $8,752.91 $9,024.76 Citicare Public Safety 200709 PRE65 95 $30,824.01 $23,942.37 $54,766.38 Citicare Public Safety 200710 POST65 38 $757.15 $10,071.37 $10,828.52 Citicare Public Safety 200710 PRE65 96 $32,230.02 $23,812.78 $56,042.80 Citicare Public Safety 200711 POST65 40 $5,581.18 $8,828.11 $14,409.29 Citicare Public Safety 200711 PRE65 101 $104,834.14 $20,865.51 $125,699.65 Citicare Public Safety 200712 POST65 39 $8,884.21 $8,761.12 $17,645.33 Citicare Public Safety 200712 PRE65 100 $61,929.01 $27,430.31 $89,359.32 Citicare Public Safety 200801 POST65 43 $5,154.55 $9,967.65 $15,122.20 Citicare Public Safety 200801 PRE65 101 $59,798.63 $20,673.62 $80,472.25 Citicare Public Safety 200802 POST65 40 $3,054.61 $8,445.57 $11,500.18 Citicare Public Safety 200802 PRE65 108 $83,754.69 $21,253.27 $105,007.96 Citicare Public Safety 200803 POST65 39 $717.21 $10,597.85 $11,315.06 Citicare Public Safety 200803 PRE65 109 $66,251.11 $23,769.04 $90,020.15 Citicare Public Safety 200804 POST65 42 $2,374.43 $8,789.67 $11,164.10 Citicare Public Safety 200804 PRE65 109 $60,621.23 $25,293.81 $85,915.04 Citicare Public Safety 200805 POST65 40 $6,679.06 $9,809.95 $16,489.01 Citicare Public Safety 200805 PRE65 108 $77,968.70 $28,080.35 $106,049.05 Citicare Public Safety 200806 POST65 40 $6,050.51 $8,024.39 $14,074.90 Citicare Public Safety 200806 PRE65 113 $82,895.29 $24,321.49 $107,216.78 Citicare Public Safety 200807 POST65 43 $4,407.60 $9,628.06 $14,035.66 Citicare Public Safety 200807 PRE65 113 $65,005.82 $23,287.54 $88,293.36 Citicare Public Safety 200808 POST65 42 $4,297.40 $9,877.69 $14,175.09 Citicare Public Safety 200808 PRE65 110 $49,962.31 $28,694.37 $78,656.68 Citicare Public Safety 200809 POST65 43 $3,345.19 $11,265.13 $14,610.32 Citicare Public Safety 200809 PRE65 110 $59,560.69 $25,558.51 $85,119.20 Citicare Public Safety 200810 POST65 43 $5,112.72 $8,270.16 $13,382.88 Citicare Public Safety 200810 PRE65 107 $119,363.63 $29,427.88 $148,791.51 Citicare Public Safety 200811 POST65 41 $3,920.42 $8,372.78 $12,293.20 Citicare Public Safety 200811 PRE65 102 $126,348.08 $22,341.98 $148,690.06 Citicare Public Safety 200812 POST65 40 $3,801.70 $10,479.30 $14,281.00 Citicare Public Safety 200812 PRE65 98 $79,145.22 $30,283.28 $109,428.50 Citicare Public Safety 200901 POST65 45 $3,985.59 $8,678.89 $12,664.48 Citicare Public Safety 200901 PRE65 108 $75,047.88 $27,872.68 $102,920.56 Citicare Public Safety 200902 POST65 2 $0.00 $416.97 $416.97 Citicare Public Safety 200902 PRE65 10 $0.00 $599.46 $599.46 CITY OF CORPUS CHRISTI GROUP #675908 ENROLLMENT - RETIREE DIVISION ONLY by CLUSTERS REPORTING PERIOD: 8/1/2007 - 1/31/2009 Report Cluster Coverage Month Pre 65 Post 65 Total Members Citicare Aug -07 223 237 460 Citicare Sep -07 225 236 461 Citicare Oct -07 230 237 467 Citicare Nov -07 232 237 469 Citicare Dec -07 237 241 478 Citicare Jan -08 234 232 466 Citicare Feb -08 231 232 463 Citicare Mar -08 237 232 469 Citicare Apr -08 238 230 468 Citicare May -08 233 228 461 Citicare Jun -08 232 228 460 Citicare Jul -08 228 229 457 Citicare Aug -08 232 229 461 Citicare Sep -08 234 228 462 Citicare Oct -08 239 229 468 Citicare Nov -08 240 229 469 Citicare Dec -08 241 230 471 Citicare Jan -09 238 228 466 Citicare Fire Aug -07 123 66 189 Citicare Fire Sep -07 122 66 188 Citicare Fire Oct -07 119 67 186 Citicare Fire Nov -07 118 68 186 Citicare Fire Dec -07 116 67 183 Citicare Fire Jan -08 122 68 190 Citicare Fire Feb -08 121 68 189 Citicare Fire Mar -08 120 70 190 Citicare Fire Apr -08 117 71 188 Citicare Fire May -08 116 72 188 Citicare Fire Jun -08 115 71 186 Citicare Fire Jul -08 112 70 182 Citicare Fire Aug -08 111 69 180 Citicare Fire Sep -08 110 69 179 Citicare Fire Oct -08 112 69 181 Citicare Fire Nov -08 112 69 181 Citicare Fire Dec -08 111 70 181 Citicare Fire Jan -09 112 70 182 Citicare Public Safety Aug -07 139 45 184 Citicare Public Safety Sep -07 139 45 184 Citicare Public Safety Oct -07 139 45 184 Citicare Public Safety Nov -07 139 45 184 Citicare Public Safety Dec -07 138 46 184 Citicare Public Safety Jan -08 149 46 195 Citicare Public Safety Feb -08 147 46 193 Citicare Public Safety Mar -08 146 46 192 Citicare Public Safety Apr -08 148 46 194 Citicare Public Safety May -08 150 46 196 Citicare Public Safety Jun -08 143 47 190 Citicare Public Safety Jul -08 143 47 190 Page 4 of 25 Report Cluster Coverage Month Pre 65 Post 65 Total Members Citicare Public Safety Aug -08 143 47 190 Citicare Public Safety Sep -08 143 47 190 Citicare Public Safety Oct -08 143 47 190 Citicare Public Safety Nov -08 140 50 190 Citicare Public Safety Dec -08 140 50 190 Citicare Public Safety Jan -09 148 50 198 Page 5 of 25 H z 0 2 W N Co W U 0 cc a U) cc w t- N N cn Um a >- J CC Z CC o� o z N W 0 W S2 � H ¢ o 0 P cc � N 0 a. cc O »aa m 8 2 O V O H O 0 Shock Amount '^ ) C) Co. o D ((00 CV roet 69 o co. N 69 O) . m ao COD N sr 49 O) . ao (0 N er 69 O) . co CCD N et 69 O) . ao CCD N et E9 O) . ao co_ N et E9 0) . co CD CO N eT 69 O) . co co. N et 69 0) . co O COD N et 69 0 . N et E9 0) . m co Co co. N er E9 0) . co. N et E9 0) . Co N et $412,688.791 ) . D co O co N 7 E9 0) . N et 69 0) O) . co Co O co N et et ER O) . Co co N et 69 O) . CD (00 N et 69 O) . m Co coo N et 69 . CO co. N f9 0) O) . CD co N er et 69 0) . Co co. N et E9 0) . CD O co. N et 69 O) . co co. N et CO 0) . O N er 49 O) . Co Co co. N et 69 O) . co Co CD CCDD N eY E9 CD . CO N et E9 0) . m CD (00 N et 0) . CD CCD N et V9 69 CA . CO. N et . m Co A CO N V9 ER 0) . co o CO N et 69 0) . N er Net Paid Amount j :V I- N D 9494949696094949 CC) LO O M of N ON) et O .- N a C0 co CD C7 CO N O) C7 C0 C((vpv�� O CCO _O it) c O CO O) Cn CD C") P N N O) et N CV ER Sr co N. O r 4949 er O N O O) Cn co N 0) CQ W co 94� CO N N O ei 0 N $1,536.651 .0 ' ct CO Q l9 OOD et C H9 f9 L W N r` CV N M CC) r '-- V969 N CO O r` N Vi N CD CD V9 C9 N CO O) (0 CO m N CO Cn CO 4 E9 et Q r` a E9 O Cn V N (9 co N N CO N ff9 O N CO N 69 ^ er N 69 Co N N N Ef9 et CO et CA 0 N E9 CO (O O) (fl CO C9 N E9 CCU) N CO E9 N CO CO N Vi DX Description END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE TEND STAGE RENAL DISEASE SPRAIN AND STRAIN OF OTHER SPECIFIED SITES OF SHOULDER AND UPPER ARM PHARMACY HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE INONTRAUMATIC RUPTURE OF TENDONS OF BICEPS (LONG HEAD) OTHER ALTERATION OF CONSCIOUSNESS I 0 2 X I o_ 'PHARMACY 'PHARMACY 'PHARMACY 'SYNCOPE AND COLLAPSE BICIPITAL TENOSYNOVITIS PHARMACY PHARMACY PHARMACY SUBJECTIVE TINNITUS OTHER MALAISE AND FATIGUE SPRAIN AND STRAIN OF UNSPECIFIED SITE OF SHOULDER AND UPPER ARM OTHER MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL 'PULMONARY COLLAPSE OTHER MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER � 'OTHER MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL 'UNSPECIFIED PSYCHOSIS 'OTHER MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL Q W Z a Q a w W _1 Cl) 0 w LL w a z DX Code 5856 5856 5856 5856 5856 5856 5856 5856 O LO I.0 O 0 Pharmacy 40391 72762 78009 Pharmacy >. > H Merl ' Pharmacy 8 72612 Pharmacy Pharmacy Pharmacy 38831 78079 8409 1732 co ^ 1732 co n 78057 Pre65 / Post65 PRE65 PRE65 Q o_ PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 'PRE65 PRE65 PRE65 Lo co Cr o_ PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 Lo co Q Claimant # Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 r O 0 c (C E U Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 ICIaimant #001 e r r 0 0 0 0 0 0 'EEC' as co as E E E U o U ICIaimant #001 0 0 0 c co E U ICIaimant #001 .- 0 0 0 0 0 c c as as E E U U 0 0 0 0 0 0 0 0 0 0 0 0 0 00000 c c c c c c as as as as as as E E E E E E U U U U U U `Claimant #001 200806 200810 200803 200807 200811 200805 200804 200802 200812 200809 200801 200808 200805 200809 200802 200805 200804 200803 200805 200712 200807 200804 200804 200804 1200806 200802 200804 200804 200809 200807 200803 200805 200809 200809 200810 1200803 IReport Cluster I Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety ICiticare Public Safety 1 > > ca N CO CO U U .0 10 as C) `) Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Shock Amount '^ ) •�NNNNNNNNNNNhNnnN Xi co X) CO O. CO _ �I avavvaavvvvvv 9 49 0) CO _ CO N 63 rn CO m CO _ CO. N 09 m CO CO N 0) 0) m CO _ CO, N 09 m CO N 09 49 0) 0) m CO m _ N 69 Cn m m CO _ N 403 0) m m m CO _ N N Vi 0) CO _ CO f9 CI) m m CO m _ _ N N 69 61 rn 0) m m CO m _ N w3 CI) m CO m _ N 63 0) m CO m CO. _ N vavvvv 69 0) m CO N f9 0) m CO m _ N f9 - 0) m CO m _ N E9 0) NNNNN m CO m _ N vi 0) m CO m _ N 0) m m CO m m _ N N vv �f9 co CO _ 63 m m _ N $412,688.791 ) Cn - o ao o CO o ca D. V 76avvvvcvvvvvvM03E9O3 9v3 Cn NNNNNNNNNNNNCOCOCOM. CO _ N 63 Cn m CO m _ N 69 0) m m CO m m _ N N 69 0) O) m CO m CO. _ _ N 69 f9 Cn m CO CO N 03 m CO m CO., _ N 09 m Cn m CO CO_ N Vi 0) m CO N f9 O) m CO m CO._ N. N E9 Cn m CO CO N 09 CO m _ r� N f9 CO N NI O N fA CO N m N O N V3 CO N m r N. O N f9f C N r m F r O C N r Net Paid Amount LO C A a fl N O p a) .— m m C O r .- 69 m O Lo O E9 m N 0) CA r V303 r Ct) r 0) 0) O) CO 0369 0 O G Ti CO 03030949f94903 m m N CO r m Tr N N m m CO N m N m CO U) C) O N to CC) v f969K369696969 N 0) O CO m O O CV v 0 0 v CO 0) m.— m m 0 CO N Q 0 CO CO 0 M V' $34.301 D O CO 7 77 CO 9696903 N 0 O 0 m N 0 N 0 mt 6 o 696969f9 R N C) M N O CO O Ca O Ti 09 a m 0 03 0 0 0 03 69 0 0 0 69 0 0 0 SriU)aCO 0 U Ti N CO N U) V, 0 (0 r 0 O fa 69 N O) VI CO i N C O) C m C m I ro' < DX Description PHARMACY OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS SYNCOPE AND COLLAPSE PULMONARY COLLAPSE ACTINIC KERATOSIS METABOLIC ENCEPHALOPATHY SYNCOPE AND COLLAPSE m• S 0 Z 0 CC CO w I- D 0 PAIN IN JOINT, UPPER ARM I ACUTE UPPER RESPIRATORY INFECTIONS OF UNSPECIFIED SITE PHARMACY 'UNSPECIFIED TINNITUS OTHER ACNE UNSPECIFIED ANEMIA PHARMACY SYNCOPE AND COLLAPSE ELEVATED PROSTATE SPECIFIC ANTIGEN (PSA) SPRAIN AND STRAIN OF CARPOMETACARPAL (JOINT) OF HAND BICIPITAL TENOSYNOVITIS OTHER DYSPNEA AND RESPIRATORY ABNORMALITIES CARBUNCLE AND FURUNCLE OF UNSPECIFIED SITE OBSTRUCTIVE CHRONIC BRONCHITIS, WITHOUT EXACERBATION UNSPECIFIED CARDIOVASCULAR DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED � 'OTHER PULMONARY EMBOLISM AND INFARCTION 'UNSPECIFIED ESSENTIAL HYPERTENSION IOSTEOARTHROSIS, UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED, LOWER LEG SPRAIN AND STRAIN OF CARPOMETACARPAL (JOINT) OF HAND PRE - OPERATIVE RESPIRATORY EXAMINATION ELEVATED PROSTATE SPECIFIC ANTIGEN (PSA) ICARDIOMEGALY 1BICIPITAL TENOSYNOVITIS ENCOUNTER FOR THERAPEUTIC DRUG MONITORING ENCOUNTER FOR THERAPEUTIC DRUG MONITORING METABOLIC ENCEPHALOPATHY 'SYNCOPE AND COLLAPSE 'CARBUNCLE AND FURUNCLE OF BUTTOCK 'END STAGE RENAL DISEASE 'END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE DX Code U c6 C6 0 5589 7802 CO N 7020 34831 7802 t0a v 71942 1 4659 Pharmacy 38830 m ON 2859 Pharmacy 7802 79093 84211 72612 78609 O _ cma 149120 ON) v 40390 41519 �p O Cr0) o— v r 184211 V7282 79093 4293 72612 V5883 V5883 34831 O N 0 Cmo 15856 15856 N m 5856 15856 Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 POST65 POST65 POST65 POST65 I POST65 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 0 O C co E cd U 0 O C C6 E m U 0 0 C m E 'N U Claimant #001 Claimant #001 Claimant #001 'Claimant #001 Claimant #001 0 0 0 E Z E E o ia U U 0 0 0 0 E E E E m m U U 0 0 0 0 E E E E 'o ro U U Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #001 Claimant #002 Claimant #002 Claimant #002 Claimant #002 'Claimant #002 Processed Month 200808 200810 200807 200804 200810 200811 200803 200712 200805 200811 200810 200804 200803 200808 200801 200802 200803 200712 200806 200807 200806 200805 200811 200712 200802 200809 200805 200806 200804 200806 200804 200809 200712 200806 200812 200812 200806 200811 200802 200807 200805 O m 0 0 N > 16 U ) U 2 a E m 0 U Citicare Public Safety Citicare Public Safety >. >+ >. >, >. T N N d N N N 13 16 16 (6 16 (6 U ) CO CO CO U ) CO C 0_ U_ U 0 U_ .0.0.0.0.0.0.0.0.0 7 7 7 7 7 7 a a a n. a a E E E d E a) m as m V m c6 0 0 0 0 0 0 000000000 >. N N 16 15 C O CO U U_ 7 7 a a E E t6 c6 0 0 T > N 16 CO U 7 a m co 0 Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety >, >. d N 16 16 CO U) U_ U a Cl. E c6 t6 0 0 >. T Z. >. >. 1515 N N N 16 15 i0 N l6 CO CO CO U) CO U_ U_ U_ C) 0_ .0.0.0.0.0.0.0.0.0.0.0.0.0.0 7 7 7 7 7 a a a a a E EEE ` as 6) c6 co c6 ( ) 0 0 0 0 0 0000 >. T >. >. >. >. >. >. >. d N N d m1'6161611 16 16 16 f6 f6 16 16 16 16 CO CO U) U) U) Cl) CO CO U) U U U_ U_ 0_ U U_ U_ U 7 7 7 7 m 7 7 7 m a a a a a a a a a E E E E E E E E E E E E E co at m m co co co r6 t6 c6 as c6 c 0 0 0 0 0 0 0 0 0 0 0 0 C U0 U0C00000 000.' Citicare Shock Amount M M N n�LO rn 0 nnnnnnMMnnnnnnnnnnnnn CO 's M M CO n 0 CO M C? n Nnnnnnnnntnnt.nthnn 0 69616969 M C? n �0in��LO 0 M n 0 M M n 0 M M n 0 U96M969 M M n 0 M M n 0 M M n �LO 0 MK CO M CM M c? n 0 C? n �LO 0 VIES M CO n 0 M h v>�LO 0 VI0,66969 M M n 0 M M C? n LO 0 M C? n uO� 0 CO M co n 0 M n 0 1 $370,757.331 7 7) o > A 1 $370,757.331 " ? c? ninLO > 9CO� M n NI o nn M M n N o $370,757.331 7 ? CO 0LO ■nnn 5 ■ C9 M M CO n tON o nnn CO 0 M n 0 $370,757.331 7 ) CO O1.0 - D tsN- 0494969 M CO n II) nrrnnnt.t 0 M co CO n LOL)U)LO 0 CO h t: 0 NC�NN.N(�I M CO 0 �V, M CO n 0 fAE M c n r L o c Net Paid Amount CO N . O) LLD C o 69 N CO u) LO LO CO CO N CO r O LO r N ( N n 6 Cn n 69� O Cn CO N. CD O CO N N CO DP 69 N n n 69 CO N. a CO CO CO M 69 nt O) CO M r` N CO N O a 69 O O M n LO d_ -- 69 n n t O - 69U, O o Tr N CA 0 CO 69 n CO N. Cn Ti CO CO Cf) CA CO O CO CO 69 CO CA to CO 69 CO n t 6 CO 69 V O n CO 69 M 0 O O $420.00 7 ) D 0 Cf f) $405.00 O O 7 7 fl 69 n r CO O) LO M co o 69 O c r n CO 69 f9 n NLO CO O) CO N 69 M CO CO N 69 O in O C? CO N 69 N $256.38 O CD O A r N 9 69 CO N M co V CO N 69 CO N CO N 69 O CO N CO N 69 nt N CO n CO O Co n 69 69 N t V' C 1 DX Description END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE, IMPLANT, AND GRAFT OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE, IMPLANT, AND GRAFT ENCOUNTER FOR CHANGE OR REMOVAL OF NONSURGICAL WOUND DRESSING NEOPLASM OF UNSPECIFIED NATURE OF BRAIN SWELLING, MASS, OR LUMP IN HEAD AND NECK MALIGNANT NEOPLASM OF FRONTAL LOBE OF BRAIN OTHER CONVULSIONS NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG) EDEMA ACUTE RESPIRATORY FAILURE PHARMACY CHRONIC AIRWAY OBSTRUCTION, NOT ELSEWHERE CLASSIFIED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED PHARMACY I DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NW STATED AS UNCONTROLLED PHARMACY OTHER CONDITIONS OF BRAIN CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED PHARMACY MALIGNANT NEOPLASM OF CEREBRUM, EXCEPT LOBES AND VENTRICLES ULCER OF OTHER PART OF FOOT ENCOUNTER FOR FITTING AND ADJUSTMENT OF NON - VASCULAR CATHETER NEC DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED ULCER OF OTHER PART OF FOOT ACUTE, BUT ILL- DEFINED, CEREBROVASCULAR DISEASE PHARMACY SWELLING, MASS, OR LUMP IN HEAD AND NECK END STAGE RENAL DISEASE MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS -ULCER OF OTHER PART OF FOOT 'OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE, IMPLANT, AND GRAFT d 9 O C) o 5856 5856 5856 5856 5856 5856 5856 M `Q)) 99673 O in N 7842 w 78039 79431 ,7823 151881 Pharmacy 0) 25080 Pharmacy I 25080 IPharmacy 3488 141401 40390 Pharmacy o) 70715 V5882 25042 70715 a Pharmacy 7842 5856 70715 M co 0) Pre65 / Post65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 I POST65 Claimant # Claimant #002 N O O C Cf E U Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 C L I N N N O O O O 0 0 0 0 C C C C Co MI CO CO E E E E C)U0C) Claimant #002 N O O C CO E 0 Claimant #002 Claimant #002 Claimant #002 Claimant #002 !Claimant #002 Claimant #002 Claimant #002 Claimant #002 N O O C CO E 0 Claimant #002 Claimant #002 Claimant #002 Claimant #002 N N N N 0 0 0 0 O O O O C C C C CO CO co as E E E E 0000 !Claimant #002 200810 200808 200809 200804 200803 200812 200712 200804 200807 200806 200812 200812 200901 200811 1'200807 200808 200812 200810 200812 200809 200802 200807 200804 200901 200807 200801 200807 200812 200804 200901 200812 200805 200812 200806 200901 200901 200901 200806 1200801 Report Cluster Citicare Citicare 0 N d C) N N CU CC C) C) CO CD N d CC C) C) CO co CO CO CO m m m CO CO co co ca co co co co 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 C) 0C)000C)C)C)0C)C00C)C) C)C) CO N co rn 00 C) 5 C) CD CO CU co co co CO 0 0 0 0 0000 C) N CC CO as m 0 0 0 0 0005 CU CO al CO 0 0 CO N N C) N N d N CO CO m CO co co CO CO 0 0 0 0 0 0 0 O (0000000(7 Citicare Shock Amount !h :h N4nnnnnnnnnnn n NNNNNNnNNNnn O000000000oo Nnnnnnnnnnnn :7 f9 C9 M M UUUUU0 M f9 M M M M M M Vi C4 M M 9 C9 M M M C9 M M M C9 M M UUUU M Cfl M M M C9 M M M M M M % 40 M C ) M 1 $370,757.331 7 O "'nnn 500000 noomom 9 M nnNnn N UUD nnnnn M C9 M C9 M C9 M 1 M M n U N o n M % $370,757.331 okes-rn nn ) C n n UN �NN Soo 7 A4949 C o n nn M ) m n M $370,757.331 n ? O UUM 'NN000000O000c dOmmcommod O 9 f9 M M n nna000aoaowaocoaoaoeoc M M CD M GO n ri C9 (D c0 r N f9 CD CD M N E9 CD D ri M N V9 CD w ri M N f9 CD m OD r M N E9 CD oimr M N Vi O CD 0 M N f9 CD OD oowc N CD 0 CD C r c M M C N N C V9 C9 E Net Paid Amount WO 1. ., NI ,..-M46(069.6969.6344(4, to N Cn n CD iq CD O n U) U) N U) n O U) n !7 0) , a .7 N U) CD O CDC CD M M O M M $30.31 W D CD NN,-,-,-,- EFIEOMfe. W M M CM C M M M C M M M N M M C N (D c D) 69. N cD CD CD CD (040w% N CD N O O O o 000 O 4,9 0 o w 0 0 49 H9 0 0 C7 M 0 to .- 4.9M N CD O M M U) N 0 661-4666T N a n M CD O N C) U) U) eF W a C7 N9EN9NMEN O 0) U) O Cn W U) M MO, O f W W C r U) C r 0 C t ,C9 DX Description } U < cc Q I a UNSPECIFIED PERIPHERAL VASCULAR DISEASE ( >- 0 < cc Q I a ULCER OF OTHER PART OF FOOT OTHER CONDITIONS OF BRAIN PAIN IN SOFT TISSUES OF LIMB ULCER OF OTHER PART OF FOOT ULCER OF OTHER PART OF FOOT END STAGE RENAL DISEASE PHARMACY CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY PHARMACY HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED ACUTE RESPIRATORY FAILURE PULMONARY EOSINOPHILIA OTHER CONVULSIONS OTHER CONVULSIONS PULMONARY COLLAPSE CONGESTIVE HEART FAILURE, UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED IDERMATOPHYTOSIS OF NAIL IENTHESOPATHY OF UNSPECIFIED SITE OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE, IMPLANT, AND GRAFT (DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED IPHARMACY IOTHER AND UNSPECIFIED HYPERLIPIDEMIA PHARMACY END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE 1END STAGE RENAL DISEASE END STAGE RENAL DISEASE 'END STAGE RENAL DISEASE DX Code Pharmacy 4439 Pharmacy 70715 3488 7295 70715 70715 5856 Pharmacy 41401 Pharmacy 40390 51881 5183 78039 78039 15180 N 40390 125060 o M ,- N 0) .-N-0) 25080 Pharmacy 17N-7 T U as a 5856 5856 5856 5856 5856 5856 1W-7 5856 5856 5856 5856 Pre65 / Post65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 POST65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 IPRE65 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #002 N 0 a C t0 E U N N N N 0 0 0 0 0000 c o c a CO CO CO CO E E E E _0 0 0 0 Claimant #002 Claimant #002 Claimant #002 Claimant #002 Claimant #003 Claimant #003 Claimant #003 Claimant #003 Claimant #003 Claimant #003 Claimant #003 Claimant #003 Claimant #003 Claimant #003 Claimant #003 Processed Month 200712 200810 200801 200807 200812 200810 200808 200812 200801 200803 200806 200808 200810 200901 200901 200901 200812 200901 200901 509002 200807 200809 200810 200810 200802 200809 200807 200805 200811 200803 200806 200804 200802 200805 200807 200809 200810 200808 1200801 N C) N CD N CD (D N N CD CD CD • CO CO CO a) co co co as CO co t0 co . 9 . 9 . 9 . 2 . 2 . 9 . 9 . 9 . 2 9 . 2 . 9 000000000000 CD CD CD N CD CD (1) co co CO co co CO co . 9 . 2 . 9 . 2 2 . 9 . 2 0 0 0 0 0 0 0 C) (C 2 U CO N 4) C) co (O CO co U U U U 0000 CD CD CD N N CD N CD N CD C) CD 0) CO co c0 co co CO co co co co co co co . 9 . 2 2 . 9 . 2 . 2 2 . 9 . 2 . 9 . 9 2 . 0 0 0 0 0 0 0 0 0 0 0 0 0 CD co 9 . 9 : Citicare Shock Amount a.nna O CD 0 OD 6r) o co D o Co o co V 9C9 414OO,UJJ.00 $288,033.86 091414 Of RR o 9 $288,033.861 A.nno n,1', GC D O CO o Co CO 6 cor)r)0)6 O co co D 0 0 o oa co o co co V N N 9V) 69 CO OD co 0 co co N 69 CO OD CO 0 cc 0 N 09 CC) CO CO 0 co co N 09 CO OD rir)r)c6 CO 0 co co N V) CO co CO 0 oa co N V) C0 co CO 0 co co N 69 CO co CO 0 co co N EACH CO M c9 0 co co N c0 oa r)r)ricocori M 0 co co N 0949 CD OD CO 0 co co N CO OD M 0 co co N 69 O CO C0 co CO CO 0 cc ao co co N E96940 O m M 0 0 ao co N- N $288,033.861 R9RR.033.86 CO CO c6 M 0 aD co N 69 CO OD 6 M 0 co co N 09 CD Co o M 0 co CO N 69 c0 CD CO OD co c6 M OM 0 0 co co OD CO N N 69 E9 CO co co 0 co CO N VI CO CD CO CO r) r) 0101 0 oS co OD CO N 69 E9 C0 C0 CO OD r)r)r)r)rio M 040404010 O 0 0 o co CO CO N N N Vf 09 CO OD 0 ao CO N 6969 CO co 0 co 0 N CO co 0 ao CO N V)6 O 0 C a a C Net Paid Amount ,^ O 0 CO j 7 CO 7 CD A A 41'f,13O r .oa $3,247.38 @9 Odd in 0 - 7 ' fl $3,141.881 o C0 (O - 'Ch n O v n O N N V N r _ 6909 9 V) CD O Q n (O CV CO n 6909 0) n 0) N CO 0 C9 CO V969696969 N r 0) N Cr a r N CO Cr 0) O Ti ID a N 0 M M a co O v Vi n 0 IO 49 N M 0) N 09 O O r V) E9 m M N 0 n 0 0 V) O W O O O) cm 0) 1s Vi E9 O t0 O CO E9 m O N If) Vi 0 C'7 Ti M E9 A O M M et Ti CO CO E9 E9 O M Tr CO V) $27.23 D p 0 D. M M 0 O) co N 9 V) 69 0) C0 co 69 0 Cr. co 09 0 Cr co I c E DX Description URINARY TRACT INFECTION, SITE NOT SPECIFIED END STAGE RENAL DISEASE DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED PROLIFERATIVE DIABETIC RETINOPA I HY DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED VITREOUS HEMORRHAGE PROLIFERATIVE DIABETIC RETINOPATHY FT OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE, IMPLANT, AND GRA PHARMACY BACKGROUND DIABETIC RETINOPATHY VITREOUS HEMORRHAGE PHARMACY PHARMACY PHARMACY [PHARMACY [PHARMACY [UNSPECIFIED SEPTICEMIA GANGRENE PHARMACY BACKGROUND DIABETIC RETINOPATHY VITREOUS HEMORRHAGE PHARMACY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED CYSTOID MACULAR DEGENERATION OF RETINA ICELLULITIS AND ABSCESS OF LEG, EXCEPT FOOT CYSTOID MACULAR DEGENERATION OF RETINA RETINOPATHY BACKGROUND DIABETIC SPONDYLOSIS OF UNSPECIFIED SITE WITHOUT MENTION OF MYELOPATHY DIZZINESS AND GIDDINESS ACUTE UPPER RESPIRATORY INFECTIONS OF UNSPECIFIED SITE DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II UN UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED GANGRENE DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED FLUID OVERLOAD PHARMACY PRE - OPERATIVE CARDIOVASCULAR EXAMINATION 'ESSENTIAL HYPERTENSION, BENIGN PHARMACY CC U)) 5856 25050 36202 25050 37923 36202 99673 Pharmacy 36201 37923 Pharmacy Pharmacy Pharmacy Pharmacy Pharmacy 0389 7854 Pharmacy 36201 37923 Pharmacy 25000 36253 6826 36253 36201 72190 7804 U 25000 7854 25040 2766 Pharmacy _ CD N > r 0v Irnarmacy Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 a s a PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 a CO O C C0 E mm C) M M 0 0 CCD C0 E E 66 C.) C) M O C0 E C) M M M 0 0 0 C0 as as E E E 'mmcommmmmmmmmmm C) C)UC)C)UC)C)C)C)C)C)UC)C)C)C)C.) cM O as E M O as E M O CCO E M 0 co E CO O CC6 E CO O C0 E CO O as E CO O as E CO O CC0 E CO O ca E CO 0 al E CO CO O O C0 C0 E E mmm CO 0 al E M M O 0 aS al E E 'm"m'm7m'm'm'm'm UUUUUUUU CO 0 it E M 0 ca E C9 CO 0 0 C0 al E E M 0 al E CO 0 CO E CO 0 m E CO O Ca E as C) CO O CCa E C) CO 0 CCCCC C0 E 'ma'm'ma C)C)C)UC., CO 0 OS E CO 0 E M 0 CO E C 0 Of E Claimant #003 n . O OD 0 0 N N vr O 0- OD 0 O 0 0 N N V' O CO 0 0 N O CO O O CO OD 0 0 0 0 0 0 0 N N N O 0) 0 0 N O CO 0 0 N O CO 0 0 N O co 0 0 N to O CO 0 0 N n O CO 0 0 N O CO 0 0 N M O CO 0 0 N N h 0 0 N r 0 CO 0 0 N N 0 CO 0 0 N N N 0 0 CO CO 0 0 0 0 N N CO 0 CO 0 0 N Tr O 0 CO CO 0 O 0 0 N N 200805 1176.76--- 200802 200810 200807 12[17.- 200808 0) 0 M 0 O N 200808 CO O CO 0 0 N N O CO 0 0 N CO O CO 0 0 N 10 O CO 0 0 N r a C C C J200809 R nnrt Cluetar I ) j C, ICiticare Citicare ICiticare Inifinnro ) CO j O 5 5 Citicare ICiticare ICiticare ICiticare ICiticare ICiticare ICiticare ICiticare ICiticare ICiticare Citicare Citicare Citicare Citicare Citicare Citicare Citicare Citicare Citicare Citicare Citicare Citicare a) t.,i ut.ai C Citicare Citicare N U ICiticare Citicare ICiticare ICiticare Page 10 of 25 Shock Amount ^^ D ) b..0.0 O CWD N C1340.01 W moo 66 mm N W M N 1 $288,033.861 toast 11•1•1 RR CD D W 7 M 7 M D00000 CWD CWD N A fA EA W W M M CWD N E9 W (D W M M CWD N fA W M M CWD N EA W W M M N $288,033.861 olkomes "So", ell, D O O n D (n N 06944,(00.4,440-4:40.49E949.6541). 0 N M W (n N 0 N M W Cn (n N 0 N M Cn N 0 N M W (n N 0 0 N N M M W W to N N 0 N M W to N 0 N M N (q N 0 N M W (D N 0 N M W (n N 0 N M W VI N 0 N M (C) (n N 0 N M (n V1 N 1 $281,553.201 C9R1 sc/ 211 N M W q to D W N 9 E9 N M W (n W N Efl N N M M W W (n (n W W N N f9 Ei N M W (C) W N fA N N M M W W Lil (n W W N N d9 69 N M W (n W N Cfl N M W (t1 W N EA N M W (n (1) W N EA EA N M W Cn W N EA N C M C W U u W C N C E Net Paid Amount V n r` 4,-6 f) iA 0 E. 0 O $0.00 It 1 ')n\ E,-.1..1:-Rae V O N V C\ 69.49 N M W W O ��� 9.14(. V V N O V a ($5,664.39)1 n A r CC) .,..-M6469-4.9.49(49.0.0. fl *E9 M N W N N N W N N U) a W O O W N (C) N V' O O +- a M M W N W N t- N N N CD M _ b M W W CC) _ W O N M M _ c9 M O T r _- N O W W CO E9 W W O O CO EA W W W W N E9 W N N M n E9 $714.33 caao 90 A O V n A W D W D W . 0. V W CA N (A EA C') M N W W N W O (n (A Vi EA N O W V EA O N W W Cn M C\ N V E9 W N W N N V EA N r n W V EA W N C: N V EA EA V V T cri M C� EA M C O C f C E DX Description PHARMACY CARDIOMEGALY CYSTOID MACULAR DEGENERATION OF RETINA DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED CYSTOID MACULAR DEGENERATION OF RETINA PHARMACY BACKGROUND DIABETIC RETINOPATHY END STAGE RENAL DISEASE PROLIFERATIVE DIABETIC RETINOPATHY URINARY TRACT INFECTION, SITE NOT SPECIFIED DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED END STAGE RENAL DISEASE ALCOHOLIC CIRRHOSIS OF LIVER STREPTOCOCCAL SEPTICEMIA CIRRHOSIS OF LIVER WITHOUT MENTION OF ALCOHOL (ALCOHOLIC CIRRHOSIS OF LIVER OTHER SEQUELAE OF CHRONIC LIVER DISEASE UNSPECIFIED ACUTE RENAL FAILURE CHRONIC AIRWAY OBSTRUCTION, NOT ELSEWHERE CLASSIFIED IHEPATORENAL SYNDROME 'UNSPECIFIED PERITONITIS [OTHER ASCITES 'FITTING AND ADJUSTMENT OF VASCULAR CATHETER OTHER SEQUELAE OF CHRONIC LIVER DISEASE L TENDERNESS OTHER SPECIFIED SITE ABDOMINA DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED 'OTHER MALAISE AND FATIGUE pPONTANEOUS BACTERIAL PERITONITIS SPONTANEOUS BACTERIAL PERITONITIS UNSPECIFIED PERITONITIS SPONTANEOUS BACTERIAL PERITONITIS ABDOMINAL PAIN, UNSPECIFIED SITE UNSPECIFIED HYPOTENSION ESOPHAGEAL VARICES WITHOUT MENTION OF BLEEDING UNSPECIFIED HYPOTENSION ATRIAL FIBRILLATION PERITONITIS (ACUTE) GENERALIZED Cn N 0 O U Q CIRRHOSIS OF LIVER WITHOUT MENTION OF ALCOHOL !OTHER SEQUELAE OF CHRONIC LIVER DISEASE DX Code Pharmacy 4293 36253 25050 36253 Pharmacy 36201 5856 36202 DO) (n 25050 5856 5712 0380 W N. 5712 5728 5849 496 5724 5679 78959 V5881 5728 co _N 25082 78079 56723 56723 5679 56723 78900 4589 4561 4589 42731 56721 2762 5715 5728 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 (PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 (PRE65 Claimant #003 Claimant #003 Claimant #003 Claimant #003 M M M M M 0 0 0 0 0 0 0 0 0 0 ***It* C C C C C CO CO CO c0 CO E E E E E 00000 Claimant #003 M M V V V V V 00000000. 0 0 0 0 0 0 0 * ik * 3k * ik it C C C C C C C (0 CO CO fC CO m CO E E E E E E E 00000000 Claimant #004 Claimant #004 Claimant #004 V Yk C (0 E 0 V V 0 0 9k 9k C C CC al E E 0 0 V 0 ik C taco E 0 V 0 * C E 0 V 0000 0000 # C m E 0000i00;000000 V ik C (a E V * C CO E Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 V V 0 0 0 0 9k 4k C C E E V V V V 0 0 0 0 0 0 0 0 Ok 3k # * C C C C E E E E 'Claimant #004 Processed Month 200811 200808 200809 200808 200804 200808 200803 200812 200901 200901 200901 200901 200806 200802 200805 200805 200804 V W W W W W M W 200805 200805 W W M W W 0 (0(0(0 0 0 N V 0 0 0 N V 0 0 0 N 200805 200804 200802 9nfRnF V O W .00 '00 INN 1200804 200803 N V W N O O O O W W W W 1200806 d tD N CO CO as 0 0 0 000 U_) i0 0 0 d `) `) `) `) co (0 co CO CO 0 0 0 0 0 0 0 0 0 0 2 co 0 0 2 `) 0) `) `) `) d CO co CO co co co (0 0 0 0 0 0 0 0 00000000000000_0 E C0 0 E co 0 d co 0 2 C0 0 d as 0 2 CO 0 N (C 0 N co 0 2, as 0 0 `) as 0 0 `) (0 0 0 N d (0 m 0 0 0 0 92 CO 0 0 d `) CO co 0 0 0 0 0_) 0) 0 0 0)) C0 0 0 �) d `) C: CO as as co 0 0 0 0 0 0 0 0 Citicare Page 11 of 25 Shock Amount D N CI O U) O CO N 69 0 N C') (O U) Cb N 09 f9 0 N C') U) U) N 0 N C) U) U) CO N CO 0 N C') U) N CO N 69 49 0 N (') C') U) U) Cn CO N 0 N U) CD CO CO N 49 CO 0 N 0 CO LI) U) N 0 N CO U) CD CO N 69 49 0 N C7 U) U) CO N f9 0 N U) CI) U) CO N 49 0 N M C') U) CO N 49 0 C7 U) CI) U) CO N 49 0 N (7 LC) U) N 49 0 N U) CI) CO N 49 0 N CO CO U) CO N fig 0 N C) U) U) CO CO N CA 0 N C') U) U) N 0 N Cl) U) U) CO N 69 49 0 N Cl U) U) CO CO N f9 0 N Cl U) U) CO N 49 0 N C') U) In U) CO N 49 0 N co U) N 49 0 N co U) U) CO N 0 N Cl) U) U) CO CO N V) 0 N Cl) U) U) CD N 69 69 0 N C7 U) U) CO N 49 0 N U) U) CO N 49 0 M U) U) N 49 0 M C') U) U) U) CD CO N 49 0 CO C') CD U) Cl) N 49 CO CD Cl) CD N N_ C'N') f9 CD CD c6 CD N 49 CD CD CD N CO co CO CO CD M Cl) CD N (N') 49 CD CD CO CD N (N') 49 CO CD Cl) CD N CN') 49 CD co CO N 49 (O CD N CO CN') 49 CO CD M C` CD N Cl) 49 CD CD )Cl) CD N Cl) 49 CO CD CO co CD N 49 N C0) Net Paid Amount O O U) CO N Ifi 0 CO U) CO N 49 C9 N O CO N 69 N CO N N 49 NO O U) 0 N f9 CO O 0 N 69 U) O Cl) O) 49 O N O 0) 49 C9 CO co CO 69 N N O N CD 69 49 N CD 49 C7 co r. U) 01 0 in a a 49 49 0 O) 0 N .- U) D) d9 f9 O N CO f9 N (h CO a CO E9 CO n N f9 N n f9 0 N CA U) Ti- CO f9 U) n co f9 CO n N f9 a CD N N fr9 CO r 1- co f9 U) CO N n v9 0 0 0 69 49 0 0 O f9 O 0 O 49 0 0 O N CO N 49 U) N n T 'Cr CO N N. Cp a Cn N 49 U) N CD N 49 O Co 0 n N N N E9 N CO n a .- r f9 69 a N N N. f9 N a N M N CO f9 N Cr! CO O V' U) CO CO C7 r CD CO r) Cl) 10 f9 O a CD CO f9 CO N CO CO f9 N O co a Q Cl) DX Description UNSPECIFIED HYPOTHYROIDISM OTHER DYSPNEA AND RESPIRATORY ABNORMALITIES OTHER ASCITES OTHER ASCITES ALCOHOLIC CIRRHOSIS OF LIVER OTHER ASCITES PHARMACY UNSPECIFIED INFECTION OF KIDNEY ABDOMINAL PAIN, UNSPECIFIED SITE OTHER ASCITES ALCOHOLIC CIRRHOSIS OF LIVER PHARMACY PHARMACY HEPATIC COMA OTHER SPECIFIED CARDIAC DYSRHYTHMIAS ENCOUNTER FOR FITTING AND ADJUSTMENT OF NON - VASCULAR CATHETER NEC ALCOHOLIC CIRRHOSIS OF LIVER co 0 'TRANSIENT ALTERATION OF AWARENESS 'DEPRESSIVE DISORDER, NOT ELSEWHERE CLASSIFIED UNSPECIFIED ACUTE EDEMA OF LUNG CIRRHOSIS OF LIVER WITHOUT MENTION OF ALCOHOL '5715 'ATRIAL FIBRILLATION STREPTOCOCCAL SEPTICEMIA !ABDOMINAL PAIN, UNSPECIFIED SITE CIRRHOSIS OF LIVER WITHOUT MENTION OF ALCOHOL CIRRHOSIS OF LIVER WITHOUT MENTION OF ALCOHOL UNSPECIFIED SEPTICEMIA PHARMACY CIRRHOSIS OF LIVER WITHOUT MENTION OF ALCOHOL � 'CIRRHOSIS OF LIVER WITHOUT MENTION OF ALCOHOL OTHER FOLLOW -UP EXAMINATION AFTERCARE FOLLOWING ORGAN TRANSPLANT � 'AFTERCARE FOLLOWING ORGAN TRANSPLANT AFTERCARE FOLLOWING ORGAN TRANSPLANT � 'OTHER FOLLOW -UP EXAMINATION PHARMACY PHARMACY PHARMACY DISORDER OF BONE AND CARTILAGE, UNSPECIFIED OTHER DISEASES OF LUNG, NOT ELSEWHERE CLASSIFIED PHARMACY } U a CC a I DX Code 2449 78609 78959 78959 5712 78959 Pharmacy 5909 78900 78959 $712 Pharmacy Pharmacy N LO 42789 V5882 5712 N CO N N 00 N co ,-- C') CCD 1n 5715 42731 O 0 78900 5715 15715 0389 Pharmacy 1- C N. 5715 as n > V5844 V5844 V5844 V6759 a U co E ca a Pharmacy Pharmacy 809 co CD CO 1n a C) co E Ca a 'Pharmacy Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 (PRE65 Claimant # Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 ,Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #004 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 'Claimant #005 Processed Month 200805 200804 200803 0D N a co N 200804 200712 200804 200804 200802 200802 200802 200801 '200804 '200804 200806 200803 200806 200804 200805 200802 200801 200808 200803 200809 200803 200809 200802 200803 200808 200810 200806 200803 200801 200811 200808 200811 200808 200809 200803 200802 200803 1200807 a) M m W 3 U t O m ce ICiticare d CC) 0 U ICiticare ICiticare ICiticare N N CO co 0 0 UC) d co 0 C) N N N N N N d it LL it it it it CL d `) N E i) N d N N `) Cl) N N N N 2 N N N N N C (D ) N d d d N d N co co co (a co co co co co Cl) co co co co co co co co co co Q) co CO co CO CO CO CO CO CO 0 0 0 0 0 C) 0 0 C) C) 0 0 C) 0 0 C) 0 C) C) 0 0 0 C) 0 C) () C) 0 U C) UUUUUC DUUCDUUUUUUUUUUUCDC)C)UUUUUCDCD N N CC N it it it LL N N d d CO CO CO CO 0 0 0 U )UUCD Citicare Fire Shock Amount ^^ O (O D CO i (0 O �I ) 96969 co CO (9 O (D N CC) co (O CO (0 CO N co (O CO CC c0 N ) co V969 CO CO CD CO N CO CO CO N C)() 69 69 CO CO ri C0 CO N co 69 CO ((o CO N N co 69 (D O ao D (O N N 69 (D CO CO CO N M 69 (D CO (O (O N V) 69 c0 CO CO cD N 69 (0 CO CO CO N � C9 C0 CO CD Ny 0) 4i 619 CO CO ri CO CO N C9 CO a) CO CO N 0 Vi 69 CO (0 (D N C0 CA O (O CO (D N 0 C9 69(A CD CO C0 O CO N (0 CO CO CO N 0 49 c0 CO CO CO N C9 C9 696969 (0 C(ri CO N CD m CO D CO N OD co CO CO D CD N CC0 69 N $133,263.861 D CO o CO D (0 D CD V 7 C0 9690949696969696969696969 CD OD CD N CO (' CO CO 6 CD N V) (D CO 6 CO N CO CO (0 CD N 0 Cri (D CO (0 (0 CD N (D CO ( CD N C9 CO CO i CO C N 0) co CO CO i ( (O N CD CO i (0 CD N CO CO CD CO ( CD N C) CD CO i (0 N CO (O CO C0 O cD N O f969 (D CO CD ( N C) (MI C a i ( ( N( C E Net Paid Amount ^_ D) CD '9 ^9 o- '7 9 (9 a N co 69 r CO 0) (A N N 40 N a O 09 N CO CO to 0 CO CD CA CO U) C) N. 40 CA O CD .7 n 40 IN O 0 r CO 49 69 CO CO n O (O 49 CO CO d' aD IN 69 CD O CO 69 O CA CO O C) iR CO O 69 CO a O U) Q 69 O CO U) er R 6A O CO 0) to of 69 N in 0 sr CO 69 0) C9 0) C'') 69 N .7 O ' N CO C9 69 CO n IN C9 CO 69 CO 0 49 N CD 0) V' co N 69 O N ER U) O U) N 69 U7 0 U) N (n 0 U) N 69 f9 /� 0) U) 0 N EA N N r) 0 N O CD U) U) V9 69 n (n N 69 O CD CO CO N 69 CO (D Co r 69 CD (O Co r 69 CO r 69 U) r r 69 O) U) 1,. m (O 0 (9 N 0 CO 0 (D 0 CO O CA 0 69 CO q C') 69 7 (9 In 69 U) • C 1 6 DX Description PHARMACY PHARMACY NEED FOR PROPHYLACTIC IMMUNOTHERAPY PHARMACY PHARMACY PHARMACY AFTERCARE FOLLOWING ORGAN TRANSPLANT AFTERCARE FOLLOWING ORGAN TRANSPLANT LUNG REPLACED BY TRANSPLANT PHARMACY AFTERCARE FOLLOWING ORGAN TRANSPLANT PHARMACY DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY LUNG REPLACED BY TRANSPLANT OTHER MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE AFTERCARE FOLLOWING ORGAN TRANSPLANT �CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM LUNG REPLACED BY TRANSPLANT OTHER MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY COMPLICATIONS OF TRANSPLANTED LUNG AFTERCARE FOLLOWING ORGAN TRANSPLANT 'OTHER MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL 'OBSERVATION FOR UNSPECIFIED SUSPECTED CONDITION IPOSTINFLAMMATORY PULMONARY FIBROSIS NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD 'UNSPECIFIED VIRAL WARTS ICELLULITIS AND ABSCESS OF UNSPECIFIED SITE 'OTHER NONSPECIFIC ABNORMAL FINDING IN BODY SUBSTANCES UNSPECIFIED VIRAL WARTS 1� ICELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM 'LUNG REPLACED BY TRANSPLANT 'IDIOPATHIC FIBROSING ALVEOLITIS IDIOPATHIC FIBROSING ALVEOLITIS DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY (ACUTE PHARYNGITIS 'LUNG REPLACED BY TRANSPLANT IOLECRANON BURSITIS 'OTHER NONSPECIFIC ABNORMAL FINDING IN BODY SUBSTANCES 'OTHER MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL UNSPECIFIED CHEST PAIN LUNG REPLACED BY TRANSPLANT DX Code Pharmacy Pharmacy ✓ 072 Pharmacy Pharmacy Pharmacy V5844 ✓ 5844 ✓ 426 Pharmacy V5844 Pharmacy 7220 to N N' > C') C9 N. r V5844 16823 (D N > c') CO r r 17220 acD CO 0) 0) 1V5844 N C9 n r 0) n > U) (n CO 0) N O CO N- 0 O N CO CO 17929 O CO N 0 6823 CO 'a > C) U) CD N(0 u) 7220 CO 'U V426 72633 7929 1732 78650 N V > Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 (PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 IPRE65 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 Claimant #005 (0(0(0(0(0(0(0(0(0(0(0(0(0(0(0(0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O 0 0 0 0 0 0 0 0 c c c c c c c c c c c c c c c c m 0) 0) 0) 0) 0) 0 (0 0) 0) 0) 0) 0) 0) 0) 0) E E E E E E E E E E E E E E E E .0 •0 • i •0 is a a •0 •0 •0 •s •0 TO •0 •0 •a 'Claimant #005 Processed Month 200806 200801 200803 200805 200804 200802 200809 200812 200808 200712 200802 200810 200811 200811 200804 200808 200808 200803 200803 200812 200803 200804 200812 200806 200802 200803 200806 200806 200808 200808 200807 200806 200802 200801 200810 200803 200804 200808 200901 200811 200803 1200807 E E ` ) d E 0 0 ) 0 ) 0 0 0 ) 0 ) 0) 0 a) N O N N a) a 2 `) N N LL LL Cr LL LL LL LL LL Il LL LL LL LL LL LE LL LL LL it it LL LL LL LL LL N 2 `) N N 2 `) E 0) d 0) ` E d d 92 N 2 0) E N N N `7 d o m m CO (o m m m m as as m as as m m Co as as as as as as m m 0 0 0 C) 0 0 C) 0 0 0 C) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000000000000000000_ 0 d N d d CD 0 a) cD 0 N d 0 0 d `) L.L. LL LL LL It LL LL LL LL LL LL LL LL LL IL LL N N N E N N d 2 a d ) E N d N N as co as at co co as as as co m as as co as (0 0 C) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000000000 Citicare Fire Shock Amount ^^ D (0 0 OD 7 C9 0 (0 N )) CO ft CO CD co co CD N O CO C E9 CO OD CO N CC7 E9 CO co M (o CO N CO CO (D N CO Co vi E9 (0 CD M CO OC� CO E9 CO OD M co CO N CO CO E9 (0 O CO co M co CO CD N N CO C Yi C9 CO co C) CO N CO CA CO co CO CD N CO E9 I $133,263.861 $133,263.86 tvZZ 7RZ RR CD OD (o O CO n M 9 CA (0 OD M (0 N co 69 CO OD (o CD N co C Ee () OD c6 (0 N co c 69 O CD CO co M co CO CO N co co C9 64 CO (0 co 00 M M CO CO N N N 0) M (A 69 CO CO CO (O N CO E9 CD CO M CO N M CO O 00 co M co CD CD ( Ni co 69 69 O (O co (o CO N M 69 CO CO CO N M E9 CO co M CO N CO M Vi (D co M co CD CO M CO E9 CO co co CO N CO C E9 (D CO CO OD M C7 CD (0 N CO CO 69 E9 CO OD (o CD N CO EA CO OD CO N OC� E9 CO CO M (o CD CO 0) E9 CO CO M CO CO 0) ei 69 CO 00 (o CD N co CO 49 CD CD M CD N C) 69 (D OD M CD CO CO EA Net Paid Amount 4' LO )0 N Y9 E9 O O O P E9 O O O ui n CD E9 CO Q) Cl �p E9 (0 co E9 0 (n 0) (n 0 CO N O) N (n U) E9 0 0 O N O N O a E9 E9 O) V et E9 O CO O et 69 $40.80 (n CO O) (O O d' CO CO 09 E9 CO 0 .cr CO V) O 0 a CO E9 0 0 M E9 O 0 (o O7 69 (0 0* O N CO 09 64 r CO n CO R n CO (D CO N E9 Cfl O O b CO 69 0) N M CO 04 O N,- 6 +- N 49 E9 N (n 0 (0 O CO E9 0 CO O 69 0 CO O O Ti 64 (n 0) 69 O) IN LI) Ti E9 E9 O CO E9 CO O E9 V• 0 6ri 0 0 O O 0 0 09 0 O 0 E9 0 O 0 E9 N N N- DX Description OTHER MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE POSTINFLAMMATORY PULMONARY FIBROSIS UNSPECIFIED DERMATOMYCOSIS CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM PHARMACY POSTINFLAMMATORY PULMONARY FIBROSIS UNSPECIFIED OSTEOPOROSIS OTHER FOLLOW -UP EXAMINATION BALANOPOSTHITIS LUNG REPLACED BY TRANSPLANT LUNG REPLACED BY TRANSPLANT OTHER DISEASES OF LUNG, NOT ELSEWHERE CLASSIFIED NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD BOTHER DISEASES OF LUNG, NOT ELSEWHERE CLASSIFIED LUNG REPLACED BY TRANSPLANT OTHER SPONTANEOUS PNEUMOTHOHAX (PRIMARY OPEN -ANGLE GLAUCOMA � (PPRIMARY OPEN -ANGLE GLAUCOMA RIMARY OPEN -ANGLE GLAUCOMA NEED FOR PROPHYLACTIC IMMUNOTHERAPY AFTERCARE FOLLOWING ORGAN TRANSPLANT [ OLECRANON BURSITIS U E 0 >- ¢ I a 0 w I— m 0 •st LUNG REPLACED BY TRANSPLANT LUNG REPLACED BY TRANSPLANT UNSPECIFIED TACHYCARDIA UNSPECIFIED OSTEOPOROSIS IPOSTINFLAMMATORY PULMONARY FIBROSIS DISORDER OF BONE AND CARTILAGE, UNSPECIFIED CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM N ANGLE GLAUCOMA PRIMARY OPE NEED FOR PROPHYLACTIC IMMUNOTHERAPY DISORDER OF BONE AND CARTILAGE, UNSPECIFIED OLECRANON BURSITIS CELLULITIS AND ABSCESS OF UNSPECIFIED SITE PATHOLOGIC FRACTURE OF VERTEBRAE PATHOLOGIC FRACTURE OF VERT Et3HAE LUNG REPLACED BY TRANSPLANT PATHOLOGIC FRACTURE OF VEH I EtiHAE AFTERCARE FOLLOWING ORGAN TRANSPLANT DX Code 1733 515 O 6823 Pharmacy (C) t0 73300 V6759 f r- COO V426 V426 51889 7931 7931 151889 CO N > 5128 36511 36511 36511 V072 V5844 72633 1462 V426 V426 7850 73300 515 ER C") CO COO co COO :ibb 1 1 V072 177597-- 72633 N 73313 73313 V426 73313 'V5844 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 IPRE65 N CO 0 O CD 00 c c CO CO E E (o 'a 00 Claimant #005 I Claimant #005 (n U) 0 0 0 ik 4k c c CO CO E E .s 'co 0 0 (n 0 0 4k c (O E 'm 0 Claimant #005 Claimant #005 t0 (n O O 0 O 4k 4k c c How E E 'm '(o 0 0 (n O O 4k c CO E s 0 Claimant #005 I (0 0 0 4k c was E 'ro 000000 (n 0 0 4k c E '(o U) 0 0 4k c (O E at LO 0 0 4k c (C E '(v (n 0 0 4k c (O E ro Claimant #005 Claimant #005 Claimant #005 Claimant #005 U) 0 0 4k c E (a 0 (n 0 0 4k c E 'Es 0 (n (n 0 0 0 0 4k 4k c c (0 E E s m 0 0 0 0 * c (D E c 0 Claimant #005 Thai mant #005 Claimant #005 (n O O 4k c CO 'R U Claimant #005 Claimant #005 Claimant #005 Claimant #005 CD 0 O 4k c O) E A 0 Claimant #005 (n 0 O 4k c as '(o 0 Claimant #005 Claimant #005 Claimant #005 Processed I Month n O O CO CO 0 0 O O N N 200806 200810 200812 200804 a O co O CD CO CD) O O co c0 O O 0 0 CO CO 200805 200810 200811 N O CO O 0 N O CO 0 0 N co O CO 0 0 CO O CO 0 0 CO r CO 0 O N CO O CO 0 O CO N to v IN O O O 0 CO CO CO CO 0 0 0 0 O O O O CO CO N N N N 0 O CO O O CO 0 O N N N O CO CO 0 0 O O CO CO CO 0 CO 0 0 N N 0 CO 0 0 CO IN 0 CO 0 0 CO et 0 CO 0 0 CO r CO 0 0 CO N N 0 0 CO CO 0 0 0 0 CO CO n 0 CO 0 0 CO 0 Co 0 0 CO CO 0 CO 0 0 N CO 0 CO 0 0 CO 0) 0 CO 0 0 N 0) 0 CO 0 0 CO O O CO C) 0 0 0 0 N CO I I O) N i LL it I CO ID • co co 0 0 0 0 E 2 it LL CO (1) CO CO 0 0 0 0 E E LL LL C) 0) CO CO 0 0 0 0 O) LL CO CO 0 0 2 2 LL Cr. CD CO CO CO 0 0 0 0 it 0) CO 0 0 E it CD CO 0 0 N U_ N CO 0 0 N LL O) CO U 0 CO LL C) CO U 0 E it O) CO U 0 O) LL CO CO U 0 O) CL C) CO U 0 d LL CD Cc U 0 CD 4 w LL CD O (o c U C 0 C: ICiticare Fire ) . ) 1 ) ) N it CO CO U 0 d 11 O) CO U 0 N N LL LE c) D) CO CO U U 0 0 E LL CO CO C) 0 d LL O) CO U 0 E it N CO O 0 E LL C) N Q 0 O LL O c C C: ICiticare Fire f .itica ro Fire ) N . it ) CD i (O ) U ) 0 E LL N CO U 0 d LL CO CO U 0 2. CL 0) CO U 0 d w Co is C) 0 N it N CO U 0( Citicare Fire Citicare Fire Shock Amount O et D DOrO ID N. ft M 0 N'■ rn O $109,704.341 r h 0 .. r, )0 7 ; 4 M O 0 $109,704.341 r er ? C9 rOOO44444OOOOOOOOOOOOOOOOO D ,nnr nofo) 0 9 69 er O 0 69 M C9 O ofrnofofof 0 49 V et C9 O Ps. 0 49 C9 O O V er CO O nnnr O * 69 et O O 49 et M CO O or; 0 09 er CO O O r-r_r�nnr"nnnnnnnr"nnnr-rrnr:nr crcrrnrnwrnrn 0 0 49 et C9 O 0 49 er er VD V) O 0 69 49 et O 0 69 er M C9 O 0 49 V V) o 0 0 0 49 er et CO C9 0 0 on' rnrnrnrnrnrnrnrno)ofrncrrnrncro 0 0 69 49 V' M CD 0 0 69 49 V et C9 0 0 69 CO 0 0 09 V* C9 0 0 0 0 49 V- C9 0 0 49 of of M C7 0 0 69 69 er C9 0 0 69 er et C0 V) rersr 0 0 O O 69 69 er 0 O 69 er M C7 4 0 0 69 er CO s 444 0 o 49 er C9 0 r 0 49 er C9 0 r-r 0 69 c 0 C me 0 C E Net Paid Amount • )D C) CO CO Mi� O Of U) $24,288.961 A CO CD CD 1) co ) t49 W N et CO CO O O CD h CA N M 6949 CD M N C) N M O O C�) 69 69 O CA O U) O C�) a O E969 h '- r O O 6 O O O O 9 N r U) c0 OD 49 69 O O O O 49 O CO h Cn M co h 0) h CO 49 er C7 Cn h 0 69 0 x O Ch O 0 CD 69 449 0 0 CO 0 0 C O er 09 69 h N 0 C7 N N U) a 49 O CO h N N LO N CO er Cr) 09 49 N O CO N CO 49 49 NO h CtO� Cr) 69 N N er CO 09 r,- N CO *69696969449490949694949694 n N C9 N,- r CD C) O et CO N N O N CO CO O O N co O U) et O O c N -� OO), m CD C M r _ DX Description OTHER FOLLOW -UP EXAMINATION I DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC LOCALIZED OSTEOARTHROSIS NOT SPECIFIED WHETHER PRIMARY OR SECONDARY, SHOULDER REGION DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY I UNSPECIFIED FOOD POISONING OSTEOARTHROSIS, UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED, SHOULDER REGION NONTRAUMATIC RUPTURE OF TENDONS OF BICEPS (LONG HEAD) PHARMACY SPINAL STENOSIS OF LUMBAR REGION CONGENITAL SPONDYLOLISTHESIS PHARMACY PHARMACY PAIN IN JOINT, SHOULDER REGION VOMITING ALONE PHARMACY (PHARMACY THORACIC OR LUMBOSACRAL NEURITIS OH RADICULITIS, UNSPECIFIED DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC PHARMACY LUMBAGO } 0 < 2 CC < S a PAIN IN JOINT, SHOULDER REGION PHARMACY PHARMACY PHARMACY SPINAL STENOSIS IN CERVICAL REGION PHARMACY 'CARPAL TUNNEL SYNDROME 'PHARMACY UNSPECIFIED ESSENTIAL HYI'EH I ENSIGN THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS, UNSPECIFIED PAIN IN JOINT, SHOULDER REGION UNSPECIFIED OPEN -ANGLE GLAUCOMA THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS, UNSPECIFIED UNSPECIFIED OPEN -ANGLE GLAUCOMA AFTERCARE FOLLOWING SURGERY OF THE MUSCULOSKELETAL SYSTEM, NEC DISPLACEMENT OF INTERVERTEBRAL DISC, SITE UNSPECIFIED, WITHOUT MYELOPAI MY CONGENITAL SPONDYLOLISTHESIS SPINAL STENOSIS OF LUMBAR REGION PAIN IN JOINT, FOREARM [DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC DX Code V6759 72252 71531 72210 U) o O 71591 72762 Pharmacy 72402 75612 Pharmacy Pharmacy 71941 78703 Pharmacy Pharmacy 7244 72252 Pharmacy 7242 Pharmacy 71941 Pharmacy Pharmacy Pharmacy 7230 Pharmacy 3540 Pharmacy 4019 7244 rn 36510 7244 36510 V5878 7222 75612 72402 71943 172252 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 co Ili CC CL PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 CO OD IX o_ PRE65 OD L11 CC a (PRE65 U) 0 0 * c CIS E 'm U Claimant #006 CO 0 0 4t c m E 'm U Claimant #006 cD 0 0 a c CO E m U CD CO CD CO 0 0 0 0 0 0 0 0 4e*4zx c c c c m m m CO E E E E -m 'c 'm -ca 0 0 0 0 CO CO CO 0 0 0 0 0 0 *fc* c c c CO m m E E E 'ca 'm 'm 0 0 0 Claimant #006 CO 0 O 4t c m E m 0 CD 0 po *** c m E 'm 0 CO 0 0 c m E m 0 CO O 0 0 0 0 c c m m E E LU m 0 0 Claimant #006 Claimant #006 CD 0 0 *xaU c CO E m , 0 CO CD 0 0 0 0 c c m m E E 'm 'm 0 0 CO CO 0 0 0 0 c c CD m E E 'm 'm 0 0 Claimant #006 Claimant #006 ICIaimant #006 O O 0 0 0 0 as c c OS E E 'm 'm 0 0 Claimant #006 IClaimant #006 Claimant #006 Claimant #006 Claimant #006 Claimant #006 Claimant #006 CO 0 0 le c co E m 0 CO 0 0 u c m E 'm 0 CO 0 0 c m E -m 0 'Claimant #006 Processed Month 200807 200808 O CO O N 200807 200802 200712 200802 200807 200806 200807 200811 200804 200802 200803 200712 O CO 0 N _N O 0 h CO 0 0 N N CO 0 CO 0 N CO 0 CO 0 C) _O CO 0 C) CA 0 0 CO CO 0 0 O) CO 0 0 CO O 0 0 N CO 0 CO 0 N N 0 CO 0 er 0 CO 0 N 1200808 200712 er O CO O N CD O CO O N 200811 200803 200803 200807 CO 0 CO 0 N O 0 CO 0 N U) 0 O 0 N er O CO 0 N 1200810 ■ `) L LL ■ C) CO • 0 U 2) LL C) m 0 C) C) LL 0 CC 0 C) C)) LL C) as 0 C) `) LE C) as 0 C) d `) N C) LL LL Il LL CD N 0 CD m m m m 0 C) 0 0 C) C) 0 C) C) N d LL LL LL CD 0 0 m m as 0 0 0 C) 0 0 N LL C) m 0 0 C) LL N m 0 C) 0 LL 0 m C) 0 d Ll C) at 0 0 2 2 LL LL C) 0 as m 0 0 C) _ 0 d LL 0 m 0 0 2 LL 0 m 0 0 N LL CD CO 0 0 d d LL LL C) N CO CO 0 0 C) C) C) E LL LL C) CD CO CO 0 0 C) 0 N L. C) m C) 0 E 11 CD m 0 C) d LL C) m C) 0 C) LL C) as 0 0 C) C) LL LL CD CD m m 0 0 C) 0 C) LL C) m 0 0 C) N C) 2 LL LL LL LL 0 C) 0 0 as m m as 0 0 O 0 0 0 C) 0 C) LL N co 0 C) d LL C) m 0 U 2 I1 C) m 0 C) 6 LL 0 CO C 0 Citicare Fire Page 15 of 25 Shock Amount I' et '� co d' D N Di D 9 E9 ei co of O n r a) to 0 to et et o . r. 0 CA et M R 0 0 0 69 et M CO 4 ei 0 n of 0 69 et of 0 n r ai 0 E9 et M CO et 0 „ r a) 0 69 et 0 . a) 0 :9 et M CO V 0 n ai 0 C9 et V 0 n of 0 E9 M CO V 0 N . r M 0 69 CO 4 0 . r. d1 0 et CO V 0 o 0 09 et CO 4 0 n r o 0 69 'a' CO 4 0 . a) 0 VT 03 CO 4 0 N. O) 0 69 V Q et 0 N.N. O) O) 0 69 R •V M C7 et 0 0 69 17 C7 0 N 0 to 0 69 0 N 0 $109,704.341 t et 7 co 7 et D . ri D 9 49 () of 0 n ai of 0 Cfl V 0 n 0 V M et O n oi- 0 E9 $109,704.341 t et ? C? S D )i D 9 49 et C7 R 0 a) 0 E9 •et V et 0 of o) 0 E9 M 0 N 0 $109,704.341 t et 7 Y D . » ai 2 9 f9 et M R eT 0 n of 0 E9 M 0 n 0 Ea V et M C`7 V 0 n w 0 C9 eY 4 e! 0 N of of 0 f9 et M C°) 0 N of 0 69 V 0 N 0 Net Paid Amount ) T co 9 E9 CO N CO o) co E9 a Co, 0 co 69 CO E9 CD O CD O CO 69 (O M N 69 M N N E9 O CD N O N CO E9 a) CD (1) CD E9 n a) CO CO E9 co 4 CO 69 M CD E9 O N CD 69 N et in N CO CO a O E9 O M OD O R E9 M M V et f9 0 Q) 69 0 a) CT E9 0 a) V• $37.381 D NI 1- () (n ') CO 9 69 M CO et CO E9 N CO T IT. M E9 $30.64 DV' D ) N 9 E9 «) a N R CO O O) 69 E9 n n h N CO O (A 49 E9 M el' of N et E9 N M •- 64 M et CO 69 E9 et o E9 O 0 E9 O 4 0 DX Description PAIN IN JOINT, SHOULDER REGION PAIN IN JOINT, SHOULDER REGION DISPLACEMENT OF INTERVERTEBRAL DISC, SITE UNSPECIFIED, WITHOUT MYELOPATHY AFTERCARE FOLLOWING SURGERY OF THE MUSCULOSKELETAL SYSTEM, NEC DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY PAIN IN JOINT, SHOULDER REGION OTHER CHEST PAIN ABDOMINAL OR PELVIC SWELLING, MASS OR LUMP, UNSPECIFIED SITE SPINAL STENOSIS OF LUMBAR REGION MIXED HYPERLIPIDEMIA CARPAL TUNNEL SYNDROME DISORDER OF BONE AND CARTILAGE, UNSPECIFIED SPINAL STENOSIS OF LUMBAR REGION OTHER UNSPECIFIED BACK DISORDER THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS, UNSPECIFIED ANXIETY STATE, UNSPECIFIED OPEN WOUND OF TOE(S), WITHOUT MENTION OF COMPLICATION x 0 D o CARPAL TUNNEL SYNDROME ANXIETY STATE, UNSPECIFIED DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED INONTRAUMATIC RUPTURE OF TENDONS OF BICEPS (LONG HEAD) SHOULDER JOINT REPLACEMENT BY OTHER MEANS DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED 1FOOT AND TOE(S), SUPERFICIAL FOREIGN BODY (SPLINTER), WITHOUT MAJOR OPEN WOUND AND WITHOUT MENTION OF INFECTION DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY � 'OTHER SPECIFIED PRE - OPERATIVE EXAMINATION 'PAIN IN JOINT, FOREARM 'UNSPECIFIED ESSENTIAL HYPERTENSION 'DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED PAIN IN JOINT, SHOULDER REGION LUMBAR SPRAIN AND STRAIN IPRE-OPERATIVE RESPIRATORY EXAMINATION NAUSEA WITH VOMITING OTHER UNSPECIFIED BACK DISORDER IPRE-OPERATIVE CARDIOVASCULAR EXAMINATION W I- Cn 0 W LL 0 W a U) z 2 z a a Q z 0 o 0 DX Code 71941 I� 7222 V5878 O N n 71941 78659 78930 72402 2722 3540 o co M CO 72402 cr) n ,7244 30000 8930 CV co 3540 30000 25001 72762 V4361 72210 25001 9176 72210 V7283 M r- O Ov 25000 71941 8472 V7282 78701 7249 CO > 178900 Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 (PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 1PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 1PRE65 Claimant # Claimant #006 I Claimant #006 CO 0 0 * c CO E 0 Claimant #006 Claimant #006 Claimant #006 Claimant #006 Claimant #006 Claimant #006 Claimant #006 Claimant #006 Claimant #006 CO 0 0 * c CO E 0 Claimant #006 Claimant #006 Claimant #006 Claimant #006 Claimant #006 CO CD 0 0 0 0 * * c c co as E E 0 0 CD CD CD CD 0 0 0 0 0 0 0 0 * * iC * C C C C c0 co as co E E E E 0 0 0 0 CD 0 0 4 c CO E 0 Claimant #006 Claimant #006 Claimant #006 CO CD 0 0 0 0 4 4 c c as t0 E E 0 0 #006 CO 0 0 0 0 0 * * c c co (0 E E a3 as 0 0 CD (D 0 0 9 00 aF c c co CO E E cz CO 0 0 CD 0 00 c co E CI 0 CD 0 00 c c0 E VS 0 !Claimant #006 200810 200805 200807 200808 200901 200803 200801 200802 200808 200808 200807 200712 200807 200804 200809 200802 200810 200809 200805 200811 200804 200712 200801 200805 1200802 200811 200809 200801 200807 200809 200808 1200804 Report Cluster 2 N 0) L E LL LL 4) 2 O) (0 CO (0 0 0 0 000 N 0) N 2 N N N 0) 0) 2 0) 0) 0) N O) E. E LL LL LL E. LL it LL LL LL LL LL LL LL LL LL LL E 2 2 02 N N 2 2 2 2 '2 0) 0) 2 E E 0) d (6 C6 RS R) C) CO (O CO CO (d Of CO al (C (O as co 0 0 C) C) 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000000000000 N N N E LL LL LL Il 2 2 0 0_) (0 as (0 (O 0 0 0 0 0000 02 LL 2 CO 0 0 0) 0) 0 E 0) (L LL 11 LL LL 0)0(000 at iV (0 as (O 0 C) 0 0 0 00000 00)0000)0 LL LL LL LL LL LL LL 0000000 (O CC (C (O (C CO C: 0 0 0 0 0 0 0 0000000 1C- iticare Fire Shock Amount $109,704.34 v :7 Ti o h A o E..9- $109,704.341 .- I O D '1 V o W9 (9 n N m m N N m 49 n N m m N N m (9 n N m m N N m n N m m N N m 0, (9 n N m m N N m (9 n N m m N N m 69 N. N m m N' N m (9 n N m m N N m 09 n N m m N N m EA n N m m N N m (9 n N m m N N m (9 n N m m N N m E9 n N m m N N m CO 09 n N m OD m N N (9 N. N m N N m 09 n N m m N N m 41 n N m m N N m (9 n N m m N N m 69 n N m m N N m 69 n N m m N N m 69 n N m m N N m 09 n N m m N N m to N.N. N m m N N m CO 69 N m m N N (9 n N. N m m N N m (9 N m m N N m CO 09 n N m m N N $82,288.271 nnn /17 V O O V Ni O 9 (9 n N m m N N m (9 n N m m N N m 09 n N m m N N m CO 09 n N m m N N 1 $82,288.271 V O 0 V V O 9 Net Paid Amount CO (O f9 (9 N` r N O O O f9 r r m N Ch m CA 69 O CO N CO 69 (9 m co (. O) Tr IN LO n N Ti f`D m (O 69 (9 O N O M O r O) m co OD 69 n m 0) 69(9 O 0 m O m Ch O) O m m N 09 09 N.—co n W Ch 0 n N n 0) r N 69 09 Tr O) m r CO r N (9 n n M m CO (9 O N m n 09 m n m N M 09 m N Ti in m N 69 0 Tr m LO m CO r 09 N (A T 09 0) et '7 0 r 69 O) tO 0 C'') 0 CA C9 N m C` CO CA 6% o tO f9 T 'N N LC) O n f9 O Ti O n CO E9 O(0 a (� 0) CO CO 0) CO Vl 49 Tr N O) LO 69 0 R Ti 0) $545.36 0 CO N C') O 13 sr r 9 (9 c') m Tr (9 N a v 09 N 0) co O) C') O Tt co 09 N N m 0) co O N C') (9 N N n N V) DX Description DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY I OSTEOARTHROSIS, UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED, SHOULDER REGION MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE PHARMACY PHARMACY MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE UNSPECIFIED ANEMIA UNSPECIFIED ANEMIA UNSPECIFIED ANEMIA UNSPECIFIED ANEMIA MALIGNANT NEOPLASM OF CHOROID !MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS !UNSPECIFIED ANEMIA !PHARMACY UNSPECIFIED CEREBRAL ARTERY OCCLUSION WITH CEREBRAL INFARCTION UNSPECIFIED ANEMIA UNSPECIFIED ANEMIA PHARMACY SECONDARY MALIGNANT NEOPLASM OF LIVER r Cr 0 I a 'MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS 1 'ENLARGEMENT OF LYMPH NODES 'UNSPECIFIED CEREBRAL ARTERY OCCLUSION WITH CEREBRAL INFARCTION OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE 'SECONDARY MALIGNANT NEOPLASM OF LUNG SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRATHORACIC LYMPH NODES Y 0 LL I a 'ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY 'OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE !- SHORTNESS OF BREATH 'ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY 'MALIGNANT NEOPLASM OF EYEBALL, EXCEPT CONJUNCTIVA, CORNEA, RETINA, AND CHOROID >- 0 CC I a In o X Q 25001 72210 71591 00) m 0) Of 0) 0) 0) 01 Pharmacy Pharmacy I 1890 O) O) 2859 2859 12859 2859 0 0) 00) m 00) m 12859 0 co ( a 143491 m N ump N IPharmacy T r Pharmacy 0) r 17856 43491 1991 N. r co r Pharmacy r > 78605 r > O 0) 'Pharmacy Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 IPRE65 Claimant # Claimant #006 Claimant #006 Claimant #006 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 I Claimant #007 n 0 0 c co E 0 n 0 °46000 C co E 0 'Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 200807 200808 200801 200803 200802 200806 200808 200801 200712 200802 200804 200808 200809 200806 200807 200801 200804 200809 200804 200807 200801 200805 200810 200804 200809 200806 200806 200806 200806 200807 200802 200804 200805 200803 200712 200808 200804 O m O O N 1200803 Report Cluster I E.1.' E LL LL N d (c m 0 0 00 N 2 2 d E N N N N d d d N E N d N d N d 112 N N N N N E N E. L. LL U. LL 11 LL LL LL LL LL LL LL LL Ll LL LL LL LL LL LL LL LL U LL lL I1 LL LL LL E d d d d N d d d N E d E E E d 0) i) O) d N E N d N N 2 d N co (o m CO CO m co (o (o `o m co `m m ro co (`a m m (o `co (o co co (o (o (o co `o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0( 0( 00 (000000000C)C)(UC00000000000CUU E N d d 2 N U. LL LL (L U. LL O) E N d 2 `7 m et ro (o as co 0 0 v_ 0 0 0 000000 2 LL it (( a C' Citicare Fire Page 17 of 25 Shock Amount N N CD CD N N D Y) fR N N . D N N D f9 N N W CD O N N D N N N N CCpp A N N M D N N D V N N O O N N M N N 0 CD N N D N N CD CD D N N O A N N CD N N D V) EA N N m N N D $82,288.271 NNNNNNNNN N D U :V bO N M �������� N N D A N W N N D A N N N D A CA N M N N D N M N N D A N O N N D fA N W N N D N O N N D V! $82,288.271 D CD D NN N =COW N O N N D D N N $82,288.271 $82,288.27 D D CD NI N D CD N O N N Op N D C M N N CD N D N N N C CO CD N N M N N N M N b D N N D $82,288.271 N o o��� NN V A fl to N N � N D EA N N � N N M N N � N N M vi Net Paid Amount M a O CD NN HN9 O 0 c N CD r NN W CD Cn O W v- O O V3 N N M Cn V) N M M Cn EA N 0) R D i9 t9 M M CD U) M CA W N- N v N CD 0) 69 C9 M CO .0 CD C9 CO N t` N CA CO N n N V3 C9 M CO O N CD C9 LO M 0) CD C9 r` O CD CA CD CA M C9 N n U) $56.641 M r 1) O) n U694.9 O MN O h ' $43.851 N CO N N- M fA CO N M C'7 H9 f9 N fA 0) W CD N 69 M W o fA a N N a LD W r 49 69 W 0) CD CA CD fA EA. O N O CA CD M L) fA a N f9 o 0 O DX Description UNSPECIFIED CEREBRAL ARTERY OCCLUSION WITH CEREBRAL INFARCTION NEOPLASM RELATED PAIN (ACUTE) (CHRONIC) PHARMACY PHARMACY MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS MALIGNANT NEOPLASM OF CHOROID PHARMACY UNSPECIFIED CEREBRAL ARTERY OCCLUSION WITH CEREBRAL INFARCTION MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS CHRONIC AIRWAY OBSTRUCTION, NOT ELSEWHERE CLASSIFIED SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRATHORACIC LYMPH NODES OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE SHORTNESS OF BREATH 1CHRONIC AIRWAY OBSTRUCTION, NOT ELSEWHERE CLASSIFIED CHRONIC KIDNEY DISEASE, STAGE I NEOPLASM RELATED PAIN (ACUTE) (CHRONIC) MALIGNANT NEOPLASM OF CHOROID MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS ESSENTIAL HYPERTENSION, BENIGN ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY MALIGNANT NEOPLASM OF EYEBALL, EXCEPT CONJUNCTIVA, CORNEA, RETINA, AND CHOROID MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS ACUTE BRONCHITIS 14660 'OTHER DISEASES OF LUNG, NOT ELSEWHERE CLASSIFIED 1NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD (NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD MALIGNANT NEOPLASM OF RECTUM 1 MALIGNANT NEOPLASM OF RECTUM SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION MALIGNANT NEOPLASM OF CHOROID ESSENTIAL HYPERTENSION, BENIGN SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW 1NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD ABDOMINAL PAIN, UNSPECIFIED SITE 17-45--1 'MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS (MALIGNANT NEOPLASM OF CHOROID } 0 Q 2 Q Q I 0 DX Code 43491 3383 Pharmacy Pharmacy 00) CD 0 O) Pharmacy 43491 00) CO 496 CD W O) D) 78605 CD v u) 0 OMD ('o M 0 D) 1890 r'- O) v> 00 0) 1890 4660 51889 0) 0) N- r) 0) N v LO r v u) r CCD 0) r 1540 o — aCD MOM r a 7931 p0 Oi m N co 0) 'Pharmacy Pre65 / Post65 PRE65 w Q PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 Claimant # Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 r- 0 o* c CD E 0 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 N N 00 00 xa; c c CC CC E E 0 0 N 0 0U c CC E 0 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Claimant #007 N 0 0 It c CD E 0 Claimant #007 Claimant #007 Claimant #007 Claimant #007 Processed Month 200812 200807 200808 200809 200808 200812 200802 200807 200801 0) 0 0 N 200807 200810 200807 200812 200805 200808 200804 200807 200804 200807 200806 200812 1200802 200802 200802 200804 200802 200803 200806 200803 200809 200807 200712 1200807 0 ao N 200805 200806 0 co N Report Cluster Citicare Fire Citicare Fire Citicare Fire Citicare Fire Citicare Fire Citicare Fire Citicare Fire Citicare Fire Citicare Fire ICiticare Fire N LL N C U 0 ICiticare Fire ICiticare Fire ICiticare Fire N d C) d E N LL U. LL lL 11 11 d E.D. N d N d CC CCC CC C C C) 0 C) 0 0 2 N d LL 1L 92 U CC CD 0 0 0 0 d d LL L. N N CD CC 0 0 0 0 N LL ` CC U 0 N d N d d N d d 0. LL LL LL LL U LL it d ` N d E C) CD 912 CC CC CD CC CC CD CD CO U C) 0 0 0 0 0 0 00000000 N LL N CO 0 0 d 1L d CC (] 0 Citicare Fire Citicare Fire ICiticare Fire Page 18 of 25 Shock Amount ^' N CO CD co \I \I ,gyp CO f 694999494999490949 N N CO N N C`7 N CO 0 N CO n IN CO 0 N M Ch CO CO CO 0 N CD N CO 0 N M CO CD N CO 0 N C7 N 0 N t7 CD N CO CO 0 N CD CD n CO 0 N M CD N 49936999 CO 0 N M Ch co N OD 0 N CO n CO 0 N M C'7 co N CD 0 N C7 CID N 49499) 0 N CD N M CO 0 N M CO CD N CO 0 N CO CD N 49 CO 0 N CO CD n 69 CO. 0 N CD N 99 CO 0 N M C7 co n 99 CD 0 N CO CD n CD 0 N N 99 69 CO 0 N M m co N IN 99 CO 0 N M CO CD 49 0 N n $78,320.811 D TO 6 V '� D co A CD 0 N M CD n 9969 0 N n $78,320.811 D CO 'J 7 CO O D CC) 9699499 CO 0 N CO. co N CO CO 0 N co n 0 C) M n $78,320.811 CO D CO V `7 CO 0 D CD 69 6999 CO 0 N CO CD n CO 0 0 N N CO CD N N 49 O C C C C r 0 Net Paid Amount J 0 J 49 O 0 O 99 CO LO CO CO CO N r 49 99 CD CO r CD In CO 4 N Cn CO CO 9 CO a N CO srs 99 49 O 0 49 O co CO 0 us O CO co CD CO CD CD CO a E9 O n CO CO in Tr 99 O CD CO M CO CO 49 CO O) 49 O CO O '- N 9i O r n CO 0 N 99 69 n CO 0 R a C) n M N 99 49 O 0 C7 TT' CO 49 N CO CO 0 O .— n 0) CO 99 O CO C'7 m O CO CD 99 et: 99 O Ch in W CD 99 CO CA CD 69 N N 99 09 O O O O N $621.491 O O D C�) CO )C ffl N CD V N 99 N v V* $117.89 D , D r CD 09 9 N N CO V' O) CO O C!) n CO 49 49 N $62.49 N ) CD LO 9 CO O) C'7 v CO 99 69 If) N V CO 99 C C O C C DX Description MALIGNANT NEOPLASM OF KIDNEY, EXCEPT PELVIS AORTIC VALVE DISORDERS END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE 'END STAGE RENAL DISEASE PHARMACY PHARMACY PHARMACY PHARMACY PHARMACY PHARMACY PHARMACY PHARMACY ABDOMINAL PAIN, UNSPECIFIED SITE PHARMACY ABDOMINAL PAIN, OTHER SPECIFIED SITE DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DISTURBANCES IN TOOTH ERUPTION PHARMACY OTHER SYMPTOMS INVOLVING CARDIOVASCULAR SYSTEM (DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED OTHER SPECIFIED PRE - OPERATIVE EXAMINATION ESSENTIAL HYPERTENSION, BENIGN PHARMACY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED PROLIFERATIVE DIABETIC RETINOPATHY (UNSPECIFIED ESSENTIAL HYPERTENSION INEED FOR PROPHYLACTIC VACCINATION AND INOCULATION, INFLUENZA NEED FOR PROPHYLACTIC VACCINATION AND INOCULATION, INFLUENZA PROLIFERATIVE DIABETIC RETINOPATHY DX Code 1890 4241 5856 5856 5856 5856 O 5856 5856 O U) 5856 5856 (D U) 5856 Pharmacy Pharmacy Pharmacy Pharmacy Pharmacy Pharmacy 'Pharmacy T U CO CC 0_ p° O) r, Pharmacy 78909 25002 5206 ITgarn-7-71cy LO n 125002 125043 CO CD r N 0 Sa Pharmacy 25002 36202 _ O CO 0 O v>> V0481 36202 Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 Claimant # n 0 0 It E as E .m Claimant #007 Claimant #008 Claimant #008 Claimant #008 Claimant #008 Claimant #008 Claimant #008 co CO CC 0 0 0 0 0 0 * 4# * c c c CO as as E E E .m.m.m U U 3 Claimant #008 CD 0 0 It c as E m U Claimant #008 CD CD CD CO CO CD CO CO aD CO CO 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 w* It f****** It c c c c c c c c c c c CO as CC CC) CO CO CO CO co as m E E E E E E E E E E E m m-m.m•mAAA-m.mA U U U U U U o U U U U CO CO CO CD 0 0 0 0 0 0 0 0 It I It I c c c c as CC CD co E E E E m m•mA 0 0 0 0 CO CO CO CO CO 0 0 0 0 0 0 0 0 0 0 * a tit a C C C C C co co CC as as E E E E E m mAA'm U U U U U Claimant #008 Claimant #008 Claimant #008 Claimant #008 Claimant #008 Claimant #008 1 200712 200808 200808 0 0 200804 200805 200812 200803 200801 200807 200802 0 O N 200809 200811 200810 200811 200808 200807 200803 200806 200801 200802 200805 200804 200804 200801 200812 200805 200809 200811 200810 200809 200811 200809 200807 200810 200807 200807 200811 1200801 Report Cluster Citicare Fire C) LL C) CD U C) C) Ctl C) 0 C) 0 U 0 N CO U 0 N as U 0 ) CO C) 0 C) CO U 0 cD C) d co CO co t) C) O U U 0 0 co C) U C) CO C) 0 CD CO 0 0 N cD C) 0 N C) C) cD C) D cD CO CO co co m as as CO CO CO co 0 C) 0 0 C) C) 0 0 C) C) C) 0 U 0 U 0 UUUUU 5 C) N cD W as co as co O U U U 0 0 0 0 C) CD d N N CO co co CO as 0 C) U O C) U U U U U d C) C) N co as CO CO C) C) CJ C) U U U U Citicare Citicare Shock Amount CO . �NNNNNNN N :h CO - 9 49 (0 N M CO n 69 N co. CO n 69 (0(0 N M O CO n 69 N M n 69 N CO. C CO n E9 OCO )i0) n N CO n CO n N n 0)0) NNNN- n N CO CO n 49 69 n N n 69 n N 0 n 69 n N 07 n NrnrnrnrnrnrnrnmrnrnrnrnrnrnNN n N M n 49 69 rna)airnrnrnrnrn(8)�i�iCD0)0))0O) n n N N M co n n 69 n N CO N 69 69 n N M CO n 69 n N CM n 69 n N n 49 n N M C7 n n N C7 n 49 n N C7 n 49 64 n N CO n 49 n N C7 n 49 n N C7 n n N (`i n 49 694949 n N (7 n N N Ch n n N n $73,279.961 ,) n V 7 0)0)0)00))0)0)00))0) O) N N ri n EA) 49 N. N N ri n 69- W0. N N M n 49 n N m n Ee•49 NNN N N C 6 (o n n N N 6 n n 69. CO N. N N ri n 69- Net Paid Amount N 0) co N E9 N O N 69 O N 43 O O 0 N CO 49 V 0 69 O O 0 CO r 0) tO N CO CO N 49CO O 0 O n (O CO O CA CO n 69696969 n n O 0 N r O V IA O CO 09 0 O V CO CO n CO CO N O CO CO O 0 CO 9 O O O so N n tO 49 � O CO O 9) O CO 69 O O O O O CO O O n N- 49 N et co O CO n O) n 49 1.0 V (D N O N 49 CO to N t0 N et 49 49 0) N N r 49 V r Ill r 49 N IA CO CO CO 49 tO n 49 CD 4) r r CO O CO CD 69 O 9) 4i O C C N CD CD 69 69 O CO N CO N O 43 O) n CO V CO 4i 69 n O to N CO n C) CO N 49 49 O O O N 49 DX Description ESSENTIAL HYPERTENSION, BENIGN OTHER SPECIFIED PRE - OPERATIVE EXAMINATION UNSPECIFIED RENAL FAILURE ESSENTIAL HYPERTENSION, BENIGN HYPERPOTASSEMIA CHRONIC KIDNEY DISEASE, UNSPECIFIED CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION OTHER MALIGNANT LYMPHOMAS, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES UNSPECIFIED SEPTICEMIA CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION (OTHER CHEST PAIN UNSPECIFIED LEUKEMIA, WITHOUT MENTION Or HAVING ACHIEVED REMISSION CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION UNSPECIFIED CHEST PAIN UNSPECIFIED CHEST PAIN SEPSIS CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION ACUTE MYOCARDIAL INFARCTION, UNSPECIFIED SITE, INITIAL EPISODE OF CARE PHARMACY LUMBAGO CHRONIC LYMPHOID LEUKEMIA IN REMISSION CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY PHARMACY PHARMACY ACUTE BRONCHITIS �� LUMBAGO !DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED ENLARGEMENT OF LYMPH NODES DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED LUMBAGO URINARY TRACT INFECTION, SITE NOT SPECIFIED UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION (PAIN IN JOINT, SHOULDER REGION OTHER DISEASES OF LUNG, NOT ELSEWHERE CLASSIFIED ACUTE BRONCHITIS a) 'o 0 C.) Q 4011 V7283 co in 4011 2767 5859 20410 20410 20280 0389 20410 20410 ,20410 78659 20890 20410 78650 78650 O) 00) CO 20410 41091 Pharmacy 7242 120411 41401 Pharmacy Pharmacy O co O V 7242 o IOO N CO Cp n 25000 N N N O O) U) 120890 20410 171941 51889 4660 Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 (PRE65 (PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 IPRE65 Claimant # Claimant #008 Claimant #008 Claimant #008 Claimant #008 Claimant #008 Claimant #008 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 O) O O 4 C (9 E m U 'Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 (Claimant #009 Claimant #009 co O) O O 0 0 46 46 C C CO CO E E (6 'm U U Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 200801 200812 200812 200810 200806 200801 200810 200806 200807 200804 200805 200807 200804 200804 200804 200811 200804 200805 200804 200809 200804 200801 200801 200804 200805 200803 200712 200801 200806 200805 200803 200811 200802 200810 200809 200808 200810 200804 1200809 Report Cluster ' d d 2 2 d 2 2 o (o m m CO m CO 0 0 0 0 0 0 0 00000000 2 (a 0 N N CC N N N al as `co m m m 0 0 0 0 0 0 000000000000000000000 d N d tC N d d 2 N N N d y d o m as o o CO CO CO as `tn `m (`o CO ro m 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 N N (9 4* 0 0 00 C) N N d 2 N cV m m co m `m 0 0 0 0 0 0 0000000 Citicare Citicare I Page 20 of 25 Shock Amount $73,279.96 CO CD O) T N N :h Vi CD O CA N N M N V) E9 O CA N N M N CO O (A (` N M N Ea EH CD (D CO CA N N M I\ CO 0) N N N M N Ell E9 CO O N N N M N E9 O) O N r` N M C'�) N f9 O CD 0) N CA N N E9 0) N C M C) N E9 O 0) N N N N $73,279.961 D CO ) . A fA N �1 :) I,- ffl E9 CO O) N N M ER O O N r` N M co N Ea O D) O N co N EA CD N co O) CA N N co N CO CO CA CA N. C N co N E9 N N f9 O CO O Cn O N t` N M N E9 O) N C M co N f9 O) O) N N CD 0) N N NI C9 N E9 CD CD o) CA cri C N co C) N f9 CO 0) CA N N N C) N V) f9 tC) O) CO CO N CO N CO N CO to N O CO CO co co CO CD N co (O CO O CO CD CO N CO CD O CO CD CO N co O CO CO CO N co CO E9 O 1.0 CO CD CD N CO CD CO CD CD N CO CO Vi (A O CO CO CO N CO CO ER O . N Net Paid Amount $14.10 Of C0 Ni FA 0 0 r.- (9 0 0 E9 0 0 � (9 CC) M O fA u) 0 _O fA L0 0 _O f9 f9 O 0 O_ fA O 0 O_ fA O 0 O_ fA CO CO. co $8.441 0 CO fl Eti 0 0 N f9 0 0 O f9 0 0 O 0 0 O E9 f9 0 0 O E9 0 0 O 0 0 O vi f9 0 0 O f9 0 0 O N M dv f0 N $ co 2 CA CO r M U) Of9 $2,235.60 '0 CO Ct N Cf f! U) CD O) M CO N V3 E9 v CO N CO CA — f9 CA (D 6 O) o V CD et CO N N NN M N n ,- DX Description OTHER MALIGNANT LYMPHOMAS, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES PHARMACY CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION LYMPHADENITIS, UNSPECIFIED, EXCEPT MESENTERIC CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION PHARMACY PHARMACY PHARMACY PHARMACY PHARMACY PHARMACY FEVER AND OTHER PHYSIOLOGIC DISTURBANCES OF TEMPERATURE REGULATION DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED LYMPHADENITIS, UNSPECIFIED, EXCEPT MESENTERIC LUMBAGO URINARY TRACT INFECTION, SITE NOT SPECIFIED URINARY TRACT INFECTION, SITE NOT SPECIFIED PHARMACY URINARY TRACT INFECTION, SITE NOT SPECIFIED ILYMPHADENITIS, UNSPECIFIED, EXCEPT MESENTERIC URINARY TRACT INFECTION, SITE NOT SPECIFIED ACUTE LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION ACUTE LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED CHRONIC LYMPHOID LEUKEMIA WITHOUT MENTION OF REMISSION UNSPECIFIED SEPTICEMIA (UNSPECIFIED ARTHROPATHY, LOWER LEG 1LOCALIZED OSTEOARTHROSIS NOT SPECIFIED WHETHER PRIMARY OR SECONDARY, LOWER LEG SPRAIN AND STRAIN OF UNSPECIFIED SITE OF KNEE AND LEG PRIMARY LOCALIZED OSTEOARTHROSIS, LOWER LEG SPRAIN AND STRAIN OF UNSPECIFIED SITE OF KNEE AND LEG SPRAIN AND STRAIN OF UNSPECIFIED SITE OF KNEE AND LEG SPRAIN AND STRAIN OF UNSPECIFIED SITE OF KNEE AND LEG OTHER AND UNSPECIFIED HYPERLIPIDEMIA PHARMACY OPEN WOUND OF KNEE, LEG (EXCEPT THIGH), AND ANKLE, WITHOUT MENTION OF COMPLICATION DX Code 20280 Pharmacy 20410 2893 20410 Pharmacy Pharmacy Pharmacy Pharmacy Pharmacy C) C) c0 E CO a=. CD O CND 25000 2893 7242 0 0) (MO 0 w co O Pharmacy 00 L ) C) ) N 6 0 CO 20400 20400 25000 125000 120410 0389 CO n 171536 0) co c 71516 8449 8449 8449 12724 Pharmacy m 0 co Pre65 / Post65 to W CC a PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 Claimant # Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 Claimant #009 as 0 E ro E .cis U Claimant #009 Claimant #009 rn 0 E co E co U Claimant #009 Claimant #009 Claimant #009 us 0 c co E co U Claimant #009 Claimant #009 es 0 c co E m 0 Claimant #009 ICIaimant #009 Claimant #009 D)rnrn 0 0 00 c c c «t m co E E E 'R 'm U U U ICIaimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 0 0 c CO E a U Claimant #010 Processed Month 200808 200807 200812 200803 0 N 200806 0 0 N 200804 200809 200811 200805 200803 200801 200808 200809 200805 200809 200802 200801 200804 1200806 0 N 1200810 0 0 N 200901 200901 200805 200811 200811 200812 200811 200811 200803 200806 200810 200809 o 0 N Report Cluster `) CO C) 0 ICiticare d CO C) 0 d CO C) 0 d C 0 0 i) Cd C) (0 i) CO C) 0 22 CO U 0 `) N COO C) 0 0 0 d C 0 0 N C C) 0 ICiticare 1 22 CO () 0 C) m C) 0 d CC O 0 02 R) C) 0 22 CO 0 0 N N OO 0 0 0 0 d CO C) 0 N CO 0 0 N CO C) 0 N CO C.) 0 U d N CO CC CO CD O U U U U ICiticare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Page 21 of 25 Shock Amount ODCOOOD . co co N CO 49 . co co N CO f9 CO . Co CO N CO 49 . CO D CD N CO E9 49 . co Co N CD OOOommmmmma` . Co Co N CO 49 CO . co CO N CO 69 . CO Co N o 49 . Co CO N Co CO . Co co Co N Co CD 49 . N N 69 49 . Co co Co N co Co . N N 49 . Co CD N Co Co 49 OoCOCOCONnr-N-�nnnN�I,n�NNN . CO co CO N CO 49 CO . co Co N CO 69 E9 CO . co Co N Co E9 . Co CO N CO . Co CD N CD 69 . Co CO N Co 69 CO . Co N CC . r r__________ r 49 CA . rn CD 69 . r o CO 46 . rn CD . r a0 69 49 . r CD 49 . r . r 0 49 fH . r OD . r Co 49 CA . r Co 49 . r Co fA . rn ____ CD fA . r CD . r GD 69 4:49 N. r CD NNNN . rn ____ aD E9 49 . rn Co to . rn aD CA . rn Co I 1 Net Paid Amount 0 CO. co C1 C9 0 CA C0 M C9 0 0 co r t9 0 Cn CD M 49 V O C0 N C9 St CO CO CO FA CC) N Cp Co E9 O O Cn 69 N CD . n (9 6 0 LO N t0 Cfl Co CD o et fA CO CD 0 a 49 CO CO o 69 f19 CO CD cp et fA��fR CD Cn .1 CO r N CC) N CD fA 0 O 0 EA 0 CO C7 0 O O 69 0 O O 69 CO O N n Co N I- 0 CO CD 0) CD O) N n CO C9 E9 0 N O 0 0 0) 0) r LL) 69 0 Cn o CD CD CO Co 46 CO CO CO C7 09 O 0 CD CD 0 O N Vi N CO. O V Cl. 09 E9 0 CO M Cl. 0 CO CO Cl 40 69 N O N. N. O CD CO a N N. 69 CD N N. n 63 f9 CO 0) Q w CD N. N CO (D ". 0 O CO 0 6 $594.52 D P.. CA � E9 CO N N Vi r C O ' N �'' W. 4 DX Description URINARY TRACT INFECTION, SITE NOT SPECIFIED PHARMACY PHARMACY PHARMACY PHARMACY ESSENTIAL HYPERTENSION, BENIGN OSTEOARTHROSIS, UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED, LOWER LEG UNSPECIFIED ARTHROPATHY, LOWER LEG PRIMARY LOCALIZED OSTEOARTHROSIS, LOWER LEG PRIMARY LOCALIZED OSTEOARTHROSIS, LOWER LEG PHARMACY PHARMACY PHARMACY PHARMACY PHARMACY (PRIMARY LOCALIZED OSTEOARTHROSIS, LOWER LEG OTHER SPECIFIED PRE - OPERATIVE EXAMINATION PRIMARY LOCALIZED OSTEOARTHROSIS, LOWER LEG AFTERCARE FOLLOWING JOINT REPLACEMENT ENCOUNTER FOR THERAPEUTIC DRUG MONITORING ENCOUNTER FOR THERAPEUTIC DRUG MONITORING UNSPECIFIED ACUTE RENAL FAILURE END STAGE RENAL DISEASE END STAGE RENAL DISEASE 'END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE END STAGE RENAL DISEASE MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT � 'END STAGE RENAL DISEASE 'END STAGE RENAL DISEASE (UNSPECIFIED BACTERIAL PNEUMONIA (ACUTE MYOCARDIAL INFARCTION, UNSPECIFIED SITE, INITIAL EPISODE OF CARE (CHRONIC KIDNEY DISEASE, UNSPECIFIED PHARMACY (MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT PHARMACY DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED PHARMACY PHARMACY PHARMACY (OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE, IMPLANT, AND GRAFT DX Code 5990 Pharmacy Pharmacy Pharmacy Pharmacy 4011 CD 0) N. CD CO n CD Cn N CD N n Pharmacy Pharmacy Pharmacy Pharmacy Pharmacy CD CA n V7283 CD O n V5481 V5883 V5883 5849 CO u) 5856 15856 CO LO Cn 5856 5856 00) 0) 5856 CO O LO CO N a' 0 v m C0 Pharmacy 00) 0) Pharmacy 125040 Pharmacy Pharmacy Pharmacy CD 0) 0) Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 COD W CC a PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 coo W cC a CCD W II a C00 W CC a PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 Claimant # Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 •Claimant #010 Claimant #010 Claimant #010 Claimant #010 0 o as E U Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #010 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Processed Month 200805 200805 200602 200807 200610 0 co ON 0 co N N 0 co N 200810 200802 200804 200808 200803 200806 200811 200809 200810 200806 o co N r co 1200812 1200804 1200810 200805 200809 200812 200808 200804 200810 200806 200811 200804 200804 200809 200808 200809 200804 200808 200712 200802 0 CO N 1200810 Report Cluster Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety Citicare Public Safety > N c U_ 7 a d CU U Citicare Public Safety ICiticare Public Safety 4) CC CD C) ICiticare a) 4) d d 4) 4) CD d CO CO R) CC CC CO CO CC U U U U U U U U 000)00000) ICiticare ICiticare ICiticare d as al U U 0 U ICiticare Citicare 92 CC CU U U C)U Citicare (Citicare Page 22 of 25 Shock Amount M NN r mid ) )n 59 E9 M rn M NN rn CD cn )n 4949494949694969494949494949 M rn CD cn M N r- rn CD )n M r� rn CD )n M I rn CD )n M rn CD )n M rn CD cn M rn CD )n M N rn CD )n M N r.- rn CD cn M rn CD M rn CD u) )n M rn CD M rn CD u) $58,119.791 ) , r n . 35.66c6cOccid n cn rn ` rn )n rn n rn rn n rn o )n rn n rn Ln rn O) n rn n rn CD $58,119.791 m N. rn ao 19 $58,119.791 M n — aD )n cn I9 M - rn m ao )n K9 f9 M N rn 19 M M N N rn rn c ao o in E9 co E9 M N rn o E9 M N rn m m 19 M N rn w 0 in /9 O N rn r < W e c E Net Paid Amount o .a• N_ )9m f0 M O) $298.80 0 o : O 7 N (0969%%464040 aD O O N N O O N N N V N O V n N 10 10 o O 01 ul r r r` aD N : 69 19 O) (O 6 1 O c0 f9 r` 6 1 1D O M 6 t0 V9 O O 4 d9 19 V O 6 O )-0,3-).-)—VW ( N WWWV (,04969494901 O N 0) N C N o r r` M )n C) '7 f9 $41.401 $34.30 $34.30 $34.30 ) - D mNNr ,49E469(90)6969 N N v O O O O) O r` O V v N a N C) Nr (7 a 1 1 N f E DX Description END STAGE RENAL DISEASE I UNSPECIFIED DISORDER OF KIDNEY AND URETER DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED PHARMACY OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE, IMPLANT, AND GRAFT OTHER AND UNSPECIFIED ANGINA PECTORIS PHARMACY END STAGE RENAL DISEASE UNSPECIFIED DISORDER OF KIDNEY AND URETER CARDIOMEGALY 'PROTEINURIA OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE PHARMACY 'UNSPECIFIED DISORDER OF KIDNEY AND URETER MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT � 'CYSTOID MACULAR DEGENERATION OF RETINA DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED ENCOUNTER FOR EXTRACORPOREAL DIALYSIS OTHER SPECIFIED PRE - OPERATIVE EXAMINATION UNSPECIFIED ACUTE RENAL FAILURE UNSPECIFIED ACUTE RENAL FAILURE OTHER SPECIFIED PREOPERATIVE EXAMINATION PHARMACY PNEUMONIA, ORGANISM UNSPECIFIED (OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITHOUT MENTION OF CEREBRAL INFARCTION !DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED (DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED !DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) PULMONARY EOSINOPHILIA 'CYSTOID MACULAR DEGENERATION OF RETINA PROLIFERATIVE DIABETIC RETINOPATHY IPRE-OPERATIVE CARDIOVASCULAR EXAMINATION OTHER DISEASES OF LUNG, NOT ELSEWHERE CLASSIFIED NAUSEA WITH VOMITING ICARDIOMEGALY (OTHER SPECIFIED PRE - OPERATIVE EXAMINATION DX Code 5856 O U) 25000 Pharmacy n OO) 4139 Pharmacy 5856 O) U) 4293 O n 4148 Pharmacy O) cow U) m 36253 25042 0 (II J V7283 1747-1 0 inn IV7283 Pharmacy 486 43330 25002 25042 125040 15853 N U) 136253 36202 > 51889 78701 4293 V7283 Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 'PRE65 Claimant # Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 Claimant #011 0 0 0 0 0 0 0 c c c c c c c ca a) a7 a) a) a) CO E E E E E E E 0000000 0 c a) E 0 0 c a) E 0 'Claimant #011 0 0 E E ca a) E E 0 0 Claimant #011 Claimant #011 00000 cc c c c CO 10 CO a) CO E E£ E E 00000 'Claimant #011 Processed Month 200803 200803 200810 200805 200809 200804 200803 200807 200801 200804 200802 200804 200807 200804 200901 200801 200803 200808 200805 200802 200803 200808 200801 200805 200804 1200712 0 03 N 200804 200802 200804 200809 200807 200811 200803 200804 200803 1200807 Report Cluster Citicare Citicare a) a) (1) a) a) a) a) a) a) a) a) a) a) a) ca a) a) as CI CO CZ RS cC a) a) c0 CO c6 0 0 0 0 0 0 0 0 0 0 U U U 0 00000000000000 a) a) a) a) a) a) a) a) a) a7 a) a) as co co cc as a) U U U U U U U U 0 00000000_ U a) ca 0 U a) ca 0 U a) a) a) a) a) a) as co 0 0 0 0 000000000 a) a) a) w a) as at as co as 0 0 0 0 0 Citicare Page 23 of 25 Shock Amount $58,119.79 ) ) n A Cn CA I- oioioia)rnoi co in 69 69 CD n in CA 0) n 69 n u) 69 O 0) n 6 n co 09 $58,119.791 V O co rvvvv444:44vvvvvvvvvacv4444Ti o al o <o 9 69 N co al 69 N al U) 69 N m al u) 6A N m co al U) U) 69 N co al ff! N co al U) 69 N co al U) U) 09 N CM OD al U) 69 CO <o fA N CO al O U) iA N N CO al U) 69 N CO w O CA CM co al LD CA N co 00 al al U) 69 69 N co al U) to N co al U) 49 N a0 al U) 69 N co Co U) 09 N co al CA N CM al N u) CA m a0 ao U) 69 N co ao U) CA N co az <n 69 N co ao 69 N C a c O C Net Paid Amount 0 CO O 69 69 0 et CD O er CO m fA 69 CO co. N 69 N CA O O O 69 O O O 69 O O O O CO O CD 09 0o to. Cr) CD O C� ri er 6A r n co r 69 O CD ■ n cC) O V N Vi CO a O U) !A O CO O CO O U7 !A 6A CO 4 er aD M r: N 69 CO C) 0 r iA CO U) u) 0 O co 69 fe et 0 co CO O r O u) u) H 69 CD N N et 69 O CD co 69 C+) 0) et M CO 69 69 0 O op et 69 0 Tr N CO N 69 CO et N r aD 69 09 O et U) C9 1: CD CD et 09 69 et CO 69. CO M fA er 6 CO O U) 09 CA O C 0 C O< C DX Description HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE PRE - OPERATIVE CARDIOVASCULAR EXAMINATION I DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED PHARMACY PREOPERATIVE CARDIOVASCULAR EXAMINATION CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) ANEMIA OF OTHER CHRONIC DISEASE PHARMACY INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT CHRONIC SYSTOLIC HEART FAILURE PAROXYSMAL VENTRICULAR TACHYCARDIA ATRIAL FIBRILLATION PHARMACY PHARMACY 2 ix I a ��ATRIAL FIBRILLATION BRONCHITIS, NOT SPECIFIED AS ACUTE OR CHRONIC CHRONIC RHINITIS < 2 OC I a PHARMACY I cc d PHARMACY I 2 ¢ a PHARMACY PHARMACY 'PHARMACY 'BRONCHITIS, NOT SPECIFIED AS ACUTE OR CHRONIC ENCOUNTER FOR LONG -TERM (CURRENT) USE OF ANTICOAGULANTS )- Q 0 W O 5 U 'ENCOUNTER FOR LONG -TERM (CURRENT) USE OF ANTICOAGULANTS 'ENCOUNTER FOR LONG -TERM (CURRENT) USE OF ANTICOAGULANTS 'ENCOUNTER FOR LONG -TERM (CURRENT) USE OF ANTICOAGULANTS 'ATRIAL FIBRILLATION 'ENCOUNTER FOR LONG -TERM (CURRENT) USE OF ANTICOAGULANTS ENCOUNTER FOR LONG-TERM (CURRENT) USE OF ANTICOAGULANTS ENCOUNTER FOR LONG -TERM (CURRENT) USE OF ANTICOAGULANTS (ENCOUNTER FOR LONG -TERM (CURRENT) USE OF ANTICOAGULANTS DX Code co 0 V7281 25000 Pharmacy V7281 5853 28529 Pharmacy co <�i O 42822 4271 42731 Pharmacy 0 <0 co L a Pharmacy 42731 0 Si n erer Pharmacy 0 co C L a Pharmacy Pharmacy 'Pharmacy Pharmacy Pharmacy 0 a) <0 0 co t O U) aer> 4293 V5861 V5861 V5861 42731 co co <n La >> V5861 co U) > Pre65 / Post65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 1PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 PRE65 1PRE65 Claimant #011 Claimant #011 O O C C co co E E U U Claimant #011 Claimant #011 Claimant #011 TT. . O C ca E U r N_ O O C C co co E E U U N_ N_ O O C C ca as E E U U Claimant #012 Claimant #012 Claimant #012 Claimant #012 N N 0 0 C C co as E E U U CM N_ 0 0 C C co m E E U U N 0 C CO E U CM 0 C as E U N 0 C <C E U CM N_ N_ N N_ N N CM N T. N_ N_ 0 0 0 0 0 0 0 0 0 0 0 0 C C C C C C C C C C C C co co co co co co co co co co ro co E E E E E E E E E E E E U U U U U U U U U U U U N T. 0 C co E U 'Claimant #012 Processed Month 200808 200805 200811 200809 200808 200810 200802 200806 200811 200812 200812 200811 200810 200805 200808 200810 200811 200804 et CD O O aD aD O O O O N N 200809 200803 O O O 200811 200802 200812 200810 200811 200812 200809 200808 200803 200809 200805 200806 200810 1200802 ■ E `) ca co 0 U 00 N a) `) N d d co co c6 c0 co co C) c) U 0 U U 000000 d 22 ca ca 0 0 0 0 N Q co co 0 0 0 0 N d E N co co co co 0 0 0 0 0 0 0 0 Q a) co co 0 0 0 0 CU d co co 0 0 0 0 CU co 0 0_0 ED- co C) d co C) 0 d W d a) a) `) N d a) N d N `) co co co co co co <0 <a c6 c6 co as ca 0 0 0 C) 0 0 C) C) C) 0 0 0 C) 0 0 0 0 0 0 0 0 0 0 0 0 0 N cC 0 0 675908 675908 675908 675908 675908 675908 675908 675908 675908 67590804 67590809 67590814 67590818 67590822 67590826 67590830 67590834 67590839 Citicare Citicare Citicare Citicare Citicare Fire Citicare Fire Citicare Public Safety Citicare Public Safety Alternate Choice RETIREE RETIREE RETIREE RETIREE RETIREE RETIREE RETIREE RETIREE RETIREE REQUEST FOR PROPOSAL ADDENDUM CITY OF CORPUS CHRISTI PURCHASING DIVISION Request for Proposal No.: BI- 0153 -09 Addendum No.: 1 March 26, 2009 Prospective Proposers are hereby notified of the following modifications to Request for Proposal No. BI- 0153-09. All terms, conditions and specifications of the original Request for Proposal not in conflict with this addendum remain unchanged and continue in full force and effect. I. The following is added to this RFP as Exhibit J: Retiree Contribution Rates Since 2006 etiree on ri • u on it, ontri • ution ota $310.09 - EE Only < 65 $ 310.09 EE + Spouse (< 65) 646.45 - 646.45 EE + Children ( <65) 577.67 - 577.67 EE + Family (< 65) 854.46 - 854.46 Spouse Only 368.35 - 368.35 Children Only 299.56 - 299.56 Retiree's Spouse & Children 576.36 - 576.36 EE Only > 65 240.66 - 240.66 Spouse Only > 65 240.66 - 240.66 EE + Spouse (both >65) 449.32 - 449.32 EE > 65, Spouse < 65 577.00 - 577.00 EE <65, Spouse >65 518.73 - 518.73 Retiree > 65 & children 508.20 - 508.20 Spouse >65, Children 508.20 - 508.20 EE >65, Family <65 785.02 - 785.02 Retiree < 65,Spouse >65, children 786.30 - 786.30 Retiree & Spouse >65 &children 716.88 - 716.88 Retiree Contribution Association Total $ 392.40 $ 392.40 +ctu.a.i�.Cr'�a5;+3c.e:.r"'i . �" t"" a�; �• Sn'. k'�.`t 5-fid EE Only < 65 $ - EE + Spouse (< 65) 474.98 392.40 867.38 EE + Children ( <65) 378.01 392.40 770.41 EE + Family (< 65) 768.48 392.40 1,160.88 Spouse Only 474.99 - 474.99 Children Only 378.01 - 378.01 Retiree's Spouse & Children 768.48 - 768.48 EE Only> 65 - 294.55 294.55 Spouse Only > 65 294.55 - 294.55 EE + Spouse (both >65) 294.53 294.55 589.08 EE > 65, Spouse < 65 474.98 294.55 769.53 EE <65, Spouse >65 294.56 392.40 686.96 Retiree >65, children 378.02 294.55 672.57 Spouse >65, Children 672.57 - 672.57 EE >65, Family <65 768.47 294.55 1,063.02 Retiree <65,Spouse >65,children 672.57 392.40 1,064.97 Retiree&Spouse>65, children 672.54 294.55 967.09 Retiree Contribution Association Total $ 324.98 $ 103.72 EE Only < 65 $ 221.26 EE + Spouse (< 65) 613.99 103.72 717.71 EE + Children ( <65) 533.65 103.72 637.37 EE + Family (< 65) 856.36 103.72 960.08 Spouse Only 392.73 - 392.73 Children Only 312.40 - 312.40 Retiree's Spouse & children 635.13 - 635.13 EE Only > 65 244.07 - 244.07 Spouse Only > 65 244.07 - 244.07 EE + Spouse (both >65) 488.17 - 488.17 EE > 65, Spouse < 65 636.83 - 636.83 EE < 65, Spouse > 65 465.32 103.72 569.04 EE > 65 & Children 556.48 - 556.48 EE <65, Spouse >65,Children 777.72 103.72 881.44 Spouse >65, Children 556.48 - 556.48 EE >65, Family <65 879.19 - 879.19 Retiree &Spouse >65,children 800.57 - 800.57 "ALL OTHER ITEMS AND CONDITIONS REMAIN UNCHANGED" Paul Pierce Procurement Manager ACKNOWLEDGED BY: FIRM NAME AUTHORIZED SIGNATURE DATE ONE ORIGINAL SIGNED AND DATED ADDENDUM 1 AND TWELVE COPIES OF THIS ORIGINAL SIGNED AND DATED ADDENDUM 1 MUST BE RETURNED TO THE PURCHASING DIVISION WITH YOUR PROPOSAL. CITY OF CORPUS CHRISTI, TEXAS BI- 0153 -09 Request for Proposal FULLY - INSURED RETIREE HEALTH INSURANCE Table of Contents Section 1.0 Notice of Request for Proposal 1.1 Request for Proposal 1.2 Submission of Proposal 1.3 Tentative Schedule 1.4 Acknowledgment Form Section 2.0 Conditions Governing the Procurement 2.1 Acceptance of General Requirements 2.2 RFP Notice Requirement 2.3 RFP Procedural and Content Questions 2.4 Basis for Proposal 2.5 Opening of Proposals 2.6 Proposal Terms and Conditions 2.7 Disclosure of Proposal Contents 2.8 Late Proposals 2.9 Signing of Proposals 2.10 Cost of Proposal 2.11 Minority Business Enterprise Information Form 2.12 Disclosure of Interest 2.13 Equal Employment Opportunity 2.14 Ownership of Proposals 2.15 Disqualification or Rejection of Proposals 2.16 Rejection of Proposals 2.17 Right to Waive Irregularities 2.18 Withdrawal of Proposals 2.19 Amending of Proposals 2.20 Proposal Offer Firm 2.21 Proposer's Qualifications 2.22 Exceptions to RFP Specifications 2.23 Consideration of Proposals 2.24 Termination of RFP 2.25 Service Agreement 2.26 Precedence of Contract Documents 2.27 Governing Law 2.28 No Obligation 2.29 Contract Deviations 2.30 Sufficient Appropriation 2.31 Recommendation to City Council 2.32 Award of Contract 2.33 Execution of Contract 2.34 Disputes 2.35 Change in Proposer's Representative 2.36 Term 2.37 Change Requests 2.38 Termination of Contract 2.39 Indemnification 2.40 Insurance Provisions 2.41 Right to Publish 2.42 Proposer's Ethical Behavior 2.43 Quantities Section 3.0 Scope of Work 3.1 Introduction 3.2 Background 3.3 General Requirements 3.4 Proposer's Profile and Qualifications 3.5 Technical Solution 3.6 Rate Schedule Section 4.0 Proposal Format and Organization 4.1 General Instructions 4.2 Proposal Format 4.3 Transmittal Letter 4.4 Table of Contents Section 5.0 Proposal Evaluation 5.1 Evaluation Committee 5.2 Evaluation Criteria Attachments Exceptions Form Minority Business Enterprise Information Form Disclosure of Interest Form Exhibits Exhibit A Exhibit B Exhibit C Exhibit D Exhibit E Exhibit F Exhibit G Exhibit H Exhibit I SPD — Citicare (use this SPD for Alternate Choice Plan) SPD — Citicare Fire SPD — Citicare Public Safety Benefit Summary — Citicare Benefit Summary — Alternate Choice Tentative Plan Design Benefit Summary — Citicare Fire Benefit Summary — Citicare Public Safety Census and Claims Data File Rate (Funding) History CITY OF CORPUS CHRISTI, TEXAS BI- 0153 -09 FULLY - INSURED RETIREE HEALTH INSURANCE Section 1 Notice of Request for Proposal A. The City of Corpus Christi "City" hereby issues this request for proposal (RFP). The City is seeking proposals from qualified Proposers for FULLY - INSURED RETIREE HEALTH INSURANCE. The City shall enter into a contract(s) resulting herefrom for a period of three years with an option to extend for up to two additional one -year periods. B. The City hereby designates Paul Pierce as the Procurement Officer with overall responsibility for procurement and administration of this service. Mr. Pierce's information is as follows: Paul J. Pierce Procurement Manager City of Corpus Christi P.O. Box 9277 Corpus Christi, Texas 78469 -9277 Phone: (361) 826 -3164 Fax: (361) 826 -3174 paulp @cctexas.com D. All inquiries or requests regarding this RFP must be submitted, in writing, to the Procurement Officer as indicated above, or his duly authorized designee, as specified in writing. Other employees do not have the authority to respond for the City in writing and any attempt to question other employees regarding this RFP may result in the City disqualifying that Proposer. Only written responses from the Procurement Officer or his duly authorized designee will be binding with regard to inquiries requesting clarification or additional information. The Procurement Officer's or his duly authorized designee's written responses will be forwarded simultaneously to all prospective Proposers. E. A pre - proposal conference will be held at the date and time and in the location specified therefor in Section 1.3 of this RFP. 1. The purpose of the pre - proposal conference is to provide an opportunity for prospective Proposers to discuss, pose questions and obtain clarification from the City regarding this RFP. 2. All questions and requests for clarification from the City shall be received, in writing, by the Procurement Officer specified herein by the date and time specified therefor in Section 1.3 of this RFP. Questions and requests for clarification received after such time shall be deemed late and shall not be considered. Questions and requests for clarification may be transmitted to the Procurement Officer regular mail, private courier, facsimile or electronic mail service or by delivery in person. Facsimile and electronic mail service is . provided by the City as a convenience and the City makes no guarantees, express or implied, regarding the functionality of said services. It is solely the responsibility of the Proposer to ensure questions and requests for clarification are received by the Procurement Officer by the deadline for same detailed herein. The electronic time -stamp in the Purchasing Division of the City of Corpus Christi at City Hall, 1201 Leopard Street, Corpus Christi, Texas, shall be the official time stamp and shall maintain the official time for the purpose of this Request for Proposal. 3. The City shall provide written responses to all prospective Proposers in the form of written addenda, if such information is necessary to Proposers in submitting proposals or if the lack of such information would be prejudicial to uninformed Proposers. Oral explanations or instructions provided by the City before the award of the contract shall not be binding upon the City. A. The Proposer must submit one (1) original and twelve (12) copies of its proposal with an electronic version on one compact disk or flash (thumb) drive with files in either Microsoft Word, Excel or Adobe Acrobat (PDF) format to the City of Corpus Christi as specified below. All proposals must be complete and accurate and in City approved format as referenced in Section 4.2. B. The City will review and evaluate the written proposals in response to this RFP. The City may conduct additional interviews with selected Proposers for the purpose of further exploring and clarifying the Proposer's response. The City will rank the Proposers based on the suggested evaluation criteria set forth in the Evaluation Model of this RFP. The City will then negotiate applicable terms and conditions into the final form of the Contract with the first - ranked Proposer. If contract negotiations are not successful with the selected Proposer, the City will begin negotiations with the next highest ranked Proposer on the list. The City reserves the right to award one contract to one Proposer, multiple contracts to one Proposer or multiple contracts to multiple Proposers. The City further reserves the right to not award a contract(s) at all. Award will be made based on the best overall value to the City. C. Proposals will be evaluated to ascertain which Proposer best meets the needs of the City. The City intends to utilize an Evaluation Model specifically designed for this analysis. The Evaluation and Selection process will be based on: 1) Proposer's Profile and Qualifications, 2) Technical Solution, 3) Rate Schedule and 4) Exceptions. The final weight assigned to each of these parameters will be determined by the Evaluation Committee. D. Proposals should be returned in a sealed envelope /container marked with the Proposer's name, address and the RFP number corresponding to this RFP. Proposals will be received through the date and time specified in Section 1.3 of this RFP. Without exception, proposals received after this deadline are late, shall be deemed non - responsive and will not be considered. E. Proposers may mail proposals to the following address: City of Corpus Christi (1 original & 12 copies) Purchasing Division P.O. Box 9277 Corpus Christi, Texas 78469 -9277 OR, Proposers may deliver the Proposal in person or by courier to the following address: City of Corpus Christi (1 original & 12 copies) Purchasing Division 4th Floor, City Hall 1201 Leopard St. Corpus Christi, Texas 78401 -2825 F. Delivery to or receipt in any other area of the City will not satisfy the requirement for delivery to the Purchasing Division. G. Proposers shall comply with the additional detailed instructions regarding submission of Proposals found in Section 4 of this RFP. f evaluation and selection activities: Date Activity March 20, 2009 Request for Proposal issued March 30, 2009 Pre - proposal Conference at: 2:00 p.m. Central Time (CT) Human Resources Conference Room 2nd Floor, City Hall 1201 Leopard Street Corpus Christi, Texas April 1, 2009 5:00 p.m. CT deadline for submission of: 1) written questions 2) Acknowledgment of Receipt and Notice of Intent to Submit Proposal April 24, 2009 Proposals due by 5:00 p.m. CT May 26, 2009 Projected Date of Award of Contract by City Council June 9, 2009 Projected Alternate Date of Award of Contract by City Council It is important that the City is able to verify prospective Proposers' receipt of this RFP. The following ACKNOWLDGMENT OF RECEIPT AND NOTICE OF INTENT TO SUBMIT PROPOSAL ( "NOTICE") should be completed and returned as soon as possible, but no later than the date and time specified in Section 1.3 above. Failure to return said Notice by this deadline may prevent a prospective Proposer from receiving amendments, responses to questions, etc. ACKNOWLEDGMENT OF RECEIPT AND NOTICE OF INTENT TO SUBMIT PROPOSAL REQUEST FOR PROPOSAL BI- 0153 -09 FULLY - INSURED RETIREE HEALTH INSURANCE In acknowledgment of receipt of this Request for Proposal, the undersigned agrees that a complete copy of this RFP has been received and offers notice of their intent to submit a proposal(s) to provide FULLY - INSURED RETIREE HEALTH INSURANCE described in this RFP. This ACKNOWLEDGMENT OF RECEIPT AND NOTICE OF INTENT TO SUBMIT PROPOSALS in response to this RFP should be signed by an authorized representative and returned to the Procurement Officer no later than date and time specified in Section 1.3 of this RFP. This will assure that any addenda, additional information and written answers to written questions will be forwarded to you. Proposers who choose to mail this form should send it by registered or certified U.S. mail to the address set forth in Section 1.1 on page 1 of this RFP, or fax to (361) 826 -3174 Attention: Paul Pierce, Procurement Manager or by email to paulp @cctexas.com. Facsimile service is provided as a courtesy to Proposers, however, the City assumes no responsibility for documents transmitted via facsimile and not received by the Procurement Officer in a timely manner. The person named herein shall also serve as the contact person who must be available, with little or . no notice, to answer questions posed by the Evaluation Committee during the evaluation process and represent the Offeror in negotiations with the City. COMPANY NAME: REPRESENTED BY: NAME: TITLE: ADDRESS: CITY /STATE /ZIP CODE: SIGNATURE: DATE: E -MAIL: FACSIMILE #: TELEPHONE #: Section 2 Conditions Governing the Procurement The Proposer must specifically accept all project requirements contained in Section 2, Conditions Governing the Procurement, and Section 3, Scope of Work, in the transmittal letter as set forth in Section 4.3 of this RFP. Notice of the Request for Proposal shall be published in the Corpus Christi Caller Times once a week for two consecutive weeks. The date of the first publication will be at least fourteen (14) days prior to the proposal due date. A. Any Proposer requiring further clarification of the Request for Proposal procedures contained herein should submit specific questions in writing to the Procurement Officer at the address set out in Section 1.1 of this RFP. B. During a review of this RFP and preparation of the proposal, certain errors, omissions or ambiguities may be discovered. If so, or if there are doubts or concerns about the meaning of any part of this RFP, written questions should be submitted to the Procurement Officer at the address set out in Section 1.1 of this RFP no later than the date and time prescribed for same as provided in Section 1.3 of this RFP. This should allow sufficient time for the City to answer the written questions and distribute the written responses so that all prospective Proposers will have the benefit of the revised information. Only the information contained in this RFP, amendments hereto and information supplied by the City in writing through the Procurement Officer identified herein should be used in the preparation of the Proposer's proposal(s). Proposals must be sent to the City in a sealed envelope /container marked with the Proposer's name, address and RFP number BI- 0118 -09. The proposals shall be received until date and time specified for same in Section 1.3 of this RFP. Proposals must be mailed or delivered in accordance with the instructions and to the addresses set out in Section 1.2 of this RFP. By means of time stamp, the Purchasing Division will record receipt of the proposal and forward it to the Procurement Officer. The official time for closing of this REP is that which is specified for same as provided in Section 1.3 of this RFP per the Purchasing Division's date /time stamp. A formal opening of the Proposals shall not take place. The Proposer must submit, with each copy of the Proposal, a complete set of any additional terms and conditions proposed for inclusion in the sample Service Agreement (also referred to herein as the "Contract ") enclosed herein. Proposals will be opened in a manner that avoids disclosure of the contents to competing Proposers and keeps the proposals secret during negotiations. All proposals are open for public inspection after the contract(s) are awarded; however, trade secrets and confidential information in the proposals are not open for public inspection. It is specifically provided, however, that each Proposer must identify any information contained in its proposal which it asserts is either a trade secret or confidential information. Such material must be conspicuously identified by marking each page containing such information as "confidential" or "proprietary ". If such material is not conspicuously identified, then by submitting its proposal, a Proposer agrees that such material shall be considered public information. Without exception, proposals must be submitted in sufficient time to be received and date /time stamped in the Purchasing Division, on the 4th floor of the City Hall Building, on or before the deadline specified in Section 1.3. Any proposal received after the time and date specified in Section 1.3 will be a late and shall not be considered. The City will return all late proposals unopened. By submitting and signing a proposal, the Proposer indicates its intention to adhere to the provisions described in this RFP. Proposals signed for a partnership shall be signed in the Proposer's name by at least one partner or in the Proposer's name by an attorney -in -fact. If signed by an attorney -in -fact, there should be attached to the proposal, a Power -of- Attorney evidencing authority to sign proposals, dated the same date as the proposal, and executed in accordance with the legal requirements of the Proposer. Proposals signed for a corporation shall have the correct corporate name thereon and shall bear the president's or vice president's original signature with the name and title written below the corporate name. Any other signature must be accompanied by a resolution of the Board of Directors authorizing such signature to contract in the corporation's name. The title of the office held by the person signing for the corporation shall appear below the signature of the officer. This RFP does not commit the City to pay any costs incurred by a Proposer for preparation and/or submission of a proposal or for procuring or contracting for the items to be furnished under this RFP. All costs directly or indirectly related to preparing and responding to this RFP, including all costs incurred for supplementary documentation, shall be borne solely by the Proposer. The City of Corpus Christi requires all persons or Proposers seeking to do business with the City to provide the Minority Business Enterprise Information Form on the City- supplied form included herewith. Every question must be answered. If the question is not applicable, answer with N /A. The City of Corpus Christi Code of Ordinances, Section 2 -349, as amended, requires all persons or Proposers seeking to do business with the City to provide the Disclosure of Interest information on the City- supplied form included herewith. Every question must be answered. If the question is not applicable, answer with N /A. Proposers are obligated to provide updated information concerning the disclosure of interest, as warranted, for the duration of time the proposals are under consideration. Proposers are expected to comply with the City's Affirmative Action Policy Statement on file with the City's Human Relations Department, with respect to its provisions concerning Proposers. Any complaints filed with the City alleging that a Proposer is not an Equal Opportunity Employer, due to activities arising during a previous City contract, will be referred to the City's Human Relations Commission ( "Commission ") for the purpose of review and recommendation. Summaries of reports by the Human Relations Administrator or the Commission may be considered in any future bid awards by the City. The City expressly reserves the right to consider such reports in determining the best proposal. All documents submitted in response to this RFP shall become the property of the City of Corpus Christi. Proposers may be disqualified for any of the following reasons: e There is reason to believe that collusion exists among the Proposers; • The Proposer is involved in any litigation against the City; • The Proposer is in arrears on an existing contract or has defaulted on previous contracts with the City; • The Proposer lacks financial stability; • The Proposer has failed to perform under previous or present contracts with the City; • . The Proposer has failed to use the City's approved forms; • The Proposer has failed to adhere to one or more of the provisions established in this RFP; • The Proposer has failed to submit its Proposal in the format specified herein; • The Proposer has failed to submit its Proposal on or before the deadline established herein; • The Proposer has failed to adhere to generally accepted ethical and professional principles during the Proposal process; or, • The Proposer has failed to provide a detailed cost summary in the proposal. Proposals may be rejected if they show any alteration of words or figures, additions not called for, conditional or uncalled -for alternate proposals, incomplete proposals, erasures or irregularities of any kind. Proposals tendered or delivered after the official time designated for receipt of proposals shall be deemed non - responsive and shall not be considered. Proposals shall be considered "irregular" if they show any admissions, alterations of form, additions or conditions not called for, unauthorized alternate proposals or irregularities of any kind. The Procurement Officer reserves the right to waive minor irregularities and mandatory requirements, provided that all responsive proposals failed to meet the same mandatory requirements and the failure to do so does not otherwise materially affect the procurement. This right shall be exercised at the sole discretion of the Procurement Officer. Proposals may be withdrawn by written notice received by the City's Purchasing Division prior to the exact hour and date specified for receipt of proposals. A Proposal may be withdrawn (in person) by a Proposer or his/her duly authorized representative, provided his/her identity is made known and he /she signs a receipt for the proposal, but only if the withdrawal is made prior to the exact hour and date set for the receipt of proposals. Proposals cannot be withdrawn after the hour and date set for the receipt of proposals. A Proposer may submit an amended proposal, however, such amended proposal must be received prior to the exact hour and date set for the receipt of proposals; must be a complete replacement of a previously submitted proposal; and, such amended proposal must be clearly identified as such in the transmittal letter. The City will not merge, collate or assemble proposal materials for a Proposer. Proposals cannot be amended after the hour and date set for the receipt of proposals. By submission of its proposal, the Proposer affirms that its proposal is firm for one hundred eighty (180) days after the due date for receipt of proposals. The Evaluation Committee "Committee ", as defined in Section 5.1 of this RFP, may make such investigations as necessary to determine the ability of the Proposer to adhere to the requirements specified herein. The Procurement Officer will reject the proposal of any Proposer who is not a responsible Proposer. Although the specifications in the following sections represent the City's anticipated needs, there may be instances in which it is in the City's best interest to permit exceptions to specifications and evaluate alternatives. It is vital that the Proposer make very clear where exceptions are taken to the specifications and how the Proposer will provide alternatives. Therefore, exceptions, conditions or qualifications to the provisions of the City's specifications must be clearly identified as such, tofether with reasons for taking exception and inserted in the proposal at that point. In addition, the Proposer must provide responses on the "Exceptions" page to address any and all items found in all bid documents that the Proposer cannot meet or provide. If the Proposer does not make clear that an exception is being taken, the City will assume the Proposer is, in its proposal, responding to and will meet the specifications of this RFP. , Discussions may be conducted with responsible Proposers qualified to be selected for award for the purpose of clarification to assure full understanding of and responsiveness to the solicitation requirements. In discussions, there shall not be disclosure of any information derived from proposals submitted by competing Proposers. The City reserves the right to reject any or all proposals, to waive technicalities, to re- advertise for new proposals or to proceed with the work in any manner as may be considered in the best interest of the City. Should the City require clarification from the Proposer, the City shall contact the individual named in the ACKNOWLEDGMENT OF RECEIPT AND NOTICE OF INTENT TO SUBMIT PROPOSAL. Evaluation of the proposal is the first step in a series of evaluation steps that will be conducted by the Committee. The City may elect to conduct post- submission reference checks or Proposer interviews with any Proposers that are not eliminated based on their proposal. The City reserves the right to cancel this RFP at any time. The City reserves the right to reject any or all proposals submitted in response to this RFP. The fully executed service agreement, as amended, the request for proposal, as amended and the proposal constitute the agreement, in its entirety, between the City and the Contractor. Any other terms and conditions shall be null and void. In case of a conflict in the contract documents, first precedence shall be given to the fully executed contract, as amended; second precedence will be given to the request for proposal, including addenda and third precedence will be give to the proposal. The laws of the State of Texas will govern any Contract resulting herefrom. The contract shall be executed in Nueces County, Texas. The applicable law for legal disputes arising out of the Contract resulting herefrom shall be the law of the State of Texas. This RFP in no manner obligates the City or any of its agencies to the eventual services offered until confirmed by an executed written Contract approved by the Corpus Christi City Council. Any additional terms or conditions, which may be the subject of negotiation, will be discussed only between the City and the qualified Proposers. Any Contract awarded as a result of this RFP process may be terminated if sufficient appropriations or authorizations do not exist. Such termination will be effected by sending written notice to the Contractor. The City's decision as to whether sufficient appropriations and authorizations are available shall be accepted by the Proposer as final. The City Manager will recommend to the City Council that award be made to the Proposer(s) whose proposal is determined by the City to be the most advantageous ( "Best Value ") to the City. The City reserves the right to withhold final action on proposals for a reasonable time not to exceed one hundred eighty (180) days subsequent to the deadline for receipt of proposals. The award of a Contract(s), if an award is made, will be to the most responsible and responsive Proposer(s) that give the City "Best Value" and whose proposals meet the requirements and criteria set forth in this RFP. The City Council shall authorize award of the Contract to the successful Proposer(s) and shall designate the successful Proposer(s) ( "Contractor ") as the City's Provider(s). The City will require the Contractor(s) to sign the documents necessary to enter into the required Contract with the City and to provide the necessary evidence of insurance as required in the Contract documents. No Contract for this project may be signed by the City without the authorization of the City Council and no Contract shall be binding on the City unless and until it has been approved as to form by the City Attorney or her designee, and executed by the City Manager or his designee. In the case of any doubt or difference of opinion with regard to the items to be furnished by a Proposer or the interpretation of the provisions of this RFP, the decisions of the City shall be final and binding upon all parties. The City reserves the right to negotiate a change in Proposer's representatives if the assigned representatives are not, in the opinion of the City, adequately meeting the needs of the City. The service agreement resulting herefrom will be for a term of three years with an option to extend for up to two additional one -year periods, subject to the approval of the City Manager or his designee. By submission of its proposal, the Proposer agrees that the pricing and compensation quoted in its proposal is fixed and firm for the duration of the initial one year term of the service agreement resulting herefrom. Adjustments to price and cost may be considered upon expiration of the initial one- year term and prior to extension of the contract for either of the two additional twelve -month extensions. Contract changes may only be made by an amendment to the Contract resulting herefrom and executed in writing by the City and the Contractor and approved by the City Council. The City Manager may terminate this Agreement for Contractor's failure to perform the services specified in this RFP. Failure to keep all insurance policies in force for the entire term of this Agreement is grounds for termination. The Contract Administrator must give Contractor 5 work -days written notice of the breach and set out a reasonable opportunity to cure. If the Contractor has not cured within the cure period, the City Manager may terminate this Agreement immediately thereafter. Alternatively, City may terminate this Agreement, with or without cause, upon 20 days written notice to Contractor. However, City may terminate this Agreement on 24 -hours written notice to Contractor for failure to pay or provide proof of payment of taxes as set out herein. If the City terminates its Contract under the foregoing paragraph, the City shall pay the Contractor for goods provided and services actually performed prior to such termination, less such payments as have been previously made. Contractor shall not be entitled to any further compensation for goods provided or work performed by the Contractor or anyone under its control or direction from the date of receipt of notice of cancellation including any and all costs related to the transferring of any files to another Contractor or any costs related to the electronic transfer of any information including, but not limited to, tape transfers, downloads, uploads, compact disc, etc. Upon termination of the Contract, the Contractor shall provide the City reproducible copies of all work completed or partially completed documents prepared under the Contract — all such documents thereinafter being the sole property of the City within thirty (30) days of such termination at the Contractor's expense. CONTRACTOR SHALL FULLY INDEMNIFY, DEFEND (WITH COUNSEL SATISFACTORY THE CITY), SAVE, AND HOLD HARMLESS THE CITY OF CORPUS CHRISTI, ITS OFFICERS, EMPLOYEES, REPRESENTATIVES, AND AGENTS (INDEMNITEES) AGAINST ANY AND ALL DAMAGES, LOSSES, PROPERTY LOSSES AND DAMAGES; PERSONAL INJURIES, (INCLUDING WITHOUT LIMITATION, WORKERS' COMPENSATION AND DEATH CLAIMS), JUDGMENTS, CLAIMS, AND ANY OTHER DAMAGE OR LOSS OF ANY KIND, ARISING OUT OF OR IN CONNECTION WITH CONTRACTOR'S PERFORMANCE, UNDER THIS AGREEMENT, INCLUDING ALL EXPENSES OF LITIGATION; COURT COSTS; AND ATTORNEYS' FEES. THIS INDEMNITY SHALL SURVIVE TERMINATION OF THIS AGREEMENT. TO THE EXTENT NOT PROHIBITED BY THE STATUTES OF THE STATE OF TEXAS AND THE TEXAS CONSTITUTION, THE CITY SHALL INDEMNIFY, SAVE, AND HOLD HARMLESS THE CONTRACTOR, ITS OFFICERS, EMPLOYEES, AND REPRESENTATIVES AGAINST ANY AND ALL DAMAGES, LOSSES, JUDGMENTS, CLAIMS OR OTHER MONETARY LOSSES RECOVERED FROM THE PROPOSER ON ACCOUNT OF ANY PROPERTY LOSS OR DAMAGE OF ANY KIND, OR ANY OTHER KIND OF DAMAGES WHICH ARE ATTRIBUTABLE TO THE CITY'S GROSS NEGLIGENCE, WILLFUL ACTS OR OMISSIONS (AS DETERMINED BY FINAL JUDGMENT OF A COURT OF COMPETENT JURISDICTION WHICH IS NO LONGER SUBJECT TO APPEAL OR FURTHER REVIEJ 9 WHILE RECEIVING SERVICES UNDER THIS AGREEMENT AND INCLUDING ALL EXPENSES OF LITIGATION, COURT COSTS, AND ATTORNEYS' FEES INCURRED BY THE CITY IN CONNECTION WITH DEFENDING ITSELF IN ANY ACTIONS RESULTING IN THESE MONETARY LOSSES. A. Proposer must not commence work under this permit until all insurance required herein has been obtained and such insurance has been approved by the City. Proposer must not allow any subcontractor to commence work until all similar insurance required of the subcontractor has been obtained. B. Proposer must furnish to the City's Risk Manager or designee with 2 copies of Certificates of Insurance, showing the following minimum coverage by an insurance company(s) acceptable to the City's Risk Manager. The City must be named as an additional insured for the General liability policy and a blanket waiver of subrogation is required on all applicable policies. TYPE OF INSURANCE MINIMUM INSURANCE COVERAGE 30 day written notice of cancellation, material change, non - renewal or termination is required on all certificates Bodily Injury and Property Damage Per occurrence - aggregate Commercial General Liability including: 1. Commercial Form 2. Premises - Operations 3. Products/ Completed Operations 4. Contractual Liability 5. Independent Contractors 6. Personal Injury — Advertising Injury $1,000,000 Combined Single Limit Professional Liability $3,000,000 per claim to pay on behalf of the insured all sums which insured shall become legally obligated to pay as damages by reason of any act, malpractice, error or omission in professional services; if written on a "Claims Made" form, must provide for an extended reporting period of twenty - four (24) months after the date of contract termination or expiration. Commercial Crime /Fidelity Bond $1,000,000 Workers' Compensation Employers' Liability Which Complies With the Texas Workers' Compensation Act and this Section $500,000 C. In the event of accidents of any kind, the Proposer must furnish the Risk Manager with copies of all reports of any accidents within 10 days of the accident. D. Proposer must obtain workers' compensation coverage through a licensed insurance company. The contract for coverage must be written on a policy and with endorsements approved by the Texas Department of Insurance. The coverage provided must be in an amount sufficient to assure that all workers' compensation obligations incurred by Proposer will be promptly met. E. Certificate of Insurance: 1. The City of Corpus Christi must be named as an additional insured on the General Liability coverage, and a blanket waiver of subrogation in favor of the City of Corpus Christi is required on all applicable policies. 2. If your insurance company uses the standard ACORD form, the cancellation clause bottom right) must be amended by adding the wording "changed or" between "be" and "canceled ", and deleting the words, "endeavor to ", and deleting the wording after left". In lieu of modification of the ACORD form, separate policy endorsements addressing the same substantive requirements are mandatory. 3. The name of the project must be listed under "Description of Operations ". 4. At a minimum, a 30 -day written notice of cancellation, material change, non - renewal or termination is required. Throughout the duration of the procurement process and resulting Contract term, potential Proposers must secure from the City written approval prior to the release of any information that pertains to the potential work or activities covered by the RFP or the resulting Contract. Failure to adhere to this requirement may result in disqualification of the Proposer's proposal or termination of the Contract. By submission of its proposal, the Proposer promises that Proposer's officers, employees, or agents will not attempt to lobby or influence a vote or recommendation related to the Proposer's proposal submitted in response to this RFP, directly or indirectly, through any contact with City Council members or other City officials between the deadline for submission of proposals and the date a contract resulting herefrom is awarded by the City Council. Such behavior will be cause for rejection of the Proposer's proposal at the discretion of the City Manager or his designee. Quantities described herein are estimates and do not obligate the City to order or accept more than the City's actual requirements during the term of any contract resulting herefrom, nor do the estimates limit the City to ordering less than its actual needs during the term of any contract resulting herefrom, subject to availability of appropriated funds. Section 3 Scope of Work The City of Corpus Christi is seeking proposals from qualified firms to provide fully- insured retiree health insurance for both Medicare Eligible and Non- Medicare Eligible retirees. The enclosed questionnaire and exhibits have been developed to provide the data, required coverage and other information needed to respond to this Request for Proposal (RFP). The contract awarded will cover a three -year initial term beginning August 1, 2009 and continuing through July 31, 2012, with the option to extend for up to two additional twelve -month periods. A. Since August 2003, the City's self- funded Healthcare Program has been administered by Humana. The City's Healthcare Program provides benefits to approximately 7,600 employees, dependents, retirees and COBRA participants, including Fire and Public Safety employees. Approximately 3,000 employees participate in the health plans, with approximately 550 retirees participating. B. The current group medical plans offered are identified as Citicare, Fire and Public Safety. C. Plan descriptions for each plan are included in Exhibits A - G. Retirees and surviving spouses and eligible dependents may participate in the plan in which they were enrolled at retirement. The current benefit designs for each retiree plan are the same for active, Non - Medicare Eligible retirees and Medicare Eligible retirees. Funding rates for each plan are blended between active and retired enrollees. While there is no direct subsidy to the retiree "rates", the city recognizes that the retiree rates are subsidized at this time. A final determination regarding the amount of the City's subsidy, if any, toward the cost of fully insured retiree health insurance plans will be determined after reviewing the proposals received. D. For retiree census and claim details refer to Exhibit H. E. Healthcare Strategy The City's healthcare strategy is founded on five core principles: 1. Fiscally Responsible: manage the City's investment in employee and retiree healthcare in a prudent manner. 2. Improve Employee Health: offer employees and their families the tools and resources such as wellness and disease management programs to help them improve their health and live a better quality of life. 3. Consumer Engagement: help employees become informed consumers by helping them get more value for their dollar. 4. Simplicity: offer programs and plans that are easy for employees to understand. 5. Access: provide employees access to timely and quality care. It is expected that each proposer will detail in their transmittal letter how you will help support the City's five core principles. F. Eligibility and Participation 1. A new full -time employee is eligible to participate in any of the City's benefits upon the date of hire without a waiting period, but must elect coverage within the first 31 days of hire. Health coverage selected during this period will be effective as of the date of hire. Subsequent changes to coverage are permitted within 31 days of the date of a qualifying event or at the City's annual enrollment. Employees are eligible to select continued health coverage upon retirement with the City, but must select said coverage within 31 days of retirement. The eligibility formula for retiree eligibility for health benefits is 20 years of service at any age, or 5 years of service at age 60 or greater. If elected, coverage would be effective as of the date of retirement. Retirees may not elect retirement insurance again once they have dropped the coverage. Retirees may not add dependents to the plan at any time. 2. The dependents of an employee are eligible for coverage on the same day that the employee becomes eligible (date of hire) and may be covered under the insurance of a retiree only if they were covered on the day the employee retired. Newly acquired dependents of active employees are eligible for coverage within 31 days of birth or adoption, provided, however, that if an employee already has child coverage, additional time for notice is permitted. In the event such notice exceeds 90 days, the Plans' pre- existing condition clause may apply. Surviving dependents of a deceased retiree may elect to continue coverage if they had been covered under the retiree's insurance prior to death. Unmarried, financially dependent children are eligible to be covered up to the last day of the month in which they turn 25. Dependents may be continued under retiree coverage until they no longer meet the definition of an eligible dependent only if they were covered as a dependent on the date of retirement. Dependents may not be added to a retiree's coverage at any time past the date of retirement. G. Funding Sources Funding for the City's retiree benefits is provided by contributions from the retiree only. However the funding rates are calculated based upon a blended rate calculated annually using all participants in the various plans. The City may or may not subsidize the cost of Fully Insured retiree medical insurance. Clarify any contingencies associated with your offer regarding minimum contribution or participation requirements. H. Offered Plans 1. The City prefers to contract with one proposer to manage the offering of insured coverages for both Non - Medicare Eligible and Medicare Eligible retirees. Preferred plan designs include PPO based plans for both retiree populations. For the Medicare Eligible retirees, the City will consider plans that coordinate benefits secondary to Medicare, Medicare Supplement offers, Medicare Part D offers and Medicare Advantage Plan offers. The intent is to provide a comprehensive medical and prescription drug benefit to all retiree beneficiaries. The offered Plan design should closely match the Citicare Civilian PPO plan found in Exhibit A and Exhibit D. Please indicate that you agree with each statement. Failure to do so may result in disqualification. If you are unable to meet a condition, please give an explanation. 1. The selected vendor may be expected to perform the types of services as outlined in the table below. This list is not all inclusive and additional services may be requested. 2. The City has four self - insured PPO medical plans. The plans are Citicare (Civilian), City Alternate Choice Plan, Citicare Fire, and Citicare Public Safety. Prescriptions are covered in each plan rather than as a separate benefit. 3. At a minimum, provide all services described herein. 4. Fully warrant and guarantee all information provided. 5. Comply with all local, state and federal insurance laws and regulations relative the contents of your proposal. Proposer affirms that all proposals are in compliance with applicable laws. 6. Attend quarterly review meetings at the City's desired location in Corpus Christi, Texas. 7. Provide a specimen Contract and Business Associate Agreement. 8. Provide a plan of comparable design and level of benefits as the current Citicare Civilian plan. The benefits should be interpreted and claims processed in accordance with the summary plan description. Highlight any deviations from the current Citicare Civilian benefits offered. See attached Exhibits A and D. 9. Notify service providers of the effective date of the contract award of City business and provide the billing address for claim submission relating to City participants for services rendered after the effective date of this change. This will ensure a smooth transition for claims processing and payments. 10. An Explanation of Benefits is to be provided following receipt of a claim submitted by a member, as to the disposition of the claim. In case of delay, an explanation of the reason for the delay is to be provided. If a claim is disputed, fair resolution and written notice of the reason for the denial and appeal process procedures are to be provided. 11. In case of denial of a claim for payment for any reason, the claimant should be notified in writing in a clear, concise and easy to understand manner giving the reason for denial. If there is an appeal process involved, the claimant is to be provided full information relating to the procedures and steps to follow. 12. It will be the responsibility of the Contractor to defend at their cost and expense, any and all claims and actions, which may be filed for failure to pay covered benefits under the plan(s) offered. 13. The Contractor shall identify claims for which there is potential for subrogation of the rights of the covered persons, and such listing shall be provided to the City on a quarterly basis. 14. Supply updated provider directories as needed. 15. Maintain eligibility files and receive updates from the City as required. The Contractor must maintain eligibility files throughout the term of the contract. 16. The City prefers online access for real time updating of the eligibility data. 17. Eligibility software must be HIPAA compliant. 18. Mail I.D. cards to participants' home address within ten (10) working days after receiving the initial enrollment eligibility file and at the beginning of each plan year. Thereafter, new I.D. cards must be provided to a participant within five (5) working days of receiving any change request. 19. Provide assistance in plan communication and enrollment of retirees. 20. Maintain, print and mail summary plan document (SPD) booklets to plan members. SPD booklets and provider directories shall be mailed to the member's home address at the time of initial enrollment. Thereafter, the summary plan document shall be mailed to all subscribers' home address annually. 21. The summary plan document (SPD) must be developed and submitted to each participant no later than November 1, 2009, unless another date has been agreed upon by the City. 22. Assist in developing and mail plan amendments to all members at their home address. 23. Supply the City with Summary Plan Document (SPD) booklets, marketing materials and provider directories for distribution as needed. 24. Provide the City with plan specific comprehensive experience reports monthly and /or summary reports annually. Provide copies of your standard reporting package. Cost of these reports must be included in the rate bid. 25. All reports must be received by the last day of the following month. 26. Provide web -based access to standard reports. At a minimum, standard reports must include: Medical • Plan demographics • Medical cost recap (e.g. total paid, PMPM, provider type, In vs. Out of Network) ■ Claims expense stratification by dollars and age • Provide utilization (input, output, physician) compared to benchmark • Large claims ■ Major diagnostic categories • Case management activity Pharmacy • Membership summary • Executive summary • Generic vs. Retail Utilization • Channel Utilization • Top drug and classes 27. Provide a single point -of- contact account manager and local contact. This person shall be available through a toll -free telephone number and a direct telephone number. 28. Conduct an annual member satisfaction survey. 29. Properly staffed and supervised customer /member service representatives as well as bi- lingual staff must be available to plan participants via a toll free number. 30. Keep records on complaints and concerns expressed by City participants categorized in appropriate sections against health care providers, vendor services, hospital networks, etc., and make these records available for City's administration to review. 31. Renewal rate computations must be furnished at least 4 months prior to the end of the contract year. 32. Waive actively -at -work clause on new entrants into the plan. 33. The City does not guarantee a minimum participation in the plan. 34. New member ID cards are mailed to member's homes. Summary plan documents are updated annually, provided to the City, and mailed annually to member's homes. 1. Where is your organization headquartered? Where is the management office responsible for Corpus Christi or Nueces County located? State the location where administrative services will be provided for the City of Corpus Christi (customer service, claims processing, issuing and distribution of I.D. cards, etc.) 2. Have any lawsuits been filed against your organization relative to any of your health care products or administrative services in the last two years? Please describe the nature of any lawsuits, dates and final outcomes. 3. How many clients have left your organization during the last two years? 4. Provide a copy of your most recent annual financial reports and the annual financial reports of your parent company. 5. Provide most recent A.M. Best, Standard & Poor's, Weiss, and Moody's Ratings (if applicable). 6. Provide a detailed explanation of any common ownership or relationship among supporting vendors and subcontractors. 7. Indicate the location of the group claims office, corporate and local, which would be responsible for paying claims and the number of claim representatives in that office that will be dedicated to the City's account. 8. Provide an organizational chart, locations, and biographies of team members assigned to the City's account. 9. How long have you provided the specific services you propose? Are any of the services proposed "new" to your organization, and therefore either not fully developed or client- tested? 10. What attributes make your organization qualified to provide health care coverage to Non Medicare and Medicare Eligible retirees? How are you differentiated from your competitors? 11. Provide three current client references and three former client references for which you provided the same services. References should be based on the office that will be providing services to the City. CURRENT CLIENT Reference 1 Organization name: Contact and title: Address: Phone number: Effective date of contract: Number of enrolled retirees: Description of services provided: CURRENT CLIENT Reference 2 Organization name: Contact and title: Address: Phone number: Effective date of contract: Number of enrolled retirees: Description of services provided: CURRENT CLIENT Reference 3 Organization name: Contact and title: Address: Phone number: Effective date of contract: Number of enrolled retirees: Description of services provided: FORMER CLIENT Reference 1 Organization name: Contact and title: Address: Phone number: Effective date of contract: Number of enrolled retirees: Number of enrolled retirees at date of termination: Description of services provided: Reason for termination: FORMER CLIENT Reference 2 Organization name: Contact and title: Address: Phone number: Effective date of contract: Number of enrolled retirees: Number of enrolled retirees at date of termination: Description of services provided: Reason for termination: FORMER CLIENT Reference 3 Organization name: Contact and title: Address: Phone number: Effective date of contract: Number of enrolled retirees: Number of enrolled retirees at date of termination: Description of services provided: Reason for termination: A. Provider / Network Access and Administration 1. Using the census provided in Exhibit H, please provide Geo- Access Reports using the following standards: ork: Provider Group Urban and Suburban Access Standards Rural Access Standards Primary Care Physicians* 2 in 8 miles 2 in 25 miles All Other Specialists 2 in 15 miles 2 in 25 miles Hospitals 2 in 15 miles 2 in 25 miles *Primary care physicians include Internists, Family Practitioners, OB /GYNs, In addition to the hard copy report, the data must be supplied in electronic format that has read /write capabilities (Le. Excel). Do not send the data in a read -only file. Use only physicians accepting new patients in your Geo- Access provider file. 2. Provide list of hospitals and providers local to Corpus Christi. 3. Provide access to national networks in the event employees are traveling or dependent students are out of state. 4. Describe any alternative PPO networks that are based on provider quality and cost criteria. 5 Will an implementation manager and support team be assigned to lead and coordinate the implementation activities with the City? 6. What minimum amount of notice would you require to be able to implement these plans by August 1, 2009? 7 Please discuss your procedures and processes for handling the following during the transition period. a. Transfer of claim and benefit history b. Retirees /dependents in active treatment c. Pregnancy (2nd & 3rd trimesters) d. Members undergoing chemotherapy or radiation e. Members confined in hospital at changeover dates f. Members under case management g. Services that have been pre - certified but not completed as of the effective date h. Retiree communications regarding change in administrators 8. Please discuss your process in handling patients that are currently receiving care in a non- network hospital as well as those currently receiving outpatient services. 9. Provide a plan for continuation of current treatment during transition. Please provide samples of plans you have used for other large employers in your response. 10. Can your system automatically edit for age triggers, requiring a plan change upon attainment of age 65 or Medicare Eligibility? 11. Does your system allow automatically for split family administration between Non Medicare and Medicare Eligible family members? Describe how a Non Medicare Eligible Family transitions into Medicare Eligible membership at carious points in time and the impact on accumulators and premiums. 12. Provide a detailed implementation timetable, including an outline of the activities you expect to be performed prior to the stated effective date, completion dates, and the individuals or groups who will have major responsibility for each activity must be provided, including: • Contracts completed • Banking arrangements established • Customer service toll -free phone line operational • ID cards mailed to retirees • Electronic access established with the City • Program operational and ready to deliver benefits to members • Summary Plan Documents • Welcome packets • Sample ID card • Samples of communication materials (i.e. benefit summary documents distributed to members). • Samples of retiree communication materials on use of the network, utilization review, etc. • Sample claim forms. • Sample copy of standard EOB (explanation of benefits) form. B. Centers of Excellence - Networks 13. Do you have a network of Centers of Excellence? 14. Indicate high -risk and high technology services coordinated with the Centers of Excellence. a. Bone Marrow transplants b. Heart transplants c. Lung transplants d. Kidney transplants e. Other transplants (please specify) f. Cancer g. Neonatal Critical Care h. HIV i. Joint Replacement j. Cardiac Surgery and Interventional Cardiac procedures k. Other non - transplant procedures (please specify) Complete the following table for your top five (5) Centers of Excellence by volume. Center Type Facility Name Location Date of Participation 15. Are there a selection criteria or prior authorization processes to gain access to the centers? 16. How are these members case managed (i.e., Are they handled in a unit separate from other catastrophic cases ?)? 17. Will there be any changes in the coming year to your current Centers of Excellence arrangements? C. Medical Claims Administration 18. Explain payment process to In- network hospitals, group practices, primary care physicians and specialists, along with the claims handling procedures. 19. Explain payment process to Out -of- network hospitals, group practices, primary care physicians and specialists, along with the claims handling procedures. 20. What is the standard turnaround time for making payments to: a) hospitals, b) physicians and c) members? 21. How are complaints handled from members who receive collection agency or late payment notices when the covered charges are clearly the responsibility of the plan? 22. How will subrogation rights be communicated to the participants? Please provide a flowchart to explain the process. 23. What is your definition of a "paid" claim, a "clean" claim, a "suspense or pending" claim? Please state the time frames it will require to process the claims proposed for each of the types mentioned. If additional types exist, please list them and state the time frames for processing those types of claims. 24. Describe the claims filing procedures proposed. 25. How are usual and customary professional fees profiles established and maintained? How often are profiles updated? What percentage of claims are accepted without reduction? Do retirees become responsible for payments which exceed reasonable and customary charges? 26. Describe how your claim system interfaces with your utilization review program. 27. In what manner does your claims system handle the following? (Indicate whether process is automated or manual.) a. Accumulation of deductibles b. Co- payments. c. Benefit dollar limits d. Benefit service limits e. Lifetime limits f. Scheduled benefits g. Co- insurance at various levels for in and out -of- network claims h. Out -of- pocket maximums for in and out -of- network claims i. Coordination of benefit claims j. Subrogation claims k. Duplicate claims 28. Describe the process by which network, out -of- network, and out -of -area claim services are adjudicated from the date the service is rendered in a provider's office or facility to the date of payment. 29. What percent of claims are automatically adjudicated? 30. What percentage of claims that are submitted on paper are electronically scanned into your processing systems? 31. Describe how your system handles eligibility changes for retirees and dependents (including coordination of benefits information, student status and disabled dependents). Explain the process of verifying the status of disabled dependents. 32. Describe your appeals process in the plans offered. Please provide a flowchart of your standard appeals process. 33. Is there a contingency plan(s), procedure, and system in place to provide backup service in the event of strike, natural disaster, or backlog? D. Quality Control 34. Describe your policy and procedures for auditing hospital bills /claims. 35. Overall, what percent of claims are subject to internal audit? 36. How frequently are external audits performed? 37. Overall, what percent of claims are subject to external audit? 38. What process or systems edits do you have for identifying potential hospital /provider related negative outcomes, i.e. medical malpractice? 39. Describe your policies and procedures for detecting and investigating potential fraudulent claims. 40. What safeguards and provisions are in place to safeguard against "balanced billing "? 41. Describe the procedures for preventing and monitoring creative billing, up- coding, unbundling, etc. 42. What services are available to assist retirees on disputes with providers? E. Medical Management 43. Do you have a full -time medical director on staff for this area's network? 44. Describe the medical director's roles and responsibilities, in particular how it applies to utilization management and percent of time allocated to each responsibility. 45. Identify the procedure(s) used to handle after -hours calls to the medical management department. 46. Describe how utilization review services are provided. In- house? Contracted (please provide the name of the vendor)? 47. Are any utilization review or case management functions delegated to participating provider groups? If yes, please specify groups. 48. If there is more than one utilization review vendor, how will the services and information be integrated and tracked to ensure consistent application of the health plan's utilization review? 49. How are utilization review and pre - certification information coordinated with the claim administration department? 50. Describe the process and criteria used for hospital pre - certification. a. Please note whether surgical procedures are authorized on medical necessity or place of service. b. If based on medical necessity, describe how the guidelines were developed, for how many procedures guidelines exist, and what percent of requested procedures did not meet the guidelines in 2008? c. Have the guidelines been shared with plan physicians? d. Are the medical necessity criteria local, regional or national? e. How often are the medical necessity criteria updated? 51. Describe the process and criteria used for concurrent review. Is concurrent review performed on -site, electronically or telephonically? Please explain. 52. With what frequency is a patients need for continued hospitalization under the concurrent review program reassessed? 53. Please describe your discharge planning process. 54. Describe the process and criteria used for case management. Please address the following issues: a. How are case management situations identified? b. If you use a list of diagnosis, please describe them in detail. c. If you use a claims dollar threshold, what is the amount? d. What is the process for determining whether to pursue a case for management? e. Is patient consent required to initiate case management services? f. In a self - funded arrangement, when is the employer included in the process? g. How do the case managers interact with the patients, family, and physicians? h. Are reports provided and what type of reports? Provide samples. 55. How are members educated as to the services offered through case management? 56. How do case managers identify and evaluate local health care resources for alternative treatment? 57. Is any part of the Utilization Review function delegated to subcontractors? If yes, please address the following: a. To whom is it delegated or subcontracted and what are their credentials? b. Are they required to use the guidelines? c. How is consistency ensured in the process? d. Discuss the timing of the process. 58. How are patients with chronic disease (i.e., heart disease, diabetes, asthma, etc.) identified by the health plan? 59. If a member incurs large outpatient expenses (i.e. greater than $20,000 in outpatient chemotherapy) without having an inpatient stay, how would the patient be identified and case managed by your health plan? 60. What action is taken if a provider's planned treatment fails a Utilization Review screen? 61. Do local network physicians participate in the review of a clinical appeal? 62. What criteria must be met in order to have a case sent to a medical director? F. Disease Management, Wellness, Special Programs for Retirees 63. Describe your overall disease management philosophy including an opt -in vs opt -out approach and how it integrates with your other services such as case management, 24- hour nurse line and pharmacy benefits management. 64. Provide copies of any case studies or white papers describing the success of your programs. 65. Describe your approach for communicating the disease management program to members, providers, and the community resources utilized by members. Provide samples of communications. 66. Upon receipt of member eligibility and claims files, please describe the strategies used to contact members and enroll them into the program. 67. Describe how you will stratify disease management program members including methodology and predictive modeling tools. How do interventions vary by risk level? 68. Describe how you would manage at a minimum the following conditions: Congestive Heart Failure, Diabetes, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Asthma and High Risk Maternity. 69. Describe on how you monitor, evaluate and report outcomes. 70. Describe in detail your methodology to calculate Return on Investment. Has your organization received Certification in Savings Measurement from the Disease Management Purchasing Consortium International, Inc? 71. Describe the 24- hour/7 days a week nurse call service including staff qualifications, staffing model and location of services. 72. Describe the types of wellness programs you can offer including how you will help support and communicate those programs. 73. Do you have a full -time employee that is an expert in the health promotion / wellness field whose role is to assist your employer groups with their wellness strategy and program implementation? If so, please provide this individuals resume. 74. Do you subcontract your wellness services? If so, name this subcontractor along with the nature of the relationship and contract terms. 75. Describe any programs or plan options designed specifically to address retirees' health care needs. 76. Describe any programs in place that support value based health care decisions, i.e. modified deductibles or co -pays. 77. Describe any programs in place which will assist members in making informed health care decisions regarding value added treatments. 78. Provide a short summary of what you would consider best practice in adding additional benefits or incentives that would successfully improve retirees' health. 79. Describe any current programs that promote retiree consumerism for future consideration. 80. Provide three examples of innovative approaches to retiree health care that you have successfully implemented with other clients. G. Pharmacy Claims Administration 81. Describe your preferred drug list program including committee, adding /removing drugs. How often is your formulary list updated and are members notified when these changes occur? 82. Please provide information regarding available network options offered by your organization. Include number of chains and independents for both Corpus Christi and national. Also, identify which national or major regional chains are included. 83. What existing programs e.g. — step therapy, generic promotions are in place to help the client manage their pharmacy costs? 84. How are charges handled when the prescription cost is less than the applicable co- pay? 85. In the event of a new drug coming on the market, how will Vendor communicate this information to the City and the patients? 86. What processes does Vendor have to promote the use of generic drugs? 87. How frequently and on what basis does Vendor evaluate the formulary drugs chosen for utilization in Vendor's program? Please provide a list of Vendor's formulary Brands. 88. What innovative programs and services are in development now or to be developed in the near term that would be of benefit to the City and their drug plan members? 89. Does Vendor offer a 90 -day "at retail' program in conjunction with mail service for maintenance medication fulfillment? 90. Specify the data available on -line at the retail level when prescriptions are ordered and filled. 91. Explain your organizations specialty pharmacy capabilities. Describe the flow of services through the dispensing facility. 92. Provide a flow chart illustrating your organization's traditional and medical COB processes and what options are available to the city. 93. Describe in detail your coverage management program e.g. dose optimization, step - therapy and prior authorization. 94. Describe in detail your concurrent and retrospective drug utilization programs. 95. Does your organization contract directly, own or subcontract your pharmacy network? If not owned, provide details of arrangement including length of contract. 96. Provide 2 different client examples that demonstrate actual dollar savings from utilization review /management programs including measurable results and savings methodology. 97. Explain your organizations mail order capabilities. Including process for initial fill and subsequent refills. 98. Do you own your mail order facility? If not, name subcontractor along with length of current contract. H. Communications and Enrollment If your response differs for medical and pharmacy, you must provide details for each program separately. 99. Will you be willing to have representatives available at annual enrollment meetings to answer questions? Please keep in mind City employees work at various locations, around the clock. 100. What unique approaches are used to communicate with retirees? 101. Are EOBs mailed for in- network and out -of- network services? If so provide a sample. 102. Are EOBs automatically produced by the claims administration system? 103. Does the EOB show the amount of deductible that the retiree has yet to satisfy? 104. What is the average I.D. card turnaround (number of days between employer reporting a new member and plan mailing I.D. card)? 105. Please provide a copy of a new member communication /orientation package. 106. Describe your communication strategy and tools to encourage consumerism and help educate retirees about their health. I. Reporting 107. Describe enhanced reporting capabilities beyond your standard reporting package. Describe any additional fees for ad hoc or special reporting. 108. Do you have normative data against which the city's claims experience can be compared? Is this included in standard reports? If not, explain. J. Customer Service and Account Management If your response differs for medical and pharmacy, you must provide details for each program separately. 109. What are the telephone hours and the office location for the member services unit that will service the City? 110. State what the standards are for the following? a. Length of time for a call to be answered b. Abandonment rate c. Length of time a caller is placed on hold d. Maximum length of time to return a call 111. What is the average speed to answer in seconds? 112. What is the percent call abandonment rate? 113. What is the ratio of member services staff per 1,000 members? 114. Identify the specific services and information a member would access via your toll -free number with regard to eligibility, benefits, pre - certification, claim questions, network information, complaints, etc. 115. Do you have a correspondence tracking system to log in, assign, and track correspondence? 116. Describe the computer and phone system that supports and tracks member services calls and staffing. 117. What percentage of participant calls is recorded? 118. What is your initial call resolution rate? 119. Will your member services department support the City's annual enrollment by answering questions from retirees or providers participating in your network? 120. Can I.D. cards be customized for the City? 121. Provide a detailed list of the types of plan services participants can perform via Internet, IVR and service representative. 122. Will a dedicated member service representative be available to answer City staff questions? 123. Can calls that are more appropriately serviced by other areas be automatically re- routed by member services? 124. Are customer service satisfaction surveys conducted regularly? If so: a. How often and by whom? b. Can they be client specific? c. What have the results been? 125. Provide information as to how the incoming mail is logged and handled. K. Performance Guarantees If your response differs for medical and pharmacy, you must provide details for each program separately. 126. Provide performance guarantees detailed connection with the implementation of services and for those services that are to be provided on an ongoing basis. The details of these guarantees will be negotiated during the finalist selection process. For the standards listed below please indicate whether or not you will agree to the performance standards and the percent of fees you are willing to put at risk. The Proposer will be expected to conduct regular internal audits and report the results to the City for use in enforcing performance guarantees. If you are not willing to meet the proposed standard, please explain and propose an alternative performance measure. 127. Member ID Card must be processed and mailed to participant within ten (10) working days of member's data being submitted by City staff. 128. 90% of all City enrollees' calls routed to the selected Contractor's automatic call distribution system unit shall be answered and serviced within an average of 45 seconds during normal business hours. 129. 95% of all enrollees /providers' appeals shall be resolved within 60 days of receipt. 130. At a minimum, the City requires the following claims service guarantees: a. All enrollees' clean claims will be paid within a minimum of 14 calendar days from receipt date. b. 93% of all claims will be correctly coded. c. 93% of all claims will be accurately processed. d. 95% of all claims will be paid accurately. e. 95% of all claims will be accurately coordinated with other plans. f. 99% of all claims will be financially drafted correctly. g. 95% of all City enrollees claims submitted by the Contractor to the insurer shall be paid within 21 days of receipt. 131. Selected Contractor shall provide a quarterly report indicating their compliance with their published performance standards. Proposers shall provide monetary remedies for failure to meet their performance standards. Describe how you will monitor your performance of these standards. 132. The Contractor must guarantee that accurate management reports will be delivered no later than the agreed upon due date. 133. The Contractor must guarantee at a minimum, that enrollment data provided by the City will be loaded into the Proposer's enrollment system within 24 hours of receipt. An eligibility discrepancy report must be provided to the City within seven (7) working days following receipt of enrollment data. 134. What level of in- network discount guarantees will you give to the city? Detail how this discount will be calculated. L. Contract 135. PROPOSER SHALL PROVIDE ALL CONTRACT DOCUMENTS THAT CITY WILL BE REQUIRED TO SIGN. SAID CONTRACT DOCUMENTS SHALL BE COMPLETED AND SIGNED BY PROPOSER'S AUTHORIZED REPRESENTATIVE AND SHALL BE READY FOR CITY'S COUNTER - SIGNATURE. 1. Quotes shall be provided net of fees and taxes. The City will not pay commissions and /or fees to an agent or broker working on behalf of Contractor. Any commission /fees must be paid to the agent/broker by the Proposer at Proposer's expense. Any such fees paid or to be paid must be fully disclosed including specific amounts /percentages and the name and address of the individual or organization to whom said fees are paid. 2. Rates must be guaranteed for a one -year period of time. Extended rate guarantees are invited. Fully detail any contingencies impacting rate guarantees. 3. Please explain your renewal rating methodology. 4. Illustrate rates in a four - tiered format for Non - Medicare Eligible retirees: Retiree Only Retiree & Spouse Retiree & Child(ren) Retiree & Family 5. Illustrate rates for Medicare Eligible retirees on a Per - Member, Per -Month basis and provide how rates for eligible children will be calculated. Section 4 Proposal Format & Organization This section provides specific instructions on format and organization of the proposal to be submitted by the Proposer. Each Proposer may submit only one Proposal in a totally self - supporting format without reference to any other proposal(s). A. To provide for ease and uniformity and to aid in the evaluation of proposals, Proposers shall comply with the sequence outlined herein. IN NUMBERING THE PROPOSAL, THE PROPOSER SHALL USE THE SAME SECTION NUMBERS AND TITLES AND SHALL PROVIDE ITS RESPONSES IN THE SAME ORDER AS EACH QUESTION IS NUMBERED AND ORDERED HEREIN. Failure to comply may result in rejection of the proposal. The proposal shall be completed in sections, which are described below. For ease in handling, Proposers shall submit the Proposal on 8.5" x 11" paper (larger paper is permissible for charts, maps or spreadsheets) and place the proposal in binders with tabs delineating each section. B. Proposers should be aware that all technical and operational specifications, equipment descriptions and marketing material submitted or made available will be incorporated by reference into any contract(s) resulting herefrom. The City discourages the inclusion of general marketing material or equipment manuals unless they are used to provide specific information or specifically requested by the City. This information may be submitted under separate cover from the proposal. C. The Proposer shall provide one (1) original and twelve (12) identical copies of their proposal with an electronic version on one compact disk or flash (thumb) drive with files in either Microsoft Word, Excel or Adobe Acrobat (PDF) format to the location specified in Section 1.2 on or before the closing date and time for receipt of proposals. Proposals transmitted orally, telephonically, electronically or via facsimile shall not be considered. A. This section outlines the minimum requirements for preparation and presentation of a response. B. The Proposer shall define the capabilities of their organization to supply and maintain the services as requested in this RFP. The response should be specific and complete in every detail and prepared in a simple and straightforward manner. C. Proposers are expected to examine the entire RFP including all specifications, standard provisions and instructions. Failure to do so will be at the Proposer's risk. Proposers should provide their best pricing on each type of service. D. Proposer shall submit its proposal, in Microsoft Word or PDF format, on one compact disc or flash (thumb) drive. Please refer to the following web page for an electronic version of the RFP: http:// www. cctexas .com /purchasinE/admin /webrpt bidscurrent.cfm The transmittal letter shall indicate the intention of the Proposer to adhere to the provision described in the RFP without modification. The letter of transmittal MUST: 1. Be presented on company letterhead; 2. Identify the submitting organization; 3. Describe your approach to supporting the city's five core principles as described in Section 3.2 of the RFP; 4. Explicitly indicate acceptance of the requirements as described in the RFP Requirements; 5. Acknowledge receipt of any addenda to this RFP; 6. Detail how you will help support the City's five core principles as listed in Section 3.2; 7. Reference the City of Corpus Christi Minority Business Enterprise Information Form and Disclosure of Interest Form, the completed versions of which should follow the transmittal letter; and, 8. Identify. by name and title. and be sinned by the person authorized by the organization to obligate the organization contractually and include the completed. signed and dated contract immediately after the Disclosure of Interest Form. A table of contents, listing titles, sections, and major sub - sections shall follow the Disclosure of Interest form referenced above. All pages shall have a unique identifier and be numbered sequentially within each section. Section 5 Proposal Evaluation The City of Corpus Christi will conduct a comprehensive, fair and impartial evaluation of all Proposals received in response to this RFP. Each Proposal will first be analyzed to determine overall responsiveness and completeness as defined in Section 4.0 Proposal Format and Organization and Section 5.2 Evaluation Criteria. Failure to comply with the instructions or submissions of an incomplete Proposal that does not satisfy Section 4.0 and 5.2 will result in the proposal being deemed non - responsive and may, at the discretion of the Committee, as defined in Section 5.1 below, be eliminated from further consideration. An Evaluation Committee ( "Committee ") has been established to assist the City in the selection of a qualified Proposer. The Committee is comprised of representatives from various using departments. Committee will determine the responsiveness and acceptability of each Proposal. The Committee will then engage in a detailed review of each Proposal to evaluate the response in relation to the four (4) major evaluation factors identified in Section 5. A. The proposal evaluation and selection process will be based on the following criteria: 1) Technical Solution, 2) Proposer's Profile & Qualifications, 3) Rate Schedule and 4) Exceptions. The final weight assigned to each of these parameters will be determined by the Evaluation Committee and will be within the ranges for each criterion as indicated below. Some of the criteria contained within this model may look similar to the following Proposed Evaluation Model. Each Proposer shall provide detailed responses including reference to any existing "in- house" procedures, policies, etc. as they reference all requirements of this RFP. In determining "Best Overall Value ", the Evaluation Committee will evaluate the entire proposal, including, but not limited to, the criteria enumerated in Sections 3.3, 3.4 and 3.5 of this RFP and any exceptions taken. Proposer's Profile & Qualifications 10 -20% —1 Technical Solution 30-40% Rate C Exceptions I Total Schedule 30 -40% [ 5 -15% 100% B. The Evaluation Committee shall determine the final percentage assigned to each proposed evaluation criterion. In no case shall the percentage assigned to each criterion be smaller or greater than the stated minimum or maximum, respectively. The sum of the final percentages for all criteria shall equal 100 %. C. The Proposer's failure to provide information relative to the above criteria may result in the City deeming such proposal non- responsive and may, at the discretion of the Committee, as defined in the paragraphs above, result in elimination of said proposal from further consideration. The Committee reserves the right to conduct other evaluation and measurements of the proposals as may be necessary to make an informed decision. EXCEPTIONS Proposer: Document Exceptions Proposer shall clearly state the exception and the reason for taking exception. Proposer shall describe each item and state clearly any price consequences. Important Note: The Proposer must complete this form. If the Proposer has no objection or exception, the Proposer should indicate "NONE" on this page. This completed form must be included with each copy of the proposal submitted. Proposer's Authorized Signature: Name of Proposer's Authorized Representative: (Print) Telephone Number (_ _ _) _ _ _ - Date: / / — CITY OF CORPUS CHRISTI FINANCE DEPARTMENT / PURCHASING DIVISION MINORITY BUSINESS ENTERPRISE INFORMATION FORM THIS FORM MUST BE SUBMITTED ALONG WITH BID PLEASE INDICATE WHETHER THE COMPANY IS A CERTIFIED MINORITY BUSINESS. EXAMPLES OF CERTIFICATIONS RECOGNIZED BY THE CITY INCLUDE: ❑ YES ❑ NO - CERTIFIED HISTORICALLY UNDERUTILIZED BUSINESS (HUB) Select all that are appropriate: ❑ ASIAN PACIFIC ❑ BLACK ❑ HISPANIC ❑ NATIVE AMERICAN ❑ WOMAN Please visit the following website for information on becoming a Certified HUB: http: / /www. window. state .tx.us /procurement/proe/hub/ ❑ YES ❑ NO - LOCAL SMALL BUSINESS (LSB) A for - profit entity employing less than 49 employees located within the City limits of Corpus Christi, Texas DYES ❑ NO OTHER (PLEASE SPECIFY): ❑ THIS COMPANY IS NOT A CERTIFIED HUB or LSB THE ABOVE MINORITY BUSINESS INFORMATION IS REQUESTED FOR STATISTICAL AND TRACKING PURPOSES AND WILL NOT INFLUENCE THE AMOUNT OF EXPENDITURES THE CITY WILL MAKE WITH ANY GIVEN COMPANY. BID INVITATION NO: BI- Firm Name: Telephone: Address: Fax: City: State: Zip: E -mail: Signature of Person Authorized to Sign Form Signer's Name: (Please print or type) Date: Title: Ext. ••+4' SUPPLIER NUMBER City of TO BE ASSIGNED BY CITY spas PURCHASING DIVISION Christi CITY OF CORPUS CHRISTI DISCLOSURE OF INTEREST City of Corpus Christi Ordinance 17112, as amended, requires all persons or firms seeking to do business with the City to provide the following information. Every question must be answered. If the question is not applicable, answer with "NA ". See reverse side for definitions. COMPANY NAME: P. O. BOX: STREET ADDRESS: CITY: ZIP: FIRM IS: 1. Corporation 2. Partnership ❑ 3. Sole Owner ❑ 4. Association 5. Other DISCLOSURE QUESTIONS If additional space is necessary, please use the reverse side of this page or attach separate sheet. 1. State the names of each "employee" of the City of Corus Christi having an ownership interest" constituting 3% or more of the ownership in the above named "firm."- Name Job Title and City Department (if known) 2. State the names of each "official" of the City of Corpus Christi having an "ownership interest" constituting 3% or more of the ownership in the above named "firm." Name Title 3. State the names of each "board member" of the City of Corpus Christi having an "ownership interest" constituting 3% or more of the ownership in the above named "firm." Name Board, Commission or Committee 4. State the names of each employee or officer of a "consultant" for the City of Corpus Christi who worked on any matter related to the subject of this contract and has an "ownership interest" constituting 3% or more of the ownership in the above named "firm." Name Consultant CERTIFICATION I certify that all information provided is true and correct as of the date of this statement, that I have not knowingly withheld disclosure of any information requested; and that supplemental statements will be promptly submitted to the City of Corpus Christi, Texas as changes occur. Certifying Person: Title: (Type or Print) Signature of Certifying Person: Date: DEFINITIONS a. "Board member." A member of any board, commission, or committee appointed by the City Council of the City of Corpus Christi, Texas. b. "Employee." Any person employed by the City of Corpus Christi, Texas either on a full or part-time basis, but not as an independent contractor. c. "Firm." Any entity operated for economic gain, whether professional, industrial or commercial, and whether established to produce or deal with a product or service, including but not limited to, entities operated in the form of sole proprietorship, as self - employed person, partnership, corporation, joint stock company, joint venture, receivership or trust, and entities which for purposes of taxation are treated as non - profit organizations. d. "Official." The Mayor, members of the City Council, City Manager, Deputy City Manager, Assistant City Managers, Department and Division Heads, and Municipal Court Judges of the City of Corpus Christi, Texas. e. "Ownership Interest." Legal or equitable interest, whether actually or constructively held, in a firm, including when such interest is held through an agent, trust, estate, or holding entity. "Constructively held" refers to holdings or control established through voting trusts, proxies, or special terms of venture or partnership agreements." f. "Consultant." Any person or firm, such as engineers and architects, hired by the City of Corpus Christi for the purpose of professional consultation and recommendation. City of us Chnsti %41040•000.41001, CITY OF CORPCS CHRISTI, TEXAS PLAN DOCUMENT FOR THE CITY OF CORPUS CHRISTI HEALTH PLAN CITICARE Effective August 1, 2004 This Plan Document contains the terms under which the City of Corpus Christi agrees to cover eligible group members and pay benefits in consideration of the application and payment of the premium. The City of Corpus Christi, and Humana Health Network have agreed to all the terms of this Plan Document. THIS IS NOT A POLICY OF WORKERS COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY ESTABLISHING THIS PLAN. TABLE OF CONTENTS IMPORTANT PLAN INFORMATION Claim Dispute Information SCHEDULE OF BENEFITS Prior Authorization Penalty 1 Deductibles 1 Out -of- Pocket 1 Hospital Services 2 Psychiatric Disorders 4 Additional Medical Services ..5 ELIGIBILITY REQUIREMENTS Effective Date of Coverage 7 Eligible Class of Employees 8 Ineligible Class(es) 10 Qualifying Events 10 Becoming Eligible For Dependent Coverage 10 Certificate of Insurance 10 Changes in Coverage 11 Misstatements 11 DEFINITIONS Defmitions 12 HEALTH PLAN BENEFITS What the Plan Pays 23 The Annual Deductible .. 23 Annual Deductible Carryover 24 Out -of- Pocket Expense Limit 24 Maximum Benefit — Reinstatement of Benefits .. 24 Pre - Authorization Provisions 25 Maternity Admissions 26 When Emergency Hospitalization is Required . 26 Pre - Authorization Penalty 26 Appeals Procedure 26 Adoption Benefit 27 Newborn Expenses 27 Basic Hospital Benefit 28 Physician Benefits . 28 Psychiatric Disorders . 29 Chemical Dependency Benefits 30 Prescription Benefit Description 30 Additional Medical Services . 32 Pre - Admission Testing Benefit .. 34 Medical Case Management Benefit 35 Second Surgical Opinion Benefit . 36 Spinal Manipulation Benefit .36 Serious Mental Illness . 36 Well Child Care 36 Leaves of Absence and the Family Medical Leave Act 36 LIMITATIONS AND EXCLUSIONS Pre- Existing Conditions Limitation 37 Other Limitations and Exclusions 37 EXTENSION OF BENEFITS COVERAGE AFTER TERMINATION Extension of Benefits Coverage after Termination 40 FEDERAL CONTINUATION OF COVERAGE Consolidated Omnibus Budget Reconciliation Act (COBRA) 40 Continuation Coverage for Employees in the Uniformed Services 44 COORDINATION OF BENEFITS Allowable Expense 45 Claim Determination Period 45 Plan 45 This Plan 46 What Coordination of Benefits Provision Does 46 Order of Benefit Determination 46 How Benefits are Coordinated 47 MEDICARE ELIGIBLES Medicare Part A 47 Medicare Part B 47 Integration With Medicare 47 TEFRA Options 48 Category 1 Medicare Eligible 48 Category 2 Medicare Eligible 48 Calculation and Payment of Benefits 48 All Other Covered Persons Not Full -Time Employees Disability Due to End Stage Renal Disease 49 CLAIMS The Plan Must Be Notified of Intent to File a Claim 49 When to File Proof of Claim .49 The Plan May Extend Time Limits .. 49 The Plan's Right to Require Medical Exams 49 To Whom Benefits are Payable 50 When the Plan Pays 50 Right of Recovery 50 Subrogation . 50 Right of Reimbursement • 50 Duplication of Benefits /Other Insurance 51 Cooperation Required 52 Legal Actions and Limitations 52 Payment to the State of Texas 52 Complaint Notice 52 TERMINATION PROVISIONS Termination of Your Coverage 52 Termination for Cause 53 Termination of Dependent Coverage 53 Disabled Children .53 MISCELLANEOUS PROVISIONS Review Authority 54 Covered Person/Provider Relationship ..54 Changes in the Plan 54 Workers Compensation 54 Assignment 54 Termination of the Plan .54 TRANSPLANT PROVISIONS Transplant Provisions 55 Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA (Privacy Rights) 55 IMPORTANT NOTICE You may call the Plan at Humana Health Network's toll -free telephone number for information or to make a complaint at: 1- 877 - 845 -1033 You may also write to Humana Health Network at: Claims Office P. O. Box 14601 Lexington, KY 40512 -4601 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at 1 -800- 252 -3438 You may write the Texas Department of Insurance: P.O. Box 149104 Austin, TX 78714 -9104 FAX #512- 475 -1771 PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact your agent or the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document. ii AVISO IMPORTANTE Usted puede lamar gratis al numero de telefono Humana Health Network para information o para someter una queja a: 1- 877 - 845 -1033 Usted tambien puede escribir a Humana Health Network: Claims Office P. O. Box 14601 Lexington, KY 40512 -4601 Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al: 1- 800 - 252 -3438 Puede escribir a Departamento de Seguros de Texas: P.O. Box 149104 Austin, TX 78714 -9104 FAX #512- 475 -1771 DISPUTAS SOME PRIMAS 0 RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse primero con su agente o la compania. Si no se resuelve la disputa, puede comunicarse con el Departamento de Seguros de Tejas. UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de information y no se convierte en parte o condicion del documento adjunto. SCHEDULE OF BENEFITS - CITICARE INDIVIDUAL MAXIMUM BENEFIT $1,000,000 PRIOR AUTHORIZATION PENALTY If any required pre - authorization of services is not obtained, the benefit payable for any medically necessary services, after any applicable deductibles or co- payments, will be reduced by 50% up to a maximum penalty of $500. If services are not medically necessary, no benefits are payable at all. This out -of- pocket amount may not be used to satisfy any Out -Of- Pocket Expense Limits. This pre - authorization penalty will apply if you received the services from a participating or non - participating provider. DEDUCTIBLES (Co- payments do not apply toward plan year deductibles) Participating Providers Individual NONE Family Special Services Providers Individual Family Non - Participating Providers Individual $750 Per Plan Year Special Services are included to cover situations where an employee, retiree and/or dependent resides away from the Corpus Christi area and the Humana network is not available. Special Services rates will not apply when there is a Humana network provider within the member's local area. Use of network providers to the maximum extent possible is encouraged. Members may check with Humana for providers in their area. NONE $200 Per Plan Year $600 Per Plan Year (Cumulative) MAXIMUM OUT -OF- POCKET EXPENSE LIMITS Participating Providers Individual $ 2,000 Per Plan Year Family $ 6,000 Per Plan Year Special Services Providers Individual Family Non - Participating Providers Individual Family $ 3,200 Per Plan Year $ 9,600 Per Plan Year (Cumulative) $ 8,000 Per Plan Year $24,000 Per Plan Year (Cumulative) When a Covered Person has incurred the out -of- pocket maximum during a Plan Year, the percentage covered by the Plan will increase to 100% for any additional eligible expenses incurred during the remainder of the plan year. An out -of- pocket expense does not include expenses incurred for the co -pays, deductibles, outpatient treatment of mental/nervous disorders (except Serious Mental Illness), substance abuse or Prior Authorization Penalties. 1 SCHEDULE OF BENEFITS (CONTINUED) HOSPITAL SERVICES Inpatient Participating Provider Special Services Non - Participating Provider Outpatient Surgical Services Participating Provider Special Services Non - Participating Provider *Outpatient Lab and X -ray are 80% Benefit Payable after $200/Plan Year Hospital Deductible* 80% Benefit Payable after $200/Plan Year Hospital Deductible* 50% Benefit Payable after Non - Participating Deductible & Inpatient Hospital Deductible of $500 80% Benefit Payable, after $200 deductible* 80% Benefit Payable, after $200 deductible* 50% Benefit Payable after $200 deductible* arid Non - Participating Deductible treated under the Laboratory & X -Ray Facility benefits. Outpatient Non - Surgical Services Participating Provider 80% Benefit Payable* Special Services 80% Benefit Payable, No Deductible Non - Participating Provider 50% Benefit Payable after Non - Participating Deductible *Outpatient Lab and X -ray are treated under the Laboratory & X -Ray Facility benefits. Emergency Room Visits Participating Provider 80% Benefit Payable after $50 Co -Pay per Visit* Special Services 80% Benefit Payable after $50 Co -Pay per Visit, No Deductible* Non - Participating Provider 50% Benefit Payable after Non - Participating Deductible The $50 Co -Pay per visit is waived if admitted. Birthing Center Participating Provider Special Services Non - Participating Provider 100% Benefit Payable 100% Benefit Payable after Special Services Deductible 100% Benefit Payable after Non - Participating Deductible PHYSICIAN SERVICES Office Visits (Excludes routine physical exams, outpatient surgery and diagnostic lab /x- rays.) Participating Provider 100% Benefit Payable after $20 Co -Pay per Visit Special Services 80% Benefit Payable, No Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible (If applicable, Lab Services Co -Pay will be in addition to Office Visit Co -Pay.) Emergency Room Visits Participating Provider 100% Benefit Payable after $15 Co -Pay per Visit Special Services 80% Benefit Payable, No Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible (Note that these charges are separate from the facility charge.) 2 SCHEDULE OF BENEFITS (CONTINUED) Laboratory Services (In Physician's Office) Participating Provider 100% Benefit Payable after $15 Co -Pay per Visit Special Services 80% Benefit Payable, No Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible (Lab Services Co -Pay will be in addition to Office Visit Co -Pay.) Birthing Center Participating Provider Special Services Non - Participating Provider Inpatient Services Participating Provider Special Services Non - Participating Provider 100% Benefit Payable after $20 Co -Pay per Visit 100% Benefit Payable after Special Services Deductible 100% Benefit Payable after Non - Participating Deductible 100% Benefit Payable after $20 Co -Pay per provider, per Confinement 80% Benefit Payable, No Deductible 70% Benefit Payable after Non - Participating Deductible Outpatient Services (Includes surgery.) Participating Provider 100% Benefit Payable after $20 Co -Pay per Visit Special Services 80% Benefit Payable, No Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible X -Rays (in doctor's office) Participating Provider 100% Benefit Payable after $15 Co -Pay per Visit Special Services 80% Benefit Payable, No Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible (X -Ray Co -Pay will be in addition to Office Visit Co -Pay.) Allergy Immunizations Participating Provider Special Services Non - Participating Provider Physical Therapy Participating Provider Special Services Non - Participating Provider Occupational Therapy Participating Provider Special Services Non - Participating Provider Speech and Hearing Therapy Participating Provider Special Services Non - Participating Provider 100% Benefit Payable after $20 Co -Pay per Visit 80% Benefit Payable, No Deductible 70% Benefit Payable after Non - Participating Deductible 100% Benefit Payable after $20 Co -Pay per Visit 80% Benefit Payable, No Deductible 70% Benefit Payable after $750 Non - Participating Deductible 100% Benefit Payable after $20 Co -Pay per Visit 80% Benefit Payable, No Deductible 70% Benefit Payable after the Non - Participating Deductible 100% Benefit Payable after $20 Co -Pay per Visit 80% Benefit Payable, No Deductible 70% Benefit Payable after Non - Participating Deductible 3 SCHEDULE OF BENEFITS (CONTINUED) PSYCHIATRIC DISORDERS Inpatient Hospital Services ** Participating Provider 80% Benefit Payable after $200/Plan Year Hospital Deductible# Special Services 70% Benefit Payable after Special Services Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible ** - Limited to 100 days per plan year; # - Family Maximum is $600 per Plan Year Inpatient Physician Services Participating Provider Special Services Non - Participating Provider 100% Benefit Payable after $20 Co -Pay per provider, per Confinement. 70% Benefit Payable after Special Services Deductible 50% Benefit Payable after Non - Participating Deductible Outpatient Services Individual Sessions * Participating Provider 100% Benefit Payable after $20 Co -Pay per Visit Special Services 70% Benefit Payable after Special Services Deductible Non - Participating Provider 50% Benefit Payable after Non - Participating Deductible Outpatient Services Group Sessions * Participating Provider 100% Benefit Payable after $20 Co -Pay per Visit Special Services 70% Benefit Payable after Special Services Deductible Non - Participating Provider 50% Benefit Payable after Non - Participating Deductible *Limited to 60 visits per individual per plan year. Any out -of- pocket expenses for the Outpatient treatment of psychiatric disorders do not apply towards any out -of- pocket expense limit. CHEMICAL DEPENDENCY The necessary care and treatment of Chemical Dependency will be covered the same as any other illness generally, and will be subject to the same deductibles, benefit percentages and limitations which will apply to any other type of illness. 4 ADDITIONAL MEDICAL SERVICES In addition to Hospital and Physician Services, benefits will be paid for the services listed below. DURABLE MEDICAL EQUIPMENT (not to exceed purchase price) Participating Provider Special Services Non - Participating Provider AMBULANCE Participating Provider Special Services Non - Participating Provider 80% Benefit Payable 70% Benefit Payable after Special Services Deductible 50% Benefit Payable after Non - Participating Deductible 80% Benefit Payable 80% Benefit Payable, No Deductible 80% Benefit Payable If the transport by ambulance is verified as a medical necessity (physician's statement from physician receiving the member at hospital or ER) or called by emergency services such as police or fire authority, the actual billed amount will be paid at 80% with the member paying the 20% remaining. This is an exception to the normal usual and customary limitation. If the transport by ambulance is called by the member and is not a medical necessity, the member will be responsible for the full billed amount. LABORATORY FACILITY (other than Physician's office) Participating Provider Special Services Non - Participating Provider X -RAY FACILITY (other than Participating Provider Special Services Non - Participating Provider PRIVATE DUTY NURSING Participating Provider Special Services Non - Participating Provider 100% Benefit Payable per Visit after $15 Co -Pay per Visit* 80% Benefit Payable, No Deductible 70% Benefit Payable after Non - Participating Deductible Physician's office) 100% Benefit Payable per Visit after $20.00 Co -Pay per Visit 80% Benefit Payable, No Deductible 70% Benefit Payable after Non - Participating Deductible 80% Benefit Payable 80% Benefit Payable, No Deductible 50% Benefit Payable after Non - Participating Deductible MAMMOGRAPHY BENEFIT (Females age 35 and over) Participating Provider 100% Benefit Payable up to $75 per Plan Year Special Services 100% Benefit Payable up to $75 per Plan Year Non - Participating Provider 100% Benefit Payable up to $75 per Plan Year SIGMOIDOSCOPY EXAMINATIONS (Age 40 and over) Participating Provider 100% Benefit Payable up to $75 Per Plan Year Special Services Provider 100% Benefit Payable up to $75 Per Plan Year Non - Participating Provider 100% Benefit Payable up to $75 Per Plan Year 5 SCHEDULE OF BENEFITS - ADDITIONAL MEDICAL SERVICES (CONTINUED) PROSTATE CANCER DETECTION EXAM Participating Provider 100% Benefit Payable to $75 per plan year Special Services Provider 100% Benefit Payable to $75 per plan year Non - Participating Provider 100% Benefit Payable to $75 per plan year PRESCRIPTION DRUG — SCHEDULE OF BENEFITS Participating Pharmacy (i.e., with prescription drug card) Generic Drug $10 Co -pay Brand Name $35 or 30 %, whichever is greater per prescription for up to a 30 -day supply Brand Name Birth Control $20 Co -pay Brand Name Maintenance Drugs 60 day supply, for 2 Co -pays 90 day supply, for 3 Co -pays Note: If the physician provides statement of medical necessity for a brand name drug where there is either no generic or substitute option, the Brand Name Co -Pay will be limited to $35 for a 30 -day supply when approved by Humana's Rx review. Special Services Pharmacy Generic Drug 80% per prescription after Non - Participating Deductible Brand Drug 80% per prescription after Non - Participating Deductible OR, Primary co -pays through network pharmacy. Non - Participating Pharmacy* Generic Drug Deductible Brand Drug Deductible 70% per prescription after Non - Participating 70% per prescription after Non - Participating *Maintenance Drugs are not covered at Non - Participating Pharmacies. 6 ALL OTHER COVERED MEDICAL EXPENSES Participating Provider Special Services Non - Participating Provider 80% Benefit Payable 70% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible SPECIAL SERVICES are those services which are provided due to residency in an area where no network provider is available (normally defined by zip code and proximity.) EMERGENCY CARE provided by a non - participating provider when a participating provider is not accessible, will be billed to the plan member at the participating level of benefits as though services were provided by an in- network provider. The out -of- network provider who may have provided the services will be paid by the lesser of the billed amount or the usual, reasonable and customary amount. Covered Services provided by non - participating providers when such services are not available through preferred providers will be billed to the plan member as though in- network and will be paid to the service provider by the lesser of the charges billed or usual, reasonable and customary. The period permitted for this exception is limited to only that required for the emergency service(s) where an in- network provider is not available and will end when in- network services can be provided or emergency care is no longer required. ELIGIBILITY EFFECTIVE DATE OF COVERAGE You may elect to be covered by completing and signing an enrollment form approved by and acceptable to the City. Subject to making any required premium contribution, your coverage will start as described in the paragraphs which follow: 1. If you become eligible after the effective date of the Plan and you enroll within 31 days after the date you first become eligible (qualifying event), your coverage will start on the date you become eligible, subject to completing any waiting period. Please see section on Qualifying Events. 2. If you elect the coverage provided by the Plan during the group's open enrollment period, your coverage becomes effective on the renewal date of the group's health benefit plan. Retirees desiring to continue in the plan must sign and submit an annual enrollment form within the specified enrollment period in order to be continued in coverage. Failure to submit enrollment forms shall result in termination of coverage effective on the first day of the plan year for which enrollment forms are not submitted 3. You may use a telephone call or e-mail to inquire regarding coverage or changes to coverage, but may not rely on a telephone call or e-mail to actually change coverage, add a dependent, or other important events. Enrollment requests or requests for change(s) in coverage must be submitted in writing within the prescribed period with appropriate documentation that may be required (e.g., birth record or certificate, divorce decree, etc.) 7 ELIGIBLE CLASS(ES): All full -time employees and part time eligible employees (as defined in Chapter 39, PERSONNEL, of the Code of Ordinances of the City of Corpus Christi, Texas) are eligible to enroll in the Plan. Ineligible employees include part-time ineligible employees (as defined in Chapter 39, PERSONNEL, of the Code of Ordinances of the City of Corpus Christi, Texas) and temporary employees. (There is a small number of employees grandfathered as eligible who work 20 hours per week.) An Eligible Employee will also include a Retired Employee who is qualified to receive a retirement pension under the retirement system of the Employer or who qualifies for disability retirement benefits under Social Security. If an Eligible Employee qualifies as both an employee and a dependent of another employee, such person may be covered as either an employee or a dependent, but not as both. An Employee desiring to carry his/her eligibility to continue medical coverage in retirement in his or her own right should ensure he/she is enrolled as an Employee on the day prior to retirement, with attention to the last annual enrollment period preceding the anticipated retirement date. An employee's coverage under Citicare coverage shall commence at 12:01 a.m. on the date such coverage is effective. 1. Coverage for an employee hired after the date this Plan commences shall be effective on the date of hire so long as the employee completes enrollment within 31 days of his/her date of hire. 2. Coverage for employees working in a benefits eligible capacity on the date this Plan becomes effective shall become effective on the effective date of the Plan, presuming the employee had previously completed enrollment. Each employee will be covered on the above effective date provided Enrollment and any required contributions have been made within thirty-one (31) days after the date of eligibility. You are eligible for enrollment of your dependents for dependent coverage only if you are eligible as a group member. If you have one or more dependents, you are eligible for dependent coverage on the date you become eligible as a group member. If you do not have any dependents on the date you become eligible as a group member, you do not qualify for dependent coverage. You will become eligible for it on the date you acquire a dependent. If your dependent is eligible, you may not enroll him or her as both an employee and a dependent. In addition, no person can be enrolled as a dependent of more than one group member. DEPENDENT means any eligible dependent whose coverage became effective and has not terminated and includes: 1. your lawful spouse (this includes a spouse by common law marriage); 2. your unmarried child to the last day of the month in which the child attains the age of 25 (an unmarried mentally retarded or physically handicapped child may continue coverage beyond the limiting age so long as appropriate documentation is provided that (a) the child is incapable of self - sustaining employment because of mental or physical disability, (b) the child chiefly relies on the covered employee for financial support, and (c) if the child is first enrolled on or after the child's 25th birthday, the child is medically certified as disabled and is dependent on the covered employee). CHILD means your unmarried 1) natural born child, 2) legally adopted child (including a child placed with You for adoption for whom You have a legal obligation for total or partial support), 3) a child you 8 are seeking to adopt if you are a party to a suit regarding the child's adoption, 4) a child for whom You are the legal guardian or who is dependent upon You for health coverage pursuant to a valid court order, including a qualified medical child support order (QMCSO) or National Medical Support Notice (NMSN), 5) a child who lives with You in a normal parent child relationship if the child qualifies at all times for the dependent exemption as defined in the Internal Revenue Code and the Federal Tax Regulations, or 6) an unmarried natural born or adopted child of Your spouse. The Plan has the right to request verification of the child's dependency status at any time and the Employee has a continuing responsibility to report immediately any change in the dependency of an enrolled spouse or child; 3. Any unmarried child (Employee's grandchild) of a covered Employee's child who is younger than 25 years of age and, at the time application for coverage is a dependent of the covered Employee for federal income tax purposes. Coverage for the covered grandchild may not be terminated solely because the covered child (Employee's child) is no longer a dependent of the covered Employee for federal income tax purposes. Documentation may be required when a change in coverage is requested based on addition or deletion of a dependent. Employees must report changes such as marriage, divorce, birth of a dependent child, etc. when the new dependent or former dependent is to be or was covered by the Plan. Report of such change must be made within 31 days of the change. If not done, the new dependent may not be added to coverage or the employee may subject himself or herself to liability for charges incurred for a former dependent who is no longer eligible. ADDITIONAL RULES REGARDING RETIREE COVERAGE 1. A retiree may enroll in Plan coverage as a retiree if he /she was enrolled in the plan on the day prior to the retirement date. The retiree may also continue coverage in retirement for his/her dependents enrolled in the Plan on the date prior to his/her retirement. Dependency status for enrolled dependents shall be subject to the same rules set forth above (e.g., lawful spouse, unmarried dependent child under the age of 25, etc.) 2. If a retiree discontinues coverage under the Plan or is removed due to failure to pay required premiums, the retiree shall not be eligible to re -enter the plan (or to enroll his/her dependents again.) 3. If a retiree discontinues coverage for a dependent after the retirement date, that dependent is not eligible to be enrolled in the Plan again, even though the dependent satisfies the dependent eligibility criteria. 4. The surviving spouse of a retiree is eligible to continue coverage for herself/himself in the event of a death of the retiree, so long as he /she enrolls as the surviving spouse within 31 days of the retiree's death and makes payments in a timely manner. 5. The surviving spouse or a dependent child's legal guardian may also continue coverage for a dependent child who was enrolled in the Plan under the retiree and was enrolled as such on the day prior to the retiree's death. 6. A retiree or surviving spouse of a retiree may not enroll additional dependents after the date of retirement. Any dependents continued on the Plan in retirement must have been covered by the retiree on the date prior to his/her retirement and, if applicable, on the day prior to the retiree's death. 7. A surviving spouse continuing under the Plan may not enroll a new spouse if he /she re- marries. 9 Changes in coverage for anyone covered under the retiree' s eligibility after the retirement date are not subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA) and notices will not be mailed to the retiree or any dependents in the event of changes in coverage. INELIGIBLE CLASSES: Part-time ineligible employees (as defined in Chapter 39, PERSONNEL, of the Code of Ordinances of the City of Corpus Christi, Texas) and temporary employees, including those hired a seasonal basis, are ineligible. However, an Ineligible Class does not include grandfathered employees discussed in the Eligibility Section above. BECOMING ELIGIBLE FOR DEPENDENT COVERAGE You are eligible for dependent coverage only if you are eligible as a group member. If you have one or more dependents, you are eligible for dependent coverage on the date you become eligible as a group member. If you do not have any dependents on the date you become eligible as a group member, you do not qualify for dependent coverage. You will become eligible for it on the date you acquire a dependent. If your dependent is eligible, you may not enroll him or her as both an employee and a dependent. In addition, no person can be enrolled as a dependent of more than one group member. LIMITATIONS ON USE OF COVERAGE UNDER TWO PLANS If an employee covers himself or herself under this Plan and elects to cover one or more eligible dependents under Citicare Basic, all dependents for whom he or she desires coverage must be covered under Citicare Basic. If any eligible dependents are to be covered under this Plan, along with the employee, all eligible dependents whom the eligible employee intends to cover must be included in this Plan. CERTIFICATE OF INSURANCE This plan document becomes the Certificate of Insurance and replaces any and all certificates and riders previously issued. This Plan Document describes the provisions and limitations of the Plan. Nothing in this Plan Document waives or alters any of the terms or conditions of the Plan. The benefits outlined in this Plan Document are effective only if you are eligible for coverage, become covered and remain covered in accordance with the terms of the Plan Document. QUALIFYING EVENTS If you had other group coverage at the time you were first eligible to enroll in the Plan and, therefore, did not elect (in writing, if required) to be covered by the Plan at that time, but subsequently lost such other coverage, you can enroll in the Plan if you apply within 31 days of losing such other coverage, provided the other coverage was either (a) COBRA coverage which was terminated, or (b) non -COBRA coverage which was cancelled due to a loss of eligibility (including legal separation, divorce, death, termination of employment, or a reduction of hours worked) or because the employer's contributions had ceased. Your coverage will start on the first day of the calendar month coinciding with or next following the date you enroll. a) An employee who gains a dependent through marriage, birth of a child, adoption of a child, or placement for adoption may enroll that new dependent in the Plan provided he or she does so within 31 days of the qualifying event/life status change (marriage date, birth date, or date of court order in the case of adoption or placement.) Coverage will be effective on the date of the qualifying event/life 10 status change. b) In the case of the marriage, birth, or adoption of a child, an eligible employee and any eligible dependent, including a spouse, may also enroll for coverage if they are otherwise eligible for coverage but not already enrolled. The coverage will begin on the date of the qualifying event. The 31 day limit by which an employee is required to apply for changes in coverage due to a qualifying event should not be confused with and does not affect the 60 day window prescribed for an employee or covered dependent with a COBRA qualibfing event to notify the City of such a COBRA qualifying event (e.g., dependent is no longer eligible under the Plan, divorce, etc.) or to make an election to continue coverage under his or her COBRA eligibility. CHANGES IN COVERAGE The Plan may be revised to increase or decrease benefits after its effective date. Changes involving a reduction in benefits can be made effective at any time during the year. Revised benefits become effective on the date of the revision unless the revision states otherwise. Employees with dependents enrolled in the Plan remain responsible for relaying notices regarding changes in plan coverage to those dependents. They are also responsible for notifying the Plan administrator when an enrolled dependent is no longer a dependent. Failure to do so may result in the employee becoming responsible for charges for a person who is no longer a dependent. MISSTATEMENTS AND OMISSIONS If an individual's age or any other important facts about an individual in relation to his or her coverage are found to be misstated, the Plan may adjust whatever aspects of the coverage are necessary to reflect the facts. The employee /retiree may become responsible for any amounts paid on behalf of that person when not eligible. If an employee fails to notify the plan administrator of the loss of dependency status for a dependent he or she has registered (dependent child marries or divorces spouse), the employee may become responsible for any amounts paid on behalf of that dependent on or after the date that the dependent loses eligibility. ADDRESS CHANGES It is the responsibility of the covered employee and other covered persons to provide updated addresses of the covered persons to the Human Resources Department of the City promptly after the change of address. Failure to provide proper addresses of the covered persons in a prompt manner could result in a loss of coverage under the Plan in certain situations (e.g., failure of a covered retiree to receive the required annual enrollment form for continued coverage, failure of a covered spouse to receive a COBRA notice for continued coverage, etc.). Covered persons must send notice of the change of address in writing to the Human Resources Department of the City, 1201 Leopard Street, Corpus Christi, Texas 78401. 11 DEFINITIONS The following terms are used frequently throughout this Plan and are defined below. Listing a term or definition does not guarantee that it is a covered benefit. ACCIDENT means an injury which is caused by an event which is sudden and unforeseen; and exact as to time and place of occurrence. If the medical costs paid by the plan may be recoverable from another party, the employee must cooperate in that recovery action. ACTIVE SERVICE means that you are performing your regular duties on a full-time basis for your employer on a regularly scheduled work day either at the customary place of employment or at some location to which travel is required; or absent solely by reason of approved leave. You will be considered to be in active service on a non - scheduled workday only if you were in active service or approved leave on the last regularly scheduled workday. A covered Dependent other than a newborn child will be considered in Active Service on any day if engaged in the normal activities of a person in good health of the same age and sex and not confined in a medical facility. AMBULANCE means a professionally operated vehicle equipped for the transportation of a sick or injured person to or from the nearest medical facility qualified to treat the person's sickness or injury. Use of the ambulance must be medically necessary and/or ordered by a physician and must be the most reasonable method of transportation. AMBULATORY SURGICAL CENTER means a public or private institution which meets all of the following requirements: 1. It must be operated by physicians and a medical staff which includes registered nurses. 2. It must have permanent facilities and equipment for the purpose of surgical procedures. 3. It must provide continuous physicians' services on an outpatient basis. 4. It must admit and discharge patients from the facility within the same work day. 5. It must be licensed in accordance with the laws of the jurisdiction where it is located. It must be run as an ambulatory surgical center as defined by those laws. 6. It must not be used for the primary purpose of terminating pregnancies, or as an office or clinic for the private practice of any physician or dentist. 7. It must have a contract with at least one nearby Hospital for immediate acceptance of patients who require Hospital Care following care in the ambulatory surgical facility. CHEMICAL DEPENDENCY means the abuse of or psychological or physical dependence on or addiction to alcohol or a controlled substance. 12 CHEMICAL DEPENDENCY TREATMENT CENTER means a facility which provides a program for the treatment of chemical dependency pursuant to a written treatment plan approved and monitored by a physician. The facility must also be: 1. affiliated with a Hospital with an established system for patient referral; 2. accredited as such a facility by the Joint Commission of Accredited Hospital Organizations (JCAHO); 3. licensed as a chemical dependency treatment program by the Texas Commission on Alcohol and Drug Abuse; or 4. approved by a state agency having legal authority to so approve. CHILD has the meaning set forth in the Dependent Subsection of the Eligibility Section above. CO- INSURANCE means the percentage of a covered expense that a covered person pays after satisfaction of any applicable deductible. CO- PAYMENT means that portion of covered medical expenses which must be paid by or on behalf of the covered person incurring the expenses. CONTROLLED SUBSTANCE means a toxic inhalant or a substance designated as a controlled substance in chapter 481, Health and Safety Code. COVERED PERSON means any eligible employee or eligible dependent whose coverage became effective and has not terminated. CREDITABLE COVERAGE means coverage provided under a self - funded or self - covered employee welfare benefit plan that provides health benefits and that is established in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.); a group health benefit plan provided by a health insurance carrier or health maintenance organization; an individual health insurance policy or evidence of coverage; Part A or Part B of Title XVIII of the Social Security Act (42 U.S.C. Section 1 396c et seq.); Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq.), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. Section 1396s); Chapter 55 of Title 10, United States Code (10 U.S.C. Section 1071 et seq.); a medical care program of the Indian Health Service or of a tribal organization; a state or political subdivision health benefits risk pool; a health plan offered under Chapter 89 of Title 5, United State Code (5 U.S.C. Section 8901 et seq.); a public health plan as defined in federal regulations; a health benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C. Section 2504(e)); and Short-Term Limited Duration Coverage. Creditable Coverage does not include coverage under accident -only, disability income insurance, or a combination of accident -only and disability income insurance; coverage issued as a supple- ment to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit only insurance; coverage for onsite medical clinics; other coverage that is similar to the coverage under which benefits for medical care are secondary or incidental to other insurance benefits and specified in federal regulations; if offered separately, coverage that provides limited scope dental or vision benefits; if offered separately, long -term care coverage or benefits, nursing home care coverage or benefits, home health care coverage or 13 benefits, community based care coverage or benefits, or any combination of those coverages or benefits; if offered separately, coverage that provides other limited benefits specified by federal regulations; if offered as independent, noncoordinated benefits, coverage for specified disease or illness; if offered as independent, noncoordinated benefits, hospital indemnity or other fixed indemnity insurance; or Medicare supplemental health insurance as defined under Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (10 U.S.C. Section 1071 et seq.), and similar supplemental coverage provided under a group plan, but only if such insurance or coverages are provided under a separate policy, certificate, or contract of insurance. CRISIS STABILIZATION UNIT means a 24 -hour residential program in a facility licensed or certified by a state Department of Mental Health and Mental Retardation, or similar entity, that is usually short-term in nature and that provides intensive supervision and highly structured activities to persons who are demonstrating an acute, demonstrable psychiatric crisis of moderate to severe proportions. DEDUCTIBLE means a specified amount of medical expenses that a covered person must incur before benefits will be paid under the Plan. DURABLE MEDICAL EQUIPMENT means equipment that meets all of the following criteria: 1. It can stand repeated use. 2. It is primarily and customarily used to serve a medical purpose. 3. It is usually not useful to a person in the absence of sickness or injury. 4. It is appropriate for home use. 5. It is related to the patient's physical disorder. 6. It is for prolonged use. 7. It is certified in writing by a physician as being medically necessary. 8. The plan administrator will determine whether purchase or rental is the more economical. 9. Only one piece will be provided (i.e., not one for home and another elsewhere.) In no event will such items as air conditioners, air purifiers, humidifiers, whirlpool baths, commodes and over -bed tables be considered eligible. ELECTIVE PROCEDURE means a medical procedure which is not considered to be an emergency by nature or one which may be delayed by the covered person to a later point in time. ELIGIBLE EMPLOYEE has the meaning set forth in the Eligible Class(es) Subsection of the Eligibility Section above. EMERGENCY CARE means health services provided in a Hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, Illness or Injury is of such a nature that failure to get immediate medical care could result in: 1. placing the patient's health in serious jeopardy; 2. serious impairment of bodily functions; 3. serious dysfunction of any bodily organ or part; 4. serious disfigurement; or 14 5. in the case of a pregnant woman, serious jeopardy to the health of the fetus. EMPLOYER means the City of Corpus Christi. EXPENSE OR CHARGE means the fees and prices regularly and customarily charged for medical services and supplies generally furnished for cases of comparable nature and severity in the particular geographical area concerned. Any agreement as to fees and charges made between the individual and the doctor shall not bind the plan in determining our liability with respect to the expense incurred. Charges incurred in- network are normally discounted for the plan. If outside the network, charges will be limited to Usual, Customary and Reasonable. EXPERIMENTAL OR INVESTIGATIONAL means a drug, drug usage, supplies, biological product, device, medical treatment or procedure that meets any one of the following criteria, as determined by the Plan: 1. Reliable Evidence shows the drug, biological product, device, medical treatment, or proce- dure when applied to the circumstances of a particular patient is the subject of ongoing phase I, II, or III clinical trials, or 2. Reliable Evidence shows the drug, biological product, device, medical treatment, or proce- dure when applied to the circumstances of a particular patient is under study with a written protocol to determine maximum tolerated dose, toxicity, safety, efficacy, or efficacy in comparison to conventional alternatives, or 3. Reliable Evidence shows the drug, biological product, device, medical treatment, or proce- dure is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board (IRB) as required and defined by federal regulations, particularity those of the U.S. Food and Drug Administration or the Department of Health and Human Services. GROSS CHARGES means the amount the provider charges without giving consideration to any of the discounts or fee negotiations which the Plan has arranged to receive from the provider. HOSPITAL means an institution which meets all of the following requirements: 1. It must provide, for a fee, medical care and treatment of sick or injured patients on an inpatient basis. 2. It must provide or operate, either on its premises or in facilities available to the hospital on a pre - arranged basis, medical, diagnostic and surgical facilities. 3. Care and treatment must be given by and supervised by physicians. Nursing services must be provided on a 24 hour basis and must be given by or supervised by registered nurses. 4. It must be licensed by the laws of the jurisdiction where it is located. It must be run as a hospital as defined by those laws. 5. It must not be primarily: a. a convalescent, rest or nursing home; or b. a facility providing custodial, educational or rehabilitative care. The term also includes: (1) licensed or accredited treatment facilities which are properly accredited to provide psychiatric, diagnostic and therapeutic services for the treatment of psychiatric disorders and drug dependency; and (2) an alcohol dependency treatment center that provides a program for the treatment of alcohol dependency pursuant to a written treatment plan approved and monitored by a physician and that is: (a) affiliated with a hospital under a 15 contractual agreement with an established system for patient referral; or (b) accredited as such a center by the Joint Commission on Accreditation of Hospitals; or (c) licensed as an alcohol treatment program by the Texas Commission on Alcohol and Drug Abuse; or (d) licensed, certified, or approved as an alcohol dependency treatment program or center by any other state agency having legal authority to so license, certify, or approve. In addition, if services specifically for the treatment of a physical disability are provided in a licensed hospital, services will not be denied solely because such hospital is primarily of a rehabilitative nature and lacks surgical facilities. However, an institution specializing in the care and treatment of a mental illness, which would qualify as a Hospital, except that it lacks organized facilities on its premises for major surgery, shall nevertheless be deemed a Hospital. "Hospital" shall also include a residential treatment facility specializing in the care and treatment of alcoholism or chemical dependency. However, the hospital must be accredited by one of the following: (1) the Joint Commission on the Accreditation of Hospitals; (2) the American Osteopathic Hospital Association; or (3) the Commission on the Accreditation of Rehabilitative Facilities. This term also includes licensed birthing centers which: 1. Provide a 24 -hour a day nursing service by or under the supervision of Registered Nurses (RNs) and Certified Nurse midwives; and 2. Is staffed, equipped and operated to provide: a. Care for patients during uncomplicated pregnancy, delivery and the immediate postpartum period; b. Care for infants born in the center who are normal or have abnormalities which do not impair function or threaten life; and c. Care for obstetrical patients and infants born in the center who require emergency and immediate life support measures to sustain life pending transfer to a Hospital. HOSPITAL CONFINEMENT or HOSPITAL CONFINED means that a covered person is a registered bed patient in a hospital as the result of a physician's recommendation. ILLNESS means disease, mental, emotional, or nervous disorders, and pregnancy. A recurrent illness shall be considered as one illness. Concurrent illnesses shall be deemed to be one illness unless such illnesses are totally unrelated. INDIVIDUAL TREATMENT PLAN means a treatment plan with specific attainable goals and objectives appropriate to both the patient and the treatment modality of the program. INJURY means bodily loss or harm. All injuries sustained by an individual in connection with any one accident shall be considered one injury. INTENSIVE CARE UNIT means a special unit of a hospital which: 1. treats patients with serious sickness, or injuries; 2. can provide special life- saving methods and equipment; 3. admits patients without regard to prognosis; and 4. provides constant observation of patients by RN's or specially trained Hospital personnel. Excludes any Hospital facility maintained for the purpose of providing normal post- operative re- covery treatment or service. 16 MEDICAID means a federal /state program of medical care for needy persons, as established under Titlel9 of the Social Security Act of 1965, as amended. MEDICAL COMPLICATIONS OF PREGNANCY means conditions needing hospital confinement where the diagnosis is different from pregnancy, but the diagnosed condition may be caused or affected by it. Included within this definition are serious conditions relating to pregnancy, such as hemopoietic nervous or endocrine systems, hyperemesis gravidarum, toxemia and eclampsia of pregnancy. It also includes non - elective cesarean section, miscarriage, and ectopic pregnancy which is terminated or the spontaneous termination of a pregnancy which occurs during a period of gestation in which a viable birth is not possible. This term does not include conditions such as false labor, occasional spotting, bed rest prescribed by a physician, morning sickness or any similar problems caused by a difficult pregnancy which cannot be classified as distinct from the pregnancy. MEDICARE means a program of medical insurance for the aged and disabled, as established under Title 18 of the Social Security Act of 1965, as amended. MEDICALLY NECESSARY SERVICES means services and supplies appropriate in the treatment of the patient's diagnosed sickness or injury. In order to be considered medically necessary, the services or supplies must be: 1. consistent with the symptom or diagnosis and treatment of the covered person's injury or sickness; 2. appropriate with regard to standards of good medical practice; 3. not solely for the convenience of a covered person, physician, hospital or ambulatory care facility; and 4. the most appropriate supply or level of services, which can be safely provided to the covered person. When applied to the care of an inpatient, it further means that the covered person's medical symptoms or conditions require that the services cannot be safely provided to the covered person on an outpatient basis. NET CHARGES are defined as gross billed charges less any discounts or fee negotiations that may have been arranged with participating providers. NON - OCCUPATIONAL means with respect to injury or illness, such injury or disease for which the person is not entitled to benefits under any Workers' Compensation Law or similar legislation; or an injury or disease not arising out of, or in the course of, any work for wage or profit. NON - PARTICIPATING HOSPITAL means a hospital which has not been designated as a Participating Hospital by the Plan. NON - PARTICIPATING PHYSICIAN means a physician who has not been designated as a Participating Physician by the Plan. NON - PARTICIPATING PROVIDER means a hospital, physician, or any other health services provider who has not been designated by the Plan to provide services to covered persons. 17 NURSE means a registered nurse (R.N.), a licensed practical nurse (L.P.N.), a licensed vocational nurse (L.V.N.), or a Nurse Practitioner (R.N.C.P.). OUTPATIENT means that a covered person is treated at a hospital and confined less than 23 consecutive hours. OUTPATIENT SURGERY means surgery that is performed in a physician's office, ambulatory surgical center, freestanding medical clinic or the outpatient department of a hospital. PARTICIPATING HOSPITAL means a hospital which has signed an agreement with either Humana Health Network or has been designated by the Plan to provide services to covered persons. PARTICIPATING PHYSICIAN means a physician who has signed an agreement with Humana Health Network or who has been designated by the Plan to provide services to covered persons. PARTICIPATING PROVIDER means a hospital, physician, or any other health services provider who has signed an agreement with Humana Health Network or who has been designated by the Plan to provide services to covered persons. PHYSICIAN means any of the following licensed medical practitioners who are practicing within the scope of his or her license and whose services are required to be covered by the laws of the jurisdiction where the treatment is given: Doctor of Medicine, Doctor of Osteopathy, Doctor of Dentistry, Doctor of Chiropractic, Doctor of Optometry, Doctor of Podiatry, Licensed Audiologist, Licensed Speech- Language Pathologist, Doctor of Psychology, Licensed Dietitian, Licensed Professional Counselor, and Licensed Hearing Aid Fitter and Dispenser; Licensed Psychological Associate; and Licensed Chemical Dependency Counselor. PLAN PARTICIPANT(S) means covered employees and dependents. PLAN AND /OR PLAN SPONSOR means the City of Corpus Christi. PLAN YEAR means the period of time which begins on any August 1st and ends on the following July 31St PREGNANCY means conditions including pregnancy, medical complications of pregnancy, re- sulting childbirth, miscarriage, or related medical conditions. PSYCHIATRIC DAY TREATMENT PROGRAM means a mental health facility which provides treatment for people suffering from acute mental and nervous disorders in a structured psychiatric program. The program must utilize individualized treatment plans with specific attainable goals and objectives appropriate both to the patient and the treatment modality of the program. The program must be clinically supervised by a physician who is certified in psychiatry by the American Board of Psychiatry and Neurology. The facility must be accredited by the Program for Psychiatric Facilities, or its successor, or the Joint Commission on Accreditation of Hospitals. 18 PSYCHIATRIC DISORDER means neurosis, psychoneurosis, psychopathy or psychosis. PSYCHIATRIC TREATMENT PROGRAM means licensed psychiatric treatment programs. These programs must be accredited by the Joint Commission on the Accreditation of Hospitals or be in compliance with equivalent standards or be approved in the state where the program is run. RECONSTRUCTIVE SURGERY means any surgery and associated expenses which are: 1. incidental to or following surgical removal of all or less than all of a body part. The surgical removal must be done as the result of Injury or illness of the body part. 2. done because of a sickness or a disorder of a normal bodily function. 3. done to repair or lessen damage caused by an Injury. 4. done to correct a congenital defect. RELIABLE EVIDENCE shall mean only published reports and articles in the authoritative medical and scientific literature; the PDO database of the National Cancer Institute; the written protocol or protocols used by the treating facility or the protocols of another facility studying substantially the same drug, biological product, device, medical treatment, or procedure; the written informed consent used by the treating facility or another facility studying substantially the same drug, biological product, device, medical treatment, or procedure; or regulations and other official actions and publications issued by the U.S. Food and Drug Administration or the Department of Health and Human Services. RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS means a child care institution that provides residential care and treatment for emotionally disturbed children and adolescents and that is accredited as a residential treatment center by the Council on Accreditation, the Joint Commission on Accreditation of Hospitals or the American Association of Psychiatric Services for Children. ROOM AND BOARD means all charges made by a hospital on its own behalf for room and meals and all general services and activities needed for the care of registered bed patients. ROUTINE NURSERY CARE means the charges made by a hospital for the use of the nursery. it includes normal services and supplies given to well newborn children following birth. Physician visits are not considered routine nursery care. Treatment of an injury, sickness, birth abnormality, congenital defect following birth and care resulting from prematurity is not considered routine nursery care. SECOND SURGICAL OPINION means a consultation with a Board Certified surgeon after a covered person has received a recommendation to have surgery. This consultation includes the physical examination, laboratory work and X -rays. The consulting surgeon must not be affiliated in practice with the surgeon who first recommended surgery. SELF - ADMINISTERED INJECTABLE DRUGS means an FDA approved medication which a person may administer to himself/herself by means of intramuscular, intravenous, or subcutaneous injection, excluding insulin, and intended for use by the covered person or the covered person's family. 19 SERIOUS MENTAL ILLNESS means the following psychiatric illnesses as defined, by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM) 111-R: 1. schizophrenia; 2. paranoid and other psychotic disorders; 3. bipolar disorders (mixed, manic, and depressive); 4. major depressive disorders (single episode or recurrent); and 5. schizo- affective disorders (bipolar or depressive). SICKNESS means an illness or disease. The term also includes pregnancy and medical compli- cations of pregnancy. A recurrent illness shall be considered as one illness. Concurrent - illnesses shall be deemed to be one illness unless such illnesses are totally unrelated. SOUND NATURAL TEETH means teeth that are free of active or chronic clinical decay, have at least 50% bony support, are functional in the arch, and have not been excessively weakened by multiple dental procedures. SURGICAL PROCEDURE includes, but is not limited to any of the following procedures (excluding oral surgical procedures): 1. incision, excision or electrocauterization of any organ or body part; 2. reconstruction of any organ or body part or the suture or repair of lacerations; 3. reduction of a fracture or dislocation by manipulation; 4. use of endoscopic procedure to explore for or to remove a stone or other object from the larynx, bronchus, trachea, esophagus, stomach, intestine, urinary bladder or ureter; 5. puncture for aspiration: 6. injection for contrast media testing; or 7. laser surgery. TOTAL DISABILITY OR TOTALLY DISABLED means any period when, as a result of injury or illness, a covered employee is completely unable to perform the duties of the employee's occupation and is not engaged in any activity for profit. A Covered Dependent will be considered Totally Disabled during any period when, as a result of injury or illness, the dependent is unable to engage in the normal activities of a person of the same age and sex. A Totally Disabled covered employee or dependent must be under the care and treatment of a physician during the term of disability. Total Disability must be certified in writing by a physician. TOXIC INHALANT means a volatile chemical under Chapter 484, Health and Safety Code, or abusable glue or aerosol paint under Section 485.001, Health and Safety Code. USUAL, CUSTOMARY AND REASONABLE CHARGES mean the following: 1. Usual charges are the fees charged by a provider in normal practice for a given service. 2. Customary Charges are the range of usual fees charged by providers for the same service in a specific geographical or economic area. 3. Reasonable Charges are either usual or customary charges or the charges that a responsible medical review committee deems appropriate for specific care due to special conditions. 20 YOU or YOUR means the Plan Participant. PRESCRIPTION DRUG BENEFIT DEFINITIONS: The following terms are used in this benefit description. BRAND NAME MEDICATION means a medication that is manufactured and distributed by only one pharmaceutical manufacturer. CO- PAYMENT means the portion of covered prescription drug expenses which must be paid by or on behalf of the covered plan participant incurring the expenses. GENERIC MEDICATION means a medication that is manufactured, distributed and available from several pharmaceutical manufacturers and identified by the chemical name. HERITABLE DISEASE means an inherited disease that may result in mental or physical retardation or death. NON - PARTICIPATING PHARMACY means a pharmacy which has not agreed to provide services under terms set fort by the plan. PARTICIPATING PHARMACY means a pharmacy which agrees to provide services under terms set forth by the Plan. PHARMACIST means a person who is licensed to prepare, compound and dispense medication and who is participating within the scope of his or her license. PHARMACY means a licensed establishment where prescription medications are dispensed by a .pharmacist. PHENYLKETONURIA means an inherited condition that may cause severe mental retardation if not treated. PHYSICIAN means a licensed medical practitioner who is practicing within the scope of his or her license and whose services are required to be covered by the laws of the jurisdiction where the treatment is given. PRE- ADMISSION TESTING BENEFIT — PRE- ADMISSION TEST means a diagnostic test ordered by the attending or consulting physician in connection with a planned hospital admission or outpatient surgery and performed on an outpatient. See Additional Medical Services section for additional information PRESCRIPTION means a direct order for the preparation and use of a drug, medicine or medication. This order may be given by a physician to a pharmacist for the benefit of and use by a covered person. The drug, medicine or medication must be obtainable only by prescription. The prescription may be given to the pharmacist verbally or in writing by the physician. The pre- scription must include: 21 1. name and address of the covered person for who the prescription is intended; 2. the type and quantity of the drug, medicine or medication prescribed, and the directions for its use; 3. the date the prescription was prescribed; and 4. the name, address of the prescribing physician. 22 HEALTH PLAN BENEFITS WHAT THE PLAN PAYS The Plan pays the applicable benefit amount or percentage shown in the Schedule of Benefits for covered expenses if they are: 1. medically necessary as a result of an injury or a sickness; 2. received by a covered person; 3. for services authorized by a physician. Deductibles, co- payments and maximum amounts, if any, for each benefit are shown in the Schedule of Benefits. The Plan calculates deductibles and co- payments by applying the dollar amount or percentage to net charges. Net charges are defined as gross billed charges less any discounts or fee negotiations that may have been arranged with participating providers. Gross charges means the amount the provider charges without giving consideration to any of the discounts or fee negotiations which the Plan has arranged to receive from the provider. The Plan will pay participating physicians for covered expenses in accordance with the fee schedules of usual, reasonable and customary charges, adjusted for any discounts gained by the Plan with in- network providers. For services rendered by participating physicians, the dollar amount of the deductible or benefit (co- insurance) percentage that is your responsibility is calculated based on the fee schedule of the participating physician rendering the services. For services rendered by non - participating physicians, the dollar amount of the deductible or benefit percentage is calculated based on the lower of charges billed or the limit of usual, reasonable and customary applied by the administrator. When using a non - participating physician, you are also responsible for any charges that exceed this reimbursement schedule and non - covered services. Use of participating providers is encouraged. A covered expense is deemed to be incurred on the date a covered service is performed or a cov- ered supply is furnished. Charges are not considered to be covered expenses until any applicable deductibles or co- payments have been satisfied. If a benefit is payable for certain covered expenses under a particular benefit section of the Plan, those covered expenses will not be considered for payment under any other benefit section of the Plan unless specified. An expense will not be covered if it is incurred after your coverage under the Group Plan is terminated unless it is required to be covered by applicable law (i.e., COBRA or court orders). THE ANNUAL DEDUCTIBLE An annual deductible is a specified dollar amount that a covered person must pay for covered medical expenses per plan year before benefits will be paid under the Plan. There are individual and family, as well as participating, special services and non - participating provider deductible amounts. Expenses incurred by a covered person which may be applied to any applicable deductible referenced under this paragraph will be applied equally toward the satisfaction of the participating, special services and non - participating provider deductibles. The participating, special services and non - participating provider deductible amounts for each covered person and each covered family are shown in the Schedule of Benefits and must be satisfied each plan year. Co- payments do not apply toward any deductibles. If two or more covered persons of the same family are injured in the same accident and incur 23 covered medical expenses for those injuries, only one deductible will be deducted from the total covered expenses resulting from the accident in the plan year in which the accident occurs. Only one deductible will be deducted from the total covered medical expenses incurred as a result of a multiple birth of two or more dependents. The covered expenses must be incurred in the same plan year as the birth and result from: 1. premature birth; 2. an abnormal congenital condition; or 3. an injury or sickness occurring within 31 days after the birth. ANNUAL DEDUCTIBLE CARRYOVER If a covered person incurs covered medical expenses during the last 3 months of a plan year, and those amounts can be applied toward the satisfaction of the annual deductible for that plan year, those same expenses will be applied toward the satisfaction of the individual annual deductible of the next plan year. This deductible carryover does not apply to the family limit deductible. OUT -OF- POCKET EXPENSE LIMIT A maximum out -of- pocket expense limit is the amount of covered expenses, excluding expenses used to satisfy deductibles, expenses in excess of Reasonable and Customary charges, and co- payments, that must be paid by each covered person before a benefit percentage will be increased. There are individual and family participating, special services and non - participating provider maximum out -of- pocket expense limits. After the individual and/or family participating provider out -of- pocket maximum expense limit has been satisfied in a plan year, the participating provider benefit percentage for covered expenses will be payable at the rate of 100% for the rest of the plan year. After the individual and/or family special services and non - participating provider maximum out -of- pocket expense limit has been satisfied in a plan year, the provider benefit percentages for covered expenses will be payable at the rate of 100% for the rest of the plan year. Benefit specific co- payments continue to be the responsibility of the covered person. Any expense incurred by a covered person for covered medical expenses that may be applied to any applicable maximum out -of- pocket expense limit referenced under this provision shall be applied equally toward the satisfaction of the participating, special services and non - participating provider maximum out -of- pocket expense limits. The single and family participating, special services and non - participating provider maximum out -of- pocket expense limit is shown to be unlimited, covered benefits will be paid at the levels indicated in the Schedule of Benefits. The covered person will be responsible for any out -of- pocket expense(s). Benefits for expenses incurred in connection with Psychiatric Disorders will be paid at the benefit level(s) shown on the Schedule of Benefits and outpatient expenses for psychiatric disorders will not apply towards any single or family out -of- pocket expense limit. MAXIMUM BENEFIT - REINSTATEMENT OF BENEFITS The total amount of benefits payable for all covered expenses incurred for a covered person will not exceed the Maximum Benefit shown on the Schedule of Benefits. If a covered person uses any portion of his or her maximum benefit, the Plan will reinstate the 24 used portion on each August 1, up to a maximum of $1,000. The $1,000 will be applied to covered services received after the date of reinstatement. Once a maximum benefit has been reached, benefits will not be reinstated. This reinstatement provision will not apply to retired employees, if any, or to expenses incurred for the treatment of psychiatric disorders. PRE - AUTHORIZATION PROVISIONS All benefits payable under the Plan must be for services and supplies that are medically necessary. In order to determine whether services and supplies meet guidelines for medical necessity, they must be authorized by us in advance. In an effort to make treatment convenient, to follow the wishes of the patient or the patient's family, to investigate the use of unproven treatment methods, or to comply with local hospital practices, a Physician may suggest or permit a method of providing care that is not medically necessary. A service which is prescribed by a Physician does not necessarily mean the service is medically necessary, nor necessarily a covered service. The covered person is responsible for alerting his or her physician regarding the need for prior approval. The identification card will alert the physician that pre - authorization is required and will show the telephone number to call to obtain the appropriate authorization. If prior approval of services or supplies is not obtained, benefits may be reduced or not paid at all. Scheduled admissions, including admissions to a psychiatric or chemical dependency facility, must be pre - authorized 48 hours prior to Hospital admission. In some instances, the Plan or Humana, as the administrator, may suggest alternative modes of treatment. By eliminating unnecessary or questionable services, the Plan and Humana Health Network can help reduce personal inconvenience and limit the increasing cost of medical care. Pre - authorization for the following procedures or equipment is also mandatory: BREAST SURGERY (INCLUDING BIOPSIES) HYSTERECTOMY, ABDOMINAL OR VAGINAL KNEE ARTHROSCOPY LIGATION AND STRIPPING OF VARICOSE VEINS DEVIATED SEPTUM/OTHER NASAL SURGERY TEMPOROMANDIBULAR JOINT DISORDER SURGERY CORONARY BYPASS HEMORRHOIDECTOMY CHOLECYSTECTOMY TONSILLECTOMY AND ADENOIDECTOMY BUNIONECTOMY LAMINECTOMY PROSTATECTOMY CATARACT REMOVAL DILATION AND CURETTAGE INGUINAL HERNIORRHAPHY OUT - PATIENT PROCEDURES 25 DURABLE MEDICAL EQUIPMENT OVER $500 PHYSICAL THERAPY SPEECH THERAPY MRI CT SCAN Note: For these procedures, if no pre - authorization is obtained, a reduction of 50% up to a maximum penalty of $500 will apply. MATERNITY ADMISSIONS Outpatient surgery with subsequent Hospital admission, other than Outpatient surgery performed in a Physician's office, must be reported within twenty -four (24) hours of the inpatient admission in order to assure maximum benefits under this Plan. A Hospital stay following an Outpatient surgery undergoes continued stay review just like a scheduled admission. However, regardless of medical necessity, coverage for hospital stays shall not be limited to less than forty-eight (48) hours for normal vaginal deliveries and ninety -six (96) hours for Cesarean section deliveries for both the mother and the newborn child (assuming the child is added to the Plan under the Eligibility provisions stated herein). WHEN EMERGENCY HOSPITALIZATION IS REQUIRED If a medical emergency requires that a covered person be admitted to a hospital, pre - authorization must take place within 48 hours or the morning of the next business day after admission. The Plan and Humana Health Network will then review the medical necessity of the admission. PRE - AUTHORIZATION PENALTY If any required pre- authorization of services is not obtained, the benefit payable for any medically necessary services, after any applicable deductibles or co- payments, will be reduced by 50% up to a maximum penalty of $500. If services are not medically necessary, no benefits are payable at all. This out -of- pocket amount may not be used to satisfy any Out -Of- Pocket Expense Limits. APPEALS PROCEDURE If the covered person is dissatisfied with our determination of medical necessity, he or she may appeal the decision. Such appeals will be handled on a timely basis and appropriate records will be kept on all appeals. The covered person must appeal in writing within 120 days to the address given on the denial letter received. The appeal will be reviewed by the Plan and a response sent to the covered person no later than 30 days following receipt of the appeal. All requests for review by the Appeals Committee must be submitted in writing. The Appeals Committee has guidelines for reviewing appeals and may conduct informal hearings about the appeal. If an informal hearing is to be held, the covered person will be notified in advance. Resolution of the appeal will be completed within 30 days. If the claim is denied again, it shall include specific reasons for denial, written in a manner understandable to the Covered Person, and will contain specific reference to the pertinent Plan provisions upon which the decision was based. 26 ADOPTION BENEFIT Benefits are available for adoption expenses incurred in connection with legal adoption proceedings, provided such proceedings result in a child being placed in the Covered Employee's home and such charges are a part of the decree of adoption. Eligible Adoption Benefit Expenses: 1. Adoption Agency Expenses payable at 100% to a maximum of $1800: a. The cost of the confinement and medical care treatment of the biological mother in a Hospital or other institution in connection with the birth of the child: b. The charges made by the Physician in connection with the delivery of the child. c. The cost of any necessary foster care of the child prior to its placement in the home of the Covered Employee. 2. Home Placement Expenses: The biological mother's Hospital and Physician' s expense will be payable at 100% up to a maximum of $500. Reimbursement will not be made for: 1. Adoption proceedings that began before the Covered Employee became covered; 2. Any expenses that the Covered Member would not be legally required to pay; 3. Any expenses that the biological mother would not be legally required to pay; 4. Attorneys' fees and other necessary legal expenses in connection with the adoption. NEWBORN EXPENSES Hospital nursery expenses and Physician's fee (including routine circumcision) for a healthy newborn will be considered eligible for the seven (7) days immediately following birth, and will be covered under the mother's maternity claim. If the baby is ill, suffers an injury or requires care other than routine care, benefits will be provided on the same basis as for any other eligible Expense, provided dependent coverage is in force at the time eligible Expenses are incurred. Newborn Children and Newly Adopted Children of Covered Employee. Coverage is automatically provided to a newborn child of the covered employee for the first thirty-one (31) days after birth. If the addition of the child would cause a higher contribution from the Employee, the child is NOT covered after the first 31 days after birth, adoption or placement for adoption unless the employee enrolls the new child within those 31 days. In order to be covered for the period immediately following birth or adoption, coverage is automatically provided to an adopted child of the covered employee for the first thirty-one (31) days after (1) the date the covered employee becomes a party to a suit in which the covered employee seeks to adopt the child, or (2) the date the adoption becomes final ((1) and (2) are collectively referred to as "adoption" for purposes of this paragraph). A child is considered to be the adopted child of a covered employee if the covered employee is a party to a suit in which the covered employee seeks to adopt the child. Coverage of a newborn child or adopted child ends on the 32nd day after the date of such child's birth or adoption, unless the covered Employee submits a Transaction/Change Card to the Plan Sponsor within thirty -one (31) days of the birth, adoption or placement for adoption and pays any required additional premium. Otherwise, the child will not be allowed to enter the plan until the next Open Enrollment Period or if he /she qualifies under the Special Enrollment Provision. If the addition of the child would not cause a higher contribution from the Employee, the child is automatically covered at birth, adoption or placement for adoption. However, the Employee 27 must submit a Transaction/Change Card to the Plan Sponsor within thirty-one (31) days following the birth, adoption or placement for adoption. This will permit the eligibility to be established and claims on behalf of the new child to be resolved. The employee may experience treatment and/or billing problems if he /she fails to enroll the new child in a timely manner. BASIC HOSPITAL BENEFIT The Plan will pay benefits incurred by a covered person while hospital confined. The hospital confinement must be ordered by a physician and be the result of an injury or sickness which occurs while covered under the Plan. The following services and supplies for which charges are made by a hospital on its own behalf will be considered covered medical expenses: 1.. Room and board. 2. Services and supplies, other than room and board, provided by a hospital to inpatients. 3. Confinement in an intensive care, cardiac care or neonatal care unit. 4. Routine nursery care for a newborn child for up to a maximum of 7 days, but not for the concurrent use of any other hospital room. 5. Services in a hospital's outpatient department in connection with outpatient surgery. 6. Services in an ambulatory surgical center in connection with outpatient surgery. 7. Services in a hospital's emergency room. 8. Necessary medical care and treatment for prenatal services, delivery of a normal Pregnancy and postpartum services rendered within 24 hours after the delivery, when performed at a state licensed birthing center of facility (other than the birthing unit of a Hospital). Such services and delivery must be performed by a Physician or a licensed registered Nurse who is certified by the American College of Nurse Midwives. 9. Includes minimum inpatient care of 48 hours following a mastectomy and 24 hours following a lymph node dissection unless the Member's attending Physician determines that a shorter period of inpatient care is appropriate. Charges for physician's services in connection with surgical operations are not considered covered hospital expenses. PHYSICIAN BENEFITS The Plan will pay benefits for covered expenses incurred by a covered person for physicians' charges. The covered person must incur physicians' charges as the result of an injury or a sickness which occurs while covered under the Plan. Reasonable charges for the following services and treatment will be considered as covered expenses. 1. Surgical procedures performed on an inpatient or outpatient basis. If several surgical proce- dures are performed through the same incision or body opening during one operation, the Plan will pay the reasonable charge for the most complex procedure. If several surgical procedures are performed through different incisions or body openings during one operation, the Plan will pay the reasonable charge for the most complex procedure. For each additional procedure the Plan will pay 50% of the reasonable charge for that procedure. 2. Obstetrical services received on an inpatient or outpatient basis including medically neces- sary prenatal and postnatal care of all female covered persons. 3. Care of a newborn child while the newborn is hospital confined immediately following birth; including routine circumcision. 4. Anesthesia administered by a physician or certified registered anesthetist attendant to a sur- gical procedure. 28 5. Radiation therapy received on an inpatient or outpatient basis. 6. Consultation charges requested by the attending physician during a hospital confinement. The benefit is limited to one consultation by any one consultant per specialty during a hospital confinement. 7. Surgical assistance provided by a physician, when medically necessary. The benefit for surgical assistance will be 20% of the reasonable charge for the chief surgeon. 8. Inpatient medical services furnished by the attending physician to a hospital confined covered person. 9. Services of a pathologist during an inpatient confinement or when associated with a surgical procedure. 10. Services of a radiologist during an inpatient hospital confinement or when associated with a surgical procedure. 11. Services of a speech therapist or pathologist to restore speech loss or impairment for restoratory or rehabilitory speech therapy when due to an illness or accidental injury (caused other than by surgery). 12. Services of a licensed audiologist to determine and measure hearing function loss. 13. Services of a licensed physiotherapist for purposes of training to aid restoration of normal physical functions when rendered by a duly qualified physical therapist who is not a member of the patient's immediate family (when referred to by and/or under direct supervision of a physician). 14. Services performed on an emergency basis in a hospital if the injury or sickness being treated results in a hospital admission. 15. Services for acupuncture that is Medically Necessary and provided by a Physician (M.D.). 16. Services of a licensed Occupational Therapist for purposes of training to aid restoration of normal physical functions when rendered by a duly qualified Occupational Therapist who is not a member of the patient's immediate family (when referred to by and/or under direct supervision of a physician). Benefits will be subject to the benefit amounts or percentages shown in the Physician section of the Schedule of Benefits. Charges for physicians' services which are payable as a hospital charge are not payable under this benefit. PSYCHIATRIC DISORDERS Benefits are payable for covered expenses incurred by a covered person while undergoing treatment for psychiatric disorders. All charges must be made by a physician, or a hospital or a psychiatric day treatment facility, and benefits are payable as follows: 1. Inpatient Charges - Charges incurred by a covered person while confined as a registered bed patient in a hospital or psychiatric day treatment facility will be considered covered expenses. 2. Outpatient Charges - Charges incurred by a covered person while not confined in a hospital or psychiatric day treatment facility will be considered as covered expenses; also Psychia- trist's charges incurred for evaluation and treatment in connection with suicide or self -in- flected injuries (including drug overdose); 3. Psychiatric Day Treatment Charges - Charges incurred by a covered person for the treatment of mental and nervous disorders in a psychiatric day treatment facility will be considered covered expenses. A physician must certify that the psychiatric day treatment is being provided in lieu of hospitalization. 4. Crisis Stabilization Unit Charges - Charges incurred by a covered person for the treatment 29 of serious mental illness based on an individual treatment plan will be considered covered expenses. A physician must certify that the treatment provided in the crisis stabilization unit is in lieu of hospitalization. Two days in a crisis stabilization unit are considered equal to one day of treatment of mental or emotional illness or disorder in a hospital or inpatient program. 5. Residential Treatment Center for Children and Adolescents Charges - Charges incurred by a covered person for the treatment of serious mental illness based on an individual treatment plan will be considered covered expenses. A physician must certify that the treatment provided in a residential treatment center for children and adolescents is in lieu of hospitalization. Two days in a residential treatment center for children and adolescents is equal to one day of treatment of mental or emotional illness or disorder in a hospital or inpatient program. 6. Deductible and Benefit Percentage - All expenses incurred for the treatment of psychiatric disorders and drug dependency are subject to the deductibles and benefit amounts or percentages shown on the Schedule of Benefits. CHEMICAL DEPENDENCY BENEFITS The necessary care and treatment of Chemical Dependency during a series of treatments will be covered the same as any other illness generally, and will be subject to the same deductibles, benefit percentages, and limitations which apply to any other type of illness. A series of treatments is a planned, structured, and organized program to promote chemical free status which may include different facilities or modalities and is complete when the covered individual is discharged on medical advice from inpatient detoxification, inpatient rehabilitation treatment, partial hospitalization or intensive outpatient or a series of these levels of treatments without lapse in treatment or when a person fails to materially comply with the treatment program for a period of 30 days. PRESCRIPTION BENEFIT DESCRIPTION Benefits are payable if covered prescription drugs are received by the covered person while he or she is covered for this benefit. The amount of the benefit provided, including self - administered injectable drugs which are defined as any FDA approved medication which a person may administer to himself/herself by means of intramuscular, intravenous or subcutaneous injection, is as follows: 1. For prescriptions filled at participating pharmacies -the sum of a, b, and c below, minus the covered person's co- payment: a. the ingredient cost, as determined by us for participating pharmacies; b. the professional dispensing fee, as determined by us for participating pharmacies; and c. any sales or provider tax. Your ID card must be presented to a participating pharmacy each time a prescription is filled or refilled. 2. For prescriptions filled at non - participating pharmacies and with claims submitted directly to the Plan by the covered person, the benefit is payable at 70% of the actual charge made by the pharmacy, after your annual deductible. 30 WHAT IS COVERED Covered prescription drugs using the prescription drug card are: 1. drugs, medicines or medications that under federal or state law, may be dispensed only by prescription from a physician; 2. insulin; diabetic supplies (including lancets, chem strips) 3. hypodermic needles or syringes on prescription for use with insulin or self - administered injectable drugs; 4. self - administered injectable drugs; 5. oral contraceptives 6. prenatal vitamins with folic acid; 7. vitamin D, vitamin K, folic acid and pediatric vitamins with folvite; 8. dexedrine; and, 9. formulas necessary for the treatment of phenylketonuria or other heritable diseases. Covered prescription drugs must: 1. be prescribed by a physician for the treatment of an injury or sickness; and 2. be dispensed by a pharmacist. Contrary to any other provisions of the Plan, prescription drug expenses covered under this benefit are not covered under any other provision in the Plan. Any amount in excess of the maximum provided under this Benefit is not covered under any other provision in the Plan. PRESCRIPTION DRUG EXCLUSIONS No benefit using the prescription drug card is provided for: 1. any oral drug, medicine or medication that is consumed or injected at the place where the prescription is given, or that is dispensed by a physician; 2. prescription refills in excess of the number specified by the physician or dispensed more than one year from the date of the physician's original order; 3. the administration of covered medication; 4. prescriptions that are to be taken by or administered to the covered person, in whole or in part, while he or she is a patient in a hospital, rest home, sanitarium, skilled nursing facility, convalescent hospital, inpatient hospice facility or other facility where drugs are ordinarily provided by the facility on an inpatient basis; 5. prescriptions that may be properly received without charge under local, state or federal pro- grams, including Worker's Compensation, except those received under Medicare; 6. any medication labeled `Caution - Limited by Federal Law to Investigational Use" or any experimental medication, even though a charge is made to the covered person; 7. immunizing agents, biological serums or allergy serums; 8. any drug or medicine that is lawfully obtainable without a prescription; 9. any drug, medicine or medication received by the covered person before becoming covered or after the date the covered person's coverage has ended; 10. therapeutic devices or appliances, including hypodermic needles, syringes, support garments, contraceptive devices, and other non - medical substances, except as stated; 11. any costs related to the mailing, sending or delivery of prescription drugs; 12. any service, supply, or therapy to eliminate or reduce a dependency on or addiction to to- bacco, and tobacco products, including but not limited to nicotine withdrawal therapies, programs, services, and medications; 31 13. mechanical pumps for the delivery of medications; except as stated under durable medical equipment. 14. any fraudulent misuse of this benefit, including prescriptions purchased for consumption by someone other than the person for whom the prescription is written. 15. any drug prescribed for intended use other than for indications approved by the FDA; 16. More than one prescription for the same drug or therapeutic equivalent medication prescribed by one or more physicians and dispensed by one or more pharmacies until at least 50% of the previous prescription has been used by the covered person. (Based on the dosage schedule prescribed by the physician.); 17. drug delivery implants; 18. diet control drugs (anorexics); 19. growth hormones. ADDITIONAL MEDICAL SERVICES The Plan will pay benefits for the following covered expenses for charges incurred by a covered person as the result of an injury or sickness which occurs while covered under the Plan. Benefits are subject to the applicable benefit amount or percentage and deductibles shown on the Schedule of Benefits. Additional Medical Services include: 1. Outpatient medical care and treatment not covered under any other benefit section of the Plan. 2. Private duty nursing in a hospital or in the home, by a nurse, if the physician orders, in writing, that it is medically necessary and not considered to be custodial care as otherwise defined in the Plan. This treatment is eligible if rendered by a registered or licensed practical nurse. However, the services must be necessary and reasonable care for the patient. 3. Radium therapy, x -ray treatments and examination (other than dental x- rays), radioactive isotope therapy cobalt and chemotherapy microscopic tests, or any lab tests or analysis made for diagnosis or treatment; including an annual screening by low -dose mammography for all females age 35 or older to detect the presence of occult breast cancer. 4. Maternity Expenses incurred by a female Covered Person for: a. Pregnancy; b. Medical complications of Pregnancy (see the Defmitions section); c. Abortions; 5. Annual Prostate Cancer Detection Exam. Includes a prostate specific antigen test for a Member who is 50 years of age and asymptomatic; or for a Member 40 years of age or older with a history of prostate cancer or another prostate cancer risk factor. 6. Services for the medically necessary diagnosis and treatment of osteoporosis for high -risk individuals, including, but not limited to, estrogen- deficient individuals who are at clinical risk for osteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long -term glucocorticoid (steroid) therapy, individuals who have primary hyperparathyroidism, and individuals who have a family history of osteoporosis. 7. The following services and supplies: a. administration of whole blood and blood components. 32 b. casts, splints, trusses, crutches and braces (excluding dental splints or dental braces); ileostomy and colostomy supplies. c. initial placement of a medically necessary prosthesis and its supportive device to replace a lost physical organ or parts or to aid in their function when impaired if the loss or impaired function occurred whiled covered under this Plan, including initial glasses and contact lenses if required following cataract surgery. The Plan will also cover the replacement of such prosthesis if it is determined by the covered person's physician to be necessary because of growth or change. d. oxygen or rental of equipment for administration of oxygen; e. the initial pair of eyeglasses or contacts needed due to cataract surgery or an accident that occurs while covered under the Plan if the eyeglasses or contacts were not needed prior to the accident; and f. the initial purchase and fitting of hearing aids; needed to correct hearing deficiency. g. the purchase or rental of medically necessary durable medical equipment. At our option, the cost or rental of durable medical equipment will be covered. If the cost of renting the equipment is more than a covered person would pay to buy it, only the cost of the purchase is considered to be a covered expense. In either case, total covered expense for durable medical equipment shall not exceed its purchase price. Any purchase must be pre - approved by us. The Plan does not pay for equipment or devices not specifically designed and intended for the care and treatment of an injury or sickness. Under no circumstances will more than one piece of a type of equipment be covered. 8. Dental work and treatment (including eligible Hospital Expenses) will be eligible only when necessitated for the treatment of Temporomandibular Joint Dysfunction (TMJ) or as the direct result of an accidental injury to the jaws, sound natural teeth, mouth or face, occurring while covered by this Plan, including replacement of such teeth within twelve (12) months after the accident. Injury caused by chewing or biting will be considered accidental injury; 9. Charges for transportation of a Covered Person by a professional licensed ambulance service as follows: a. Ground transportation used locally to or from the nearest Hospital qualified to render treatment, or other medical institution (within the continental United States) for necessary special treatment not locally obtainable; b. Air ambulance where air transportation is medically indicated to transport a Covered Person to the nearest facility qualified to render treatment; and c. Ambulance service for necessary emergency treatment as a result of and within 48 hours of an accident or medical emergency. 10. Depo Provera, birth control devices (IUD) and treatment for complications incident to the usage of such devices. 11. Elective sterilization and related expenses regardless of medical necessity. 12. Charges for hypnosis recommended by and/or under the direct supervision of the attending Physician and considered recognized medical or psychiatric treatment of the condition. 13. Treatment of obesity diagnosed as: a. Endogenous when fully documented (including test results on which the diagnosis is based); or b. Morbid, provided: 33 1) the patient is at least 100 pounds over normal weight and 2) has a medically documented disease or health condition which is life threatening and is adversely affected by the obesity. Treatment of morbid obesity will include: a. Gastro bypass /stapling if there has been a history of unsuccessful attempts to reduce weight by more conservative measures while under the care and supervision of the Physician; and b. Participating at Weight Control Clinics while under the care and supervision of the Physician. 14. Charges for initial pair of orthopedic shoes when recommended by a Physician. 15. Reconstructive surgery and related services: a. To restore bodily function or correct deformity resulting from an accidental injury occurring while covered by this Plan provided the services or procedures begin within 90 days following the accident. b. To correct a congenital deformity or birth abnormality of a newborn c. In connection with post - traumatic or post - oncology treatment, provided the original condition necessitating such treatment occurred while covered by the Plan. d. In connection with a partial or full mastectomy, charges for; (i) mammoplasty surgery following a partial or full mastectomy; (ii) all stages of reconstruction of the breast on which the mastectomy has been performed; (iii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iv) prostheses and physical complications of mastectomy, including lymphedemas 16. Charges for rhinoplasty, blepharoplasty or brow lift if due to a functional or non - functional condition after the first 12 months immediately following a Covered Person's effective date under this Plan to correct an accidental injury. 17. Charges for pap smears and office visits, abortions (including elective abortions), and testing and treatment of infertility (including artificial insemination if donor is the spouse). 18. Charges for Immunization shots, including the charge for the related office visit. 19. Charges for care or treatment rendered by a Clinical Social Worker (MSW). PRE - ADMISSION TESTING BENEFIT PRE - ADMISSION TEST means a diagnostic test ordered by the attending or consulting physician in connection with a planned hospital admission or outpatient surgery and performed on an outpatient basis within 10 days before the covered person's admission or outpatient surgery. A benefit will be payable for charges incurred by a covered person in connection with pre- admission testing when the following requirements are met: 1. The admission to the hospital or the scheduled outpatient surgery is confirmed in writing by the attending physician before the testing occurs. 2. The tests must be performed within 10 days before admission to the hospital or the outpatient surgery. 3. The tests must be ordered by the attending physician. 4. The tests are performed in a facility accepted by the hospital in place of the same tests which would normally be done while hospital confined. 34 5. The tests are not duplicated in the hospital. 6. The covered person is subsequently admitted to the hospital or the outpatient surgery is performed, unless a hospital bed is unavailable or there is a change in the covered persons' health condition which would preclude the procedure. MEDICAL CASE MANAGEMENT BENEFIT This benefit applies only to a covered person who has suffered a severe personal injury or sickness while covered under the Plan. In addition to the benefits specified in this booklet, the City of Corpus Christi may elect to offer benefits for services furnished by any provider pursuant to an approved alternative treatment plan for a Covered Person whose condition would otherwise require hospital care. The Plan shall provide such alternative benefits for so long as it determines that alternative services are Medically Necessary and cost effective, and that the total benefits paid for such services do not exceed the total benefits to which the patient would otherwise be entitled under this Plan in the absence of alternative benefits. A "severe personal injury or sickness" includes, but is not limited to, the following: Major head trauma, spinal cord injury, amputations, multiple fractures, severe burns, neonatal high risk infants, severe stroke, multiple sclerosis, amyotrophic lateral sclerosis, metastatic cancer, acquired immune deficiency syndrome (AIDS), severe cardiac diseases, major trauma, severe hepatitis, bulimia, anorexia nervosa, severe congenital anomalies. If a covered person is accepted into the Medical Case Management program, the Plan will pay benefits for usual, customary and reasonable charges for rehabilitative services and supplies furnished to the individual whose condition would otherwise require hospital care and said benefits may exceed policy limitations and may extend beyond the types of expenses covered by the Plan. The Plan will determine the amount of benefits, but in no event will benefits exceed the Individual Lifetime Maximum Benefit of the Plan. Any agreement to pay benefits in accordance with the above will be based on an objective review of: 1. the covered person's medical status; 2. the current treatment plan; 3. the projected treatment plan; 4. the long term cost implications; and 5. the effectiveness of care. Individual Medical Case Management may be terminated when the covered person has improved or deteriorated to the extent that the alternative services are no longer necessary and cost effective, the individual's coverage under the Plan ends, or the Individual Lifetime Maximum Benefit has been reached. If alternative benefits are provided for a Covered Person in one instance, the Plan shall not be ob- ligated to provide the same or similar benefits for other covered persons under this Plan in any other instance, nor shall it be construed as a waiver of the right of the Plan thereafter in strict accordance with its express terms. 35 SECOND SURGICAL OPINION BENEFIT A benefit will be payable for charges incurred by a covered person in obtaining a second surgical opinion, after he or she has received a recommendation to have elective surgery which is covered under the Plan. The charges will not be subject to a deductible or co- payment if the consulting physician personally examines the covered person and the Plan receives a copy of the opinion. If the condition stated above is not met, the applicable deductible and benefit amount or percentage will be applied to the charges for the second opinion. If the second opinion does not confirm the original recommendation, the covered person may consult another physician for a third opinion. The third opinion must be obtained, and benefits will be payable in the same manner as the second opinion. SPINAL MANIPULATION BENEFIT Benefits are payable for expenses incurred by a covered person for medically necessary manipu- lations of the skeletal structure; and for services rendered by a Doctor of Chiropractic for the de- tection and correction by manual or mechanical means (including X -rays incidental thereto) of structural imbalance, distortion or subluxation in the human body for the removal of nerve interference where such interference is the result of or related to distortion misalignment or subluxation of or in the vertebral column. SERIOUS MENTAL ILLNESS Benefits for the condition of Serious Mental Illness are covered to the same extent as coverage for any other major illness under the Plan, subject to the same limitations, deductibles and coinsurance factors. WELL CHILD CARE The Plan will pay benefits for outpatient preventive well -child care for a covered dependent child to 18 months of age. Outpatient preventive well -child care means the charges made by a personal physician for routine pediatric exams and immunizations given to a child as recommended by the American Academy of Pediatrics for children to 18 months. After age 18 months, only charges for immunization shots including the charge for the related office visit are covered. LEAVES OF ABSENCE & THE FAMILY AND MEDICAL LEAVE ACT Eligibility for coverage under the Plan may be continued during an employer- approved leave of absence, up to a period not to exceed the approved leave .The leave of absence may be granted by authority provided in the City of Corpus Christi Classification and Compensation System, the Limited -Duty Program and Reasonable Accommodation for Disabled Employees Policy, and/or for a period not to exceed the greater of twelve (12) weeks, or the minimum mandated leave period provided by the FMLA. The employee is responsible for payment of amounts that would normally be deducted from his/her pay. This provision does not provide a Participant with a Leave of Absence; rather, it is merely an attempt to coordinate with the Employer's policies. No proof of good health may be required of, and reentry into the Plan will be immediate for, any Employee and/or Dependents who discontinued coverage during a leave of absence taken under the Family Medical Leave Act (FMLA) by the Employee so long as the Employee returns to Active Employment status before or immediately following the expiration of the FMLA leave. 36 LIMITATIONS AND EXCLUSIONS PRE - EXISTING CONDITIONS LIMITATION A Pre - Existing Condition means a limitation or exclusion of benefits relating to a condition that was present before the date of enrollment for coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before such date. Health Plan benefits are limited to the first $1,000 of covered expenses incurred for a pre -ex- isting condition. Thereafter, no benefits or services will be provided for a pre - existing condition, regardless of cause, for which medical advice, diagnosis, care, or treatment was recommended or received within the six (6) month period ending on the member's enrollment date. Coverage will not be provided until the earlier of the following dates: (a) the date the member has been free of treatment for the pre - existing condition for six (6) consecutive months or (b) twelve (12) consec- utive months after the member's enrollment date, whichever occurs first. The exclusion does not apply to: (a) pregnancy; or (b) newborn children or children adopted before the age of 18 if they are covered under the Plan within 31 days of the date of birth or date of placement for adoption. The limitation period for such pre- existing condition exclusion must be reduced by all periods of creditable coverage, if any, applicable to the member as of his or her enrollment date that are not separated by a break in coverage of more than 90 days, not counting waiting periods. OTHER LIMITATIONS AND EXCLUSIONS Unless specifically stated otherwise, no benefits will be provided on account of the following: 1. An injury or sickness arising out of, or in the course of, any employment for wage, gain or profit. 2. A sickness or injury which is covered under any Workers' Compensation or similar law. This limitation also applies to a covered person who: (a) is not covered by Workers' Compensation; and (b) chose not to be. 3. Care and treatment given in a hospital owned or run by a government entity, unless the covered person is legally required to pay for such care. However, care provided by military hospitals to armed services retirees and their dependents is not excluded. 4. Any service the covered person would not be legally required to pay for in the absence of this Plan. 5. Sickness or injury for which the covered person is in any way paid or entitled to payment or care and treatment by or through a government program, other than Medicaid. 6. Medical services provided by the covered person's parent, spouse, brother, sister, or child or a person who ordinarily resides in the covered member's household or an immediate family member. 7. Investigational or experimental drugs or substances not approved by the City of Corpus Christi, or by the Food and Drug Administration or the American Medical Association; drugs or substances used for other than Food and Drug Administration approved indications; or drugs labeled: "Caution- limited by Federal law to investigational use ". 8. Treatment, services, supplies or surgery that is not medically necessary. 9. Purchase or fitting of hearing aids in excess of the initial aid(s) or devices, advice on their care, or implantable hearing devices. 10. Weekend non - emergency hospital admissions. 11. Treatment of sexual dysfunctions not related to organic disease; sex change services; reversal of elective sterilization, in -vitro fertilization, or artificial insemination (unless the 37 donor is the spouse). 12. Any drug, biological product, device, medical treatment, or procedure which is experimental or investigational that is not approved by the City of Corpus Christi or by the Food and Drug Administration or the American Medical Association; any drug, biological product, device, medical treatment or procedure which is not covered as experimental or investigational (or similar) by the HCFA Medicare Coverage Issues Manual; any drug, biological product, or device which cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and which lacks such approval at the time of its use or proposed use; and any drug or biological product categorized as a Treatment Investigational New Drug (IND) by the U.S. Food and Drug Administration or as a Group C Treatment Protocol drug by the U.S. National Cancer Institute at the time of its use or proposed use. Specifically excluded are: refractive keratoplasty or radial keratotomy, immunotherapy for recurrent abortion, chemonucleolysis, biliary lithotripsy, home uterine activity monitor, immunotherapy for food allergy, and percutaneous lumbar discectomy. 13. Dental work and treatment (including eligible Hospital Expenses) will be eligible only when necessitated for the treatment of Temporomandibular Joint Dysfunction (TMJ) or as the direct result of an accidental injury to the jaws, sound natural teeth, mouth or face, occurring while covered by this Plan, including replacement of such teeth within twelve (12) months after the accident. Injury caused by chewing or biting will be considered accidental injury; 14. Diagnosis or care and treatment of: (a) weak, strained, unstable or flat feet; (b) toenails, ex- cept removal of a nail matrix; or (c) symptomatic complaints of the feet. 15. Any: (a) superficial lesions of the feet, such as corns, calluses or hyperkeratoses; (b) tarsal - gia, metatarsalgia or bunion, except surgery which involves exposure of bones, tendons or ligaments; (c) support devices for the foot (i.e. special stockings, socks, shoe inserts). 16. Any service, supply, or treatment connected with custodial care. The Plan does not cover these services no matter who provides, prescribes, recommends or performs them. Custodial care means services designed to help a covered person meet the needs of daily living, whether or not he or she is disabled. These services include help in: a. walking or getting in or out of bed; b. personal care such as bathing, dressing, eating, or preparing special diets; or c. taking medication which the covered person would normally be able to take without help. 17. Sickness sustained or contracted or injury caused by: (a) war, whether or not declared, or insurrection; or (b) military service of any country or International organization. 18. Sickness sustained or contracted or injury caused by the covered person's: (a) engaging or attempting to work in an illegal occupation; or (b) commission of or an attempt to commit a criminal act, or voluntary participation in a riot, insurrection, or civil disobedience. 19. Enrollment in a health club; or a weight loss or similar program except as specified. 20. Purchase or rental of supplies of common household use such as: exercise cycles; air purifiers; air conditioners; water purifiers; allergenic pillows or mattresses; or waterbeds. 21. Purchase or rental of: motorized transportation equipment; escalators or elevators; saunas or swimming pools; professional medical equipment such as blood pressure kits; or supplies or attachments for any of these items. 22. Convenience or personal care services such as use of a telephone or television. 23. Any surgical procedure to reduce obesity, except as specified. 38 24. Sickness or injury for which benefits are paid or payable under: (a) the mandatory provisions of any auto insurance policy written to comply with a "no- fault" insurance law; or (b) an uncovered motorist insurance law; or benefits which would have been paid under any auto insurance policy had the covered person properly complied with the mandatory provisions of a "no- fault" insurance law. 25. Homeopathic drugs as defined in the Homeopathic Pharmacopeia. 26. Charges for nurses aid services; 27. Charges for missed appointments or completion of claim forms; 28. Charges incurred in a nursing home or convalescent hospital unless otherwise specified; 29. Charges incurred when not under the regular care of a legally qualified Physician; 30. Charges for orthotics; 31. Charges for travel and accommodations; except for the Organ Transplant Benefit. 32. Plastic, cosmetic and reconstructive surgery unless medically necessary as the result of an injury or tumor. The injury, or the initial tumor surgery, must occur while covered under the Plan. Such surgery will also be covered if an objective functional impairment is present or if required to correct a congenital defect or birth abnormality of a newborn. The pres- ence of a psychological condition will not entitle a covered person to coverage for plastic, cosmetic or reconstructive surgery unless all other conditions are met. 33.. Vision analysis and examination, testing or orthoptic training, eye refractions or the purchase of eyeglasses or contact lenses (except as specified) to correct refractive errors and related services, including surgery performed to eliminate the need for eyeglasses for refractive errors (i.e. radial Keratotomy). 34. Services and supplies which are (a) rendered in connection with mental illnesses not classi- fied in the International Classification of Diseases of the U.S. Department of Health and Human Services, (b) extended beyond the period necessary for evaluation and diagnosis of learning and behavioral disabilities or for mental retardation, or (c) for mental illnesses which, according to generally accepted professional standards, are not usually amenable to favorable modification. This exclusion shall not apply to ADD or ADHD, which shall be covered as any other illness. 35. Routine physical examinations, even when required by an employer, school or insurance company. 36. Court ordered treatment for psychiatric disorders, when such order is the result of, or arises out of conduct by the covered person which is or would be criminal activity under the laws of the state or the Federal Government. 37. Maintenance care, which consists of services and supplies furnished mainly to: a. maintain, rather than improve, a level of physical or mental function; or b. provide a protected environment free from exposure that can worsen the covered member's physical or mental condition. 38. Care and treatment rendered by a provider whose services are not required to be covered by state law, except as provided by the Plan. 39. Care and treatment of complications of non - covered procedures, unless required by law. 40. Expenses incurred prior to the effective date or after the termination date of your coverage. 41. Sickness or injury caused by the covered person's intentional self - inflicted illness, injury or attempted suicide except psychiatrist's charges incurred for treatment in connection with suicide or self - inflicted injuries, including drug overdose, will be a covered expense. 42. Charges for marital or family counseling, family planning, sex therapy, pastoral counseling or other social services. 43. Hypnotism, Acupuncture, Goal Behavior Modification Therapy, except as specified. 39 44. Charges for Home Health Care or Hospice Care; 45. Charges for care or treatment rendered by a: a) Christian Science Practitioner; b) Homeopath; c) Naturopath; d) Optometrist; e) Pastoral Counselor; or f) Pharmacist. 46. Education and training except as specified. EXTENSION OF BENEFITS COVERAGE AFTER TERMINATION If a Covered Person is Totally Disabled on the date coverage terminates, benefits will be extended (subject to all other Plan provisions and limitations) during the continuation of the disability with respect to the injury or illness causing the disability if such person is not or does not become covered under any other plan entitling such person to any benefits from that injury or illness. Benefits will be extended for Covered Expenses until the earliest of the following dates: 1. The date the Covered Person ceases to be Totally Disabled; or 2. The date the applicable plan maximum is paid; or 3. The end of a twelve (12) month period; or 4. If lesser, a period equal to the time such Covered Person was covered under the Plan beginning with the first day following the termination of coverage. Benefits are not extended under this provision if this Plan terminates. FEDERAL CONTINUATION OF COVERAGE CONSOLIDATED OMNIBUS BUDGET RECONCILLIATION ACT (COBRA) A federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), requires that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called "continuation coverage ") at group rates in certain instances where coverage under the plan would otherwise end. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. This section is intended to inform you, in a summary fashion, of your rights and obligations concerning COBRA continuation coverage. You and your covered dependents should take the time to read this section carefully. This section applies to you if you are an employee or a covered dependent of an employee of the City of Corpus Christi covered by a group health plan sponsored by the City of Corpus Christi, which includes this Plan. COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you and your dependents (spouse and children) are covered under the Plan, each of you have the right to choose continuation coverage for up to eighteen (18) months if you or your covered dependents lose group health coverage under the Plan for any of the following reasons, called "qualifying events ": • Your employment terminates (voluntarily or involuntarily) for any reason other than for gross misconduct. If you decide not to return to benefits eligible employment at the City 40 during Family & Medical Leave Act ( "FMLA ") leave, you will be offered COBRA at the date your FMLA leave ends. • You are no longer eligible for coverage due to reduced work hours. In addition, if you are a covered dependent you have the right to choose continuation coverage for up to thirty -six (36) months if you lose group health coverage under the Plan due to any of the following qualifying events: (1) For dependent children, the child no longer qualifies as a dependent under the rules of the Plan, such as reaching the maximum age. (2) Divorce or legal separation between the employee and spouse. (3) The employee becomes entitled to Medicare (i.e., enrolled in Medicare (Part A, Part B, or both). (4) The employee's death. Note: A dependent means any eligible dependent whose coverage became effective and has not terminated. This includes: 1. The lawful spouse of a covered employee. 2. An unmarried child to the end of the month in which the child attains age 25 (a mentally retarded or physically handicapped child may continue coverage beyond the limiting age if appropriate documentation is provided that (a) the child is incapable of self - sustaining employment because of mental or physical disability, (b) the child chiefly relies on the covered employee for financial support, and (c) if the child is first enrolled on or after the child's 25th birthday, the child is medically certified as disabled and is dependent on the covered employee). A child includes: (a) unmarried natural born child; or (b) unmarried legally adopted child (including a child placed with the covered employee for adoption for whom the covered employee has a legal obligation for total or partial support); or (c) an unmarried child you are seeking to adopt if the covered employee is a party to a suit regarding the child's adoption; or (d) an unmarried child for whom the covered employee was the legal guardian; or (e) a child who is dependent upon the covered employee for health coverage pursuant to a valid court order, including a qualified medical child support order (QMCSO); or (f) an unmarried child who lives with the covered employee in a normal parent child relationship if the child qualifies at all times for the dependent exemption as defined in the Internal Revenue Code and the Federal Tax Regulations; or (g) an unmarried natural born or adopted child of the covered employee's spouse (i.e.; the covered employee's step- child.) 3. Any unmarried grandchild if that unmarried grandchild is younger than 25 years of age and, at the time application for coverage of the unmarried grandchild is made under the Plan is the dependent of the covered employee for federal income tax purposes. However, once the grandchild is properly covered, coverage for the unmarried grandchild may not be terminated solely because the covered grandchild is no longer a dependent of the covered employee for federal income tax purposes. 41 4. As otherwise defined under the Plan. Each person has the right to choose continuation coverage, regardless of the covered employee's decision or that of other dependents. For example, a covered spouse or child may elect continuation coverage even if the covered employee does not do so. If you cover your spouse and/or dependents under the Plan, please ensure that your spouse and/or dependents understand the contents of this notice. If any covered dependent does not live with you, you may request an additional copy of a COBRA notice be provided directly to that dependent. That must be done in writing. You may elect to continue the coverage described above on behalf of any covered dependent, but you cannot decline continuation coverage on behalf of a covered dependent (other than a minor child or an incapacitated person for whom you are the legal representative). You may change your continuation coverage and may add or cancel continuation coverage for spouses and dependents (1) during any open enrollment period that is offered to City employees, or (2) in conjunction with a qualifying life status change under the Plan, such as the birth or adoption of a child or loss of other coverage. The change requested must be related to the life status change. Under the law, the employee, spouse, and/or dependent has the responsibility to inform the City of Corpus Christi's Human Resources Department, in writing, of a divorce or a child losing dependent status under the City's Health Care Plan. This notice must be given within 60 days of the date of the event or the date in which coverage would end under the Plan because of the event, whichever is later. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. If you fail to notify the Human Resources Department, you and vour dependents may lose rights to continuation coverage. When the Plan is notified that one of these qualifying events has happened, the City of Corpus Christi or their third party administrator will in turn notify you that you and your covered dependents have the right to choose continuation coverage. Under the law, you and your covered dependents have at least 60 days from the date you would lose coverage because of one of the events described above, or the date notice of your election rights is sent to you, whichever is later, to inform the City that you want continuation coverage. If you do not choose continuation coverage, your group health benefits will end effective the date of the qualifying event. If you choose continuation coverage, the City of Corpus Christi is required to give you coverage which, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees or covered dependents. COBRA continuation coverage is a temporary continuation of coverage. In three situations, the 18 -month period for continuation coverage (which applies if your employment is terminated or you lose coverage due to a reduction in hours) may be extended. 42 • Disabled Person. The 18 months will be extended to 29 months if an individual is disabled at the time of the qualifying event or within the first sixty (60) days of the person's continuation coverage. To be considered disabled, you must have been determined to be so by the Social Security Administration. If such a determination is made, the disabled individual and all other family members of the disabled person on continuation coverage are entitled to the extra eleven (11) months of continuation coverage. Notwithstanding anything in this paragraph to the contrary, in order to receive the extension, you must notify the Human Resources Department of the City of Corpus Christi in writing in a timely fashion at the time of COBRA election or within 60 days of the date the individual receives documentation that the Social Security Administration has determined the individual to be disabled This notice must be received no later than the end of the initial I8 -month coverage period In addition, you must notify the Human Resources Department of the City of Corpus Christi within 30 days of any final determination that the individual is no longer disabled You must send these notices to the Human Resources Department of the City of Corpus Christi at the address listed below. • Second Qualifying Event. Persons entitled to only eighteen (18) months of continuation coverage may receive an additional eighteen (18) months of continuation (for a total of 36 months) if, during the first eighteen month period, a second qualifying event occurs. For example, if an employee is terminated and the employee's spouse chooses termination coverage, and in the tenth month of the continuation coverage the former employee dies, the spouse is entitled to the additional 18 -month extension. Disabled persons and their family members who have qualified for an additional 11 -month period and who experience a second qualifying event during the additional 11 -month period can extend continuation coverage for an additional seven (7) month period, for a total continuation period of thirty-six (36) months. In all of these cases, you must make sure that the Human Resources Department of the City of Corpus Christi is notified in writing of the second qualifying event within 60 days of the second qualifying event. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. • Medicare- Entitled Employee Leaves Employment. When an employee who has been entitled to Medicare for less than 18 months loses coverage under the Plan due to retirement, voluntary or involuntary termination (for reasons other than the employee's gross misconduct) or reduction in work hours, the employee's spouse and dependents, but not the covered employee are entitled to a continuation period for longer than 18 months. In these instances, their continuation period ends thirty-six months from the date the employee became entitled to Medicare. You must make sure that the Human Resources Department of the City of Corpus Christi is notified in writing of this second qualifying event within 60 days of the second qualifying event. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. Your continuation coverage will be terminated by the City of Corpus Christi if: (1) The City of Corpus Christi no longer provides group health coverage to any of its employees. (2) The premium for your continuation coverage is not paid on time. 43 (3) You become covered under a new group health plan, either as an employee, spouse or dependent, after the date you elected COBRA continuation coverage from this Plan. However, continuation coverage will not end if the new plan has a valid provision which does not allow coverage, or limits coverage, due to a preexisting condition. (4) You become entitled to Medicare after your COBRA continuation coverage election. (5) During the additional 11 -month extension for disabled persons, you are determined to no longer be disabled by the Social Security Administration. After COBRA continuation coverage begins. under the law. the employee. spouse, and/or, dependent has the responsibility to inform the City of Corpus Christi's Human Resources Department in writing if any qualified beneficiary: (i) becomes covered under a new group health plan: (ii) becomes entitled to Medicare; or (iii) is determined to be no longer disabled by the Social Security Administration. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. You do not have to show that you are insurable to choose continuation coverage. However, you must pay your premium for your continuation coverage. There is a grace period of 30 days for payments of the regularly scheduled premiums, except for the first premium, which must be paid within 45 days from the day COBRA is first elected and must include payments for all past periods of continuation coverage beginning with the date of the qualifying event. If you have any questions about the COBRA continuation coverage, please contact the City of Corpus Christi's Human Resources Department, 1201 Leopard, Corpus Christi, TX 78401, (361) 880 -3300, or you may contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration ( "EBSA "). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website at www.dol.gov /ebsa. Also, if you have changed marital status, or you or your covered dependents have changed addresses please notify in writing the City of Corpus Christi, Human Resources Department, at the above address. In order to protect your family's rights, you should keep the Human Resources Department of the City of Corpus Christi informed in writing of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Human Resources Department. CONTINUATION COVERAGE FOR EMPLOYEES IN THE UNIFORMED SERVICES Employees on Military Leave (Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) An Employee who is absent from work for more than thirty (30) days in order to fulfill a period of duty in the Uniformed Services of the United States has a Qualifying Event as of the first day of the Employee's absence for such duty, and thus is eligible for rights under USERRA. The Employer shall furnish to the Employee a notice of the right to elect continuation coverage under USERRA and shall afford the Employee the opportunity to elect such coverage in accordance with USERRA. If the Employee elects coverage, the right to that coverage ends: A) on the day 44 after the deadline for the Employee to apply for reemployment with or return to active employment with the Employer or B) eighteen (18) months beginning on the date of the employee's absence from employment with the Employer. An employee who elects to continue coverage may be required to pay up to 102 percent of the full premium under the Plan. However, during the first thirty (30) days that the Employee is absent in order to fulfill a period of duty in the Uniformed Services of the United States, the Employee must be treated the same as any other employee. This means the higher USERRA premium cannot be collected from the Employee for the first thirty (30) days. After the Employee has been absent for more than thirty (30) days, the Employee will receive immediate USERRA coverage upon payment of the entire cost of coverage plus a reasonable administration fee. Further, the Employee will have no preexisting condition exclusions applied by the Plan upon return from service. These rights apply only to Employees and their Dependents covered under the Plan before leaving for military service. In many instances, an Employee eligible for continuation of coverage under USERRA will also be eligible for continuation of coverage under COBRA. To the extent allowed under the law, the continuation of coverage periods under COBRA and USERRA will run concurrently under the plan. Plan exclusions and waiting periods may be imposed for any Sickness or Injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, military service. PROVISIONS APPLICABLE TO ALL HEALTH PLAN BENEFITS COORDINATION OF BENEFITS Definitions - ALLOWABLE EXPENSE means any necessary, reasonable and customary item of expense at least a part of which is covered by any one of the plans that covered the person for whom claim is made. When the benefits from a plan are in the form of services, rather than cash payments, the reasonable cash value of each service is both an allowable expense and a benefit paid. CLAIM DETERMINATION PERIOD means a plan year or that part of a plan year in which the person has been covered. PLAN means the coverage of medical or dental expenses or services by: 1. any group insurance plan, blanket or franchise on an covered or uncovered basis; 2. service plan contracts, group or individual practice or other pre - payment plans; or 3. labor - management trusteed plans, union welfare plans, employers organization plans or employee benefit organization plans. 4. coverage under governmental programs or coverage required or provided by any statute, ex- cept Medicare . (Refer to the Effect of Medicare provision for treatment of this coverage under this Plan). The term does not include coverage under individual policies or contracts. Each plan or part of a plan which has the right to coordinate benefits is considered to be a separate plan. 45 THIS PLAN means the benefits of the Plan which are subject to this coordination of benefits provision. WHAT A COORDINATION OF BENEFITS PROVISION DOES If a person is covered by this plan and by any of the other plans described above, a coordination of benefits provision will be used when the amount of benefits payable by this plan and the amount of benefits payable by any of the other plans for the same medical expenses would exceed the total amount of allowable expenses in a claim determination period. A coordination of benefit provision determines: 1. the order in which all plans pay their benefits; and 2. when, depending on the order of benefit determination, a plan may reduce its benefit so that not more than 100% of the allowable expenses are paid jointly by all plans. ORDER OF BENEFIT DETERMINATION In order to administer this provision, it is first necessary to determine the order in which all of the plans pay their benefits. This order is shown below. 1. A plan which does not contain a coordination of benefits provision is considered to determine its benefits before a plan which does contain such a provision. 2. A plan which covers a person as an employee is considered to determine its benefits before a plan which covers a person as a dependent. 3. A plan which covers a person as the dependent of a person whose month and day of birth (excluding the year of birth) occurs earlier in the calendar year is considered to determine its benefits before a plan which covers the person as the dependent of a person whose month and day of birth (excluding the year of birth) occurs later in the calendar year. If either one of the plans does not have this "birthday rule" provision, then the plan without this provision is considered to determine its benefits before the plan which does contain this provision. In the case of divorced or legally separated parents, the order of payment is determined as shown below. a. If there is a court decree which establishes financial responsibility for a dependent child's health expenses, the plan of the parent with that responsibility is considered to determine its benefits before the Plan of the parent without the responsibility. b. If there is no such decree and the parent with custody of the child has not remarried, the plan which covers the child as a dependent of the parent with custody is considered to determine its benefits before the plan of the parent without custody. c. If the parent with custody of the child has remarried: 1) the Plan which covers the child as a dependent of the parent with custody determines its benefits first; 2) the Plan which covers the child as a dependent of the step - parent determines its benefits second; and 3) the Plan which covers the child as a dependent of the parent without custody de- termines its benefits third. If the above rules fail to establish the order of payment, the plan which has covered the person for the longest time is considered to determine its benefits first. However, a person may be covered as an active employee by one plan and as a retired or laid -off person or the dependent of such person by another plan. In this case, if both plans contain a provision regarding retired or laid -off employees, the plan which covers the person as an active employee or the dependent of such person is considered to determine its benefits before the plan which covers the person as a 46 retired or laid -off employee or the dependent of such person. If either one of the plans does not contain a provision for retired or laid -off employees, and as a result each plan determines its benefits after the other, the order of benefit determination shown above will be used to determine the order of payment by the plans. HOW BENEFITS ARE COORDINATED If the benefits of this plan are payable first, the benefits payable by the other plans are ignored when the Plan determines the amount payable. If this plan's benefits are payable after those of any other plan, the Plan adds up the benefits payable by each of the plans in the order in which they pay and compare the total benefits payable to the total amount of allowable expenses. If this Plan's payments would result in benefits which exceed total allowable expenses, benefits are reduced. When coordination reduces the total amount otherwise payable, each benefit that would have been payable in the absence of coordination is reduced in proportion. The reduced amounts are charged against any applicable benefit limits of this plan. In no event will this plan's payment be more than it would have been in the absence of other plans. The Plan reserves the right to release to or obtain from any other organization or person without the consent of or notice to any covered person, any information which, in the Plan's or its administrator's opinion, the Plan needs for the purpose of coordination of benefits. When payment which should have been made by this plan has been made by any other plan, this Plan has the right to pay to any organization making these payments an amount this Plan considers to be warranted. Amounts paid in this manner are considered to be benefits paid by this Plan. After this Plan makes such payments, it has no further liability. When this Plan has made an overpayment, it has the right to recover that payment to the extent of the excess. This Plan may recover the overpayment from the person to whom it was made or from any other insurance company or organization. Any Covered Person receiving benefits under This Plan must furnish information about other coverage which may be involved in applying this Coordination of Benefits provision. ELIGIBILITY FOR MEDICARE Definitions — The definitions listed below apply only to this Provision. MEDICARE PART A means the federal program which provides hospital insurance benefits. MEDICARE PART B means the federal program which provides medical insurance benefits. For the purposes of determining benefits payable for any covered person who is eligible to enroll for Medicare Part B, but does not, this Plan assumes the amount payable under Medicare Part B to be the amount the covered person would have received if he or she enrolled for it. A covered person is considered to be eligible for Medicare on the earliest date coverage under Medicare could become effective for him or her. INTEGRATION WITH MEDICARE The benefits of this Plan will be payable first for a covered person who is under age 65 and eligible for Medicare. The benefits of Medicare will be payable second. 47 TEFRA OPTIONS The Tax Equity And Fiscal Responsibility Act of 1982 (TEFRA), as amended, allows the employer's actively working covered group members age 65 or older and their covered spouses who are eligible for Medicare to choose one of the following options: OPTION 1 - The benefits of this Plan will be payable first and the benefits of Medicare will be payable second. OPTION 2 - Medicare benefits only. The group member and his or her dependents, if any, will not be covered by the Plan. You may elect Medicare as primary coverage of benefits. However, if you do elect to have Medicare as primary coverage, then you are voluntarily opting out of coverage under the Plan and your coverage will terminate. If the individual does not choose one of the above options in writing, this Plan will be primary. The group must provide each covered group member and each covered spouse with the choice to elect one of these options at least one month before the covered group member or the covered spouse becomes age 65. All new group members and newly covered spouses age 65 or older must be offered these options. If Option 1 is chosen, its issue is subject to the same requirements as for a group member or dependent under age 65. Under the TEFRA regulations, there are two categories of persons eligible for Medicare. The calculation and payment of benefits by the Plan differs for each category. CATEGORY 1 Medicare Eligible are: 1. actively working covered group members age 65 or older who choose Option 1; 2. their age 65 or older covered spouses; and 3. age 65 or older covered spouses of actively working covered group members who are under age 65. CATEGORY 2 Medicare Eligible are any other covered persons entitled to Medicare, whether or not they enrolled for it. This category includes, but is not limited to: 1. retired group members and their spouses; or 2. covered dependents of a covered group member, other than his or her spouse. CALCULATION AND PAYMENT OF BENEFITS For covered .persons in Category 1, benefits are payable by the Plan without regard to any benefits payable by Medicare. Medicare will then determine its benefits. For covered persons in Category 2, Medicare benefits are payable before any benefits are payable by the Plan. The benefits of this Plan will then be reduced by the full amount of all Medicare benefits the covered person is entitled to receive, whether or not they were actually enrolled for Medicare. Covered Retirees For Covered Retirees who are eligible for Medicare, benefits will be paid under this Plan to the extent of the difference between the dollar amount that Medicare will pay under Parts A and B and the dollar amount of benefits that would have been paid under this Plan if the Covered Person was not eligible for Medicare. This means that Medicare will pay its benefits first and then this Plan will calculate its benefits and pay the amount of the benefits less the amount that Medicare paid. All Plan maximums will apply. When a disabled, non - working employee becomes eligible for benefits under Medicare, as a result of a disability (other than End Stage Renal Disease) and chooses to remain covered under this Plan, Medicare will be the primary 48 payer of benefits. Medicare will pay benefits first, and this Plan will be the secondary payer. Disability Due to End Stage Renal Disease If a Covered Person becomes eligible for benefits under Medicare as a result of disability due to End Stage Renal Disease and chooses to remain covered under this Plan, this Plan will pay its benefits first and Medicare will be the secondary payer for the first thirty-three (33) months of disability. After the initial thirty-three (33) months, Medicare will be the primary payer. Medicare disability rules apply to the disabled family members of active employees who are not disabled. For example, Medicare would be the secondary payer of benefits for a disabled spouse of an active employee who is covered under a large group health plan. For purposes of this provision, the term "disabled" will be the definition given by Social Security. REGARDLESS OF THE PROVISIONS STATED ABOVE, THIS PLAN SHALL AT ALL TIMES COMPLY WITH MEDICARE AS ENACTED AND AMENDED. CLAIMS The Plan Must Be Notified of Intent to File a Claim Notice of a claim for benefits must be given to the Plan in writing. Any claim will be based on the written notice. The notice must be received within 30 days after the start of the loss on which the claim is based. If notice is not given in time, the claim may be reduced or invalidated. If it can be shown that it was not reasonably possible to submit the notice within the 30 -day period and that notice was given as soon as possible, the claim will not be reduced or invalidated. When to File Proof of Claim Participating providers are responsible for submitting claims for covered expenses directly to the Plan on the covered person's behalf. Health care providers who have entered into a reimbursement agreement with the Plan have agreed not to bill the covered person for an amount greater than the difference between reasonable charges and the benefit amount paid by the Plan. The covered person will need to complete and sign all necessary papers and authorize participating providers to release those medical records which may be necessary to complete the processing of your claim. Benefit payments for covered services received from a participating provider will be forwarded directly to the provider. Written proof of claim for services rendered by a non - participating provider must be given to us within 90 days after the date of the injury or sickness for which claim is made. If proof of claim is not submitted within the required time period, the claim may be reduced or invalidated. If it can be shown that it was not reasonably possible to submit within the time period and that the proof was submitted as soon as possible, the claim will not be reduced or invalidated. The Plan May Extend Time Limits If the time limit for giving notice of claim or submitting proof of loss is less than the law permits in the state where the claimant lives, the Plan extends its time limits to agree with the minimum period specified by that state's laws. The law must exist at the time the Plan is issued. The Plan's Right to Require Medical Exams The Plan has the right to require that a medical exam be performed on any claimant for whom a claim is pending as often as it may reasonably require. If the Plan requires a medical exam, it 49 will be performed at the Plan's expense. The Plan also has the right to request an autopsy in the case of death, if state law so allows. To Whom Benefits are Payable All benefits are payable to the covered group member. However, with our consent, a covered person may direct us to pay all or any part of the medical benefits to the medical care provider on whose charge the claim is based. If any covered person to whom benefits are payable is a minor or, in our opinion, not able to give a valid receipt for any payment due him or her, such payment will be made to his or her legal guardian. However, if no request for payment has been made by the legal guardian, the Plan may, at its option, make payment to the person or institution appearing to have assumed his or her custody and support. When the Plan Pays The Plan will pay benefits for covered medical services after the covered person has satisfied any deductibles and co- payment amounts. No benefits are payable for charges which are discounted, waived or rebated by a provider of services simply because the covered person is covered. The Plan shall have the right to recover from a provider of services or from a covered person any excess benefits paid for charges which were discounted, waived or rebated. All benefits will be paid not more than 60 days after the Plan receives proper written proof of claim. If a covered person dies while medical benefits remain unpaid, the Plan may choose, in its sole discretion, to pay benefits to: 1. any person or persons related to the covered person by blood or marriage who appears to be entitled to the benefits; or 2. the executors or administrators of the covered person's estate, based on our selection. The Plan will be discharged of liability to the extent of any such payments made in good faith. Right of Recovery Our intention is to preserve and assert our rights to recover for sums paid or benefits provided where circumstances warrant the assertion of our rights, to the fullest extent allowed by the applicable laws of the jurisdiction involved. Each provision below shall be considered severable, and if any provision is determined to be unenforceable or void, the remaining provisions shall remain unaffected. Subrogation This provision applies when another party (person or organization) is, or may be, considered re- sponsible for causing injury or for payment of benefits due to a covered person's injury or sickness for which benefits under the Plan have been provided or paid. To the extent of such ben- efits, the Plan is subrogated to all rights and claims for recovery the covered person has against any party (including a health care carrier) responsible for the injury for payment to the covered person on account of the injury. Right of Reimbursement If payment (by settlement, judgment or any other manner) is made, or may be made, in the future by, or on behalf of, a responsible party to the covered person (which includes any type of party who agrees to compensate or pay a covered person) with respect to the occurrence of a covered person's injury or sickness, expenses arising from the covered person's injury or sickness are not covered by the Plan, and the covered person and covered employee must promptly reimburse the 50 Plan for the payment of such expenses up to the full amount of the payments or compensation received from the other party (regardless of how that payment or compensation may be characterized and regardless of whether the covered person has been made whole). However, if the Plan receives a claim for which benefits would be payable in the absence of a responsible party as described above, the Plan will pay those benefits subject to the following conditions: 1. The covered person automatically grants to the Plan a first priority lien to the extent of benefits advanced upon any recovery, by settlement, judgment or otherwise that the covered person receives from the responsible party, or any person or organization making payment on behalf of the responsible party, including first party, undercovered and uncovered motorist coverage. The lien will be in the amount of benefits provided or paid by the Plan for the treatment of the condition for which the third party is responsible or agrees to make payment. 2. You agree to notify the claims administrator, in writing, within 60 days of your claim against the responsible party and to take such action, furnish such information, cooperate generally, and execute any documents as the Plan may require facilitating enforcement of our rights. 3. The covered person automatically assigns to the Plan any benefits the covered person may have under any automobile policy or other coverage, to the extent of the Plan's claim for reimbursement. 4. The covered person shall automatically hold any compensation or other payments received in constructive trust for the benefit of the Plan. Exclusively at our option and choice, and without any waiver of any other rights of the Plan, in the event of prejudice, non - cooperation or breach of this Plan, the covered person and covered employee hereby agree that the Plan may withhold, deduct or retract payments to or on behalf of the covered person or covered employee. Duplication of Benefits /Other Insurance This provision is intended to prevent overpayment or duplication of benefits under this Plan when other health care coverage provides the same benefits. It applies when a person is covered by us and has, or is entitled to, benefits as a result of their injuries from any other coverage including, but not limited to, first party uncovered or undercovered motorist coverage, any no fault insurance, medical payment coverage (auto, homeowners or otherwise), workers compensation settlement or awards, other group coverage (including student plans), direct recoveries from liable parties, premises medical pay or any other insurer providing coverage that would apply to pay your medical expenses, except other group health carriers in which case coverage will be determined under Coordination of Benefits. Where there is such coverage, the Plan will not duplicate other coverage available to the covered person and shall be considered secondary, except where specifically prohibited. Where double coverage exists, the Plan shall have the right to be repaid from whomever has received the overpayment to the extent of the duplicate coverage. This provision applies whether or not the covered person has made a claim under other applicable coverage. When applicable, the covered person is required to provide us with authorization to obtain information about the other coverage available, and to cooperate in the recovery of overpayments from the other coverage, including executing any assignment of rights 51 necessary to obtain payment directly from the other coverage available. Cooperation Required The covered person has a duty to cooperate by providing information and executing any documents to preserve our right and shall have the affirmative obligation of notifying the claims administrator that claims are being made against responsible parties to recover for injuries for which the Plan has paid. If the covered person enters into litigation or settlement negotiations regarding the obligations of the other party, the covered person must not prejudice, in any way, the Plan's rights to recover an amount equal to any benefits the Plan has provided or paid for the injury or sickness. Failure of the covered person to provide the Plan such notice or cooperation, or any action by the covered person resulting in prejudice to the Plan's rights will be a material breach of this Plan and will result in the covered person being personally responsible to make repayment. In such an event, the Plan may deduct from any claim any amounts the covered person owes the Plan. Legal Actions and Limitations No action at law or in equity may be brought to recover under the Plan until at least 60 days after written proof of claim has been filed with us. It action is to be taken after the 60 day period, it must be taken within 2 years of the date written proof of claim was required to be filed. Payment to the State of Texas If a covered person incurs covered expenses which are covered under the Medical Assistance Act of 1967, as amended, the Plan will reimburse to the Texas Department of Human Resources, or appropriate state agency, the actual cost of covered expenses the Department pays through medical assistance to the covered person. The Plan will be discharged of its obligation to the extent of any such payment. Complaint Notice Should any dispute arise about premium payment or about a claim that has been filed, the covered person may write to the claims administrator. If the problem is not resolved, the covered person may also contact the Texas Department of Insurance at (800) 242 -3439 or send written correspondence to P.O. Box 149104, Austin, Texas 78714 -9104. TERMINATION PROVISIONS TERMINATION OF YOUR COVERAGE Your coverage will terminate on the earliest of the following dates: 1. the date you cease to be in a class of eligible group members; 2. the last day for which you make any required premium contribution for your Plan; 3. the last day for which the policyholder has made any required premium contribution for coverage on your behalf; 4. the date your Lifetime Maximum Benefit is reached; or 5. the date the Plan is terminated. 6. the date any participant who is qualified for Medicare elects to have Medicare pay as primary coverage. 7. termination of Full -Time Employment. Subject to payment of required Contributions and rules precluding preferential selection, coverage may be continued during an approved medical leave of absence for a period not to exceed 180 days from the date of approval in 52 accordance with Employer policy. At the end of this period, Full -Time Employment is considered ended. Coverage will end unless the Covered Employee returns to Full -Time Employment or elects continuation of coverage and all required Contributions are paid; Employers subject to Family Medical Leave Act Regardless of the established leave policies mentioned above, the Plan shall comply with the Family and Medical Leave Act of 1993 as regulated by the Department of Labor. TERMINATION FOR CAUSE The Plan may terminate a covered person's coverage for cause pursuant to the following: 1. If a covered person allows an unauthorized person to use his or her identification card or uses the identification card of another member. Under these circumstances, the person who receives the services provided by use of the identification card will be responsible for paying this plan the reasonable charges for those services. 2. If a covered person or group perpetrates fraud and/or misrepresentation on claims or identification cards in order to obtain services or a higher level of benefits. This includes, but is not limited to, the fabrication and/or alteration of a claim or identification card. TERMINATION OF DEPENDENT COVERAGE A dependent's coverage will terminate on the earliest of the following dates: 1. the date the employee's coverage terminates; 2. the date the employee ceases to be in a class of members eligible for dependent coverage; 3. the last day for which the employee makes any required contribution for dependent coverage; 4. the date the dependent coverage benefit or the Plan is terminated; 5. the date a dependent reaches his or her Lifetime Maximum Benefit; or 6. the date a dependent no longer qualifies as a dependent. DISABLED CHILDREN If an unmarried dependent child who has reached the maximum age for a dependent meets all of the requirements shown below, the Plan extends dependent health coverage for that child for as long as the employee remains covered for dependent coverage. 1. The child must be incapable of self - sustaining employment because of mental or physical disability. 2. The child must chiefly rely on the employee for financial support. The employee must give the Plan proof of the child's disability within 31 days of the date the child reaches the maximum age. The Plan may request additional proof from time to time for the remainder of the child's coverage under the Plan. MISCELLANEOUS PROVISIONS This Plan Document describes the provisions and limitations of the Plan. Nothing in this Plan Document waives or alters any of the terms or conditions of the Plan. The benefits outlined in this Plan Document are effective only if you are eligible for coverage, become covered and remain covered in accordance with the terms of the Plan Document. Any changes in this Plan must be approved in writing by an authorized representative of the City 53 of Corpus Christi. Any verbal promise made will not be binding on the City of Corpus Christi unless it is contained in writing in this Plan Document by way of an amendment signed by an authorized representative of the City of Corpus Christi. REVIEW AUTHORITY The City of Corpus Christi shall have complete authority to review all denied claims for benefits under the Plan (including, but not limited to, the denial of certification of the medical necessity of hospital or medical treatment). In exercising its responsibilities, the City shall have sole and complete discretionary authority 1) to determine whether and to what extent individuals are eligible for benefits; 2) to construe disputed or doubtful Plan terms; and 3) to make determinations regarding alternative care plans when reviewed and approved by the network Independent Medical Director. Notwithstanding anything to the contrary, benefits under this Plan will be paid only if the City determines, in its sole discretion, that an individual is entitled to such benefits pursuant to the terms of the Plan or as required by law. The City shall be deemed to have properly exercised such authority unless it has abused its discretion hereunder by acting arbitrarily and capriciously. COVERED PERSON/PROVIDER RELATIONSHIP The Plan does not provide covered services, but only helps pay for covered services received by Plan Participants. The Plan is not liable for any act or omission of any Provider. The Plan has no responsibility for a Provider's failure or refusal to give covered services to Plan Participants. Plan Participants remain responsible for assessing the costs and benefits prior to the decision to use the services, whether in- network or out -of- network. CHANGES IN PLAN Changes that effect coverage or benefits may only be made in the Plan by an amendment signed by a person with the authority to bind the City of Corpus Christi including, but not limited to, the City Manager or the City's Health Benefits Manager. WORKERS' COMPENSATION The Plan does not affect or take the place of Workers' Compensation. ASSIGNMENT The Plan and its benefits may not be assigned by the policyholder. TERMINATION OF THE PLAN The Employer shall have the right, at any time, to terminate or amend this Plan. The Employer makes no promise to continue these benefits in the future and the right to future benefits will never vest. 54 TRANSPLANT PROVISIONS Medically Necessary services and supplies in connection with the following human to human organ or tissue transplant procedures, provided such procedures are not deemed as experimental or research in nature in the judgment of the Plan, considered standard practice for the diagnosis and are endorsed by the American Medical Association: 1) heart; 2) heart-lung; 3) lung; 4) kidney; 5) bone marrow (when treatment is for conditions resulting from acute leukemia, aplastic anemia or immuno - deficiency syndrome); 6) liver; 7) pancreas; 8) cornea; 9) stem cell transplant. If the donor is covered under this Plan, eligible medical expenses incurred by the donor will be considered for benefits. For donor costs to be covered, the recipient must be covered under this Plan. When the donor has other medical coverage, his or her plan will pay first. The benefits of this Plan will be reduced by the benefits payable under the donor's plan. In no event will benefits be payable in excess of the Minimum Lifetime Benefit still available to the recipient. If both the donor and the recipient are covered under this Plan, eligible medical expenses incurred by each person will be treated separately for each person. The Usual and Customary cost of securing an organ from a cadaver or tissue bank, including the surgeon's charge for removal of the organ and a hospital's charge for storage or transportation of the organ, will be considered a covered medical expense. The Plan may, at its discretion, require the patient seek a second surgical opinion prior to approval of any transplant procedure. Coverage is subject to all other terms and provisions of the Plan. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) HIPAA (Privacy Rights) Under the Health Insurance Portability and Accountability Act of 1996 ( "HIPAA "), group health plans, such as the Plan, must take steps to protect the privacy of your "protected health information." Protected health information is individually identifiable health information, including demographic information, collected from you or created or received by a health care provider, a health plan, your employer (when functioning on behalf of the group health plan), or a health care clearinghouse and that relates to: (1) your past, present, or future physical or mental health or condition; (2) the provision of health care to you; or (3) the past, present, or future payment for the provision of health care to you. The following discusses the technical HIPAA requirements of the Plan and Plan Sponsor. If you have any questions, please review the Notice of Privacy Practices located on the Plan Sponsor's website or contact a representative in the Benefits Section of the Human Resources Department. A. Plan's Disclosure of Protected Health Information to the Plan Sponsor Upon Receipt of 55 Certification of Compliance by Plan Sponsor The Plan may disclose protected health information to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor that the Plan Sponsor agrees to: 1. Not use or further disclose the information other than as permitted or required by the Plan Documents or as required by law; 2. Ensure that any agents, including a subcontractor, to whom it provides protected health information received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information; 3. Not use or disclose the information for employment - related actions and decisions or in connection with any other benefit plan of the Plan Sponsor; 4. Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for, of which it becomes aware; 5. Make available protected health information in accordance with 45 CFR 164.524; 6. Make available protected health information for amendment and incorporate any amendments to protected health information in accordance with 45 CFR 164.526; 7. Make available the information required to provide an accounting of disclosures in accordance with 45 CFR 164.528; 8. Make its internal practices, books and records relating to the use and disclosure of protected health information received from the Plan available to Health and Human Services for purposes of determining compliance by the Plan with the privacy rules; 9. If feasible, return or destroy all protected health information received from the Plan that the Plan Sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible; and 10. Ensure that adequate separation between the Plan and the Plan Sponsor has been established. B. Permitted Uses and Disclosures of Protected Health Information to the Plan Sponsor The Plan (and any business associate acting on behalf of the Plan) will disclose protected health information to the Plan Sponsor only to permit the Plan Sponsor to carry out administrative functions in relation to the Plan. Such disclosures shall be consistent with the provisions of 45 CFR 164. All disclosures of protected health information to the Plan Sponsor will comply with the 56 restrictions and requirements set forth in this HIPAA (Privacy Rights) Section. The Plan (and any business associate acting on behalf of the Plan) may not disclose protected health information to the Plan Sponsor for employment- related actions or decisions, or in connection with any other benefit plan of the Plan Sponsor. Further, the Plan Sponsor shall not use or disclose protected health information for employment- related actions and decisions, or in connection with any other benefit plan of the Plan Sponsor. The Plan Sponsor shall not use or further disclose protected health information other than as permitted by the Plan or the HIPAA privacy regulations. The Plan Sponsor shall ensure that any agent or subcontractor to whom it provides protected health information received from the Plan, agrees to the same restrictions and conditions that apply to the Plan Sponsor with respect to protected health information. The Plan Sponsor shall report to the Plan any use or disclosure of protected health information that is inconsistent with the uses or disclosures provided for in the Plan or the HIPAA privacy regulations, of which the Plan Sponsor becomes aware. C. Additional Duties of the Plan Sponsor The Plan Sponsor shall make protected health information of the individual who is the subject of the protected health information available to such individual in accordance with 45 CFR 164.524. The Plan Sponsor shall make individuals' protected health information available for amendment and incorporate any amendments to individuals' protected health information in accordance with 45 CFR 164.526. The Plan Sponsor shall make and maintain records of disclosures so that it can make available an accounting of such disclosures to individuals in accordance with 45 CFR 164.528. The Plan Sponsor shall make its internal practices, books and records relating to the use and disclosure of protected health information received from the Plan available to Health and Human Services for purposes of determining compliance with HIPAA's privacy rules. The Plan Sponsor shall, if feasible, return or destroy all protected health information received from the Plan that the Plan Sponsor still maintains in any form after such information is no longer needed for the purposes for which the use or disclosure was made. Additionally, the Plan Sponsor will not retain copies of such protected health information after such information is no longer needed for the purpose for which the use or disclosure was made. However, if such return or destruction is not feasible, the Plan Sponsor will limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible. The Plan Sponsor shall ensure that an adequate separation between the Plan and the Plan Sponsor is established and maintained. D. Disclosures of Summary Health Information and Enrollment and Disenrollment Information to the Plan Sponsor The Plan (and any business associate acting on behalf of the Plan) may disclose summary health information to the Plan Sponsor if the Plan Sponsor requests summary health information for the purpose of 1) obtaining premium bids from health plans for providing health insurance coverage under the Plan, or 2) modifying, amending, or terminating the Plan. 57 The Plan may disclose to the Plan Sponsor information on whether an individual is participating in the Plan or whether an individual is enrolled in or has disenrolled from the Plan. E. Required Separation Between the Plan and the Plan Sponsor In accordance with 45 CFR 164.504(f)(2)(iii), the following classes of employees or workforce members under the control of the Plan Sponsor may be provided access to protected health information received from the Plan. 1. The members of the Health Benefits Division of the Human Resources Department of the Employer; 2. The members of the Legal Department of the Employer; 3. The members of the Accounting Division of the Finance Department of the Employer; 4. The members of the MIS Department of the Employer; 5. The Senior Management Assistant of the Human Resources Department of the Employer; 6. The Director of Human Resources; 7. The Assistance City Manager for Support Services; 8. The City Manager of the City of Corpus Christi. The above list includes the classes of employees or workforce members of the Plan Sponsor who receive protected health information relating to payment under, health care operations of, or other matters pertaining to plan administration functions that the Plan Sponsor provides for the Plan. These individuals shall have access to protected health information solely to perform their job functions for the Plan Sponsor and they will be subject to disciplinary action for any use or disclosure of protected health information in violation of the provisions of 45 CFR 164. The Plan Sponsor shall promptly report any such breach or violation to the Plan and will cooperate with the Plan to correct the violation, to impose appropriate disciplinary action and to mitigate any deleterious effect of such violation. WHCRA Notice The Women's Health and Cancer Rights Act of 1998 requires the Employer /Plan Sponsor to notify you, as a participant or beneficiary of the employer /Plan Sponsor, of your rights related to benefits provided through the plan in connection with a mastectomy. You as a participant or beneficiary have rights to coverage to be provided in a manner determined in consultation with your attending physician for: 58 a) all stages of reconstruction of the breast on which the mastectomy was performed; b) surgery and reconstruction of the other breast to produce a symmetrical appearance, and c) prostheses and treatment of physical complications of the mastectomy, including lymphedema. These benefits are subject to the plan's regular deductible and co -pay as shown in the Schedule of Benefits. For further details, refer to your Summary Plan Document (booklet). Please ensure that all covered family members receive this notice and are aware of these riPhts. Keep this notice for your records and call the Employer for more information. Minimum Maternity Benefits Statement Group health plans and health insurance issuers generally may not under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, form discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). 59 crt-trear edatetf'actuus tt, rem PLAN DOCUMENT FOR THE CITY OF CORPUS CHRISTI HEALTH PLAN CITICARE FIRE Effective August 2004 Name of Plan: City of Corpus Christi — Citicare Fire Plan Number: 523000 Effective Date of this Plan Document: 03/01/99 Revised Effective as of: 08/01/04 Anniversary Date: August 1 This Plan Document contains the terms under which the City of Corpus Christi agrees to cover certain group members and pay benefits in consideration of the application and payment of the premium. The City of Corpus Christi and Humana Health Network have agreed to all the terms of this Plan Document. THIS IS NOT A POLICY OF WORKERS COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY ESTABLISHING THIS PLAN. TABLE OF CONTENTS IMPORTANT PLAN INFORMATION Claim Dispute Information SCHEDULE OF BENEFITS Prior Authorization Penalty 1 Deductibles 1 Out -of- Pocket 1 Hospital Services 1 Psychiatric Disorders 3 Additional Medical Services 4 ELIGIBILITY REQUIREMENTS Effective Date of Coverage 6 Eligible Class of Employees 7 Dependent 7 Additional Rules regarding Retiree Coverage 8 Ineligible Class(es) 9 Qualifying Events 9 Becoming Eligible For Dependent Coverage 9 Certificate of Insurance 10 Changes in Coverage 10 Misstatements 10 DEFINITIONS Defmitions 10 HEALTH PLAN BENEFITS What the Plan Pays 21 The Annual Deductible ..21 Annual Deductible Carryover 22 Out -of- Pocket Expense Limit 22 Maximum Benefit — Reinstatement of Benefits . 22 Pre - Authorization Provisions 23 Maternity Admissions 24 When Emergency Hospitalization is Required 24 Pre - Authorization Penalty 24 Appeals Procedure 24 Adoption Benefit 24 Newborn Expenses • 25 Basic Hospital Benefit 26 Physician Benefits 26 Psychiatric Disorders • 27 Chemical Dependency Benefits . 28 Prescription Benefit Description •28 Additional Medical Services 29 Pre - Admission Testing Benefit 32 Medical Case Management Benefit 32 Second Surgical Opinion Benefit 33 Spinal Manipulation Benefit ..33 Serious Mental Illness 33 Well Child Care . 33 Leaves of Absence and the Family Medical Leave Act 33 LIMITATIONS AND EXCLUSIONS Pre - Existing Conditions Limitation 34 Other Limitations and Exclusions .. 34 EXTENSION OF BENEFITS COVERAGE AFTER TERMINATION Extension of Benefits Coverage after Termination • 37 FEDERAL CONTINUATION OF COVERAGE Consolidated Omnibus Budget Reconciliation Act (COBRA) 37 Continuation Coverage for Employees in the Uniformed Services 41 COORDINATION OF BENEFITS Allowable Expense 42 Claim Determination Period 42 Plan 42 This Plan 42 What Coordination of Benefits Provision Does 42 Order of Benefit Determination 42 How Benefits are Coordinated . 43 MEDICARE ELIGIBLES Medicare Part A 44 Medicare Part B 44 Integration With Medicare 44 TEFRA Options 44 Category 1 Medicare Eligible 45 Category 2 Medicare Eligible 45 Calculation and Payment of Benefits 45 Disability Due to End Stage Renal Disease . 45 CLAIMS The Plan Must Be Notified of Intent to File a Claim 45 When to File Proof of Claim .46 The Plan May Extend Time Limits . 46 The Plan's Right to Require Medical Exams 46 To Whom Benefits are Payable 46 When the Plan Pays 46 Right of Recovery 47 Subrogation 47 Right of Reimbursement 47 Duplication of Benefits /Other Insurance 47 Cooperation Required 48 Legal Actions and Limitations • 48 Payment to the State of Texas •. 48 Complaint Notice 48 TERMINATION PROVISIONS Termination of Your Coverage 49 Termination for Cause 49 Termination of Dependent Coverage 49 Disabled Children 49 MISCELLANEOUS PROVISIONS Review Authority 50 Covered Person/Provider Relationship .50 Changes in the Plan 50 Workers Compensation 50 Assignment . 50 Termination of the Plan 50 TRANSPLANT PROVISIONS Transplant Provisions 50 Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA (Privacy Rights) 51 IMPORTANT NOTICE You may call the Plan at Humana Health Network's toll -free telephone number for information or to make a complaint at: 1- 877 - 845 -1033 You may also write to Humana Health Network at: Claims Office P. O. Box 14601 Lexington, KY 40512 -4601 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at 1 - 800 - 252 -3438 You may write the Texas Department of Insurance: P.O. Box 149104 Austin, TX 78714 -9104 FAX #512 -475 -1771 PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should contact your agent or the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document. AVISO IMPORTANTE Usted puede lamar gratis al numero de telefono de Humana Health Network para information o para someter una queja a: 1- 877 - 845 -1033 Usted tambien puede escribir a Humana Health Network: Claims Office P. O. Box 14601 Lexington, KY 40512 -4601 Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al: 1 - 800 - 252 -3438 Puede escribir a Departamento de Seguros de Texas: P.O. Box 149104 Austin, TX 78714 -9104 FAX #512- 475 -1771 DISPUTAS SOBRE PRIMAS 0 RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con su agente o la compania primero. Si no se resuelve la disputa, puede entonces comunicarse con el Departamento de Seguros de Texas. i UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de information y no se convierte en parte o condicion del documento adjunto. SCHEDULE OF BENEFITS — CITICARE FIRE INDIVIDUAL MAXIMUM BENEFIT $1,000,000 PRIOR AUTHORIZATION PENALTY If any required pre - authorization of services is not obtained, the benefit payable for any medically necessary services, after any applicable deductibles or co- payments, will be reduced by 50% up to a maximum penalty of $500. If services are not medically necessary, no benefits are payable at all. This out -of- pocket amount may not be used to satisfy any Out -Of- Pocket Expense Limits. This pre -au- thorization penalty will apply if you received the services from a participating or non - participating provider. DEDUCTIBLES (Co- payments do not apply toward plan year deductibles) Participating Providers Individual $100 Per Plan Year Family $300 Per Plan Year Special Services Providers Individual Family Non - Participating Providers Individual Family $100 Per Plan Year $300 Per Plan Year (Cumulative) $100 Per Plan Year $300 Per Plan Year (Cumulative) MAXIMUM OUT -OF- POCKET EXPENSE LIMITS Participating Providers Individual Family Special Services Providers Individual Family Non- Participating Providers Individual Family $ 525 Per Plan Year $1575 Per Plan Year $ 525 Per Plan Year $1575 Per Plan Year (Cumulative) $ 525 Per Plan Year $1575 Per Plan Year (Cumulative) When a Covered Person has incurred the out -of- pocket maximum during a Plan Year, the Plan cov- ered percentage will increase to 100% for any additional eligible expenses incurred during the re- mainder of the plan year. An out -of- pocket expense does not include expenses incurred for the co- pays, deductibles, outpatient treatment of mental/nervous disorders (except Serious Mental Illness), substance abuse or Prior Authorization Penalties. HOSPITAL SERVICES Inpatient Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Citicare Fire I SCHEDULE OF BENEFITS (CONTINUED) HOSPITAL SERVICES (CONTINUED) Outpatient Surgical Services Participating Provider Special Services Non - Participating Provider Outpatient Non - Surgical Services Participating Provider Special Services Non - Participating Provider Emergency Room Visits Participating Provider Special Services Non - Participating Provider Birthing Center Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 100% Benefit Payable after Participating Provider Deductible 100% Benefit Payable after Special Services Deductible 100% Benefit Payable after Non - Participating Deductible PHYSICIAN SERVICES Office Visits (Excludes routine physical exams, outpatient surgery and diagnostic lab /x- rays.) Participating Provider 85% Benefit Payable after Participating Provider Deductible Special Services 80% Benefit Payable after Special Services Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible Emergency Room Visits Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Laboratory Services (In Physician's Office) Participating Provider Special Services Non - Participating Provider Birthing Center Participating Provider Special Services Non - Participating Provider Inpatient Services Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 100% Benefit Payable after Participating Provider Deductible 100% Benefit Payable after Special Services Deductible 100% Benefit Payable after Non - Participating Deductible 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Citicare Fire 2 SCHEDULE OF BENEFITS (CONTINUED) PHYSICIAN'S SERVICES (CONTINUED) Outpatient Services (Includes surgery.) Participating Provider Special Services Non - Participating Provider X -Rays (in doctor's office) Participating Provider Special Services Non - Participating Provider Allergy Immunizations Participating Provider Special Services Non - Participating Provider Physical Therapy Participating Provider Special Services Non - Participating Provider Occupational Therapy Participating Provider Special Services Non - Participating Provider Speech and Hearing Therapy Participating Provider Special Services Non - Participating Provider PSYCHIATRIC DISORDERS Inpatient Services ** Participating Provider Special Services Non - Participating Provider **Limited to 100 days per plan year 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 100% Benefit Payable after $20 Co -Pay per Visit 80% Benefit Payable, No Deductible 70% Benefit Payable after the Non - Participating Deductible 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Outpatient Services Individual Sessions * Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Citicare Fire 3 SCHEDULE OF BENEFITS (CONTINUED) PSYCHIATRIC DISORDERS (CONTINUED) Group Sessions * Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible *Limited to 60 visits per individual per plan year Any out -of- pocket expenses for the out patient treatment of psychiatric disorders do not apply towards any out -of- pocket expense limit. CHEMICAL DEPENDENCY The necessary care and treatment of Chemical Dependency will be covered the same as any other illness generally, and will be subject to the same deductibles, benefit percentages and limitations which will apply to any other type of illness. ADDITIONAL MEDICAL SERVICES In addition to Hospital and Physician Services, benefits will be paid for the services listed below. DURABLE MEDICAL EQUIPMENT (not to exceed purchase price) Participating Provider 85% Benefit Payable after Participating Provider Deductible Special Services 80% Benefit Payable after Special Services Deductible • Non- Participating Provider 70% Benefit Payable after Non - Participating Deductible AMBULANCE Participating Provider Special Services Non - Participating Provider 80% Benefit Payable 80% Benefit Payable, No Deductible 80% Benefit Payable If the transport by ambulance is verified as a medical necessity (physician's statement from physician receiving the member at hospital or ER) or called by emergency services such as police or fire authority, the actual billed amount will be paid at 80% with the member paying the 20% remaining. This is an exception to the normal usual and customary limitation. If the transport by ambulance is called by the member and is not a medical necessity, the member will be responsible for the full billed amount. X -RAY FACILITY (other than Physician's office) Participating Provider 85% Benefit Payable after Participating Provider Deductible Special Services 80% Benefit Payable after Special Services Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible PRIVATE DUTY NURSING Participating Provider Special Services Non- Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Citicare Fire 4 SCHEDULE OF BENEFITS (CONTINUED) ADDITIONAL MEDICAL SERVICES (CONTINUED) MAMMOGRAPHY BENEFIT (Females age 35 and over) Participating Provider 100% Benefit Payable up to $75 per Plan Year Special Services 100% Benefit Payable up to $75 per Plan Year Non - Participating Provider 100% Benefit Payable up to $75 per Plan Year SIGMOIDOSCOPY EXAMINATIONS (Age 40 and over) Participating Provider 100% Benefit Payable up to $75 Per Plan Year Special Services Provider 100% Benefit Payable up to $75 Per Plan Year Non - Participating Provider 100% Benefit Payable up to $75 Per Plan Year PROSTATE CANCER DETECTION EXAM Participating Provider Special Services Provider Non - Participating Provider 100% Benefit Payable to $75 per plan year 100% Benefit Payable to $75 per plan year 100% Benefit Payable to $75 per plan year PRESCRIPTION DRUG Participating Pharmacy (i.e., with prescription drug card) Generic Drug No Co -pay Brand Name $10 per prescription for up to a 34 -day supply Brand Name Maintenance Drugs $20 per prescription for 35 -68 day supply $30 per prescription for 69 -102 day supply Non - Participating Pharmacy* Generic Drug Brand Drug 70% per prescription after Non - Participating Deductible 70% per prescription after Non - Participating Deductible *Maintenance Drugs are not covered at Non - Participating Pharmacies ALL OTHER ADDITIONAL MEDICAL SERVICES LISTED IN THE PLAN Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible SPECIAL SERVICES are those services that are provided outside the Service Area due to residency. EMERGENCY CARE provided by a non - participating provider when a participating provider is not accessible, will be billed to the plan member at the participating level of benefits as though services were provided by an in- network provider. The out -of- network provider who may have provided the services will be paid by the lesser of the billed amount or the usual, reasonable and customary amount. Covered Services provided by non - participating providers when such services are not available through preferred providers will be billed to the plan member as though in- network and will be paid to the service provider by the lesser of the charges billed or usual, reasonable and customary. The period permitted for this exception is limited to only that required for the emergency service(s) where an in- network provider is not available and will end when in- network services can be provided or emergency care is no longer required. Citicare Fire 5 ELIGIBILITY EFFECTIVE DATE OF COVERAGE You may elect to be covered by completing and signing an enrollment form approved by and acceptable to the City. Subject to making any required premium contribution, your coverage will start as described in the paragraphs which follow: 1. If you become eligible after the effective date of the Plan and you enroll within 31 days after the date you first become eligible (qualifying event), your coverage will start on the date you become eligible, subject to completing any waiting period. Please see section on Qualifying Events. 2. If you elect the coverage provided by the Plan during the group's open enrollment period, your coverage becomes effective on the renewal date of the group's health benefit plan. Retirees desiring to continue in the plan must sign and submit an annual enrollment form within the specified enrollment period in order to be continued in coverage. Failure to submit enrollment forms shall result in termination of coverage effective on the first day of the plan year for which enrollment forms are not submitted 3. You may use a telephone call or e-mail to inquire regarding coverage or changes to coverage, but may not rely on a telephone call or e-mail to actually change coverage, add a dependent, or other important events. Enrollment requests or requests for change(s) in coverage must be submitted in writing within the prescribed period with appropriate documentation that may be required (e.g., birth record or certificate, divorce decree, etc.) An employee's coverage under Citicare Fire coverage shall commence at 12:01 a.m. on the date such coverage is effective. 1. Coverage for an employee hired after the date this Plan commences shall be effective on the date of hire so long as the employee completes enrollment within 31 days of his/her date of hire. 2. Coverage for employees working in a benefits eligible capacity on the date this Plan becomes effective shall become effective on the effective date of the Plan, presuming the employee had previously completed enrollment. Each employee will be covered on the above effective date provided Enrollment and any required contributions have been made within thirty-one (31) days after the date of eligibility. ELIGIBLE CLASS(ES) 1. Eligible employees as defined in the defmition provision of this plan document; 2. Dependents of covered employees as defined in the defmition provision of this plan document; and, 3. Eligible retirees as defined in the defmition provision of this plan document and their dependents who are plan participants on the day before their retirement and satisfy the definition of dependent in the definition section of this plan document. (Additional explanation of retiree eligibility is furnished below.) You are eligible to elect or continue dependent coverage only if you are eligible as a group member. If you have one or more dependents, you are eligible for dependent coverage on the date you become eligible as a group member. If you do not have any dependents on the date you become eligible as a group member, you do not qualify for dependent coverage. You will become Citicare Fire 6 eligible for it on the date you acquire a dependent (unless enrolled as a retiree.) If your dependent is eligible, you may not enroll him or her as both an employee and a dependent. In addition, no person can be enrolled as a dependent of more than one group member. DEPENDENT means any eligible dependent whose coverage became effective and has not termi- nated and includes: 1. your lawful spouse (this includes a spouse by common law marriage); 2. your unmarried child to the last day of the month in which the child attains the age of 25 (an unmarried mentally retarded or physically handicapped child may continue coverage beyond the limiting age so long as appropriate documentation is provided that (a) the child is incapable of self - sustaining employment because of mental or physical disability, (b) the child chiefly relies on the covered employee for financial support, and (c) if the child is first enrolled on or after the child's 25th birthday, the child is medically certified as disabled and is dependent on the covered employee). CHILD means your unmarried 1) natural born child, 2) legally adopted child (including a child placed with You for adoption for whom You have a legal obligation for total or partial support), 3) a child you are seeking to adopt if you are a party to a suit regarding the child's adoption, 4) a child for whom You are the legal guardian or who is dependent upon You for health coverage pursuant to a valid court order, including a qualified medical child support order (QMCSO) or National Medical Support Notice (NMSN), 5) a child who lives with You in a normal parent child relationship if the child qualifies at all times for the dependent exemption as defined in the Internal Revenue Code and the Federal Tax Regulations, or 6) an unmarried natural born or adopted child of Your spouse. The Plan has the right to request verification of the child's dependency status at any time and the Employee has a continuing responsibility to report immediately any change in the dependency of an enrolled spouse or child; 3. Any unmarried child (Employee's grandchild) of a covered Employee's child who is younger than 25 years of age and, at the time application for coverage is a dependent of the covered Employee for federal income tax purposes. Coverage for the covered grandchild may not be terminated solely because the covered child (Employee's child) is no longer a dependent of the covered Employee for federal income tax purposes. Documentation may be required when a change in coverage is requested based on addition or deletion of a dependent. Employees must report changes such as marriage, divorce, birth of a dependent child, etc. when the new dependent or former dependent is to be or was covered by the Plan. Report of such change must be made within 31 days of the change. If not done, the new dependent may not be added to coverage or the employee may subject himself or herself to liability for charges incurred for a former dependent who is no longer eligible. ADDITIONAL RULES REGARDING RETIREE COVERAGE 1. A retiree may enroll in Plan coverage as a retiree if he /she was enrolled in the plan on the day prior to the retirement date. The retiree may also continue coverage in retirement for his/her dependents enrolled in the Plan on the date prior to his/her retirement. Dependency status for enrolled dependents shall be subject to the same rules set forth above (e.g., lawful spouse, unmarried dependent child under the age of 25, etc.) 2. If a retiree discontinues coverage under the Plan or is removed due to failure to pay required premiums, the retiree shall not be eligible to re -enter the plan (or to enroll his/her dependents again.) Citicare Fire 7 3. If a retiree discontinues coverage for a dependent after the retirement date, that dependent is not eligible to be enrolled in the Plan again, even though the dependent satisfies the dependent eligibility criteria. 4. The surviving spouse of a retiree is eligible to continue coverage for herself/himself in the event of a death of the retiree, so long as he /she enrolls as the surviving spouse within 31 days of the retiree's death and makes payments in a timely manner. 5. The surviving spouse or a dependent child's legal guardian may also continue coverage for a dependent child who was enrolled in the Plan under the retiree and was enrolled as such on the day prior to the retiree's death. 6. A retiree or surviving spouse of a retiree may not enroll additional dependents after the date of retirement. Any dependents continued on the Plan in retirement must have been covered by the retiree on the date prior to his/her retirement and, if applicable, on the day prior to the retiree's death. 7. A surviving spouse continuing under the Plan may not enroll a new spouse if he /she re- marries. Changes in coverage for anyone covered under the retiree's eligibility after the retirement date are not subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA) and notices will not be mailed to the retiree or any dependents in the event of changes in coverage. INELIGIBLE CLASSES: All City Employees who are not members of the Collective Bargaining Unit covered by the Collective Bargaining Agreement between the City of Corpus Christi and Corpus Christi Firefighters' Association. QUALIFYING EVENTS If you had other group coverage at the time you were first eligible to enroll in the Plan and, therefore, did not elect (in writing, if required) to be covered by the Plan at that time, but subsequently lost such other coverage, you can enroll in the Plan if you apply within 31 days of losing such other coverage, provided the other coverage was either (a) COBRA coverage which was terminated, or (b) non -COBRA coverage which was cancelled due to a loss of eligibility (including legal separation, divorce, death, termination of employment, or a reduction of hours worked) or because the employer's contributions had ceased. Your coverage will start on the first day of the calendar month coinciding with or next following the date you enroll. a) An employee who gains a dependent through marriage, birth of a child, adoption of a child, or placement for adoption may enroll that new dependent in the Plan provided he or she does so within 31 days of the qualifying event/life status change (marriage date, birth date, or date of court order in the case of adoption or placement.) Coverage will be effective on the date of the qualifying event/life status change. b) In the case of the marriage, birth, or adoption of a child, an eligible employee and any eligible dependent, including a spouse, may also enroll for coverage if they are otherwise eligible for coverage but not already enrolled. The coverage will begin on the date of the qualifying event. The 31 day limit by which an employee is required to apply for changes in coverage due to a qualifying event should not be confused with and does not affect the 60 day window prescribed for an employee or covered dependent with a COBRA qualifying event to notify the City of such a COBRA qualiffing event (e.g., dependent is no longer eligible under the Plan, divorce, etc.) or to make an election to continue coverage under his or her COBRA eligibility. CHANGES IN COVERAGE The Plan may be revised to increase or decrease benefits after its effective date. Changes involving a Citicare Fire 8 reduction in benefits can be made effective at any time during the year. Revised benefits become effective on the date of the revision unless the revision states otherwise. Employees with dependents enrolled in the Plan remain responsible for relaying notices regarding changes in plan coverage to those dependents. They are also responsible for notifying the Plan administrator when an enrolled dependent is no longer a dependent. Failure to do so may result in the employee becoming responsible for charges for a person who is no longer a dependent. BECOMING ELIGIBLE FOR DEPENDENT COVERAGE You are eligible for dependent coverage only if you are eligible as a group member. If you have one or more dependents, you are eligible for dependent coverage on the date you become eligible as a group member. If you do not have any dependents on the date you become eligible as a group member, you do not qualify for dependent coverage. You will become eligible for it on the date you acquire a dependent. If your dependent is eligible, you may not enroll him or her as both an employee and a dependent. In addition, no person can be enrolled as a dependent of more than one group member. CERTIFICATE OF INSURANCE This plan document becomes the Certificate of Insurance and replaces any and all certificates and riders previously issued. This Plan Document describes the provisions and limitations of the Plan. Nothing in this Plan Document waives or alters any of the terms or conditions of the Plan. The benefits outlined in this Plan Document are effective only if you are eligible for coverage, become covered and remain covered in accordance with the terms of the Plan Document. CHANGES IN COVERAGE The Plan may be revised to increase or decrease benefits after its effective date. Changes involving a reduction in benefits can be made effective at any time during the year. You and your dependents become covered for the revised benefits on the effective date of the revision. Employees with dependents enrolled in the Plan remain responsible for relaying notices regarding changes in plan coverage to those dependents. They are also responsible for notifying the Plan administrator in writing when an enrolled dependent is no longer a dependent. Failure to do so may result in the employee becoming responsible for charges for a person who is no longer an eligible dependent. MISSTATEMENTS AND OMISSIONS If an individual's age or any other important facts about an individual in relation to his or her coverage is found to be misstated, the Plan may adjust whatever aspects of the coverage are necessary to reflect the facts. The employee /retiree may become responsible for any amounts paid on behalf of that person when not eligible. If an employee fails to notify the plan administrator of the loss of dependency status for a dependent he or she has registered (dependent child marries or divorces spouse), the employee may become responsible for any amounts paid on behalf of that dependent on or after the date that the dependent loses eligibility. ADDRESS CHANGES It is the responsibility of the covered employee and other covered persons to provide updated addresses of the covered persons to the Human Resources Department of the City promptly after the Citicare Fire 9 change of address. Failure to provide proper addresses of the covered persons in a prompt manner could result in a loss of coverage under the Plan in certain situations (e.g., failure of a covered retiree to receive the required annual enrollment form for continued coverage, failure of a covered spouse to receive a COBRA notice for continued coverage, etc.). Covered persons must send notice of the change of address in writing to the Human Resources Department of the City, 1201 Leopard Street, Corpus Christi, Texas 78401. DEFINITIONS The following terms are used frequently throughout this Plan and are defined below. Listing a definition does not guarantee that it is a covered benefit. ACCIDENT means an injury that is caused by an event that is sudden and unforeseen and exact as to time and place of occurrence. ACTIVE SERVICE means that you are performing your regular duties or performing limited -duty duties on a full -time basis for your employer on a scheduled work day either at one of the Fire Department's places of .employment or at some location to which travel is required; or absent on approved leave. You will be considered to be in active service on a non - scheduled workday if you were in active service or approved leave on the last regularly scheduled workday. A covered Dependent other than a newborn child will be considered in Active Service on any day if engaged in the normal activities of a person in good health of the same age and sex and not confined in a medical facility. AMBULANCE means a professionally operated vehicle equipped for the transportation of a sick or injured person to or from the nearest medical facility qualified to treat the person's sickness or injury. Use of the ambulance must be medically necessary and/or ordered by a physician and must be the most reasonable method of transportation. AMBULATORY SURGICAL CENTER means a public or private institution that meets all of the following requirements: 1. It must be operated by physicians and a medical staff that includes registered nurses. 2. It must have permanent facilities and equipment for the purpose of surgical procedures. 3. It must provide continuous physicians' services on an outpatient basis. 4. It must admit and discharge patients from the facility within the same work -day. 5. It must be licensed in accordance with the laws of the jurisdiction where it is located. It must be run as an ambulatory surgical center as defined by those laws. 6. It must not be used for the primary purpose of terminating pregnancies, or as an office or clinic for the private practice of any physician or dentist. 1. It must have a contract with at least one nearby Hospital for immediate acceptance of patients who require Hospital Care following care in the ambulatory surgical facility. CHEMICAL DEPENDENCY means the abuse of or psychological or physical dependence on or ad- diction to alcohol or a controlled substance. CHEMICAL DEPENDENCY TREATMENT CENTER means a facility that provides a program for the treatment of chemical dependency pursuant to a written treatment plan approved and monitored by a physician. The facility must also be: 1. affiliated with a Hospital with an established system for patient referral; Citicare Fire 10 2. accredited as such a facility by the Joint Commission of Accredited Hospital Organizations (JCAHO); 3. licensed as a chemical dependency treatment program by the Texas Commission on Alcohol and Drug Abuse; or 4. approved by a state agency having legal authority to so approve. CHILD has the meaning set forth in the Dependent Subsection of the Eligibility Section above. CO- INSURANCE means the percentage of a covered expense that a covered person pays after satisfaction of any applicable deductible. CO- PAYMENT means that portion of covered medical expenses that must be paid by or on behalf of the covered person incurring the expenses. CONTROLLED SUBSTANCE means a toxic inhalant or a substance designated as a controlled substance in chapter 481, Health and Safety Code. COVERED PERSON means any eligible employee or eligible dependent whose coverage became effective and has not terminated. CREDITABLE COVERAGE means coverage provided under a self - funded or self - covered employee welfare benefit plan that provides health benefits and that is established in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.); a group health benefit plan provided by a health insurance carrier or health maintenance organization; an indi- vidual health insurance policy or evidence of coverage; Part A or Part B of Title XVIII of the Social Security Act (42 U.S.C. Section 1 396c et seq.); Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq.), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. Section 1396s); Chapter 55 of Title 10, United States Code (10 U.S.C. Section 1071 et seq.); a medical care program of the Indian Health Service or of a tribal organization; a state or political subdivision health benefits risk pool; a health plan offered under Chapter 89 of Title 5, United State Code (5 U.S.C. Section 8901 et seq.); a public health plan as defined in federal regulations; a health benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C. Section 2504(e)); and Short- Term Limited Duration Coverage. Creditable Coverage does not include coverage under accident -only, disability income insurance, or a combination of accident -only and disability income insurance; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit only insurance; coverage for onsite medical clinics; other coverage that is similar to the coverage under which benefits for medical care are secondary or incidental to other insurance benefits and specified in federal regulations; if offered separately, coverage that provides limited scope dental or vision benefits; if offered separately, long -term care coverage or benefits, nursing home care coverage or benefits, home health care coverage or benefits, community based care coverage or benefits, or any combination of those coverages or benefits; if offered separately, coverage that provides other limited benefits specified by federal regulations; if offered as independent, non - coordinated benefits, coverage for specified disease or illness; if offered as independent, non - coordinated benefits, hospital indemnity or other fixed indemnity insurance; or Medicare supplemental health insurance as defined under Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), coverage supplemental to the Citicare Fire 11 coverage provided under Chapter 55 of Title 10, United States Code (10 U.S.C. Section 1071 et seq.), and similar supplemental coverage provided under a group plan, but only if such insurance or coverages are provided under a separate policy, certificate, or contract of insurance. CRISIS STABILIZATION UNIT means a 24 -hour residential program in a facility licensed or certi- fied by a state Department of Mental Health and Mental Retardation, or similar entity, that is usually short-term in nature and that provides intensive supervision and highly structured activities to persons who are demonstrating an acute, demonstrable psychiatric crisis of moderate to severe proportions. DEDUCTIBLE means a specified amount of medical expenses that a covered person must incur before benefits will be paid under the Plan. DURABLE MEDICAL EQUIPMENT means equipment that meets all of the following criteria; 1. It can stand repeated use. 2. It is primarily and customarily used to serve a medical purpose. 3. It is usually not useful to a person in the absence of sickness or injury. 4. It is appropriate for home use. 5. It is related to the patient's physical disorder. 6. It is for prolonged use. 7. It is certified in writing by a physician as being medically necessary. In no event will such items as air conditioners, air purifiers, -humidifiers, whirlpool baths, commodes and over -bed tables be considered eligible. ELECTIVE PROCEDURE means a medical procedure that is not considered to be an emergency by nature or one which may be delayed by the covered person to a later point in time. ELIGIBLE EMPLOYEES means all full -time employees of the Employer who work for the Fire Department and are members, or after graduation of the Fire Academy, will be eligible to become members of the firefighters bargaining unit. If an Eligible Employee qualifies as both an employee and a dependent, such person may be covered as either an employee or a dependent, but not as both. ELIGIBLE RETIREE means a Retired member of the Fire Department who is qualified to receive a retirement pension under the firefighters' retirement system or a firefighter who qualifies for disability retirement benefits under Social Security. EMERGENCY CARE means health services provided in a Hospital emergency facility or compara- ble facility to evaluate and stabilize medical conditions of a recent onset and severity including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, Illness or Injury is of such a nature that failure to get immediate medical care could result in: 1. placing the patient's health in serious jeopardy; 2. serious impairment of bodily functions; 3. serious dysfunction of any bodily organ or part; 4. serious disfigurement; or 5. in the case of a pregnant woman, serious jeopardy to the health of the fetus. EMPLOYER means the City of Corpus Christi. EXPENSE OR CHARGE means the fees and prices regularly and customarily charged for medical Citicare Fire 12 services and supplies generally furnished for cases of comparable nature and severity in the particular geographical area concerned. Any agreement as to fees and charges made between the individual and the doctor shall not bind us in determining our liability with respect to the expense incurred. EXPERIMENTAL OR INVESTIGATIONAL means a drug, drug usage, supplies, biological product, device, medical treatment or procedure that meets any one of the following criteria, as determined by the Plan: 1. Reliable Evidence shows the drug, biological product, device, medical treatment, or procedure when applied to the circumstances of a particular patient is the subject of ongoing phase I, II, or III clinical trials, or 2. Reliable Evidence shows the drug, biological product, device, medical treatment, or procedure when applied to the circumstances of a particular patient is under study with a written protocol to determine maximum tolerated dose, toxicity, safety, efficacy, or efficacy in comparison to conventional alternatives, or 3. Reliable Evidence shows the drug, biological product, device, medical treatment, or procedure is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board (IRB) as required and defined by federal regulations, particularly those of the U.S. Food and Drug Administration or the Department of Health and Human Services. HOSPITAL means an institution that meets all of the following requirements: 1. It must provide, for a fee, medical care and treatment of sick or injured patients on an inpatient bas is. 2. It must provide or operate, either on its premises or in facilities available to the hospital on a pre- arranged basis, medical, diagnostic and surgical facilities. 3. Care and treatment must be given by and supervised by physicians. Nursing services must be provided on a 24 hour basis and must be given by or supervised by registered nurses. 4. It must be licensed by the laws of the jurisdiction where it is located. It must be run as a hospital as defined by those laws. 5. It must not be primarily a: a. convalescent, rest or nursing home; or b. facility providing custodial, educational or rehabilitative care. The term also includes: (1) licensed or accredited treatment facilities which are properly accredited to provide psychiatric, diagnostic and therapeutic services for the treatment of psychiatric disorders and drug dependency; and (2) an alcohol dependency treatment center that provides a program for the treatment of alcohol dependency pursuant to a written treatment plan approved and monitored by a physician and that is: (a) affiliated with a hospital under a contractual agreement with an established system for patient referral; or (b) accredited as such a center by the Joint Commission on Accreditation of Hospitals; or (c) licensed as an alcohol treatment program by the Texas Commission on Alcohol and Drug Abuse; or (d) licensed, certified, or approved as an alcohol dependency treatment program or center by any other state agency having legal authority to so license, certify, or approve. In addition, if services specifically for the treatment of a physical disability are provided in a licensed hospital, services will not be denied solely because such hospital is primarily of a rehabilitative nature and lacks surgical facilities. However, an institution specializing in the care and treatment of a mental illness, which would qualify as a Hospital, except that it lacks organized facilities on its premises for major surgery, shall nevertheless be deemed a Hospital. "Hospital" shall also include a residential treatment facility specializing in the care and treatment of alcoholism or chemical dependency. However, the hospital must be accredited by one of the following: (1) the Joint Commission on the Accreditation of Citicare Fire 13 Hospitals; (2) the American Osteopathic Hospital Association; or (3) the Commission on the Accreditation of Rehabilitative Facilities. This term also includes licensed birthing centers which: 1. Provide a 24 -hour a day nursing service by or under the supervision of Registered Nurses (RNs) and Certified Nurse midwives; and 2. Is staffed, equipped and operated to provide: a. Care for patients during uncomplicated pregnancy, delivery and the immediate postpartum period; b. Care for infants born in the center who are normal or have abnormalities which do not impair function or threaten life; and c. Care for obstetrical patients and infants born in the center who require emergency and immediate life support measures to sustain life pending transfer to a Hospital. HOSPITAL CONFINEMENT or HOSPITAL CONFINED means that a covered person is a registered bed patient in a hospital as the result of a physician's recommendation. ILLNESS means disease, mental, emotional, or nervous disorders, and pregnancy. A recurrent illness shall be considered as one illness. Concurrent illnesses shall be deemed to be one illness unless such illnesses are totally unrelated. INDIVIDUAL TREATMENT PLAN means a treatment plan with specific attainable goals and objectives appropriate to both the patient and the treatment modality of the program. INJURY means bodily loss or harm. All injuries sustained by an individual in connection with any one accident shall be considered one injury. INTENSIVE CARE UNIT means a special unit of a hospital which: 1. treats patients with serious sickness, or injuries; 2. can provide special life - saving methods and equipment; 3. admits patients without regard to prognosis; and 4. provides constant observation of patients by RN's or specially trained Hospital personnel. Excludes any Hospital facility maintained for the purpose of providing normal post- operative recovery treatment or service. MEDICAID means a federal/state program of medical care for needy persons, as established under Title 19 of the Social Security Act of 1965, as amended. MEDICAL COMPLICATIONS OF PREGNANCY means conditions needing hospital confinement where the diagnosis is different from pregnancy, but the diagnosed condition may be caused or affected by it. Included within this definition are serious conditions relating to pregnancy, such as hemopoietic nervous or endocrine systems, hyperemesis gravidarum, toxemia and eclampsia of pregnancy. It also includes non - elective cesarean section, miscarriage, and ectopic pregnancy which is terminated or the spontaneous termination of a pregnancy which occurs during a period of gestation in which a viable birth is not possible. This term does not include conditions such as false labor, occasional spotting, bed rest prescribed by a physician, morning sickness or any similar problems caused by a difficult pregnancy that cannot be classified as distinct from the pregnancy. Citicare Fire 14 MEDICARE means a program of medical insurance for the aged and disabled, as established under Title 18 of the Social Security Act of 1965, as amended. MEDICALLY NECESSARY SERVICES means services and supplies appropriate in the treatment of the patient's diagnosed sickness or injury. In order to be considered medically necessary, the services or supplies must be: 1. consistent with the symptom or diagnosis and treatment of the covered person's injury or sickness; 2. appropriate with regard to standards of good medical practice; 3. not solely for the convenience of a covered person, physician, hospital or ambulatory care facility; and 4. the most appropriate supply or level of services, which can be safely provided to the covered person. When applied to the care of an inpatient, it further means that the covered person's medical symptoms or conditions require that the services cannot be safely provided to the covered person on an outpatient basis. NON - OCCUPATIONAL means with respect to injury or illness, such injury or disease for which the person is not entitled to benefits under any Workers' Compensation Law or similar legislation; or an injury or disease not arising out of, or in the course of, any work for wage or profit. NON - PARTICIPATING HOSPITAL means a hospital which has not been designated as a Partic- ipating Hospital by the Plan. NON - PARTICIPATING PHYSICIAN means a physician who has not been designated as a Partic- ipating Physician by the Plan. NON - PARTICIPATING PROVIDER means a hospital, physician, or any other health services pro- vider who has not been designated by the Plan to provide services to covered persons. NURSE means a registered nurse (R.N.), a licensed practical nurse (L.P.N.), a licensed vocational nurse (L.V.N.), or a Nurse Practitioner (R.N.C.P.). OUTPATIENT means that a covered person is treated at a hospital and confined less than 23 consecutive hours. OUTPATIENT SURGERY means surgery that is performed in a physician's office, ambulatory sur- gical center, freestanding medical clinic or the outpatient department of a hospital. PARTICIPATING HOSPITAL means a hospital that has signed an agreement with either Humana Health Network or has been designated by the Plan to provide services to covered persons. PARTICIPATING PHYSICIAN means a physician who has signed an agreement with Humana Health Network or who has been designated by the Plan to provide services to covered persons. PARTICIPATING PROVIDER means a hospital, physician, or any other health services provider who has signed an agreement with Humana Health Network or who has been designated by the Plan to provide services to covered persons. PHYSICIAN means any of the following licensed medical practitioners who are practicing within the Citicare Fire 15 scope of his or her license and whose services are required to be covered by the laws of the jurisdiction where the treatment is given: Doctor of Medicine, Doctor of Osteopathy, Doctor of Dentistry, Doctor of Chiropractic, Doctor of Optometry,. Doctor of Podiatry, Licensed Audiologist, Licensed Speech - Language Pathologist, Doctor of Psychology, Licensed Dietitian, Licensed Pro- fessional Counselor, and Licensed Hearing Aid Fitter and Dispenser; Licensed Psychological Asso- ciate; and Licensed Chemical Dependency Counselor. PLAN PARTICIPANTS) means covered employees and dependents. PLAN AND /OR PLAN SPONSOR means the City of Corpus Christi. PLAN YEAR means the period of time which begins on any August 1St and ends on the following July 31st PREGNANCY means conditions including pregnancy, medical complications of pregnancy, resulting childbirth, miscarriage, or related medical conditions. PSYCHIATRIC DAY TREATMENT PROGRAM means a mental health facility that provides treatment for people suffering from acute mental and nervous disorders in a structured psychiatric program. The program must utilize individualized treatment plans with specific attainable goals and objectives appropriate both to the patient and the treatment modality of the program. The program must be clinically supervised by a physician who is certified in psychiatry by the American Board of Psychiatry and Neurology. The facility must be accredited by the Program for Psychiatric Facilities, or its successor, or the Joint Commission on Accreditation of Hospitals. PSYCHIATRIC DISORDER means neurosis, psychoneurosis, psychopathy or psychosis. PSYCHIATRIC TREATMENT PROGRAM means licensed psychiatric treatment programs. These programs must be accredited by the Joint Commission on the Accreditation of Hospitals or be in compliance with equivalent standards or be approved in the state where the program is run. RECONSTRUCTIVE SURGERY means any surgery and associated expenses which are: 1. incidental to or following surgical removal of all or less than all of a body part. The surgical removal must be done as the result of Injury or illness of the body part. 2. done because of a sickness or a disorder of a normal bodily function. 3. done to repair or lessen damage caused by an Injury. 4. done to correct a congenital defect. RELIABLE EVIDENCE shall mean only published reports and articles in the authoritative medical and scientific literature; the PDO database of the National Cancer Institute; the written protocol or protocols used by the treating facility or the protocols of another facility studying substantially the same drug, biological product, device, medical treatment, or procedure; the written informed consent used by the treating facility or another facility studying substantially the same drug, biological product, device, medical treatment, or procedure; or regulations and other official actions and publications issued by the U.S. Food and Drug Administration or the Department of Health and Hu- man Services. RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS means a Citicare Fire 16 child care institution that provides residential care and treatment for emotionally disturbed children and adolescents and that is accredited as a residential treatment center by the Council on Accreditation, the Joint Commission on Accreditation of Hospitals or the American Association of Psychiatric Services for Children. ROOM AND BOARD means all charges made by a hospital on its own behalf for room and meals and all general services and activities needed for the care of registered bed patients. ROUTINE NURSERY CARE means the charges made by a hospital for the use of the nursery. it includes normal services and supplies given to well newbom children following birth. Physician visits are not considered routine nursery care. Treatment of an injury, sickness, birth abnormality, congenital defect following birth and care resulting from prematurity is not considered routine nursery care. SECOND SURGICAL OPINION means a consultation with a Board Certified surgeon after a covered person has received a recommendation to have surgery. This consultation includes the physical examination, laboratory work and X -rays. The consulting surgeon must not be affiliated in practice with the surgeon who first recommended surgery. SELF- ADMINISTERED INJECTABLE DRUGS means an FDA approved medication that a person may administer to himself/herself by means of intramuscular, intravenous, or subcutaneous injection, excluding insulin, and intended for use by the covered person or the covered person's family. SERIOUS MENTAL ILLNESS means the following psychiatric illnesses as defined, by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM) 111-R: 1. schizophrenia; 2. paranoid and other psychotic disorders; 3. bipolar disorders (mixed, manic, and depressive); 4. major depressive disorders (single episode or recurrent); and 5. schizo - affective disorders (bipolar or depressive). SICKNESS means an illness or disease. The term also includes pregnancy and medical complications of pregnancy. A recurrent illness shall be considered as one illness. Concurrent- illnesses shall be deemed to be one illness unless such illnesses are totally unrelated. SOUND NATURAL TEETH means teeth that are free of active or chronic clinical decay, have at least 50% bony support, are functional in the arch, and have not been excessively weakened by multiple dental procedures. SURGICAL PROCEDURE includes, but is not limited to any of the following procedures (excluding oral surgical procedures): 1. incision, excision or electrocauterization of any organ or body part; 2. reconstruction of any organ or body part or the suture or repair of lacerations; 3. reduction of a fracture or dislocation by manipulation; 4. use of endoscopic procedure to explore for or to remove a stone or other object from the larynx, bronchus, trachea, esophagus, stomach, intestine, urinary bladder or ureter; 5. puncture for aspiration: 6. injection for contrast media testing; or 7. laser surgery. Citicare Fire 17 TOTAL DISABILITY OR TOTALLY DISABLED means any period when, as a result of injury or illness, a covered employee is completely unable to perform the duties of the employee's occupation and is not engaged in any activity for profit. A Covered Dependent will be considered Totally Disabled during any period when, as a result of injury or illness, the dependent is unable to engage in the normal activities of a person of the same age and sex. A Totally Disabled covered employee or dependent must be under the care and treatment of a physician during the term of disability. Total Disability must be certified in writing by a physician. TOXIC INHALANT means a volatile chemical under Chapter 484, Health and Safety Code, or abusable glue or aerosol paint under Section 485.001, Health and Safety Code. USUAL, CUSTOMARY AND REASONABLE CHARGES mean the following: 1. Usual charges are the fees charged by a provider in normal practice for a given service. 2. Customary Charges are the range of usual fees charged by providers for the same service in a specific geographical or economic area. 3. Reasonable Charges are either usual or customary charges or the charges that a responsible medical review committee deems appropriate for specific care due to special conditions. WEEKEND NON - EMERGENCY HOSPITAL ADMISSION means an admission to a hospital on a Friday, Saturday or Sunday at the convenience of the covered person or his or her physician when there is no cause for an emergency admission and the covered person receives no surgery or therapeutic treatment until the following Monday. YOU or YOUR means the Plan Participant. PRESCRIPTION DRUG BENEFIT DEFINITIONS: The following teens are used in this benefit description. BRAND NAME MEDICATION means a medication that is manufactured and distributed by only one pharmaceutical manufacturer. CO- PAYMENT means the portion of covered prescription drug expenses that must be paid by or on behalf of the covered incurring the expenses. GENERIC MEDICATION means a medication that is manufactured, distributed and available from several pharmaceutical manufacturers and identified by the chemical name. HERITABLE DISEASE means an inherited disease that may result in mental or physical retardation or death. NON - PARTICIPATING PHARMACY means a pharmacy that has not agreed to provide services under terms set fort by the plan. PARTICIPATING PHARMACY means a pharmacy that agrees to provide services under terms set forth by the Plan. PHARMACIST means a person who is licensed to prepare, compound and dispense medication and Citicare Fire 18 who is participating within the scope of his or her license. PHARMACY means a licensed establishment where prescription medications are dispensed by a pharmacist. PHENYLKETONURIA means an inherited condition that may cause severe mental retardation if not treated. PHYSICIAN means a licensed medical practitioner who is practicing within the scope of his or her license and whose services are required to be covered by the laws of the jurisdiction where the treatment is given. PRESCRIPTION means a direct order for the preparation and use of a drug, medicine or medication. This order may be given by a physician to a pharmacist for the benefit of and use by a covered person. The drug, medicine or medication must be obtainable only by prescription. The prescription may be given to the pharmacist verbally or in writing by the physician. The prescription must include: 1. name and address of the covered person for who the prescription is intended; 2. the type and quantity of the drug, medicine or medication prescribed, and the directions for its use; 3. the date the prescription was prescribed; and 4. the name, address of the prescribing physician. Citicare Fire 19 HEALTH PLAN BENEFITS WHAT THE PLAN PAYS The Plan pays the applicable benefit amount or percentage shown in the Schedule of Benefits for covered expenses if they are: 1. medically necessary as a result of an injury or a sickness; 2. received by a covered person; 3. for services authorized by a physician. Deductibles, co- payments and maximum amounts, if any, for each benefit are shown in the Schedule of Benefits. The Plan calculates deductibles and co- payments by applying the dollar amount or per- centage to net charges. Net charges are defined as gross billed charges less any discounts or fee negotiations that may have been arranged with participating providers. Gross charges means the amount the provider charges without giving consideration to any of the discounts or fee negotiations which the Plan has arranged to receive from the provider. The Plan will pay participating physicians for covered expenses in accordance with the fee schedules of usual, reasonable and customary charges established between the participating physicians and the Plan. For services rendered by participating physicians, the dollar amount of the deductible or benefit percentage that is your responsibility is calculated based on the fee schedule of the participating physician rendering the services. For services rendered by non - participating physicians, the dollar amount of the deductible or benefit percentage is calculated based on a reimbursement schedule established by the Plan. When using a non - participating physician, you are also responsible for any charges that exceed this reimbursement schedule and non - covered services. A covered expense is deemed to be incurred on the date a covered service is performed or a covered supply is furnished. Charges are not considered to be covered expenses until any applicable deductibles or co- payments have been satisfied. If a benefit is payable for certain covered expenses under a particular benefit section of the Plan, those covered expenses will not be considered for payment under any other benefit section of the Plan unless specified. Otherwise, an expense will not be covered if it is incurred after your coverage under the Group Plan is terminated unless it is required to be covered by applicable law (i.e.; COBRA, or court orders). THE ANNUAL DEDUCTIBLE An annual deductible is a specified dollar amount that a covered person must pay for covered medical expenses per plan year before benefits will be paid under the Plan. There are individual and family, as well as participating, special services and non - participating provider deductible amounts. Expenses incurred by a covered person which may be applied to any applicable deductible referenced under this paragraph will be applied equally toward the satisfaction of the participating, special services and non- participating provider deductibles. The participating, special services and non - participating provider deductible amounts for each covered person and each covered family are shown in the Schedule of Benefits and must be satisfied each plan year. Co- payments do not apply toward any deductibles. If two or more covered persons of the same family are injured in the same accident and incur covered medical expenses for those injuries, only one deductible will be deducted from the total covered expenses resulting from the accident in the plan year in which the accident occurs. Only one deductible will be deducted from the total covered medical expenses incurred as a result of a multiple birth of two or more dependents. The covered expenses must be incurred in the same plan Citicare Fire 20 year as the birth and result from: 1. premature birth; 2. an abnormal congenital condition; or 3. an injury or sickness occurring within 31 days after the birth. ANNUAL DEDUCTIBLE CARRYOVER If a covered person incurs covered medical expenses during the last 3 months of a plan year, and those amounts can be applied toward the satisfaction of the annual deductible for that plan year, those same expenses will be applied toward the satisfaction of the individual annual deductible of the next plan year. This deductible carryover does not apply to the family limit deductible. OUT -OF- POCKET EXPENSE LIMIT A maximum out -of- pocket expense limit is the amount of covered expenses, excluding expenses used to satisfy deductibles, in excess of Reasonable and Customary charges, and co- payments, that must be paid by each covered person before a benefit percentage will be increased. There are individual and family participating, special services and non - participating provider maximum out -of- pocket expense limits. After the individual and/or family participating provider out - of- pocket maximum expense limit has been satisfied in a plan year, the participating provider benefit percentage for covered expenses will be payable at the rate of 100% for the rest of the plan year. After the individual and/or family special services and non - participating provider maximum out -of- pocket expense limit has been satisfied in a plan year, the provider benefit percentages for covered expenses will be payable at the rate of 100% for the rest of the plan year. Benefit specific co- payments continue to be the responsibility of the covered person. Any expense incurred by a covered person for covered medical expenses that may be applied to any applicable maximum out -of- pocket expense limit referenced under this provision shall be applied equally toward the satisfaction of the participating, special services and non - participating provider maximum out -of- pocket expense limits. The single and family participating, special services and non- participating provider maximum out -of- pocket expense limit is shown to be unlimited, covered benefits will be paid at the levels indicated in the Schedule of Benefits. The covered person will be responsible for any out -of- pocket expense(s). Benefits for expenses incurred in connection with Psychiatric Disorders will be paid at the benefit level(s) shown on the Schedule of Benefits and outpatient expenses for psychiatric disorders will not apply towards any single or family out -of- pocket expense limit. MAXIMUM BENEFIT - REINSTATEMENT OF BENEFITS The total amount of benefits payable for all covered expenses incurred for a covered person will not exceed the Maximum Benefit shown on the Schedule of Benefits. If a covered person uses any portion of his or her maximum benefit, the Plan will reinstate the used portion on each August 1, up to a maximum of $1,000. The $1,000 will be applied to covered services received after the date of reinstatement. Once a maximum benefit has been reached, benefits. will not be reinstated. This reinstatement provision will not apply to retired employees, if any, or to expenses incurred for the treatment of psychiatric disorders. Citicare Fire 21 PRE- AUTHORIZATION PROVISIONS All benefits payable under the Plan must be for services and supplies that are medically necessary. In order to determine whether services and supplies meet guidelines for medical necessity, they must be authorized by us in advance. In an effort to make treatment convenient, to follow the wishes of the patient or the patient's family, to investigate the use of unproven treatment methods, or to comply with local hospital practices, a Physician may suggest or permit a method of providing care that is not Medically Necessary. A service that is prescribed by a Physician does not necessarily mean the service is Medically Necessary, nor necessarily a covered service. The covered person is responsible for alerting his or her physician regarding the need for prior ap- proval. The identification card will alert the physician that pre - authorization is required and will show the telephone number to call to obtain the appropriate authorization. If prior approval of services or supplies is not obtained, benefits may be reduced or not paid at all. Scheduled admissions, including admissions to a psychiatric or chemical dependency facility, must be pre - authorized 48 hours prior to Hospital admission. In some instances, the Plan or Humana Health Network may suggest alternative modes of treatment. By eliminating unnecessary or questionable services, the Plan and Humana Health Network can help reduce personal inconvenience and limit the increasing cost of medical care. Pre - authorization for the following procedures or equipment is also mandatory: BREAST SURGERY (INCLUDING BIOPSIES) HYSTERECTOMY, ABDOMINAL OR VAGINAL KNEE ARTHROSCOPY LIGATION AND STRIPPING OF VARICOSE VEINS DEVIATED SEPTUM /OTHER NASAL SURGERY TEMPOROMANDIBULAR JOINT DISORDER SURGERY CORONARY BYPASS HEMORRHOIDECTOMY CHOLECYSTECTOMY TONSILLECTOMY AND ADENOIDECTOMY BUNIONECTOMY LAMINECTOMY PROSTATECTOMY CATARACT REMOVAL DILATION AND CURETTAGE INGUINAL HERNIORRHAPHY OUT - PATIENT PROCEDURES DURABLE MEDICAL EQUIPMENT OVER $500 PHYSICAL THERAPY SPEECH THERAPY MRI CT SCAN Note: For these procedures, if no authorization is obtained, a reduction of 50% up to a maximum penalty of $500 will apply. Citicare Fire 22 MATERNITY ADMISSIONS Outpatient surgery with subsequent Hospital admission, other than Outpatient surgery performed in a Physician's office, must be reported within twenty -four (24) hours of the inpatient admission in order to assure maximum benefits under This Plan. A Hospital stay following an Outpatient surgery undergoes continued stay review just like a scheduled admission. However, regardless of medical necessity, coverage for hospital stays shall not be limited to less than forty-eight (48) hours for normal vaginal deliveries and ninety -six (96) hours for Cesarean section deliveries for both the mother and the newborn child (assuming the child is added to the Plan under the Eligibility provisions stated herein). WHEN EMERGENCY HOSPITALIZATION IS REQUIRED If a medical emergency requires that a covered person be admitted to a hospital, pre - authorization must take place within 48 hours or the morning of the next business day after admission. The Plan and Humana Health Network will then review the medical necessity of the admission. PRE - AUTHORIZATION PENALTY If any required pre - authorization of services is not obtained, the benefit payable for any medically necessary services, after any applicable deductibles or co- payments, will be reduced by 50% up to a maximum penalty of $500. If services are not medically necessary, no benefits are payable at all. This out -of- pocket amount may not be used to satisfy any Out -Of- Pocket Expense Limits. APPEALS PROCEDURE If tl}e covered person is dissatisfied with our determination of medical necessity, he or she may appeal the decision. Such appeals will be handled on a timely basis and appropriate records will be kept on all appeals. The covered person must appeal in writing within 120 days to the address given on the denial letter received. The appeal will be reviewed by the Plan and a response sent to the covered person no later than 30 days following receipt of the appeal. All requests for review by the Appeals Committee must be submitted in writing. The Appeals Committee has guidelines for reviewing appeals and may conduct informal hearings about the appeal. If an informal hearing is to be held, the covered person will be notified in advance. Resolution of the appeal will be completed within 30 days. If the claim is denied again, it shall include specific reasons for denial, written in a manner under- standable to the Covered Person, and will contain specific reference to the pertinent Plan provisions upon which the decision was based. ADOPTION BENEFIT Benefits are available for adoption expenses incurred in connection with legal adoption proceedings, provided such proceedings result in a child being placed in the Covered Employee's home and such charges are a part of the decree of adoption. Eligible Adoption Benefit Expenses: 1. Adoption Agency Expenses payable at 100% to a maximum of $1800: a. The cost of the confinement and medical care treatment of the biological mother in a Hospital or other institution in connection with the birth of the child: b. The charges made by the Physician in connection with the delivery of the child. c. The cost of any necessary foster care of the child prior to its placement in the home of the Covered Employee. Citicare Fire 23 2. Home Placement Expenses: The biological mother's Hospital and Physician's expense will be payable at 100% up to a maximum of $500. Reimbursement will not be made for: 1. Adoption proceedings that began before the Covered Employee became covered; 2. Any expenses that the Covered Member would not be legally required to pay; 3. Any expenses that the biological mother would not be legally required to pay; 4. Attorneys' fees and other necessary legal expenses in connection with the adoption. NEWBORN EXPENSES Hospital nursery expenses and Physician's fee (including routine circumcision) for a healthy newborn will be considered eligible for the seven (7) days immediately following birth, and will be covered under the mother's maternity claim. If the baby is ill, suffers an injury or requires care other than routine care, benefits will be provided on the same basis as for any other eligible Expense, provided dependent coverage is in force at the time eligible Expenses are incurred. NOTE: Coverage is automatically provided for the first thirty-one (31) days after birth. NEWBORN EXPENSES Hospital nursery expenses and Physician's fee (including routine circumcision) for a healthy newborn will be considered eligible for the seven (7) days immediately following birth, and will be covered under the mother's maternity claim. If the baby is ill, suffers an injury or requires care other than routine care, benefits will be provided on the same basis as for any other eligible Expense, provided dependent coverage is in force at the time eligible Expenses are incurred. Newborn Children and Newly Adopted Children of Covered Employee. Coverage is automatically provided to a newborn child of the covered employee for the first thirty-one (31) days after birth. If the addition of the child would cause a higher contribution from the Employee, the child is NOT covered after the first 31 days after birth, adoption or placement for adoption unless the employee enrolls the new child within those 31 days. In order to be covered for the period immediately following birth or adoption, coverage is automatically provided to an adopted child of the covered employee for the first thirty -one (31) days after (1) the date the covered employee becomes a party to a suit in which the covered employee seeks to adopt the child, or (2) the date the adoption becomes final ((1) and (2) are collectively referred to as "adoption" for purposes of this paragraph). A child is considered to be the adopted child of a covered employee if the covered employee is a party to a suit in which the covered employee seeks to adopt the child. Coverage of a newborn child or adopted child ends on the 32nd day after the date of such child's birth or adoption, unless the covered Employee submits a Transaction/Change Card to the Plan Sponsor within thirty-one (31) days of the birth, adoption or placement for adoption and pays any required additional premium. Otherwise, the child will not be allowed to enter the plan until the next Open Enrollment Period or if he /she qualifies under the Special Enrollment Provision. If the addition of the child would not cause a higher contribution from the Employee, the child is automatically covered at birth, adoption or placement for adoption. However, the Employee must submit a Transaction /Change Card to the Plan Sponsor within thirty-one (31) days following the birth, adoption or placement for adoption. This will permit the eligibility to be established and claims on behalf of the new child to be resolved. The employee may experience treatment and/or billing problems if he /she fails to enroll the new child in a timely manner. Citicare Fire 24 BASIC HOSPITAL BENEFIT The Plan will pay benefits incurred by a covered person while hospital confined. The hospital confinement must be ordered by a physician and be the result of an injury or sickness which occurs while covered under the Plan. The following services and supplies for which charges are made by a hospital on its own behalf will be considered covered medical expenses: 1. Room and board. 2. Services and supplies, other than room and board, provided by a hospital to inpatients. 3. Confinement in an intensive care, cardiac care or neonatal care unit. 4. Routine nursery care for a newborn child for up to a maximum of 7 days but not for the con- current use of any other hospital room. 5. Services in a hospital's outpatient department in connection with outpatient surgery. 6. Services in an ambulatory surgical center in connection with outpatient surgery. 7. Services in a hospital's emergency room. 8. Necessary medical care and treatment for prenatal services, delivery of a normal Pregnancy and postpartum services rendered within 24 hours after the delivery, when performed at a state licensed birthing center of facility (other than the birthing unit of a Hospital). Such services and delivery must be performed by a Physician or a licensed registered Nurse who is certified by the American College of Nurse Midwives. 9. Includes minimum inpatient care of 48 hours following a mastectomy and 24 hours following a lymph node dissection unless the Member's attending Physician determines that a shorter period of inpatient care is appropriate. Charges for physician's services in connection with surgical operations are not considered covered hospital expenses. PHYSICIAN BENEFITS The Plan will pay benefits for covered expenses incurred by a covered person for physicians' charges. The covered person must incur physicians' charges as the result of an injury or a sickness which occurs while covered under the Plan. Reasonable charges for the following services and treatment will be considered as covered expenses. 1. Surgical procedures performed on an inpatient or outpatient basis. If several surgical procedures are performed through the same incision or body opening during one operation, the Plan will pay the reasonable charge for the most complex procedure. If several surgical procedures are performed through different incisions or body openings during one operation, the Plan will pay the reasonable charge for the most complex procedure. For each additional procedure the Plan will pay 50% of the reasonable charge for that procedure. 2. Obstetrical services received on an inpatient or outpatient basis including medically necessary prenatal and postnatal care of all female covered persons. 3. Care of a newborn child while the newborn is hospital confined immediately following birth; including routine circumcision. 4. Anesthesia administered by a physician or certified registered anesthetist attendant to a surgical procedure. 5. Radiation therapy received on an inpatient or outpatient basis. 6. Consultation charges requested by the attending physician during a hospital confinement. The benefit is limited to one consultation by any one consultant per specialty during a hospital confinement. 7. Surgical assistance provided by a physician, when medically necessary. The benefit for surgical assistance will be 20% of the reasonable charge for the chief surgeon. 8. Inpatient medical services furnished by the attending physician to a hospital confined covered person. Citicare Fire 25 9. Services of a pathologist during an inpatient confinement or when associated with a surgical procedure. 10. Services of a radiologist during an inpatient hospital confinement or when associated with a surgical procedure. 11. Services of a speech therapist or pathologist to restore speech loss or impairment for restoratory or rehabilitory speech therapy when due to an illness or accidental injury (caused other than by surgery). 12. Services of a licensed audiologist to determine and measure hearing function loss. 13. Services of a licensed physiotherapist for purposes of training to aid restoration of normal physical functions when rendered by a duty qualified physical therapist who is not a member of the patient's immediate family (when referred to by and/or under direct supervision of a physician). 14. Services performed on an emergency basis in a hospital if the injury or sickness being treated results in a hospital admission. 15. Services for acupuncture that is Medically Necessary and provided by a Physician. (M.D.). 16. Services of a licensed Occupational Therapist for purposes of training to aid restoration of normal physical functions when rendered by a duly qualified Occupational Therapist who is not a member of the patient's immediate family (when referred to by and/or under direct supervision of a physician). Benefits will be subject to the benefit amounts or percentages shown in the Physician section of the Schedule of Benefits. Charges for physicians' services which are payable as a hospital charge are not payable under this benefit. PSYCHIATRIC DISORDERS Benefits are payable for covered expenses incurred by a covered person while undergoing treatment for psychiatric disorders. All charges must be made by a physician, or a hospital or a psychiatric day treatment facility, and benefits are payable as follows: 1. Inpatient Charges - Charges incurred by a covered person while confined as a registered bed patient in a hospital or psychiatric day treatment facility will be considered covered expenses. 2. Outpatient Charges - Charges incurred by a covered person while not confined in a hospital or psychiatric day treatment facility will be considered as covered expenses; also Psychiatrist's charges incurred for evaluation and treatment in connection with suicide or self - inflected injuries (including drug overdose); 3. Psychiatric Day Treatment Charges - Charges incurred by a covered person for the treatment of mental and nervous disorders in a psychiatric day treatment facility will be considered covered expenses. A physician must certify that the psychiatric day treatment is being provided in lieu of hospitalization. 4. Crisis Stabilization Unit Charges - Charges incurred by a covered person for the treatment of serious mental illness based on an individual treatment plan will be considered covered ex- penses. A physician must certify that the treatment provided in the crisis stabilization unit is in lieu of hospitalization. Two days in a crisis stabilization unit are considered equal to one day of treatment of mental or emotional illness or disorder in a hospital or inpatient program. 5. Residential Treatment Center for Children and Adolescents Charges - Charges incurred by a covered person for the treatment of serious mental illness based on an individual treatment plan will be considered covered expenses. A physician must certify that the treatment provided in a residential treatment center for children and adolescents is in lieu of hospitalization. Two days in a residential treatment center for children and adolescents is equal to one day of treatment of mental or emotional illness or disorder in a hospital or inpatient program. Citicare Fire 26 6. Deductible and Benefit Percentage - All expenses incurred for the treatment of psychiatric di- sorders and drug dependency are subject to the deductibles and benefit amounts or percentages shown on the Schedule of Benefits. CHEMICAL DEPENDENCY BENEFITS The necessary care and treatment of Chemical Dependency during a series of treatments will be covered the same as any other illness generally, and will be subject to the same deductibles, benefit percentages, and limitations which apply to any other type of illness. A series of treatments is a planned, structured, and organized program to promote chemical free status which may include different facilities or modalities and is complete when the covered individual is discharged on medical advice from inpatient detoxification, inpatient rehabilitation treatment, partial hospitalization or intensive outpatient or a series of these levels of treatments without lapse in treatment or when a person fails to materially comply with the treatment program for a period of 30 days. PRESCRIPTION BENEFIT DESCRIPTION Benefits are payable if covered prescription drugs are received by the covered person while he or she is covered for this benefit. The amount of the benefit provided, including self - administered injectable drugs which are defined as any FDA approved medication which a person may administer to himself/herself by means of intramuscular, intravenous or subcutaneous injection, is as follows: 1. For prescriptions filled at participating pharmacies -the sum of a, b, and c below, minus the covered person's co- payment: a. the ingredient cost, as determined by us for participating pharmacies; a. the professional dispensing fee, as determined by us for participating pharmacies; and b. any sales or provider tax. Your ID card must be presented to a participating pharmacy each time a prescription is filled or refilled. 2. For prescriptions filled at non - participating pharmacies and with claims submitted directly to the Plan by the covered person, the benefit is payable at 70% of the actual charge made by the pharmacy, after your annual deductible. WHAT 1S COVERED Covered prescription drugs using the prescription drug card are: 1. drugs, medicines or medications that under federal or state law, may be dispensed only by prescription from a physician; 2. insulin; diabetic supplies (including lancets, chem strips) 3. hypodermic needles or syringes 011 prescription for use with insulin or self - administered injectable drugs; 3. self - administered injectable drugs; 4. oral contraceptives 6. prenatal vitamins with folic acid; 7. vitamin D, vitamin K, folic acid and pediatric vitamins with folvite; 8. dexedrine; and, 9. formulas necessary for the treatment of phenylketonuria or other heritable diseases. Covered prescription drugs must: 1. be prescribed by a physician for the treatment of an injury or sickness; and 2. be dispensed by a pharmacist. Contrary to any other provisions of the Plan, prescription drug expenses covered under this benefit are not covered under any other provision in the Plan. Any amount in excess of the maximum provided Citicare Fire 27 under this Benefit is not covered under any other provision in the Plan. PRESCRIPTION DRUG EXCLUSIONS No benefit using the prescription drug card is provided for: 1. any oral drug, medicine or medication that is consumed or injected at the place where the prescription is given, or that is dispensed by a physician; 2. prescription refills in excess of the number specified by the physician or dispensed more than one year from the date of the physician's original order; 3. the administration of covered medication; 4. prescriptions that are to be taken by or administered to the covered person, in whole or in part, while he or she is a patient in a hospital, rest home, sanitarium, skilled nursing facility, convalescent hospital, inpatient hospice facility or other facility where drugs are ordinarily provided by the facility on an inpatient basis; 5. prescriptions that may be properly received without charge under local, state or federal pro- grams, including Worker's Compensation, except those received under Medicare; 6. any medication labeled `Caution - Limited by Federal Law to Investigational Use" or any experimental medication, even though a charge is made to the covered person; 7. immunizing agents, biological serums or allergy serums; 8. any drug or medicine that is lawfully obtainable without a prescription; 9. any drug, medicine or medication received by the covered person before becoming covered or after the date the covered person's coverage has ended; 10. therapeutic devices or appliances, including hypodermic needles, syringes, support garments, contraceptive devices, and other non - medical substances, except as stated; 11. any costs related to the mailing, sending or delivery of prescription drugs; 12. any service, supply, or therapy to eliminate or reduce a dependency on or addiction to tobacco, and tobacco products, including but not limited to nicotine withdrawal therapies, programs, services, and medications; 13. mechanical pumps for the delivery of medications; except as stated under durable medical equipment. 14. any fraudulent misuse of this benefit, including prescriptions purchased for consumption by someone other than the person for whom the prescription is written. 15. any drug prescribed for intended use other than for indications approved by the FDA; 16. More than one prescription for the same drug or therapeutic equivalent medication prescribed by one or more physicians and dispensed by one or more pharmacies until at least 50% of the previous prescription has been used by the covered person. (Based on the dosage schedule prescribed by the physician.); 17. drug delivery implants; 18. diet control drugs (anorexics); 19. growth hormones. ADDITIONAL MEDICAL SERVICES The Plan will pay benefits for the following covered expenses for charges incurred by a covered person as the result of an injury or sickness which occurs while covered under the Plan. Benefits are subject to the applicable benefit amount or percentage and deductibles shown on the Schedule of Benefits. Additional Medical Services include: 1. Outpatient medical care and treatment not covered under any other benefit section of the Plan. Citicare Fire 28 2. Private duty nursing in a hospital or in the home, by a nurse, if the physician orders, in writing, that it is medically necessary and not considered to be custodial care as otherwise defined in the Plan. This treatment is eligible if rendered by a registered or licensed practical nurse. However, the services must be necessary and reasonable care for the patient. 3. Radium therapy, x -ray treatments and examination (other than dental x- rays), radioactive isotope therapy cobalt and chemotherapy microscopic tests, or any lab tests or analysis made for diagnosis or treatment; including an annual screening by low -dose mammography for all females age 35 or older to detect the presence of occult breast cancer. 4. Maternity Expenses incurred by a female Covered Person for: a. Pregnancy; b. Medical complications of Pregnancy (see the Definitions section); c. Abortions; 5. Annual Prostate Cancer Detection Exam. Includes a prostate specific antigen test for a Member who is 50 years of age and asymptomatic; or for a Member 40 years of age or older with a history of prostate cancer or another prostate cancer risk factor. 6. Services for the medically necessary diagnosis and treatment of osteoporosis for high -risk in- dividuals, including, but not limited to, estrogen- deficient individuals who are at clinical risk for osteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long- term glucocorticoid (steroid) therapy, individuals who have primary hyperparathyroidism, and individuals who have a family history of osteoporosis. 7. The following services and supplies. a. administration of whole blood and blood components. b. casts, splints, trusses, crutches and braces (excluding dental splints or dental braces); ileostomy and colostomy supplies. c. initial placement of a medically necessary prosthesis and its supportive device to replace a lost physical organ or parts or to aid in their function when impaired if the loss or impaired function occurred whiled covered under this Plan, including initial glasses and contact lenses if required following cataract surgery. The Plan will also cover the replacement of such prosthesis if it is determined by the covered person's physician to be necessary because of growth or change. d. oxygen or rental of equipment for administration of oxygen; e. the initial pair of eyeglasses or contacts needed due to cataract surgery or an accident that occurs while covered under the Plan if the eyeglasses or contacts were not needed prior to the accident; and f. the initial purchase and fitting of hearing aids; needed to correct hearing deficiency. the purchase or rental of medically necessary durable medical equipment. At our option, the cost or rental of durable medical equipment will be covered. If the cost of renting the equipment is more than a covered person would pay to buy it, only the cost of the purchase is considered to be a covered expense. In either case, total covered expense for durable medical equipment shall not exceed its purchase price. Any purchase must be pre- approved by us. The Plan does not pay for equipment or devices not specifically designed and intended for the care and treatment of an injury or sickness. 8. Dental work and treatment (including eligible Hospital Expenses) will be eligible only when necessitated for the treatment of Temporomandibular Joint Dysfunction (TMJ) or as the direct result of an accidental injury to the jaws, sound natural teeth, mouth or face, occurring while covered by this Plan, including replacement of such teeth within twelve (12) months after the accident. Injury caused by chewing or biting will be considered accidental injury; Citicare Fire 29 9. Charges for transportation of a Covered Person by a professional licensed ambulance service as follows: a. Ground transportation used locally to or from the nearest Hospital qualified to render treatment, or other medical institution (within the continental United States) for necessary special treatment not locally obtainable; b. Air ambulance where air transportation is medically indicated to transport a Covered Person to the nearest facility qualified to render treatment; and c. Ambulance service for necessary emergency treatment as a result of and within 48 hours of an accident or medical emergency. 10. Depo Provera, birth control devices (IUD) and treatment for complications incident to the usage of such devices. 11. Elective sterilization and related expenses regardless of medical necessity. 12. Charges for hypnosis recommended by and/or under the direct supervision of the attending Physician and considered recognized medical or psychiatric treatment of the condition. 13. Treatment of obesity diagnosed as: c. Endogenous when fully documented (including test results on which the diagnosis is based); or b. Morbid, provided: 1) the patient is at least 100 pounds over normal weight and 2) has a medically documented disease or health condition which is life threatening and is adversely affected by the obesity. Treatment of morbid obesity will include: a. Gastro bypass /stapling if there has been a history of unsuccessful attempts to reduce weight by more conservative measures while under the care and supervision of the Physician; and b. Participating at Weight Control Clinics while under the care and supervision of the Physician. 14. Charges for initial pair of orthopedic shoes when recommended by a Physician. 15. Reconstructive surgery and related services: a. To restore bodily function or correct deformity resulting from an accidental injury occurring while covered by this Plan provided the services or procedures begin within 90 days following the accident. b. To correct a congenital deformity or birth abnormality of a newborn c. In connection with post - traumatic or post - oncology treatment, provided the original con - dition necessitating such treatment occurred while covered by the Plan. d. In connection with a partial or full mastectomy, charges for; (i) mammoplasty surgery following a partial or full mastectomy; (ii) all stages of reconstruction of the breast on which the mastectomy has been performed; (iii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iv) prostheses and physical complications of mastectomy, including lymphedemas. 16. Charges for rhinoplasty, blepharoplasty or brow lift if due to a functional or non - functional condition after the first 12 months immediately following a Covered Person's effective date under this Plan to correct an accidental injury. 17. Charges for pap smears and office visits, abortions (including elective abortions), and testing and treatment of infertility (including artificial insemination if donor is the spouse). 18. Charges for Immunization shots, including the charge for the related office visit. 19. Charges for care or treatment rendered by a Clinical Social Worker (MSW). Citicare Fire 30 PRE- ADMISSION TESTING BENEFIT PRE - ADMISSION TEST means a diagnostic test ordered by the attending or consulting physician in connection with a planned hospital admission or outpatient surgery and performed on an outpatient basis within 10 days before the covered person's admission or outpatient surgery. A benefit will be payable for charges incurred by a covered person in connection with pre - admission testing when the following requirements are met: 1. The admission to the hospital or the scheduled outpatient surgery is confirmed in writing by the attending physician before the testing occurs. 2. The tests must be performed within 10 days before admission to the hospital or the outpatient surgery. 3. The tests must be ordered by the attending physician. 4. The tests are performed in a facility accepted by the hospital in place of the would normally be done while hospital confined. 5. The tests are not duplicated in the hospital. 6. The covered person is subsequently admitted to the hospital or the outpatient formed, except if a hospital bed is unavailable or because there is a change persons' health condition which would preclude the procedure. same tests that surgery is per- in the covered MEDICAL CASE MANAGEMENT BENEFIT This benefit applies only to a covered person who has suffered a severe personal injury or sickness while covered under the Plan. In addition to the benefits specified in this booklet, the City of Corpus Christi may elect to offer benefits for services furnished by any provider pursuant to an approved alternative treatment plan for a Covered Person whose condition would otherwise require hospital care. The Plan shall provide such alternative benefits for so long as it determines that alternative services are Medically Necessary and cost effective, and that the total benefits paid for such services do not exceed the total benefits to which the patient would otherwise be entitled under this Plan in the absence of alternative benefits. A "severe personal injury or sickness" includes, but is not limited to, the following: Major head trauma, spinal cord injury, amputations, multiple fractures, severe burns, neonatal high risk infants, severe stroke, multiple sclerosis, amyotrophic lateral sclerosis, metastatic cancer, acquired immune deficiency syndrome (AIDS), severe cardiac diseases, major trauma, severe hepatitis, bulimia, anorexia nervosa, severe congenital anomalies. If a covered person is accepted into the Medical Case Management program, the Plan will pay benefits for usual, customary and reasonable charges for rehabilitative services and supplies furnished to the individual whose condition would otherwise require hospital care and said benefits may exceed policy limitations and may extend beyond the types of expenses covered by the Plan. The Plan will determine the amount of benefits, but in no event will benefits exceed the Individual Lifetime Maximum Benefit of the Plan. Any agreement to pay benefits in accordance with the above will be based on an objective review of: 1. the covered person's medical status; 2. the current treatment plan; 3. the projected treatment plan;; 4. the long term cost implications; and 5. the effectiveness of care. Citicare Fire 31 Individual Medical Case Management may be terminated when the covered person has improved or deteriorated to the extent that the alternative services are no longer necessary and cost effective, the individual's coverage under the Plan ends, or the Individual Lifetime Maximum Benefit has been reached. If alternative benefits are provided for a Covered Person in one instance, the Plan shall not be ob- ligated to provide the same or similar benefits for other covered persons under this Plan in any other instance, nor shall it be construed as a waiver of the right of the Plan thereafter in strict accordance with its express terms. SECOND SURGICAL OPINION BENEFIT A benefit will be payable for charges incurred by a covered person in obtaining a second surgical opinion, after he or she has received a recommendation to have elective surgery which is covered under the Plan. The charges will not be subject to a deductible or co- payment if the consulting physician personally examines the covered person and the Plan receives a copy of the opinion. If the condition stated above is not met, the applicable deductible and benefit amount or percentage will be applied to the charges for the second opinion. If the second opinion does not . confirm the original recommendation, the covered person may consult another physician for a third opinion. The third opinion must be obtained, and benefits will be payable in the same manner as the second opinion. SPINAL MANIPULATION BENEFIT Benefits are payable for expenses incurred by a covered person for medically necessary manipulations of the skeletal structure; and for services rendered by a Doctor of Chiropractic for the detection and correction by manual or mechanical means (including X -rays incidental thereto) of structural imbalance, distortion or subluxation in the human body for the removal of nerve interference where such interference is the result of or related to distortion misalignment or subluxation of or in the vertebral column. SERIOUS MENTAL ILLNESS Benefits for the condition of Serious Mental Illness are covered to the same extent as coverage for any other major illness under the Plan, subject to the same limitations, deductibles and coinsurance factors. WELL CHILD CARE The Plan will pay benefits for outpatient preventive well -child care for a covered dependent child to 18 months of age. Outpatient preventive well -child care means the charges made by a personal physician for routine pediatric exams and immunizations given to a child as recommended by the American Academy of Pediatrics for children to 18 months. After age 18 months, only charges for immunization shots including the charge for the related office visit are covered. LEAVES OF ABSENCE & THE FAMILY AND MEDICAL LEAVE ACT Eligibility for coverage under the Plan may be continued during an employer- approved leave of absence, up to a period not to exceed the approved leave .The leave of absence may be granted by authority provided in the City of Corpus Christi Classification and Compensation System, the Limited - DutyProgram and Reasonable Accommodation for Disabled Employees Policy, and/or for a period not to exceed the greater of twelve (12) weeks, or the minimum mandated leave period provided by the FMLA. The employee is responsible for payment of amounts that would normally be deducted from his/her pay. This provision does not provide a Participant with a Leave of Absence; rather, it is merely an attempt to coordinate with the Employer's policies. Citicare Fire 32 No proof of good health may be required of, and reentry into the Plan will be immediate for, any Employee and/or Dependents who discontinued coverage during a leave of absence taken under the Family Medical Leave Act (FMLA) by the Employee so long as the Employee returns to Active Employment status before or immediately following the expiration of the FMLA leave. LIMITATIONS AND EXCLUSIONS PRE - EXISTING CONDITIONS LIMITATION A Pre - Existing Condition means a limitation or exclusion of benefits relating to a condition that was present before the date of enrollment for coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before such date. Health Plan benefits are limited to the first $1,000 of covered expenses incurred for a pre - existing condition. Thereafter, no benefits or services will be provided for a pre- existing condition, regardless of cause, for which medical advice, diagnosis, care, or treatment was recommended or received within the six (6) month period ending on the member's enrollment date. Coverage will not be provided until the earlier of the following dates: (a) the date the member has been free of treatment for the pre- existing condition for six (6) consecutive months or (b) twelve (12) consecutive months after the member's enrollment date, whichever occurs first. The exclusion does not apply to: (a) pregnancy; or (b) newborn children or children adopted before the age of 18 if they are covered under the Plan within 31 days of the date of birth or date of placement for adoption. The limitation period for such pre - existing condition exclusion must be reduced by all periods of creditable coverage, if any, applicable to the member as of his or her enrollment date that are not separated by a break in coverage of more than 90 days, not counting waiting periods. OTHER LIMITATIONS AND EXCLUSIONS Unless specifically stated otherwise, no benefits will be provided for the following: 1. An injury or sickness arising out of, or in the course of, any employment for wage, gain or profit. 2. A sickness or injury that is covered under any Workers' Compensation or similar law. This limitation also applies to a covered person who: (a) is not covered by Workers' Compensation; and (b) chose not to be. 3. Care and treatment given in a hospital owned or run by a government entity, unless the covered person is legally required to pay for such care. However, care provided by military hospitals to armed services retirees and their dependents is not excluded. 4. Any service the covered person would not be legally required to pay for in the absence of this Plan. 5. Sickness or injury for which the covered person is in any way paid or entitled to payment or care and treatment by or through a government program, other than Medicaid. 6. Medical services provided by the covered person's parent, spouse, brother, sister, or child or a person who ordinarily resides in the covered member's household or an immediate family member. 7. Investigational or experimental drugs or substances not approved by The City of Corpus Christi or by the Food and Drug Administration or the American Medical Association; drugs or substances used for other than Food and Drug Administration approved indications; or drugs labeled: "Caution- limited by Federal law to investigational use ". 8. Treatment, services, supplies or surgery that is not medically necessary. Citicare Fire 33 9. Purchase or fitting of hearing aids in excess of the initial aid(s) or devices, advice on their care, or implantable hearing devices. 10. Weekend non - emergency hospital admissions. 11. Treatment of sexual dysfunctions not related to organic disease; sex change services; reversal of elective sterilization, in -vitro fertilization, or artificial insemination (unless the donor is the spouse). 12. Any drug, biological product, device, medical treatment, or procedure which is experimental or investigational that is not approved by the City of Corpus Christi Food and Drug Administration or the American Medical Association; any drug, biological product, device, medical treatment or procedure which is not covered as experimental or investigational (or similar) by the HCFA Medicare Coverage Issues Manual; any drug, biological product, or device which cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and which lacks such approval at the time of its use or proposed use; and any drug or biological product categorized as a Treatment Investigational New Drug (IND) by the U.S. Food and Drug Administration or as a Group C Treatment Protocol drug by the U.S. National Cancer Institute at the time of its use or proposed use. Specifically excluded are: refractive keratoplasty or radial keratotomy, immunotherapy for recurrent abortion, chemonucleolysis, biliary lithotripsy, home uterine activity monitor, immunotherapy for food allergy, and percutaneous lumbar discectomy. 13. Dental work and treatment (including eligible Hospital Expenses) will be eligible only when necessitated for the treatment of Temporomandibular Joint Dysfunction (TMJ) or as the direct result of an accidental injury to the jaws, sound natural teeth, mouth or face, occurring while covered by this Plan, including replacement of such teeth within twelve (12) months after the accident. Injury caused by chewing or biting will be considered accidental injury; 14. Diagnosis or care and treatment of: (a) weak, strained, unstable or flat feet; (b) toenails, except removal of a nail matrix; or (c) symptomatic complaints of the feet. 15. Any: (a) superficial lesions of the feet, such as corns, calluses or hyperkeratoses; (b) tarsalgia, metatarsalgia or bunion, except surgery which involves exposure of bones, tendons or ligaments; (c) support devices for the foot (i.e. special stockings, socks, shoe inserts). 16. Any service, supply, or treatment connected with custodial care. The Plan does not cover these services no matter who provides, prescribes, recommends or performs them. Custodial care means services designed to help a covered person meet the needs of daily living, whether or not he or she is disabled. These services include help in: a. walking or getting in or out of bed; b. personal care such as bathing, dressing, eating, or preparing special diets; or c. taking medication which the covered person would normally be able to take without help. 17. Sickness sustained or contracted or injury caused by: (a) war, whether or not declared, or in- surrection; or (b) military service of any country or International organization. 18. Sickness sustained or contracted or injury caused by the covered person's: (a) engaging or attempting to in an illegal occupation; or (b) commission of or an attempt to commit a criminal act, or voluntary participation in a riot, insurrection, or civil disobedience. 19. Enrollment in a health club; or a weight loss or similar program except as specified. 20. Purchase or rental of supplies of common household use such as: exercise cycles; air purifiers; air conditioners; water purifiers; allergenic pillows or mattresses; or waterbeds. 21. Purchase or rental of: motorized transportation equipment; escalators or elevators; saunas or swimming pools; professional medical equipment such as blood pressure kits; or supplies or attachments for any of these items. 22. Convenience or personal care services such as use of a telephone or television. 23. Any surgical procedure to reduce obesity, except as specified. 24. Sickness or injury for which benefits are paid or payable under: (a) the mandatory provisions of Citicare Fire 34 any auto insurance policy written to comply with a "no- fault" insurance law; or (b) an uncovered motorist insurance law; or benefits which would have been paid under any auto insur- ance policy had the covered person properly complied with the mandatory provisions of a "no- fault" insurance law. 25. Homeopathic drugs as defined in the Homeopathic Pharmacopeia. 26. Charges for nurses aid services; 27. Charges for missed appointments or completion of claim forms; 28. Charges incurred in a nursing home or convalescent hospital unless otherwise specified; 29. . Charges incurred when not under the regular care of a legally qualified Physician; 30. Charges for orthotics; 31. Charges for travel and accommodations; except for the Organ Transplant Benefit. 32. Plastic, cosmetic and reconstructive surgery unless medically necessary as the result of an injury or tumor. The injury, or the initial tumor surgery, must occur while covered under the Plan. Such surgery will also be covered if an objective functional impairment is present or if required to correct a congenital defect or birth abnormality of a newborn. The presence of a psychological condition will not entitle a covered person to coverage for plastic, cosmetic or reconstructive surgery unless all other conditions are met. 33. Vision analysis and examination, testing or orthoptic training, eye refractions or the purchase of eyeglasses or contact lenses (except as specified) to correct refractive errors and related services, including surgery performed to eliminate the need for eyeglasses for refractive errors (i.e. radial Keratotomy). 34p Services and supplies which are (a) rendered in connection with mental illnesses not classified in the International Classification of Diseases of the U.S. Department of Health and Human Services, (b) extended beyond the period necessary for evaluation and diagnosis of learning and behavioral disabilities or for mental retardation, or (c) for mental illnesses which, according to generally accepted professional standards, are not usually amenable to favorable modification. This exclusion shall not apply to ADD or ADHD, which shall be covered as any other illness. 35. Routine physical examinations, even when required by an employer, school or insurance company. 36. Court ordered treatment for psychiatric disorders, when such order is the result of, or arises out of conduct by the covered person which is or would be criminal activity under the laws of the state or the Federal Government. 37. Maintenance care, which consists of services and supplies furnished mainly to: a. maintain, rather than improve, a level of physical or mental function; or b. provide a protected environment free from exposure that can worsen the covered member's physical or mental condition. 38. Care and treatment rendered by a provider whose services are not required to be covered by state law, except as provided by the Plan. 39. Care and treatment of complications of non - covered procedures, unless required by law. 40. Expenses incurred prior to the effective date or after the termination date of your coverage. 41. Sickness or injury caused by the covered person's intentional self - inflected illness, injury or attempted suicide except psychiatrist's charges incurred for treatment in connection with suicide or self - inflected injuries, including drug overdose, will be a covered expense. 42. Charges for marital or family counseling, family planning, sex therapy, pastoral counseling or other social services. 43. Hypnotism, Acupuncture, Goal Behavior Modification Therapy, except as specified. 44. Charges for Home Health Care or Hospice Care; 45. Charges for care or treatment rendered by a: a) Christian Science Practitioner; b) Homeopath; c) Naturopath; d) Optometrist; e) Pastoral Counselor; or f) Pharmacist. Citicare Fire 35 46. Education and training except as specified. EXTENSION OF BENEFITS COVERAGE AFTER TERMINATION If a Covered Person is Totally Disabled on the date coverage terminates, benefits will be extended (subject to all other Plan provisions and limitations) during the continuation of the disability with respect to the injury or illness causing the disability if such person is not or does not become covered under any other plan entitling such person to any benefits from that injury or illness. Benefits will be extended for Covered Expenses until the earliest of the following dates: 1. The date the Covered Person ceases to be Totally Disabled; or 2. The date the applicable plan maximum is paid; or 3. The end of a twelve (12) month period; or 4. If lesser, a period equal to the time such Covered Person was covered under the Plan beginning with the first day following the termination of coverage. Benefits are not extended under this provision if this Plan terminates. FEDERAL CONTINUATION OF COVERAGE CONSOLIDATED OMNIBUS BUDGET RECONCILLIATION ACT (COBRA) A federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), requires that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called "continuation coverage ") at group rates in certain instances where coverage under the plan would otherwise end. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. This section is intended to inform you, in a summary fashion, of your rights and obligations concerning COBRA continuation coverage. You and your covered dependents should take the time to read this section carefully. This section applies to you if you are an employee or a covered dependent of an employee of the City of Corpus Christi covered by a group health plan sponsored by the City of Corpus Christi, which includes this Plan. COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you and your dependents (spouse and children) are covered under the Plan, each of you have the right to choose continuation coverage for up to eighteen (18) months if you or your covered dependents lose group health coverage under the Plan for any of the following reasons, called "qualifying events ": • Your employment terminates (voluntarily or involuntarily) for any reason other than for gross misconduct. If you decide not to return to benefits eligible employment at the City during Family & Medical Leave Act ( "FMLA ") leave, you will be offered COBRA at the date your FMLA leave ends. • You are no longer eligible for coverage due to reduced work hours. In addition, if you are a covered dependent you have the right to choose continuation coverage for up to thirty -six (36) months if you lose group health coverage under the Plan due to any of the following qualifying events: Citicare Fire 36 For dependent children, the child no longer qualifies as a dependent under the rules of the Plan, such as reaching the maximum age. Divorce or legal separation between the employee and spouse. The employee becomes entitled to Medicare (i.e., enrolled in Medicare (Part A, Part B, or both). The employee's death. Note: A dependent means any eligible dependent whose coverage became effective and has not terminated. This includes: 1. The lawful spouse of a covered employee. 2. An unmarried child to the end of the month in which the child attains age 25 (a mentally retarded or physically handicapped child may continue coverage beyond the limiting age if appropriate documentation is provided that (a) the child is incapable of self - sustaining employment because of mental or physical disability, (b) the child chiefly relies on the covered employee for financial support, and (c) if the child is first enrolled on or after the child's 25th birthday, the child is medically certified as disabled and is dependent on the covered employee). A child includes: (a) unmarried natural born child; or (b) unmarried legally adopted child (including a child placed with the covered employee for adoption for whom the covered employee has a legal obligation for total or partial support); or (c) an unmarried child you are seeking to adopt if the covered employee is a party to a suit regarding the child's adoption; or (d) an unmarried child for whom the covered employee was the legal guardian; or (e) a child who is dependent upon the covered employee for health coverage pursuant to a valid court order, including a qualified medical child support order (QMCSO); or (f) an unmarried child who lives with the covered employee in a normal parent child relationship if the child qualifies at all times for the dependent exemption as defined in the Internal Revenue Code and the Federal Tax Regulations; or (g) an unmarried natural born or adopted child of the covered employee's spouse (i. e.; the covered employee's step- child.) 3. Any unmarried grandchild if that unmarried grandchild is younger than 25 years of age and, at the time application for coverage of the unmarried grandchild is made under the Plan is the dependent of the covered employee for federal income tax purposes. However, once the grandchild is properly covered, coverage for the unmarried grandchild may not be terminated solely because the covered grandchild is no longer a dependent of the covered employee for federal income tax purposes. 4. As otherwise defined under the Plan. Each person has the right to choose continuation coverage, regardless of the covered employee's decision or that of other dependents. For example, a covered spouse or child may elect continuation coverage even if the covered employee does not do so. If you cover your spouse and/or dependents under the Plan, please ensure that your spouse and/or dependents understand the contents of this notice. If any covered dependent does not live with you, Citicare Fire 37 you may request an additional copy of a COBRA notice be provided directly to that dependent. That must be done in writing. You may elect to continue the coverage described above on behalf of any covered dependent, but you cannot decline continuation coverage on behalf of a covered dependent (other than a minor child or an incapacitated person for whom you are the legal representative). You may change your continuation coverage and may add or cancel continuation coverage for spouses and dependents (1) during any open enrollment period that is offered to City employees, or (2) in conjunction with a qualifying life status change under the Plan, such as the birth or adoption of a child or loss of other coverage. The change requested must be related to the life status change. Under the law, the employee, spouse, and/or dependent has the responsibility to inform the City of Corpus Christi's Human Resources Department, in writing, of a divorce or a child losing dependent status under the City's Health Care Plan. This notice must be given within 60 days of the date of the event or the date in which coverage would end under the Plan because of the event, whichever is later. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. If you fail to notify the Human Resources Department, you and your dependents may lose rights to continuation coverage. When the Plan is notified that one of these qualifying events has happened, the City of Corpus Christi or their third party administrator will in turn notify you that you and your covered dependents have the right to choose continuation coverage. Under the law, you and your covered dependents have at least 60 days from the date you would lose coverage because of one of the events described above, or the date notice of your election rights is sent to you, whichever is later, to inform the City that you want continuation coverage. If you do not choose continuation coverage, your group health benefits will end effective the date of the qualifying event. If you choose continuation coverage, the City of Corpus Christi is required to give you coverage which, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees or covered dependents. COBRA continuation coverage is a temporary continuation of coverage. In three situations, the 18- month period for continuation coverage (which applies if your employment is terminated or you lose coverage due to a reduction in hours) may be extended. • Disabled Person. The 18 months will be extended to 29 months if an individual is disabled at the time of the qualifying event or within the first sixty (60) days of the person's continuation coverage. To be considered disabled, you must have been determined to be so by the Social Security Administration. If such a determination is made, the disabled individual and all other family members of the disabled person on continuation coverage are entitled to the extra eleven (11) months of continuation coverage. Notwithstanding anything in this paragraph to the contrary, in order to receive the extension, you must not, the Human Resources Department of the City of Corpus Christi in writing in a timely fashion at the time of COBRA election or within 60 days of the date the individual receives documentation that the Social Security Administration has determined the individual to be disabled. This notice must be received no later than the end of the initial 18 -month coverage period In addition, you must notify the Human Resources Department of the City of Corpus Christi within 30 days of any final determination that the individual is no longer disabled You must send Citicare Fire 38 these notices to the Human Resources Department of the City of Corpus Christi at the address listed below. • Second Qualifying Event. Persons entitled to only eighteen (18) months of continuation coverage may receive an additional eighteen (18) months of continuation (for a total of 36 months) if, during the first eighteen month period, a second qualifying event occurs. For example, if an employee is terminated and the employee's spouse chooses termination coverage, and in the tenth month of the continuation coverage the former employee dies, the spouse is entitled to the additional 18 -month extension. Disabled persons and their family members who have qualified for an additional 11 -month period and who experience a second qualifying event during the additional 11 -month period can extend continuation coverage for an additional seven (7) month period, for a total continuation period of thirty-six (36) months. In all of these cases, you must make sure that the Human Resources Department of the City of Corpus Christi is notified in writing of the second qualing event within 60 days of the second qualifying event You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. o Medicare- Entitled Employee Leaves Employment. When an employee who has been entitled to Medicare for less than 18 months loses coverage under the Plan due to retirement, voluntary or involuntary termination (for reasons other than the employee's gross misconduct) or reduction in work hours, the employee's spouse and dependents, but not the covered employee are entitled to a continuation period for longer than 18 months. In these instances, their continuation period ends thirty-six months from the date the employee became entitled to Medicare. You must make sure that the Human Resources Department of the City of Corpus Christi is noted in writing of this second qualifying event within 60 days of the second qualiffing event. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. Your continuation coverage will be terminated by the City of Corpus Christi if: (1) The City of Corpus Christi no longer provides group health coverage to any of its employees. (2) The premium for your continuation coverage is not paid on time. (3) You become covered under a new group health plan, either as an employee, spouse or dependent, after the date you elected COBRA continuation coverage from this Plan. However, continuation coverage will not end if the new plan has a valid provision which does not allow coverage, or limits coverage, due to a preexisting condition. (4) You become entitled to Medicare after your COBRA continuation coverage election. (5) During the additional 11 -month extension for disabled persons, you are determined to no longer be disabled by the Social Security Administration. After COBRA continuation coverage begins, under the law, the employee, spouse, and/or dependent has the responsibility to inform the City of Corpus Christi's Human Resources Department in writing if any qualified beneficiary: (1) becomes covered under a new group health plan: (ii) becomes entitled to Medicare: or (iii) is determined to be no longer disabled by the Social Security Administration. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. You do not have to show that you are insurable to choose continuation coverage. However, you must pay your premium for your continuation coverage. There is a grace period of 30 days for payments of Citicare Fire 39 the regularly scheduled premiums, except for the first premium, which must be paid within 45 days from the day COBRA is first elected and must include payments for all past periods of continuation coverage beginning with the date of the qualifying event. If you have any questions about the COBRA continuation coverage, please contact the City of Corpus Christi's Human Resources Department, 1201 Leopard, Corpus Christi, TX 78401, (361) 880 -3300, or you may contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration ( "EBSA "). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website at www.dol.gov /ebsa. Also, if you have changed marital status, or you or your covered dependents have changed addresses please notify in writing the City of Corpus Christi, Human Resources Department, at the above address. In order to protect your family's rights, you should keep the Human Resources Department of the City of Corpus Christi informed in writing of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Human Resources Department. CONTINUATION COVERAGE FOR EMPLOYEES IN THE UNIFORMED SERVICES Employees on Military Leave (Uniformed Services. Employment and Reemployment Rights Act of 1994 (USERRA) An Employee who is absent from work for more than thirty (30) days in order to fulfill a period of duty in the Uniformed Services of the United States has a Qualifying Event as of the first day of the Employee's absence for such duty, and thus is eligible for rights under USERRA. The Employer shall furnish to the Employee a notice of the right to elect continuation coverage under USERRA and shall afford the Employee the opportunity to elect such coverage in accordance with USERRA. If the Employee elects coverage, the right to that coverage ends: A) on the day after the deadline for the Employee to apply for reemployment with or return to active employment with the Employer or B) eighteen (18) months beginning on the date of the employee's absence from employment with the Employer. An employee who elects to continue coverage may be required to pay up to 102 percent of the full premium under the Plan. However, during the first thirty (30) days that the Employee is absent in order to fulfill a period of duty in the Uniformed Services of the United States, the Employee must be treated the same as any other employee. This means the higher USERRA premium cannot be collected from the Employee for the first thirty (30) days. After the Employee has been absent for more than thirty (30) days, the Employee will receive immediate USERRA coverage upon payment of the entire cost of coverage plus a reasonable administration fee. Further, the Employee will have no preexisting condition exclusions applied by the Plan upon return from service. These rights apply only to Employees and their Dependents covered under the Plan before leaving for military service. In many instances, an Employee eligible for continuation of coverage under USERRA will also be eligible for continuation of coverage under COBRA. To the extent allowed under the law, the continuation of coverage periods under COBRA and USERRA will run concurrently under the plan. Citicare Fire 40 Plan exclusions and waiting periods may be imposed for any Sickness or Injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, military service. IF THE EMPLOYEE TURNS 65 AND CONTINUES WORKING FULL -TIME All actively employed Employees and their covered spouses over age 65 have the option to accept or reject benefits under this Plan. if the Employee or spouse rejects this Plan (in writing to the Plan Administrator), Medicare will remain the Primary Payor. PROVISIONS APPLICABLE TO ALL HEALTH PLAN BENEFITS COORDINATION OF BENEFITS Definitions - Here are some terms used in this provision. ALLOWABLE EXPENSE means any necessary, reasonable and customary item of expense at least a part of which is covered by any one of the plans that covered the person for whom claim is made. When the benefits from a plan are in the form of services, rather than cash payments, the reasonable cash value of each service is both an allowable expense and a benefit paid. CLAIM DETERMINATION PERIOD means a plan year or that part of a plan year in which the person has been covered. PLAN means the coverage of medical or dental expenses or services by: 1. any group insurance plan, blanket or franchise on an covered or uncovered basis; 2. service plan contracts, group or individual practice or other pre - payment plans; or 3. labor - management trusteed plans, union welfare plans, employers organization plans or em- ployee benefit organization plans. 4. Coverage under governmental programs or coverage required or provided by any statute, except Medicare. (Refer to the Effect of Medicare provision for treatment of this coverage under This Plan.) The term does not include coverage under individual policies or contracts. Each plan or part of a plan which has the right to coordinate benefits is considered to be a separate plan. THIS PLAN means the benefits of the Plan which are subject to this coordination of benefits provision. WHAT A COORDINATION OF BENEFITS PROVISION DOES If a person is covered by this plan and by any of the other plans described above, a coordination of benefits provision will be used when the amount of benefits payable by this plan and the amount of benefits payable by any of the other plans for the same medical expenses would exceed the total amount of allowable expenses in a claim determination period. A coordination of benefit provision determines: 1. the order in which all plans pay their benefits; and 2. when, depending on the order of benefit determination, a plan may reduce its benefit so that not more than 100% of the allowable expenses are paid jointly by all plans. ORDER OF BENEFIT DETERMINATION In order to administer this provision, it is first necessary to determine the order in which all of the plans pay their benefits. This order is shown below. 1. A plan which does not contain a coordination of benefits provision is considered to determine its Citicare Fire 41 benefits before a plan which does contain such a provision. 2. A plan which covers a person as an employee is considered to determine its benefits before a plan which covers a person as a dependent. 3. A plan which covers a person as the dependent of a person whose month and day of birth (excluding the year of birth) occurs earlier in the calendar year is considered to determine its benefits before a plan which covers the person as the dependent of a person whose month and day of birth (excluding the year of birth) occurs later in the calendar year. If either one of the plans does not have this "birthday rule" provision, then the plan without this provision is considered to determine its benefits before the plan which does contain this provision. In the case of divorced or legally separated parents, the order of payment is determined as shown below. a. If there is a court decree which establishes financial responsibility for a dependent child's health expenses, the plan of the parent with that responsibility is considered to determine its benefits before the Plan of the parent without the responsibility. b. If there is no such decree and the parent with custody of the child has not remarried, the plan which covers the child as a dependent of the parent with custody is considered to determine its benefits before the plan of the parent without custody. c. if the parent with custody of the child has remarried: 1) the Plan which covers the child as a dependent of the parent with custody determines its benefits first; 2) the Plan which covers the child as a dependent of the step - parent determines its benefits second; and 3) the Plan which covers the child as a dependent of the parent without custody de- termines its benefits third. If the above rules fail to establish the order of payment, the plan which has covered the person for the longest time is considered to determine its benefits first. However, a person may be covered as an active employee by one plan and as a retired or laid -off person or the dependent of such person by another plan. In this case, if both plans contain a provision regarding retired or laid -off employees, the plan which covers the person as an active employee or the dependent of such person is considered to determine its benefits before the plan which covers the person as a retired or laid -off employee or the dependent of such person. If either one of the plans does not contain a provision for retired or laid -off employees, and as a result each plan determines its benefits after the other, the order of benefit determination shown above will be used to determine the order of payment by the plans. HOW BENEFITS ARE COORDINATED If the benefits of this plan are payable first, the benefits payable by the other plans are ignored when the Plan determines the amount payable. If this plan's benefits are payable after those of any other plan, the Plan adds up the benefits payable by each of the plans in the order in which they pay and compare the total benefits payable to the total amount of allowable expenses. If this Plan's payments would result in benefits which exceed total allowable expenses, benefits are reduced. When coordination reduces the total amount otherwise payable, each benefit that would have been payable in the absence of coordination is reduced in proportion. The reduced amounts are charged against any applicable benefit limits of this plan. In no event will this plan's payment be more than it would have been in the absence of other plans. The Plan reserves the right to release to or obtain from any other organization or person without the consent of or notice to any covered person, any information which, in the Plan's or its administrator's opinion, the Plan needs for the purpose of coordination of benefits. Citicare Fire 42 When payment which should have been made by this plan has been made by any other plan, this Plan has the right to .pay to any organization making these payments an amount this Plan considers to be warranted. Amounts paid in this manner are considered to be benefits paid by this Plan. After this Plan makes such payments, it has no further liability. When this Plan has made an overpayment, it has the right to recover that payment to the extent of the excess. This Plan may recover the overpayment from the person to whom it was made or from any other insurance company or organization. Any Covered Person receiving benefits under This Plan must furnish information about other coverage which may be involved in applying this Coordination of Benefits provision. ELIGIBILITY FOR MEDICARE ELIGIBLES Definitions — The definitions below apply only to this Provision MEDICARE PART A means the federal program that provides hospital insurance benefits. MEDICARE PART B means the federal program that provides medical insurance benefits. For the purposes of determining benefits payable for any covered person who is eligible to enroll for Medicare Part B, but does not, this Plan assumes the amount payable under Medicare Part B to be the amount the covered person would have received if he or she enrolled for it. A covered person is considered to be eligible for Medicare on the earliest date coverage under Medicare could become effective for him or her. INTEGRATION WITH MEDICARE When an employer employs 100 or more persons, the benefits of this Plan will be payable first for a covered person who is under age 65 and eligible for Medicare. The benefits of Medicare will be payable second. TEFRA OPTIONS The Tax Equity And Fiscal Responsibility Act of 1982 (TEFRA), as amended, allows the employer's actively working covered group members age 65 or older and their covered spouses who are eligible for Medicare to choose one of the following options: OPTION 1 - The benefits of this Plan will be payable first and the benefits of Medicare will be payable second. OPTION 2 - Medicare benefits only. The group member and his or her dependents, if any, will not be covered by the Plan. You may elect Medicare as primary coverage of benefits. However, if you do elect to have Medicare as primary coverage, then you are voluntarily opting out of coverage under the Plan and your coverage will terminate. If the individual does not choose one of the above options in writing, this Plan will be primary. The group must provide each covered group member and each covered spouse with the choice to elect one of these options at least one month before the covered group member or the covered spouse becomes age 65. All new group members and newly covered spouses age 65 or older must be offered these options. If Option 1 is chosen, its issue is subject to the same requirements as for a group member or dependent under age 65. Under the TEFRA regulations, there are two categories of persons eligible for Medicare. The calculation and payment of benefits by the Plan differs for each category. Citicare Fire 43 CATEGORY 1 Medicare Eligible are: 1. actively working covered group members age 65 or older who choose Option 1; 2. their age 65 or older covered spouses; and 3. age 65 or older covered spouses of actively working covered group members who are under age 65. CATEGORY 2 Medicare Eligible are any other covered persons entitled to Medicare, whether or not they enrolled for it. This category includes, but is not limited to: 1.. retired group members and their spouses; or 2. covered dependents of an covered group member, other than his or her spouse. CALCULATION AND PAYMENT OF BENEFITS For covered persons in Category 1, benefits are payable by the Plan without regard to any benefits payable by Medicare. Medicare will then determine its benefits. For covered persons in Category 2, Medicare benefits are payable before any benefits are payable by the Plan. The benefits of this Plan will then be reduced by the full amount of all Medicare benefits the covered person is entitled to receive, whether or not they were actually enrolled for Medicare. Covered Retirees For Covered Retirees who are eligible for Medicare, benefits will be paid under This Plan to the extent of the difference between the dollar amount that Medicare will pay under Parts A and B and the dollar amount of benefits that would have been paid under This Plan if the Covered Person was not eligible for Medicare. This means that Medicare will pay its benefits first and then This Plan will calculate its benefits and pay the amount of the benefits less the amount that Medicare paid. All Plan maximums will apply. When a disabled, non - working employee becomes eligible for benefits under Medicare, as a result of a disability (other than End Stage Renal Disease) and chooses to remain covered under this Plan, Medicare will be the primary payer of benefits. Medicare will pay benefits first, and this Plan will be the secondary payer. Disability Due to End Stage Renal Disease If a Covered Person becomes eligible for benefits under Medicare as a result of disability due to End Stage Renal Disease and chooses to remain covered under this Plan, this Plan will pay its benefits first and Medicare will be the secondary payer for the first thirty-three (33) months of disability. After the initial thirty -three (33) months, Medicare will be the primary payer. Medicare disability rules apply to the disabled family members of active employees who are not disabled. For example, Medicare would be the secondary payer of benefits for a disabled spouse of an active employee who is covered under a large group health plan. For purposes of this provision, the term "disabled" will be the defmition given by Social Security. REGARDLESS OF THE PROVISIONS STATED ABOVE, THIS PLAN SHALL AT ALL TIMES COMPLY WITH MEDICARE AS ENACTED AND AMENDED. CLAIMS The Plan Must Be Notified of Intent to File a Claim Notice of a claim for benefits must be given to the Plan in writing. Any claim will be based on the written notice. The notice must be received within 30 days after the start of the loss on which the claim is based. If notice is not given in time, the claim may be reduced or invalidated. If it can be shown that it was not reasonably possible to submit the notice within the 30 -day period and that notice was given as soon as possible, the claim will not be reduced or invalidated. Citicare Fire 44 When to File Proof of Claim Participating providers are responsible for submitting claims for covered expenses directly to the Plan on the covered person's behalf. Health care providers who have entered into a reimbursement agreement with the Plan have agreed not to bill the covered person for an amount greater than the difference between reasonable charges and the benefit amount paid by the Plan. The covered person will need to complete and sign all necessary papers and authorize participating providers to release those medical records which may be necessary to complete the processing of your claim. Benefit payments for covered services received from a participating provider will be forwarded directly to the provider. Written proof of claim for services rendered by a non - participating provider must be given to us within 90 days after the date of the injury or sickness for which claim is made. If proof of claim is not submitted within the required time period, the claim may be reduced or invalidated. If it can be shown that it was not reasonably possible to submit within the time period and that the proof was submitted as soon as possible, the claim will not be reduced or invalidated. The Plan May Extend Time Limits If the time limit for giving notice of claim or submitting proof of loss is less than the law permits in the state where the claimant lives, the Plan extends its time limits to agree with the minimum period specified by that state's laws. The law must exist at the time the Plan is issued. The Plan's Right to Require Medical Exams The Plan has the right to require that a medical exam be performed on any claimant for whom a claim is pending as often as it may reasonably require. If the Plan requires a medical exam, it will be per- formed at the Plan's expense. The Plan also has the right to request an autopsy in the case of death, if state law so allows. To Whom Benefits are Payable All benefits are payable to the covered group member. However, with our consent, a covered person may direct us to pay all or any part of the medical benefits to the medical care provider on whose charge the claim is based. If any covered person to whom benefits are payable is a minor or, in our opinion, not able to give a valid receipt for any payment due him or her, such payment will be made to his or her legal guardian. However, if no request for payment has been made by the legal guardian, the Plan may, at its option, make payment to the person or institution appearing to have assumed his or her custody and support. When the Plan Pays The Plan will pay benefits for covered medical services after the covered person has satisfied any de- ductibles and co- payment amounts. No benefits are payable for charges which are discounted, waived or rebated by a provider of services simply because the covered person is covered. The Plan shall have the right to recover from a provider of services or from a covered person any excess benefits paid for charges which were discounted, waived or rebated. All benefits will be paid not more than 60 days after the Plan receives proper written proof of claim. If a covered person dies while medical benefits remain unpaid, the Plan may choose, in its sole discretion, to pay benefits to: 1. any person or persons related to the covered person by blood or marriage who appears to be entitled to the benefits; or 2. the executors or administrators of the covered person's estate, based on our selection. The Plan will be discharged of liability to the extent of any such payments made in good faith. Citicare Fire 45 Right of Recovery Our intention is to preserve and assert our rights to recover for sums paid or benefits provided where circumstances warrant the assertion of our rights, to the fullest extent allowed by the applicable laws of the jurisdiction involved. Each provision below shall be considered severable, and if any provision is determined to be unenforceable or void, the remaining provisions shall remain unaffected. Subrogation This provision applies when another party (person or organization) is, or may be, considered re- sponsible for causing injury or for payment of benefits due to a covered person's injury or sickness for which benefits under the Plan have been provided or paid. To the extent of such benefits, the Plan is subrogated to all rights and claims for recovery the covered person has against any party (including a health care carrier) responsible for the injury for payment to the covered person on account of the injury. Right of Reimbursement If payment (by settlement, judgment or any other manner) is made, or may be made, in the future by, or on behalf of, a responsible party to the covered person (which includes any type of party who agrees to compensate or pay a covered person) with respect to the occurrence of a covered person's injury or sickness, expenses arising from the covered person's injury or sickness are not covered by the Plan, and the covered person and covered employee must promptly reimburse the Plan for the payment of such expenses up to the full amount of the payments or compensation received from the other party (regardless of how that payment or compensation may be characterized and regardless of whether the covered person has been made whole). However, if the Plan receives a claim for which benefits would be payable in the absence of a responsible party as described above, the Plan will pay those benefits subject to the following conditions: 1. 2. 3. 4. The covered person automatically grants to the Plan a first priority lien to the extent of benefits advanced upon any recovery, by settlement, judgment or otherwise that the covered person receives from the responsible party, or any person or organization making payment on behalf of the responsible party, including first party, undercovered and uncovered motorist coverage. The lien will be in the amount of benefits provided or paid by the Plan for the treatment of the condition for which the third party is responsible or agrees to make payment. You agree to notify the claims administrator, in writing, within 60 days of your claim against the responsible party and to take such action, furnish such information, cooperate generally, and execute any documents as the Plan may require facilitating enforcement of our rights. The covered person automatically assigns to the Plan any benefits the covered person may have under any automobile policy or other coverage, to the extent of the Plan's claim for reimbursement. The covered person shall automatically hold any compensation or other payments received in constructive trust for the benefit of the Plan. Exclusively at our option and choice, and without any waiver of any other rights of the Plan, in the event of prejudice, non - cooperation or breach of this Plan, the covered person and covered employee hereby agree that the Plan may withhold, deduct or retract payments to or on behalf of the covered person or covered employee. Duplication of Benefits /Other Insurance This provision is intended to prevent overpayment or duplication of benefits under this Plan when Citicare Fire 46 other health care coverage provides the same benefits. It applies when a person is covered by us and has, or is entitled to, benefits as a result of their injuries from any other coverage including, but not limited to, first party uncovered or undercovered motorist coverage, any no -fault insurance, medical payment coverage (auto, homeowners or otherwise), workers compensation settlement or awards, other group coverage (including student plans), direct recoveries from liable parties, premises medical pay or any other insurer providing coverage that would apply to pay your medical expenses, except other group health carriers in which case coverage will be determined under Coordination of Benefits. Where there is such coverage, the Plan will not duplicate other coverage available to the covered person and shall be considered secondary, except where specifically prohibited. Where double coverage exists, the Plan shall have the right to be repaid from whomever has received the overpayment to the extent of the duplicate coverage. This provision applies whether or not the covered person has made a claim under other applicable coverage. When applicable, the covered person is required to provide us with authorization to obtain information about the other coverage available, and to cooperate in the recovery of overpayments from the other coverage, including executing any assignment of rights necessary to obtain payment directly from the other coverage available. Cooperation Required The covered person has a duty to cooperate by providing information and executing any documents to preserve our right and shall have the affirmative obligation of notifying the claims administrator that claims are being made against responsible parties to recover for injuries for which the Plan has paid. If the covered person enters into litigation or settlement negotiations regarding the obligations of the other party, the covered person must not prejudice, in any way, the Plan's rights to recover an amount equal to any benefits the Plan has provided or paid for the injury or sickness. Failure of the covered person to provide the Plan such notice or cooperation, or any action by the covered person resulting in prejudice to the Plan's rights will be a material breach of this Plan and will result in the covered person being personally responsible to make repayment. In such an event, the Plan may deduct from any claim any amounts the covered person owes the Plan. Legal Actions and Limitations No action at law or in equity may be brought to recover under the Plan until at least 60 days after written proof of claim has been filed with us. It action is to be taken after the 60 day period, it must be taken within 2 years of the date written proof of claim was required to be filed. Payment to the State of Texas If a covered person incurs covered expenses which are covered under the Medical Assistance Act of 1967, as amended, the Plan will reimburse to the Texas Department of Human Resources, or appropriate State agency, the actual cost of covered expenses the Department pays through medical assistance to the covered person. The Plan will be discharged of its obligation to the extent of any such payment. Complaint Notice Should any dispute arise about premium payment or about a claim that has been filed, the covered person may write to the claims administrator. If the problem is not resolved, the covered person may also contact this plan directly by writing to the Texas State Board of Insurance at (800) 242 -3439 or send written correspondence to P.O. Box 149104, Austin, Texas 78714 -9104. Citicare Fire 47 TERMINATION PROVISIONS - TERMINATION OF YOUR COVERAGE A. Your coverage will terminate on the earliest of the following dates: 1. the date you cease to be in a class of eligible group members; 2. the last day for which you make any required premium contribution for your Plan; 3. the last day for which the policyholder has made any required premium contribution for coverage on your behalf; 4. the date your Lifetime Maximum Benefit is reached; or 5. the date the Plan is terminated. B. Coverage under this Plan will terminate for an employee who is qualified for Medicare and elects to have Medicare pay as primary coverage. C. Subject to payment of required premiums rules precluding preferential selection, coverage may be continued during an approved medical leave of absence in accordance with Employer Policy, Chapter 143 of the Texas Local Government Code, and the Collective Bargaining Agreement . If an employee is unable to return to full time employment, his/her employment will be terminated and coverage as a full time employee shall end. D. Failure to sign and submit annual open enrollment forms shall result in termination of coverage effective on the first day of the plan year for which enrollment forms are not signed and submitted. E. Failure to submit address changes that result in the Benefit Sections' inability to contact you will result in termination of coverage. Employers subject to Family Medical Leave Act Regardless of the established leave policies mentioned above, the Plan shall comply with the Family and Medical Leave Act of 1993 as regulated by the Department of Labor. TERMINATION FOR CAUSE The Plan may terminate a covered person's coverage for cause pursuant to the following: 1. If a covered person allows an unauthorized person to use his or her identification card or uses the identification card of another member. Under these circumstances, the person who receives the services provided by use of the identification card will be responsible for paying us the reasonable charges for those services. 2. If a covered person or group perpetrates fraud and/or misrepresentation on claims or identification cards in order to obtain services or a higher level of benefits. This includes, but is not limited to, the fabrication and/or alteration of a claim or identification card. TERMINATION OF DEPENDENT COVERAGE A dependent's coverage will terminate on the earliest of the following dates: 1. the date the employee's coverage terminates; 2. the date the employee ceases to be in a class of members eligible for dependent coverage; 3. the last day for which the employee makes any required contribution for dependent coverage; 4. the date the dependent coverage benefit or the Plan is terminated; 5. the date a dependent reaches his or her Lifetime Maximum Benefit; or 6. the date a dependent no longer qualifies as a dependent. DISABLED CHILDREN If an unmarried dependent child who has reached the maximum age for a dependent meets all of the requirements shown below, the Plan extends dependent health coverage for that child for as long as the employee remains covered for dependent coverage. 1. The child must be incapable of self - sustaining employment because of mental or physical Citicare Fire 48 disability. 2. The child must rely on the employee for fmancial support. The employee must give the Plan proof of the child's disability within 31 days of the date the child reaches the maximum age. The Plan may request additional proof from time to time for the remainder of the child's coverage under the Plan. MISCELLANEOUS PROVISIONS REVIEW AUTHORITY The City of Corpus Christi shall have complete authority to review all denied claims for benefits under the Plan (including, but not limited to, the denial of certification of the medical necessity of hospital or medical treatment). In exercising its responsibilities, the City shall have sole and complete discretionary authority 1) to determine whether and to what extent individuals are eligible for benefits; 2) to construe disputed or doubtful Plan terms; and, 3) to make determinations regarding alternative care plans when reviewed and approved by the network [Independent] Medical Director. Notwithstanding anything to the contrary, benefits under this Plan will be paid only if the City determines, in its sole discretion, that an individual is entitled to such benefits pursuant to the terms of the Plan or as required by law. The City shall be deemed to have properly exercised such authority unless it has abused its discretion hereunder by acting arbitrarily and capriciously. COVERED PERSON/PROVIDER RELATIONSHIP The Plan does not provide covered services. The Plan helps pay for covered services Plan Participants receive. The Plan is not liable for any act or omission of any Provider. The Plan has no responsibility for a Provider's failure or refusal to give covered services to Plan Participants. CHANGES IN PLAN Changes that affect coverage or benefits may only be made in the Plan by an amendment signed by a person with the authority to bind the City of Corpus Christi including, but not limited to, the City' s Health Benefits Manager. WORKERS' COMPENSATION The Plan does not affect or take the place of Workers' Compensation. ASSIGNMENT The Plan and its benefits may not be assigned by the policyholder. TERMINATION OF THE PLAN The Employer shall have the right, at any time, to terminate or amend This Plan. The Employer makes no promise to continue these benefits in the future and the right to future benefits will never vest. TRANSPLANT PROVISIONS Medically Necessary services and supplies otherwise covered under the Plan that are incurred for in connection with the following human to human organ or tissue transplant procedures, provided such procedures are not deemed as experimental or research in nature in the judgment of the Plan, considered standard practice for the diagnosis and are endorsed by the American Medical Association: 1) heart; 2) heart-lung; 3) lung; 4) kidney; 5) bone marrow (when treatment is for conditions resulting from acute leukemia, aplastic anemia or immuno - deficiency syndrome); 6) liver; 7) pancreas; 8) cornea; 9) stem cell transplant. Citicare Fire 49 If the donor is covered under this Plan, eligible medical expenses incurred by the donor will be considered for benefits. For donor costs to be covered, the recipient must be covered under this Plan. When the donor has other medical coverage, his or her plan will pay first. The benefits of this Plan will be reduced by the benefits payable under the donor's plan. In no event will benefits be payable in excess of the Minimum Lifetime Benefit still available to the recipient. If both the donor and the recipient are covered under this Plan, eligible medical expenses incurred by each person will be treated separately for each person. The Usual and Customary cost of securing an organ from a cadaver or tissue bank, including the surgeon's charge for removal of the organ and a hospital's charge for storage or transportation of the organ, will be considered a covered medical expense. The Plan may, at its discretion, require the patient seek a second surgical opinion prior to approval of any transplant procedure. Coverage is subject to all other terms and provisions of the Plan. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) HIPAA (Privacy Rights) Under the Health Insurance Portability and Accountability Act of 1996 ( "HIPAA "), group health plans, such as the Plan, must take steps to protect the privacy of your "protected health information." Protected health information is individually identifiable health information, including demographic information, collected from you or created or received by a health care provider, a health plan, your employer (when functioning on behalf of the group health plan), or a health care clearinghouse and that relates to: (1) your past, present, or future physical or mental health or condition; (2) the provision of health care to you; or (3) the past, present, or future payment for the provision of health care to you. The following discusses the technical HIPAA requirements of the Plan and Plan Sponsor. If you have any questions, please review the Notice of Privacy Practices located on the Plan Sponsor's website or contact a representative in the Benefits Section of the Human Resources Department. A. Plan's Disclosure of Protected Health Information to the Plan Sponsor Upon Receipt of Certification of Compliance by Plan Sponsor The Plan may disclose protected health information to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor that the Plan Sponsor agrees to: 1. Not use or further disclose the information other than as permitted or required by the Plan Documents or as required by law; 2. Ensure that any agents, including a subcontractor, to whom it provides protected health information received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information; 3. Not use or disclose the information for employment- related actions and decisions or in connection with any other benefit plan of the Plan Sponsor; 4. Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for, of which it becomes aware; Citicare Fire 50 5. Make available protected health information in accordance with 45 CFR 164.524; 6. Make available protected health information for amendment and incorporate any amendments to protected health information in accordance with 45 CFR 164.526; 7. Make available the information required to provide an accounting of disclosures in accordance with 45 CFR 164.528; 8. Make its internal practices, books and records relating to the use and disclosure of protected health information received from the Plan available to Health and Human Services for purposes of determining compliance by the Plan with the privacy rules; 9. If feasible, return or destroy all protected health information received from the Plan that the Plan Sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible; and 10. Ensure that adequate separation between the Plan and the Plan Sponsor has been established. B. Permitted Uses and Disclosures of Protected Health Information to the Plan Sponsor The Plan (and any business associate acting on behalf of the Plan) will disclose protected health information to the Plan Sponsor only to permit the Plan Sponsor to carry out administrative functions in relation to the Plan. Such disclosures shall be consistent with the provisions of 45 CFR 164. All disclosures of protected health information to the Plan Sponsor will comply with the restrictions and requirements set forth in this HIPAA (Privacy Rights) Section. The Plan (and any business associate acting on behalf of the Plan) may not disclose protected health information to the Plan Sponsor for employment- related actions or decisions, or in connection with any other benefit plan of the Plan Sponsor. Further, the Plan Sponsor shall not use or disclose protected health information for employment - related actions and decisions, or in connection with any other benefit plan of the Plan Sponsor. The Plan Sponsor shall not use or further disclose protected health information other than as permitted by the Plan or the HIPAA privacy regulations. The Plan Sponsor shall ensure that any agent or subcontractor to whom it provides protected health information received from the Plan, agrees to the same restrictions and conditions that apply to the Plan Sponsor with respect to protected health information. The Plan Sponsor shall report to the Plan any use or disclosure of protected health information that is inconsistent with the uses or disclosures provided for in the Plan or the HIPAA privacy regulations, of which the Plan Sponsor becomes aware. C. Additional Duties of the Plan Sponsor The Plan Sponsor shall make protected health information of the individual who is the subject of the protected health information available to such individual in accordance with 45 CFR 164.524. The Citicare Fire 51 Plan Sponsor shall make individuals' protected health information available for amendment and incorporate any amendments to individuals' protected health information in accordance with 45 CFR 164.526. The Plan Sponsor shall make and maintain records of disclosures so that it can make available an accounting of such disclosures to individuals in accordance with 45 CFR 164.528. The Plan Sponsor shall make its internal practices, books and records relating to the use and disclosure of protected health information received from the Plan available to Health and Human Services for purposes of determining compliance with HIPAA' s privacy rules. The Plan Sponsor shall, if feasible, return or destroy all protected health information received from the Plan that the Plan Sponsor still maintains in any form after such information is no longer needed for the purposes for which the use or disclosure was made. Additionally, the Plan Sponsor will not retain copies of such protected health information after such information is no longer needed for the purpose for which the use or disclosure was made. However, if such return or destruction is not feasible, the Plan Sponsor will limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible. The Plan Sponsor shall ensure that an adequate separation between the Plan and the Plan Sponsor is established and maintained. D. Disclosures of Summary Health Information and Enrollment and Disenrollment Information to the Plan Sponsor The Plan (and any business associate acting on behalf of the Plan) may disclose summary health information to the Plan Sponsor if the Plan Sponsor requests summary health information for the purpose of 1) obtaining premium bids from health plans for providing health insurance coverage under the Plan, or 2) modifying, amending, or terminating the Plan. The Plan may disclose to the Plan Sponsor information on whether an individual is participating in the Plan or whether an individual is enrolled in or has disenrolled from the Plan. E. Required Separation Between the Plan and the Plan Sponsor In accordance with 45 CFR 164.504(f)(2)(iii), the following classes of employees or workforce members under the control of the Plan Sponsor may be provided access to protected health information received from the Plan. 1. The members of the Health Benefits Division of the Human Resources Department of the Employer; 2. The members of the Legal Department of the Employer; 3. The members of the Accounting Division of the Finance Department of the Employer; 4. The members of the MIS Department of the Employer; 5. The Senior Management Assistant of the Human Resources Department of the Employer; 6. The Director of Human Resources; Citicare Fire 52 7. The Assistance City Manager for Support Services; 8. The City Manager of the City of Corpus Christi. The above list includes the classes of employees or workforce members of the Plan Sponsor who receive protected health information relating to payment under, health care operations of, or other matters pertaining to plan administration functions that the Plan Sponsor provides for the Plan. These individuals shall have access to protected health information solely to perform their job functions for the Plan Sponsor and they will be subject to disciplinary action for any use or disclosure of protected health information in violation of the provisions of 45 CFR 164. The Plan Sponsor shall promptly report any such breach or violation to the Plan and will cooperate with the Plan to correct the violation, to impose appropriate disciplinary action and to mitigate any deleterious effect of such violation. WHCRA Notice The Women's Health and Cancer Rights Act of 1998 requires the Employer/Plan Sponsor to notify you, as a participant or beneficiary of the employer/Plan Sponsor, of your rights related to benefits provided through the plan in connection with a mastectomy. You as a participant or beneficiary have rights to coverage to be provided in a manner determined in consultation with your attending physician for: a) all stages of reconstruction of the breast on which the mastectomy was performed; b) surgery and reconstruction of the other breast to produce a symmetrical appearance, and c) prostheses and treatment of physical complications of the mastectomy, including lymphedema. These benefits are subject to the plan's regular deductible and co -pay as shown in the Schedule of Benefits. Please ensure that all covered family members receive this notice and are aware of these rights. Keep this notice for your records and call the Employer for more information. Minimum Maternity Benefits Statement Group health plans and health insurance issuers generally may not under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, form discharging the mother or her newbom earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Citicare Fire 53 :OTT CiE CORNA CfRLST1, TEXAS PLAN DOCUMENT FOR THE CITY OF CORPUS CHRISTI HEALTH PLAN CITICARE PUBLIC SAFETY Effective August 2004 Name of Plan: City of Corpus Christi — Citicare Public Safety Plan Number: 523000 Effective Date of this Plan Document: 03/01/99 Revised Effective as of: 08/01/04 Anniversary Date: August 1 This Plan Document contains the terms under which the City of Corpus Christi agrees to cover certain group members and pay benefits in consideration of the application and payment of the premium. The City of Corpus Christi and Humana Health Network have agreed to all the terms of this Plan Document. THIS IS NOT A POLICY OF WORKERS COMPENSATION INSURANCE. THE ' EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY ESTABLISHING THIS PLAN. TABLE OF CONTENTS IMPORTANT PLAN INFORMATION Claim Dispute Information SCHEDULE OF BENEFITS Prior Authorization Penalty 1 Deductibles 1 Out -of- Pocket 1 Hospital Services 1 Psychiatric Disorders 3 Additional Medical Services 4 ELIGIBILITY REQUIREMENTS Effective Date of Coverage 6 Eligible Class of Employees 6 Ineligible Class(es) 8 Qualifying Events 8 Becoming Eligible For Dependent Coverage 9 Certificate of Insurance 9 Changes in Coverage 9 Misstatements 9 DEFINITIONS Definitions 10 HEALTH PLAN BENEFITS What the Plan Pays 20 The Annual Deductible .. 20 Annual Deductible Carryover 21 Out -of- Pocket Expense Limit 21 Maximum Benefit — Reinstatement of Benefits 21 Pre - Authorization Provisions 21 Maternity Admissions 22 When Emergency Hospitalization is Required 23 Pre- Authorization Penalty 23 Appeals Procedure 23 Adoption Benefit 23 Newborn Expenses 24 Basic Hospital Benefit 24 Physician Benefits 25 Psychiatric Disorders 26 Chemical Dependency Benefits 26 Prescription Benefit Description 27 Additional Medical Services 28 Pre - Admission Testing Benefit 30 Medical Case Management Benefit 31 Second Surgical Opinion Benefit 31 Spinal Manipulation Benefit 32 Serious Mental Illness 32 Well Child Care 32 Leaves of Absence and the Family Medical Leave Act 32 LIMITATIONS AND EXCLUSIONS Pre- Existing Conditions Limitation 32 Other Limitations and Exclusions ..33 EXTENSION OF BENEFITS COVERAGE AFTER TERMINATION Extension of Benefits Coverage after Termination 35 FEDERAL CONTINUATION OF COVERAGE Consolidated Omnibus Budget Reconciliation Act (COBRA) 35 Continuation Coverage for Employees in the Uniformed Services .39 COORDINATION OF BENEFITS Allowable Expense 40 Claim Determination Period .40 Plan 40 This Plan 41 What Coordination of Benefits Provision Does 41 Order of Benefit Determination 41 How Benefits are Coordinated 42 MEDICARE ELIGIBLES Medicare Part A 42 Medicare Part B 42 Integration With Medicare 42 TEFRA Options 42 Category 1 Medicare Eligible 43 Category 2 Medicare Eligible 43 Calculation and Payment of Benefits 43 Disability Due to End Stage Renal Disease . 43 CLAIMS The Plan Must Be Notified of Intent to File a Claim 44 When to File Proof of Claim .44 The Plan May Extend Time Limits .. 44 The Plan's Right to Require Medical Exams 44 To Whom Benefits are Payable 44 When the Plan Pays 45 Right of Recovery 45 Subrogation . 45 Right of Reimbursement 45 Duplication of Benefits /Other Insurance 45 Cooperation Required 46 Legal Actions and Limitations 46 Payment to the State of Texas . 46 Complaint Notice 46 TERMINATION PROVISIONS Termination of Your Coverage 47 Termination for Cause 47 Termination of Dependent Coverage 47 Disabled Children 47 MISCELLANEOUS PROVISIONS Review Authority 48 Covered Person/Provider Relationship 48 Changes in the Plan 48 Workers Compensation 48 Assignment 48 Termination of the Plan 48 TRANSPLANT PROVISIONS Transplant Provisions 48 Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA (Privacy Rights) 49 IMPORTANT NOTICE You may call the Plan at Humana Health Network's toll -free telephone number for information or to make a complaint at: 1- 877 - 845 -1033 You may also write to Humana Health Network at: Claims Office P. 0. Box 14601 Lexington, KY 40512 -4601 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at 1 - 800 - 252 -3438 You may write the Texas Department of Insurance: P.O. Box 149104 Austin, TX 78714 -9104 FAX #512- 475 -1771 PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should contact your agent or the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document. AVISO IMPORTANTE Usted puede lamar gratis al numero de telefono de Humana Health Network para information o para someter una queja a: 1- 877 - 845 -1033 Usted tambien puede escribir a Humana Health Network: Claims Office P. O. Box 14601 Lexington, KY 40512 -4601 Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al: 1 -800- 252 -3438 Puede escribir a Departamento de Seguros de Texas: P.O. Box 149104 Austin, TX 78714 -9104 FAX #512- 475 -1771 DISPUTES SOBRE PRIMAS 0 RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con su agente o la compania primero. Si no se resuelve la disputa, puede entonces comunicarse con el departamento. UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de information y no se convierte en parte o condicion del documento adjunto. SCHEDULE OF BENEFITS — CITICARE PUBLIC SAFETY INDIVIDUAL MAXIMUM BENEFIT $1,000,000 PRIOR AUTHORIZATION PENALTY If any required pre - authorization of services is not obtained, the benefit payable for any medically necessary services, after any applicable deductibles or co- payments, will be reduced by 50% up to a maximum penalty of $500. If services are not medically necessary, no benefits are payable at all. This out -of- pocket amount may not be used to satisfy any Out -Of- Pocket Expense Limits. This pre - authorization penalty will apply if you received the services from a participating or non - participating provider. DEDUCTIBLES (Co-payments do not apply toward plan year deductibles) Participating Providers Individual NONE Family NONE Special Services Providers Individual $100 Per Plan Year Family $250 Per Plan Year (Cumulative) Non - Participating Providers Individual $200 Per Plan Year Family $500 Per Plan Year (Cumulative) MAXIMUM OUT -OF- POCKET EXPENSE LIMITS Participating Providers Individual $ 500 Per Plan Year Family $1,250 Per Plan Year Special Services Providers Individual Family Non - Participating Providers Individual Family $ 700 Per Plan Year $1,750 Per Plan Year (Cumulative) $ 700 Per Plan Year $1,750 Per Plan Year (Cumulative) When a Covered Person has incurred the out -of- pocket maximum during a Plan Year, the Plan covered percentage will increase to 100% for any additional eligible expenses incurred during the remainder of the plan year. An out -of- pocket expense does not include expenses incurred for the co -pays, deductibles, outpatient treatment of mental/nervous disorders (except Serious Mental Illness), substance abuse or Prior Authorization Penalties. HOSPITAL SERVICES Inpatient Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after $200 per Individual/$600 per Family Hospital Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Citicare Public Safety 1 SCHEDULE OF BENEFITS (CONTINUED) HOSPITAL SERVICES (CONTINUED) Outpatient Surgical Services Participating Provider Special Services Non - Participating Provider Outpatient Non - Surgical Services Participating Provider Special Services Non - Participating Provider Emergency Room Visits Participating Provider Special Services Non - Participating Provider Birthing Center Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after $100 per Individual/$250 per Family Hospital Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 85% Benefit Payable after $100 per Individual /$250 per Family Hospital Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 80% Benefit Payable after $50 Co -Pay per Visit 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 100% Benefit Payable 100% Benefit Payable after Special Services Deductible 100% Benefit Payable after Non - Participating Deductible PHYSICIAN SERVICES Office Visits (Excludes routine physical exams, outpatient surgery and diagnostic lab /x- rays.) Participating Provider 100% Benefit Payable after $15 Co -Pay per Visit Special Services 80% Benefit Payable after Special Services Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible Emergency Room Visits Participating Provider Special Services Non- Participating Provider Laboratory Services (In Physician's Participating Provider Special Services Non - Participating Provider Birthing Center Participating Provider Special Services Non - Participating Provider Inpatient Services Participating Provider Special Services Non - Participating Provider 100% Benefit Payable after $15 Co -Pay per Visit 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Office) 100% Benefit Payable after $10 Co -Pay per Visit 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 100% Benefit Payable after $15 Co -Pay per Visit 100% Benefit Payable after Special Services Deductible 100% Benefit Payable after Non - Participating Deductible 100% Benefit Payable after $15 Co -Pay per Provider, per Confinement. 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Citicare Public Safety 2 SCHEDULE OF BENEFITS (CONTINUED) PHYSICIAN'S SERVICES (CONTINUED) Outpatient Services (Includes surgery.) Participating Provider Special Services Non - Participating Provider X -Rays (in doctor's office) Participating Provider Special Services Non - Participating Provider Allergy Immunizations Participating Provider Special Services Non - Participating Provider Physical Therapy Participating Provider Special Services Non - Participating Provider Occupational Therapy Participating Provider Special Services Non - Participating Provider Speech and Hearing Therapy Participating Provider Special Services Non - Participating Provider PSYCHIATRIC DISORDERS Inpatient Hospital Services ** Participating Provider Special Services Non- Participating Provider ** Limited to 100 days per plan year Inpatient Physician Services Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 100% Benefit Payable after $10 Co -Pay per Visit 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 100% Benefit Payable after $15 Co -Pay per Visit 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 100% Benefit Payable after $15 Co -Pay per Visit 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non- Participating Deductible 100% Benefit Payable after $15 Co -Pay per Visit 80% Benefit Payable, No Deductible 70% Benefit Payable after the Non - Participating Deductible 100% Benefit Payable after $15 Co -Pay per Visit 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Outpatient Services Individual Sessions * Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Citicare Public Safety 3 SCHEDULE OF BENEFITS (CONTINUED) Outpatient Services Group Sessions * Participating Provider 85% Benefit Payable after Participating Provider Deductible Special Services 80% Benefit Payable after Special Services Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible *Limited to 60 visits per individual per plan year Any out -of- pocket expenses for the Outpatient treatment of psychiatric disorders do not apply towards any out -of- pocket expense limit. CHEMICAL DEPENDENCY The necessary care and treatment of Chemical Dependency will be covered the same as any other illness generally, and will be subject to the same deductibles, benefit percentages and limitations that will apply to any other type of illness. ADDITIONAL MEDICAL SERVICES In addition to Hospital and Physician Services, benefits will be paid for the services listed below. DURABLE MEDICAL EQUIPMENT (not to exceed purchase price) Participating Provider 85% Benefit Payable after Participating Provider Deductible Special Services 80% Benefit Payable after Special Services Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible AMBULANCE Participating Provider Special Services Non - Participating Provider 80% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 80% Benefit Payable after Non- Participating Deductible If the transport by ambulance is verified as a medical necessity (physician's statement from physician receiving the member at hospital or ER) or called by emergency services such as police or fire authority, the actual billed amount will be paid at 80% with the member paying the 20% remaining. This is an exception to the normal usual and customary limitation. If the transport by ambulance is called by the member and is not a medical necessity, the member will be responsible for the full billed amount. LABORATORY FACILITY (other than Physician's office) Participating Provider 100% Benefit Payable per Visit after $10 Co -Pay per Visit Special Services 80% Benefit Payable, No Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible X -RAY FACILITY (other than Physician's office) Participating Provider 100% Benefit Payable per Visit after $15.00 Co -Pay per Visit Special Services 80% Benefit Payable, No Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible PRIVATE DUTY NURSING Participating Provider Special Services Non - Participating Provider 85% Benefit Payable after Participating Provider Deductible 80% Benefit Payable after Special Services Deductible 70% Benefit Payable after Non - Participating Deductible Citicare Public Safety 4 SCHEDULE OF BENEFITS (CONTINUED) ADDITIONAL MEDICAL SERVICES (CONTINUED) MAMMOGRAPHY BENEFIT (Females age 35 and over) Participating Provider 100% Benefit Payable up to $75 per Plan Year Special Services 100% Benefit Payable up to $75 per Plan Year Non - Participating Provider 100% Benefit Payable up to $75 per Plan Year SIGMOIDOSCOPY EXAMINATIONS (Age 40 and over) Participating Provider 100% Benefit Payable up to $75 Per Plan Year Special Services Provider 100% Benefit Payable up to $75 Per Plan Year Non - Participating Provider 100% Benefit Payable up to $75 Per Plan Year PROSTATE CANCER DETECTION EXAM Participating Provider 100% Benefit Payable to $75 per plan year Special Services Provider 100% Benefit Payable to $75 per plan year Non - Participating Provider 100% Benefit Payable to $75 per plan year PRESCRIPTION DRUG CO- PAYMENT Participating Pharmacy (i.e., with prescription drug card) Generic Drug $5 Co -pay Brand Name $20 Co -pay per prescription for up to a 34 day supply Brand Name Maintenance Drugs $40 Co -pay per prescription for a 35 -68 day supply $60 Co -pay per prescription for a 69 -102 day supply Non- Participating Pharmacy* Generic Drug Brand Drug 70% per prescription after Non - Participating Deductible 70% per prescription after Non - Participating Deductible *Maintenance Drugs are not covered at Non - Participating Pharmacies ALL OTHER ADDITIONAL MEDICAL SERVICES LISTED IN THE PLAN Participating Provider 85% Benefit Payable after Participating Provider Deductible Special Services 80% Benefit Payable after Special Services Deductible Non - Participating Provider 70% Benefit Payable after Non - Participating Deductible SPECIAL SERVICES are those services that are provided outside the Service Area due to resi- dency. EMERGENCY CARE provided by a non - participating provider when a participating provider is not accessible, will be billed to the plan member at the participating level of benefits as though services were provided by an in- network provider. The out -of- network provider who may have provided the services will be paid by the lesser of the billed amount or the usual, reasonable and customary amount. Covered Services provided by non - participating providers when such services are not available through preferred providers will be billed to the plan member as Citicare Public Safety 5 though in- network and will be paid to the service provider by the lesser of the charges billed or usual, reasonable and customary. The period permitted for this exception is limited to only that required for the emergency service(s) where an in- network provider is not available and will end when in- network services can be provided or emergency care is no longer required. ELIGIBILITY EFFECTIVE DATE OF COVERAGE You may elect to be covered by completing and signing an enrollment form approved by and acceptable to the City. Subject to premium contributions being made by you or the Police Officers' Association on your behalf, your coverage will be effective as follows: 1. If you become eligible after the effective date of the Plan and you enroll within 30 days after the date you first become eligible (qualifying event), your coverage will start on the date you become eligible, subject to completing any waiting period. Please see section on Qualifying Events. 2. If you elect the coverage provided by the Plan during the group's open enrollment period, your coverage becomes effective on the renewal date of the group's health benefit plan. Retirees desiring to continue in the plan must sign and submit an annual enrollment form within the specked enrollment period in order to be continued in coverage. Failure to submit enrollment forms shall result in termination of coverage effective on the first day of the plan year for which enrollment forms are not submitted. 3. You may use a telephone call or e-mail to inquire regarding coverage or changes to coverage, but may not rely on a telephone call or e-mail to actually change coverage, add a dependent, or other important events. Enrollment requests or requests for change(s) in coverage must be submitted in writing within the prescribed period with appropriate documentation that may be required (e.g., birth record or certificate, divorce decree, etc.) An employee's coverage under Citicare Public Safety coverage shall commence at 12:01 a.m. on the date such coverage is effective. 1. Coverage for an employee hired after the date this Plan commences shall be effective on the date of hire so long as the employee completes enrollment within 31 days of his/her date of hire. 2. Coverage for employees working in a benefits eligible capacity on the date this Plan becomes effective shall become effective on the effective date of the Plan, presuming the employee had previously completed enrollment. Each employee will be covered on the above effective date provided Enrollment and any required contributions have been made within thirty-one (31) days after the date of eligibility. ELIGIBLE CLASS(ES): 1. Eligible Employees as defined in the definition section of this plan; 2. Dependents of covered employees as defined in the definition section of this plan; 3. Eligible Retirees as defined in the definition section of this plan. (Additional explanation of retiree eligibility is furnished below.) If an Eligible Employee qualifies as both an employee and a dependent, such person may be covered as either an employee or a dependent, but not as both. If an eligible retiree qualifies as both a retiree and a dependent such person may be covered as either a retiree or a dependent, but not as both. Citicare Public Safety 6 You are eligible for dependent coverage only if you are eligible as a group member. If you have one or more dependents, you are eligible for dependent coverage on the date you become eligible as a group member. If you do not have any dependents on the date you become eligible as a group member, you do not qualify for dependent coverage. You will become eligible for it on the date you acquire a dependent. If your dependent is eligible, you may not enroll him or her as both an employee and a dependent. In addition, no person can be enrolled as a dependent of more than one group member. DEPENDENT means any eligible dependent whose coverage became effective and has not terminated and includes: 1. your lawful spouse (this includes a spouse by common law marriage); 2. your unmarried child to the last day of the month in which the child attains the age of 25 (an unmarried mentally retarded or physically handicapped child may continue coverage beyond the limiting age so long as appropriate documentation is provided that (a) the child is incapable of self - sustaining employment because of mental or physical disability, (b) the child chiefly relies on the covered employee for financial support, and (c) if the child is first enrolled on or after the child's 25th birthday, the child is medically certified as disabled and is dependent on the covered employee). CHILD means your unmarried 1) natural born child, 2) legally adopted child (including a child placed with You for adoption for whom You have a legal obligation for total or partial support), 3) a child you are seeking to adopt if you are a party to a suit regarding the child's adoption, 4) a child for whom You are the legal guardian or who is dependent upon You for health coverage pursuant to a valid court order, including a qualified medical child support order (QMCSO) or National Medical Support Notice (NMSN), 5) a child who lives with You in a normal parent child relationship if the child qualifies at all times for the dependent exemption as defined in the Internal Revenue Code and the Federal Tax Regulations, or 6) an unmarried natural born or adopted child of Your spouse. The Plan has the right to request verification of the child's dependency status at any time and the Employee has a continuing responsibility to report immediately any change in the dependency of an enrolled spouse or child; 3. Any unmarried child (Employee's grandchild) of a covered Employee's child who is younger than 25 years of age and, at the time application for coverage is a dependent of the covered Employee for federal income tax purposes. Coverage for the covered grandchild may not be terminated solely because the covered child (Employee's child) is no longer a dependent of the covered Employee for federal income tax purposes. Documentation may be required when a change in coverage is requested based on addition or deletion of a dependent. Employees must report changes such as marriage, divorce, birth of a dependent child, etc. when the new dependent or former dependent is to be or was covered by the Plan. Report of such change must be made within 31 days of the change. If not done, the new dependent may not be added to coverage or the employee may subject himself or herself to liability for charges incurred for a former dependent who is no longer eligible. ADDITIONAL RULES REGARDING RETIREE COVERAGE 1. A retiree may enroll in Plan coverage as a retiree if he /she was enrolled in the plan on the day prior to the retirement date. The retiree may also continue coverage in retirement for his/her dependents enrolled in the Plan on the date prior to his/her retirement. Dependency status for enrolled dependents shall be subject to the same rules set forth above (e.g., lawful spouse, unmarried dependent child under the age of 25, etc.) Citicare Public Safety 7 2. if a retiree discontinues coverage under the Plan or is removed due to failure to pay required premiums, the retiree shall not be eligible to re -enter the plan (or to enroll his/her dependents again.) 3. If a retiree discontinues coverage for a dependent after the retirement date, that dependent is not eligible to be enrolled in the Plan again, even though the dependent satisfies the dependent eligibility criteria. 4. The surviving spouse of a retiree is eligible to continue coverage for herself/himself in the event of a death of the retiree, so long as he /she enrolls as the surviving spouse within 31 days of the retiree's death and makes payments in a timely manner. 5. The surviving spouse or a dependent child's legal guardian may also continue coverage for a dependent child who was enrolled in the Plan under the retiree and was enrolled as such on the day prior to the retiree's death. 6. A retiree or surviving spouse of a retiree may not enroll additional dependents after the date of retirement. Any dependents continued on the Plan in retirement must have been covered by the retiree on the date prior to his/her retirement and, if applicable, on the day prior to the retiree's death. 7. A surviving spouse continuing under the Plan may not enroll a new spouse if he /she re- marries. Changes in coverage for anyone covered under the retiree's eligibility after the retirement date are not subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA) and notices will not be mailed to the retiree or any dependents in the event of changes in coverage. INELIGIBLE CLASSES: Persons who are not covered by the collective bargaining agreement between the City of Corpus Christi and the Police Officers' Association. QUALIFYING EVENTS If you had other group coverage at the time you were first eligible to enroll in the Plan and, therefore, did not elect (in writing, if required) to be covered by the Plan at that time, but subsequently lost such other coverage, you can enroll in the Plan if you apply within 31 days of losing such other coverage, provided the other coverage was either (a) COBRA coverage that was terminated, or (b) non - COBRA coverage that was cancelled due to a loss of eligibility (including legal separation, divorce, death, termination of employment, or a permanent reduction of hours worked) or because the employer's contributions had ceased. Your coverage will start on the first day of the calendar month coinciding with or next following the date you enroll. a) If dependent coverage is available under the Plan, a special enrollment period of at least 31 days must be provided for individuals who become dependents through marriage, birth, adoption, or placement for adoption, beginning on the later of the date dependent coverage is made available or the date of the qualifying event. b) In the case of marriage, an eligible employee and eligible spouse may enroll for coverage if they are otherwise eligible for coverage but not already enrolled. The coverage will begin on the date of the qualifying event provided the application for enrollment is submitted in writing within 31 days of the qualifying event. c) In the case of the birth or adoption of a child, the child may be enrolled as a dependent. The coverage will begin on the date of birth or adoption of the child. d) If enrollment on behalf of a dependent is requested within 31 days of the qualifying event, dependent coverage will become effective no later than (i) the date of marriage, (ii) the date of birth, or (iii) the date of adoption or placement for adoption, except as otherwise indicated. Citicare Public Safety 8 BECOMING ELIGIBLE FOR DEPENDENT COVERAGE You are eligible for dependent coverage only if you are eligible as a group member. If you have one or more dependents, you are eligible for dependent coverage on the date you become eligible as a group member. If you do not have any dependents on the date you become eligible as a group member, you do not qualify for dependent coverage. You will become eligible for it on the date you acquire a dependent. If your dependent is eligible, you may not enroll him or her as both an employee and a dependent. In addition, no person can be enrolled as a dependent of more than one group member. CERTIFICATE OF INSURANCE This plan document becomes the Certificate of Insurance and replaces any and all certificates and riders previously issued. This Plan Document describes the provisions and limitations of the Plan. Nothing in this Plan Document waives or alters any of the terms or conditions of the Plan. The benefits outlined in this Plan Document are effective only if you are eligible for coverage, become covered and remain covered in accordance with the terms of the Plan Document. Any changes in this Plan must be approved in writing by an authorized representative of the City of Corpus Christi. Any verbal promise made by an authorized representative of the City of Corpus Christi, or any plan vendor including, but not limited to, Humana Health Network, will not be binding on the City of Corpus Christi unless it is contained in writing in this Plan Document by way of an amendment signed by an authorized representative of the City of Corpus Christi. CHANGES IN COVERAGE The Plan may be revised to increase or decrease benefits after its effective date. Changes involving a reduction in benefits can be made effective at any time during the year. You and your dependents become covered for the revised benefits on the effective date of the revision. Employees with dependents enrolled in the Plan remain responsible for relaying notices regarding changes in plan coverage to those dependents. They are also responsible for notifying the Plan administrator when an enrolled dependent is no longer a dependent. Failure to do so may result in the employee becoming responsible for charges for a person who is no longer a dependent. MISSTATEMENTS If an individual's age or any other important facts about an individual in relation to his or her coverage are found to be misstated, the Plan may adjust whatever aspects of the coverage are necessary to reflect the facts. Citicare Public Safety 9 DEFINITIONS The following terms are used frequently throughout this Plan and are defined below. Listing a deflation does not guarantee that it is a covered benefit. ACCIDENT means an injury that is caused by an event that is sudden and unforeseen; and exact as to time and place of occurrence. ACTIVE SERVICE means that you are performing your regular duties or performing limited - duty duties on a full -time basis for your employer on a regularly scheduled work day either at one of the Police Department's places of employment or at some location to which travel is required; or absent by reason of approved leave. You will be considered to be in active service on a non - scheduled workday only if you were in active service on the last regularly scheduled workday. A covered Dependent other than a newborn child will be considered in Active Service on any day if engaged in the normal activities of a person in good health of the same age and sex and not confined in a medical facility. AMBULANCE means a professionally operated vehicle equipped for the transportation of a sick or injured person to or from the nearest medical facility qualified to treat the person's sickness or injury. Use of the ambulance must be medically necessary and/or ordered by a physician and must be the most reasonable method of transportation. AMBULATORY SURGICAL CENTER means a public or private institution that meets all of ' the following requirements. 1. It must be operated by physicians and a medical staff that includes registered nurses. 2. It must have permanent facilities and equipment for the purpose of surgical procedures. 3. It must provide continuous physicians' services on an outpatient basis. 4. It must admit and discharge patients from the facility within the same work -day. 5. It must be licensed in accordance with the laws of the jurisdiction where it is located. It must be run as an ambulatory surgical center as defined by those laws. 6. It must not be used for the primary purpose of terminating pregnancies, or as an office or clinic for the private practice of any physician or dentist. 7. It must have a contract with at least one nearby Hospital for immediate acceptance of patients who require Hospital Care following care in the ambulatory surgical facility. CHEMICAL DEPENDENCY means the abuse of or psychological or physical dependence on or addiction to alcohol or a controlled substance. CHEMICAL DEPENDENCY TREATMENT CENTER means a facility that provides a program for the treatment of chemical dependency pursuant to a written treatment plan approved and monitored by a physician. The facility must also be: 1. affiliated with a Hospital with an established system for patient referral; 2. accredited as such a facility by the JCAHO; 3. licensed as a chemical dependency treatment program by the Texas Commission on Alcohol and Drug Abuse; or 4. approved by a state agency having legal authority to so approve. CHILD means your unmarried 1) natural born child, 2) legally adopted child, or 3) a child you are seeking to adopt if you are a party to a suit regarding the child's adoption. The term also includes any unmarried child for whom you are the legal guardian; who is dependent upon you for health care coverage pursuant to a valid court order; or who lives with you if the child Citicare Public Safety 10 qualifies at all times for the dependent exemption as defined in the Internal Revenue Code and the Federal Tax Regulations. The Plan has the right to request proof of the child's dependency status at any time. The employee enrolling a child as a dependent remains responsible for notifying the plan immediately if that dependent status changes. Failure to do so could result in charges for that child being referred to the employee from the actual date dependency no longer exists. CO- INSURANCE means the percentage of a covered expense that a covered person pays after satisfaction of any applicable deductible. CO- PAYMENT means that portion of covered medical expenses that must be paid by or on be- half of the covered person incurring the expenses. CONTROLLED SUBSTANCE means a toxic inhalant or a substance designated as a controlled substance in chapter 481, Health and Safety Code. COVERED PERSON means any eligible employee or eligible dependent whose coverage became effective and has not terminated. CREDITABLE COVERAGE means coverage provided under a self - funded or self - covered employee welfare benefit plan that provides health benefits and that is established in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.); a group health benefit plan provided by a health insurance carrier or health maintenance organization; an individual health insurance policy or evidence of coverage; Part A or Part B of Title XVIII of the Social Security Act (42 U.S.C. Section 1 396c et seq.); Title XIX of the Social Security Act (42 U.S.C. Section 1396 et seq.), other than coverage consisting solely of benefits under Section 1928 of that Act (42 U.S.C. Section 1396s); Chapter 55 of Title 10, United States Code (10 U.S.C. Section 1071 et seq.); a medical care program of the Indian Health Service or of a tribal organization; a state or political subdivision health benefits risk pool; a health plan offered under Chapter 89 of Title 5, United State Code (5 U.S.C. Section 8901 et seq.); a public health plan as defined in federal regulations; a health benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C. Section 2504(e)); and Short-Term Limited Duration Coverage. Creditable Coverage does not include coverage under accident -only, disability income insurance, or a combination of accident -only and disability income insurance; coverage issued as a supple- ment to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit only insurance; coverage for onsite medical clinics; other coverage that is similar to the coverage under which benefits for medical care are secondary or incidental to other insurance benefits and specified in federal regulations; if offered separately, coverage that provides limited scope dental or vision benefits; if offered separately, long -term care coverage or benefits, nursing home care coverage or benefits, home health care coverage or benefits, community based care coverage or benefits, or any combination of those coverages or benefits; if offered separately, coverage that provides other limited benefits specified by federal regulations; if offered as independent, noncoordinated benefits, coverage for specified disease or illness; if offered as independent, noncoordinated benefits, hospital indemnity or other fixed indemnity insurance; or Medicare supplemental health insurance as defined under Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (10 U.S.C. Section 1071 et seq.), and similar supplemental coverage provided under a group plan, but only if such insurance or coverages are provided under a separate policy, certificate, or contract of insurance. Citicare Public Safety 11 CRISIS STABILIZATION UNIT means a 24 -hour residential program in a facility licensed or certified by a state Department of Mental Health and Mental Retardation, or similar entity, that is usually short-term in nature and that provides intensive supervision and highly structured activities to persons who are demonstrating an acute, demonstrable psychiatric crisis of moderate to severe proportions. DEDUCTIBLE means a specified amount of medical expenses that a covered person must incur before benefits will be paid under the Plan. DURABLE MEDICAL EQUIPMENT means equipment, recognized as such by Medicare Part B, that meets all of the following criteria. 1. It can stand repeated use. 2. It is primarily and customarily used to serve a medical purpose. 3. It is usually not useful to a person in the absence of sickness or injury. 4. It is appropriate for home use. 5. It is related to the patient's physical disorder. 6. It is for prolonged use. 7. It is certified in writing by a physician as being medically necessary. In no event will such items as air conditioners, air purifiers, humidifiers, whirlpool baths, commodes and over -bed tables be considered eligible. ELECTIVE PROCEDURE means a medical procedure that is not considered to be an emergency by nature or one which may be delayed by the covered person to a later point in time. ELIGIBLE EMPLOYEES means all full -time employees of the Employer who are in Active Service on or subsequent to the effective date of this Plan and are members of the bargaining unit, or after graduation from the Police Academy, will be eligible to become members of the bargaining unit covered by the contract between the City of Corpus Christi and the Corpus Christi Police Officers Association. If an Eligible Employee qualifies as both an employee and a dependent, such person may be covered as either an employee or a dependent, but not as both. ELIGIBLE RETIREE means a retired police officer who was a member of the police officers' bargaining unit under the collective bargaining agreement between the City and the Corpus Christi Police Officers Association and who is eligible to receive a pension under the retirement system of the Employer or who qualifies for the disability retirement benefits under Social Security. If an Eligible Retiree qualifies as both an employee and a dependent, such person may be covered as either a retiree or a dependent, but not as both. EMERGENCY CARE means Health Services provided in a Hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, Illness or Injury is of such a nature that failure to get immediate medical care could result in: 1. placing the patient's health in serious jeopardy; 2. serious impairment of bodily functions; 3. serious dysfunction of any bodily organ or part; 4. serious disfigurement; or 5. in the case of a pregnant woman, serious jeopardy to the health of the fetus. Examples of a Medical Emergency are: apparent heart attack, severe bleeding, sudden loss of consciousness, severe or multiple injuries, convulsions, apparent poisoning. Some examples of Citicare Public Safety 12 conditions that are NOT considered Medical Emergencies are: colds, influenza, ordinary sprains, ear infections, nausea, headaches. EMPLOYER means the organization or any affiliated company providing employment to the covered employee. EXPENSE OR CHARGE means the fees and prices regularly and customarily charged for medical services and supplies generally furnished for cases of comparable nature and severity in the particular geographical area concerned. Any agreement as to fees and charges made between the individual and the doctor shall not bind us in determining our liability with respect to the expense incurred. EXPERIMENTAL OR INVESTIGATIONAL means a drug, drug usage, supplies, biological product, device, medical treatment or procedure that meets any one of the following criteria, as determined by the Plan: 1. Reliable Evidence shows the drug, biological product, device, medical treatment, or proce- dure when applied to the circumstances of a particular patient is the subject of ongoing phase I, II, or III clinical trials, or 2. Reliable Evidence shows the drug, biological product, device, medical treatment, or proce- dure when applied to the circumstances of a particular patient is under study with a written protocol to determine maximum tolerated dose, toxicity, safety, efficacy, or efficacy in comparison to conventional alternatives, or 1. Reliable Evidence shows the drug, biological product, device, medical treatment, or proce- dure is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board (IRB) as required and defmed by federal regulations, particularity those of the U.S. Food and Drug Administration or the Department of Health and Human Services. FULL -TIME for an employee, means a work -week of at least 40 hours. GROUP means the persons for whom this Plan is provided. GROUP MEMBER means a Plan Participant. HOSPITAL means an institution that meets all of the following requirements. 1. It must provide, for a fee, medical care and treatment of sick or injured patients on an inpatient basis. 2. It must provide or operate, either on its premises or in facilities available to the hospital on a pre - arranged basis, medical, diagnostic and surgical facilities. 3. Care and treatment must be given by and supervised by physicians. Nursing services must be provided on a 24 hour basis and must be given by or supervised by registered nurses. 4. It must be licensed by the laws of the jurisdiction where it is located. It must be run as a hospital as defmed by those laws. 5. It must not be primarily a: a. convalescent, rest or nursing home; or b. facility providing custodial, educational or rehabilitative care. The term also includes: (1) licensed or accredited treatment facilities which are properly accredited to provide psychiatric, diagnostic and therapeutic services for the treatment of psychiatric disorders and drug dependency; and (2) an alcohol dependency treatment center that provides a program for the treatment of alcohol dependency pursuant to a written treatment plan Citicare Public Safety 13 approved and monitored by a physician and that is: (a) affiliated with a hospital under a contractual agreement with an established system for patient referral; or (b) accredited as such a center by the Joint Commission on Accreditation of Hospitals; or (c) licensed as an alcohol treatment program by the Texas Commission on Alcohol and Drug Abuse; or (d) licensed, certified, or approved as an alcohol dependency treatment program or center by any other state agency having legal authority to so license, certify, or approve. In addition, if services specifically for the treatment of a physical disability are provided in a licensed hospital, services will not be denied solely because such hospital is primarily of a rehabilitative nature and lacks surgical facilities. However, an institution specializing in the care and treatment of a mental illness, which would qualify as a Hospital, except that it lacks organized facilities on its premises for major surgery, shall nevertheless be deemed a Hospital. "Hospital" shall also include a residential treatment facility specializing in the care and treatment of alcoholism or chemical dependency. However, the hospital must be accredited by one of the following: (1) the Joint Commission on the Accreditation of Hospitals; (2) the American Osteopathic Hospital Association; or (3) the Commission on the Accreditation of Rehabilitative Facilities. This term also includes licensed birthing centers which: 1. Provide a 24 -hour a day nursing service by or under the supervision of Registered Nurses (RNs) and Certified Nurse midwives; and 2. Is staffed, equipped and operated to provide: a. Care for patients during uncomplicated pregnancy, delivery and the immediate postpartum period; b. Care for infants born in the center who are normal or have abnormalities which do not impair function or threaten life; and c. Care for obstetrical patients and infants born in the center who require emergency and immediate life support measures to sustain life pending transfer to a Hospital. HOSPITAL CONFINEMENT or HOSPITAL CONFINED means that a covered person is a registered bed patient in a hospital as the result of a physician's recommendation. ILLNESS means disease, mental, emotional, or nervous disorders, and pregnancy. A recurrent illness shall be considered as one illness. Concurrent illnesses shall be deemed to be one illness unless such illnesses are totally unrelated. INDIVIDUAL TREATMENT PLAN means a treatment plan with specific attainable goals and objectives appropriate to both the patient and the treatment modality of the program. INJURY means bodily loss or harm. All injuries sustained by an individual in connection with any one accident shall be considered one injury. COVERED PERSON means the employee and any of the employee's covered dependents. INTENSIVE CARE UNIT means a special unit of a hospital which: 1. treats patients with serious sickness, or injuries; 2. can provide special life - saving methods and equipment; 3. admits patients without regard to prognosis; and 4. provides constant observation of patients by RN's or specially trained Hospital personnel. Excludes any Hospital facility maintained for the purpose of providing normal post - operative re- covery treatment or service. MEDICAID means a federal/state program of medical care for needy persons, as established Citicare Public Safety 14 under Title 19 of the Social Security Act of 1965, as amended. MEDICAL COMPLICATIONS OF PREGNANCY means conditions needing hospital confinement where the diagnosis is different from pregnancy, but the diagnosed condition may be caused or affected by it. Included within this definition are serious conditions relating to pregnancy, such as hemopoietic nervous or endocrine systems, hyperemesis gravidarum, toxemia and eclampsia of pregnancy. It also includes non - elective cesarean section, miscarriage, and ectopic pregnancy which is terminated or the spontaneous termination of a pregnancy which occurs during a period of gestation in which a viable birth is not possible. This term does not include conditions such as false labor, occasional spotting, bed rest prescribed by a physician, morning sickness or any similar problems caused by a difficult pregnancy that cannot be classified as distinct from the pregnancy. MEDICARE means a program of medical insurance for the aged and disabled, as established under Title 18 of the Social Security Act of 1965, as amended. MEDICALLY NECESSARY SERVICES means services and supplies appropriate in the treatment of the patient's diagnosed sickness or injury. In order to be considered medically necessary, the services or supplies must be: 1. consistent with the symptom or diagnosis and treatment of the covered person's injury or sickness; 2. appropriate with regard to standards of good medical practice; 3. not solely for the convenience of a covered person, physician, hospital or ambulatory care facility; and 4. the most appropriate supply or level of services, which can be safely provided to the covered person. When applied to the care of an inpatient, it further means that the covered person's medical symptoms or conditions require that the services cannot be safely provided to the covered person on an outpatient basis. NON - OCCUPATIONAL means with respect to injury or illness, such injury or disease for which the person is not entitled to benefits under any Workers' Compensation Law or similar legislation; or an injury or disease not arising out of, or in the course of, any work for wage or profit. NON - PARTICIPATING HOSPITAL means a hospital that has not been designated as a Participating Hospital by the Plan. NON - PARTICIPATING PHYSICIAN means a physician who has not been designated as a Participating Physician by the Plan. NON - PARTICIPATING PROVIDER means a hospital, physician, or any other health services provider who has not been designated by the Plan to provide services to covered persons. NURSE means a registered nurse (R.N.), a licensed practical nurse (L.P.N.), a licensed vocational nurse (L.V.N.), or a Nurse Practitioner (R.N.C.P.). OUTPATIENT means that a covered person is treated at a hospital and confined less than 23 consecutive hours. OUTPATIENT SURGERY means surgery that is performed in a physician's office, ambulatory surgical center, freestanding medical clinic or the outpatient department of a hospital. Citicare Public Safety 15 PARTICIPATING HOSPITAL means a hospital that has signed an agreement with either Humana Health Network or has been designated by the Plan to provide services to covered persons. PARTICIPATING PHYSICIAN means a physician who has signed an agreement with Humana Health Network or who has been designated by the Plan to provide services to covered persons. PARTICIPATING PROVIDER means a hospital, physician, or any other health services provider who has signed an agreement with Humana Health Network or who has been designated by the Plan to provide services to covered persons. PHYSICIAN means any of the following licensed medical practitioners who are practicing within the scope of his or her license and whose services are required to be covered by the laws of the jurisdiction where the treatment is given: Doctor of Medicine, Doctor of Osteopathy, Doctor of Dentistry, Doctor of Chiropractic, Doctor of Optometry,. Doctor of Podiatry, Licensed Audiologist, Licensed Speech- Language Pathologist, Doctor of Psychology, Licensed Dietitian, Licensed Professional Counselor, and Licensed Hearing Aid Fitter and Dispenser; Licensed Psychological Associate; and Licensed Chemical Dependency Counselor. PLAN PARTICIPANT(S) means covered employees and dependents. PLAN AND /OR PLAN SPONSOR means the City of Corpus Christi. PLAN YEAR means the period of time which begins on any August 1st and ends on the following July 31St PREGNANCY means conditions including pregnancy, medical complications of pregnancy, re- sulting childbirth, miscarriage, or related medical conditions. PSYCHIATRIC DAY TREATMENT PROGRAM means a mental health facility that provides treatment for people suffering from acute mental and nervous disorders in a structured psychiatric program. The program must .utilize individualized treatment plans with specific attainable goals and objectives appropriate both to the patient and the treatment modality of the program. The program must be clinically supervised by a physician who is certified in psychiatry by the American Board of Psychiatry and Neurology. The facility must be accredited by the Program for Psychiatric Facilities, or its successor, or the Joint Commission on Accreditation of Hospitals. PSYCHIATRIC DISORDER means neurosis, psychoneurosis, psychopathy or psychosis. PSYCHIATRIC TREATMENT PROGRAM means licensed psychiatric treatment programs. These programs must be accredited by the Joint Commission on the Accreditation of Hospitals or be in compliance with equivalent standards or be approved in the state where the program is run. RECONSTRUCTIVE SURGERY means any surgery and associated expenses that are: 1. incidental to or following surgical removal of all or less than all of a body part. The surgical removal must be done as the result of Injury or illness of the body part. 2. done because of a sickness or a disorder of a normal bodily function. 3. done to repair or lessen damage caused by an Injury. Citicare Public Safety 16 4. done to correct a congenital defect. RELIABLE EVIDENCE shall mean only published reports and articles in the authoritative medical and scientific literature; the PDO database of the National Cancer Institute; the written protocol or protocols used by the treating facility or the protocols of another facility studying substantially the same drug, biological product, device, medical treatment, or procedure; the written informed consent used by the treating facility or another facility studying substantially the same drug, biological product, device, medical treatment, or procedure; or regulations and other official actions and publications issued by the U.S. Food and Drug Administration or the Department of Health and Human Services. RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS means a child care institution that provides residential care and treatment for emotionally disturbed children and adolescents and that is accredited as a residential treatment center by the Council on Accreditation, the Joint Commission on Accreditation of Hospitals or the American Association of Psychiatric Services for Children. ROOM AND BOARD means all charges made by a hospital on its own behalf for room and meals and all general services and activities needed for the care of registered bed patients. ROUTINE NURSERY CARE means the charges made by a hospital for the use of the nursery. it includes normal services and supplies given to well newborn children following birth. Physician visits are not considered routine nursery care. Treatment of an injury, sickness, birth abnormality, congenital defect following birth and care resulting from prematurity is not considered routine nursery care. SECOND SURGICAL OPINION means a consultation with a Board Certified surgeon after a covered person has received a recommendation to have surgery. This consultation includes the physical examination, laboratory work and X -rays. The consulting surgeon must not be affiliated in practice with the surgeon who first recommended surgery. SELF - ADMINISTERED INJECTABLE DRUGS means an FDA approved medication that a person may administer to himself/herself by means of intramuscular, intravenous, or subcutaneous injection, excluding insulin, and intended for use by the covered person or the covered person's family. SERIOUS MENTAL ILLNESS means the following psychiatric illnesses as defined, by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM) 111-R: 1. schizophrenia; 2. paranoid and other psychotic disorders; 3. bipolar disorders (mixed, manic, and depressive); 4. major depressive disorders (single episode or recurrent); and 5. schizo - affective disorders (bipolar or depressive). SICKNESS means an illness or disease. The term also includes pregnancy and medical compli- cations of pregnancy. A recurrent illness shall be considered as one illness. Concurrent - illnesses shall be deemed to be one illness unless such illnesses are totally unrelated. SOUND NATURAL TEETH means teeth that are free of active or chronic clinical decay, have at least 50% bony support, are functional in the arch, and have not been excessively weakened by multiple dental procedures. Citicare Public Safety 17 SURGICAL PROCEDURE includes, but is not limited to any of the following procedures (excluding oral surgical procedures): 1. incision, excision or electro cauterization of any organ or body part; 2. reconstruction of any organ or body part or the suture or repair of lacerations; 3. reduction of a fracture or dislocation by manipulation; 4. use of endoscopic procedure to explore for or to remove a stone or other object from the larynx, bronchus, trachea, esophagus, stomach, intestine, urinary bladder or ureter; 5. puncture for aspiration: 6. injection for contrast media testing; or 7. laser surgery. TOTAL DISABILITY OR TOTALLY DISABLED means any period when, as a result of injury or illness, a covered employee is completely unable to perform the duties of the employee's occupation and is not engaged in any activity for profit. A Covered Dependent will be considered Totally Disabled during any period when, as a result of injury or illness, the dependent is unable to engage in the normal activities of a person of the same age and sex. A Totally Disabled covered employee or dependent must be under the care and treatment of a physician during the term of disability. Total Disability must be certified in writing by a physician. TOXIC INHALANT means a volatile chemical under Chapter 484, Health and Safety Code, or abusable glue or aerosol paint under Section 485.001, Health and Safety Code. USUAL, CUSTOMARY AND REASONABLE CHARGES mean the following: 1. Usual charges are the fees charged by a provider in normal practice for a given service. 2. Customary Charges are the range of usual fees charged by providers for the same service in a specific geographical or economic area. 3. Reasonable Charges are either usual or customary charges or the charges that a responsible medical review committee deems appropriate for specific care due to special conditions. WEEKEND NON - EMERGENCY HOSPITAL ADMISSION means an admission to a hospital on a Friday, Saturday or Sunday at the convenience of the covered person or his or her physician when there is no cause for an emergency admission and the covered person receives no surgery or therapeutic treatment until the following Monday. YOU or YOUR means the Plan Participant. PRESCRIPTION DRUG BENEFIT Definitions - The following terms are used in this benefit description. BRAND NAME MEDICATION means a medication that is manufactured and distributed by only one pharmaceutical manufacturer. CO- PAYMENT means the portion of covered prescription drug expenses which must be paid by or on behalf of the covered incurring the expenses. GENERIC MEDICATION means a medication that is manufactured, distributed and available from several pharmaceutical manufacturers and identified by the chemical name. Citicare Public Safety 18 HERITABLE DISEASE means an inherited disease that may result in mental or physical retardation or death. NON - PARTICIPATING PHARMACY means a pharmacy that has not agreed to provide services under terms set fort by the plan. PARTICIPATING PHARMACY means a pharmacy that agrees to provide services under terms set forth by the Plan. PHARMACIST means a person who is licensed to prepare, compound and dispense medication and who is participating within the scope of his or her license. PHARMACY means a licensed establishment where prescription medications are dispensed by a pharmacist. PHENYLKETONURIA means an inherited condition that may cause severe mental retardation if not treated. PHYSICIAN means a licensed medical practitioner who is practicing within the scope of his or her license and whose services are required to be covered by the laws of the jurisdiction where the treatment is given. PRESCRIPTION means a direct order for the preparation and use of a drug, medicine or medication. This order may be given by a physician to a pharmacist for the benefit of and use by a covered person. The drug, medicine or medication must be obtainable only by prescription. The prescription may be given to the pharmacist verbally or in writing by the physician. The pre- scription must include: 1. name and address of the covered person for who the prescription is intended; 2. the type and quantity of the drug, medicine or medication prescribed, and the directions for its use; 3. the date the prescription was prescribed; and 4. the name, address of the prescribing physician. This plan document becomes the Certificate of Insurance and replaces any and all certificates and riders previously issued. This Plan Document describes the provisions and limitations of the Plan. Nothing in this Plan Document waives or alters any of the terms or conditions of the Plan. The benefits outlined in this Plan Document are effective only if you are eligible for coverage, become covered and remain covered in accordance with the terms of the Plan Document. Any changes in this Plan must be approved in writing by an authorized representative of the City of Corpus Christi. Any verbal promise made by an authorized representative of the City of Corpus Christi, or any plan vendor including, but not limited to, Humana Health Network will not be binding on the City of Corpus Christi unless it is contained in writing in this Plan Document by way of an amendment signed by an authorized representative of the City of Corpus Christi. Citicare Public Safety 19 HEALTH PLAN BENEFITS WHAT THE PLAN PAYS The Plan pays the applicable benefit amount or percentage shown in the Schedule of Benefits for covered expenses if they are: 1. medically necessary as a result of an injury or a sickness; 2. received by a covered person; 3. for services authorized by a physician. Deductibles, co- payments and maximum amounts, if any, for each benefit are shown in the Schedule of Benefits. The Plan calculates deductibles and co- payments by applying the dollar amount or percentage to net charges. Net charges are defined as gross billed charges less any discounts or fee negotiations that may have been arranged with participating providers. Gross charges means the amount the provider charges without giving consideration to any of the discounts or fee negotiations which the Plan has arranged to receive from the provider. The Plan will pay participating physicians for covered expenses in accordance with the fee schedules of usual, reasonable and customary charges established between the participating physicians and the Plan. For services rendered by participating physicians, the dollar amount of the deductible or benefit percentage that is your responsibility is calculated based on the fee schedule of the participating physician rendering the services. For services rendered by non- participating physicians, the dollar amount of the deductible or benefit percentage is calculated based on a reimbursement schedule established by the Plan. When using a non - participating phy- sician, you are also responsible for any charges that exceed this reimbursement schedule and non - covered services. A covered expense is deemed to be incurred on the date a covered service is performed or a cov- ered supply is furnished. Charges are not considered to be covered expenses until any applicable deductibles or co- payments have been satisfied. If a benefit is payable for certain covered expenses under a particular benefit section of the Plan, those covered expenses will not be considered for payment under any other benefit section of the Plan unless specified. Otherwise, an expense will not be covered if it is incurred after your coverage under the Group Plan is terminated unless it is required to be covered by applicable law (i.e.; COBRA, or court orders). THE ANNUAL DEDUCTIBLE An annual deductible is a specified dollar amount that a covered person must pay for covered medical expenses per plan year before benefits will be paid under the Plan. There are individual and family, as well as participating, special services and non - participating provider deductible amounts. Expenses incurred by a covered person that may be applied to any applicable deductible referenced under this paragraph will be applied equally toward the satisfaction of the participating, special services and non - participating provider deductibles. The participating, special services and non - participating provider deductible amounts for each covered person and each covered family are shown in the Schedule of Benefits and must be satisfied each plan year. Co- payments do not apply toward any deductibles. If two or more covered persons of the same family are injured in the same accident and incur covered medical expenses for those injuries, only one deductible will be deducted from the total covered expenses resulting from the accident in the plan year in which the accident occurs. Only one deductible will be deducted from the total covered medical expenses incurred as a result of a multiple birth of two or more dependents. The covered expenses must be incurred in Citicare Public Safety 20 the same plan year as the birth and result from: 1. premature birth; 2. an abnormal congenital condition; or 3. an injury or sickness occurring within 31 days after the birth. ANNUAL DEDUCTIBLE CARRYOVER If a covered person incurs covered medical expenses during the last 3 months of a plan year, and those amounts can be applied toward the satisfaction of the annual deductible for that plan year, those same expenses will be applied toward the satisfaction of the individual annual deductible of the next plan year. This deductible carryover does not apply to the family limit deductible. OUT -OF- POCKET EXPENSE LIMIT A maximum out -of- pocket expense limit is the amount of covered expenses, excluding expenses used to satisfy deductibles, in excess of Reasonable and Customary charges, and co- payments, that must be paid by each covered person before a benefit percentage will be increased. There are individual and family participating, special services and non - participating provider maximum out -of- pocket expense limits. After the individual and/or family participating provider out -of- pocket maximum expense limit has been satisfied in a plan year, the participating provider benefit percentage for covered expenses will be payable at the rate of 100% for the rest of the plan year. After the individual and/or family special services and non - participating provider maximum out -of- pocket expense limit has been satisfied in a plan year, the provider benefit percentages for covered expenses will be payable at the rate of 100% for the rest of the plan year. Benefit specific co- payments continue to be the responsibility of the covered person. Any expense incurred by a covered person for covered medical expenses that may be applied to any applicable maximum out -of- pocket expense limit referenced under this provision shall be applied equally toward the satisfaction of the participating, special services and non - participating provider maximum out -of- pocket expense limits. The single and family participating, special services and non - participating provider maximum out -of- pocket expense limit is shown to be unlimited, covered benefits will be paid at the levels indicated in the Schedule of Benefits. The covered person will be responsible for any out -of- pocket expense(s). Benefits for expenses incurred in connection with Psychiatric Disorders will be paid at the benefit level(s) shown on the Schedule of Benefits and outpatient expenses for psychiatric disorders will not apply towards any single or family out -of- pocket expense limit. MAXIMUM BENEFIT - REINSTATEMENT OF BENEFITS The total amount of benefits payable for all covered expenses incurred for a covered person will not exceed the Maximum Benefit shown on the Schedule of Benefits. If a covered person uses any portion of his or her maximum benefit, the Plan will reinstate the used portion on each March 1, up to a maximum of $1,000. The $1,000 will be applied to covered services received after the date of reinstatement. Once a maximum benefit has been reached, benefits will not be reinstated. This reinstatement provision will not apply to retired employees, if any, or to expenses incurred for the treatment of psychiatric disorders. PRE- AUTHORIZATION PROVISIONS Citicare Public Safety 21 All benefits payable under the Plan must be for services and supplies that are medically necessary. In order to determine whether services and supplies meet guidelines for medical necessity, they must be authorized by us in advance. In an effort to make treatment convenient, to follow the wishes of the patient or the patient's family, to investigate the use of unproven treatment methods, or to comply with local hospital practices, a physician may suggest or permit a method of providing care that is not medically necessary. A service that is prescribed by a physician does not necessarily mean the service is medically necessary, nor necessarily a covered service. The covered person is responsible for alerting his or her physician regarding the need for prior approval. The identification card will alert the physician that pre - authorization is required and will show the telephone number to call to obtain the appropriate authorization. If prior approval of services or supplies is not obtained, benefits may be reduced or not paid at all. Scheduled admissions, including admissions to a psychiatric or chemical dependency facility, must be pre - authorized 48 hours prior to Hospital admission. In some instances, the Plan or Humana Health Network may suggest alternative modes of treatment. By eliminating unnecessary or questionable services, the Plan and Humana Health Network can help reduce personal inconvenience and limit the increasing cost of medical care. Pre - authorization for the following procedures or equipment is also mandatory: BREAST SURGERY (INCLUDING BIOPSIES) HYSTERECTOMY, ABDOMINAL OR VAGINAL KNEE ARTHROSCOPY LIGATION AND STRIPPING OF VARICOSE VEINS DEVIATED SEPTUM /OTHER NASAL SURGERY TEMPOROMANDIBULAR JOINT DISORDER SURGERY CORONARY BYPASS HEMORRHOIDECTOMY CHOLECYSTECTOMY TONSILLECTOMY AND ADENOIDECTOMY BUNIONECTOMY LAMINECTOMY PROSTATECTOMY CATARACT REMOVAL DILATION AND CURETTAGE INGUINAL HERNIORRHAPHY OUT - PATIENT PROCEDURES DURABLE MEDICAL EQUIPMENT OVER $500 PHYSICAL THERAPY SPEECH THERAPY MRI CT SCAN Note: For these procedures, if no authorization is obtained, a reduction of 50% up to a maximum penalty of $500 will apply. Citicare Public Safety 22 MATERNITY ADMISSIONS Outpatient surgery with subsequent Hospital admission, other than Outpatient surgery performed in a Physician's office, must be reported within twenty -four (24) hours of the inpatient admission in order to assure maximum benefits under This Plan. A Hospital stay following an Outpatient surgery undergoes continued stay review just like a scheduled admission. However, regardless of medical necessity, coverage for hospital stays shall not be limited to less than forty-eight (48) hours for normal vaginal deliveries and ninety -six (96) hours for Cesarean section deliveries for both the mother and the newborn child (assuming the child is added to the Plan under the Eligibility provisions stated herein). WHEN EMERGENCY HOSPITALIZATION IS REQUIRED If a medical emergency requires that a covered person be admitted to a hospital, pre - authorization must take place within 48 hours or the morning of the next business day after admission. The Plan and Humana Health Network will then review the medical necessity of the admission. PRE - AUTHORIZATION PENALTY If any required pre - authorization of services is not obtained, the benefit payable for any medically necessary services, after any applicable deductibles or co- payments, will be reduced by 50% up to a maximum penalty of $500. If services are not medically necessary, no benefits are payable at all. This out -of- pocket amount may not be used to satisfy any Out -Of- Pocket Expense Limits. ' APPEALS PROCEDURE If the covered person is dissatisfied with our determination of medical necessity, he or she may appeal the decision. Such appeals will be handled on a timely basis and appropriate records will be kept on all appeals. The covered person must appeal in writing within 120 days to the address given on the denial letter received. The appeal will be reviewed by the Plan and a response sent to the covered person no later than 30 days following receipt of the appeal. All requests for review by the Appeals Committee must be submitted in writing. The Appeals Committee has guidelines for reviewing appeals and may conduct informal hearings about the appeal. If an informal hearing is to be held, the covered person will be notified in advance. Resolution of the appeal will be completed within 30 days. If the claim is denied again, it shall include specific reasons for denial, written in a manner understandable to the Covered Person, and will contain specific reference to the pertinent Plan provisions upon which the decision was based. ADOPTION BENEFIT Benefits are available for adoption expenses incurred in connection with legal adoption proceedings, provided such proceedings result in a child being placed in the Covered Employee's home and such charges are a part of the decree of adoption. Eligible Adoption Benefit Expenses: 1. Adoption Agency Expenses payable at 100% to a maximum of $1800: a. The cost of the confinement and medical care treatment of the biological mother in a Hospital or other institution in connection with the birth of the child: b. The charges made by the Physician in connection with the delivery of the child. c. The cost of any necessary foster care of the child prior to its placement in the home of the Covered Employee. Citicare Public Safety 23 2. Home Placement Expenses: The biological mother's Hospital and Physician's expense will be payable at 100% up to a maximum of $500. Reimbursement will not be made for: 1. Adoption proceedings that began before the Covered Employee became covered; 2. Any expenses that the Covered Member would not be legally required to pay; 3. Any expenses that the biological mother would not be legally required to pay; 4. Attorneys' fees and other necessary legal expenses in connection with the adoption. NEWBORN EXPENSES Hospital nursery expenses and Physician's fee (including routine circumcision) for a healthy newborn will be considered eligible for the seven (7) days immediately following birth, and will be covered under the mother's maternity claim. If the baby is ill, suffers an injury or requires care other than routine care, benefits will be provided on the same basis as for any other eligible Expense, provided dependent coverage is in force at the time eligible Expenses are incurred. Newborn Children and Newly Adopted Children of Covered Employee. Coverage is automatically provided to a newborn child of the covered employee for the first thirty-one (31) days after birth. If the addition of the child would cause a higher contribution from the Employee, the child is NOT covered after the first 31 days after birth, adoption or placement for adoption unless the employee enrolls the new child within those 31 days. In order to be covered for the period immediately following birth or adoption, coverage is automatically provided to an adopted child of the covered employee for the first thirty-one (31) days after (1) the date the covered employee becomes a party to a suit in which the covered employee seeks to adopt the child, or (2) the date the adoption becomes final ((1) and (2) are collectively referred to as "adoption" for purposes of this paragraph). A child is considered to be the adopted child of a covered employee if the covered employee is a party to a suit in which the covered employee seeks to adopt the child. Coverage of a newborn child or adopted child ends on the 32nd day after the date of such child's birth or adoption, unless the covered Employee submits a Transaction/Change Card to the Plan Sponsor within thirty-one (31) days of the birth, adoption or placement for adoption and pays any required additional premium. Otherwise, the child will not be allowed to enter the plan until the next Open Enrollment Period or if he /she qualifies under the Special Enrollment Provision. If the addition of the child would not cause a higher contribution from the Employee, the child is automatically covered at birth, adoption or placement for adoption. However, the Employee must submit a Transaction/Change form to the Plan Sponsor within thirty-one (31) days following the birth, adoption or placement for adoption. This will permit the eligibility to be established and claims on behalf of the new child to be resolved. The employee may experience treatment and/or billing problems if he /she fails to enroll the new child in a timely manner. BASIC HOSPITAL BENEFIT The Plan will pay benefits incurred by a covered person while hospital confined. The hospital confinement must be ordered by a physician and be the result of an injury or sickness which occurs while covered under the Plan. The following services and supplies for which charges are made by a hospital on its own behalf will be considered covered medical expenses: 1. Room and board. 2. Services and supplies, other than room and board, provided by a hospital to inpatients. 3. Confinement in an intensive care, cardiac care or neonatal care unit. 4. Routine nursery care for a newborn child for up to a maximum of 7 days but not for the concurrent use of any other hospital room. Citicare Public Safety 24 5. Services in a hospital's outpatient department in connection with outpatient surgery. 6. Services in an ambulatory surgical center in connection with outpatient surgery. 7. Services in a hospital's emergency room. 8. Necessary medical care and treatment for prenatal services, delivery of a normal Pregnancy and postpartum services rendered within 24 hours after the delivery, when performed at a state licensed birthing center of facility (other than the birthing unit of a Hospital). Such services and delivery must be performed by a Physician or a licensed registered Nurse who is certified by the American College of Nurse Midwives. 9. Includes minimum inpatient care of 48 hours following a mastectomy and 24 hours following a lymph node dissection unless the Member's attending Physician determines that a shorter period of inpatient care is appropriate. Charges for physician's services in connection with surgical operations are not considered covered hospital expenses. PHYSICIAN BENEFITS The Plan will pay benefits for covered expenses incurred by a covered person for physicians' charges. The covered person must incur physicians' charges as the result of an injury or a sickness which occurs while covered under the Plan. Reasonable charges for the following services and treatment will be considered as covered expenses. 1. Surgical procedures performed on an inpatient or outpatient basis. If several surgical proce- dures are performed through the same incision or body opening during one operation, the Plan will pay the reasonable charge for the most complex procedure. If several surgical procedures are performed through different incisions or body openings during one operation, the Plan will pay the reasonable charge for the most complex procedure. For each additional procedure the Plan will pay 50% of the reasonable charge for that procedure. 2. Obstetrical services received on an inpatient or outpatient basis including medically neces- sary prenatal and postnatal care of all female covered persons. 3. Care of a newborn child while the newborn is hospital confined immediately following birth; including routine circumcision. 4. Anesthesia administered by a physician or certified registered anesthetist attendant to a sur- gical procedure. 5. Radiation therapy received on an inpatient or outpatient basis. 6. Consultation charges requested by the attending physician during a hospital confinement. The benefit is limited to one consultation by any one consultant per specialty during a hospital confmement. 7. Surgical assistance provided by a physician, when medically necessary. The benefit for surgical assistance will be 20% of the reasonable charge for the chief surgeon. 8. Inpatient medical services furnished by the attending physician to a hospital confined covered person. 9. Services of a pathologist during an inpatient confinement or when associated with a surgical procedure. 10. Services of a radiologist during an inpatient hospital confmement or when associated with a surgical procedure. 11. Services of a speech therapist or pathologist to restore speech loss or impairment for restoratory or rehabilitory speech therapy when due to an illness or accidental injury (caused other than by surgery). 12. Services of a licensed audiologist to determine and measure hearing function loss. 13. Services of a licensed physiotherapist for purposes of training to aid restoration of normal physical functions when rendered by a duty qualified physical therapist who is not a Citicare Public Safety 25 member of the patient's immediate family (when referred to by and/or under direct supervision of a physician). 14. Services performed on an emergency basis in a hospital if the injury or sickness being treated results in a hospital admission. 15. Services for acupuncture that is Medically Necessary and provided by a Physician (M.D.). 16. Services of a licensed Occupational Therapist for purposes of training to aid restoration of normal physical functions when rendered by a duly qualified Occupational Therapist who is not a member of the patient's immediate family (when referred to by and/or under direct supervision of a physician. Benefits will be subject to the benefit amounts or percentages shown in the Physician section of the Schedule of Benefits. Charges for physicians' services which are payable as a hospital charge are not payable under this benefit. PSYCHIATRIC DISORDERS Benefits are payable for covered expenses incurred by a covered person while undergoing treatment for psychiatric disorders. All charges must be made by a physician, or a hospital or a psychiatric day treatment facility, and benefits are payable as follows: 1. Inpatient Charges - Charges incurred by a covered person while confined as a registered bed patient in a hospital or psychiatric day treatment facility will be considered covered expenses. 2. Outpatient Charges - Charges incurred by a covered person while not confined in a hospital or psychiatric day treatment facility will be considered as covered expenses; also Psychia- trist's charges incurred for evaluation and treatment in connection with suicide or self -in- flected injuries (including drug overdose); 3. Psychiatric Day Treatment Charges - Charges incurred by a covered person for the treatment of mental and nervous disorders in a psychiatric day treatment facility will be considered covered expenses. A physician must certify that the psychiatric day treatment is being provided in lieu of hospitalization. 4. Crisis Stabilization Unit Charges - Charges incurred by a covered person for the treatment of serious mental illness based on an individual treatment plan will be considered covered expenses. A physician must certify that the treatment provided in the crisis stabilization unit is in lieu of hospitalization. Two days in a crisis stabilization unit are considered equal to one day of treatment of mental or emotional illness or disorder in a hospital or inpatient program. 5. Residential Treatment Center for Children and Adolescents Charges - Charges incurred by a covered person for the treatment of serious mental illness based on an individual treatment plan will be considered covered expenses. A physician must certify that the treatment provided in a residential treatment center for children and adolescents is in lieu of hospitalization. Two days in a residential treatment center for children and adolescents is equal to one day of treatment of mental or emotional illness or disorder in a hospital or inpatient program. 6. Deductible and Benefit Percentage - All expenses incurred for the treatment of psychiatric disorders and drug dependency are subject to the deductibles and benefit amounts or percentages shown on the Schedule of Benefits. CHEMICAL DEPENDENCY BENEFITS The necessary care and treatment of Chemical Dependency during a series of treatments will be covered the same as any other illness generally, and will be subject to the same deductibles, benefit percentages, and limitations which apply to any other type of illness. A series of treatments is a planned, structured, and organized program to promote chemical free status which Citicare Public Safety 26 may include different facilities or modalities and is complete when the covered individual is discharged on medical advice from inpatient detoxification, inpatient rehabilitation treatment, partial hospitalization or intensive outpatient or a series of these levels of treatments without lapse in treatment or when a person fails to materially comply with the treatment program for a period of 30 days. PRESCRIPTION BENEFIT DESCRIPTION Benefits are payable if covered prescription drugs are received by the covered person while he or she is covered for this benefit. The amount of the benefit provided, including self - administered injectable drugs which are defined as any FDA approved medication which a person may administer to himself/herself by means of intramuscular, intravenous or subcutaneous injection, is as follows: 1. For prescriptions filled at participating pharmacies -the sum of a, b, and c below, minus the covered person's co- payment: a. the ingredient cost, as determined by us for participating pharmacies; a. the professional dispensing fee, as determined by us for participating pharmacies; and b. any sales or provider tax. Your ID card must be presented to a participating pharmacy each time a prescription is filled or refilled. 2. For prescriptions filled at non - participating pharmacies and with claims submitted directly to the Plan by the covered person, the benefit is payable at 70% of the actual charge made by the pharmacy, after your annual deductible. WHAT IS COVERED Covered prescription drugs using the prescription drug card are: 1. drugs, medicines or medications that under federal or state law, may be dispensed only by prescription from a physician; 2. insulin; diabetic supplies (including lancets, chem strips) 3. hypodermic needles or syringes 011 prescription for use with insulin or self - administered injectible drugs; 2.self- administered injectable drugs; 3 .oral contraceptives 6. prenatal vitamins with folic acid; 7. vitamin D, vitamin K, folic acid and pediatric vitamins with folvite; 8. dexedrine; and, 9. formulas necessary for the treatment of phenylketonuria or other heritable diseases. Covered prescription drugs must: 1. be prescribed by a physician for the treatment of an injury or sickness; and 2. be dispensed by a pharmacist. Contrary to any other provisions of the Plan, prescription drug expenses covered under this benefit are not covered under any other provision in the Plan. Any amount in excess of the maximum provided under this Benefit is not covered under any other provision in the Plan. PRESCRIPTION DRUG EXCLUSIONS No benefit using the prescription drug card is provided for: 1. any oral drug, medicine or medication that is consumed or injected at the place where the prescription is given, or that is dispensed by a physician; 2. prescription refills in excess of the number specified by the physician or dispensed more than one year from the date of the physician's original order; 3. the administration of covered medication; Citicare Public Safety 27 4. prescriptions that are to be taken by or administered to the covered person, in whole or in part, while he or she is a patient in a hospital, rest home, sanitarium, skilled nursing facility, convalescent hospital, inpatient hospice facility or other facility where drugs are ordinarily provided by the facility on an inpatient basis; 5. prescriptions that may be properly received without charge under local, state or federal pro- grams, including Worker's Compensation, except those received under Medicare; 6. any medication labeled `Caution- Limited by Federal Law to Investigational Use" or any experimental medication, even though a charge is made to the covered person; 7. immunizing agents, biological serums or allergy serums; 8. any drug or medicine that is lawfully obtainable without a prescription; 9. any drug, medicine or medication received by the covered person before becoming covered or after the date the covered person's coverage has ended; 10. therapeutic devices or appliances, including hypodermic needles, syringes, support garments, contraceptive devices, and other non - medical substances, except as stated; 11. any costs related to the mailing, sending or delivery of prescription drugs; 12. any service, supply, or therapy to eliminate or reduce a dependency on or addiction to to- bacco, and tobacco products, including but not limited to nicotine withdrawal therapies, programs, services, and medications; 13. mechanical pumps for the delivery of medications; except as stated under durable medical equipment. 14. any fraudulent misuse of this benefit, including prescriptions purchased for consumption by someone other than the person for whom the prescription is written. 15. any drug prescribed for intended use other than for indications approved by the FDA; 16. More than one prescription for the same drug or therapeutic equivalent medication prescribed by one or more physicians and dispensed by one or more pharmacies until at least 50% of the previous prescription has been used by the covered person. (Based on the dosage schedule prescribed by the physician.); 17. drug delivery implants; 18. diet control drugs (anorexics); 19. growth hormones. ADDITIONAL MEDICAL SERVICES The Plan will pay benefits for the following covered expenses for charges incurred by a covered person as the result of an injury or sickness which occurs while covered under the Plan. Benefits are subject to the applicable benefit amount or percentage and deductibles shown on the Schedule of Benefits. Additional Medical Services include: 1. Outpatient medical care and treatment not covered under any other benefit section of the Plan. 2. Private duty nursing in a hospital or in the home, by a nurse, if the physician orders, in writing, that it is medically necessary and not considered to be custodial care as otherwise defined in the Plan. This treatment is eligible if rendered by a registered or licensed practical nurse. However, the services must be necessary and reasonable care for the patient. 3. Radium therapy, x -ray treatments and examination (other than dental x- rays), radioactive isotope therapy cobalt and chemotherapy microscopic tests, or any lab tests or analysis made for diagnosis or treatment; including an annual screening by low -dose mammography for all females age 35 or older to detect the presence of occult breast cancer. Citicare Public Safety 28 4. Maternity Expenses incurred by a female Covered Person for: a. Pregnancy; b. Medical complications of Pregnancy (see the Definitions section); c. Abortions; 5. Annual Prostate Cancer Detection Exam. Includes a prostate specific antigen test for a Member who is 50 years of age and asymptomatic; or for a Member 40 years of age or older with a history of prostate cancer or another prostate cancer risk factor. 6. Services for the medically necessary diagnosis and treatment of osteoporosis for high -risk individuals, including, but not limited to, estrogen - deficient individuals who are at clinical risk for osteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long -term glucocorticoid (steroid) therapy, individuals who have primary hyperparathyroidism, and individuals who have a family history of osteoporosis. 7. The following services and supplies. a. administration of whole blood and blood components. b. casts, splints, trusses, crutches and braces (excluding dental splints or dental braces); ileostomy and colostomy supplies. c. initial placement of a medically necessary prosthesis and its supportive device to replace a lost physical organ or parts or to aid in their function when impaired if the loss or impaired function occurred whiled covered under this Plan, including initial glasses and contact lenses if required following cataract surgery. The Plan will also cover the replacement of such prosthesis if it is determined by the covered person's physician to be necessary because of growth or change. d. oxygen or rental of equipment for administration of oxygen; e. the initial pair of eyeglasses or contacts needed due to cataract surgery or an accident that occurs while covered under the Plan if the eyeglasses or contacts were not needed prior to the accident; and f. the initial purchase and fitting of hearing aids; needed to correct hearing deficiency. g. the purchase or rental of medically necessary durable medical equipment. At our option, the cost or rental of durable medical equipment will be covered. if the cost of renting the equipment is more than a covered person would pay to buy it, only the cost of the purchase is considered to be a covered expense. In either case, total covered expense for durable medical equipment shall not exceed its purchase price. Any purchase must be pre- approved by us. The Plan does not pay for equipment or devices not specifically designed and intended for the care and treatment of an injury or sickness. 8. Dental work and treatment (including eligible Hospital Expenses) will be eligible only when necessitated for the treatment of Temporomandibular Joint Dysfunction (TMJ) or as the direct result of an accidental injury to the jaws, sound natural teeth, mouth or face, occurring while covered by this Plan, including replacement of such teeth within twelve (12) months after the accident. Injury caused by chewing or biting will be considered accidental injury; 9. Charges for transportation of a Covered Person by a professional licensed ambulance service as follows: a. Ground transportation used locally to or from the nearest Hospital qualified to render treatment, or other medical institution (within the continental United States) for necessary special treatment not locally obtainable; b. Air ambulance where air transportation is medically indicated to transport a Covered Person to the nearest facility qualified to render treatment; and c. Ambulance service for necessary emergency treatment as a result of and within 48 hours of an accident or medical emergency. 10. Depo Provera, birth control devices (IUD) and treatment for complications incident to the Citicare Public Safety 29 usage of such devices. 11. Elective sterilization and related expenses regardless of medical necessity. 12. Charges for hypnosis recommended by and/or under the direct supervision of the attending Physician and considered recognized medical or psychiatric treatment of the condition. 13. Treatment of obesity diagnosed as: c. Endogenous when fully documented (including test results on which the diagnosis is based); or b. Morbid, provided: 1) the patient is at least 100 pounds over normal weight and 2) has a medically documented disease or health condition which is life threatening and is adversely affected by the obesity. Treatment of morbid obesity will include: a. Gastro bypass /stapling if there has been a history of unsuccessful attempts to reduce weight by more conservative measures while under the care and supervision of the Physician; and b. Participating at Weight Control Clinics while under the care and supervision of the Physician. 14. Charges for initial pair of orthopedic shoes when recommended by a Physician. 15. Reconstructive surgery and related services: a. To restore bodily function or correct deformity resulting from an accidental injury occurring while covered by This Plan provided the services or procedures begin within 90 days following the accident. b. To correct a congenital deformity or birth abnormality of a newborn; c. In connection with post - traumatic or post - oncology treatment, provided the original condition necessitating such treatment occurred while covered by the Plan. d. In connection with a partial or full mastectomy, charges for: (i)mammoplasty surgery following a partial or full mastectomy; (ii) all stages of reconstruction of the breast on which the mastectomy has been performed; (iii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iv) prostheses and physical complications of mastectomy, including lymphedemas. 16. Charges for rhinoplasty, blepharoplasty or brow lift if due to a functional or non - functional condition after the first 12 months immediately following a Covered Person's effective date under this Plan to correct an accidental injury. 17. Charges for pap smears and office visits, abortions (including elective abortions), and testing and treatment of infertility (including artificial insemination if donor is the spouse). 18. Charges for Immunization shots, including the charge for the related office visit. 19. Charges for care or treatment rendered by a Clinical Social Worker (MSW). PRE - ADMISSION TESTING BENEFIT PRE- ADMISSION TEST means a diagnostic test ordered by the attending or consulting physician in connection with a planned hospital admission or outpatient surgery and performed on an outpatient basis within 10 days before the covered person's admission or outpatient surgery. A benefit will be payable for charges incurred by a covered person in connection with pre- admission testing when the following requirements are met: 1. The admission to the hospital or the scheduled outpatient surgery is confirmed in writing by the attending physician before the testing occurs. 2. The tests must be performed within 10 days before admission to the hospital or the outpatient surgery. 3. The tests must be ordered by the attending physician. 4. The tests are performed in a facility accepted by the hospital in place of the same tests Citicare Public Safety 30 which would normally be done while hospital confined. 5. The tests are not duplicated in the hospital. 6. The covered person is subsequently admitted to the hospital or the outpatient surgery is performed, except if a hospital bed is unavailable or because there is a change in the covered persons' health condition which would preclude the procedure. MEDICAL CASE MANAGEMENT BENEFIT This benefit applies only to a covered person who has suffered a severe personal injury or sickness while covered under the Plan. In addition to the benefits specified in this booklet, the City of Corpus Christi may elect to offer benefits for services furnished by any provider pursuant to an approved alternative treatment plan for a Covered Person whose condition would otherwise require hospital care. The Plan shall provide such alternative benefits for so long as it determines that alternative services are Medically Necessary and cost effective, and that the total benefits paid for such services do not exceed the total benefits to which the patient would otherwise be entitled under this Plan in the absence of alternative benefits. A "severe personal injury or sickness" includes, but is not limited to, the following: Major head trauma, spinal cord injury, amputations, multiple fractures, severe burns, neonatal high risk infants, severe stroke, multiple sclerosis, amyotrophic lateral sclerosis, metastatic cancer, acquired immune deficiency syndrome (AIDS), severe cardiac diseases, major trauma, severe hepatitis, bulimia, anorexia nervosa, severe congenital anomalies. If a covered person is accepted into the Medical Case Management program, the Plan will pay benefits for usual, customary and reasonable charges for rehabilitative services and supplies furnished to the individual whose condition would otherwise require hospital care and said benefits may exceed policy limitations and may extend beyond the types of expenses covered by the Plan. The Plan will determine the amount of benefits, but in no event will benefits exceed the Individual Lifetime Maximum Benefit of the Plan. Any agreement to pay benefits in accordance with the above will be based on an objective review of: 1. the covered person's medical status; 2. the current treatment plan; 3. the projected treatment plan;; 4. the long term cost implications; and 5. the effectiveness of care. Individual Medical Case Management may be terminated when the covered person has improved or deteriorated to the extent that the alternative services are no longer necessary and cost effective, the individual's coverage, under the Plan ends, or the Individual Lifetime Maximum Benefit has been reached. If alternative benefits are provided for a Covered Person in one instance, the Plan shall not be ob- ligated to provide the same or similar benefits for other covered persons under this Plan in any other instance, nor shall it be construed as a waiver of the right of the Plan thereafter in strict accordance with its express terms. SECOND SURGICAL OPINION BENEFIT A benefit will be payable for charges incurred by a covered person in obtaining a second surgical opinion, after he or she has received a recommendation to have elective surgery which is covered under the Plan. The charges will not be subject to a deductible or co- payment if the consulting Citicare Public Safety 31 physician personally examines the covered person and the Plan receives a copy of the opinion. if the condition stated above is not met, the applicable deductible and benefit amount or percentage will be applied to the charges for the second opinion. If the second opinion does not confirm the original recommendation, the covered person may consult another physician for a third opinion. The third opinion must be obtained, and benefits will be payable in the same manner as the second opinion. SPINAL MANIPULATION BENEFIT Benefits are payable for expenses incurred by a covered person for medically necessary manipu- lations of the skeletal structure; and for services rendered by a Doctor of Chiropractic for the de- tection and correction by manual or mechanical means (including X -rays incidental thereto) of structural imbalance, distortion or subluxation in the human body for the removal of nerve interference where such interference is the result of or related to distortion misalignment or subluxation of or in the vertebral column. SERIOUS MENTAL ILLNESS Benefits for the condition of Serious Mental Illness are covered to the same extent as coverage for any other major illness under the Plan, subject to the same limitations, deductibles and coinsurance factors. WELL CHILD CARE The Plan will pay benefits for outpatient preventive well -child care for a covered dependent child to 18 months of age. Outpatient preventive well -child care means the charges made by a personal physician for routine pediatric exams and immunizations given to a child as recommended by the American Academy of Pediatrics for children to 18 months. After age 18 months, only charges for immunization shots including the charge for the related office visit are covered. LEAVES OF ABSENCE & THE FAMILY AND MEDICAL LEAVE ACT Eligibility for coverage under the Plan may be continued during an employer - approved Leave of Absence including leave for a FMLA- covered event. This provision does not provide a Participant with a Leave of Absence, rather, it is merely an attempt to coordinate with the Employer's policies. LIMITATIONS AND EXCLUSIONS PRE- EXISTING CONDITIONS LIMITATION A Pre - Existing Condition means a limitation or exclusion of benefits relating to a condition that was present before the date of enrollment for coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before such date. Health Plan benefits are limited to the first $1,000 of covered expenses incurred for a pre -ex- isting condition. Thereafter, no benefits or services will be provided for a pre - existing condition, regardless of cause, for which medical advice, diagnosis, care, or treatment was recommended or received within the six (6) month period ending on the member's enrollment date. Coverage will not be provided until the earlier of the following dates: (a) the date the member has been free of treatment for the pre - existing condition for six (6) consecutive months or (b) twelve (12) consec- utive months after the member's enrollment date, whichever occurs first. The exclusion does not apply to: (a) pregnancy; or (b) newborn children or children adopted before the age of 18 if they are covered under the Plan within 31 days of the date of birth or date of placement for adoption. Citicare Public Safety 32 The limitation period for such pre- existing condition exclusion must be reduced by all periods of creditable coverage, if any, applicable to the member as of his or her enrollment date that are not separated by a break in coverage of more than 90 days, not counting waiting periods. OTHER LIMITATIONS AND EXCLUSIONS Unless specifically stated otherwise, no benefits will be provided on account of the following: 1. An injury or sickness arising out of, or in the course of, any employment for wage, gain or profit. 2. A sickness or injury that is covered under any Workers' Compensation or similar law. This limitation also applies to a covered person who: (a) is not covered by Workers' Compen- sation; and (b) chose not to be. 3. Care and treatment given in a hospital owned or run by a government entity, unless the covered person is legally required to pay for such care. However, care provided by military hospitals to armed services retirees and their dependents is not excluded. 4. Any service the covered person would not be legally required to pay for in the absence of this Plan. 5. Sickness or injury for which the covered person is in any way paid or entitled to payment or care and treatment by or through a government program, other than Medicaid. 6. Medical services provided by the covered person's parent, spouse, brother, sister, or child or a person who ordinarily resides in the covered member's household or an immediate family member. 7. Investigational or experimental drugs or substances not approved by The City of Corpus Christi or by the Food and Drug Administration or the American Medical Association; drugs or substances used for other than Food and Drug Administration approved indications; or drugs labeled: "Caution- limited by Federal law to investigational use ". 8. Treatment, services, supplies or surgery that is not medically necessary. 9. Purchase or fitting of hearing aids in excess of the initial aid(s) or devices, advice on their care, or implantable hearing devices. 10. Weekend non - emergency hospital admissions. 11. Treatment of sexual dysfunctions not related to organic disease; sex change services; reversal of elective sterilization, in -vitro fertilization, or artificial insemination (unless the donor is the spouse). 12. Any drug, biological product, device, medical treatment, or procedure which is experimental or investigational that is not approved by the City of Corpus Christi Food and Drug Administration or the American Medical Association; any drug, biological product, device, medical treatment or procedure which is not covered as experimental or investigational (or similar) by the HCFA Medicare Coverage Issues Manual; any drug, biological product, or device which cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and which lacks such approval at the time of its use or proposed use; and any drug or biological product categorized as a Treatment Investigational New Drug (IND) by the U.S. Food and Drug Administration or as a Group C Treatment Protocol drug by the U.S. National Cancer Institute at the time of its use or proposed use. Specifically excluded are: refractive keratoplasty or radial keratotomy, immunotherapy for recurrent abortion, chemonucleolysis, biliary lithotripsy, home uterine activity monitor, immunotherapy for food allergy, and percutaneous lumbar discectomy. 13. Dental work and treatment (including eligible Hospital Expenses) will be eligible only when necessitated for the treatment of Temporomandibular Joint Dysfunction (TMJ) or as the direct result of an accidental injury to the jaws, sound natural teeth, mouth or face, occurring while covered by this Plan, including replacement of such teeth within twelve Citicare Public Safety 33 (12) months after the accident. Injury caused by chewing or biting will be considered accidental injury; 14. Diagnosis or care and treatment of: (a) weak, strained, unstable or flat feet; (b) toenails, ex- cept removal of a nail matrix; or (c) symptomatic complaints of the feet. 15. Any: (a) superficial lesions of the feet, such as corns, calluses or hyperkeratosis; (b) tarsal - gia, metatarsalgia or bunion, except surgery which involves exposure of bones, tendons or ligaments; (c) support devices for the foot (i.e. special stockings, socks, shoe inserts). 16. Any service, supply, or treatment connected with custodial care. The Plan does not cover these services no matter who provides, prescribes, recommends or performs them. Custodial care means services designed to help a covered person meet the needs of daily living, whether or not he or she is disabled. These services include help in: a. walking or getting in or out of bed; b. personal care such as bathing, dressing, eating, or preparing special diets; or c. taking medication which the covered person would normally be able to take without help. 17. Sickness sustained or contracted or injury caused by: (a) war, whether or not declared, or insurrection; or (b) military service of any country or International organization. 18. Sickness sustained or contracted or injury caused by the covered person's: (a) engaging or attempting to in an illegal occupation; or (b) commission of or an attempt to commit a criminal act, or voluntary participation in a riot, insurrection, or civil disobedience. 19. Enrollment in a health club; or a weight loss or similar program except as specified. 20. Purchase or rental of supplies of common household use such as: exercise cycles; air purifiers;; air conditioners; water purifiers; allergenic pillows or mattresses; or waterbeds. 21. Purchase or rental of: motorized transportation equipment; escalators or elevators; saunas or swimming pools; professional medical equipment such as blood pressure kits; or supplies or attachments for any of these items. 22. Convenience or personal care services such as use of a telephone or television. 23. Any surgical procedure to reduce obesity, except as specified. 24. Sickness or injury for which benefits are paid or payable under: (a) the mandatory provisions of any auto insurance policy written to comply with a "no- fault" insurance law; or (b) an uncovered motorist insurance law; or benefits which would have been paid under any auto insurance policy had the covered person properly complied with the mandatory provisions of a "no- fault" insurance law. 25. Homeopathic drugs as defined in the Homeopathic Pharmacopoeia. 26. Charges for nurses aid services; 27. Charges for missed appointments or completion of claim forms; 28. Charges incurred in a nursing home or convalescent hospital unless otherwise specified; 29. Charges incurred when not under the regular care of a legally qualified Physician; 30. Charges for orthotics; 31. Charges for travel and accommodations; except for the Organ Transplant Benefit. 32. Plastic, cosmetic and reconstructive surgery unless medically necessary as the result of an injury or tumor. The injury, or the initial tumor surgery, must occur while covered under the Plan. Such surgery will also be covered if an objective functional impairment is present or if required to correct a congenital defect or birth abnormality of a newborn. The pres- ence of a psychological condition will not entitle a covered person to coverage for plastic, cosmetic or reconstructive surgery unless all other conditions are met. 33. Vision analysis and examination, testing or orthoptic training, eye refractions or the purchase of eyeglasses or contact lenses (except as specified) to correct refractive errors and related services, including surgery performed to eliminate the need for eyeglasses for refractive errors (i.e. radial Keratotomy). 34. Services and supplies which are (a) rendered in connection with mental illnesses not classi- Citicare Public Safety 34 fled in the International Classification of Diseases of the U.S. Department of Health and Human Services, (b) extended beyond the period necessary for evaluation and diagnosis of learning and behavioral disabilities or for mental retardation, or (c) for mental illnesses which, according to generally accepted professional standards, are not usually amenable to favorable modification. This exclusion shall not apply to ADD or ADHD, which shall be covered as any other illness. 35. Routine physical examinations, even when required by an employer, school or insurance company. 36. Court ordered treatment for psychiatric disorders, when such order is the result of, or arises out of conduct by the covered person which is or would be criminal activity under the laws of the state or the Federal Government. 37. Maintenance care, which consists of services and supplies furnished mainly to: a. maintain, rather than improve, a level of physical or mental function; or b. provide a protected environment free from exposure that can worsen the covered member's physical or mental condition. 38. Care and treatment rendered by a provider whose services are not required to be covered by state law, except as provided by the Plan. 49. Care and treatment of complications of non - covered procedures, unless required by law. 40. Expenses incurred prior to the effective date or after the termination date of your coverage. 41. Sickness or injury caused by the covered person's intentional self - inflected illness, injury or attempted suicide except psychiatrist's charges incurred for treatment in connection with suicide or self - inflected injuries, including drug overdose, will be a covered expense. 42. Charges for marital or family counseling, family planning, sex therapy, pastoral counseling or other social services. 43. Hypnotism, Acupuncture, Goal Behavior Modification Therapy, except as specified. 44. Charges for Home Health Care or Hospice Care; 45. Charges for care or treatment rendered by a: a) Christian Science Practitioner; b) Homeopath; c) Naturopath; d) Optometrist; e) Pastoral Counselor; or fj Pharmacist. 46. Education and training except as specified. EXTENSION OF BENEFITS COVERAGE AFTER TERMINATION If a Covered Person is Totally Disabled on the date coverage terminates, benefits will be extended (subject to all other Plan provisions and limitations) during the continuation of the disability with respect to the injury or illness causing the disability if such person is not or does not become covered under any other plan entitling such person to any benefits from that injury or illness. Benefits will be extended for Covered Expenses until the earliest of the following dates: 1. The date the Covered Person ceases to be Totally Disabled; or 2. The date the applicable plan maximum is paid; or 3. The end of a twelve (12) month period; or 4. If lesser, a period equal to the time such Covered Person was covered under the Plan beginning with the first day following the termination of coverage. Benefits are not extended under this provision if this Plan terminates. FEDERAL CONTINUATION OF COVERAGE CONSOLIDATED OMNIBUS BUDGET RECONCILLIATION ACT (COBRA) A federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), requires that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called "continuation coverage ") at group rates in certain instances where coverage under the plan would otherwise end. This notice Citicare Public Safety 35 generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it This section is intended to inform you, in a summary fashion, of your rights and obligations concerning COBRA continuation coverage. You and your covered dependents should take the time to read this section carefully. This section applies to you if you are an employee or a covered dependent of an employee of the City of Corpus Christi covered by a group health plan sponsored by the City of Corpus Christi, which includes this Plan. COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you and your dependents (spouse and children) are covered under the Plan, each of you have the right to choose continuation coverage for up to eighteen (18) months if you or your covered dependents lose group health coverage under the Plan for any of the following reasons, called "qualifying events ": • Your employment terminates (voluntarily or involuntarily) for any reason other than for gross misconduct. If you decide not to return to benefits eligible employment at the City during Family & Medical Leave Act ( "FMLA ") leave, you will be offered COBRA at the date your FMLA leave ends. • You are no longer eligible for coverage due to reduced work hours. In addition, if you are a covered dependent you have the right to choose continuation coverage for up to thirty-six (36) months if you lose group health coverage under the Plan due to any of the following qualifying events: (1) For dependent children, the child no longer qualifies as a dependent under the rules of the Plan, such as reaching the maximum age. (2) Divorce or legal separation between the employee and spouse. (3) The employee becomes entitled to Medicare (i. e., enrolled in Medicare (Part A, Part B, or both). (4) The employee's death. Note: A dependent means any eligible dependent whose coverage became effective and has not terminated. This includes: 1. The lawful spouse of a covered employee. 2. An unmarried child to the end of the month in which the child attains age 25 (a mentally retarded or physically handicapped child may continue coverage beyond the limiting age if appropriate documentation is provided that (a) the child is incapable of self - sustaining employment because of mental or physical disability, (b) the child chiefly relies on the covered employee for fmancial support, and (c) if the child is first enrolled on or after the child's 256 birthday, the child is medically certified as disabled and is dependent on the covered employee). A child includes: (a) unmarried natural born child; or Citicare Public Safety 36 (b) unmarried legally adopted child (including a child placed with the covered employee for adoption for whom the covered employee has a legal obligation for total or partial support); or (c) an unmarried child you are seeking to adopt if the covered employee is a party to a suit regarding the child's adoption; or (d) an unmarried child for whom the covered employee was the legal guardian; or (e) a child who is dependent upon the covered employee for health coverage pursuant to a valid court order, including a qualified medical child support order (QMCSO); or (f) an unmarried child who lives with the covered employee in a normal parent child relationship if the child qualifies at all times for the dependent exemption as defined in the Internal Revenue Code and the Federal Tax Regulations; or (g) an unmarried natural born or adopted child of the covered employee's spouse (i.e.; the covered employee's step - child.) 3. Any unmarried grandchild if that unmarried grandchild is younger than 25 years of age and, at the time application for coverage of the unmarried grandchild is made under the Plan is the dependent of the covered employee for federal income tax purposes. However, once the grandchild is properly covered, coverage for the unmarried grandchild may not be terminated solely because the covered grandchild is no longer a dependent of the covered employee for federal income tax purposes. 4. As otherwise defined under the Plan. Each person has the right to choose continuation coverage, regardless of the covered employee's decision or that of other dependents. For example, a covered spouse or child may elect continuation coverage even if the covered employee does not do so. If you cover your spouse and/or dependents under the Plan, please ensure that your spouse and/or dependents understand the contents of this notice. If any covered dependent does not live with you, you may request an additional copy of a COBRA notice be provided directly to that dependent That must be done in writing. You may elect to continue the coverage described above on behalf' of any covered dependent, but you cannot decline continuation coverage on behalf of a covered dependent (other than a minor child or an incapacitated person for whom you are the legal representative). You may change your continuation coverage and may add or cancel continuation coverage for spouses and dependents (1) during any open enrollment period that is offered to City employees, or (2) in conjunction with a qualifying life status change under the Plan, such as the birth or adoption of a child or loss of other coverage. The change requested must be related to the life status change. Under the law, the employee, spouse, and/or dependent has the responsibility to inform the City of Corpus Christl's Human Resources Departments in writing, of a divorce or a child losing dependent status under the City's Health Care Plan. This notice must be given within 60 days of the date of the event or the date in which coverage would end under the Plan because of the event, whichever is later. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. If vou fail to notify the Human Resources Department, vou and your dependents may lose rights to continuation coverage. Citicare Public Safety 37 When the Plan is notified that one of these qualifying events has happened, the City of Corpus Christi or their third party administrator will in turn notify you that you and your covered dependents have the right to choose continuation coverage. Under the law, you and your covered dependents have at least 60 days from the date you would lose coverage because of one of the events described above, or the date notice of your election rights is sent to you, whichever is later, to inform the City that you want continuation coverage. If you do not choose continuation coverage, your group health benefits will end effective the date of the qualifying event. If you choose continuation coverage, the City of Corpus Christi is required to give you coverage which, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees or covered dependents. COBRA continuation coverage is a temporary continuation of coverage. In three situations, the 18 -month period for continuation coverage (which applies if your employment is terminated or you lose coverage due to a reduction in hours) may be extended. • Disabled Person. The 18 months will be extended to 29 months if an individual is disabled at the time of the qualing event or within the first sixty (60) days of the person's continuation coverage. To be considered disabled, you must have been determined to be so by the Social Security Administration. If such a determination is made, the disabled individual and all other family members of the disabled person on continuation coverage are entitled to the extra eleven (11) months of continuation coverage. Notwithstanding anything in this paragraph to the contrary, in order to receive the extension, you must notify the Human Resources Department of the City of Corpus Christi in writing in a timely fashion at the time of COBRA election or within 60 days of the date the individual receives documentation that the Social Security Administration has determined the individual to be disabled This notice must be received no later than the end of the initial 18 -month coverage period In addition, you must notify the Human Resources Department of the City of Corpus Christi within 30 days of any final determination that the individual is no longer disabled. You must send these notices to the Human Resources Department of the City of Corpus Christi at the address listed below. • Second Qualifying Event. Persons entitled to only eighteen (18) months of continuation coverage may receive an additional eighteen (18) months of continuation (for a total of 36 months) if, during the first eighteen month period, a second qualifying event occurs. For example, if an employee is terminated and the employee's spouse chooses termination coverage, and in the tenth month of the continuation coverage the former employee dies, the spouse is entitled to the additional 18 -month extension. Disabled persons and their family members who have qualified for an additional 11 -month period and who experience a second qualifying event during the additional 11 -month period can extend continuation coverage for an additional seven (7) month period, for a total continuation period of thirty-six (36) months. In all of these cases, you must make sure that the Human Resources Department of the City of Corpus Christi is notified in writing of the second qualifying event within 60 days of the second qual jing event. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. Citicare Public Safety 38 o Medicare - Entitled Employee Leaves Employment. When an employee who has been entitled to Medicare for less than 18 months loses coverage under the Plan due to retirement, voluntary or involuntary termination (for reasons other than the employee's gross misconduct) or reduction in work hours, the employee's spouse and dependents, but not the covered employee are entitled to a continuation period for longer than 18 months. In these instances, their continuation period ends thirty-six months from the date the employee became entitled to Medicare. You must make sure that the Human Resources Department of the City of Corpus Christi is notified in writing of this second qualifying event within 60 days of the second qualifying event. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. Your continuation coverage will be terminated by the City of Corpus Christi if: (1) The City of Corpus Christi no longer provides group health coverage to any of its employees. (2) The premium for your continuation coverage is not paid on time. (3) You become covered under a new group health plan, either as an employee, spouse or dependent, after the date you elected COBRA continuation coverage from this Plan. However, continuation coverage will not end if the new plan has a valid provision which does not allow coverage, or limits coverage, due to a preexisting condition. (4) You become entitled to Medicare after your COBRA continuation coverage election. (5) During the additional 11 -month extension for disabled persons, you are determined to no longer be disabled by the Social Security Administration. After COBRA continuation coverage begins, under the law, the employee, spouse, and/or dependent has the responsibility to inform the City of Corpus Christi's Human Resources Department in writing if any qualified beneficiary: (i) becomes covered under a new group health plan: (ii) becomes entitled to Medicare; or (iii) is determined to be no longer disabled by the Social Security Administration. You must send this notice to the Human Resources Department of the City of Corpus Christi at the address listed below. You do not have to show that you are insurable to choose continuation coverage. However, you must pay your premium for your continuation coverage. There is a grace period of 30 days for payments of the regularly scheduled premiums, except for the first premium, which must be paid within 45 days from the day COBRA is first elected and must include payments for all past periods of continuation coverage beginning with the date of the qualifying event. If you have any questions about the COBRA continuation coverage, please contact the City of Corpus Christi's Human Resources Department, 1201 Leopard, Corpus Christi, TX 78401, (361) 880 -3300, or you may contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration ( "EBSA "). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website at www.dol.gov /ebsa. Also, if you have changed marital status, or you or your covered dependents have changed addresses please notify in writing the City of Corpus Christi, Human Resources Department, at the above address. In order to protect your family's rights, you should keep the Human Resources Department of the City of Corpus Christi informed in writing of any changes in the addresses of family Citicare Public Safety 39 members. You should also keep a copy, for your records, of any notices you send to the Human Resources Department. CONTINUATION COVERAGE FOR EMPLOYEES IN THE UNIFORMED SERVICES Employees on Military Leave (Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) An Employee who is absent from work for more than thirty (30) days in order to fulfill a period of duty in the Uniformed Services of the United States has a Qualifying Event as of the first day of the Employee's absence for such duty, and thus is eligible for rights under USERRA. The Employer shall furnish to the Employee a notice of the right to elect continuation coverage under USERRA and shall afford the Employee the opportunity to elect such coverage in accordance with USERRA. If the Employee elects coverage, the right to that coverage ends: A) on the day after the deadline for the Employee to apply for reemployment with or return to active employment with the Employer or B) eighteen (18) months beginning on the date of the employee's absence from employment with the Employer. An employee who elects to continue coverage may be required to pay up to 102 percent of the full premium under the Plan. However, during the first thirty (30) days that the Employee is absent in order to fulfill a period of duty in the Uniformed Services of the United States, the Employee must be treated the same as any other employee. This means the higher USERRA premium cannot be collected from the Employee for the first thirty (30) days. After the Employee has been absent for more than thirty (30) days, the Employee will receive immediate USERRA coverage upon payment of the entire cost of coverage plus a reasonable administration fee. Further, the Employee will have no preexisting condition exclusions applied by the Plan upon return from service. These rights apply only to Employees and their Dependents covered under the Plan before leaving for military service. In many instances, an Employee eligible for continuation of coverage under USERRA will also be eligible for continuation of coverage under COBRA. To the extent allowed under the law, the continuation of coverage periods under COBRA and USERRA will run concurrently under the plan. Plan exclusions and waiting periods may be imposed for any Sickness or Injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, military service. PROVISIONS APPLICABLE TO ALL HEALTH PLAN BENEFITS COORDINATION OF BENEFITS Definitions - Here are some terms used in this provision. ALLOWABLE EXPENSE means any necessary, reasonable and customary item of expense at least a part of which is covered by any one of the plans that covered the person for whom claim is made. When the benefits from a plan are in the form of services, rather than cash payments, the reasonable cash value of each service is both an allowable expense and a benefit paid. CLAIM DETERMINATION PERIOD means a plan year or that part of a plan year in which the person has been covered. PLAN means the coverage of medical or dental expenses or services by: 1. any group insurance plan, blanket or franchise on an covered or uncovered basis; Citicare Public Safety 40 2. service plan contracts, group or individual practice or other pre - payment plans; or 3. labor - management trusteed plans, union welfare plans, employers organization plans or employee benefit organization plans. 4. Coverage under governmental programs or coverage required or provided by any statute, except Medicare. (Refer to the Effect of Medicare provision for treatment of this coverage under This Plan.) The term does not include coverage under individual policies or contracts. Each plan or part of a plan which has the right to coordinate benefits is considered to be a separate plan. THIS PLAN means the benefits of the Plan which are subject to this coordination of benefits provision. WHAT A COORDINATION OF BENEFITS PROVISION DOES If a person is covered by this plan and by any of the other plans described above, a coordination of benefits provision will be used when the amount of benefits payable by this plan and the amount of benefits payable by any of the other plans for the same medical expenses would exceed the total amount of allowable expenses in a claim determination period. A coordination of benefit provision determines: 1. the order in which all plans pay their benefits; and 2. when, depending on the order of benefit determination, a plan may reduce its benefit so that not more than 100% of the allowable expenses are paid jointly by all plans. ORDER OF BENEFIT DETERNIINATION In order to administer this provision, it is first necessary to determine the order in which all of the plans pay their benefits. This order is shown below. 1. A plan which does not contain a coordination of benefits provision is considered to determine its benefits before a plan which does contain such a provision. 2. A plan which covers a person as an employee is considered to determine its benefits before a plan which covers a person as a dependent. 3. A plan which covers a person as the dependent of a person whose month and day of birth (excluding the year of birth) occurs earlier in the calendar year is considered to determine its benefits before a plan which covers the person as the dependent of a person whose month and day of birth (excluding the year of birth) occurs later in the calendar year. If either one of the plans does not have this "birthday rule" provision, then the plan without this provision is considered to determine its benefits before the plan which does contain this provision. In the case of divorced or legally separated parents, the order of payment is determined as shown below. a. If there is a court decree which establishes financial responsibility for a dependent child's health expenses, the plan of the parent with that responsibility is considered to determine its benefits before the Plan of the parent without the responsibility. b. If there is no such decree and the parent with custody of the child has not remarried, the plan which covers the child as a dependent of the parent with custody is considered to determine its benefits before the plan of the parent without custody. c. If the parent with custody of the child has remarried: 1) the Plan which covers the child as a dependent of the parent with custody determines its benefits first; 2) the Plan which covers the child as a dependent of the step - parent determines its benefits second; and 3) the Plan which covers the child as a dependent of the parent without custody de- termines its benefits third. If the above rules fail to establish the order of payment, the plan which has covered the person Citicare Public Safety 41 for the longest time is considered to determine its benefits first. However, a person may be covered as an active employee by one plan and as a retired or laid -off person or the dependent of such person by another plan. In this case, if both plans contain a provision regarding retired or laid -off employees, the plan which covers the person as an active employee or the dependent of such person is considered to determine its benefits before the plan which covers the person as a retired or laid -off employee or the dependent of such person. If either one of the plans does not contain a provision for retired or laid -off employees, and as a result each plan determines its benefits after the other, the order of benefit determination shown above will be used to determine the order of payment by the plans. HOW BENEFITS ARE COORDINATED If the benefits of this plan are payable first, the benefits payable by the other plans are ignored when the Plan determines the amount payable. If this plan's benefits are payable after those of any other plan, the Plan adds up the benefits payable by each of the plans in the order in which they pay and compare the total benefits payable to the total amount of allowable expenses. If this Plan's payments would result in benefits which exceed total allowable expenses, benefits are reduced. When coordination reduces the total amount otherwise payable, each benefit that would have been payable in the absence of coordination is reduced in proportion. The reduced amounts are charged against any applicable benefit limits of this plan. In no event will this plan's payment be more than it would have been in the absence of other plans. The Plan reserves the right to release to or obtain from any other organization or person without the consent of or notice to any covered person, any information which, in the Plan's or its administrator's opinion, the Plan needs for the purpose of coordination of benefits. When payment which should have been made by this plan has been made by any other plan, this Plan has the right to pay to any organization making these payments an amount this Plan considers to be warranted. Amounts paid in this manner are considered to be benefits paid by this Plan. After this Plan makes such payments, it has no further liability. When this Plan has made an overpayment, it has the right to recover that payment to the extent of the excess. This Plan may recover the overpayment from the person to whom it was made or from any other insurance company or organization. Any Covered Person receiving benefits under This Plan must furnish information about other coverage which may be involved in applying this Coordination of Benefits provision. ELIGIBILITY FOR MEDICARE Definitions — The definitions listed below apply only to this Provision. MEDICARE PART A means the federal program which provides hospital insurance benefits. MEDICARE PART B means the federal program which provides medical insurance benefits. For the purposes of determining benefits payable for any covered person who is eligible to enroll for Medicare Part B, but does not, this Plan assumes the amount payable under Medicare Part B to be the amount the covered person would have received if he or she enrolled for it. A covered person is considered to be eligible for Medicare on the earliest date coverage under Medicare could become effective for him or her. INTEGRATION WITH MEDICARE Citicare Public Safety 42 The benefits of this Plan will be payable first for a covered person who is under age 65 and eligible for Medicare. The benefits of Medicare will be payable second. TEFRA OPTIONS The Tax Equity And Fiscal Responsibility Act of 1982 (TEFRA), as amended, allows the employer's actively working covered group members age 65 or older and their covered spouses who are eligible for Medicare to choose one of the following options: OPTION 1 - The benefits of this Plan will be payable first and the benefits of Medicare will be payable second. OPTION 2 - Medicare benefits only. The group member and his or her dependents, if any, will not be covered by the Plan. You may elect Medicare as primary coverage of benefits. However, if you do elect to have Medicare as primary coverage, then you are voluntarily opting out of coverage under the Plan and your coverage will terminate. If the individual does not choose one of the above options in writing, this Plan will be primary. The group must provide each covered group member and each covered spouse with the choice to elect one of these options at least one month before the covered group member or the covered spouse becomes age 65. All new group members and newly covered spouses age 65 or older must be offered these options. If Option 1 is chosen, its issue is subject to the same requirements as for a group member or dependent under age 65. Under the TEFRA regulations, there are two categories of persons eligible for Medicare. The calculation and payment of benefits by the Plan differs for each category. CATEGORY 1 Medicare Eligible are: 1. actively working covered group members age 65 or older who choose Option 1; 2. their age 65 or older covered spouses; and 3. age 65 or older covered spouses of actively working covered group members who are under age 65. CATEGORY 2 Medicare Eligible are any other covered persons entitled to Medicare, whether or not they enrolled for it. This category includes, but is not limited to: 1. retired group members and their spouses; or 2. covered dependents of a covered group member, other than his or her spouse. CALCULATION AND PAYMENT OF BENEFITS For covered persons in Category 1, benefits are payable by the Plan without regard to any benefits payable by Medicare. Medicare will then determine its benefits. For covered persons in Category 2, Medicare benefits are payable before any benefits are payable by the Plan. The benefits of this Plan will then be reduced by the full amount of all Medicare benefits the covered person is entitled to receive, whether or not they were actually enrolled for Medicare. Covered Retirees For Covered Retirees who are eligible for Medicare, benefits will be paid under this Plan to the extent of the difference between the dollar amount that Medicare will pay under Parts A and B and the dollar amount of benefits that would have been paid under this Plan if the Covered Person was not eligible for Medicare. This means that Medicare will pay its benefits first and then this Plan will calculate its benefits and pay the amount of the benefits less the amount that Medicare paid. All Plan maximums will apply. When a disabled, non - working employee becomes eligible for benefits under Medicare, as a result of a disability (other than End Stage Renal Disease) and chooses to remain covered under this Plan, Medicare will be the primary payer of benefits. Medicare will pay benefits first, and this Plan will be the secondary payer. Citicare Public Safety 43 Disability Due to End Stage Renal Disease If a Covered Person becomes eligible for benefits under Medicare as a result of disability due to End Stage Renal Disease and chooses to remain covered under this Plan, this Plan will pay its benefits first and Medicare will be the secondary payer for the first thirty-three (33) months of disability. After the initial thirty-three (33) months, Medicare will be the primary payer. Medicare disability rules apply to the disabled family members of active employees who are not disabled. For example, Medicare would be the secondary payer of benefits for a disabled spouse of an active employee who is covered under a large group health plan. For purposes of this provision, the term "disabled" will be the definition given by Social Security. REGARDLESS OF THE PROVISIONS STATED ABOVE, THIS PLAN SHALL AT ALL TIMES COMPLY WITH MEDICARE AS ENACTED AND AMENDED. CLAIMS The Plan Must Be Notified of Intent to File a Claim Notice of a claim for benefits must be given to the Plan in writing. Any claim will be based on the written notice. The notice must be received within 30 days after the start of the loss on which the claim is based. If notice is not given in time, the claim may be reduced or invalidated. If it can be shown that it was not reasonably possible to submit the notice within the 30 -day period and that notice was given as soon as possible, the claim will not be reduced or invalidated. When to File Proof of Claim Participating providers are responsible for submitting claims for covered expenses directly to the Plan on the covered person's behalf. Health care providers who have entered into a reimbursement agreement with the Plan have agreed not to bill the covered person for an amount greater than the difference between reasonable charges and the benefit amount paid by the Plan. The covered person will need to complete and sign all necessary papers and authorize participating providers to release those medical records which may be necessary to complete the processing of your claim. Benefit payments for covered services received from a participating provider will be forwarded directly to the provider. Written proof of claim for services rendered by a non - participating provider must be given to us within 90 days after the date of the injury or sickness for which claim is made. If proof of claim is not submitted within the required time period, the claim may be reduced or invalidated. If it can be shown that it was not reasonably possible to submit within the time period and that the proof was submitted as soon as possible, the claim will not be reduced or invalidated. The Plan May Extend Time Limits If the time limit for giving notice of claim or submitting proof of loss is less than the law permits in the state where the claimant lives, the Plan extends its time limits to agree with the minimum period specified by that state's laws. The law must exist at the time the Plan is issued. The Plan's Right to Require Medical Exams The Plan has the right to require that a medical exam be performed on any claimant for whom a claim is pending as often as it may reasonably require. If the Plan requires a medical exam, it will be performed at the Plan's expense. The Plan also has the right to request an autopsy in the case of death, if state law so allows. To Whom Benefits are Payable All benefits are payable to the covered group member. However, with our consent, a covered Citicare Public Safety 44 person may direct us to pay all or any part of the medical benefits to the medical care provider on whose charge the claim is based. If any covered person to whom benefits are payable is a minor or, in our opinion, not able to give a valid receipt for any payment due him or her, such payment will be made to his or her legal guardian. However, if no request for payment has been made by the legal guardian, the Plan may, at its option, make payment to the person or institution appearing to have assumed his or her custody and support. When the Plan Pays The Plan will pay benefits for covered medical services after the covered person has satisfied any deductibles and co- payment amounts. No benefits are payable for charges which are discounted, waived or rebated by a provider of services simply because the covered person is covered. The Plan shall have the right to recover from a provider of services or from a covered person any excess benefits paid for charges which were discounted, waived or rebated. All benefits will be paid not more than 60 days after the Plan receives proper written proof of claim. If a covered person dies while medical benefits remain unpaid, the Plan may choose, in its sole discretion, to pay benefits to: 1. any person or persons related to the covered person by blood or marriage who appears to be entitled to the benefits; or 2. the executors or administrators of the covered person's estate, based on our selection. The Plan will be discharged of liability to the extent of any such payments made in good faith. Right of Recovery Our intention is to preserve and assert our rights to recover for sums paid or benefits provided where circumstances warrant the assertion of our rights, to the fullest extent allowed by the applicable laws of the jurisdiction involved. Each provision below shall be considered severable, and if any provision is determined to be unenforceable or void, the remaining provisions shall remain unaffected. Subrogation This provision applies when another party (person or organization) is, or may be, considered re- sponsible for causing injury or for payment of benefits due to a covered person's injury or sickness for which benefits under the Plan have been provided or paid. To the extent of such ben- efits, the Plan is subrogated to all rights and claims for recovery the covered person has against any party (including a health care carrier) responsible for the injury for payment to the covered person on account of the injury. Right of Reimbursement If payment (by settlement, judgment or any other manner) is made, or may be made, in the future by, or on behalf of, a responsible party to the covered person, expenses arising from the covered person's injury or sickness are not covered by the Plan. However, if the Plan receives a claim for which benefits would be payable in the absence of a responsible party as described above, the Plan will pay those benefits subject to the following conditions: 1. The Plan will automatically have a lien to the extent of benefits advanced upon any recovery, by settlement, judgment or otherwise that you receive from the responsible party, or any person or organization making payment on behalf of the responsible party, including first party, undercovered and uncovered motorist coverage. The lien will be in the amount of benefits provided or paid by the Plan for the treatment of the condition for which the third party is responsible. 2. You agree to notify the claims administrator, in writing, within 60 days of your claim against the responsible party and to take such action, furnish such information, cooperate generally, and execute any documents as the Plan may require to facilitate enforcement of Citicare Public Safety 45 our rights. Exclusively at our option and choice, and without any waiver of any other rights of the Plan, in the event of prejudice, non - cooperation or breach of this Plan, the Plan may withhold, deduct or retract payments to or on behalf of the covered person. Duplication of Benefits /Other Insurance This provision is intended to prevent overpayment or duplication of benefits under this Plan when other health care coverage provides the same benefits. It applies when a person is covered by us and has, or is entitled to, benefits as a result of their injuries from any other coverage including, but not limited to, first party uncovered or undercovered motorist coverage, any no- fault insurance, medical payment coverage (auto, homeowners or otherwise), workers compensation settlement or awards, other group coverage (including student plans), direct recoveries from liable parties, premises medical pay or any other insurer providing coverage that would apply to pay your medical expenses, except other group health carriers in which case coverage will be determined under Coordination of Benefits. Where there is such coverage, the Plan will not duplicate other coverage available to the covered person and shall be considered secondary, except where specifically prohibited. Where double coverage exists, the Plan shall have the right to be repaid from whomever has received the overpayment to the extent of the duplicate coverage. This provision applies whether or not the covered person has made a claim under other applicable coverage. When applicable, the covered person is required to provide us with authorization to obtain information about the other coverage available, and to cooperate in the recovery of overpayments from the other coverage, including executing any assignment of rights necessary to obtain payment directly from the other coverage available. Cooperation Required The covered person has a duty to cooperate by providing information and executing any documents to preserve our right and shall have the affirmative obligation of notifying the claims administrator that claims are being made against responsible parties to recover for injuries for which the Plan has paid. If the covered person enters into litigation or settlement negotiations regarding the obligations of the other party, the covered person must not prejudice, in any way, the Plan's rights to recover an amount equal to any benefits the Plan has provided or paid for the injury or sickness. Failure of the covered person to provide the Plan such notice or cooperation, or any action by the covered person resulting in prejudice to the Plan' s rights will be a material breach of this Plan and will result in the covered person being personally responsible to make repayment. In such an event, the Plan may deduct from any claim any amounts the covered person owes the Plan. Legal Actions and Limitations No action at law or in equity may be brought to recover under the Plan until at least 60 days after written proof of claim has been filed with us. It action is to be taken after the 60 day period, it must be taken within 2 years of the date written proof of claim was required to be filed. Payment to the State of Texas If a covered person incurs covered expenses which are covered under the Medical Assistance Act of 1967, as amended, the Plan will reimburse to the Texas Department of Human Resources, or appropriate state agency, the actual cost of covered expenses the Department pays through medical assistance to the covered person. The Plan will be discharged of its obligation to the extent of any such payment. Citicare Public Safety 46 Complaint Notice Should any dispute arise about premium payment or about a claim that has been filed, the covered person may write to the claims administrator. If the problem is not resolved, the covered person may also contact this plan directly by writing to the Texas State Board of Insurance at (800) 242 -3439 or send written correspondence to P.O. Box 149104, Austin, Texas 78714 -9104. TERMINATION PROVISIONS - TERMINATION OF YOUR COVERAGE A. Your coverage will terminate on the earliest of the following dates: 1. the date you cease to be in a class of eligible group members; 2. the last day for which you or the Police Officers' Association, on your behalf, make any required premium contribution for your Plan; 3. the last day for which the policyholder has made any required premium contribution for coverage on your behalf; 4. the date your Lifetime Maximum Benefit is reached; or the date the Plan is terminated. B. Termination of your coverage under this Plan will occur when you qualify for Medicare and elect to have Medicare pay as primary coverage C. Subject to payment of required Contributions and rules precluding preferential selection, coverage may be continued during an approved medical leave of absence in accordance with Employer policy, Chapter 143 of the Texas Local Government Code and the Collective Bargaining Agreement. If an employee is unable to return to full time employment at the end of the medical leave of absence, employment will be terminated and coverage as a full time employee will end. D. Failure to sign and submit enrollment forms during annual open enrollment will result in termination of coverage at the beginning of the plan year. E. Failure to update your mailing address resulting in the Benefit Section's inability to contact you will result in termination of coverage. Employers subject to Family Medical Leave. Act Regardless of the established leave policies mentioned above, the Plan shall comply with the Family and Medical Leave Act of 1993 as regulated by the Department of Labor. TERMINATION FOR CAUSE The Plan may terminate a covered person's coverage for cause pursuant to the following: 1. If a covered person allows an unauthorized person to use his or her identification card or uses the identification card of another member. Under these circumstances, the person who receives the services provided by use of the identification card will be responsible for paying us the reasonable charges for those services. 2. If a covered person or group perpetrates fraud and/or misrepresentation on claims or identification cards in order to obtain services or a higher level of benefits. This includes, but is not limited to, the fabrication and/or alteration of a claim or identification card. TERMINATION OF DEPENDENT COVERAGE A dependent's coverage will terminate on the earliest of the following dates: 1. the date the employee's coverage terminates; 2. the date the employee ceases to be in a class of members eligible for dependent coverage; 3. the last day for which the employee makes any required contribution for dependent coverage; 4. the date the dependent coverage benefit or the Plan is terminated; 5. the date a dependent reaches his or her Lifetime Maximum Benefit; or Citicare Public Safety 47 6. the date a dependent no longer qualifies as a dependent. DISABLED CHILDREN If an unmarried dependent child who has reached the maximum age for a dependent meets all of the requirements shown below, the Plan extends dependent health coverage for that child for as long as the employee remains covered for dependent coverage. 1. The child must be incapable of self - sustaining employment because of mental or physical disability. 2. The child must chiefly rely on the employee for financial support. The employee must give the Plan proof of the child's disability within 31 days of the date the child reaches the maximum age. The Plan may request additional proof from time to time for the remainder of the child's coverage under the Plan. MISCELLANEOUS PROVISIONS REVIEW AUTHORITY The City of Corpus Christi shall have complete authority to review all denied claims for benefits under the Plan (including, but not limited to, the denial of certification of the medical necessity of hospital or medical treatment). In exercising its responsibilities, the City shall have sole and complete discretionary authority 1) to determine whether and to what extent individuals are eligible for benefits; 2) to construe disputed or doubtful Plan terms; and, 3) to make determinations regarding alternative care plans when reviewed and approved by the network [Independent] Medical Director. Notwithstanding anything to the contrary, benefits under this Plan will be paid only if the City determines, in its sole discretion, that an individual is entitled to such benefits pursuant to the terms of the Plan or as required by law. The City shall be deemed to have properly exercised such authority unless it has abused its discretion hereunder by acting arbitrarily and capriciously. COVERED PERSON/PROVIDER RELATIONSHIP The Plan does not provide covered services. The Plan helps pay for covered services Plan Participants receive. The Plan is not liable for any act or omission of any Provider. The Plan has no responsibility for a Provider's failure or refusal to give covered services to Plan Participants. CHANGES IN PLAN Changes that affect coverage or benefits may only be made in the Plan by an amendment signed by a person with the authority to bind the City of Corpus Christi including, but not limited to, the City's Health Benefits Manager. WORKERS' COMPENSATION The Plan does not affect or take the place of Workers' Compensation. ASSIGNMENT The Plan and its benefits may not be assigned by the policyholder. TERMINATION OF THE PLAN The Employer shall have the right, at any time, to terminate or amend This PIan. The Employer makes no promise to continue these benefits in the future and the right to future benefits will never vest. Citicare Public Safety 48 TRANSPLANT PROVISIONS Medically Necessary services and supplies otherwise covered under the Plan that are incurred for in connection with the following human to human organ or tissue transplant procedures, provided such procedures are not deemed as experimental or research in nature in the judgment of the Plan, considered standard practice for the diagnosis and are endorsed by the American Medical Association: 1) heart; 2) heart-lung; 3) lung; 4) kidney; 5) bone marrow (when treatment is for conditions resulting from acute leukemia, aplastic anemia or immuno- deficiency syndrome); 6) liver; 7) pancreas; 8) cornea; 9) stem cell transplant. If the donor is covered under this Plan, eligible medical expenses incurred by the donor will be considered for benefits. For donor costs to be covered, the recipient must be covered under this Plan. When the donor has other medical coverage, his or her plan will pay first. The benefits of this Plan will be reduced by the benefits payable under the donor's plan. In no event will benefits be payable in excess of the Minimum Lifetime Benefit still available to the recipient. If both the donor and the recipient are covered under this Plan, eligible medical expenses incurred by each person will be treated separately for each person. The Usual and Customary cost of securing an organ from a cadaver or tissue bank, including the surgeon's charge for removal of the organ and a hospital's charge for storage or transportation of the organ, will be considered a covered medical expense. The Plan may, at it's discretion, require the patient seek a second surgical opinion prior to approval of any transplant procedure. Coverage is subject to all other terms and provisions of the Plan. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) HIPAA (PRIVACY RIGHTS) Under the Health Insurance Portability and Accountability Act of 1996 ( "HIPAA "), group health plans, such as the Plan, must take steps to protect the privacy of your "protected health information." Protected health information is individually identifiable health information, including demographic information, collected from you or created or received by a health care provider, a health plan, your employer (when functioning on behalf of the group health plan), or a health care clearinghouse and that relates to: (1) your past, present, or future physical or mental health or condition; (2) the provision of health care to you; or (3) the past, present, or future payment for the provision of health care to you. The following discusses the technical HIPAA requirements of the Plan and Plan Sponsor. If you have any questions, please review the Notice of Privacy Practices located on the Plan Sponsor's website or contact a representative in the Benefits Section of the Risk Management Department. A. Plan's Disclosure of Protected Health Information to the Plan Sponsor Upon Receipt of Certification of Compliance by Plan Sponsor The Plan may disclose protected health information to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor that the Plan Sponsor agrees to: 1. Not use or further disclose the information other than as permitted or required by the Plan Citicare Public Safety 49 Documents or as required by law; 2. Ensure that any agents, including a subcontractor, to whom it provides protected health information received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information; 3. Not use or disclose the information for employment- related actions and decisions or in connection with any other benefit plan of the Plan Sponsor; 4. Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for, of which it becomes aware; 5. Make available protected health information in accordance with 45 CFR 164.524; 6. Make available protected health information for amendment and incorporate any amendments to protected health information in accordance with 45 CFR 164.526; 7. Make available the information required to provide an accounting of disclosures in accordance with 45 CFR 164.528; 8. Make its internal practices, books and records relating to the use and disclosure of protected health information received from the Plan available to Health and Human Services for purposes of determining compliance by the Plan with the privacy rules; 9. If feasible, return or destroy all protected health information received from the Plan that the Plan Sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible; and 10. Ensure that adequate separation between the Plan and the Plan Sponsor has been established. B. Permitted Uses and Disclosures of Protected Health Information to the Plan Sponsor The Plan (and any business associate acting on behalf of the Plan) will disclose protected health information to the Plan Sponsor only to permit the Plan Sponsor to carry out administrative functions in relation to the Plan. Such disclosures shall be consistent with the provisions of 45 CFR 164. All disclosures of protected health information to the Plan Sponsor will comply with the restrictions and requirements set forth in this HIPAA (Privacy Rights) Section. The Plan (and any business associate acting on behalf of the Plan) may not disclose protected health information to the Plan Sponsor for employment - related actions or decisions, or in connection with any other benefit plan of the Plan Sponsor. Further, the Plan Sponsor shall not use or disclose protected health information for employment- related actions and decisions, or in connection with any other benefit plan of the Plan Sponsor. The Plan Sponsor shall not use or further disclose protected health information other than as permitted by the Plan or the HIPAA privacy regulations. The Plan Sponsor shall ensure that any agent or subcontractor to whom it provides protected Citicare Public Safety 50 health information received from the Plan, agrees to the same restrictions and conditions that apply to the Plan Sponsor with respect to protected health information. The Plan Sponsor shall report to the Plan any use or disclosure of protected health information that is inconsistent with the uses or disclosures provided for in the Plan or the HIPAA privacy regulations, of which the Plan Sponsor becomes aware. C. Additional Duties of the Plan Sponsor The Plan Sponsor shall make protected health information of the individual who is the subject of the protected health information available to such individual in accordance with 45 CFR 164.524. The Plan Sponsor shall make individuals' protected health information available for amendment and incorporate any amendments to individuals' protected health information in accordance with 45 CFR 164.526. The Plan Sponsor shall make and maintain records of disclosures so that it can make available an accounting of such disclosures to individuals in accordance with 45 CFR 164.528. The Plan Sponsor shall make its internal practices, books and records relating to the use and disclosure of protected health information received from the Plan available to Health and Human Services for purposes of determining compliance with HIPAA's privacy rules. The Plan Sponsor shall, if feasible, return or destroy all protected health information received from the Plan that the Plan Sponsor still maintains in any form after such information is no longer needed for the purposes for which the use or disclosure was made. Additionally, the Plan Sponsor will not retain copies of such protected health information after such information is no longer needed for the purpose for which the use or disclosure was made. However, if such return or destruction is not feasible, the Plan Sponsor will limit further uses and disclosures to those purposes that make the return or destruction .of the information infeasible. The Plan Sponsor shall ensure that an adequate separation between the Plan and the Plan Sponsor is established and maintained. D. Disclosures of Summary Health Information and Enrollment and Disenrollment Information to the Plan Sponsor The Plan (and any business associate acting on behalf of the Plan) may disclose summary health information to the Plan Sponsor if the Plan Sponsor requests summary health information for the purpose of 1) obtaining premium bids from health plans for providing health insurance coverage under the Plan, or 2) modifying, amending, or terminating the Plan. The Plan may disclose to the Plan Sponsor information on whether an individual is participating in the Plan or whether an individual is enrolled in or has disenrolled from the Plan. E. Required Separation Between the Plan and the Plan Sponsor In accordance with 45 CFR 164.504(f)(2)(iii), the following classes of employees or workforce members under the control of the Plan Sponsor may be provided access to protected health information received from the Plan. 1. The members of the Health Benefits Division of the Human Resources Department of the Employer; Citicare Public Safety 51 2. The members of the Legal Department of the Employer; 3. The members of the Accounting Division of the Finance Department of the Employer; 4. The members of the MIS Department of the Employer; 5. The Senior Management Assistant of the Human Resources Department of the Employer; 6. The Director of Human Resources; 7. The Assistant City Manager for Support Services; 8. The City Manager of the City of Corpus Christi. The above list includes the classes of employees or workforce members of the Plan Sponsor who receive protected health information relating to payment under, health care operations of, or other matters pertaining to plan administration functions that the Plan Sponsor provides for the Plan. These individuals shall have access to protected health information solely to perform their job functions for the Plan Sponsor and they will be subject to disciplinary action for any use or disclosure of protected health information in violation of the provisions of 45 CFR 164. The Plan Sponsor shall promptly report any such breach or violation to the Plan and will cooperate with the Plan to correct the violation, to impose appropriate disciplinary action and to mitigate any deleterious effect of such violation. WHCRA Full Annual Notice The Women's Health and Cancer Rights Act of 1998 requires the Employer /Plan Sponsor to notify you, as a participant or beneficiary of the employer /Plan Sponsor, of your rights related to benefits provided through the plan in connection with a mastectomy. You as a participant or beneficiary have rights to coverage to be provided in a manner determined in consultation with your attending physician for: a) all stages of reconstruction of the breast on which the mastectomy was performed; b) surgery and reconstruction of the other breast to produce a symmetrical appearance, and c) prostheses and treatment of physical complications of the mastectomy, including lymphedema. These benefits are subject to the plan's regular deductible and co -pay as shown in the Schedule of Benefits. For further details, refer to your Summary Plan Document (booklet). Pleased ensure that all covered family members receive this notice and are aware of these rights. Keep this notice for your records and call the Employer for more information. Minimum Maternity Benefits Statement Group health plans and health insurance issuers generally may not under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, form discharging the mother or her newborn Citicare Public Safety 52 earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Citicare Public Safety 53 Citicare Plan Summary of Benefits Effective 08/01/08 - 07/31/09 BENEFITS IN NETWORK (Participating Providers) OUT OF NETWORK PHYSICIAN SERVICES Primary Care Physician (PCP) 1 In & Out Patient $15.00 Co -Pay Includes: Family, General, Pediatrician, Internal, Nurse Practitioner, Physician Assistant, Registered Nurse, OB -GYN $750 Individual Deductible Then 70/30% Co- insurance PHYSICIAN SERVICES Specialist, Urgent Care, Emergency Room In & Out - Patient $30.00 Co -Pay $750 Individual Deductible Then 70/30% Co- insurance Diagnostic Out - patient Lab, X -ray, Allergy Testing Dr's Office, Lab, Hospitals $20.00 Co -Pay $750 Individual Deductible Then 70/30% Co- insurance Diagnostic Out - patient (MRI, CAT, PET, SPECT Scans) Dr's Office, Lab, Hospitals $50.00 Co -Pay $750 Individual Deductible Then 70/30% Co- insurance HOSPITAL SERVICES Out - Patient Services $150 Individual Deductible $600 Family Deductible Then 80/20% Co- insurance $750 Individual Deductible Then 50/50% Co- insurance HOSPITALIZATION In- Patient Hospital Services $200 Individual Deductible $600 Family Deductible Then 80/20% Co- insurance $500 Individual Deductible Then 50/50% Co- insurance EMERGENCY ROOM $100.00 Co -Pay Then 80/20% Co insurance $750 Individual Deductible Then 50/50% Co- insurance PRESCRIPTIONS 2 Rx3: Tier 1 - $10.00 (Generic) Tier 2 - $30.00 (Brand Formulary) Tier 3 - $50.00 (Non- Formulary) Rx3: All tiers reimbursed at in- network cost Tier 1 Tier 2 Tier 3 OUT -OF- POCKET COST Excluding Co -Pays & Deductibles $2,000 Individual $6,000 Family $8,000 Individual $24,000 Family Lifetime Maximum benefit per individual paid by plan $2,000,000.00 Humana Customer Service 1- 800 - 448 -6262 www.humana.com Humana/Choice Care Network PPO This is a summary only, plan document will govern. 1 A primary care physician, or PCP, is a physician who provides both the first contact for a person with undiagnosed health concerns as well as continuing care of v; medical conditions, not limited by cause, organ system, or diagnosis. Deductibles $6,000 Family Lifetime Maximum benefit per individual paid by plan $2,000,000.00 $24,000 Family Humana Customer Service 1- 800 - 448 -6262 www.humana.com Humana/Choice Care Network PPO This is a summary only, plan document will govern. 1 A primary care physician, or PCP, is a physician who provides both the first contact for a person with undiagnosed health concerns as well as continuing care of vi medical conditions, not limited by cause, organ system, or diagnosis. 2 Prescri tion Co -Pa s a 1 to Partici • atin. Pharmacies er • rescri • ion u • to a 30 da su I . • • • IETWORK Jai Deductible Co- insurance Jai Deductible Co- insurance Jai Deductible Co- insurance Jai Deductible Co- insurance ual Deductible Co- insurance ual Deductible o Co- insurance ual Deductible o Co- insurance irsed at in- 10 Individual )0 Family 000.00 ;oncerns as well as continuing care of varied Family 00.00 ncerns as well as continuing care of varied City of Corpus Christi Alternate Choice Plan Summary of Benefits Effective 8/01/08 to 7/31/09 BENEFITS IN NETWORK (Participating Providers) OUT OF NETWORK PHYSICIAN SERVICES , Primary Care Physician (PCP) In & Out Patient $25.00 Co Pay Includes: Family, General, Pediatrician, Internal, Nurse Practitioner, Physician Assistant, Registered Nurse, OB -GYN o 60/40% Co- insurance (after deductible is met) PHYSICIAN SERVICES Specialist, Urgent Care, Emergency Room In & Out - Patient Chiropractic Care $40.00 Co -Pay $40.00 Co -Pay Limited to 52 visits per plan year 60/40% Co- insurance (after deductible is met) 60/40% Co- insurance Limited to 52 visits per plan year Diagnostic Out - patient Lab, X -ray, Allergy Testing Dr's Office, Lab, Hospitals $30.00 Co -Pay (after deductible is met) 60/40% Co- insurance (after deductible is met) Diagnostic Out - patient (MRI, CAT, PET, SPECT Scans) Dr's Office, Lab, Hospitals 80/20% Co- insurance (after deductible is met) 60/40% Co- insurance (after deductible is met) HOSPITAL SERVICES Out - Patient Services 80/20% Co- insurance (after deductible is met) 50/50% Co- insurance (after deductible is met) HOSPITALIZATION In- Patient Hospital Services 80/20% Co- insurance (after deductible is met) 50/50% Co- insurance (after deductible is met) EMERGENCY ROOM $150.00 Co -Pay Then 80/20% Co- insurance (after deductible is met) $150.00 Co -Pay Then 50/50% Co- insurance (after deductible is met) PRESCRIPTIONS s Rx3: $10.00 (Generic) $30.00 (Brand Formulary) $50.00 (Non - Formulary) Rx3: All tiers reimbursed at in- network cost Tier 1 Tier 2 Tier 3 Plan Year Deductible OUT -OF- POCKET COST $750 Individual $2,250 Family OUT -OF- POCKET COST $1,500 Individual $4,500 Family OUT -OF- POCKET COST Excluding Co -Pays, Deductibles, and In or Out patient service fee $3,000 Individual $9,000 Family $9,000 Individual $27,000 Family Lifetime Maximum benefit per individual paid by plan $2,000,000. Humana Customer Service 1- 800 - 448 -6262 Lifetime Maximum benefit per individual paid by plan $2,000,000. Humana Customer Service 1- 800 - 448 -6262 www.humana.com Humana/Choice Care Network PPO This is a summary only, plan document will govern. A primary care physician, or PCP, is a physician who provides both the first contact for a person with undiagnosed health concerns as well as ontinuing care of varied medical conditions, not limited by cause, organ system, or diagnosis Prescri stion Co-Pa a..ly to Participating Pharmacies srescri .tion u to a 30 da su..ly. 1 ier 3 Plan Year Deductible OUT -OF- POCKET COST $750 Individual $2,250 Family OUT -OF- POCKET COST $1,500 Individual $4,500 Family OUT -OF- POCKET COST Excluding Co -Pays, Deductibles, and In or Out patient service fee $3,000 Individual $9,000 Family $9,000 Individual $27,000 Family Lifetime Maximum benefit per individual paid by plan $2,000,000. Humana Customer Service 1- 800 - 448 -6262 www.humana.com Humana/Choice Care Network PPO This is a summary only, plan document will govern. A primary care physician, or PCP, is a physician who provides both the first contact for a person with undiagnosed health concerns as well as ontinuing care of varied medical conditions, not limited by cause, organ system, or diagnosis Prescri stion Co-Pa a..ly to Participating Pharmacies srescri .tion u to a 30 da su..ly. FORK irance is met) irance is met) trance 3r plan year irance is met) .r ra is h.-0 .arance is met) urance is met) Pay insurance is met) r network cost idual ly :T T idual ly lual r COST lual health concerns as well as Citicare Fire Summary of Benefits Effective 08/01/08-07/31/09 THIS IS NOT A GUARANTEE OF BENEFITS. BENEFITS (parti pIN NETWORK at g Providers) SPECIAL SERVICES' OUT OF NETWORK PHYSICIAN SERVICES In- Patient Out - Patient Emergency Room $100 Individual Deductible $300 Family Deductible Then 85/15% Reimbursement $100 Individual Deductible $300 Family Deductible Then 80/20% Reimbursement $100 Individual Deductible $300 Family Deductible Then 70/30% Reimbursement LAB WORK Physician's Office Lab Facilities Hospitals $100 Individual Deductible $300 Family Deductible Then 85/15% Reimbursement $100 Individual Deductible $300 Family Deductible Then 80/20% Reimbursement $100 Individual Deductible $300 Family Deductible Then 70/30% Reimbursement X -RAYS Physician's Office: X -Ray Facilities: Hospitals: $100 Individual Deductible $300 Family Deductible Then 85/15% Reimbursement $100 Individual Deductible $300 Family Deductible Then 80/20% Reimbursement $100 Individual Deductible $300 Family Deductible Then 70/30% Reimbursement HOSPITAL SERVICES Out - Patient Services $100 Individual Deductible $300 Family Deductible Then 85/15% Reimbursement $100 Individual Deductible $300 Family Deductible Then 80/20% Reimbursement $100 Individual Deductible $300 Family Deductible Then 70/30% Reimbursement HOSPITALIZATION In- Patient Hospital Services $100 Individual Deductible $300 Family Deductible Then 85/15% Reimbursement $100 Individual Deductible $300 Family Deductible Then 80/20% Reimbursement $100 Individual Deductible $300 Family Deductible Then 70/30% Reimbursement EMERGENCY ROOM $100 Individual Deductible $300 Family Deductible Then 85/15% Reimbursement $100 Individual Deductible $300 Family Deductible Then 80/20% Reimbursement $100 Individual Deductible $300 Family Deductible Then 70/30% Reimbursement PRESCRIPTIONS 2 Generic -0- Brand $10.00 $100 Individual Deductible $300 Family Deductible Then 80/20% Reimbursement $100 Individual Deductible $300 Family Deductible Then 70/30% Reimbursement OUT -OF- POCKET COST Excluding Co -Pays & Deductibles $525 Individual $1,575 Family $525 Individual $1,575 Family $525 Individual $1,575 Family Lifetime Maximum benefit per individual paid by plan $2,000,000.00 Humana Customer Service 1- 800 - 448 -6262 www.humana.com Humana/Choice Care Network PPO This is a summary only, plan document will govern. Rev. 08/08 1 Special Services applies to services provided outside the service area due to residency only. Use of Out of Network providers due to an Emergency or Unavailability of medical services in PPO Network will be treated under the In- Network Benefits. 2 Prescription Co -Pays apply to Participating Pharmacies per prescription up to a 30 day supply. www.humana.com Humana/Choice Care Network PPO This is a summary only, plan document will govern. Rev. 08/08 1 Special Services applies to services provided outside the service area due to residency only. Use of Out of Network providers due to an Emergency or Unavailability of medical services in PPO Network will be treated under the In- Network Benefits. 2 Prescription Co -Pays apply to Participating Pharmacies per prescription up to a 30 day supply. prc, s due to an Emergency or r OF NETWORK idividual Deductible Family Deductible Then 70/30% leimbursement ldividual Deductible Family Deductible Then 70/30% leimbursement ndividual Deductible Family Deductible Then 70/30% leim bursement ndividual Deductible Family Deductible T1 '0/30% leit,. .rsement ndividual Deductible Family Deductible Then 70/30% leimbursement ndividual Deductible 1 Family Deductible Then 70/30% ieim bursement ndividual Deductible Family Deductible Then 70/30% leimbursement 525 Individual $1,575 Family ).00 providers due to an Emergency or Citicare Public Safety Summary of Benefits Effective 08/01/08- 07/31/09 THIS IS NOT A GUARANTEE OF BENEFITS. BENEFITS IN NETWORK (Participating Providers) SPECIAL SERVICES OUT -OF- NETWORK PHYSICIAN SERVICES In- Patient Out- Patient Emergency Room $15.00 Co -Pay 80/20% Reimbursement 70/30% Reimbursement Lab Work Physician's Office Lab Facilities Hospitals $10.00 Co -Pay 80/20% Reimbursement 70/30% Reimbursement X -Rays Physician's Office: X -Ray Facilities: $10.00 Co -Pay $15.00 Co -Pay 80/20% Reimbursement 70/30% Reimbursement Hospital Emergency Room Services' $50 Co -Pay Then 80/20% Reimbursement 80/20% Reimbursement 70/30% Reimbursement Hospitalization (In- Patient) $200 Per Individual $600 Max Family (Ded) Then 85/15% Reimbursement $100 Per Individual $600 Max Family Then 80/20% Reimbursement $200 Per Individual $500 Max Family Then 70/30% Reimbursement Hospitalization (Out- Patient) $100 Per Individual $250 Max Family (Ded) Then 85/15% Reimbursement $100 Per Individual $250 Max Family Then 80/20% Reimbursement $200 Per Individual $500 Max Family Then 70/30% Reimbursement Prescriptions2 Co -Pays: $5 Generic $20 Brand No Deductible 80/20% Reimbursement No Deductible 70/30% Reimbursement Out -Of- Pocket Cost (Excluding Co -Pays & Deductibles) $500 Per Individual $1,250 Max Family $700 Per Individual $1,850 Max Family $700 Per Individual $1,750 Max Family Lifetime Maximum benefit per individual paid by plan $2,000,000.00 Humana Customer Service 1- 800 - 448 -6262 www.humana.com Humana/Choice Care Network PPO This is a summary only, plan document will govern. Rev. 08/08 Emergency Room Services: Co -Pay will increase to $50.00 provided that 2 minor emergency clinics are included, one on the Southside of Corpus Christi and the other in the Ca!alien area. Should the number of minor emergency clinics fall below 2 for more than 90 consecutive days, the Co -Pay will be $15.00 2 Employees and Dependents covered by the Public Safety Citicare will be excluded from the drug formulary. This is a summary only, plan document will govern. Rev. 08/08 Emergency Room Services: Co -Pay will increase to $50.00 provided that 2 minor emergency clinics are included, one on the Southside of Corpus Christi and the other in the CalaIlen area. Should the number of minor emergency clinics fall below 2 for more than 90 consecutive days, the Co -Pay will be $15.00 2 Employees and Dependents covered by the Public Safety Citicare will be excluded from the drug formulary. -OF- NETWORK Y0 Reimbursement Y0 Reimbursement Yo Reimbursement • Reimbursement O Per Individual 00 x Family Irh■ J /30% aim bursement 10 Per Individual 00 Max Family Then 70/30% eimbursement Jo Deductible 70/30% eimbursement 10 Per Individual 750 Max Family 1.00 le on the Southside of Corpus 0 consecutive days, the Co -Pay ie Southside of Corpus 0 consecutive days, the Co -Pay 306 19290109 77449 F 20030801 P CCARE 309 19281031 78415 M 20030801 J CCARE 309 19371011 78415 F 20030801 SP 1 J CCARE 310 19230906 76556 M 20040901 P CCARE 312 19201208 78405 M 20030801 P CCARE 313 19270714 78411 M 20030801 R CCARE 313 19280227 78411 F 20030801 SP 1 R CCARE 314 19221103 78411 F 20030801 SP 1 Q CCARE 318 19230113 78410 F 20030801 SP 1 Q CCARE 319 19270625 78412 F 20071022 SP 1 Q CCARE 321 19220427 78416 F 20030801 SP 1 Q CCARE 322 19300829 78404 F 20030801 SP 1 Q CCARE 323 19231116 78415 F 20030801 SP 1 Q CCARE 324 19241229 78412 F 20030801 SP 1 Q CCARE 326 19221126 78412 F 20030801 SP 1 Q CCARE 329 19210906 78411 M 20030801 P CCARE 331 19240922 78645 M 20030801 R CCARE 331 19310123 78645 F 20030801 SP 1 R CCARE 334 19271008 78411 M 20050401 R CCARE 334 19400412 78411 F 20050401 SP 1 R CCARE 336 19290727 78368 F 20030801 P CCARE 339 19330429 78415 M 20030801 R CCARE 339 19311015 78415 F 20030801 SP 1 R CCARE 341 19280725 78412 M 20030801 R CCARE 341 19310710 78412 F 20030801 SP 1 R CCARE 346 19340726 78414 F 20030801 SP 1 Q CCARE 347 19301025 78411 F 20061205 SP 1 Q CCARE 348 19211123 75855 F 20030801 SP 1 Q CCARE 349 19290618 78410 F 20030801 P CCARE 352 19231230 75707 F 20061127 SP 1 Q CCARE 353 19281015 78416 M 20030801 R CCARE 353 19330901 78416 F 20030801 SP 1 R CCARE 354 19101112 78412 F 20030801 P CCARE 356 19201102 78413 F 20030801 P CCARE 366 19321129 78413 M 20030801 R CCARE 366 19350220 78413 F 20030801 SP 1 R CCARE 368 19240321 78410 M 20030801 P CCARE 369 19330909 78383 M 20030801 R CCARE 369 19350427 78383 F 20030801 SP 1 R CCARE 380 19300407 71837 F 20040801 SP 1 Q CCARE 381 19240507 78628 F 20030801 P CCARE 385 19251122 78412 M 20030801 P CCARE 387 19411119 78414 F 20061101 P CCARE 390 19320305 78370 M 20040801 R CCARE 390 19390815 78370 F 20040801 SP 1 R CCARE 392 19350303 78405 F 20030801 SP 1 Q CCARE 393 19320915 78415 F 20030801 SP 1 Q CCARE 394 19320619 78404 F 20030801 P CCARE 397 19250913 78411 M 20030801 R CCARE 397 19301231 78411 F 20030801 SP 1 R CCARE 400 19320131 78409 M 20030801 R CCARE 400 19360416 78409 F 20030801 SP 1 R CLARE 419 19320206 78412 F 20031103 SP 1 Q CCARE 432 19300105 78414 F 20030801 SP 1 Q CCARE 435 19290819 78501 M 20030801 P CCARE 440 19280913 78411 M 20081223 P CCARE 445 19411207 76016 M 20061201 P CCARE 448 19390630 78415 M 20040801 R CCARE 448 19441206 78415 F 20040801 SP 1 R CCARE 451 19280219 79720 M 20030801 R CCARE 451 19360105 79720 F 20030801 SP 1 R CCARE 456 19250818 78404 F 20030801 P CCARE 457 19470404 78410 M 20030801 I CCARE 459 19390219 78410 M 20040201 R CCARE 459 19390206 78410 F 20040201 SP 1 R CCARE 463 19280201 78415 F 20030801 P CCARE 466 19490208 78125 F 20030801 R CCARE 466 19411026 78125 M 20030801 SP 1 R CCARE 467 19310921 78418 M 20070326 P CCARE 468 19331220 78411 F 20030801 SP 1 Q CCARE 474 19340724 78414 M 20030801 P CCARE 475 19361015 78480 M 20030801 P CCARE 481 19361217 78411 M 20050901 R CCARE 481 19400906 78411 F 20050901 SP 1 R CCARE 483 19321027 773991075 M 20030801 S CCARE 483 19451017 773991075 F 20030801 SP 1 S CCARE 484 19410804 78405 M 20060901 S CCARE 484 19451222 78405 F 20060901 SP 1 S CCARE 487 19370704 78411 M 20040429 R CCARE 487 19400528 78411 F 20040429 SP 1 R CCARE 488 19380114 78480 F 20030801 P CCARE 493 19320513 78416 M 20070611 P CCARE 495 19430130 78415 M 20080101 S CCARE 495 19450313 78415 F 20080101 SP 1 S CCARE 499 19341210 78411 M 20030801 R CCARE 499 19360901 78411 F 20030801 SP 1 R CCARE 500 19330105 78404 M 20060901 P CCARE 501 19471214 78410 F 20070918 SP 1 M CCARE 505 19311224 78410 M 20030801 R CCARE 505 19310430 78410 F 20030801 SP 1 R CCARE 512 19290104 78415 F 20030801 SP 1 Q CCARE 518 19350928 78405 M 20030801 P CCARE 521 19310614 78413 F 20030801 P CCARE 537 19301130 78401 F 20060522 SP 1 Q CCARE 539 19330901 78411 M 20061027 SP 1 Q CCARE 545 19300814 78404 M 20030801 R CCARE 545 19311028 78404 F 20030801 SP 1 R CCARE 547 19460413 78620 F 20030801 I CCARE 557 19341231 78404 M 20030801 P CCARE 561 19330906 78415 F 20030818 P CCARE 579 19310407 78063 F 20030801 P CCARE 582 19310713 78404 M 20030801 R CCARE 582 19301212 78404 F 20030801 SP 1 R CCARE 583 19380706 78405 F 20030801 SP 1 Q CCARE 588 19381210 78415 M 20030801 J CCARE 588 19400124 78415 F 20030801 SP 1 J CCARE 591 19461204 78418 F 20040801 1 CCARE 597 19310617 78336 M 20030801 S CCARE 597 19450908 78336 F 20030801 SP 1 S CCARE 600 19301001 78404 F 20030801 P CCARE 619 19350618 78413 M 20040301 R CCARE 619 19390321 78413 F 20040301 SP 1 R CCARE 628 19440414 78405 M 20081001 R CCARE 628 19480223 78405 F 20081001 SP 1 R CCARE 636 19480415 78467 M 20060601 1 CCARE 638 19350324 78410 F 20030801 R CCARE 638 19340218 78410 M 20030801 SP 1 R CCARE 643 19470706 78250 M 20030801 P CCARE 670 19240727 78416 M 20030801 R CCARE 670 19300126 78416 F 20030801 SP 1 R CCARE 673 19270504 78416 M 20050301 P CCARE 680 19261025 78384 F 20030801 P CCARE 681 19171002 78023 M 20050512 P CCARE 684 19250725 75418 M 20030801 SP 1 Q CCARE 686 19300215 78411 F 20030801 SP 1 Q CCARE 687 19280809 78411 F 20030801 SP 1 Q CCARE 696 19311120 78412 F 20030801 P CCARE 697 19240704 78416 F 20030801 SP 1 Q CCARE 701 19220729 78410 M 20060201 S CCARE 701 19520305 78410 F 20060201 SP 1 S CCARE 706 19191102 78413 M 20030801 P CCARE 707 19420609 78413 F 20070601 SP 1 Q CCARE 1033 19440805 78102 M 20050101 1 CCARE 1037 19480130 77478 F 20070430 1 CCARE 1041 19480131 77550 F 20080901 1 CCARE 1059 19291011 78415 F 20030801 P CCARE 1104 19481106 76065 F 20030801 1 CCARE 1106 19500410 78412 F 20030801 1 CCARE 1110 19421002 77449 -0036 F 20071001 R CCARE 1110 19400515 78415 M 20071001 SP 1 R CCARE 1120 19511201 78411 F 20040223 1 CCARE 1129 19481219 78412 M 20030801 1 CCARE 1137 19420421 78412 M 20070401 P CCARE 1142 19490826 78415 F 20050404 1 CCARE 1148 19420201 78413 M 20070101 S CCARE 1148 19470807 78413 F 20070101 SP 1 S CCARE 1149 19450302 78408 F 20070402 1 CCARE 1158 19450213 78411 F 20080623 1 CCARE 1167 19470403 78401 F 20080804 1 CCARE 1187 19510730 78407 F 20081208 J CCARE 1187 19470116 78407 M 20081208 SP 1 J CCARE 1214 19450804 78416 F 20061101 P CCARE 1222 19430129 78577 M 20080201 P CCARE 1232 19400512 78374 M 20050501 P CCARE 1242 19501119 78405 F 20080331 1 CCARE 1249 19470908 78414 M 20030801 1 CCARE 1250 19540515 78415 M 20030801 1 CCARE 1251 19350223 78022 M 20030801 S CCARE 1251 19480716 78022 F 20030801 SP 1 S CCARE 1256 19470922 78216 F 20031006 1 CCARE 1263 19510209 78362 F 20070917 1 CCARE 1269 19440812 78411 F 20030801 1 CCARE 1278 19450321 78130 F 20030801 1 CCARE 1296 19430720 78412 M 20080701 R CCARE 1296 19430629 78412 F 20080701 SP 1 R CCARE 1297 19470205 78415 M 20080401 J CCARE 1297 19460109 78415 F 20080401 SP 2 J CCARE 1299 19460824 78413 M 20030909 J CCARE 1299 19490622 78413 F 20030909 SP 2 J CCARE 1308 19501117 78412 F 20041018 K CCARE 1308 19860830 78412 M 20041018 S 2 K CCARE 1311 19420508 78413 M 20070501 S CCARE 1311 19440414 78413 F 20070501 SP 1 S CCARE 1314 19500804 78463 F 20030801 1 CCARE 1319 19451010 78412 F 20030801 1 CCARE 1323 19531016 78414 M 20051101 P CCARE 1333 19481126 78402 M 20060306 J CCARE 1333 19500522 78412 F 20060306 SP 1 J CCARE 1334 19471019 78404 F 20030801 1 CCARE 1386 19500408 78416 M 20031112 1 CCARE 1399 19380905 78415 M 20061005 P CCARE 1400 19401221 78411 F 20051201 P CCARE 1401 19450819 78416 M 20070820 J CCARE 1401 19460718 78416 F 20070820 SP 1 J CCARE 1402 19430704 78415 M 20060206 J CCARE 1402 19450621 78415 F 20060206 SP 2 J CCARE 1403 19480518 78416 M 20030801 J CCARE 1403 19480806 78416 F 20030801 SP 1 J CCARE 1440 19480919 78415 M 20030801 S CCARE 1440 19470930 78415 F 20030801 SP 1 S CCARE 1467 19450826 78417 M 20030801 1 CCARE 1478 19441011 78465 M 20030801 1 CCARE 1479 19441224 78408 M 20070205 1 CCARE 1483 19570417 78417 F 20070801 SP 1 M CCARE 1512 19430913 78410 M 20080901 S CCARE 1512 19460507 78410 F 20080901 SP 1 S CCARE 1542 19501201 78412 M 20030801 L CCARE 1542 19500227 78412 F 20030801 SP 1 L CCARE 1542 19860811 78412 F 20030801 D 3 L CCARE 1544 19540823 784143942 M 20030801 J CCARE 1544 19540527 784143942 F 20030801 SP 1 J CCARE 1549 19291124 78413 F 20040501 SP 1 Q CCARE 1562 19371031 78412 F 20050307 P CCARE 1563 19521105 78413 M 20090101 1 CCARE 1573 19420214 78340 M 20070201 S CCARE 1573 19490702 78340 F 20070201 SP 3 S CCARE 1580 19471022 78374 F 20040405 J CCARE 1580 19470628 78374 M 20040405 SP 1 J CCARE 1581 19230511 78411 F 20030801 P CCARE 1592 19401021 78382 F 20051001 P CCARE 1595 19521122 78410 F 20080707 1 CCARE 1613 19461019 78416 M 20030801 1 CCARE 1624 19350205 78413 F 20030801 P CCARE 1690 19540718 78418 M 20080303 1 CCARE 2047 19420711 78415 M 20070701 S CCARE 2047 19441009 78415 F 20070701 SP 1 S CCARE 2167 19510803 78411 F 20080107 1 CCARE 2190 19390808 78602 -6818 F 20050801 P CCARE 2238 19551008 78415 F 20050110 1 CCARE 2240 19480815 78416 F 20030801 1 CCARE 2298 19570710 78418 F 20080303 1 CCARE 2315 19480123 78408 F 20060417 1 CCARE 2318 19331214 78412 F 20040308 U CCARE 2318 19960617 78412 F 20040308 GD 2 U CCARE 2668 19460922 78414 M 20080121 J CCARE 2668 19510711 78414 F 20080121 SP 1 J CCARE 2670 19451221 78472 F 20070611 J CCARE 2670 19450817 78472 M 20070611 SP 2 J CCARE 2679 19460917 78415 M 20070108 J CCARE 2679 19480813 78415 F 20070108 SP 1 J CCARE 2689 19431218 78415 M 20070601 S CCARE 2689 19450502 78415 F 20070601 SP 1 S CCARE 2693 19450302 78427 M 20080107 1 CCARE 2694 19491130 78415 M 20050901 S CCARE 2694 19520329 78415 F 20050901 SP 1 S CCARE 2738 19370304 78416 M 20030801 S CCARE 2738 19430916 78416 F 20030801 SP 3 S CCARE 2746 19731005 78410 M 20060904 P CCARE 2748 19490201 78415 M 20090105 1 CCARE 2779 19420510 78404 F 20080303 P CCARE 2795 19440126 78412 M 20090101 S CCARE 2795 19490707 78412 F 20090101 SP 1 S CCARE 2880 19420816 78405 F 20070801 SP 1 Q CCARE 2914 19470822 78407 M 20030801 1 CCARE 2932 19500626 78408 F 20081202 SP 1 M CCARE 2944 19430305 78368 M 20080301 P CCARE 2958 19560125 78620 F 20061002 1 CCARE 2962 19460823 78407 F 20040308 1 CCARE 2977 19500330 78418 F 20060320 1 CCARE 2986 19490104 78401 M 20080204 1 CCARE 3101 19451029 78624 F 20070901 T CCARE 3101 19420918 78624 M 20070901 SP 1 T CCARE 3298 19470124 78411 F 20060109 1 CCARE 3320 19511225 78414 M 20080331 1 CCARE 3321 19350325 78412 F 20030801 P CCARE 3339 19301117 78619 -9998 F 20030801 P CCARE 3364 19501210 78343 M 20040112 1 CCARE 3388 19541130 78374 M 20070901 L CCARE 3388 19570604 78374 F 20070901 SP 2 L CCARE 3388 19850910 78374 M 20070901 S 3 L CCARE 3388 19910617 78374 F 20070901 D 4 L CCARE 3389 19401011 78411 M 20051001 S CCARE 3389 19450525 78411 F 20051001 SP 1 S CCARE 3390 19470910 78412 F 20051003 1 CCARE 3417 19461116 78411 F 20080121 1 CCARE 3439 19290819 78405 M 20030801 P CCARE 3442 19491227 78372 M 20081013 J CCARE 3442 19550127 78372 F 20081013 SP 1 J CCARE 3447 19420126 78413 M 20070101 P CCARE 3448 19320723 78620 M 20030801 P CCARE 3456 19381222 78415 M 20031201 S CCARE 3456 19471212 78415 F 20031201 SP 1 S CCARE 3457 19440309 78415 M 20080201 T CCARE 3457 19430202 78415 F 20080201 SP 1 T CCARE 3473 19390622 78410 F 20050124 P CCARE 3493 19481129 78416 M 20031215 1 CCARE 3498 19480320 78467 M 20030801 1 CCARE 3499 19560808 78380 M 20080707 1 CCARE 3511 19361120 78410 M 20040117 P CCARE 3520 19470506 78415 M 20080915 K CCARE 3520 19840210 78415 F 20080915 D 1 K CCARE 3528 19520622 78411 M 20030801 J CCARE 3528 19520507 78411 F 20030801 SP 1 J CCARE 3569 19880731 78411 F 20040801 D 3 N CCARE 3569 19960201 78411 F 20040801 D 4 N CCARE 3584 19620701 78418 F 20081027 L CCARE 3584 19540113 78418 M 20081027 SP 1 L CCARE 3584 19880323 78418 F 20081027 D 2 L CCARE 3584 19850807 78418 M 20081027 S 3 L CCARE 3585 19480625 78414 M 20030801 J CCARE 3585 19500110 78414 F 20030801 SP 1 J CCARE 3593. 19550905 78415 M 20080804 1 CCARE 3598 19460825 78414 M 20070820 J CCARE 3598 19460914 78415 F 20070820 SP 1 J CCARE 3599 19490903 78460 M 20030801 1 CCARE 3615 19400911 78405 M 20050901 R CCARE 3615 19400928 78405 F 20050901 SP 1 R CCARE 3616 19510405 78412 M 20070122 1 CCARE 3627 19421206 78414 M 20071201 S CCARE 3627 19530725 78414 F 20071201 SP 1 S CCARE 3644 19460528 78408 M 20071001 T CCARE 3644 19460519 78408 F 20071001 SP 1 T CCARE 3668 19451215 78413 M 20080331 J CCARE 3668 19460131 78413 F 20080331 SP 1 J CCARE 3672 19470110 78410 M 20070820 J CCARE 3672 19481021 78410 F 20070820 SP 1 J CCARE 3685 19470129 78415 M 20030801 J CCARE 3685 19460623 78415 F 20030801 SP 1 J CCARE 3688 19541022 78411 M 20081001 1 CCARE 3708 19351123 78404 M 20030801 R CCARE 3708 19361209 78404 F 20030801 SP 1 R CCARE 3711 19560530 78403 M 20080609 K CCARE 3711 19860630 78403 M 20080609 S 2 K CCARE 3711 19880409 78403 F 20080609 D 3 K CCARE 3731 19441220 78408 M 20030801 J CCARE 3731 19460614 78408 F 20030801 SP 1 J CCARE 3734 19441122 78405 M 20030801 1 CCARE 3743 19541128 78411 M 20070903 J CCARE 3743 19550426 78411 F 20070903 SP 1 J CCARE 3744 19420906 78416 M 20070901 S CCARE 3744 19470814 78416 F 20070901 SP 1 S CCARE 3746 19500723 78411 M 20080107 J CCARE 3746 19521205 78411 F 20080107 SP 4 J CCARE 3771 19360826 78413 M 20041101 R CCARE 3771 19391113 78413 F 20041101 SP 1 R CCARE 3772 19520505 78418 F 20070625 1 CCARE 3773 19411223 78411 M 20030801 S CCARE 3773 19461015 78411 F 20030801 SP 1 S CCARE 3782 19461211 78413 M 20040112 J CCARE 3782 19510323 78413 F 20040112 SP 1 J CCARE 3789 19390417 78415 M 20060601 R CCARE 3789 19410610 78415 F 20060601 SP 1 R CCARE 3813 19471124 78411 M 20030801 J CCARE 3813 19500708 78411 F 20030801 SP 1 J CCARE 3817 19490616 78411 M 20060123 1 CCARE 3821 19520620 78415 M 20030801 1 CCARE 3822 19400716 78022 M 20050701 P CCARE 3825 19390515 78413 F 20040501 R CCARE 3825 19350411 78413 M 20040501 SP 1 R CCARE 3827 19530222 78413 M 20080331 1 CCARE 3828 19530606 78467 F 20060912 SP 1 M CCARE 3838 19430813 78405 M 20080801 S CCARE 3838 19450519 78405 F 20080801 SP 1 S CCARE 3882 19490924 78413 M 20050110 1 CCARE 3941 19430808 78380 M 20080801 R CCARE 3941 19420616 78380 F 20080801 SP 1 R CCARE 3952 19310601 78414 M 20040503 P CCARE 3953 19450108 78405 M 20070625 1 CCARE 3972 19520317 78404 M 20070430 J CCARE 3972 19470220 78404 F 20070430 SP 2 J CCARE 4014 19570828 78415 F 20030801 J CCARE 4014 19460105 78415 M 20030801 SP 2 J CCARE 4053 19491224 78408 M 20050221 1 CCARE 4068 19471230 78405 M 20030801 J CCARE 4068 19551029 78405 F 20030801 SP 2 J CCARE 4186 19500928 78414 M 20081208 J CCARE 4186 19650325 78414 F 20081208 SP 5 J CCARE 4207 19291218 78412 F 20061018 SP 1 Q CCARE 4220 19420421 78411 M 20070401 R CCARE 4220 19401203 78411 F 20070401 SP 1 R CCARE 4222 19440211 78415 M 20090202 S CCARE 4222 19450126 78415 -4948 F 20090202 SP 1 S CCARE 4236 19450819 78597 M 20080831 1 CCARE 4239 19330207 78374 M 20080218 R CCARE 4239 19400716 78374 F 20080218 SP 1 R CCARE 4244 19460222 78411 M 20061016 T CCARE 4244 19370527 78411 F 20061016 SP 1 T CCARE 4262 19411015 78415 M 20061001 P CCARE 4263 19590328 78415 M 20081027 K CCARE 4263 19920211 78415 M 20081027 S 2 K CCARE 4263 19890116 78415 M 20081027 S 3 K CCARE 4267 19311013 78415 F 20030801 P CCARE 4268 19490720 78624 M 20050110 J CCARE 4268 19500209 78410 F 20050110 SP 1 J CCARE 4269 19570415 78413 M 20030801 1 CCARE 4291 19410429 33458 M 20060401 R CCARE 4291 19381105 33458 F 20060401 SP 1 R CCARE 4293 19390726 78405 M 20040801 R CCARE 4293 19280128 78405 F 20040801 SP 1 R CCARE 4295 19350208 78415 M 20040101 R CCARE 4295 19400810 78415 F 20040101 SP 1 R CCARE 4298 19361217 78415 M 20030801 R CCARE 4298 19330221 78415 F 20030801 SP 1 R CCARE 4311 19430525 78368 M 20080501 S CCARE 4311 19630624 78368 F 20080501 SP 2 S CCARE 4323 19411004 78411 M 20061001 S CCARE 4323 19450803 78411 F 20061001 SP 1 S CCARE 4325 19650601 75063 F 20080406 SP 1 M CCARE 4353 19421229 78414 F 20071201 P CCARE 4385 19490804 16901 F 20070111 1 CCARE 4387 19420423 78415 F 20070401 P CCARE 4412 19440405 75119 M 20030812 1 CCARE 4420 19490609 78413 F 20081013 1 CCARE 4427 19450120 78413 M 20070402 1 CCARE 4429 19450205 78412 F 20061207 J CCARE 4429 19440129 78412 M 20061207 SP 1 J CCARE 4451 19470831 78411 F 20030801 1 CCARE 4460 19451115 78411 F 20060626 1 CCARE 4534 19290104 78416 M 20030801 R CCARE 4534 19320118 78416 F 20030801 SP 1 R CCARE 4584 19351220 78413 M 20070801 R CCARE 4584 19420802 78413 F 20070801 SP 1 R CCARE 4586 19210825 78407 F 20051024 SP 1 Q CCARE 4593 19470509 78411 F 20070801 SP 1 M CCARE 4602 19500916 78404 M 20051201 R CCARE 4602 19490901 78404 F 20051201 SP 1 R CCARE 4603 19451108 78415 F 20030801 1 CCARE 4609 19421231 78411 F 20030801 P CCARE 4613 19351217 78368 M 20030801 P CCARE 4618 19170416 78415 F 20030801 P CCARE 4619 19360118 78411 F 20030801 P CCARE 4624 19431012 78412 F 20081001 P CCARE 4657 19200920 78411 F 20030801 SP 1 Q CCARE 4799 19500824 78411 M 20040126 K CCARE 4799 19950429 78411 F 20040126 D 1 K CCARE 4799 19930322 78411 M 20040126 S 2 K CCARE 4799 19910701 78411 F 20040126 D 3 K CCARE 4799 19860915 78411 M 20040126 S 4 K CCARE 5431 19471218 78412 M 20080107 I CCARE 5613 19510118 78411 M 20080915 L CCARE 5613 19840403 78411 M 20080915 S 2 L CCARE 5613 19860320 78411 F 20080915 D 3 L CCARE 5613 19550718 78411 F 20080915 SP 4 L CCARE 5629 19470104 78412 M 20070601 I CCARE 6420 19590821 78336 F 20071029 J CCARE 6420 19500728 78336 M 20071029 SP 1 J CCARE 6421 19491224 78412 M 20080414 J CCARE 6421 19451014 78412 F 20080414 SP 1 J CCARE 6467 19561009 78418 M 20060710 I CCARE 7137 19470306 79760 F 20040112 I CCARE 7188 19440825 78374 M 20081110 L CCARE 7188 19450317 78374 F 20081110 SP 1 L CCARE 7188 20060321 78374 M 20081110 S 2 L CCARE 8472 19550625 78413 F 20080609 I CCARE 437 19370619 78361 M 20030801 P CCFIR 527 19370308 78415 M 20030801 R CCFIR 527 19341010 78415 F 20030801 SP 1 R CCFIR 611 19400602 78412 M 20060901 R CCFIR 611 19410927 78412 F 20060901 SP 1 R CCFIR 396 19390914 78247 M 20040801 I CCPOL 482 19330128 78411 M 20030801 S CCPOL 482 19491005 78411 F 20030801 SP 1 S CCPOL 515 19330616 78413 M 20030801 R CCPOL 515 19350816 78413 F 20030801 SP 1 R CCPOL 517 19360901 78413 M 20030801 R CCPOL 517 19360218 78413 F 20030801 SP 1 R CCPOL 542 19400922 77534 F 20070212 SP 1 Q CCPOL 596 19370727 78408 M 20041031 P CCPOL 1782 19371128 78412 M 20040801 P CCPOL 1847 19510827 78412 M 20051001 I CCPOL 1918 19450507 77964 M 20051101 R CCPOL 1918 19460217 77964 F 20051101 SP 1 R CCPOL 1999 19450205 78414 M 20060306 I CCPOL 4595 19360129 78404 F 20041019 SP 1 Q CCPOL 303 19290301 78332 F 20030801 SP 1 Q FIRE 332 19290417 77995 -6611 M 20050220 P FIRE 337 19201206 78412 M 20030801 P FIRE 362 19330419 78411 M 20030801 R FIRE 362 19320116 78411 F 20030801 SP 1 R FIRE 364 19261030 30642 M 20030801 R FIRE 364 19290208 30642 F 20030801 SP 1 R FIRE 376 19330714 78404 M 20030801 R FIRE 376 19350905 78404 F 20030801 SP 1 R FIRE 379 19320427 78405 M 20030801 F FIRE 386 19330824 75450 M 20030801 S FIRE 386 19520508 75450 F 20030801 SP 1 S FIRE 391 19341226 78377 F 20041231 SP 1 Q FIRE 406 19341024 78404 M 20030801 P FIRE 410 19361026 78416 M 20030801 SP 1 Q FIRE 411 19331001 78374 M 20030801 P FIRE 422 19371003 78415 F 20030801 SP 1 0 FIRE 431 19370916 78415 M 20040201 R FIRE 431 19380807 78415 F 20040201 SP 1 R FIRE 476 19470330 78408 M 20030801 I FIRE 480 19330806 78412 M 20030801 R FIRE 480 19331213 78412 F 20030801 SP 1 R FIRE 489 19510129 29209 M 20030801 I FIRE 498 19340416 78416 M 20030801 R FIRE 498 19350717 78416 F 20030801 SP 1 R FIRE 519 19600906 78412 M 20030801 I FIRE 525 19331030 78413 M 20030801 R FIRE 525 19300615 78413 F 20030801 SP 1 R FIRE 534 19430109 78411 M 20030801 K FIRE 534 19910914 78411 F 20030801 D 2 K FIRE 562 19580131 78412 M 20030801 I FIRE 568 19351220 78418 M 20030801 P FIRE 613 19340418 78412 M 20080401 R FIRE 613 19430415 78412 F 20080401 SP 1 R FIRE 615 19401230 78415 M 20051201 S FIRE 615 19441019 78415 F 20051201 SP 1 S FIRE 617 19370617 78387 M 20030801 I FIRE 618 19510710 78418 M 20080109 T FIRE 618 19470905 78418 F 20080109 SP 1 T FIRE 621 19430517 78412 M 20080901 R FIRE 621 19430330 78412 F 20080901 SP 1 R FIRE 631 19320402 78418 M 20030801 S FIRE 631 19470510 78418 F 20030801 SP 1 S FIRE 657 19320915 78415 M 20030801 R FIRE 657 19320703 78415 F 20030801 SP 1 R FIRE 669 19371230 78336 M 20080722 P FIRE 672 19311005 78412 M 20030801 R FIRE 672 19360413 78412 F 20030801 SP 1 R FIRE 679 19190204 78413 F 20030801 SP 1 Q FIRE 699 19200415 78415 M 20030801 R FIRE 699 19251202 78415 F 20030801 SP 1 R FIRE 704 19300902 78415 M 20080624 P FIRE 705 19280113 78411 M 20030801 P FIRE 710 19310716 78413 F 20030801 SP 1 Q FIRE 2351 19440723 78413 M 20070829 I FIRE 2362 19381012 78413 M 20031001 P FIRE 2364 19540625 78418 M 20030801 I FIRE 2365 19540212 75461 F 20030801 K FIRE 2365 19930812 75461 F 20030801 D 1 K FIRE 2369 19500504 78415 M 20041201 I FIRE 2372 19510609 78412 M 20080218 I FIRE 2374 19541021 78412 M 20080701 S FIRE 2374 19550822 78412 F 20080701 SP 1 S FIRE 2376 19480713 78408 M 20070108 J FIRE 2376 19491025 78408 F 20070108 SP 1 J FIRE 2380 19460425 78374 M 20030801 J FIRE 2380 19500514 78374 F 20030801 SP 1 J FIRE 2381 19360311 783771917 M 20030801 R FIRE 2381 19340810 783771917 F 20030801 SP 4 R FIRE 2382 19570309 78414 F 20081017 SP 1 M FIRE 2384 19530522 78413 M 20090119 I FIRE 2399 19420923 78413 M 20070901 S FIRE 2399 19451219 78413 F 20070901 SP 1 S FIRE 2400 19401024 78460 M 20030801 J FIRE 2400 19510302 78460 F 20030801 SP 1 J FIRE 2401 19440926 78415 M 20030801 J FIRE 2401 19440714 78415 F 20030801 SP 1 J FIRE 2402 19470228 78340 M 20030801 I FIRE 2403 19490215 78410 M 20060109 J FIRE 2403 19460826 78410 F 20060109 SP 1 J FIRE 2404 19480926 78413 M 20070108 J FIRE 2404 19451106 78413 F 20070108 SP 1 J FIRE 2406 19470702 78415 M 20050110 I FIRE 2415 19500829 78255 M 20060206 K FIRE 2415 19940205 78255 F 20060206 D 2 K FIRE 2415 19900301 78255 M 20060206 S 3 K FIRE 2416 19491104 78410 M 20070108 I FIRE 2419 19510211 78411 M 20080107 K FIRE 2419 20000227 78411 M 20080107 S 6 K FIRE 2428 19391119 78343 M 20041101 S FIRE 2428 19441120 78343 F 20041101 SP 2 S FIRE 2430 19460403 78410 M 20030801 J FIRE 2430 19501112 78410 F 20030801 SP 2 J FIRE 2431 19490817 78411 M 20070108 J FIRE 2431 19550114 78411 F 20070108 SP 1 J FIRE 2451 19560323 78418 M 20030801 J FIRE 2451 19561101 78418 F 20030801 SP 1 J FIRE 2453 19510330 78410 M 20090119 I FIRE 2457 19440727 78412 M 20080201 I FIRE 2458 19450727 78384 M 20080201 I FIRE 2459 19441010 78408 M 20070401 I FIRE 2460 19451003 78380 M 20030801 L FIRE 2460 19580611 78380 F 20030801 SP 1 L FIRE 2460 19860505 78380 F 20030801 D 2 L FIRE 2461 19490523 78410 M 20060918 J FIRE 2461 19510323 78410 F 20060918 SP 2 J FIRE 2464 19500922 78413 M 20080121 I FIRE 2466 19490625 71910 M 20080317 J FIRE 2466 19510905 71910 F 20080317 SP 1 J FIRE 2467 19490627 78411 M 20060109 Y FIRE 2467 19510729 78411 F 20060109 SP 1 Y FIRE 2467 19880819 78411 F 20060109 D 2 Y FIRE 2469 19490802 78332 M 20030801 I FIRE 2470 19530914 78415 M 20080107 i FIRE 2475 19581121 78336 M 20030801 I FIRE 2495 19510923 78410 M 20081027 J FIRE 2495 19500521 78410 F 20081027 SP 2 J FIRE 2496 19461027 78418 2499 19520729 78416 2499 19530501 78416 2509 19381108 78380 2511 19481029 78412 2511 19520122 78412 2512 19470914 78070 2512 19470905 78070 2513 19460906 78418 2513 19500318 78418 2519 19360913 78416 2519 19350202 78416 2522 19361125 77954 2547 19440807 78380 2547 19400729 78380 2548 19420614 78412 2557 19421214 78413 2560 19430113 78411 2562 19450629 78415 2562 19490930 78415 2563 19461112 78412 2563 19500429 78412 2565 19471029 78416 2567 19481028 78415 2567 19600108 78415 2568 19500812 78253 2568 19520106 78253 2568 20040217 78253 2583 19481116 78389 2594 19430627 78411 2594 19430309 78411 2595 19441012 78415 2595 19560327 78415 2596 19431221 78408 2596 19440708 78408 2597 19440809 78380 2597 19461105 78380 2602 19431006 78411 2602 19471217 78411 2604 19460906 78413 2604 19390829 78413 2613 19460804 78411 2613 19540424 78411 2614 19510107 78411 2614 19481029 78411 2614 19840418 78411 2620 19510316 78418 2633 19420502 75450 2633 19450628 75450 2642 19311110 78412 2642 19340607 78412 2644 19371219 78412 M 20050701 I FIRE M 20090202 J FIRE F 20090202 SP 1 J FIRE M 20050501 P FIRE M 20060403 J FIRE F 20060403 SP 3 J FIRE M 20030801 J FIRE F 20030801 SP 1 J FIRE M 20030801 J FIRE F 20030801 SP 1 J FIRE M 20030801 J FIRE F 20030801 SP 1 J FIRE M 20071101 P FIRE M 20050701 T FIRE F 20050701 SP 1 T FIRE M 20080701 I FIRE F 20071201 SP 1 Q FIRE M 20080101 P FIRE M 20060404 J FIRE F 20060404 SP 1 J FIRE M 20030801 J FIRE F 20030801 SP 1 J FIRE M 20050110 I FIRE M 20040126 J FIRE F 20040126 SP 3 J FIRE M 20060107 L FIRE F 20060107 SP 1 L FIRE F 20060107 GD 4 L FIRE M 20030801 I FIRE M 20080801 R FIRE F 20080801 SP 1 R FIRE M 20030801 J FIRE F 20030801 SP 1 J FIRE M 20081201 S FIRE F 20081201 SP 1 S FIRE M 20051017 J FIRE F 20051017 SP 1 J FIRE M 20081001 S FIRE F 20081001 SP 2 S FIRE M 20060501 T FIRE F 20060501 SP 2 T FIRE M 20070108 T FIRE F 20070108 SP 3 T FIRE M 20080107 L FIRE F 20080107 SP 1 L FIRE F 20080107 D 3 L FIRE M 20040726 I FIRE M 20070501 S FIRE F 20070501 SF 1 S FIRE M 20030801 R FIRE F 20030801 SP 1 R FIRE M 20030801 S FIRE 2644 19580317 78412 F 2647 19510510 78411 M 2647 19540616 78411 F 2649 19460519 77414 M 2649 19470213 77414 F 2654 19471125 78412 M 2654 19570109 78412 F 4169 19490628 78640 M 5173 19410819 78415 M 5173 19460825 78415 F 5174 19410523 78410 M 5174 19531003 78410 F 5180 19420626 78407 M 5180 19440430 78407 F 6067 19500326 79912 M 6067 19500806 79912 F 384 19331126 78164 M 384 19380109 78164 F 395 19291214 78141 M 395 19311130 78141 F 399 19311130 78416 M 413 19351104 78411 M 416 19340812 78368 M 416 19340709 78368 F 427 19400922 78418 M 427 19870831 78418 M 427 19890711 78418 F 428 19450130 78413 M 438 19441009 78611 M 443 19310612 78415 M 443 19410107 78415 F 461 19380925 78411 M 469 19340129 78412 M 470 19360917 77995 M 523 19480527 78414 M 531 19380904 78411 M 531 19390117 78411 F 532 19381005 78414 M 533 19351022 78404 M 533 19380912 78404 F 536 19360111 78412 M 536 19471019 78412 F 574 19441219 78412 M 574 19450618 78412 F 587 19490815 72207 M 595 19410403 78413 M 598 19391223 78416 F 601 19390804 78412 M 602 19500517 75117 M 629 19470321 78410 M 1647 19380222 78414 M 1651 19451012 78666 M 20030801 20040112 20040112 20030812 20030812 20030801 20030801 20040112 20060801 20060801 20060501 20060501 20070601 20070601 20030801 20030801 20030801 20030801 20030801 20030801 20030801 20030801 20030801 20030801 20080301 20080301 20080301 20030801 20040610 20060101 20060101 20030801 20030801 20030801 20030801 20040101 20040101 20050131 20030901 20030901 20030801 20030801 20030801 20030801 20030801 20060401 20080603 20040901 20051001 20040901 20080901 20060801 SP 2 S FIRE J FIRE SP 3 J FIRE J FIRE SP 4 J FIRE J FIRE SP 1 J FIRE I FIRE S FIRE SP 1 S FIRE S FIRE SP 1 S FIRE S FIRE SP 1 S FIRE J FIRE SP 1 J FIRE R PUBSTY SP 1 R PUBSTY R PUBSTY SP 2 R PUBSTY P PUBSTY P PUBSTY R PUBSTY SP 1 R PUBSTY U PUBSTY S 2 U PUBSTY D 3 U PUBSTY I PUBSTY I PUBSTY R PUBSTY SP 1 R PUBSTY I PUBSTY P PUBSTY P PUBSTY I PUBSTY R PUBSTY SP 1 R PUBSTY P PUBSTY R PUBSTY SP 1 R PUBSTY P PUBSTY SP 1 S PUBSTY R PUBSTY SP 1 R PUBSTY I PUBSTY P PUBSTY SP 1 M PUBSTY P PUBSTY PUBSTY I PUBSTY I PUBSTY T PUBSTY 1651 19490127 78666 F 20060801 SP 1 T PUBSTY 1652 19490101 78131 M 20030801 1 PUBSTY 1658 19460804 78416 F 20080504 SP 2 M PUBSTY 1663 19470521 78413 M 20050110 J PUBSTY 1663 19480703 78413 F 20050110 SP 2 J PUBSTY 1666 19510116 78411 M 20060403 1 PUBSTY 1674 19411223 78418 M 20081101 T PUBSTY 1674 19431111 78418 F 20081101 SP 1 T PUBSTY 1676 19500123 78418 M 20080121 1 PUBSTY 1679 19481130 78801 M 20070122 J PUBSTY 1679 19550207 78801 F 20070122 SP 1 J PUBSTY 1682 19460205 78368 M 20050307 J PUBSTY 1682 19470223 78368 F 20050307 SP 1 J PUBSTY 1683 19470520 78233 M 20040809 J PUBSTY 1683 19490322 78233 F 20040809 SP 1 J PUBSTY 1684 19481205 78415 M 20080121 J PUBSTY 1684 19530227 78415 F 20080121 SP 1 J PUBSTY 1685 19561114 78418 F 20090119 1 PUBSTY 1686 19580616 78411 F 20090119 J PUBSTY 1686 19470921 78411 M 20090119 SP 1 J PUBSTY 1691 19460503 78404 M 20060403 1 PUBSTY 1692 19480212 78411 M 20051017 L PUBSTY 1692 19491209 78411 F 20051017 SP 1 L PUBSTY 1692 19850411 78411 F 20051017 D 3 L PUBSTY 1692 19880225 78411 M 20051017 S 4 L PUBSTY 1693 19500610 78411 M 20030801 1 PUBSTY 1695 19511022 78413 M 20040920 1 PUBSTY 1696 19571116 78413 M 20040906 1 PUBSTY 1701 19490127 78414 M 20030801 1 PUBSTY 1715 19480223 78418 M 20030801 J PUBSTY 1715 19481016 78418 F 20030801 SP 1 J PUBSTY 1716 19441201 78413 M 20080122 1 PUBSTY 1723 19570203 78410 M 20080107 J PUBSTY 1723 19570611 78410 F 20080107 SP 1 J PUBSTY 1747 19610317 94121 M 20080122 1 PUBSTY 1751 19521117 94580 M 20080121 J PUBSTY 1751 19511130 94580 F 20080121 SP 1 J PUBSTY 1756 19490705 78414 M 20050207 J PUBSTY 1756 19501124 78414 F 20050207 SP 3 J PUBSTY 1757 19471011 78383 M 20090105 J PUBSTY 1757 19601108 78383 F 20090105 SP 1 J PUBSTY 1758 19460903 78414 M 20030801 J PUBSTY 1758 19480131 78414 F 20030801 SP 1 J PUBSTY 1765 19530522 78410 F 20030801 1 PUBSTY 1770 19470422 78410 M 20080601 J PUBSTY 1770 19461122 78410 F 20080601 SP 6 J PUBSTY 1771 19380307 78418 M 20030801 S PUBSTY 1771 19510202 78418 F 20030801 SP 1 S PUBSTY 1779 19590515 78417 M 20070402 1 PUBSTY 1784 19560120 3103 F 20070528 J PUBSTY 1784 19551222 3103 M 20070528 SP 5 J PUBSTY 1785 19491018 78028 M 20050820 1 PUBSTY 1787 19581019 78418 M 20030801 K PUBSTY 1787 19851021 78418 M 20030801 S 2 K PUBSTY 1787 19871019 78418 M 20030801 S 3 K PUBSTY 1788 19420729 78410 M 20070701 P PUBSTY 1791 19401221 78410 F 20070701 P PUBSTY 1792 19370428 78413 M 20090201 R PUBSTY 1792 19440206 78413 F 20090201 SP 3 R PUBSTY 1799 19540108 78023 M 20040504 I PUBSTY 1806 19430812 78414 M 20080801 P PUBSTY 1808 19440502 78380 M 20030801 I PUBSTY 1809 19450604 78413 M 20030801 I PUBSTY 1810 19500202 78411 M 20070205 J PUBSTY 1810 19531220 78411 F 20070205 SP 1 J PUBSTY 1812 19461005 78411 M 20030801 I PUBSTY 1813 19450522 75092 M 20040801 I PUBSTY 1814 19500218 78411 M 20050516 I PUBSTY 1816 19511230 75024 F 20050110 I PUBSTY 1830 19470919 78411 M 20030801 I PUBSTY 1831 19491126 78336 M 20090105 K PUBSTY 1831 19940124 78336 F 20090105 D 2 K PUBSTY 1831 19980303 78336 F 20090105 D 3 K PUBSTY 1831 19980303 78336 F 20090105 D 4 K PUBSTY 1831 20050409 78336 M 20090105 G D 6 K PUBSTY 1832 19500722 78413 M 20061016 I PUBSTY 1836 19561025 79546 -3811 M 20080730 L PUBSTY 1836 19621218 78343 F 20080730 SP 1 L PUBSTY 1836 19840419 79546 -3811 M 20080730 S 2 L PUBSTY 1836 19881128 79546 -3811 F 20080730 D 4 L PUBSTY 1846 19510613 78410 M 20070122 J PUBSTY 1846 19561206 78410 F 20070122 SP 2 J PUBSTY 1868 19520229 78411 M 20030801 I PUBSTY 1869 19520905 989083107 M 20030801 I PUBSTY 1874 19490718 78624 M 20040112 I PUBSTY 1875 19510406 78411 M 20030801 I PUBSTY 1883 19440908 78114 M 20030801 J PUBSTY 1883 19540823 78114 F 20030801 SP 1 J PUBSTY 1884 19511028 78109 M 20031020 T PUBSTY 1884 19510719 78413 F 20031020 SP 1 T PUBSTY 1886 19521003 78418 M 20050808 I PUBSTY 1895 19471215 78414 M 20040113 I PUBSTY 1897 19490523 78410 M 20051226 J PUBSTY 1897 19500411 78410 F 20051226 SP 2 J PUBSTY 1902 19420508 78368 -4028 M 20070501 X PUBSTY 1902 19760730 78368 -4028 M 20070501 S 1 X PUBSTY 1902 19461229 78368 -4028 F 20070501 SP 2 X PUBSTY 1907 19520409 78415 M 20070108 I PUBSTY 1910 19520915 78412 M 20051001 P PUBSTY 1916 19420211 78414 M 20070201 S PUBSTY 1916 19470807 78414 F 20070201 SP 4 S PUBSTY 1928 19431117 78418 F 20081101 P PUBSTY 1930 19470308 78410 M 20030801 I PUBSTY 1934 19560920 78142 M 20080526 I PUBSTY 1937 19610109 77494 M 20060501 1 PUBSTY 1941 19441202 784105710 M 20040113 1 PUBSTY 1952 19540605 78463 M 20030801 1 PUBSTY 1956 19610528 78413 M 20080801 1 PUBSTY 1961 19460818 78411 M 20050110 1 PUBSTY 1962 19441007 78372 M 20030801 1 PUBSTY 1963 19460122 78413 M 20030801 1 PUBSTY 1970 19460613 77808 M 20030801 1 PUBSTY 1971 19680626 78413 M 20080818 1 PUBSTY 1974 19570514 78411 M 20030801 1 PUBSTY 1985 19421209 78415 M 20071201 X PUBSTY 1985 19550729 78415 F 20071201 SP 1 X PUBSTY 1985 19990909 78415 M 20071201 S 3 X PUBSTY 1991 19521020 81521 M 20040322 1 PUBSTY 1992 19511225 78368 F 20090119 J PUBSTY 1992 19460311 78368 M 20090119 SP 1 J PUBSTY 2000 19470116 78415 M 20070201 K PUBSTY 2000 19861203 78415 M 20070201 S 2 K PUBSTY 2000 19900125 78415 M 20070201 S 3 K PUBSTY 2000 19920311 78415 F 20070201 D 4 K PUBSTY 2001 19500103 87124 M 20060109 J PUBSTY 2001 19530121 87124 F 20060109 SP 5 J PUBSTY 2004 19381021 78414 M 20070801 R PUBSTY 2004 19420831 78414 F 20070801 SP 1 R PUBSTY 2010 19520808 78411 M 20050717 J PUBSTY 2010 19530924 78411 F 20050717 SP 1 J PUBSTY 2011 19540911 78411 M 20090105 1 PUBSTY 2019 19510304 50675 M 20060320 1 PUBSTY 2022 19601107 78418 M 20080801 1 PUBSTY 2025 19531023 78411 M 20040614 1 PUBSTY 2026 19500322 78412 M 20081101 T PUBSTY 2026 19431103 78412 F 20081101 SP 1 T PUBSTY 2027 19470808 78390 M 20030801 1 PUBSTY 2044 19460122 78418 M 20030801 1 PUBSTY 2045 19541031 78410 M 20090119 J PUBSTY 2045 19521119 78410 F 20090119 SP 1 J PUBSTY 2172 19460614 78383 M 20040308 L PUBSTY 2172 19880623 78383 M 20040308 S 1 L PUBSTY 2172 19530502 78383 F 20040308 SP 2 L PUBSTY 2224 19520523 78402 M 20030801 1 PUBSTY 2229 19420225 78413 M 20070201 P PUBSTY 2230 19470226 75202 M 20030801 1 PUBSTY 2231 19541016 78413 M 20070108 1 PUBSTY 2304 19450714 78413 M 20050110 1 PUBSTY 2308 19480202 78415 M 20050110 1 PUBSTY 2309 19471105 78413 M 20080331 1 PUBSTY 4582 19380601 78410 M 20030801 S PUBSTY 4582 19450405 78410 F 20030801 SP 1 S PUBSTY 4585 19400322 78368 M 20050301 S PUBSTY 4585 19441102 78368 F 20050301 SP 1 S PUBSTY 4590 19390320 78407 M 20041101 P PUBSTY 4591 19410108 78414 M 20060101 S PUBSTY 4591 19440815 78414 F 20060101 SP 1 S PUBSTY 4596 19350816 78383 M 20030801 R PUBSTY 4596 19361016 78383 F 20030801 SP 1 R PUBSTY 4608 19470914 78415 M 20030801 1 PUBSTY 4611 19380312 78418 M 20030801 P PUBSTY 5178 19361107 78415 M 20030801 S PUBSTY 5178 19510617 78415 F 20030801 SP 1 S PUBSTY 7469 19461118 78415 M 20030801 1 PUBSTY CITY OF CORPUS CHRISTI GROUP #675908 CLAIMS - RETIREE DIVISION ONLY REPORTING PERIOD: 8/1 /2007 - 1/31/2009 INCURRED BASIS Pre65 / Post65 # of Claimants Medical Claim Dollars Pharamcy Claim Dollars Total Net Paid Amount PRE65 570 $4,118,185.77 $1,361,394.10 $5,479,579.87 POST65 386 $995,465.99 $1,192,917.47 $2,188,383.46 Proposal Prepared For City of Corpus Christi Quote Date: April 24, 2009 Effective Date: August 1, 2009 HUMANA. Guidance when you need it most HUMANA OFFERING COMPANY STATEMENT The benefits outlined in this proposal are offered by the following companies, hereafter referred to collectively as "Humana:" The fully- insured Medicare Advantage Regional PPO plan in Texas is insured by Humana Insurance Company. Note that Humana Inc. is the parent company and not an offering company. Humana Inc. holds no insurance licenses or health plan licenses. ^ity of Corpus Christi 1 April 24, 2009 Paul J. Pierce Procurement Manager City of Corpus Christi P.O. Box 9277 1201 Leopard Street Corpus Christi, Texas 78469 -9277 Louisville, KY 40202 www.humana.com H MANA. rridarncewhen -you need it most Dear Paul J. Pierce: Thank you for the opportunity to respond to the City of Corpus Christi's request for a health plan proposal on behalf of the City of Corpus Christi. This proposal offers Medicare Advantage Regional PPO (RPPO) benefits for the Corpus Christi markets. As one of the nation' s largest and most highly regarded publicly traded health benefits companies, Humana offers comprehensive retiree medical coverage through a full range of HMO, PPO, and PFFS plans. Additionally, Humana's portfolio of prescription drug plans can be offered in conjunction with its retiree medical plans or on a stand -alone basis. In today's challenging healthcare environment, spiraling medical and prescription costs demand innovative solutions. Humana's Medicare Advantage products and services are designed to help control costs and empower Medicare- eligible retirees to become active participants in their own healthcare decision- making. Humana' s consumer- driven approach gives members information, tools, and resources to make confident healthcare decisions, reduce their personal expenses, and reduce the administrative burden for the City of Corpus Christi. Humana supports this strategy with state -of -the -art services and capabilities that include: • The ability to model scenarios, predict outcomes, and assume the financial risk creating a partnership arrangement and a value proposition that is unsurpassed in the industry. • Unique and best -in -class care management resources, strategies, and methods designed to increase quality and improve outcomes, while reducing costs. Humana provides oversight of care and service throughout the continuum of care — medical, behavioral, and social. • Humana's award - winning SmartSummary RxsM, a personalized monthly statement that summarizes Humana Medicare members' prescription drug spending, shows the value of their prescription benefits, and offers tips on planning for and reducing prescription drug expenses. • Fully integrated, progressive pharmacy programs that let members receive prescription drugs while encouraging them to seek effective, lower cost options. Members get extensive information about costs, drug interactions, and efficacy. HUMANA. (ir: • z when you need it most Paul J. Pierce Page 2 April 24, 2009 In its quest to become the most trusted name in retiree healthcare solutions, Humana is committed to meeting the needs of the City of Corpus Christi, supported by customer service that exceeds expectations. This proposal describes how Humana intends to accomplish these objectives. Please be aware that our responses include information we consider proprietary and confidential in nature. We are pleased to provide this response to your request for proposal and simply ask that you agree to treat it as confidential. This information is released on the condition that it will be used for no purpose other than to determine your choice of healthcare provider and, that Humana - specific data will not be sold or released for publication. Your acceptance of this information is considered your agreement to these conditions. Please do not hesitate to call me should you have any questions or need clarification regarding this matter, or any aspect of this request for proposal. Humana's solution addresses the City of Corpus Christi's five core principles as described below. 1. Fiscally Responsible: manage the City's investment in employee and retiree healthcare in a prudent manner. Humana's Group Medicare Advantage (MA) solution replaces original Medicare and Medicare supplements with a single, privately underwritten and administered medical plan. The solution can also incorporate Part D prescription drug coverage as a rider, eliminating the need for freestanding retiree pharmacy benefits. Consequently, MA provides a materially more efficient and often less costly approach to providing retiree medical benefits. Retirees deal with only one plan, doing away with duplicate EOBs and the need to contact or understand two or three separate plans. With Humana's MA solution it is possible to provide both simple and sophisticated medical and care management programs that can improve care quality and reduce trend. The City of Corpus Christi should consider Group MA as the centerpiece of its retiree medical program because of the following reasons: • Potentially less costly retiree medical benefits • Increased efficiency and ease of administration • Possible reduction in financial risk and FAS 106 /GASB 45 liability • Ability to provide greater value and predictability for retirees • Plans that are flexible, easy to use and understandable for members • Care management programs are available to support retirees that are not available via Medicare or most supplemental plans • Extra benefits and services (i.e., fitness program, wellness, seminars) 2. Improve Employee Health: offer employees and their families the tools and resources such as wellness and disease management programs to help them improve their health and live a better quality of life. Humana offers a number of programs to manage retirees' health and improve their quality of life. These programs are described below. HUMA. Diu -- when you need it most Paul J. Pierce Page 3 April 24, 2009 Care Management A key part of Humana's guidance solution relies on its expertise and insight in care delivery and care management for the senior population. Keeping claims cost trends to less than the Medicare claims trend is imperative to maintaining benefit levels. To meet those challenges, Humana uses research and analysis to identify new opportunities to fulfill its mission to provide guidance, improve outcomes, and educate members and providers on making appropriate, cost - effective healthcare decisions. Humana utilizes customized care management resources, strategies, and methods designed to increase quality and improve outcomes, while reducing costs. A small group of members use the greatest amount of health services and need the most care. When Humana identifies these individuals and helps them manage their conditions more efficiently and effectively, their health outcomes improve. Humana also provides care management for moderately ill members who are at risk of becoming more seriously ill. As a result of these care management measures, costs go down. Health Resources Health resources for Medicare members include specialized case management and disease management programs, including field case management home/site visits for members who may benefit from such a service to identify health needs. Case Management Humana's case management program is a continuous process of identifying individuals at risk for problems associated with complex and/or chronic healthcare needs, assessing opportunities to coordinate care, efficiently utilizing the continuum of care, and managing the member's full spectrum of care to optimize outcomes. The case management team consists of a licensed registered nurse and social worker who collaborate with Humana's behavioral health and pharmacy teams to provide optimal support to the member. This team provides case management, discharge planning, disease management referrals, and disease- specific case management. Field Case Management The field case manager is an additional member on the care management team. The field case manager works with individuals to help them achieve the highest level of health, quality of life, and independence even while facing serious illness and physical limitations. Effective health support services are based on the development of a deep partnership between a participant and his or her telephonic case manager or disease manager. Participants work with their telephonic case /disease manager to identify areas of concern and together work to bridge gaps in access to care, social support, education, and personal motivation. This partnership is supported by field case managers who work with participants in their homes and in nursing homes, hospitals, and doctors' offices. They are also supported by community health workers who hold group classes where participants gain support from each other for their personal action plans. All members of the Humana care management team are trained to work with participants along this spectrum to help them maintain their dignity and independence, preserve their access to care, and work with them to make choices that are aligned with their personal values and preferences. HUMANA. (ir when you need it most Paul J. Pierce Page 4 April 24, 2009 Disease Management Programs Humana's disease management programs support seniors with certain chronic conditions, including congestive heart failure, end -stage renal disease, diabetes, and chronic obstructive pulmonary disease (COPD). These award- winning, accredited programs have achieved proven clinical outcomes. HumanaFirst® HumanaFirst is a telephonic nurse triage and health planning service available 24 hours a day, seven days a week. It is a quick and confidential way for members to decide whether they need to see their doctor, seek urgent or emergent care, or begin treatment at home. It also alleviates unnecessary calls to the doctor in the middle of the night or inappropriate trips to the emergency room. In addition, the program provides an audio library that allows members to hear recorded information on several health topics. Humana Active Outlook Humana Active Outlook is an enriching health and wellness education program exclusively for Humana Medicare Advantage members. The Humana Active Outlook program consists of the following: • Nurture! Caregiving Program: A comprehensive program of resources and services to enhance the caregiving and grandparent experiences • QuitNet Comprehensive: A tobacco cessation program with nicotine replacement therapy, phone counseling, and Website support • Meals on Wheels: Depending on the Humana Medicare Advantage plan chosen, some members are eligible to receive health meals after a hospital stay • Heal!: A program that provides condition - specific information and health coaching on managing a variety of conditions, including diseases, physical ailments, and weight management • HAO Magazine: Humana's quarterly award- winning publication with inspiring stories for active, fun, healthy living • Live It Up! Digest: a quarterly publication to help members with chronic conditions manage their health • Specialty Kits: available to Humana Medicare Advantage members at no cost for the first copy • HumanaActiveOutlook.com: A source for custom senior health information and interactive tools on the Web • Classes and Seminars: Local health and wellness classes to help members learn more about the right way to exercise, how to eat healthy, and how to use computers and technology SilverSneakers Humana offers the SilverSneakersfitness program, a health and wellness program for Medicare members. For no additional charge, Medicare members can use fitness centers with locations carefully selected for their warm, friendly, and safe environments. Steam and sauna rooms, heated pools, body conditioning classes, and strengthening tools are just a few of the benefits offered by SilverSneakers. Additionally, SilverSneakers offers classes designed specifically for increasing strength and flexibility and are taught by trained instructors. A specially- trained Senior Advisor is available at each of the SilverSneakers fitness locations to greet participants and introduce them to all the benefits of the SilverSneakers fitness program. Hl.JMANA.. (rt: when you need it most Paul J. Pierce Page 5 April 24, 2009 3. Consumer Engagement: help employees become informed consumers by helping them get more value for their dollar. MyHumana One of Humana's top priorities is to make it as simple and convenient as possible for members to get the services they need, when they need them. Guidance begins when the member joins a Humana Medicare Advantage plan and continues throughout the term of the coverage. Humana offers dedicated customer service as well as online access to the member's own personalized homepage at Humana.com. Through Humana's Website, members can access a wealth of health information, including claims and copayment history, which can be accessed 24 hours a day, seven days a week. Humana promotes wellness to members through its Website, newsletters, targeted mailings, and reminder programs. Members who sign on to Humana.com can go directly to MyHumana, their password - protected, personal home page, which has many unique features: • Health Library: Humana offers access to health information and options from experts such as Healthwise, WholeHealth MD, First Data Bank, Staywell, and Wired MD. • Health Tools: Members can take a dynamic health assessment, use Physician Finder Plus, and stop by the Healing Kitchen for great recipes and tips on nutrition. • Health Programs: Members can find out about Humana's disease management programs and transplant services. • MyHealth Record: Members can organize, simplify, and secure their most important medical information within MyHealth Record. In one file, they can record and update their medical conditions and procedures, medications, family medical history, and other personal health information. • MyPlan Benefits: Members can review their health plan coverage and benefits. • MyClaims Center: Members will find their medical claims history and inpatient/outpatient authorizations. • Condition Center: Members can visit chat rooms and use self - management tools to help them monitor their condition and understand their healthcare options. A health topic search box allows members to peruse the Healthwise database, right from MyHumana. SmartSummary Humana's Smart Summary is designed to be a more clear, concise, and consumer - friendly form of an explanation of benefits (EOB). Experts from Humana conducted extensive research asking seniors what they wanted to see in a health benefits statement regarding their pharmacy expenses. Consumers said they want an EOB that clearly and easily explained Part D benefits, as well as one that provided personalized guidance regarding quality of care, healthcare spending, pharmacy expenses, and overall healthcare decisions. Humana responded by developing a new pharmacy EOB called the SmartSummary Rx. HUMANA. when you need it most Paul J. Pierce Page 6 April 24, 2009 In 2008, medical members began receiving a SmartSummary with medical claims. The medical claim information is not a substitute for the medical EOB. Members will receive a Smart Summary based on their plan type: • MA only members will receive a medical SmartSummary statement each month they incur medical claims. • MAPD members will receive a consolidated medical and prescription SmartSummary each month they incur medical claims or Part D prescription claims. • PDP members will continue to receive a SmartSummary Rx statement as their Part D EOB. 4. Simplicity: offer programs and plans that are easy for employees to understand. Humana's RPPO plan provides a large service area and multiple states to retirees for in- network healthcare access. Humana's RPPO network is one of the largest of all MA providers across the country. Humana provides benefit summaries and enrollment information prior to enrollment to allow retirees to understand the plan. Humana's Medicare Advantage pre - enrollment customer service unit can assist retirees with any questions they may have. Humana also offers open enrollment seminars that provide retirees information and explanations of the plan and available programs. These seminars also allow retirees to ask questions and interact with Humana representatives. After enrollment, Humana sends welcome kits, which include benefit summaries, program information, provider directories, and other valuable information to newly enrolled retirees. Humana also offers a number of resources on Humana.com and provides a dedicated Medicare customer service unit. Humana provides the resources and programs to allow retirees to become more informed and more active in their healthcare. 5. Access: provide employees access to timely and quality care. With RPPO plans, members residing within a specific service area can obtain covered services from any provider, but the plan pays more toward services from participating (in- network) providers. Humana offers its RPPO in 23 states, which provides a large service area and network for retirees to access. Members are free to seek care outside of the service area; however, they may face increased out -of- pocket cost sharing. We look forward to further discussing Humana's proposal with you. Feel free to contact me with any estions at ;713 -513 -4915. ( & orner, Group Medicare Consultant 1980 Post Oak Boulevard, Suite 1900 Houston, Texas 77056 cc: Pam J. Taylor Enclosure CITY OF CORPUS CHRISTI FINANCE DEPARTMENT / PURCHASING DIVISION MINORITY BUSINESS ENTERPRISE INFORMATION FORM THIS FORM MUST BE SUBMITTED ALONG WITH BID PLEASE INDICATE WHETHER THE COMPANY IS A CERTIFIED MINORITY BUSINESS. EXAMPLES OF CERTIFICATIONS RECOGNIZED BY THE CITY INCLUDE: ❑ YES ® NO - CERTIFIED HISTORICALLY UNDERUTILIZED BUSINESS (HUB) Select all that are appropriate: ❑ ASIAN PACIFIC BLACK HISPANIC ❑ NATIVE AMERICAN WOMAN Please visit the following website for information on becoming a Certified HUB: htto://www.window.state.ocus/orocurement/prog/hub/ ❑ YES "1 NO - LOCAL SMALL BUSINESS (LSB) A for -profit entity employing less than 49 employees located within the City limits of Corpus Christi, Texas OYES NO OTHER (PLEASE SPECIFY): THIS COMPANY IS NOT A CERTIFIED HUB or LSB THE ABOVE MINORITY BUSINESS INFORMATION IS REQUESTED FOR STATISTICAL AND TRACKING PURPOSES AND WILL NOT INFLUENCE THE AMOUNT OF EXPENDITURES THE CITY WILL MAKE WITH ANY GIVEN COMPANY. BID INVITATION NO: BI- 0153 -09 Firm Name: Humana Insurance Company Address: 500 West Main Street Telephone: 502-580-1000 Fax: 502- 476 -5044 City: Lou isville State: Kentucky Zip: 40202 E -mail: jbloem@humana.com Date: April 21, 2009 Sign. :f Person Authorized to Sign Form Title: Senior Vice President and Chief Signer's Name: James H. Bloem Financial Officer and Treasurer (Please print or type) CERTIFICATION I certify that all information provided is true and correct as of the date of this statement, that I have not knowingly withheld disclosure of any information requested; and that supplemental statements will be promptly submitted to the City of Corpus Christi, Texas as changes occur. Certifying Person: James H. Bloem Signature of Certifying Person: (Type or Print) Senior Vice President and Chief Title: Financial Officer and Treasurer DEFINITIONS Date: April21, 2009 a. "Board member." A member of any board, commission, or committee appointed by the City Council of the City of Corpus Christi, Texas. b. "Employee." Any person employed by the City of Corpus Christi, Texas either on a full or part-time basis, but not as an independent contractor. c. "Firm." Any entity operated for economic gain, whether professional, industrial or commercial, and whether established to produce or deal with a product or service, including but not limited to, entities operated in the form of sole proprietorship, as self - employed person, partnership, corporation, joint stock company, joint venture, receivership or trust, and entities which for purposes of taxation are treated as non - profit organizations. d. "Official." The Mayor, members of the City Council, City Manager, Deputy City Manager, Assistant City Managers, Department and Division Heads, and Municipal Court Judges of the City of Corpus Christi, Texas. e. "Ownership Interest." Legal or equitable interest, whether actually or constructively held, in a firm, including when such interest is held through an agent, trust, estate, or holding entity. "Constructively held" refers to holdings or control established through voting trusts, proxies, or special terms of venture or partnership agreements." f. "Consultant." Any person or firm, such as engineers and architects, hired by the City of Corpus Christi for the purpose of professional consultation and recommendation. SUPPLIER NUMBER TO BE ASSIGNED BY CITY PURCHASING DIVISION of City CITY OF CORPUS CHRISTI Corpus DISCLOSURE OF INTEREST City of Corpus Christi Ordinance 17112, as amended, requires all persons or firms seeking to do business with the City to provide the following information. Every question must be answered. If the question is not applicable, answer with "NA ". See reverse side for definitions. COMPANY NAME: Humana Insurance Company P. O. BOX: Not applicable STREET ADDRESS: 500 West Main Street CITY: Louisville ZIP: 40202 FIRM IS: 1. Corporation El 4. Association ❑ 2. Partnership ❑ 3. Sole Owner ❑ 5. Other ❑ DISCLOSURE QUESTIONS If additional space is necessary, please use the reverse side of this page or attach separate sheet. 1. State the names of each "employee" of the City of Corpus Christi having an "ownership interest" constituting 3% or more of the ownership in the above named "firm." Name Job Title and City Department (if known) Not applicable Not applicable 2. State the names of each "official" of the City of Corpus Christi having an "ownership interest" constituting 3% or more of the ownership in the above named "firm." Name Title Not applicable Not applicable 3. State the names of each "board member" of the City of Corpus Christi having an "ownership interest" constituting 3% or more of the ownership in the above named "firm." Name Board, Commission or Committee Not applicable Not applicable 4. State the names of each employee or officer of a "consultant" for the City of Corpus Christi who worked on any matter related to the subject of this contract and has an "ownership interest" constituting 3% or more of the ownership in the above named "firm." Name Consultant Not applicable Not applicable CONFLICT OF INTEREST QUESTIONNAIRE FORM C 1 Q For vendor or other person doing business with local governmental entity This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the govemmental entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code. A person commits an offense if the person violates Section 176.006, Local Govemment Code. An offense under this section is a Class C misdemeanor. OFFICE USE ONLY Date Received 1. Name of person doing business with local govemmental entity. Humana Insurance Company 2. authority not later than Code, is pending and or inaccurate.) • 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 September 1 of the year for which an activity described in Section 176.006(a), Local Govemment not later than the 7th business day after the date the originally filed questionnaire becomes incomplete 3. Describe each affiliation or business relationship with an employee or contractor of the local govemment entity who makes recommendations to a local government officer of the local govemment entity with respect to expenditure of money. This is not applicable to Humana. 4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local govemment officer of the local government entity that is the subject of this questionnaire. This is not applicable to Humana. Amended 1/13/2006 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity FORM CIQ Page 2 6. Name of local govemment officer with whom filer has affiliation or business relationship. (Complete thls section only if the answer to A, B, or C is YES. This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or other relationship. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire? ❑ Yes ❑ No B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local govemment officer named in this section AND the taxable income is not from the local governmental entity? ❑ Yes ❑ No C.Is the filer of this questionnaire affiliated with a corporation or other business entity that the IOCal govemment officer serves as an officer or director, or holds an ownership of 10 percent or more? ❑ Yes ❑ No D. Describe each affiliation or business relationship. This section is not applicable to Humana. 6. Describe any other affiliation or business relationship that might cause a conflict of interest. This is not applicable to Humana. 1 04/21/09 James H. oem Date Senior Vice President and Chief Financial Officer and Treasurer Adopted 11/0212005 HUMANA® Guidance when you need it most TABLE OF CONTENTS Transmittal Letter Minority Business Enterprise Form Disclosure of Interest Conflict of Interest Questionnaire I. Executive Summary II. Section 3.3 General Requirements III. Section 3.4 Proposer's Profile and Qualifications IV. Section 3.5 Technical Solution V. Section 3.6 Rate Schedule VI. Exceptions VII. Acknowledgement of Addenda VIII. Rates IX. Benefits Attachments A. Sample Group Medicare Agreement Regional PPO Network GeoAccess Report Regional PPO Network List of Providers and Facilities 2008 Humana Insurance Company Financial Statements B. Sample Business Associate Agreement C. Sample Medicare PlanCompass Reporting Package D. List of Lawsuits for Humana Insurance Company E. 2008 Annual Report F. South Texas Market Organization Chart G. Sample Medicare Implementation Timeline H. Subrogation Process Flowchart I. Claims Processing Procedures Flowchart J. Medicare Appeal Process Flowchart K. Sample Disease Management Communication Piece L. Sample Explanation of Benefits M. Sample SmartSummary N. Sample Enrollment Kit Materials O. Medicare Member Communication Experience P. List of Local and Nationwide Pharmacies Q. Humana Group Medicare Drug List City of Corpus Christi 1 HUMANAO Guidance when you need it most R. Humana Active Outlook S. Medicare Advantage Snapshot T. Humana Snapshot City of Corpus Christi 2 HUMANA. Guidance when you need it most EXECUTIVE SUMMARY Humana's Medicare Advantage solution replaces original Medicare and Medicare supplements with a single, privately underwritten and administered medical plan. The solution can also incorporate Part D prescription drug coverage as a rider, eliminating the need for freestanding retiree pharmacy benefits. Consequently, Medicare Advantage provides a materially more efficient and often less costly approach to providing retiree medical benefits. Retirees are enrolled in only one plan, eliminating duplicate EOB' s and the need to contact or understand two or three separate plans. With Humana's Medicare Advantage solution it is possible to provide both simple and sophisticated medical and care management programs that can improve care quality and reduce trend. Humana's proposal will illustrate its expertise in Medicare product designs, competitive pricing strategies, wellness programs for the senior population, and dedicated customer service units. Humana will bring many valuable lessons learned to its partnership with the City of Corpus Christi, and together Humana can help the City: • Develop a sustainable healthcare model for retirees • Simplify medical offerings and reduce administrative burdens • Execute an effective communication strategy • Provide effective and unique care management and wellness programs specifically designed for Medicare participants With over two decades of experience in designing and delivering group health benefits, Humana can help the City tailor a successful health benefits strategy to meet their unique needs. In its quest to become the most trusted name in healthcare solutions, Humana offers its clients a full range of health benefits programs, extensive provider networks, award- winning clinical programs, notable technological expertise and outstanding customer service. A Stable Solution Humana is widely recognized by large employers and benefit consultants as one of the top players in the Medicare Advantage market nationally. By engaging in a relationship with Humana, the City will be able to take advantage of Humana's 21 continuous years of experience serving Medicare beneficiaries. Due to a strong commitment to innovation, Humana was one of the first health plans in the country to offer Private - Fee- for - Service plans through 2002 demonstration projects with CMS and will bring many valuable lessons learned to its partnership with the City. Humana promises to provide the resources, tools, information, and assistance necessary to help ensure that the City's retiree medical programs become easy to use and understandable for members. Financial Analysis and Forecasting Underwriting and Actuarial Support Humana has created an experienced unit of actuaries and underwriters dedicated solely to the Medicare market. This team is available to work consultatively with groups to craft benefit solutions and programs along with corresponding rates to ensure that financial as well as retiree benefit goals are being satisfied. This ,City of Corpus Christi 1 HUMANA. Guidance when you need it most ability to model scenarios, predict outcomes, and assume the financial risk creates a partnership arrangement and a value proposition that are unsurpassed in the industry. Rate Sustainability Over the past twenty years, Humana has developed strong Medicare- specific actuarial, risk adjustment, and pricing capabilities in the Medicare replacement plan segment. Humana is very confident in its ability to underwrite and adequately rate for the risk associated with this population segment. Humana's rates were developed and peer reviewed by an actuarial and underwriting team that is totally dedicated to the Group Medicare market using a proven rating methodology. Product Design Humana' s suite of available Medicare Advantage products offers the City a number of choices and advantages over other potential options. Humana's Private Fee - For - Service (PFFS) product provides retirees with the highest level of access to care and can provide employers the ease of a single plan design for all retirees regardless of where they reside. Humana has the country's largest Medicare Advantage PPO presence, with Local PPOs in 34 local markets and Regional PPOs in 24 states. Humana also offers well established Medicare Advantage HMO plans in 12 major markets. This depth, coupled with its national PFFS capability, gives Humana unequalled flexibility to meet cost and benefit design needs of virtually any employer's retiree population. Humana looks forward to working with the City's benefits team to determine the best combination of Medicare Advantage options that will provide retirees the choices they need. Account Service Implementation Humana applies an all- inclusive, project management approach toward implementation. This approach properly aligns Humana's substantial resources around the City's specific needs and minimizes disruption. Each new group implementation begins immediately upon award of the contract with the formation of an implementation strategy team. The team will work together to ensure a thorough and seamless implementation. The activities of the group include: • Determining specific client goals, and designing a customized plan to meet those needs • Developing, approving and communicating a finalized strategy and timeline to all who will be a part of or impacted by the implementation • Coordinating strategic marketing communication campaigns • Providing comprehensive decision support resources The City will have a dedicated Humana account executive. This approach will ease the administrative burden and minimize disruption. Once basic parameters have been established between Humana and the group for the implementation of the product, the process is handled entirely by Humana's implementation strategy team. The account executive will be responsible for ongoing account management and customer service and ensuring that: • Each potential member has been given the materials and information they need to make an informed enrollment decision • All members have been enrolled correctly and in a timely manner City of Corpus Christi 2 HUMANA. Guidance when you need it most • Each member receives the materials they need (ID cards, etc) to properly access their providers • All internal and external parties have worked together jointly, are well - informed, and feel content with the overall results of the process The account executive's interaction does not end with the completion of the implementation phase. Instead, their relationship with the City is just beginning. At this point, they assume the role of ongoing account management for the group. The account executive's goal is to ensure that needs and expectations are met before, during, and after implementation. Communications and Enrollment Humana deploys a multi- pronged, comprehensive communication and enrollment strategy. Written information and group seminars will be offered to beneficiaries. Humana's nationwide network of dedicated Medicare sales representatives are trained and certified by Humana. The representatives ensure that beneficiaries have the information and guidance they need when they need it. Humana's `Let's Talk' campaign even features one -on -one guidance for seniors and their families. Humana's Medicare Direct Marketing Services (DMS) Call Center will be a valuable tool to assist with enrolling eligible beneficiaries. The call center has the ability to contact every retiree via outbound calls inviting them to attend a group seminar or to arrange in -home appointments. On an inbound basis, DMS can collect meeting RSVPs and provide other logistics services. Humana will make earnest attempts to reach out to every single eligible retiree and family member for initial and future enrollments. Ongoing Customer Service Humana's Medicare Advantage plans are serviced by Customer Care representatives who have been specially trained and are dedicated exclusively to servicing Medicare clients. Representatives have on -line access to plan designs and membership information. They are able to immediately respond to member inquiries regarding benefits, network and other concerns. Humana's service centers are open from 8 a.m. to 8 p.m. (member's time zone), Monday through Friday. An automated information line is available 24 hours a day, 7 days a week. Extensive self- service functions are also available on Humana's Website, Humana.com. Health Resources and Care Management A key part of Humana's guidance solution relies on its expertise and insight in care delivery and care management for the senior population. Keeping claims cost trends to less than the Medicare claims trend is imperative to maintaining benefit levels. To meet those challenges and reduce costs to less than trend, Humana uses research and analysis to identify new opportunities to fulfill its mission to provide guidance, improve outcomes, and educate members and providers assisting them to make appropriate, cost - effective healthcare decisions. Medicare beneficiaries, representing 10 percent of those enrolled, generally consume 90 percent of expenditures. Humana is proposing care management resources, strategies, and methods designed to increase quality and improve outcomes, while reducing costs. Because Humana believes that the physician providers are the primary touch - points for its members, Humana does not position itself between the physician and the patient. Humana provides oversight of care and service throughout the continuum of care — medical, behavioral and social. Program offerings are expected to decrease the impact of cost trend on the City. City of Corpus Christi 3 HUMANA® Gui :ante when you need it most Humana's approach focuses on giving consumers information, tools, and resources to engage them in making decisions about their healthcare. Each aspect of Humana's care management program will produce a guidance opportunity, with focus on: • Pre - authorization/Notification • Discharge Planning • Ensure movement to most appropriate level of care • Post Discharge Care • High Utilizer/Re -admit reports • Care Level Management • Case Management • Managing inpatient length of stay (per diem environment) • Disease management including congestive heart failure, end -stage renal disease, diabetes, coronary artery disease, COPD, and 13 rare diseases Pharmacy Products and Services In the United States, prescription drug use is dramatically rising every year. The Centers for Medicare and Medicaid Services estimated that in 2006 Americans spent approximately $225 billion in prescriptions. By 2011, it is projected that expenditures will be over $400 billion. With this escalating trend, Medicare beneficiaries want financial security and peace of mind regarding their prescription drug expenses. Humana, as a pioneer in Medicare benefits, offers prescription drug and medical coverage, which gives these members the protection and guidance they are seeking when it comes to healthcare. Humana offers a full array of Prescription Drug Plan (PDP) options. Humana has offered prescription drug coverage as a part its Medicare Advantage plans for many years. Employers have the option of offering their Medicare members drug benefits through Humana PDP, or they can enroll in Medicare Advantage plans which can include PDP riders. Humana's PDP offerings provide measurable value to Medicare- eligible retirees through innovative plan design and meaningful, nationally recognized programs and services including: • Extensive four -tier formulary covering all Part D drugs in the lowest two tiers • Award winning, consumer- friendly Smart Summary RxsM • Medication Therapy Management program • Extensive, national pharmacy network including Humana's mail -order facility, RightSourcesM • Internet pharmacy tools including patent - pending RxCalculatorsM • Managed dispensing limits, step therapy, and drug utilization review City of Corpus Christi 4 HUMANA. Guidance when you need it most Benefits and Value -Added Services Humana is here to guide its members to resources that help them get the most from their plan and the most out of life. Humana takes a personal interest in keeping members healthy — something not all insurers focus on. It is just one of the many extras that make Humana Medicare Advantage coverage so valuable. Humana offers the following programs at no additional cost to the member: • MyHumana: Personal, secure Web page on Humana.com where members can access benefits information, health tools, claims history and more • Humana Active Outlook: Magazine featuring health, travel, and lifestyle articles • HumanaFirst: Humana's demand management toll -free 24 -hour health information line • SilverSneakers ®, Forever Fit, Silver and Fit: Special fitness and wellness programs that are available to Medicare Advantage members nationwide • Complimentary & Alternative Medicine: Discounts at more then 25,000 providers nationwide • EyeMed Vision Discount Program: Discounts on eyewear, contact lenses, laser vision correction, and eye exams • Nutritional Supplements /OTC Medications: Discounts for nutritional supplements and various OTC medications Note: The list above is a sample of Humana's benefits and value -added services and does not include all programs available to Medicare - eligible members. City of Corpus Christi 5 HUMANA® Guidance when you need it most SECTION 3.3 GENERAL REQUIREMENTS Please indicate that you agree with each statement. Failure to do so may result in disqualification. If you are unable to meet a condition, please give an explanation. 1. The selected vendor may be expected to perform the types of services as outlined in the table below. This list is not all inclusive and additional services may be requested. Humana is proposing benefits that are substantially similar to the requested plan designs below. Please refer to Section IX for a benefit summary for the proposed plan and for plan design deviations. Humana will evaluate any additional requested services when requested by the City of Corpus Christi (the City). 2. The City has four self - insured PPO medical plans. The plans are Citicare (Civilian), City Alternate Choice Plan, Citicare Fire, and Citicare Public Safety. Prescriptions are covered in each plan rather than as a separate benefit. In accordance with the addendum issued by the City, Humana is proposing a fully- insured Medicare Advantage Regional PPO (RPPO) plan for the City, which includes prescription drug benefits. Please refer to Section IX for the benefit summary for the plan. 3. At a minimum, provide all services described herein. Humana is proposing fully- insured Medicare Advantage plans for all segments of the City. Humana's proposal includes the services requested by the City. 4. Fully warrant and guarantee all information provided. Humana agrees to provide the services proposed. Humana's rates are guaranteed from August 1, 2009 to December 31, 2009. Rates for 2010 are not available at this time. Rates for 2010 should be available by the end of June and can be provided at that time. 5. Comply with all local, state and federal insurance laws and regulations relative the contents of your proposal. Proposer affirms that all proposals are in compliance with applicable laws. Humana complies with all applicable state and federal regulations related to fully- insured Group Medicare Advantage business. 6. Attend quarterly review meetings at the City's desired location in Corpus Christi, Texas. The assigned account management team will meet on a quarterly basis with the City at the City's desired location to discuss quarterly reporting results and to discuss the performance of the account. 7. Provide a specimen Contract and Business Associate Agreement. Please refer to Attachment A for a sample Group Medicare Advantage agreement and Attachment B for a sample business associate agreement. City of Corpus Christi 1 HUMANA® Guidance when you need it most 8. Provide a plan of comparable design and level of benefits as the current Citicare Civilian plan. The benefits should be interpreted and claims processed in accordance with the summary plan description. Highlight any deviations from the current Citicare Civilian benefits offered. See attached Exhibits A and D. Humana has complied with the addendum issued by the City and has provided one plan for all segments of the City. Please refer to Section IX for Humana's proposed plan design and for plan deviations. 9. Notify service providers of the effective date of the contract award of City business and provide the billing address for claim submission relating to City participants for services rendered after the effective date of this change. This will ensure a smooth transition for claims processing and payments. Providers will be notified of a patient's change of insurance information through the member's ID card, which should be requested at the time of service. Humana's claims address information is located on the back of the member's ID card. 10. An Explanation of Benefits is to be provided following receipt of a claim submitted by a member, as to the disposition of the claim. In case of delay, an explanation of the reason for the delay is to be provided. If a claim is disputed, fair resolution and written notice of the reason for the denial and appeal process procedures are to be provided. The Explanation of Benefits (EOB) is provided when the claim is processed by Humana. The EOB reflects provider reimbursement and member responsibility. On the Humana claim system, when a claim with inaccurate or missing information is received, the claim is pended. The claim adjuster first attempts to locate the necessary information by researching the claim history. Depending on the information required, Humana contacts the provider or the member. Humana maintains a daily report that reflects the aging of pended claims. If the necessary data is not obtained within an appropriate time frame, the claim is denied, and an EOB is sent to the member with an explanation of the member's appeal rights. Humana follows the state and federal mandates pertaining to sending acknowledgment letters and delay /notice letters. Typically, if a claim requires additional information to be processed, the letter must be sent within 15 days. Acknowledgment letters are sent if a claim has not been paid within 10 days. If a letter is generated for preexisting conditions or coordination of benefits, the letter is sent to both the member and provider. 11. In case of denial of a claim for payment for any reason, the claimant should be notified in writing in a clear, concise and easy to understand manner giving the reason for denial. If there is an appeal process involved, the claimant is to be provided full information relating to the procedures and steps to follow. Humana' s process for denying a claim is initiated by missing or incorrect claim information. If a claim is missing information, the system edits for this information and a claim adjudicator manually reviews the City of Corpus Christi 2 HUMANA. Guidance when you need it most claim for resolution. If the edit cannot be resolved, the claim is denied with an explanation sent to the provider of the service and the member. This explanation includes an EOB and an explanation of the member's appeal rights. 12. It will be the responsibility of the Contractor to defend at their cost and expense, any and all claims and actions, which may be filed for failure to pay covered benefits under the plan(s) offered. Humana agrees to take responsibility for and defend at its cost, any and all claim actions which arise from a failure to pay for covered benefits. Humana agrees to indemnify and hold the City harmless from and against damages, claims, or liabilities that arise as a result of acts or omissions on its part or the part of its employees in the performance of the contract. 13. The Contractor shall identify claims for which there is potential for subrogation of the rights of the covered persons, and such listing shall be provided to the City on a quarterly basis. Humana will identify potential subrogation claims. Humana's automated subrogation process identifies and resolves more subrogation opportunities than any manual screening process, which is why Humana uses the same process for its own employee plan. Many national and local employers, including those with in -house legal departments capable of reviewing subrogation claims, use Humana's subrogation services because of Humana's superior ability to contribute to the reduction of premiums. Subrogation reports can be produced monthly, quarterly, or annually. 14. Supply updated provider directories as needed. Humana provides provider directories to Medicare Advantage members upon enrollment. If a member would like another provider directory at a later date, the member may call Humana's customer service center to request a printed directory. Members also receive a new provider directory upon renewal of the plan. Members may also access provider directories online at Humana.com. 15. Maintain eligibility files and receive updates from the City as required. The Contractor must maintain eligibility files throughout the term of the contract. Humana can provide automated enrollment and maintenance of eligibility information for groups via electronic transfer. Humana typically requires the enrollment file to be in either the standard Humana layout or the HIPAA 834 layout. The layout must be able to support the products sold to the group. If the City requests automated enrollment, Humana requires an appropriate lead time prior to the group's effective date for setup and programming. Humana has two requirements for automation: • Provide data in Humana's standard layout or the HIPAA 834 file layout depending on the products sold. Humana can accept other layouts depending on the size of the group. • Electronic capability via Electronic Data Interchange/Transfer (EDI/T) Humana requests that groups send a monthly "full file" containing all membership in a standard format specified by Humana or, in specific pre- negotiated circumstances, a format agreed upon by Humana and the City as part of the contract negotiation. Adds, changes, and deletes in the standard or mutually City of Corpus Christi 3 HUMANA. G//ti ut .ancc when you need it most agreeable format are requested on a weekly basis. In addition, the eligibility file is updated anytime there are additions or terminations within the City or if there is a change in a member's data. Humana agrees to maintain eligibility throughout the term of the contract. 16. The City prefers online access for real time updating of the eligibility data. Humana does not offer online access for eligibility updates at this time; however, Humana can provide automated enrollment and maintenance of eligibility information for the City via electronic transfer. Adds, changes, and deletes in the standard or mutually agreeable format are requested on a weekly basis. In addition, the eligibility file is updated anytime there are additions or terminations within the City or if there is a change in a member's data. 17. Eligibility software must be HIPAA compliant. Humana's eligibility software is HIPAA- compliant. 18. Mail I.D. cards to participants' home address within ten (10) working days after receiving the initial enrollment eligibility file and at the beginning of each plan year. Thereafter, new I.D. cards must be provided to a participant within five (5) working days of receiving any change request. Humana agrees to mail ID cards to members' homes. Humana requests approximately 12 to 15 business days for installation of the group and membership. ID cards are postmarked from the vendor within three business days of the request being issued from Humana's Enrollment department. Enrollment cycle times vary depending on the time of month the account is received and the completeness of the received applications. During the contract year, enrollment changes are processed within three to five business days. ID cards are postmarked from the vendor within three business days of the request being issued from Humana's Enrollment department. The member can order a replacement ID card via Humana's Website, Humana.com. 19. Provide assistance in plan communication and enrollment of retirees. Written information and group seminars will be offered to beneficiaries. Humana's nationwide network of dedicated Medicare sales representatives are trained and certified by Humana. The representatives ensure that beneficiaries have the information and guidance they need when they need it. The `Let's Talk' campaign even features one -on -one guidance for seniors and their families. Humana's Medicare Direct Marketing Services call center can be a valuable tool to assist with enrolling eligible beneficiaries. The call center has the ability to contact every retiree via outbound calls inviting them to attend a group seminar or to arrange in -home appointments. On an inbound basis, the call center can collect meeting RSVPs and provide other logistics services. Humana will make earnest attempts to reach out to every single eligible retiree and family member for initial and subsequent enrollments. Humana's enrollment approach allows retirees to be active in the enrollment process while receiving assistance from Human's specially- trained enrollment staff. Humana deploys a multi - pronged, comprehensive communication and enrollment strategy. Humana enrolls the Medicare members into the employer selected plans. Typically, the member completes the paper application, which is then electronically scanned to capture the necessary information. Humana offers EDI enrollment to its City of Corpus Christi 4 HUMANA. Guidance when you need it most Medicare Advantage groups, which provides an efficient means of data transfer reducing the likelihood of errors that may occur via paper enrollment. Humana also offers Web -based enrollment with the assistance of a certified agent. Although the City's retirees will not be able to enroll into a group Medicare plan online, Humana's certified enrollment agent will process the enrollment for each retiree. Humana is currently in the process of exploring Internet -based and other telephonic enrollment capabilities that would not require the involvement of a Humana agent. 20. Maintain, print and mail summary plan document (SPD) booklets to plan members. SPD booldets and provider directories shall be mailed to the member's home address at the time of initial enrollment. Thereafter, the summary plan document shall be mailed to all subscribers' home address annually. Summary plan descriptions are not applicable to fully - insured Medicare Advantage groups; however, Humana sends a copy of the Evidence of Coverage to each member upon enrolling in the plan and on an annual basis. Benefits summaries are also sent to members for open enrollment and are provided on an annual basis thereafter. Members may also access benefit summaries via the secured MyHumana member portal at Humana.com. Humana sends provider and pharmacy directories to members at the time of enrollment and on an annual basis. Humana also encourages members to access Physician Finder Plus, Humana's online tool for provider information. Searches can be customized by proximity to the member's home, physician gender, languages spoken, specialty, and other criteria. Members can print the results of their search and directions to the provider office. Physician Finder Plus, located at Humana.com, is updated daily. 21. The summary plan document (SPD) must be developed and submitted to each participant no later than November 1, 2009, unless another date has been agreed upon by the City. As requested by the City, the effective date of the proposed contract is August 1, 2009. Summary Plan Descriptions are not applicable to fully- insured Medicare Advantage groups; however, Humana sends a copy of the Evidence of Coverage to each member upon enrolling in the plan and on an annual basis. Therefore, the Evidence of Coverage is sent to the member prior to the effective date of the plan. Benefits summaries are also sent to members prior to open enrollment and are provided on an annual basis thereafter; therefore, benefit summaries are provided prior to the effective date. 22. Assist in developing and mail plan amendments to all members at their home address. Humana Medicare Advantage plan members are notified annually of benefits changes through the CMS approved annual notification process, which includes the delivery of a letter, summary of benefits, and the Evidence of Coverage. 23. Supply the City with Summary Plan Document (SPD) booklets, marketing materials and provider directories for distribution as needed. Humana sends a number of retiree communication materials to each retiree before and after enrollment. These communication materials include benefit summaries, informational brochures, a guidebook, and City of Corpus Christi 5 HUMANA. Guidance when you need it most other communication materials related to the plan. Humana also provides the Evidence of Coverage and provider directories at the time of enrollment. 24. Provide the City with plan specific comprehensive experience reports monthly and/or summary reports annually. Provide copies of your standard reporting package. Cost of these reports must be included in the rate bid. Humana provides standard reporting to its Medicare Advantage groups on a quarterly basis. Humana's claims and related operating systems are fully integrated and in- sourced allowing Humana to provide the City a vast array of reports using its preferred method of delivery. Humana's capabilities range from providing a standard set of reports to customized ad hoc reporting to delivery of a detailed claims file to a data management firm. As part of Humana's initial planning/implementation meeting, it will work with the City to design a reporting plan that aligns with the City's specific needs. As an industry- leading Medicare Advantage plan, Humana generates thousands of internal and external (e.g. CMS) reports relating to the areas referenced in this questionnaire. Below are samples of the standard reports that are typically requested by Humana's Group Medicare Advantage customers. Basic Reporting Package Population Demographic Profile • Membership distribution by age and gender • Spend distribution by age and gender • Claims stratification by dollars Clinical Assessment • Wellness and preventive screenings • Clinical condition prevalence • Top 10 clinical conditions • Detailed review of top three conditions • Clinical program savings • Program referrals and large claimant program participation Utilization Summary • Physician office visits • Inpatient and outpatient care • Emergency /urgent care and ancillary services • Utilization trend scorecard • Large claimants impact Pharmacy Profile • Prescription utilization summary • Pharmacy opportunity savings • Maximize Your Benefit City of Corpus Christi 6 HUMANA. Guidance when you need it most Member Engagement and Service Profile • Member contact and Web utilization • Inbound call contacts, caller frequency and call volume Humana provides its standard reporting package at no cost to the City. Humana is willing to discuss customer - specific reporting needs; including details such as scope, frequency, contact, and associated costs prior to making commitments in connection with client- specific reports. Any applicable fees can be negotiated at the time of the request. Please refer to Attachment C for a sample reporting package. 25. All reports must be received by the last day of the following month. Humana will provide its standard reporting package on a quarterly basis and will provide the reports by the last day of the following month. 26. Provide web -based access to standard reports. At a minimum, standard reports must include: Humana's Group Medicare Advantage reports are provided directly to the plan sponsor and are not available on Humana.com at this time. • Medical • Plan demographics This report is included in Humana's standard reporting package. • Medical cost recap (e.g. total paid, PMPM, provider type, In vs. Out of Network) This report is included in Humana's standard reporting package. • Claims expense stratification by dollars and age This report is included in Humana's standard reporting package. • Provide utilization (input, output, physician) compared to benchmark This report is included in Humana's standard reporting package. • Large claims This report is included in Humana's standard reporting package. City of Corpus Christi 7 HUMANA. Guidance when you need it most • Major diagnostic categories This report is included in Humana's standard reporting package. • Case management activity This report is included in Humana's standard reporting package. • Pharmacy • Membership summary This report is included in Humana's standard reporting package. • Executive summary This report is included in Humana's standard reporting package. • Generic vs. Retail Utilization This report is included in Humana's standard reporting package. • Channel Utilization This report is included in Humana's standard reporting package. • Top drug and classes This report is included in Humana's standard reporting package. Humana's standard reporting package includes the reports above and additional reporting capabilities, such as an analysis and recommendations on each report. Please refer to Attachment C for a sample Medicare PlanCompass Reporting Package. 27. Provide a single point -of- contact account manager and local contact. This person shall be available through a toll-free telephone number and a direct telephone number. The local account manager will be the City's current account executive, Pam Taylor. Pam will serve as the single point of contact and will be available through a toll -free phone number and a direct phone number. 28. Conduct an annual member satisfaction survey. Humana has partnered with UCNBenchmarkPortal to utilize a tool called Every Customer Has Opinions or ECHO. ECHO is a customer - focused tool that provides a random outbound- automated phone survey to Humana members. ECHO surveys are conducted on a daily basis. It gives Humana an opportunity to listen to members and gauge their experience with Humana. Through ECHO, randomly selected members City of Corpus Christi 8 HUMANA. Guidance when you need it most are asked a series of questions about their experience after their call with one of Humana's Customer Care representatives in the dedicated Medicare customer service unit. Humana does not publish the results of ECHO surveys externally; instead, survey results are used to identify customer service improvement opportunities. 29. Properly staffed and supervised customer /member service representatives as well as bi- lingual staff must be available to plan participants via a toll free number. All associates in Humana's dedicated Group Medicare customer service unit have call center experience prior to being placed in this area. CMS requires Humana to answer 80 percent of incoming calls within 30 seconds. These calls are randomly recorded and monitored. This process allows Humana to provide a basis for tracking information to ensure excellent customer service. Humana's Customer Care representatives in the Group Medicare dedicated unit are required to attend Humana's internally- developed sensitivity training classes. The main objective of the training is to heighten Humana associates' awareness of the senior population, to dispel negative images, and to provide facts. The training is structured to enable associates to provide appropriate, enhanced service to Humana' s senior members. Humana's customer service unit also employs a number of bilingual Customer Care representatives to provide service to Spanish - speaking members. - Members may contact the Medicare customer service unit by calling the toll -free phone number on the back of their ID cards. The Medicare member service hours of operation are 8 a.m. to 11 p.m. Eastern Time, Monday through Friday, and 8 a.m. to 6 p.m. Eastern Time, Saturday (customer service hours of operation may be extended during peak operating times). An automated information line is available 24 hours a day, seven Humana also has a pre - enrollment, toll -free customer service unit located in Tampa Florida for its Medicare customers. This customer service unit is staffed with licensed sales agents whose duties include answering benefits questions, explaining the enrollment process, and setting up in -home appointments for Medicare eligible employees and retirees interested in the Humana plan. The hours of operation are 8:30 a.m. to 5 p.m., Eastern Time, Monday through Friday. 30. Keep records on complaints and concerns expressed by City participants categorized in appropriate sections against health care providers, vendor services, hospital networks, etc., and make these records available for City's administration to review. Complaints regarding providers, vendor services, and hospital networks are sent from Humana's customer service unit to Humana's Grievances and Appeals department. When received, grievances are coded as a grievance case type and are categorized based on the following categories: quality, access, or attitude. Quality, access, and attitude grievances are coded as such in Humana's Customer Care Portal by the applicable grievance reason code. Reporting can be generated by group, case type, and reason code upon request. These reports can be provided to the City if requested. City of Corpus Christi 9 HUMANA. Guidance when you need it most 31. Renewal rate computations must be furnished at least 4 months prior to the end of the contract year. Medicare Advantage renewal rates will be provided at least 120 days prior to the end of the contract year. 32. Waive actively -at -work clause on new entrants into the plan. This is not applicable to Medicare Advantage products since the individuals enrolling in the plan are retirees. 33. The City does not guarantee a minimum participation in the plan. For Humana's Group Medicare Advantage plans, Humana requires a minimum case size of 10 members per product. All renewing groups also require a minimum of 10 members per product. 34. New member ID cards are mailed to member's homes. Summary plan documents are updated annually, provided to the City, and mailed annually to member's homes. Member ID cards are mailed to members' homes upon enrollment in the plan. Upon renewal, Humana will only send a new ID card if there is a change in the plan that prompts the generation of a new ID card. Benefit summaries and the Evidence of Coverage are also mailed to members upon enrollment and on an annual basis. Humana will also provide the Evidence of Coverage and benefit summaries to the City on annual basis. City of Corpus Christi 10 HUMANA. Guidance when you need it most SECTION 3.4 PROPOSER'S PROFILE AND QUALIFICATIONS 1. Where is your organization headquartered? Where is the management office responsible for Corpus Christi or Nueces County located? State the location where administrative services will be provided for the City of Corpus Christi (customer service, claims processing, issuing and distribution of I.D. cards, etc.) The headquarters for Humana Inc., the parent company of Humana Insurance Company, is located in Louisville, Kentucky. Claims processing and customer service will be provided by Humana's customer service center located in Louisville, Kentucky. ID card production and distribution is provided by Humana's subcontracted vendor, Personix, which is located in Stafford, Texas. The local Humana market office that will provide account management for the City is located in Corpus Christi, Texas. 2. Have any lawsuits been filed against your organization relative to any of your health care products or administrative services in the last two years? Please describe the nature of any lawsuits, dates and final outcomes. Humana health plans and insurance subsidiaries have been involved in several legal actions primarily concerning claim disputes. Humana does not believe any of these disputes have a material impact on the plans or their operations. Please refer to Attachment D for a list of lawsuits for Humana Insurance Company that have occurred within the last two years in the state of Texas. 3. How many clients have left your organization during the last two years? In 2007 and 2008 combined, 586 large group clients terminated their membership. 4. Provide a copy of your most recent annual financial reports and the annual financial reports of your parent company. The offering company for Humana's proposal is Humana Insurance Company. The parent company for Humana Insurance Company is Humana Inc. Please refer to Attachment E for Humana Inc's 2008 annual report and Attachment A for Humana Insurance Company's 2008 financial statements. 5. Provide most recent A.M. Best, Standard & Poor's, Weiss, and Moody's Ratings (if applicable). The industry ratings for Humana Insurance Company are as follows: Standard and Poor's Ilatin2 Uati A- A.M. Best A- April 15, 2008 June 5, 2008 Weiss C June 19, 2007 Moody's A3 June 19, 2007 City of Corpus Christi 1 HUMANA. Guidance when you need it most 6. Provide a detailed explanation of any common ownership or relationship among supporting vendors and subcontractors. Humana has agreements in place with a variety of vendors for business and administrative services, as well as member services. The list below includes many of the subcontractors that may deliver services that directly impact the City's employees. Many of the services provided are seamless to members. Subcontracted services include, but are not limited to the following: Pharmacy Claim Administrator To provide pharmacy claim administration, Humana contracts with Argus, a leading provider of information services and administrative support for pharmacy program management. Argus Health Systems, Inc. 1300 Washington Street Kansas City, Missouri 64105 -1433 24 -Hour Nurse Line (Demand Management) The plan contracts with Intellicare to provide the HumanaFirst® program which is a 24 -hour, seven- day -a- week, nurse advice line available to eligible plan members. Intellicare Corporate Offices 500 Southborough Drive South Portland, Maine 04106 Subrogation Services Subrogation services are performed by Humana in partnership with its subcontracted vendor, Troyer Solutions Inc., located in Louisville, Kentucky. Troyer Solutions Inc. 9390 Bunsen Parkway Louisville, KY 40245 502- 214 -1340 Mail Room Services for Claims Affiliated Computer Services, Inc., (ACS) located in Lexington, Kentucky, provides services for opening, sorting, preparing, and scanning paper claims. The electronic data files are then submitted to the appropriate customer service center for final disposition. Affiliated Computer Services, Inc. P.O. Box 14601 Lexington, Kentucky 40512 City of Corpus Christi 2 HUMANA. Guidance when you need it most Health Information and Tools MyHumana also provides members access to a network of complementary and alternative health providers (American WholeHealth), condition centers that host health quizzes, calculators and assessments (Staywell), information for specific conditions (Healthwise Health Library), and a healthy recipe library (WholeHealthMD.com). WholeHealthMD LLC 11150 Sunset Hills Road, Suite 210 Reston, Virginia 20190 StayWell/Krames Krames / StayWell, a Division of MediMedia USA 201 Main Street, Suite 2500 Fort Worth, Texas 76102 Voice Application Technology. Eliza services, Humana's voice activated technology (VAT) system, is utilized for communicating various information to members such as outbound prevention reminders, notification of member copayment savings, pharmacy initiatives, etc. Eliza 100 Cummings Center, Suite 350C Beverly, Massachusetts 01915 Retiree Medical Savings Accounts and VEBA solutions Genesis Employee Benefits, Inc. provides services towards Humana's retiree medical savings accounts and VEBA solutions. Crosstown Woods Corporate Centre 10125 Crosstown Circle, Suite 170 Minneapolis, Minnesota 55344 -3327 Disease Management Programs Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD) • Alere Medical provides services for members with congestive heart failure and Chronic Obstructive Pulmonary Disease. Alere Medical, Inc. 595 Double Eagle Court, Suite 1000 Reno, Nevada 89521 City of Corpus Christi 3 HUMANA. Guidance when you need it most End Stage Renal Disease (ESRD): • Village Health focuses on education and coordination of care for Humana members with ESRD. Village Health Three Hawthorne Parkway, Suite 410 Vernon Hills, Illinois 60061 Fulfillment Vendor SHPS is a leading provider of outsourced benefits administration and care management services. They have been Humana Marketing's warehouse and fulfillment vendor since June 2000. Humana currently has over 10,000 items available for order through SHPS Order Entry System (OES). Items are ordered in both bulk quantities and collated into kits. SHPS 11405 Bluegrass Parkway Louisville, Kentucky 40299 ID Cards The production of Medicare ID cards is outsourced to our subcontractor, Personix. Personix 13100 North Promenade Boulevard Stafford, Texas 77477 7. Indicate the location of the group claims office, corporate and local, which would be responsible for paying claims and the number of claim representatives in that office that will be dedicated to the City's account. Claims for the City will be processed by Humana's customer service center located in Louisville, Kentucky. This claim processing unit is the central claim processing unit for all Medicare Advantage claims. Humana does not utilize regional claim processing centers. Humana employs at a total of 291 full - time claim processors in its Medicare Advantage claim processing unit. Humana is not offering dedicated claims processors for the City, but offers a team approach to managing claims inquires. Humana's team approach allows Humana to manage claims from a global basis so all accounts receive the same level of excellence. Human's service centers have the ability to handle an undefined number of clients with memberships ranging from two to over 100,000. Humana's advanced abilities are attributable to the high -level capabilities of its claims payment system and the structure of its customer service staff. Many of Humana's members' claims have an auto - adjudication rate of 75 to 80 percent. With this rate of performance, Humana is able to streamline its processes and assign designated teams of associates to work on similar types of claims to ensure its clients' expectations are met. City of Corpus Christi 4 HUMANA. Guidance when you need it most 8. Provide an organizational chart, locations, and biographies of team members assigned to the City's account. The City will continue to receive account management services from the local account executive and account advisor assigned to the account. Pam Taylor, the account executive, and Judy Smith, the account advisor, are located in Corpus Christi. The biographies for Pam and Judy are provided below. Pam J. Taylor, Account Executive Pam Taylor has been an Account Executive with Humana since 2005. Pam has over 20 years of insurance experience and has worked for major insurance carriers in the areas of sales and account management. Pam holds bachelor's degrees in marketing and business from the University of Oklahoma and South Western University. Judy Smith, Account Advisor Judy Smith has been with Humana for 18 years and provides guidance to Humana's large group clients. Judy has extensive knowledge of Humana's various systems. Judy is responsible for educating her clients and their members on Humana's available Web functions, their plan benefits and how to best utilize them, and Humana's additional products and services. Judy assists with client enrollment and educational meeting throughout the year. Humana will assign an account implementation team for the Medicare Advantage plan upon award of business. The assigned account installation manager will be Janelle Cain. Her biography is provided below. Janelle Cain, Account Installation Manager Janelle has been with Humana since June 2006. Her career consists of three years experience within the insurance industry with a primary focus on customer service and account management. Janelle has also held an account concierge specialist position in the Group Medicare Customer Service Operations department at Humana. Some of Janelle's role responsibilities include consulting with clients to understand their implementation needs and guiding and educating clients about Humana's implementation processes. Her role allows her to be a liaison between the clients, sales, and operations. Janelle graduated with a bachelor's of arts degree in secondary education from Kentucky State University. Please refer to Attachment F for an organization chart of Humana's South Texas sales and account management office. 9. How long have you provided the specific services you propose? Are any of the services proposed "new" to your organization, and therefore either not fully developed or client - tested? Humana has been licensed to provide its Regional PPO plans in the state of Texas since 2005. All services included in the premiums for the City have been in place for several years; therefore, none of the proposed services are "new." City of Corpus Christi 5 HUMANA. Guidance when you need it most 10. What attributes make your organization qualified to provide health care coverage to Non Medicare and Medicare Eligible retirees? How are you differentiated from your competitors? With over two decades of experience in designing and delivering group health benefits, Humana can help the City tailor a successful health benefits strategy to meet their unique needs. In its quest to become the most trusted name in healthcare solutions, Humana offers its clients a full range of health benefits programs, extensive provider networks, award - winning clinical programs, notable technological expertise, and outstanding customer service. Humana is widely recognized by large employers and benefit consultants as one of the top players in the Medicare Advantage market nationally. By engaging in a relationship with Humana, the City will be able to take advantage of Humana's 21 continuous years of experience serving Medicare beneficiaries. Due to a strong commitment to innovation, Humana was one of the first health plans in the country to offer Private - Fee - for - Service plans through 2002 demonstration projects with CMS and will bring many valuable lessons learned to its partnership with the City. Humana's approach focuses on giving consumers information, tools, and resources to engage them in making decisions about their healthcare. Each aspect of Humana's care management program will produce a guidance opportunity, with focus on: • Pre- authorization/Notification • Discharge Planning • Ensure Movement to Most Appropriate Level of Care • Post Discharge Care • High Utilizer/Re -admit Reports • Care Level Management • Case Management • Managing Inpatient Length of Stay • Disease management including congestive heart failure, end -stage renal disease, diabetes, and COPD Humana is here to guide its members to resources that help them get the most from their plan and the most out of life. Humana takes a personal interest in keeping members healthy, which is something not all insurers focus on. It is just one of the many extras that make Humana Medicare Advantage coverage so valuable. Humana offers the following programs at no additional cost to the member: • MyHumana: Personal, secure Web page on Humana.com where members can access benefits information, health tools, claims history and more • Humana Active Outlook: Program addressing numerous health and wellness topics; Magazine featuring health, travel, and lifestyle articles • Humana First: Humana's demand management toll -free 24 -hour health information line • SilverSneakers®: Special fitness and wellness program that is available to Medicare Advantage members nationwide • Complimentary & Alternative Medicine: Discounts at more then 25,000 providers nationwide City of Corpus Christi 6 HUMANA. Y Gui d ance when you need it most • EyeMed Vision Discount Program: Discounts on eyewear, contact lenses, laser vision correction, and eye exams • Nutritional Supplements/OTC Medications: Discounts for nutritional supplements and various OTC medications 11. Provide three current dient references and three former client references for which you provided the same services. References should be based on the office that will be providing services to the City. Organization name: City of Tampa Contact and title: Therese Rodgers, Benefits Administrator Address: 411 North Franklin Street, 2nd Floor Phone number: 813- 274 -5904 Tampa, Florida 33602 Effective date of contract: 01/01/2005 Number of enrolled retirees: 520 Description of services provided: Medicare Advantage HMO with Prescription Drug Plan ( 1 IatI AI ( 1 II AI In„ Organization name: City of St. Petersburg Address: P.O. Box 2842 St. Petersburg, Florida 33731 Effective date of contract: 02/01/1999 Contact and title: Jason Hall, Benefits Administrator Phone number: 727 - 893 -7462 Number of enrolled retirees: 320 Description of services provided: Medicare Advantage HMO and RPPO with Prescription Drug Plan I■ I \ s III vl fGlc1 Organization name: State of Louisiana Address: 7389 Florida Blvd Suite 400 Baton Rouge, Louisiana 70806 Effective date of contract: 07/01/2009 Contact and title: Rusti White, Benefits Administrator Phone number: 225- 925 -3936 Number of enrolled retirees: 1,377 Description of services provided: Medicare Advantage HMO and PFFS with Prescription Drug Plan City of Corpus Christi 7 HUMANA. Guidance when you need it most 1 i not! I ; ( 1 Organization name: Transit Management of Southeast Louisiana ii 1 1 Il l t I i 11, A 1 Contact and title: Doug Russell, Benefits Administrator Address: 6700 Plaza Drive New Orleans, Louisiana 70127 Phone number: 504-248 -3613 Effective date of contract: 12/01/2005 Number of enrolled retirees: 148 Number of enrolled retirees at date of termination: Not available Description of services provided: Medicare Advantage plan with Prescription Drug Plan I Reason for termination: Lack of Membership IOI: \1I Ill 1 Organization name: United Methodist Church, Florida Conference II \I I.tI(tk lit ■ Contact and title: Karen Allen, Benefits Administrator Address: 1201 Davis Street Evanston, Illinois 60201 Phone number: 312 -346 -9766 - Effective date of contract: 12/01/2005 Number of enrolled retirees: 44 Number of enrolled retirees at date of termination: Not available Description of services provided: Medicare Reason for termination: Lack of Membership Advantage plan with Prescription Drug Plan Organization name: Teamsters Local 295 and 851 Contact and title: Linda Kellner, Benefits Administrator Address: 60 Broad Street New York, New York 10004 Phone number: 212- 308 -4200 Effective date of contract: Not available Number of enrolled retirees: Not available Number of enrolled retirees at date of termination: Not available Description of services provided: Medicare Advantage plan with Prescription Drug Plan Reason for termination: Not available City of Corpus Christi 8 HUMANA. Guidance when you need it most SECTION 3.5 TECHNICAL SOLUTION A. Provider / Network Access and Administration 1. Using the census provided in Exhibit H, please provide Geo- Access Reports using the following standards: Medical Network: Ith (.tuull Pri - Care Ph sicians* All Other S I ecialists Hos ' itals 1 11;111 Anil'Nuhurii:in 2 in 8 miles 2 in 15 miles 2in15miles �LUUluril� 2 in 25 miles 2 in 25 miles 2 in 25 miles *Primary care physicians include Internists, Family Practitioners, OB /GYNs, In addition to the hard copy report, the data must be supplied in electronic format that has read/write capabilities (i.e. Excel). Do not send the data in a read -only file. Use only physicians accepting new patients in your Geo- Access provider file. Humana has provided GeoAccess reporting based on the urban, suburban, and rural standards requested for its Medicare Advantage Regional PPO (RPPO) network. Please refer to Attachment A for PDF and Excel versions of Humana's GeoAccess report. 2. Provide list of hospitals and providers local to Corpus Christi. Please refer to Attachment A for a list of RPPO network hospitals and providers in the Corpus Christi area. 3. Provide access to national networks in the event employees are traveling or dependent students are out of state. Humana' s proposed RPPO plan provides members access to Humana's RPPO network, which offers reciprocity in all 23 states in which the network is offered. Retirees and their dependents may access Humana's RPPO network in any of Humana's 23 RPPO states. 4. Describe any alternative PPO networks that are based on provider quality and cost criteria. Humana offers its Medicare Advantage Regional PPO network to the City's Medicare eligible retirees. This network provides broad provider scope in each RPPO state. While Humana does not offer an alternate PPO network for Medicare Advantage plans, members may research provider quality and cost using Humana's online transparency tools. Members have access to the following transparency tools via their secured MyHumana page at Humana.com. Compare Hospitals: Provider Quality and Cost The Compare Hospitals tool allows members to research hospital quality and compare the costs of 51 hospital procedures in 13 categories. Hospital quality indicators measured by this tool include in- hospital City of Corpus Christi 1 HUMANA. Guidance when you need it most mortality, major complications, failure to rescue, volume of patients, average length of stay, CMS/HQA recommended care measures, Leapfrog group patient safety measures, and cost. Based on the quality indicators and scoring weights that members select in their initial search, the Compare Hospitals tool displays a side -by -side comparison of hospital performance and cost based on Humana's contracted facility rates. Each screen includes information from WebMD about the measures that are used to calculate quality and performance information. The Compare Hospital tool includes a link to additional information on Healthwise.net that assists members in understanding the procedure they are considering. This comprehensive information source explains the surgery in detail, including its risks, why it is done, how well it works, and what members should expect after the surgery. Compare Doctors The Compare Doctors tool allows members to view the estimated costs for common types of doctor's office visits, including 36 routine conditions and up to four specialties. The tool displays cost estimates for individual doctors compared to average costs in a member - specified location. The estimate includes a breakdown of the cost based on the percentage of the total that is comprised of the office visit, laboratory tests, and pharmacy, and it also provides a link to Humana's Rx CalculatorsM that shows member - specific pharmacy utilization and cost. In addition to cost information, the Compare Doctors tool includes descriptive information for each of the 36 conditions, a "Questions to ask your doctor" section from the American Academy of Family Physicians, and a link to Familydoctor.org for additional condition - specific information. Compare Outpatient Facilities The Compare Outpatient Facilities tool allows members to view and print the estimated costs for services that take place at a hospital or a freestanding center on an outpatient basis, including 20 outpatient surgical procedures and six diagnostic tests. In addition to the cost information, this tool also provides an explanatory description of each specific procedure and condition, including preventive care guidelines where applicable. For members who would like in -depth information, this tool also links for each procedure to additional resources at Familydoctor.org. Pharmacy Tools Humana's Rx Calculator is a patent- pending tool that helps members manage their drug costs. The information displayed in this tool is based on a member's specific prescription benefits plan, current prescription claims, and future drug utilization. Generic equivalents and possible alternatives are highlighted as cost saving opportunities, as is the member's ability to substitute and price. Humana keeps this information current for its members by updating drug and pricing data weekly and updating claims in real -time. Additional features of the Rx Calculator include: • Pricing of maintenance medications at both retail pharmacy and mail order pharmacy rates • Pricing of drugs based on the most commonly prescribed quantity • A display of the member's prescription benefits in a snapshot box carried throughout the tool City of Corpus Christi 2 HUMANA® Guidance when you need it most • The Medicine Cabinet, which prices and saves a listing of the member's medications for future reference • A listing of current prescription out -of- pocket expenses based on claims history and a refill calculator tool • A display of maximum out -of- pocket information based on selected drugs 5. Will an implementation manager and support team be assigned to lead and coordinate the implementation activities with the City? Yes, the assigned dedicated Medicare account installation manager, Janelle Cain, will serve as a single point of contact for the City during implementation. Not only does the account installation manager act as the single point of contact through the implementation, but continues to service the City throughout the life of the account. Initially, the account installation manager serves the client by coordinating and managing the implementation of the account. The account installation manager will be responsible for ensuring that the implementation experience includes: • Coordination of status meetings for the duration of the implementation • Benefit plan is built and is open to pay claims prior to plan effective date • All members are enrolled in a timely manner • All members receive the required materials (ID cards, etc.) to properly access their benefits • Provide enrollment reporting as requested 6. What minimum amount of notice would you require to be able to implement these plans by August 1, 2009? Assuming the proposed plans, Humana will require a minimum of at least 60 days notice of the contract award to ensure a timely account installation. For the City's requested August 1, 2009 effective date, Humana will require contract award notification by June 1, 2009 or earlier. 7. Please discuss your procedures and processes for handling the following during the transition period. a. Transfer of claim and benefit history Humana can transfer claim and benefit history either electronically or by hard copy. Humana' s Medicare Advantage claims history requirements are: • Claims data needs to be separated for each unique benefit plan offering. • Monthly medical claims for the most recent 24 months for Medicare - eligible subscribers and Medicare - eligible dependents, including either monthly member counts or per member per month information must be given. • Monthly prescription drug claims for the most recent 24 months for Medicare- eligible subscribers and Medicare - eligible dependents including member counts and script counts by month must be given. • Any received or accrued drug subsidy amounts should be disclosed. • If pharmacy claims are not net of rebates, the City should provide rebate amounts. City of Corpus Christi 3 HUMANA® Guidance when you need it most b. Retirees /dependents in active treatment For continuity of care issues for acute, active treatment, a Humana PPO member may receive treatment from the current provider until the acute treatment is completed. Requests for services to be rendered by a non- network provider related to continuity of care issues are reviewed by the market medical director through Humana's normal processes on an individual basis. c. Pregnancy (2nd & 3rd trimesters) Transition of care procedures for maternity do not apply to Humana's Medicare Advantage plans. Humana transitions newly enrolled members from another insurance plan to Humana without interrupting a covered medically necessary treatment plan that is currently in progress. By identifying ongoing health issues and necessary medical services, this process assists members in creating a bridge to a network or accepting Medicare provider. Transition of care benefits apply to, but are not limited to, the following conditions: • Member having or who has recently had surgery • Member receiving home healthcare or is under case management from prior insurance • Acute medical conditions in active treatment, such as chemotherapy and radiation To begin the transition of care process, members complete a transition of care form and either fax or mail the request to Humana. Upon receipt, the request is forwarded to Humana's care management team in the member's region. The care management team's review includes an assessment of the current condition and course of treatment related to the medical needs of members. Should additional information be required, a telephone call is made to the members and/or the attending physician. Once the additional information is received, Humana will reach out to the members and/or provider and facilitate care with the appropriate provider. d. Members undergoing chemotherapy or radiation Humana transitions newly enrolled members from another insurance plan to Humana without interrupting a covered medically necessary treatment plan that is currently in progress. By identifying ongoing health issues and necessary medical services, this process assists members in creating a bridge to a network or accepting Medicare provider. Transition of care benefits apply to, but are not limited to, the following conditions: • Member having or who has recently had surgery • Member receiving home healthcare or is under case management from prior insurance • Acute medical conditions in active treatment, such as chemotherapy and radiation To begin the transition of care process, members complete a transition of care form and either fax or mail the request to Humana. Upon receipt, the request is forwarded to Humana's care management team in the member's region. City of Corpus Christi 4 HUMANA. Guidance when you need it most The care management team's review includes an assessment of the current condition and course of treatment related to the medical needs of members. Should additional information be required, a telephone call is made to the members and/or the attending physician. Once the additional information is received, Humana will reach out to the members and/or provider and facilitate care with the appropriate provider. e. Members confined in hospital at changeover dates When members are confined in a hospital on the carrier transition date, the members will receive discharge planning and transition of care services as needed to assist the member in moving to the appropriate level care based upon the member's health needs and treatment plan. Humana's utilization management and case management nurses will be available to work with hospital discharge planning staff, providers, members, and members' families to assist in any transition of care issues and to assist with care coordination based upon the member's benefit plan and health needs. f. Members under case management g• Humana transitions newly enrolled members from another insurance carrier to Humana without interrupting a covered medically necessary treatment plan that is currently in progress. By identifying ongoing health issues and necessary medical services, this policy assists the member in creating a bridge to a network provider. For members participating in the case management program, Humana will screen the members and determine if they should be placed in a Humana case management or disease management program. Services that have been pre - certified but not completed as of the effective date A Regional PPO member must seek care from a network provider to obtain the highest level of care. The member needs to follow required precertification or preauthorization processes required for a particular service. Specific continuity of care issues are reviewed, and a process is put into place to make a determination on an individual basis. A transition of care request may be completed by the member regarding any specific medical or mental health services either already preauthorized or being received at the time of their transition to Humana. A clinical advisor at Humana reviews with the member participating providers, new plan language if applicable, and completes appropriate authorizations. h. Retiree communications regarding change in administrators When new plans are introduced, Humana will meet with the City to develop a transition and enrollment strategy. During the meeting, Humana also provides guidance based on Humana's experience and best practices. Generally speaking, Humana typically recommends sending an announcement letter to the new members on City's behalf. Humana can guide the City in developing the announcement letter and can also mail the letter to the members directly. After the announcement letter is sent, Humana mails enrollment kits to the new members that provide Humana - specific information. Humana also has the ability to offer seminars for members to ask City of Corpus Christi 5 HUMANA. Guidance when you need it most questions and learn more about their new plan. The communication strategy will be developed by Humana and the City to specifically address the City's needs. This strategy can include information about Humana and the transition of care process if desired. 8. Please discuss your process in handling patients that are currently receiving care in a non- network hospital as well as those currently receiving outpatient services. Humana transitions newly enrolled members from another insurance plan to Humana without interrupting a covered medically necessary treatment plan that is currently in progress. By identifying ongoing health issues and necessary medical services, this process assists members in creating a bridge to a network or accepting Medicare provider. Transition of care benefits apply to, but are not limited to, the following conditions: • Member having or who has recently had surgery • Member receiving home healthcare or is under case management from prior insurance • Acute medical conditions in active treatment, such as chemotherapy and radiation To begin the transition of care process, members complete a transition of care form and either fax or mail the request to Humana. Upon receipt, the request is forwarded to Humana's care management team in the member' s region. The care management team's review includes an assessment of the current condition and course of treatment related to the medical needs of members. Should additional information be required, a telephone call is made to the members and/or the attending physician. Once the additional information is received, Humana will reach out to the members and/or provider and facilitate care with the appropriate provider. 9. Provide a plan for continuation of current treatment during transition. Please provide samples of plans you have used for other large employers in your response. New enrollees will complete the transition of care form after they have elected Humana as their insurance carrier. The form can be obtained from their benefits administrator, Humana Customer Care representatives, or during an open enrollment function. The form will be sent to Humana as instructed on the form to the designated address or fax number. An example of a case appropriate for transition of care would be an enrollee who is in treatment for an acute condition by a non - participating provider. According to Humana's transition of care procedures, the member will be allowed to continue treatment with the non - participating provider until the current episode of treatment ends or until treatment has been in place for 90 days. Approval periods for transition of care will be based on a clinical review of the member's case, as well as regulatory guidelines and the member's benefit plan. The following requirements are necessary for the member to begin the transition of care process: • Must be new to a Humana product or has re- enrolled in a different Humana product prior to requesting transition of care. • Must be undergoing active treatment as of the member's effective date of the Humana plan. City of Corpus Christi 6 HUMANA® Guidance when you need it most • Transition of care forms may be submitted for review up to 90 days after the plan effective date. Based on the information provided, the transition of care nurse advisor will make a determination as to whether the member has met the transition of care criteria. If the transition of care criteria are met, an authorization will be issued for a duration of up to 90 days after the effective date unless otherwise specified in regulatory guidelines. The member and provider of service will receive verbal and written communication based on regulatory requirements. Additionally, the letter will inform all parties of the need for care to be transitioned to a participating provider. If additional review is required, the nurse advisor will follow the medical director referral policy. If criteria are not met, the nurse advisor will follow the non - approval requirement policy. Additionally, within 90 days after the effective date, Humana contacts newly enrolled members by phone in order to welcome them to the health plan and conduct a health questionnaire that helps Humana understand their clinical transition needs. Any identified transition needs are passed along to a member of the clinical or behavioral health case management staff, based upon responses to the health questionnaire. A member of the appropriate clinical team will contact the member to follow up on their transition needs following the welcome contact. Authorization of treatments, procedures and services, as well as clinical care coordination, during the transition are arranged by Humana's case management staff based upon the member's particular health needs and benefit coverage under their new benefit plan. 10. Can your system automatically edit for age triggers, requiring a plan change upon attainment of age 65 or Medicare Eligibility? Yes, Medicare coordination of benefits information is requested by Humana's claim system after a member reaches age 65. 11. Does your system allow automatically for split family administration between Non Medicare and Medicare Eligible family members? Describe how a Non Medicare Eligible Family transitions into Medicare Eligible membership at carious points in time and the impact on accumulators and premiums. Yes, Humana's system can administer split family enrollment for Medicare Advantage retirees and their non - Medicare eligible dependents. Both the retiree and the non - Medicare eligible family member receive individual ID cards in their own name when one enrolls in a Medicare Advantage plan and the other a commercial plan. The Medicare Advantage member and the commercial member are assigned different customer numbers, which are reflected on the ID cards. The Medicare Advantage member and the commercial member are billed separately for their coverage. Each non - Medicare- eligible family member is associated with the retiree's social security number for tracking purposes. For premium and eligibility reporting purposes, the non - Medicare family member has their own contract, identifiable by their individual social security number. The Medicare Advantage member is billed separately from the commercial member. Administrative costs for split billing are included in the premium quoted for the City. City of Corpus Christi 7 HUMANA. Guidance when you need it most Humana's claim and eligibility system automatically detects if a pre -65 member is approaching the age of 65. Humana mails Medicare Advantage applications to members who are approaching age 65. After completing the applications, the members are enrolled in Humana's Medicare Advantage plan. Their accumulators are adjusted to the new plan. If the City uses an EDI file as its enrollment method, Humana can automatically enroll members in the Medicare Advantage plan. If this is requested by the City, Humana would set up the account to include indicators in Humana's claim system that would identify members who have turned 65 and have enrolled in Medicare Parts A and B. Premiums for members who switch from the pre-65 commercial plan to the Medicare Advantage plan during the year will be adjusted based on the new plan. 12. Provide a detailed implementation timetable, including an outline of the activities you expect to be performed prior to the stated effective date, completion dates, and the individuals or groups who will have major responsibility for each activity must be provided, including: • Contracts completed • Banking arrangements established • Customer service toll -free phone line operational • ID cards mailed to retirees • Electronic access established with the City • Program operational and ready to deliver benefits to members • Summary Plan Documents • Welcome packets • Sample ID card • Samples of communication materials (i.e. benefit summary documents distributed to members). • Samples of retiree communication materials on use of the network, utilization review, etc. • Sample claim forms. • Sample copy of standard EOB (explanation of benefits) form. Humana takes an all- inclusive, project management approach toward account implementation. This approach properly aligns Humana's substantial resources around the City's specific needs. Each new group implementation begins with the formation of an implementation strategy team. The team will work together to ensure a thorough and seamless implementation. The team is specifically responsible for: • The Member Experience • The Client Experience • The Post Enrollment Experience When the City chooses a Humana Group Medicare plan, it will have a dedicated Humana account installation manager, Janelle Cain, who will serve as a single point of contact for the group during implementation. Not only does the account installation manager act as the single point of contact through the implementation, but continues to service the City throughout the life of the account. Please refer to Attachment G for a detailed implementation timeline including each activity listed above. City of Corpus Christi 8 HUMANA Guidance when you need it most B. Centers of Excellence - Networks 13. Do you have a network of Centers of Excellence? Yes, Humana offers a National Transplant Network to members requiring high -cost, highly specialized transplant procedures. Humana evaluates and selects specific transplant programs to participate in this network based upon the program's ability to meet outcomes criteria. Contracts are negotiated with leading transplant centers that are strategically located to best serve Humana's plan members. 14. Indicate high -risk and high technology services coordinated with the Centers of Excellence. Humana offers a National Transplant Network to members requiring high -cost, highly specialized transplant procedures. Humana evaluates and selects specific transplant programs to participate in this network based upon the program's ability to meet outcomes criteria. Humana's National Transplant Network includes the following Texas facilities and procedures: • Seton Medical Center in Austin: Heart Transplants • Baylor Medical Center in Dallas: Stem Cell, Heart, Lung, Kidney, Pancreas, Liver • Children's Medical Center of Dallas: Stem Cell, Heart, Kidney, Liver • Medical City in Dallas: Stem Cell, Heart • Methodist Hospital of Dallas: Kidney, Pancreas, Liver • St. Paul University Hospital in Dallas: Heart, Lung • Zale Lipshy Univeristy Hospital in Dallas: Stem Cell • Baylor All Saints Hospital in Fort Worth: Kidney, Liver • Cook's Children's Hospital: Stem Cell • M.D. Anderson in Houston: Stem Cell • Memorial Hermann Hospital in Houston: Kidney, Liver • The Methodist Hospital in Houston: Stem Cell, Kidney, Pancreas, Liver • St. Luke's Episcopal Hospital in Houston: Heart, Liver • Texas Children's Hospital of Houston: Stem Cell, Heart, Lung, Kidney, Liver • Christus Santa Rosa in San Antonio: Kidney, Pancreas • Methodist Specialty and Transplant Hospital in San Antonio: Heart, Kidney, Pancreas, Liver • Texas Transplant Institute in San Antonio: Stem Cell • University Hospital in San Antonio: Kidney, Liver a. Bone Marrow transplants Humana's transplant program includes Centers of Excellence facilities for bone marrow transplants. b. Heart transplants Humana's transplant program includes numerous Centers of Excellence facilities for heart transplants. City of Corpus Christi 9 HUMANA. Guidance when you need it most c. Lung transplants Humana's transplant program includes numerous Centers of Excellence facilities for lung transplants. d. Kidney transplants Humana's transplant program includes numerous Centers of Excellence facilities for kidney transplants. e. Other transplants (please specify) Humana's transplant program includes Centers of Excellence facilities for stem cell, pancreas, intestinal, and liver transplants. f. Cancer Humana provides cancer management through its cancer disease management program. In addition, Humana is currently developing a Centers of Excellence program for cancer treatment. Neonatal Critical Care Humana's Centers of Excellence program includes transplants and does not include neonatal critical care. Please note that neonatal care is not applicable to Humana's Medicare Advantage plans. g. h. HIV Humana's Centers of Excellence program includes transplants and does not include treatment for HIV. Members with HIV are managed through the Humana Cares complex case management program. i. Joint Replacement Humana's Centers of Excellence program does not include joint replacement treatment. j. Cardiac Surgery and Interventional Cardiac procedures Humana's Centers of Excellence program includes facilities for heart transplants only. k. Other non - transplant procedures (please specify) Humana's Centers of Excellence program is focused on transplants only. City of Corpus Christi 10 HUMANA€ Guidance when you need it most Complete the following table for your top five (5) Centers of Excellence by volume. The top five Centers of Excellence transplant facilities by volume are provided below. Lexington, Kentucky 15. Are there a selection criteria or prior authorization processes to gain access to the centers? Humana members are referred to the transplant management program from a number of sources, including the following: • Transplant centers • Attending physicians, including primary care physicians • Member self - referral • Management service organization/independent practice association groups • Utilization management nurses • Personal Nurse® service • Catastrophic case management nurses • Disease management vendor staff • Customer Care representatives • Account management staff These sources work together to notify the plan of a transplant patient. 16. How are these members case managed (i.e., Are they handled in a unit separate from other catastrophic cases ?)? Humana offers a transplant- specific case management program for transplant program participants. Once a member is referred to a transplant center, a transplant clinical advisor (RN) is assigned and continues to work with that member throughout the transplant procedure and hospital stay. The transplant clinical advisor is available to assist with any discharge needs and continues to follow the member concurrently, for transplant - related purposes, for one year post - transplant. 17. Will there be any changes in the coming year to your current Centers of Excellence arrangements? Humana does not anticipate any changes in its National Transplant Network arrangements within the next year. City of Corpus Christi 11 Hospital Jackson Memorial Hospital Miami, Florida 1993 Hospital Jewish Hospital Louisville, Kentucky 1997 Hospital Froedtert Memorial Lutheran Hospital Milwaukee, Wisconsin 1993 Hospital M.D. Anderson Cancer Center Houston, Texas 1995 15. Are there a selection criteria or prior authorization processes to gain access to the centers? Humana members are referred to the transplant management program from a number of sources, including the following: • Transplant centers • Attending physicians, including primary care physicians • Member self - referral • Management service organization/independent practice association groups • Utilization management nurses • Personal Nurse® service • Catastrophic case management nurses • Disease management vendor staff • Customer Care representatives • Account management staff These sources work together to notify the plan of a transplant patient. 16. How are these members case managed (i.e., Are they handled in a unit separate from other catastrophic cases ?)? Humana offers a transplant- specific case management program for transplant program participants. Once a member is referred to a transplant center, a transplant clinical advisor (RN) is assigned and continues to work with that member throughout the transplant procedure and hospital stay. The transplant clinical advisor is available to assist with any discharge needs and continues to follow the member concurrently, for transplant - related purposes, for one year post - transplant. 17. Will there be any changes in the coming year to your current Centers of Excellence arrangements? Humana does not anticipate any changes in its National Transplant Network arrangements within the next year. City of Corpus Christi 11 HUMANA® Guidance when you need it most C. Medical Claims Administration 18. Explain payment process to In- network hospitals, group practices, primary care physicians and specialists, along with the claims handling procedures. In- network providers are reimbursed according to the payment terms specified in their contract. Contracts are normally based on industry standards such as Medicare's Resource Based Relative Value Scale. Provider discounts and payment terms are loaded in Humana's automated claim system, which allows the claim system to automatically apply provider - specific discounts when processing claims. 19. Explain payment process to Out -of- network hospitals, group practices, primary care physicians and specialists, along with the claims handling procedures. Out -of- network services are processed and reimbursed according to each member's specific plan design for those services. Claims are processed according to service codes without any additional discount, and providers are reimbursed based on the coinsurance of the associated plan design. 20. What is the standard turnaround time for making payments to: a) hospitals, b) physicians and c) members? Checks for reimbursement to employees and non - network providers are released during a nightly batch claim reimbursement process. Network providers are generally reimbursed by weekly vouchers. However, a provider's contract may stipulate more or less frequent reimbursement. Humana's internal goal for processing and paying claims to providers and hospitals is to process 90 percent of clean claims within 14 days. To monitor and manage claim inventory turnaround time, Humana's Claim Operations area utilizes a Web -based application maintained by Humana's Finance department. This application contains both inventory levels as well as claim aging and receipt information. Cycle time reports are also reviewed on a monthly basis, ensuring Humana is meeting its internal cycle goals as well as the goals associated with performance guarantees provided to specific employer groups. When applicable, member reimbursement checks are typically issued on a biweekly basis and are sent directly to the members' homes. 21. How are complaints handled from members who receive collection agency or late payment notices when the covered charges are clearly the responsibility of the plan? If members receive unexpected balance bills from Humana that they believe should have been paid by Humana or the provider, those members are encouraged to contact customer service. Humana's Customer Care representatives are available to identify the reason for the balance bill and provide assistance in resolving the issue. In the event that a complaint regarding unexpected charges has not been settled at the informal level and the member is dissatisfied, the member is provided his or her appeal rights. Humana will accept and City of Corpus Christi 12 HUMANA. Guidance ance when you need it most process any oral or written appeal from a member or an authorized representative expressing dissatisfaction with Humana's adverse determination. Appeals should be submitted within 60 calendar days of receipt of a final adverse determination. The member or member's representative has the option to submit supporting documentation, such as issues, comments, documents, records, or other information that should be considered during the review. This information becomes part of the file. Written acknowledgment will be issued upon receipt of the appeal to the member within 15 calendar days. The appeal is investigated and a written response is sent to the member no later than 30 calendar days for medical necessity issues and 60 calendar days for contractual issues. 22. How will subrogation rights be communicated to the participants? Please provide a flowchart to explain the process. When a member incurs a large claim that should be covered by other insurance, such as automobile insurance, Humana contacts the member to gather details about the claim. If the member's treatment should be covered by a carrier other than Humana, Humana obtains detailed information about the claim from the member and provides the claim event number to the member for his or her records. Humana then proceeds with its subrogation process to collect the appropriate payment from the correct insurance carrier. Please refer to Attachment H for a flowchart of Humana's subrogation process. 23. What is your definition of a "paid" claim, a "clean" claim, a "suspense or pending" claim? Please state the time frames it will require to process the claims proposed for each of the types mentioned. If additional types exist, please list them and state the time frames for processing those types of claims. Humana's definition of a "paid" claim is one that has been received, processed, and a payment has been issued to the provider or facility. A "clean" claim is a claim that does not require additional information and can be processed as is. "Processed" means that a claim has been paid or denied without requiring additional information from an external source. Humana' s performance standard goal is to process 90 percent of all clean claims within 14 calendar days. On the Humana claim system, when a claim with inaccurate or missing information is received, the claim is considered to be a "pended claim." For pended claims, the claim adjuster first attempts to locate the necessary information by researching the claim history. Depending on the information required, Humana contacts the provider or the member. Humana maintains a daily report that reflects the aging of pended claims. If the necessary data is not obtained within an appropriate time frame, the claim is denied, and an Explanation of Benefits is sent to the member. Humana follows the state and federal mandates pertaining to sending acknowledgment letters and delay letters. Typically, if a claim requires additional information to be processed, the letter must be sent within 15 days. Acknowledgment letters are sent if a claim has not been paid within 10 days. City of Corpus Christi 13 HUMANA. Guidance when you need it most 24. Describe the claims filing procedures proposed. Providers may submit claims to Humana electronically, online, or in paper form. Providers have a number of options for submitting claims electronically. While Humana has identified Availity LLC as its central gateway for EDI transactions, providers can still submit to a variety of clearinghouses, which include: • Availity • Emdeon (previously WebMD) • ENS • McKESSON • Medifax • Nebo • NDC Health • PerSe • Proxymed • SSI Group • THIN • ZirMed Humana.com, through a relationship with ZirMed, can also support electronic submission needs. Registered users can access the Claim Management Center within the Humana Website, Humana.com self - service center and submit Humana claims at no cost to the physician or provider. Paper claims are processed through an agreement between Humana and Affiliated Computer Services, Inc., (ACS) located in Lexington, Kentucky. ACS converts these paper transactions into electronic data files and images where they are then processed electronically by Humana. 25. How are usual and customary professional fees profiles established and maintained? Reasonable and customary allowances are used when a maximum allowable reimbursement is not available. A dollar conversion factor is developed for each predefined area (e.g., Louisville, Miami, San Antonio, etc.), and code series (e.g., medicine, surgery, lab, radiology, evaluation and management, etc.). The unit values are multiplied by the developed dollar conversion factor to determine the dollar allowable for each CPT code. Humana uses an industry standard relative value system, such as McGraw -Hill, and purchases Prevailing Healthcare System (PHCS) formerly the Health Insurance Association of America, also known as Ingenix, and MDR (Medicode) from Ingenix. How often are profiles updated? Medicare schedule updates occur at the beginning of the year. What percentage of claims are accepted without reduction? Humana will require further clarification of this question in order to provide a response. City of Corpus Christi 14 HUMANA. Guidance when you need it most Do retirees become responsible for payments which exceed reasonable and customary charges? For participating providers, Humana's agreement requires the provider to accept the contracted rate along with any copayment, coinsurance, deductible, and other cost shares for covered services as payment in full. For non - participating providers, the excess charge above the maximum allowable fee may, at the provider's discretion, be charged to the patient. These fees are typically charged according to the member's out -of- network plan benefits. 26. Describe how your claim system interfaces with your utilization review program. Humana's claim, customer service, utilization review, and medical management systems are fully integrated applications that share common files and common data coding standards. These applications are capable of the following: • Supporting electronic enrollment, claims /encounters, and referrals • Interpreting participant eligibility • Identifying duplicate claims • Assessing reasonableness of charges • Automatically applying correct provider reimbursement methodologies • Distinguishing participating from non - network providers • Interpreting covered versus non - covered benefits • Applying pre- existing exclusions • Determining medical appropriateness • Recognizing upcoding and unbundling practices (and automatically re- bundling) • Investigating coordination of benefits • Detecting fraud and abuse • Researching potential Medicare/Medicaid eligibility issues • Assessing subrogation opportunities • Applying penalties for non - compliance with medical management rules • Applying a variety of cost sharing and other benefit calculations • Storing and centralizing data that Customer Care representatives can use to answer questions from members and providers 27. In what manner does your claims system handle the following? (Indicate whether process is automated or manual.) The claim system provides instant access to Humana's complete up -to -date insurance claim files. When a claim adjuster enters claim information, charges, and instructions into a terminal, the computer audits the information, subtracts proper deductible or copayment amounts, calculates the payment amount, and updates the claimant's history. a. Accumulation of deductibles The accumulation of deductibles is automatically processed on Humana's claim system. City of Corpus Christi 15 HUMANA® Guidance ance when you need it most b. Co- payments Copayments are automatically processed on Humana's claim system. c. Benefit dollar limits Benefit dollar limits are automatically processed on Humana's claim system. d. Benefit service limits Benefit service limits are automatically processed on Humana's claim system. e. Lifetime limits Lifetime limits are automatically processed on Humana's claim system. f. Scheduled benefits Scheduled benefits are automatically processed on Humana's claim system. g. Co- insurance at various levels for in and out -of- network claims Coinsurance is typically processed automatically on Humana's claim system; however, some coinsurance levels require manual intervention. h. Out -of- pocket maximums for in and out -of- network claims Out -of- pocket maximums are automatically processed on Humana's claim system. i. Coordination of benefit claims Coordination of benefits claims are automatically processed on Humana's claim system. Subrogation claims Upon identification, subrogation claims are manually processed on Humana's claim system pending subrogation investigation and resolution. k. Duplicate claims Humana's claim system automatically identifies duplicate claims. Duplicate claims are typically processed automatically; however, manual intervention may be required. City of Corpus Christi 16 HUMANA. Guidance when you need it most 28. Describe the process by which network, out -of- network, and out -of -area claim services are adjudicated from the date the service is rendered in a provider's office or facility to the date of payment. The majority of the claims submitted to Humana are paper claims. The following process applies for all paper claims, including in- network, out -of- network, and out -of -area claims: Paper claims are mailed directly to Humana's vendor, Affiliated Computer Services, Inc. (ACS), in Lexington, Kentucky, where the claims are sorted and prepared for imaging. Once scanned, each claim is assigned a document control number and undergoes a scanning quality check. The claim is then forwarded to Optical Character Recognition or manual data entry. ACS enters missing data and performs additional quality checks on the claim. At this point, all paper claims have been electronically scanned. All scanned paper claims and claims that were originally submitted to Humana electronically are then electronically transferred within 24 hours to the appropriate Humana customer service center. Humana's claim system automatically performs a claim edit to screen for issues such as duplicate charges, missing statistical data, dependent child age, exhausted benefits, coordination of benefits, invalid procedure codes, procedure and diagnostic conflicts, and charges incurred after the termination date of coverage. The system identifies billing errors, excessive billing, fragmented billing, unbundling, incidental procedures, procedures specific to age and/or gender, and cosmetic procedures. The claim system automatically rebundles and corrects the claim, if necessary. When the claim reaches this point, it is paid, pended, or rejected. If the claim is pended, the claim adjudicator reviews the claim and either resolves the issue or denies the claim. An explanation is sent to the member and the provider. The claim data history is stored into Humana's online claims system for up to 24 months and then archived for several years. Please refer to Attachment I for a flowchart of Humana's claim processing procedures. 29. What percent of claims are automatically adjudicated? In 2008, 82.6 percent of claims were automatically adjudicated by Humana's claim system. 30. What percentage of claims that are submitted on paper are electronically scanned into your processing systems? All paper claims are electronically scanned by Humana's vendor, ACS, and are sent to the claims system for processing. 31. Describe how your system handles eligibility changes for retirees and dependents (including coordination of benefits information, student status and disabled dependents). Explain the process of verifying the status of disabled dependents. Eligibility data is entered by hard copy or by electronic transfer and maintained online. The file contains name, address, date of birth, relationship, sex, Social Security number, marital status, customer number, subgroup number, student or disability status, hire date, effective date, and market identification number. City of Corpus Christi 17 HUMANA. Guidance when you need it most Humana requires that coordination of benefits (COB) information be entered into the Humana claim system upon receipt by date. The existence of other coverage is a required field in Humana's claims processing system, and must be updated at each individual member's group renewal date. If the field indicator is blank, the claim is pended, and the member is contacted to obtain an answer as to the existence of other coverage. The COB information field is referenced whenever a claim is presented for payment. The date field alerts the examiner to request information if the member's group renewal date has passed. The claim is pended according to ERISA guidelines until updated information is received. The eligibility file is updated anytime there are additions or terminations within the group or if there is a change in a member's data. Upon receipt of information indicating that a dependent is handicapped, Humana's Billing and Enrollment department initiates an outbound letter to the subscriber requesting documentation supporting or verifying that the child is indeed handicapped. Member records and eligibility are updated based upon the information received. If the requested documentation is not received and the child exceeds the maximum dependent age, the dependent child is termed from the subscriber's policy due to failure to provide the requested verification documentation. Verification is sought only when a member indicates a change in dependent child status. There is no proactive "annual" certification or recertification process but Humana reserves the right to recertify annually if deemed necessary. Please note that student status verification does not apply to Medicare Advantage plans because Medicare Advantage is only available to post -65 retirees, post -65 dependents, and disabled members. 32. Describe your appeals process in the plans offered. Please provide a flowchart of your standard appeals process. An overview of Humana's general Medicare Advantage grievance and appeals procedures is given below. The time period and language presented are those most commonly used in its standard contracts. The Evidence of Coverage issued for the City contains the exact coverage and should be examined in detail. Filing a Complaint If a member has a complaint regarding plan administration or the quality of care received, he/she should call Humana at the telephone number referenced on the member identification card. Most problems are resolved in this manner. If the complaint cannot be resolved during the telephone conversation, the plan provides a resolution within 30 calendar days. Filing a Grievance If the member's complaint has not been resolved by a telephone conversation (and does not involve a denied claim or service), the member may file a grievance in writing. If the problem involves a denied claim or service, the appeals process should be followed. City of Corpus Christi 18 HUMANA Guidance when you need it most Grievances may be filed if the member is dissatisfied with: • The quality of care received • Involuntary disenrollment • Administrative procedures • The denial of any services /claims that cannot be appealed through the appeals process Grievances must be submitted within one year of occurrence. For members' convenience, grievance forms are available in the new -member orientation packet as well as from customer service. Grievances must contain the following information • Name, address, and member identification number • A summary of the grievance, any previous contact with us, and a description of the relief being sought • The member's signature or that of an authorized representative • The date the grievance is signed Upon completion, the information should be mailed to the attention of the grievance manager at the address in the member's Evidence of Coverage. The grievance is acknowledged within five working days and is investigated by the grievance manager, who notifies the member in writing of a decision within 30 calendar days following receipt of the grievance. Please refer to Attachment J for Humana's Medicare appeal flowchart. 33. Is there a contingency plan(s), procedure, and system in place to provide backup service in the event of strike, natural disaster, or backlog? Humana has a Disaster Recovery Program in place. Humana uses a variety of technical recovery strategies including tape backup, data replication, and disk -to -disk backups based upon the urgency of the application data and recovery time objective. For claims processing after a natural disaster, Humana would assess the situation and create a team of individuals to address the issues that arise from a natural disaster (e.g., paying in- network benefits at out - of- network facilities). Given the extent of the disaster and the involvement of the regulatory authorities, the team would make recommendations on how to proceed. These recommendations would be reviewed and approved by senior leadership, and Humana would then put its plan into effect. D. Quality Control 34. Describe your policy and procedures for auditing hospital bills/claims. Humana performs hospital bill audits, which are included as a service under this proposal. Trained claim personnel in the Fraud and Abuse unit and the Financial Recovery unit identify for in -depth claims scrutiny those providers who consistently overcharge or perform unnecessary procedures. These teams use a variety of complex'methods to identify offenders. These methods include, but are not limited to, ad hoc reports, provider trend analyses, and personal referrals or tips. The plan has a strong commitment to detect, investigate, and seek prosecution against any individual who perpetuates fraud against Humana policyholders. In order to achieve its goals, Humana has trained claims personnel on the detection of City of Corpus Christi 19 HUMANA. Guidance when you need it most potential fraud and abuse and has established internal audits to monitor personnel activities to properly identify fraudulent claim situations. 35. Overall, what percent of claims are subject to internal audit? All claims processed by Humana are eligible to be selected for an internal claim audit. Humana's prepay audit process generally reviews between 1.5 percent and 2.0 percent of claims monthly. Errors are identified, categorized, and trended in order to examine root causes and make process improvements. In addition to the "end to end" auditing performed by the National Quality Audit area, auditors perform a minimum of 10 to 25 audits per month for each adjuster as part of the performance management audit. These audits are performed daily for monthly results which are reported on monthly associate scorecards and are part of the associate's annual performance. In addition, all claims exceeding $75,000 are audited by giving special temporary security access to a seasoned claim staff member. Before the claim specialist can release the claim, the claim is reviewed by the supervisor for accuracy. In addition, Humana also utilizes a systematic prepay process. This process allows certain claim types and claims with specific pay out ranges to be reviewed a final time before the check is issued. While all claims are subject to an internal audit, approximately three to four percent of all claims are officially audited through one of Humana's internal audit procedures. 36. How frequently are external audits performed? Humana's external auditor, PricewaterhouseCoopers, LLP, conducts service audits in accordance with the Statement on Auditing Standards No. 70, "Reports on the Processing of Transactions by Service Organizations" (SAS 70). The SAS 70 audits are conducted twice a year, one covering the period of April 1 through September 30 and another covering the period of October 1 through March 31, with the results available to self - funded client groups on an ongoing basis. In addition, Humana's service centers are frequently audited by various government organizations such as the Centers for Medicare & Medicaid Services, state departments of insurance, and consulting firms. 37. Overall, what percent of claims are subject to external audit? External audits are conducted as service audits as opposed to claim audits. Humana's external auditor, PricewaterhouseCoopers, LLP, conducts service audits in accordance with the Statement on Auditing Standards No. 70, "Reports on the Processing of Transactions by Service Organizations" (SAS 70). Humana also provides the right to its customers to conduct audits. Humana permits either one desk audit or one onsite claims audit during any 12 month period. Generally, Humana compiles documentation for a sample of claims, and a limited system access for those claims provided. For an onsite audit, Humana can provide up to four associates to assist the auditors with system navigation, questions, and any other reasonable needs for a one week period. Business -wide external claim audits are not conducted. City of Corpus Christi 20 HUMANA. Guidance ui dance when you need it most 38. What process or systems edits do you have for identifying potential hospital/provider related negative outcomes, i.e. medical malpractice? Typically, suspicious claim activity or inappropriate treatment patterns are identified through Humana's claim system triggers. These claims are pended for review. At this point, the claim is investigated and is approved or denied. In some instances, these claims are sent to Humana's special investigations unit to ensure the provider is providing appropriate treatments and is not attempting claim fraud. Humana's special investigation unit is responsible for the investigation of potentially fraudulent matters or claims that indicate unnecessary treatment. Referrals are received from internal and external sources. Once a potential fraudulent matter is presented to the unit, it is the responsibility of the special investigation team to obtain information surrounding the allegation. Humana utilizes a number of systems in the identification process to assist the unit. The unit is responsible for examining the matter and determining the validity of a charge. Although the area is not involved in determining medical necessity and coding issues, the unit becomes involved if a pattern develops and appears to be a continuing problem with a provider, which subsequently must be referred to a regulatory/law enforcement agency. 39. Describe your policies and procedures for detecting and investigating potential fraudulent claims. Humana maintains a highly skilled staff that pursues claim fraud investigations on its behalf. This special investigations unit is responsible for detecting, investigating, and seeking prosecution against those who perpetrate fraud against Humana. Humana's objective is to investigate all complaints or suspicions seriously and to investigate them to the fullest extent to prove or disprove any accusations. The special investigations unit is notified of potential claim fraud in a variety of ways, including by the FBI, other insurance carriers, Humana members, and other branches of law enforcement as well as via analysis of Humana's database. Humana also has a variety of automated system tools which facilitate fraud detection and aid in investigative follow -up. When the special investigations unit receives notice of possible claim fraud, the investigators gather information, conduct interviews with Humana members and/or providers, review records and claims, and make a recommendation on how the claim should be processed. The special investigations unit works to resolve the problem by contacting the providers and following up to ensure that the recommendations have been implemented. In addition, the unit also complies with state anti -fraud requirements and reports "suspected" fraud to the appropriate law enforcement agencies. Human's Special Investigations Unit has implemented a fraud hotline for members to utilize if they suspect fraud, waste, or abuse. The toll -free hotline number is 800- 614 -4126. The hotline number is listed in all EOB, Explanation of Remittance, and Smart Summary statements. In addition, the toll -free number is listed on Humana.com under the Fraud, Waste, and Abuse web link. Humana's Fraud, Waste, and Abuse group is also trained yearly in mandatory ethics training. New Humana associates are trained within 30 days of hire. Part of the training consists of "Red Flag Indicators" which trains the associates how to identify potential fraudulent or wasteful claims. Additional training is available upon request by the internal department. City of Corpus Christi 21 HUMANA. Guidance when you need it most 40. What safeguards and provisions are in place to safeguard against "balanced billing "? A hold harmless clause is part of the contractual agreement signed by a network provider and prohibits providers from balance billing for any unpaid amounts for covered services for eligible members, other than any coinsurance, copayments, and deductibles. If a member receives a balance bill from a contracted provider for an amount other than the copayment or coinsurance amounts, excluding non - covered services, the member should contact the customer service center for assistance. Customer Care representatives can resolve issues with the providers' offices to ensure members are not held financially responsible for amounts not designated as "member responsibility." In the event that a trend is identified with a specific provider, the market -level provider relations department is contacted for intervention with the provider office. 41. Describe the procedures for preventing and monitoring creative billing, up- coding, unbundling, etc. Code editing software has been integrated into the claim system and is invoked automatically as part of the prepayment edit process. The system process identifies coding and billing errors including excessive billing, fragmented billing, unbundling, incidental procedures, incorrect use of codes for procedures specific to age and/or gender and cosmetic procedures. In most cases, the claim system automatically rebundles, corrects, or denies incorrect billings. The claim adjusters see these edits as the claims are processed online. In those instances where additional follow -up is needed, the system or adjuster flags the claim for manual review. When necessary, the Special Investigations department pursues providers suspected to be abusive. This unbundling software is invoked systematically whenever a service is billed using standard procedural terminology (CPT -4, HCPCS, ICD9) codes (e.g., physician claims). The logic is updated regularly to reflect changes in the code sets. 42. What services are available to assist retirees on disputes with providers? Members should contact Humana's customer service for assistance at 800 - 457 -4708 if they receive a balance bill from a contracted provider for an amount other than the copayment or coinsurance amounts (excluding non - covered services or in an instance wherein plan guidelines have not been met, e.g., if a referral has not been received). Members may also call customer service for any disputes. In some instances, the Customer Care representative may contact Humana's provider relations associate for the applicable market, who will then contact the provider to resolve the issue. Once the member contacts customer service, a Customer Care representative attempts to resolve the issue with the provider's office to ensure that the member is not held financially responsible for any amount not designated as "member responsibility." If providers believe they are not contractually obligated to write off the balance of charges above the contracted allowable amount, their disputes are addressed by Humana's Provider Affairs Complex Resolution unit. The Provider Affairs unit becomes involved if a balance billing trend is identified with a specific provider. City of Corpus Christi 22 HUMANA. Guidance when you need it most E. Medical Management 43. Do you have a full -time medical director on staff for this area's network? Yes, Scott Weston, M.D., is the medical director for South Texas. Dr. Weston is a full -time Humana employee whose role includes only medical director responsibilities. 44. Describe the medical director's roles and responsibilities, in particular how it applies to utilization management and percent of time allocated to each responsibility. Humana's medical directors' responsibilities include reviewing preauthorization requests, addressing clinical concerns of select hospitalized members, analyzing utilization data to identify clinical concerns and cost drivers, assisting in quality improvement efforts, assisting in peer reviews, and providing administrative support for the Health Services Department. The allocation of each task is outlined below: • 45 percent of time spent in reviewing referral requests (for acute rehab hospitalization, long -term acute care hospitalization, continued stay in skilled nursing facilities, and for designated outpatient procedures) for medical necessity and coverage; addressing clinical concerns on hospitalized members (as identified by hospital liaison nurses) or long term case management members • 25 percent of time spent analyzing utilization data to identify and address clinical concerns and major cost drivers • 20 percent of time spent on quality improvement, peer review, and network physician relationships and education activities • 10 percent of time spent on administrative support and staff development for the Health Services Department 45. Identify the procedure(s) used to handle after -hours calls to the medical management department. Humana offers HumanaFirst®, a 24- hour -a -day, seven -day -a -week, telephonic nurse triage and health planning service. Humana provides a toll -free HumanaFirst number to members on the reverse side of their ID cards. HumanaFirst provides an easy way for members to receive assistance in selecting the right care at the right time. HumanaFirst is offered to the City's retirees at no additional cost. In addition, Humana has implemented an interactive voice response line for use by network providers to accommodate after -hours calls. The automated authorization line is available 24 hours a day, seven days a week to physicians and facilities. The interactive voice response system is a fast and efficient way to initiate preauthorization requests and admission notifications for inpatient hospital, skilled nursing, acute rehabilitation admissions, and 23 -hour observations. Status checks on existing authorizations can also be accessed through the interactive voice response system. City of Corpus Christi 23 HUMANA. Guidance when you need it most 46. Describe how utilization review services are provided. In- house? Contracted (please provide the name of the vendor)? Humana provides all utilization review administration internally. Humana performs the following utilization management services for its Medicare Advantage members: Prospective Management Prospective management applies to a selected set of inpatient, ambulatory, and procedural services. The selected set of services requiring prospective management has been identified by Humana's corporate medical leadership. The member's physician provider is responsible for initiating a prospective request for services. The provider is afforded several methods of obtaining an authorization: telephonically, through interactive voice response, fax, or via Human's provider portal Internet site, at Humana.com. Discharge Planning Timely and appropriate discharge planning is an essential component of both the concurrent and case management processes. The utilization management nurse and case manager (if member has participated in case management previous to admission, the case manager works with the utilization management nurse on discharge planning during hospitalization), collaborates with the attending physician, the primary care physician, the member and/or the member's family, and the facility's discharge planning staff to facilitate a smooth transition to the appropriate next level of care. While most of Humana's nurses work with facility discharge planning staff and providers telephonically, Humana's case managers and utilization staff have access to medical records for all members. This access to medical records ensures a safe and efficient transition of care planning process for the member and member's family. Following discharge from an inpatient facility (i.e.: hospital, long term acute care facility, skilled nursing facility, rehabilitation center), a member of the regional case management/utilization management team places a call to the member to ensure the following items are in place: • Member received discharge instructions and fully understands their post - discharge care • Member is in a safe environment with support system in place; if there are concerns that member may not be safe or further evaluation is needed, a field care manager would be sent to the member's home • Member was able to obtain all post - discharge medications and understands how to take them, is able to identify side effects and complications, and knows when to report concerns; if there is concern that member does not understand medications, a field care management visit is requested. Additionally, if the member cannot afford medications, the case management team works with the member on obtaining medications from community resources, pharmaceutical companies or contacts the physician's office for assistance • Member's caregiver /support system is in place and able to adequately provide post- discharge support for member • If home health services, durable medical equipment, etc. were ordered at discharge, case manager ensures that all appropriate services are in place • Follow -up doctor's visits and outpatient care is arranged according to post- discharge instructions; • Assesses member for any complications or new problems since arriving home that should be reported to physician • Member is educated on their new conditions and post - discharge care, as well as understands how to report any complications to their physician, and when to seek medical care (ie: when it is appropriate to go to the emergency room, call their physician, etc.) City of Corpus Christi 24 HUMANA® Quid anc a when you need it most • Assesses for behavioral health needs, such as depression or anxiety, following the inpatient stay and refers to the Integrated Medical Behavioral Health program as appropriate • Addresses any other outstanding issues to ensure member is safe and well cared for in their post - discharge location. The goals of the discharge planning program are to avoid readmissions and unnecessary emergency room visits, ensure member is in a safe environment and receiving the care they need, coordinate any medical services that are still needed or unaddressed, and educate members on the types of things they need to know and do to avoid complications. Following the post- discharge call and assessment of needs, the case manager or utilization management nurse follows up with the physician regarding any concerns and continues to assist with coordination of care activities. Additionally, the case manager or utilization management nurse assesses whether or not the member has ongoing case management needs that may require further intervention and follow -up, including assessing the need for a field care manager home visit. If a member is found to have any ongoing health needs, they are scheduled for appropriate follow up with a case manager, and contacted accordingly. Retrospective Review Retrospective review is the process of reviewing medical services and/or claims after the service has been initiated. The process focuses on services without valid authorizations. Licensed nurse reviewers may request operative notes or medical records as needed to perform retrospective review. When criteria have not been met, the case is referred to the medical director /physician designee for review and determination of appropriateness. Denials are only made by the medical director /physician designee and result in a denial letter being sent to the practitioner /provider and member. Retrospective reviews and submission of denial notifications are performed within the timeliness standards set by the Plan following submission by the provider. The medical director /physician designee may refer a case to a like - specialty, extemal review agent for direction in making his/her determination. Humana performs this review automatically; however CMS does not require it. 47. Are any utilization review or case management functions delegated to participating provider groups? If yes, please specify groups. Humana does not delegate any utilization review or case management function to network provider groups. Humana's utilization review and case management areas perform these functions. 48. If there is more than one utilization review vendor, how will the services and information be integrated and tracked to ensure consistent application of the health plan's utilization review? This is not applicable since Humana does not utilize a utilization review vendor. City of Corpus Christi 25 HUMANA. Guidance when you need it most 49. How are utilization review and pre - certification information coordinated with the claim administration department? Humana's claim, customer service, and medical management systems are fully integrated applications that share common files and common data coding standards. These applications are capable of the following: • Supporting electronic enrollment, claims/encounters, and referrals • Interpreting participant eligibility • Identifying duplicate claims • Assessing reasonableness of charges • Automatically applying correct provider reimbursement methodologies • Distinguishing participating from non - network providers • Interpreting covered versus non - covered benefits • Applying pre- existing exclusions • Determining medical appropriateness • Recognizing upcoding and unbundling practices (and automatically re- bundling) • Investigating coordination of benefits • Detecting fraud and abuse • Researching potential Medicare/Medicaid eligibility issues • Assessing subrogation opportunities • Applying penalties for non - compliance with medical management rules • Applying a variety of cost sharing and other benefit calculations • Storing and centralizing data that Customer Care representatives can use to answer questions from members and providers 50. Describe the process and criteria used for hospital pre - certification. a. Please note whether surgical procedures are authorized on medical necessity or place of service. Surgical procedures are authorized based upon medical necessity review. b. If based on medical necessity, describe how the guidelines were developed, for how many procedures guidelines exist, and what percent of requested procedures did not meet the guidelines in 2008? For Medicare Advantage members in non -HMO products, precertification is only required for a few specific conditions, such as bariatric surgery. Non - certification rates are not tracked, since the hospital admissions do not require review. Humana medical necessity and length of stay reviews are conducted by nurse reviewers and they utilize the following review guidelines: • Medicare Coverage Guidelines: The coverage criteria for Humana's Medicare contracts is developed by the Center for Medicare and Medicaid Services (CMS) or by regional administrators of the program - National Coverage Determinations (NCD) and Local Coverage Determinations (LCD). These criteria are housed on the CMS website: Cms.hhs.gov/homelmedicare.asp City of Corpus Christi 26 HUMANA. Guidance when you need it most • . Humana Coverage Issue Guidelines: These guidelines are developed and reviewed annually by Humana's Technology Assessment Forum (TAF) comprised of medical directors, researchers, and practicing physicians to determine the safety and efficacy in development of clinical guidelines. The criteria is accessible on the Humana Website. • InterQual® Guidelines: These guidelines are developed by physicians and nurses, and are based on actual practices of clinical physicians throughout the United States. The guidelines are evaluated at least annually. They are reviewed by participating physicians, academic physician advisors in specific areas of specialty practices and users of the guideline. More information is available on the Interqual Website at Interqual.com. • Milliman Care Guidelines: The Care Guidelines are written by an experienced editorial staff of physicians, nurses and other healthcare professionals, and represent a compilation of best practices drawn from the current best medical evidence. The guidelines are evaluated at least annually. More information is available on the Milliman Website at Careguidelines.com. c. Have the guidelines been shared with plan physicians? Yes, Humana's preauthorization guidelines are shared with plan physicians and are available to providers online through the MyHumana provider portal at Humana.com. d. Are the medical necessity criteria local, regional or national? Humana's medical necessity criteria vary based upon the criteria set. Medicare Coverage Guidelines are developed at national, regional, and local levels. Other criteria are developed at a national level. e. How often are the medical necessity criteria updated? Humana's internally developed criteria are updated annually. All other criteria are updated at least annually. 51. Describe the process and criteria used for concurrent review. Is concurrent review performed on- site, electronically or telephonically? Please explain. Clinical nursing staff in Humana's Medicare regions collect and consider all relevant member information to support utilization management decision - making as part of the concurrent review process. Clinical information collected may include, but is not limited to the following: • Office and hospital records • History of the presenting problem • Clinical exam • Diagnostic testing results • Treatment plans and progress notes • Patient psychosocial history • Information on consults with the treating practitioner • Evaluations from other health care practitioners and providers • Photographs • Operative and pathological reports • Rehabilitation evaluations City of Corpus Christi 27 HUMANA. Guidance when you need it most • Printed copy of criteria related to the request • Information regarding benefits for services or procedures • Information regarding the local delivery system • Patient characteristics and information • Information from responsible family members or significant others Concurrent reviews are conducted either telephonically or through onsite review depending on several factors. Onsite reviews are determined based upon the following factors including but not limited to: • Facility admission volume • Facility location • Average length of stay • Case specific factors For those facilities or member cases not meeting the above criteria thresholds, telephonic concurrent reviews are conducted with discharge planning staff at the hospital. The Humana utilization management nurse contacts the utilization management staff at the facility to provide notification of the intended date of the onsite or telephonic review when a new admission is noted on the daily census. Following the initial admission review, ongoing concurrent reviews are scheduled based upon the member's individual health status and treatment plan, utilizing guidance from Humana's utilization management guidelines. If discharge needs are anticipated, Humana nurse reviewers work closely and regularly with hospital discharge planning staff and the physicians involved in the member's care to arrange needed services. 52. With what frequency is a patient's need for continued hospitalization under the concurrent review program reassessed? The Humana utilization management nurse contacts the utilization management staff at the facility to provide notification of the intended date of the onsite or telephonic review when a new admission is noted on the daily census. Following the initial admission review, ongoing concurrent reviews are scheduled based upon the member's individual health status and treatment plan, utilizing guidance from the criteria noted below. If discharge needs are anticipated, Humana nurse reviewers work closely and regularly with hospital discharge planning staff and the physicians involved in the member's care to arrange needed services. Humana's nurse reviewers utilize the following concurrent review criteria to assist in utilization management/concurrent review frequency and decision making: • Medicare Coverage Guidelines • Humana Coverage Issue Guidelines • InterQual Guidelines • Milliman Care Guidelines 53. Please describe your discharge planning process. Timely and appropriate discharge planning is an essential component of both the concurrent and case management processes. The utilization management nurse and case manager (if member has participated City of Corpus Christi 28 HUMANA Guidance when you need it most in case management prior to admission, the case manager works with the utilization management nurse on discharge planning during hospitalization), collaborates with the attending physician, the primary care physician, the member and/or the member's family, and the facility's discharge planning staff to facilitate a smooth transition to the appropriate next level of care. While most of Humana's nurses work with facility discharge planning staff and providers telephonically, Humana's case managers and utilization staff have access to medical records for all members. This access to medical records ensures a safe and efficient transition of care planning process for the member and member's family. Following discharge from an inpatient facility (i.e., hospital, long term acute care facility, skilled nursing facility, rehabilitation center), a member of the regional case management/utilization management team places a call to the member to ensure the following items are in place: • Member received discharge instructions and fully understands their post- discharge care • Member is in a safe environment with support system in place; if there are concerns that member may not be safe or further evaluation is needed, a field care manager would be sent to the member's home • Member was able to obtain all post- discharge medications and understands how to take them, is able to identify side effects and complications, and knows when to report concerns; if there is concern that member does not understand medications, a field care management visit is requested. Additionally, if the member cannot afford medications, the case management team works with the member on obtaining medications from community resources, pharmaceutical companies or contacts the physician's office for assistance • Member's caregiver /support system is in place and able to adequately provide post - discharge support for member • If home health services, durable medical equipment, etc. were ordered at discharge, case manager ensures that all appropriate services are in place • Follow -up doctor's visits and outpatient care is arranged according to post - discharge instructions • Assesses member for any complications or new problems since arriving home that should be reported to physician • Member is educated on their new conditions and post- discharge care, as well as understands how to report any complications to their physician, and when to seek medical care (ie: when it is appropriate to go to the emergency room, call their physician, etc.) • Assesses for behavioral health needs, such as depression or anxiety, following the inpatient stay and refers to the Integrated Medical Behavioral Health program as appropriate • Addresses any other outstanding issues to ensure member is safe and well cared for in their post - discharge location. The goals of the discharge planning program are to avoid readmissions and unnecessary emergency room visits, ensure member is in a safe environment and receiving the care they need, coordinate any medical services that are still needed or unaddressed, and educate members on the types of things they need to know and do to avoid complications. Following the post- discharge call and assessment of needs, the case manager or utilization management nurse follows up with the physician regarding any concerns and continues to assist with coordination of care activities. Additionally, the case manager or utilization management nurse assesses whether or not the member has ongoing case management needs that may require further intervention and follow -up, including assessing the need for a field care manager home visit. If a member is found to have any City of Corpus Christi 29 HUMANA. (guidance when you need it most ongoing health needs, they are scheduled for appropriate follow up with a case manager, and contacted accordingly. 54. Describe the process and criteria used for case management. Please address the following issues: a. How are case management situations identified? Humana uses a predictive modeling tool to identify potential case management participants. The predictive tool, which is run on a monthly basis, is prospective and identifies members with a high propensity for future claims and health events. The predictive modeling tool takes into account impactable conditions and high cost drivers, such as medical conditions, claims history, inappropriate medications, medication compliance, and a frailty index. Based on predictive modeling results, the top three percent of high risk members identified by the proprietary predictive claims -based algorithm are targeted for the Humana Cares complex case management program. The Humana Cares program then ranks these members by risk and tier to prioritize its case management outreach efforts. Humana identifies members who may benefit from the short-term case management program by analyzing the following reports: • Data collected through the utilization management/hospitalization process • Hospital admission and readmission reports • Health risk assessment reports • DRG outlier reports • Ad hoc referrals from internal or external parties b. If you use a list of diagnosis, please describe them in detail. Humana has two primary types of case management programs: complex case management and short- term case management. The methods for identifying cases for both types of case management programs are described below. Members are selected for the Humana Cares Complex Case Management program based on a proprietary algorithm called the Claims Based Algorithm Predictive Tool. Humana Cares participants include the top three percent of high risk members identified by the proprietary predictive claims based tool. The predictive tool is prospective and identifies members with a high propensity for future claims and health events. The tool takes into account impactable conditions and high cost drivers such as medical conditions, claims history, inappropriate medications, medication compliance, a frailty index, and a comorbidity index. Humana's short-term case management program identifies members who may benefit from short- term or acute case management by analyzing the following reports: • Data collected through the utilization management/hospitalization process • Hospital admission and readmission reports • Health risk assessment reports • DRG outlier reports • Ad hoc referrals from internal or external parties City of Corpus Christi 30 HUMANA. Guidance when you need it most c. If you use a claims dollar threshold, what is the amount? While claims dollars spent on a procedure or condition is a consideration for short -term and complex case management programs, it is not the determining factor as to whether a case is evaluated further for participation in a program. Humana does not use a set claims dollar threshold for determining appropriate cases. Instead Humana's proprietary predictive algorithms consider claims dollars as a part of their predictive science. d. What is the process for determining whether to pursue a case for management? Based on predictive modeling results, the top three percent of high risk members identified by the proprietary predictive claims -based algorithm are targeted for the Humana Cares complex case management program. The Humana Cares program then ranks these members by risk and tier to prioritize its case management outreach efforts. Humana identifies members who may benefit from the short-term case management program by analyzing the following reports: • Data collected through the utilization management /hospitalization process • Hospital admission and readmission reports • Health risk assessment reports • DRG outlier reports • Ad hoc referrals from internal or external parties e. Is patient consent required to initiate case management services? Yes, a member is given the ability to accept or decline case management services during the initial assessment phone call. The case manager explains the benefits of the program to the member and encourages participation in the program; however, the member has the right to decline participation in the program. f. In a self - funded arrangement, when is the employer included in the process? This is not applicable to Humana's proposal for the City since Humana is proposing a fully- insured Medicare Advantage plan. Traditionally, Humana's case management program is centered on member and provider relationships; however, the case managers may interact with a plan sponsor if absolutely necessary. The case manager must protect the personal health information (PHI) in accordance with HIPAA. g. How do the case managers interact with the patients, family, and physicians? Humana believes that the physicians are the primary source of medical care and referrals for Humana members; therefore, Humana does not position itself between the physician and the patient. The plan provides oversight of care and service in a variety of settings (e.g., inpatient, outpatient, rehabilitation, home health and skilled nursing facilities). The various components of the case management program are designed to guide and monitor the member's health and medical needs throughout the healthcare delivery system. City of Corpus Christi 31 HUMANA. Guidance when you need it most When a member authorizes or consents to their Humana case manager working directly with their physician to coordinate care on their behalf or assist with the case management process, the Humana case manager will reach out to the physician as appropriate. All interactions with a provider are authorized by the member or member's legal representative before the case manager interacts directly with the provider. Similarly, with a case management member's consent, Humana's case managers will work with family members or legally authorized personal representatives of the member in the case management process. Humana's case management assessment includes questions related to family dynamics and needs or issues that could impact the member's family. During discharge planning and care coordination, case managers frequently interface with family members and providers to identify problems and to clarify goals, especially with guardianship cases. Humana's case managers strive to achieve the appropriate level of interaction with the families and providers of each member to facilitate a smooth discharge planning and care coordination process. h. Are reports provided and what type of reports? Provide samples. Humana's standard reporting package contains the list of paid claims and diagnoses in excess of $25,000. The reporting package also includes case management and clinical program savings, the number of eligible participants, the number of members who participated in the program, the percentage of eligible members participating in the programs, the number of members who decline participation, and the number of eligible members that Humana was unable to contact. Please refer to Attachment C for a sample of Humana's Medicare Advantage reporting package. 55. How are members educated as to the services offered through case management? Members are educated on case management services during the first 90 days of active enrollment and at various intervals as a Humana member through several channels, which include the following: • Humana's Medicare Advantage welcome packet provides a description of case management services and services included in the program. • Humana's Medicare welcome call and health risk assessment are provided during the first 90 days of active enrollment with Humana; Customer Care representatives describe Humana's case management and other clinical programs to the member, as well as assessment for clinical programs. • Humana Active Outlook Publications sent to the member throughout their enrollment with Humana provide details and descriptions of Humana's clinical programs and services. • Humana.com provides a description of Humana's clinical programs and eligibility criteria. 56. How do case managers identify and evaluate local health care resources for alternative treatment? The availability of alternative services is assessed and identified during the case management assessment process. As members are identified for case management, they are assessed for current needs, evaluation of current services in place, and potential alternative services that may exist. The case management assessment tool allows for evaluation of all member needs including physical compromises, cognitive, social, and financial issues. Multiple co- morbidities, conditions of the frail and elderly, isolation, depression, and poly - pharmacy are only some of the challenges that would trigger a deeper evaluation of City of Corpus Christi 32 HUMANA. Guidance when you need it most the member's current services, as well as a search for additional support and alternative resources available to the member. Humana' s holistic approach and prospective orientation will allow it to identify potential problems and to intervene quickly and appropriately. As unmet needs or the possibility of alternative services are found the case manager works with the member's physician, Humana social workers, community health educators, pharmacists, and other members of the clinical team to identify alternative services. Additionally, a comprehensive, internally developed community resource directory has been developed for Humana clinical team members to utilize when identifying and referring members to appropriate alternative services. The directory contains thousands of healthcare providers, financial assistance programs, service providers, support groups, agencies, associations, and professional organizations, along with the services they provide and contact information, for the clinical team member to refer the member. The directory of resources is divided into various categories and subcategories including geographic locations, disease states served by the resources, categories of unmet needs that the resources provide, type of resources provided, and various other search categories. As Humana case managers find an alternative service that may work for a member, the case manager first checks with the member for permission to research the alternative service with the member's physician. Upon permission from the member, the physician is consulted and then referrals are made to appropriate service organizations based upon the physician's decision. 57. Is any part of the Utilization Review function delegated to subcontractors? If yes, please address the following: Humana conducts all utilization review functions internally. a. To whom is it delegated or subcontracted and what are their credentials? This is not applicable since Humana conducts all utilization review functions internally. b. Are they required to use the guidelines? This is not applicable since Humana conducts all utilization review functions internally. c. How is consistency ensured in the process? This is not applicable since Humana conducts all utilization review functions internally. d. Discuss the timing of the process. This is not applicable since Humana conducts all utilization review functions internally. 58. How are patients with chronic disease (i.e., heart disease, diabetes, asthma, etc.) identified by the health plan? Candidates for Humana's Medicare Advantage disease management programs are identified through automated monthly claims data mining based on preselected program criteria and through the use of Humana's predictive modeling tool. Humana's Medicare Advantage disease management programs include Diabetes, COPD, Congestive Heart Failure, and End Stage Renal Disease programs. In addition, City of Corpus Christi 33 HUMANA. Guidance when you need it most internal case management nurses refer members to the programs based on their interactions with members. 59. If a member incurs large outpatient expenses (i.e. greater than $20,000 in outpatient chemotherapy) without having an inpatient stay, how would the patient be identified and case managed by your health plan? The predictive modeling tool takes into account impactable conditions and high cost drivers, such as medical conditions, claims history, inappropriate medications, medication compliance, and a frailty index. Based on predictive modeling results, the top three percent of high risk members identified by the proprietary predictive claims -based algorithm are targeted for the Humana Cares complex case management program. The Humana Cares program then ranks these members by risk and tier to prioritize its case management outreach efforts. Humana identifies members who may benefit from the short-term case management program by analyzing the following reports: • Data collected through the utilization management/hospitalization process • Hospital admission and readmission reports • Health risk assessment reports • DRG outlier reports • Ad hoc referrals from intemal or external parties 60. What action is taken if a provider's planned treatment fails a Utilization Review screen? Each market office has a medical director assigned and available during regular business hours to intervene on "problem" admissions or certifications. If the medical director denies the service, a letter is mailed to the patient and physician on the day of the decision. 61. Do local network physicians participate in the review of a clinical appeal? Humana's Grievance and Appeal Department researches and investigates the grievance or appeal to determine if any additional information is needed, such as medical records. A Humana Medical Director will review medical records and/or other clinical issues. The member may also submit any additional supporting documentation regarding the case. A resolution letter detailing the reasons for the decision and any additional grievance rights is sent to the member in accordance with the timeframes specified in state and/or federal regulations. For states that require a panel or a grievance committee review, the panel is comprised of members according to state regulations. The Grievance Committee will conduct a review of the case, reach a determination by the required timeframe, and notify the member of the decision. The Grievance and Appeals committee is comprised of members from the health plan, various leaders within the plan who have not had any previous involvement in the case, and appropriate medical expertise when applicable. The Grievance and Appeals committee does not involve network providers in the appeal decision; however, a member's provider may provide information to be used for the appeal. City of Corpus Christi 34 HUMANA. Guidance when you need it most 62. What criteria must be met in order to have a case sent to a medical director? Humana's streamlined, automated utilization management model eliminates many of the precertification and ongoing concurrent review requirements previously employed. On occasions when the admission or ongoing length of stay in an acute setting is not automatically approved, the utilization management nurse reviews the case utilizing Medicare Coverage Guidelines, Humana Coverage Issue Guidelines, InterQual Guidelines, and Milliman guidelines. The nurse reviewer obtains information from the hospital or physician and applies medical necessity criteria for the level of care requested. Cases that do not meet the guidelines for the level of care requested are forwarded to the medical director for review. The medical director performs a review of the case, contacts the provider if more information is needed, and makes a final determination. All avenues for negotiation are explored to ensure members receive the most from their health plan benefits. F. Disease Management, Wellness, Special Programs for Retirees 63. Describe your overall disease management philosophy including an opt -in vs opt -out approach and how it integrates with your other services such as case management, 24 -hour nurse line and pharmacy benefits management. Each disease management program has its own process for engaging and enrolling participants; however, all programs utilize an "opt in" approach that allows candidates to decide whether or not they would like to enroll in a program. Candidates for all disease management programs are sent a welcome letter inviting them to enroll, followed by telephonic outreach from the program's engagement team. After it is determined that a member is eligible for a program, the member may decide to participate or may decline the invitation. Members who agree to participate are enrolled in the program and receive follow -up calls from a disease management nurse. Disease management is not integrated with Humana's case management programs because members typically only participate in one of the programs. Members with congestive heart failure, diabetes, end stage renal disease, and COPD are managed by disease management program specific to the condition. All other members with high acuity conditions are managed by Humana's complex case management program or short-term case management program. The HumanaFirst 24 -hour nurse line is involved with disease management in that the HumanaFirst line allows Humana to identify possible disease management candidates. If a member is identified as being eligible, HumanaFirst makes a referral to the appropriate disease management program. Prescription drug claims can also be used to identify members who may be eligible for disease management. Humana's predictive modeling tool utilizes prescription data in numerous ways to identify high risk members. If a member is identified based on pharmacy claims data, this individual is noted on Humana's predictive modeling reports. Upon identification, Humana contacts the member to determine if he or she is eligible for the program and provides an invitation to enroll in the program. City of Corpus Christi 35 HUMANA. Guidance when you need it most 64. Provide copies of any case studies or white papers describing the success of your programs. Humana's disease management programs have resulted in numerous success stories. Provided below are two examples of success from the congestive heart failure program and COPD program, which are administered by Alere. Success Story 1: Possible Prevention of Hospital Readmission for Heart Failure A Humana Medicare Advantage member who was enrolled in the congestive heart failure program was exhibiting negative symptoms related to heart failure. Upon learning that the member was not on "class" medications for heart failure and was displaying heart failure- related symptoms and weight gain, the nurse contacted the member's provider. The nurse suggested that the provider prescribe class medications and increase the member's diuretics. When the provider received the report, the provider contacted the member, prescribed class medications, increased the member's diuretics, and scheduled an appointment for the following day. During the nurse's follow up call to the member, the nurse educated the member on the proper usage of his medications and explained the reason for the member's fluid retention. The nurse instructed the member to begin weighing himself daily to monitor any weight gain. The member had been on his way to the hospital because he was alarmed at his increasing fluid retention, but decided not to go to the hospital after the phone call. This resulted in the prevention of an unnecessary readmission and the member was pleased with the nurse's guidance. Success Story 2: Successful Coordination of Care in the COPD Program A newly enrolled participant in the COPD management program was declining rapidly due to the condition, poor nutritional status, and non - adherence to medications. The Alere nurse assigned to the member conducted an assessment and discovered the member was not on the standard medications recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), was exhibiting signs of poor nutrition, and was severely underweight. After this observation, the nurse sent a status report to the member's provider that recommended the member be placed on a long - acting broncodilator or anticholonergic. The nurse also informed the provider of the member's nutritional needs and his need for financial assistance for medications. The nurse also contacted Humana's market case management department for assistance with the member's financial difficulties and nutritional needs. The nurse later followed up with the local Humana case manager, who stated that she had spoken to the member's family and provided them with information about medication and nutritional aid. At a later date, the nurse followed up with the member, who informed the nurse that he had applied for financial aid and had received nutritional supplements from his provider. The Alere nurse continued to place follow up calls to the member to ensure his health is stable and his condition is under control. 65. Describe your approach for communicating the disease management program to members, providers, and the community resources utilized by members. Provide samples of communications. Humana works closely, with its disease management vendors to ensure timely communication to members. Initial communication is conducted via letter and is customized to the needs of the member. The letter outlines the conditions of a specific disease and the available disease management program. City of Corpus Christi 36 HUMANA. Guidance when you need it most Subsequent communication is handled by Humana' s disease management vendors. Types of communication include letters, information packages, newsletters, Website education, telephone outreach, and face -to -face contact for some programs. Humana provides education to providers regarding disease management programs through Humana's physician newsletters and, in some cases, program - specific letters. Humana's quality department nurses educate providers on the programs when making visits to the physician offices. These nurses also leave behind brochures which briefly explain the programs, the criteria for referral, and the methods for referral. Please refer to Attachment K for a sample disease management communication piece. 66. Upon receipt of member eligibility and claims files, please describe the strategies used to contact members and enroll them into the program. Each Humana member is screened for high acuity disease management program participation using advanced proprietary algorithms. Participants are also identified via medical and pharmacy claims review, from Personal Nurses working with moderate- acuity members, HumanaFirst (24 hour -a -day, seven- day -a- week nurse assistance line), case managers, providers, and through self - referral. These referrals are received either electronically or via telephone, which are then screened for program eligibility. Once identified, an outbound call is placed to members in order to invite them to participate in the in the program. 67. Describe how you will stratify disease management program members including methodology and predictive modeling tools. How do interventions vary by risk level? Humana refers members to disease management programs according to established criteria, data mining, and its predictive modeling tool. For members who qualify for more than one program, there is a hierarchy in place to assure the member is referred to the program that will best meet their needs. Once Humana's disease management vendor has made contact with and enrolled the member, the vendor uses its own internal tools to stratify the member based on the member's responses to the assessment. Interventions vary by vendor but those stratified as the highest risk and acuity receive the most intense management. 68. Describe how you would manage at a minimum the following conditions: Congestive Heart Failure, Diabetes, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Asthma and High Risk Maternity. Humana's Medicare Advantage disease management programs aim to provide access to knowledgeable professionals focused on specific conditions. Disease management professionals strive to provide education and guidance on: • The importance of following physicians' treatment plans — including diet, exercise, and drug adherence • Monitoring of symptoms and early warning signs • Addressing side effects of therapy • Transition after treatment — recovery or end -of -life decisions, if appropriate City of Corpus Christi 37 HUMANA. Guidance when you need it most Humana offers disease management programs to its Medicare Advantage members for the following conditions: Congestive Heart Failure, End Stage Renal Disease (ESRD), Diabetes, and Chronic Obstructive Pulmonary Disease (COPD). Humana's Congestive Heart Failure program is managed by Alere Medical, which employs cardiac - trained critical care nurses for managing and slowing the progression of heart failure. Approximately 92 percent of participants enrolled in the program show a stabilized or improved disease status compared to the industry average of 26 percent. The ESRD program, which is managed by Village Health, focuses on education and coordination of care for members with ESRD. Approximately 93 percent of Humana's enrolled dialysis patients receive 'adequate hemodialysis compared to the 84 percent national average. The COPD program is a disease management program administered by Alere Medical. This high acuity program focuses on education and physician visit preparation to make the most of the time in the doctor's office. The COPD program has shown a consistent increase in the number of participants using controller medications by the time they have been on the program for six months. Humana's internal Diabetes management program promotes: • Preventing recurrence of symptoms • Reduces hospitalizations and emergency room visits • Prolonging periods of wellness, decreasing periods of illness • Maximizing quality of life • Reducing the need for future health services • Improving health outcomes • Reducing costs The Diabetes case manager works with participants to establish personal goals for their condition. In addition, the goals of the program are to improve outcomes by: • Slowing progression of the disease • Increasing compliance with American Diabetes Association guidelines • Educating members to detect and report early signs of complications • Improving quality of life Humana does not offer disease management programs for Medicare Advantage members for the following conditions: Coronary Artery Disease, Asthma, and high risk maternity. A high risk maternity program is typically not necessary for Medicare Advantage members. However, Humana offers its Personal Nurse service to members with these conditions. Humana monitors other high risk conditions through its Humana cares complex case management program. 69. Describe on how you monitor, evaluate and report outcomes. Humana receives quarterly outcomes reports from each vendor that provides operational and clinical metrics and performance. There are performance targets set for each vendor for clinical and operational metrics. Anytime a vendor fails to meet the established target, Humana works closely with them to bring their performance back up to target or a corrective action plan is put in place. Outcomes are reviewed by City of Corpus Christi 38 HUMANA. Guidance when you need it most and are reported to market, regional, and corporate clinical staff including Humana's Corporate Quality Committee. Humana also releases group- specific program data that addresses program participation and savings. 70. Describe in detail your methodology to calculate Return on Investment. Has your organization received Certification in Savings Measurement from the Disease Management Purchasing Consortium International, Inc? The measure of return on investment (ROI) for disease management programs is calculated by dividing disease management gross savings by the cost of the disease management program (i.e., payments made to the disease management program vendors). Gross savings are determined by subtracting the fee -for- service claim cost, a per program participant per month cost, from the expected cost of unmanaged members with the target chronic condition. Humana does not participate in the certification program for Certification in Savings Measurement from the Disease Management Consortium International, Inc. Humana is not seeking certification from the program because the program evaluation is not in line with Humana's disease management philosophy. The program evaluates each program separately and based on program components instead of evaluating the methodology. Humana may conduct its evaluations of its programs using a different methodology than the methodology used in this certification program. Humana conducts studies on its programs based on the recommendations from the Disease Management Association of America (DMAA). 71. Describe the 24- hour /7 days a week nurse call service including staff qualifications, staffing model and location of services. Humana offers HumanaFirst, a 24- hour - a-day, seven - day -a -week, telephonic nurse triage and health planning service. Humana provides a toll -free HumanaFirst number to members on the reverse side of their ID cards. HumanaFirst provides an easy way for members to receive assistance in selecting the right care at the right time. When a member calls HumanaFirst, registered nurses listen to the caller's symptoms and help them choose the appropriate level of care. It is a quick and confidential way for members to decide whether they need to see their doctor, seek urgent or emergent care, or begin treatment at home. HumanaFirst also alleviates unnecessary calls to doctors in the middle of the night and helps to prevent inappropriate trips to the emergency room. In addition, the program provides an audio library that allows members to hear recorded information on over 350 health topics, many of which are provided in Spanish. Members can access this library via the HumanaFirst toll -free number on the back of their ID cards or they can listen to audio health topics on the MyHumana portal of Humana's Website, Humana.com. The nurse triage service is staffed by non - clinical associates located in Green Bay, Wisconsin that complete initial call triage for prioritization and route any urgent calls directly to a registered nurse who is able to assist Humana members in selecting the appropriate level of care at the right time. HumanaFirst nurses are required to be registered nurses and have at least three years of clinical experience. City of Corpus Christi 39 HUMANA. Guidance when you need it most 72. Describe the types of wellness programs you can offer including how you will help support and communicate those programs. Humana offers valuable wellness programs to its Medicare Advantage members, including SilverSneakers® and Humana Active Outlook. SilverSneakers Humana offers the SilverSneakers fitness program, a health and wellness program for Medicare members. For no additional charge, Medicare members can use fitness centers with locations carefully selected for their warm, friendly, and safe environments. Steam and sauna rooms, heated pools, body conditioning classes, and strengthening tools are just a few of the benefits offered by SilverSneakers. Additionally, SilverSneakers offers classes designed specifically for increasing strength and flexibility and are taught by trained instructors. A specially- trained Senior AdvisorSM is available at each of the SilverSneakers fitness locations to greet participants and introduce them to all the benefits of the SilverSneakers fitness program. Members may invite their Medicare eligible friends to try the SilverSneakers program as a one- time guest. There are more than 1,000 contracted SilverSneakers fitness centers nationwide. A complete list of fitness centers is available by going online to Silversneakers.com. For more information about the SilverSneakers fitness program, potential members may call 800 -457 -4708, or TDD 800- 833 -3301, Monday through Friday between 8 a.m. and 6 p.m. Eastern Standard Time. Members are educated on the SilverSneakers through informational brochure provided during enrollment and have access to information on Humana.com. Humana Active Outlook Humana Active Outlook is an enriching health and wellness education program exclusively for Humana Medicare Advantage members. The Humana Active Outlook program consists of the following: • Nurture! Caregiving Program: A comprehensive program of resources and services to enhance the caregiving and grandparent experiences • QuitNet Comprehensive: A tobacco cessation program with nicotine replacement therapy, phone counseling, and Website support • Meals on Wheels: Depending on the Humana Medicare Advantage plan chosen, some members are eligible to receive health meals after a hospital stay • Heal!: A program that provides condition - specific information and health coaching on managing a variety of conditions, including diseases, physical ailments, and weight management • HAO Magazine: Humana's quarterly award- winning publication with inspiring stories for active, fun, healthy living • Live It Up! Digest: a quarterly publication to help members with chronic conditions manage their health • Specialty Kits: available to Humana Medicare Advantage members at no cost for the first copy • HumanaActiveOutlook.com: A source for custom senior health information and interactive tools on the Web • Classes and Seminars: Local health and wellness classes to help members learn more about the right way to exercise, how to eat healthy, and how to use computers and technology City of Corpus Christi 40 HUMANAS Guidance when you need it most 73. Do you have a full-time employee that is an expert in the health promotion / wellness field whose role is to assist your employer groups with their wellness strategy and program implementation? If so, please provide this individual's resume. Humana's Senior Products Medical Director for South Texas, Dr. Weston Scott, serves as a knowledgeable resource for retiree program strategy and opportunities. Dr. Scott can provide guidance and strategy on programs that are appropriate for the City's Medicare Advantage population. The account executive, Pam Taylor, is also available to assist in the communication strategy. Dr. Scott's biography is provided below. Dr. Weston Scott, Senior Products Medical Director and Chief Medical Officer Dr. Weston Scott has 26 years of experience in the healthcare industry. Dr. Scott joined Humana in 1997 as an assistant medical director for Humana's San Antonio market. He then served in various medical director roles until being promoted to the Senior Products Medical Director and Chief Medical Officer for Humana's South Texas region. Prior to joining Humana, Dr. Scott provided healthcare services to various United States Air Force locations, served as a family practice physician, and served as the medical director for PacifiCare. Dr. Scott received his medical degree from Tulane University and his master's of business administration from the University of Texas at Austin. Account implementation activities will be handled by the assigned account installation manager, Janelle Cain. Janelle is experienced in providing a smooth implementation for Medicare Advantage members and will assist in ensuring all programs are implemented properly. 74. Do you subcontract your wellness services? If so, name this subcontractor along with the nature of the relationship and contract terms. The Humana Active Outlook program is administered by Humana. SilverSneakers is a nationwide retiree - focused fitness program that is administered by Healthways Inc. SilverSneakers is available to any retiree nationwide who is enrolled in Medicare Parts A and B. Humana provides the SilverSneakers program to Humana Medicare Advantage members at no charge and promotes the program to its members. 75. Describe any programs or plan options designed specifically to address retirees' health care needs. Humana believes a health plan should do more than simply help members gain access to medical services. For this reason, Humana offers these additional services to Medicare- eligible beneficiaries: • MyHumana: Personal, secure Web page on Humana.com where members can access benefits information, health tools, claims history, and more • Humana Active Outlook: Program includes HAO magazine, Lifeworks Member Assistance Program, and other health and wellness materials • HumanaFirst: Humana's demand management toll -free 24 -hour health information line • SilverSneakers: Special fitness and wellness programs that are available to Medicare Advantage members nationwide • Complementary and Alternative Medicine: Discounts at more then 25,000 providers nationwide • EyeMed Vision Discount Program: Discounts on eyewear, contact lenses, laser vision correction, and eye exams City of Corpus Christi 41 HUMANA. Guidance when you need it most • Nutritional Supplements/OTC Medications: Discounts for nutritional supplements and various over -the- counter medications • QuitNet: Tobacco cessation program with nicotine replacement therapy, phone counseling, and Website support • Hearing Aids and Care: Discounts on state -of- the -art digital hearing aids, a free comprehensive hearing exam, and follow -up visits • NutriSystem SilverTM: Discount on weight loss program and multivitamins • eHarmony.com: Discount on online membership that provides retirees a safe and supportive environment to meet singles • Roadside Assistance Discount: Discount on the Auto Assist Plus® 24 -Hour Roadside Assistance Service, which may includes services such as: help with towing, flat tires, battery failure, lock -outs, savings on hotels, car rentals, automotive services and more 76. Describe any programs in place that support value based health care decisions, i.e. modified deductibles or co -pays. At this time, Humana does not offer any value -based healthcare programs that would result in reduced copayments or deductibles. However, Humana offers a number extra services to enhance the retiree's member experience, including Humana Active Outlook, SilverSneakers, QuitNet, NutriSystem Silver, eharmony.com discounts, and many other services. 77. Describe any programs in place which will assist members in making informed health care decisions regarding value added treatments. Humana offers several programs to assist the City's retirees with healthcare decisions which include, but are not limited to the following: • HumanaFirst nurse advice line • Case management • Comprehensive NeuroScience (CNS) • Medication Therapy Management (MTM) • RxMentorSM • Humana Active Outlook • SilverSneakers • Transplant management • MyHumana at Humana.com Each of the programs is described in further detail below. HumanaFirst Nurse Advice Line Humana's nurse advice line offers 24 -hour access to nursing advice on specific health questions, self - care, and place of treatment options. By providing 24 -hour assistance, Humana is able to provide peace of mind and convenience to its Medicare members. Results have shown that members who utilize the HumanaFirst program have more appropriately utilized emergency services, resulting in lower cost. City of Corpus Christi 42 HUMANA. Guidance when you need it most Case Management Humana's case management program is available to Medicare Advantage members to ensure retirees are getting the most appropriate care. Humana's case managers work to facilitate and coordinate critical care needs, help navigate and coordinate care with multiple providers, guide and support members through complex or catastrophic situations, reduce readmission rates and average hospital length of stay rates, and improve adherence to doctor's treatment plans. Comprehensive NeuroScience Humana's Comprehensive NeuroScience program helps to identify members receiving psychiatric medications who do not adhere to clinical evidence -based guidelines or have potential complications based upon the medications they are receiving. Comprehensive NeuroScience also ensures providers are alerted of the potential medication complication or non - adherence to evidence —based guidelines through a letter from Humana. Comprehensive NeuroScience provides psychiatric consultation to providers who receive these alerts and want to discuss the member's medication regimen. Medication Therapy Management (MTM) Humana's Medication Therapy Management program is a prescription drug- focused member outreach program that provides personalized mailings and telephonic consultations to members. The Medication Therapy Management program also provides face -to -face consultations through more than 6,000 pharmacies in Humana's network. Humana's Medication Therapy Management program aims to generate information to members regarding drug interactions, drug duplicates, and drug cost savings through evidence -based research. RxMentor RxMentor is a prescription drug- focused member outreach program for those members who do not qualify for the MTM program. RxMentor provides personal consultation on topics such as: safety and adherence, disease management principals, lower -cost medication alternatives, and guidance through pre and post transplantation stages. Transplant Management Humana's transplant management program aims to guide and coordinate for members the multiple services involved with transplants, from the initial diagnosis to recovery. Humana Active Outlook Humana Active Outlook is an enriching health and wellness education program exclusively for Humana Medicare Advantage members. The Humana Active Outlook program consists of the following: • Nurture! Caregiving Program: A comprehensive program of resources and services to enhance the caregiving and grandparent experiences • QuitNet Comprehensive: A tobacco cessation program with nicotine replacement therapy, phone counseling, and Website support • Meals on Wheels: Depending on the Humana Medicare Advantage plan chosen, some members are eligible to receive health meals after a hospital stay • Heal!: A program that provides condition - specific information and health coaching on managing a variety of conditions, including diseases, physical ailments, and weight management City of Corpus Christi 43 HUMANA. Guidance when you need it most • HAO Magazine: Humana's quarterly award- winning publication with inspiring stories for active, fun, healthy living • Live It Up! Digest: a quarterly publication to help members with chronic conditions manage their health • Specialty Kits: available to Humana Medicare Advantage members at no cost for the first copy • HumanaActiveOutlook.com: A source for custom senior health information and interactive tools on the Web • Classes and Seminars: Local health and wellness classes to help members learn more about the right way to exercise, how to eat healthy, and how to use computers and technology SilverSneakers Humana offers the SilverSneakersfitness program, a health and wellness program for Medicare members. For no additional charge, Medicare members can use fitness centers with locations carefully selected for their warm, friendly, and safe environments. Steam and sauna rooms, heated pools, body conditioning classes, and strengthening tools are just a few of the benefits offered by SilverSneakers. Additionally, SilverSneakers offers classes designed specifically for increasing strength and flexibility and are taught by trained instructors. A specially- trained Senior Advisor is available at each of the SilverSneakers fitness locations to greet participants and introduce them to all the benefits of the SilverSneakers fitness program. MyHumana at Humana.com Through their personal MyHumana page, retirees have a variety of information available to them. Information is displayed in panels allowing easy navigation. Employees can view plan administration details, use health and well -being tools and references, and check their financial status relating to plan benefits. These capabilities include: • Access claim history, benefits summaries, and eligibility verification • An online electronic version of a medical claims EOB (e -EOB) • Request replacement ID cards • View summary of benefits • Access secure message center • Utilize a multitude of pharmacy tools to: order prescription, view claims, view benefits, search for lower -cost drug equivalents, find a pharmacy, and research drug interactions • Find a physician, hospital, dentist, pharmacy and alternative medicine providers with Physician Finder Plus and a vision discount provider with EyeMed' s provider finder • Maintain a personal health record to share with the member' s physician, if necessary • Use specific condition centers for education and health management quizzes, calculators and assessments available to all members and those tailored to specific employers or groups of members • Compare hospitals and outcomes by procedure and condition chosen and obtain the member's estimate maximum out of pocket cost for the procedure/condition chosen • Access to health library and guides • Health Conditions Program: members can access information about programs available to all members as well as those tailored to specific groups of members through links to specific health and wellness sites • View current benefits, amounts applied toward deductibles, current total of out -of- pocket costs, and copayment history (medical and prescription drug) City of Corpus Christi 44 HUMANA® Guidance when you need it most 78. Provide a short summary of what you would consider best practice in adding additional benefits or incentives that would successfully improve retirees' health. Humana believes that the SilverSneakers and Humana Active Outlook programs are the most successful programs for encouraging members to improve their lifestyle and to seek preventive care. Preventive care is supported through the Humana's Humana Active Outlook program with literature sent to members that focus on preventive care and ways to support themselves in the areas of finance, socialization, family, healthcare, and wellness. Additionally, members receive messages in their SmartSummary statements and through interactions with Human's case management and disease management clinicians. Humana's Website also assists members in learning and tracking preventive care and wellness initiatives. 79. Describe any current programs that promote retiree consumerism for future consideration. Humana offers several programs to assist the City's retirees with healthcare decisions which include, but are not limited to the following: • HumanaFirst nurse advice line • Case management • Comprehensive NeuroScience (CNS) • Medication Therapy Management (MTM) • RxMentorsM • Humana Active Outlook • SilverSneakers • Transplant management • MyHumana at Humana.com City of Corpus Christi 45 HUMANA. Guidance when you need it most 80. Provide three examples of innovative approaches to retiree health care that you have successfully implemented with other clients. Humana has provided three examples of successful approaches to retiree healthcare for its clients. Each example includes details about the client and the savings resulting from Humana's implemented plans. Company A • Summary of Business: Company A is a branch of a global multi - industry company serving aviation and industrial markets. A Medicare Advantage quote was requested for this firm. • Eligible Population: 500 • Employer Contribution: 51 percent to 75 percent • Current Offering Basis: The branch has a self - insured Medicare supplement plan and prescription drug plan. The group's current medical offering is an 80 percent carve -out plan with a $1,000 maximum out -of- pocket. Their current prescription drug plan offering is a $500 deductible, 30 percent coinsurance, and a $1,500 maximum out -of- pocket. Humana matched these medical and prescription drug plans with a Humana Medicare Advantage plan with a prescription drug rider. The switch from a self - funded Medicare supplement plan to Humana's Medicare Advantage plan provided substantial savings for the group. The savings was estimated to be $46.59 per member per month in comparison to renewing with the current carrier. Company A Value Proposition Eff. Dt. 1/1/2008 Membership Total Medical Claims Est. Medical Renewal Claims PMPM (incl. Est. Admin fee) Total Rx Claims Est. Rx Renewal Claims PMPM (incl. Est. RDS Subsidy) 2008 Est. Total Renewal Claims PM PM 500 $352,002.51 $78.67 $919,174.30 $108.93 $187.59 Humana's MAPD Prem PMPM $141.00 Estimated Company A Renewal Rate PMPM $187.59 Humana's Total Mbr Prem PMPM $141.00 Savings PMPM Savings Percentage Estimated 12 month savings $46.59 24.84% $139,778.40 City of Corpus Christi 46 HUMANA® Guidance dance when you need it most Company B • Summary of Business: Company B is a global engineering and construction contracting firm. The company requested full replacement Private Fee - for - Service plans for four retiree classes. • Eligible Population: 2,178 • Employer Contribution: 51 percent to 75 percent on average; varies by years of service and plan category • Current Offering Basis: Company B has a self - insured Medicare supplement plan and prescription drug plan. The company's current medical offering has a $300 deductible, 100 percent covered inpatient hospital benefits, 80 percent coinsurance, and a $4,000 maximum out -of- pocket. The company's current prescription drug plan offering is a three- tiered plan design. Humana matched these medical and prescription drug plans with a Humana Medicare Advantage plan with a prescription drug plan rider, which resulted in an estimated savings of $46.27 per member month. Company B Value Proposition Eff. Dt. 4/1/2008 Membership Total Medical Claims Est. Medical Renewal Claims PMPM (incl. Admin fee) Total Rx Claims Est. Rx Renewal Claims PMPM 4/1/2008 Est. Total Renewal Claims PMPM 2,178 $1,230,851.34 $67.09 $5,564,925.37 $161.17 $228.27 Humana's MA Mbr Prem PMPM $182.00 Estimated Company B Renewal Rate PMPM $228.27 Humana's Total Mbr Prem PMPM $182.00 Savings PMPM Savings Percentage Estimated 12 month savings $46.27 20.27% $1,209,206.71 City of Corpus Christi 47 HUMANA. Guidance when you need it most Company C • Summary of Business: Company C is a public entity with bargained benefits. • Eligible Population: 747 • Employer Contribution: 76 percent to 100 percent • Current Offering Basis: Company C currently has multiple self - insured Medicare supplement plans. The company's current benefits are primarily covered in full. There are a couple of plans that have minimal cost sharing with the retirees. Humana matched the benefits of the full coverage benefits through a Humana Private -Fee- for - Service Medicare Advantage plan and recommended adding copayments for the skilled nursing benefits. Humana matched the prescription drug benefits but restructured the copayment structure to a four- tiered plan design. The company's switch to Humana provided an estimated savings of $33.57 per member per month. Company C Value Proposition Eff. Dt. 1/1/2008 - 12/31/2008 Membership Total Medical Claims Est. Medical Renewal Claims PMPM (incl. Admin fee) Total Rx Claims Est. Rx Renewal Claims PMPM (including est. RDS) Est. Total Renewal Claims PMPM 747 $990,611.64 $142.53 $1,121,396.40 $116.03 $258.57 Humana's MA Mbr Prem PMPM $225.00 Estimated Company C Renewal Rate PMPM $258.57 Humana's Total Mbr Prem PMPM $225.00 Savings PMPM $33.57 Savings Percentage 12.98% Estimated 12 month savings $300,898.93 G. Pharmacy Claims Administration 81. Describe your preferred drug list program including committee, adding/removing drugs. How often is your formulary list updated and are members notified when these changes occur? Humana Pharmacy Solutions' philosophy towards formulary is placing the best therapeutic, generic, and safe products on the lower tiers. Drugs are assigned to levels and members' cost share increases as the level increases. Educating consumers on the true cost allows them to make more informed decisions regarding prescriptions. As a result, net cost is reflected in the lower tiers. Humana Pharmacy Solutions' extensive Drug List includes both generic and brand -name products, which serves as a guideline to Humana Pharmacy Solutions' physicians with regard to prescribing, dispensing, City of Corpus Christi 48 HUMANA. Guidance when you need it most and general costs involved in selecting cost - effective treatments for Humana Pharmacy Solutions' members. The drug products selected for inclusion on the Drug List have been approved by the Humana National Pharmacy and Therapeutics committee, which includes network physicians and pharmacists from Humana health plans. The Pharmacy and Therapeutics committee evaluates various sources of clinical information when reviewing drugs for placement in Humana Pharmacy Solutions' formulary. Evidence -based effectiveness studies are considered when available and appropriate. The Humana National Pharmacy and Therapeutics committee is comprised of 15 members, which include market medical directors, corporate pharmacists, and personnel from key corporate and market departments. This committee meets on a quarterly basis to discuss and review pharmacy issues. A main function of the committee is the review and evaluation of new medications as introduced to the market, as well as the review and evaluation of current medications as new information becomes available. The Pharmacy and Therapeutics committee is responsible for the approval of medications included in the Humana Pharmacy Solutions Drug List and those needing special monitoring, and, subsequently, prior authorization. New medications are considered as quickly as possible based on available information. Medications can be added to the drug list as early as their initial release date based on the urgency of availability and alternatives currently in place on the Drug List. Humana Pharmacy Solutions considers further details of its National Pharmacy and Therapeutics committee to be proprietary; therefore, a membership listing, by specialty and affiliation, has not been included. Positive additions to the Drug List are made throughout the year as new drugs are introduced. In general, these additions apply immediately to plan participants; however, there are some exceptions: Drugs moved to a higher tier generally apply immediately to plan participants where state statute allows. Negative changes occur annually on January 1. Members who are affected by the removal of a drug from the Drug List receive notice in accordance with state mandates, or 90 days prior to the deletion. At any time, the employer or member can log onto Humana.com under the drug list search to discover information about Humana's Drug List. 82. Please provide information regarding available network options offered by your organization. Include number of chains and independents for both Corpus Christi and national. Also, identify which national or major regional chains are included. Within Humana Pharmacy Solutions' national network, Humana Pharmacy Solutions has 21,175 independent pharmacies and 40,150 chain pharmacies. In accordance with the census provided by City of Corpus Christi, Humana Pharmacy Solutions found 10 independent pharmacies in the area and 37 chain pharmacies. The national and major regional chains identified include, but are not limited to: • CVS Pharmacy • Heb Pharmacy • Target Pharmacy • Walgreen Drug Store City of Corpus Christi 49 HUMANA. Guidance when you need it most • Wal -Mart Pharmacy • Recept Pharmacy • Sam's Pharmacy • Omnicare • United Please refer to Attachment P for Humana Pharmacy Solutions' analysis of network pharmacies, including independent and chain pharmacies, within the City of Corpus Christi and nationwide. 83. What existing programs e.g. — step therapy, generic promotions are in place to help the client manage their pharmacy costs? Humana Pharmacy Solutions provides a variety of clinical edits that ensure appropriate and accurate use of medications. These edits include dispensing limits, step edits, prior authorizations, and gender edits. Humana Pharmacy Solutions also has a clinical review process wherein all cases are reviewed by a registered Pharmacist. Therapeutic Substitution/Therapeutic Interchange Humana Pharmacy Solutions therapeutic substitution/interchange program is available through RightSourceRx, Humana Pharmacy Solutions' wholly -owned mail order subsidiary. Therapeutic Interchange is used to identify member prescriptions that have been filled for a non - preferred product and attempts to convert that prescription to a preferred product, typically a lower cost generic that is a therapeutic alternative and usually done in targeted classes, such as PPIs (proton pump inhibitors such as Nexium), Statins (cholesterol lowering medications like Lipitor), and Cox Its (osteoarthritis medications such as Celebrex). Prior Authorization/Step Edits Prior Authorization is a mechanism used by Humana Pharmacy Solutions that requires a physician to pre- approve a drug that they prescribe to a member. The physician provides information to ensure the correct dosage, indication, and make sure that preferred products are used first, in order for the member to receive the prescription at a network pharmacy. During the approval process, the physician responds to a series of clinical questions, which are based on criteria for the appropriate use of the respective medication. These criteria are based on FDA approved, durations of treatment, or maximum dosing limits for a particular disease state. Prior authorization is an important program because it decreases inappropriate utilization and drives members to used lower cost alternatives. Step Edits, a component of the prior authorization program, are used to drive members toward a first line medication for targeted medications. Common targeted medications are non - sedating antihistamines, sleep aids, leukotriene inhibitors and urinary anti - spastics. When a request is received for a targeted medication, the member's prescription claims history is reviewed to see if first line medications have been utilized prior to the request. If historical claims identify first line medications, the request is automatically adjudicated at the appropriate copayment level. If not, the member is directed to take an alternative medication. Step Edits (sometimes referred to as Step Therapy) positively impacts overall trend and pricing by requiring members to utilize first -line medications, usually generics, to treat a condition when clinically appropriate. These generic City of Corpus Christi 50 HUMANA. Guidance when you need it most medications are usually on average around 80 percent cheaper than the brand name alternatives that treat the same condition. Quantity Limits (QL) Quantity limits programs promote appropriate utilization of pharmaceutical products, enhance patient safety and compliance, and can provide cost savings to the patient and the health plan. Humana Pharmacy Solutions estimates that a managed dispensing limits program can potentially save a plan $1.00 per member per month. Medication Therapy Management Medication Therapy Management is a quality program to maximize therapeutic outcomes with medication use. It is designed to reduce risk for adverse events and to address over or under utilization issues. The program targets beneficiaries with: • Two or more chronic conditions • Eight or more system Part D medications • Anticipated drug spend of $4,000 or higher per year Humana's approach to its Medication Therapy Management program differs from its competitors because the program provides tailored medication therapy management techniques based upon the beneficiary's level of risk and severity. Members with the most acute severity and the highest risk are encouraged to visit a local Medication Therapy Management - certified pharmacist. The Medication Therapy Management registered pharmacist is trained to provide tailored medication therapies and services to assist the member in attaining a positive clinical outcome. In cases where the member is at a lower risk level and the condition is less severe, Humana provides medication therapy management services by telephone. These telephonic sessions are conducted by a nurse or highly qualified technician. Humana also has an educational program for medication therapy that is comprised of mailings and Web tools for members who have little to no risk or severity level. For those members who are not eligible for Medication Therapy Management, Humana Pharmacy Solutions offers an extension of Medication Therapy Management called RxMentor. RxMentor RxMentor is a pharmacy consultation program. Humana Pharmacy Solutions invites Medicare - eligible members to use the RxMentor program if they: • Use multiple medications, but lower than the MTM threshold • Are referred from other Humana Pharmacy Solutions clinical programs • Have met a projected annual drug expenditure of $4,000 or more An outbound call is made to the member inviting them to join the program and schedule a pharmacist consultation. After the consultation is scheduled, the member receives an outbound call from the pharmacist, who offers the member a comprehensive medication review. The typical RxMentor consultation will focus on: • Medication adherence • Safety to avoid adverse reactions from potential drug interactions • Drug information and health literacy City of Corpus Christi 51 HUMANA. Guidance when you need it most • Gaps in medication therapies • Possible medication alternatives After the consultation, the member and the member's physician(s) will receive a follow -up communication alerting them to any potential medication issues and requesting a prescription for a lower - cost medicine when appropriate. Members benefit by: • Learning about their medications • Learning about possible lower -cost alternatives • Gaining improved quality of life • Avoiding acute episodes of illness • Enhancing health literacy Humana Pharmacy Solutions will provide reports on an ongoing basis and will be tracking a number of metrics to evaluate the impact of the program and member based outcomes. 84. How are charges handled when the prescription cost is less than the applicable co -pay? Humana Pharmacy Solutions uses a "best of three" logic in which the member always pays the lower of the applicable copayment, the allowable drug charge, or the pharmacy's usual and customary charge. In this situation, the member would pay the allowable prescription cost. 85. In the event of a new drug coming on the market, how will Vendor communicate this information to the City and the patients? Humana Pharmacy Solutions provides notification to members when a new generic medication comes on the market. Humana Pharmacy Solutions identifies members who cur ently take the medication and similar medications in the therapeutic class. Once appropriately identified, Humana Pharmacy Solutions notifies these members through Maximize Your Benefit Rx letters to make them aware of generically available medicines that may be right for them upon approval from their treating physician. This value added service keeps in mind that efficacy and out of pocket costs to the member are very important as they treat their disease. The Maximize Your Benefit Rx letter also helps to increase active dialogue between members and physicians and helps the member feel more empowered in treating their conditions. 86. What processes does Vendor have to promote the use of generic drugs? Humana Pharmacy Solutions has several programs in place that encourage the use of generic drugs. Maximize Your Benefit Rx is designed to help educate and inform Humana pharmacy benefit members as to their various prescription drug cost options. Many prescriptions, particularly prescriptions for brand name drugs, have lower cost generic alternatives available. When Humana Pharmacy Solutions identifies such medications or a category of medications that have efficacious alternatives that will save the member money on their prescription drug costs, a Maximize Your Benefit Rx program will be created and implemented to inform the member of these opportunities. Together with Humana Pharmacy Solutions' competitive benefit structures including Rx3 and Rx4, Maximize Your Benefit Rx is helping to convert over 7 to 10 percent of targeted members on a third tier drug. City of Corpus Christi 52 HUMANA. Guidance when you need it most Copayment Differential: Humana Pharmacy Solutions has Copayment Differential programs that can be attached to benefit designs. These pricing incentives are used to encourage members to use generic drugs. When the generic is not substituted for the brand equivalent, the member can be charged the additional cost. eProcrates: Humana Pharmacy Solutions is providing access to its Drug List by innovative handheld computer software. The Drug List has been added to the eProcrates Inc. Internet -based drug reference guide and can be downloaded to most personal digital assistants (PDAs) that are compatible with the PocketPC and Palm OS platforms. In addition to providing instant access to Humana's Drug List, the portable, high -tech tool can be used to quickly check other data, including: • Generic or other lower -cost alternatives to brand -name drugs • Dosage recommendations for both adults and children • Quantity limits • Prior authorization requirements • Potential adverse drug reactions • Potential drug interactions for people using more than one prescription medication • Contraindications Pharmacy Dispensing: Retail pharmacies are contractually required to dispense generic drugs whenever possible and to abide by applicable state laws and Humana Pharmacy Solutions' maximum allowable cost program. Pay for Performance: Humana Pharmacy Solutions has developed a Pay- for - Performance program to reward network pharmacies for increasing their pharmacy's generic dispense rate (GDR). Pharmacies that increase their GDR to targeted levels receive higher dispensing fees. Pharmacies are automatically enrolled in the program and are not obligated to take any action. To continue to qualify after the first program period, pharmacies must reach targeted GDR levels during subsequent performance periods. Pharmacies will receive quarterly GDR update reports that summarize their generic dispensing performance. Pharmacies that do not improve their GDR will not receive any incentives. Why Generics: Why Generics is a program to promote the use of generics, members still need to be encouraged and reminded to take advantage of the cost savings associated with generic medications. Studies show that members will participate in activities if: • They understand how the activity can help them reach their lifestyle goals • They trust the source of the information • They have an incentive to change a behavior • They're reminded to participate When employers reinforce the message, employees take notice. To that end, Humana Pharmacy Solutions developed a "tool kit" to help employers encourage their employees to use generics. The kit includes: • A series of posters designed to illustrate the savings associated with generic medications and how that savings can help them achieve their lifestyle goals (i.e., make home improvements, buy a new television, take a family vacation) • A payroll stuffer explaining what a generic medication is, how generics can save money, and how members can find out more information City of Corpus Christi 53 HUMANA. Guidance when you need it most • A series of newsletter articles correlating to seasonal events (i.e., spring allergy season, holiday parties, and cholesterol) • A series of e-mails reinforcing the value of generics 87. How frequently and on what basis does Vendor evaluate the formulary drugs chosen for utilization in Vendor's program? Please provide a list of Vendor's formulary Brands. The Humana National Pharmacy and Therapeutics committee meets on a quarterly basis to discuss and review pharmacy issues. A main function of the committee is the review and evaluation of new medications as introduced to the market, as well as the review and evaluation of current medications as new information becomes available. The Pharmacy and Therapeutics committee is responsible for the approval of medications included in the Humana Pharmacy Solutions Drug List and those needing special monitoring, and, subsequently, prior authorization. New medications are considered as quickly as possible based on available information. Medications can be added to the drug list as early as their initial release date based on the urgency of availability and alternatives currently in place on the Drug List. Please refer to Attachment Q for a copy of Humana Pharmacy Solutions Select Group Medicare Drug List which shows brand drugs on tiers two and three. 88. What innovative programs and services are in development now or to be developed in the near term that would be of benefit to the City and their drug plan members? Humana Pharmacy Solutions has many innovative programs and services that would benefit the City and their drug plan members. These programs are continuously being enhanced to better service Humana Pharmacy Solutions' clients. Maximize Your Benefit Rx Maximize Your Benefit Rx is designed to help educate and inform Humana pharmacy benefit members as to their various prescription drug cost options. Many prescriptions, particularly prescriptions for brand name drugs, have lower cost generic alternatives available. When Humana Pharmacy Solutions identifies such medications or a category of medications that have efficacious alternatives that will save the member money on their prescription drug costs, a Maximize Your Benefit Rx program will be created and implemented to inform the member of these opportunities. Together with Humana Pharmacy Solutions' competitive benefit structures including Rx3 and Rx4, Maximize Your Benefit Rx is helping to convert over seven to 10 percent of targeted members on a third tier drug. Why Generics Why Generics is a program to promote the use of generics, members still need to be encouraged and reminded to take advantage of the cost savings associated with generic medications. Studies show that members will participate in activities if: • They understand how the activity can help them reach their lifestyle goals • They trust the source of the information • They have an incentive to change a behavior • They are reminded to participate City of Corpus Christi 54 HUMANA. Guidance when you need it most When employers reinforce the message, employees take notice. To that end, Humana Pharmacy Solutions developed a "tool kit" to help employers encourage their employees to use generics. The kit includes: • A series of posters designed to illustrate the savings associated with generic medications and how that savings can help them achieve their lifestyle goals (i.e., make home improvements, buy a new television, take a family vacation) • A payroll stuffer explaining what a generic medication is, how generics can save money, and how members can find out more information • A series of newsletter articles correlating to seasonal events (i.e., spring allergy season, holiday parties, and cholesterol) • A series of e-mails reinforcing the value of generics Medication Therapy Management Medication Therapy Management is a quality program to maximize therapeutic outcomes with medication use. It is designed to reduce risk for adverse events and to address over or under utilization issues. The program targets beneficiaries with: • Two or more chronic conditions • Eight or more system Medicare Part D medications • Anticipated drug spend of $4,000 or higher per year Humana's approach to its Medication Therapy Management program differs from its competitors because the program provides tailored medication therapy management techniques based upon the beneficiary's level of risk and severity. Members with the most acute severity and the highest risk are encouraged to visit a local Medication Therapy Management - certified pharmacist. The Medication Therapy Management registered pharmacist is trained to provide tailored medication therapies and services to assist the member in attaining a positive clinical outcome. In cases where the member is at a lower risk level and the condition is less severe, Humana provides medication therapy management services by telephone. These telephonic sessions are conducted by a nurse or highly qualified technician. Humana also has an educational program for medication therapy that is comprised of mailings and Web tools for members who have little to no risk or severity level. For those members who are not eligible for Medication Therapy Management, Humana Pharmacy Solutions offers an extension of Medication Therapy Management called RxMentor. RxMentor RxMentor is a pharmacy consultation program. Humana Pharmacy Solutions invites Medicare- eligible members to use the RxMentor program if they: • Use multiple medications, but lower than the MTM threshold • Are referred from other Humana Pharmacy Solutions clinical programs • Have met a projected annual drug expenditure of $4,000 or more An outbound call is made to the member inviting them to join the program and schedule a pharmacist consultation. After the consultation is scheduled, the member receives an outbound call from the pharmacist, who offers the member a comprehensive medication review. The typical RxMentor consultation will focus on: • Medication adherence • Safety to avoid adverse reactions from potential drug interactions City of Corpus Christi 55 HUMANA. Guidance when you need it most • Drug information and health literacy • Gaps in medication therapies • Possible medication alternatives After the consultation, the member and the member's physician(s) will receive a follow -up communication alerting them to any potential medication issues and requesting a prescription for a lower - cost medicine when appropriate. Members benefit by: • Learning about their medications • Learning about possible lower -cost alternatives • Gaining improved quality of life • Avoiding acute episodes of illness • Enhancing health literacy Humana Pharmacy Solutions will provide reports on an ongoing basis and will be tracking a number of metrics to evaluate the impact of the program and member based outcomes. 89. Does Vendor offer a 90 -day "at retail' program in conjunction with mail service for maintenance medication fulfillment? Yes, Humana Pharmacy Solutions has 45,636 pharmacies in its broad national network that offer 90 -day at retail services for maintenance medications. 90. Specify the data available on -line at the retail level when prescriptions are ordered and filled. Claims that are received from pharmacies through retail pharmacy switching networks by Humana Pharmacy Solutions' point -of -sale system are processed real -time, and responses are provided to pharmacies within seconds if the claim submitted is accepted or rejected. Claims are accepted or rejected based on system edits and the benefit parameters set up in Humana Pharmacy Solutions' claims processing system. For claims that are denied no financial reimbursement occurs. Pharmacies must submit another claim that can be accepted. For claims that are accepted, financial reimbursement to the pharmacy occurs once per every 10 -day cycle. Humana Pharmacy Solutions is compliant with the Texas prompt pay law. 91. Explain your organizations specialty pharmacy capabilities. Describe the flow of services through the dispensing facility. Currently, specialty pharmacy services are provided through two main avenues at Humana Pharmacy Solutions: the preferred specialty channel, which includes contracted specialty pharmacies; and retail pharmacies in Humana Pharmacy Solutions broad national network. Because discount rates through the preferred specialty channel are typically greater than retail pharmacies, the member cost share is lower when coinsurance is applied. Humana Pharmacy Solutions offers its members and providers the opportunity to use its preferred specialty channel to provide cost savings, help manage compliance, and offer clinical support for any high cost bio- pharmaceutical. Discounts are typically 200 to 300 basis points better than Humana's national retail network, although some drugs may have even deeper discounts when obtained from Humana's City of Corpus Christi 56 HUMANA® Guidance when you need it most preferred specialty channel. Specialty drugs may be obtained via retail where access to the medications is a concern, but it is significantly more cost effective and beneficial to use the preferred specialty channel due to the cost savings, and the added benefit of the associated clinical programs. Humana Pharmacy Solutions preferred specialty pharmacy channel can provide medications to members in multiple ways. Medications can be shipped to: • The patient's home for self - administration or health care practitioner administration • The provider's office for administration • Another location of patient's choosing In addition to customized shipping, members receive education regarding drug administration, as well as prescription counseling and disease management materials. Case managers are also available to assist members by designing patient - specific care plans. For chronic medications, continuous delivery and follow -ups are scheduled based on member's needs. Members receive follow -up calls to remind them when it is time to refill a prescription. These value -added services allow for better care and management, as well as improved outcomes, and are included at no additional cost. Humana Pharmacy Solutions' specialty vendors' customer service units are available during normal business hours from 8 a.m. to 6 p.m., member time zone. Pharmacists and registered nurses are on call 24 hours a day, seven days a week, to assist clients, patients, and physicians with clinical situations. 92. Provide a flow chart illustrating your organization's traditional and medical COB processes and what options are available to the city. Humana's coordination of benefits process is described below. A flowchart is not available at this time. The retiree is asked to supply other health coverage information when enrolling in a Humana health plan. When a claim is filed, this information must be current in the system. Whenever a dependent enters the plan, coordination of benefits (COB) information is required as part of the enrollment process, and is updated annually. The existence of other coverage is a required field in Humana's claims processing system. If the field indicator is blank, the claim is pended, and the member is contacted to obtain an answer as to the existence of other coverage. COB information is gathered from a member's application, a submitted claim, a member's correspondence (letter) to Humana, a phone call to Humana, or a phone call from Humana via Eliza Services, its voice activated technology system. When an individual is covered under more than one group plan, he/she is entitled to benefits up to, but not exceeding, the total allowable expense. Humana applies the birthday rule provision for dependents. The birthday rule is as follows: If there is a couple who both have Humana health coverage, the subscriber whose birthday (based on month and day) occurs the earliest in the calendar year is considered to be the primary provider of coverage. COB information is updated/investigated at the beginning of the individual group's effective date with Humana. The investigation process begins with a call from Humana's VAT system. If a response is City of Corpus Christi 57 HUMANA. Guidance when you need it most received, the member's information is updated, and Humana will contact the member again the following year unless a claim is submitted with conflicting information. Upon receipt of a claim, the claim is pended if updated COB information has not been provided by the member. Outbound telephone calls are made to the member in an attempt to obtain the other insurance information. After eight attempts to contact the member or two messages are left on an answering machine, a letter is generated requesting the information. The claim is pended for 45 days, awaiting a response from the member. If no response is received, the pended claim and any additional claims are rejected since the claims cannot be processed without additional information. Upon receipt of the necessary information, claims are reprocessed and reconsidered for payment. Current members who have had no other insurance in the past and whose COB information is up for renewal will go through the proactive COB investigation. If members do not respond to its attempts to verify COB information, Humana does not begin rejecting claims. Humana will pay the claims but send the member a letter requesting COB verification. A letter will be generated for each claim that is received but will be sent only if another letter was not sent to the member in the past 21 days. 93. Describe in detail your coverage management program e.g. dose optimization, step - therapy and prior authorization. Prior Authorization/Step Edits Prior authorization is a mechanism used by Humana Pharmacy Solutions that requires a physician to pre- approve a drug that they prescribe to a member. The physician provides information to ensure the correct dosage, indication, and make sure that preferred products are used first, in order for the member to receive the prescription at a network pharmacy. During the approval process, the physician responds to a series of clinical questions, which are based on criteria for the appropriate use of the respective medication. These criteria are based on FDA approved, durations of treatment, or maximum dosing limits for a particular disease state. Prior authorization is an important program because it decreases inappropriate utilization and drives members to used lower cost alternatives. Step Edits, a component of the prior authorization program, are used to drive members toward a first line medication for targeted medications. Common targeted medications are non - sedating antihistamines, sleep aids, leukotriene inhibitors, and urinary anti - spastics. When a request is received for a targeted medication, the member's prescription claims history is reviewed to see if first line medications have been utilized prior to the request. If historical claims identify first line medications, the request is automatically adjudicated at the appropriate copayment level. If not, the member is directed to take an alternative medication. Step Edits (sometimes referred to as Step Therapy) positively impacts overall trend and pricing by requiring members to utilize first -line medications, usually generics, to treat a condition when clinically appropriate. These generic medications are usually on average around 80 percent cheaper than the brand name alternatives that treat the same condition. Quantity Limits Quantity limits promote appropriate utilization of pharmaceutical products, enhance patient safety and compliance, and can provide cost savings to the patient and the health plan. Humana Pharmacy Solutions estimates that a managed dispensing limits program can potentially save a plan $1.00 per member per month. .2ity of Corpus Christi 58 HUMANA. Guidance when you need it most 94. Describe in detail your concurrent and retrospective drug utilization programs. Humana Pharmacy Solutions identifies drug utilization problems primarily via prospective and concurrent drug utilization review and clinical services. Humana Pharmacy Solutions reviews scientific information, conducts literature searches, and stays abreast of developments in pharmaceutical research and development in order to identify and prevent drug utilization problems from occurring. Drug utilization review issues which Humana Pharmacy Solutions monitors includes: excessive utilization, min/max dosing, drug -drug interactions, duplicate therapy, availability of preferred or cost - effective alternatives (i.e. generics), late refill, multiple pharmacies /providers, drug- disease contraindications, and appropriate medication selection (via step therapy). Humana Pharmacy Solutions' online concurrent drug utilization review program performs online, real time editing of drug therapy prior to prescription dispensing. Alert messages are sent to the pharmacy when drug inconsistencies are identified. These messages, at the point of service, enable the pharmacist to educate the patient and consult the prescriber when appropriate. In addition to identifying potential drug interactions and/or compliance issues, online messages signal the pharmacist to check for other potential problems, such as, early refills, excessive drug use, and therapeutic duplications. Humana's database contains the patient's retail and mail order claims history. Humana Pharmacy Solutions' online excessive utilization edit is considered a hard edit, denying payment at the point of service when edit parameters are not met. In appropriate situations, however, these denials can be overridden. Humana Pharmacy Solutions initiatives also include implementing preclusive edits at the point -of- service. Preclusive edits monitor the use of a new drug (class) in relationship to the current medications a member has been prescribed by a medical professional. The preclusive edit takes place at the point -of- service, where it compares the new medication with the current medication. These edits are based on RDA guidelines and clinical appropriateness. For example, if a member is currently taking the drug Actos and they go to the pharmacy to fill a prescription for Tequin, Humana Phrmacy Solutions will not let the pharmacist fill the prescription for Tequin because the two drugs could react with each other causing a negative effect to the patient. 95. Does your organization contract directly, own or subcontract your pharmacy network? If not owned, provide details of arrangement including length of contract. Humana Pharmacy Solutions contracts directly with the 61,251 retail pharmacies in its broad national network, and owns RightSourceRx, a mail order pharmacy with locations in Phoenix, Arizona and Cincinnati, Ohio. City of Corpus Christi 59 HUMANA. Guidance when you need it most 96. Provide 2 different client examples that demonstrate actual dollar savings from prescription drug utilization review /management programs including measurable results and savings methodology. The following example is for a 16,000 - member group for which Humana Pharmacy Solutions provided a utilization review to compare their current utilization with Humana's book of business. The utilization review showed the following: Proton Pump Inhibitors 1)rii,4 Omeprazole Utilization Humana 22 percent ( u rrtul 10 percent Prevacid Utilization 11 percent 35 percent Cost per day Omeprazole: $1.18 Prevacid: $5.00 Diabetes 1,ru;; Metformin Utilization 1ItiE kal,a 25 percent ( urrcui 21 percent Januvia Utilization 0.61 percent 1.52 percent Cost per day Metformin: $0.41 Januvia: $5.00 Humana Pharmacy Solutions "net cost" approach favors the drug with the lowest total net cost, thus creating an annual savings for this client of $500,000. Humana Pharmacy Solutions will be happy to provide additional specific client examples upon selection as a finalist. 97. Explain your organizations mail order capabilities. Including process for initial fill and subsequent refills. RightSourceRx has the capability to dispense 59,000 prescriptions per shift and our facilities offer best -in- class quality and performance efficiencies. RightSourceRx offers a number of technological features designed to assist its personnel in providing quality medications safely and conveniently. • Prescriptions are sent to an automatic capping machine, where a cap is placed on the vial along with a heat sealed foil lining to insure the integrity of the vial contents. • Pharmacists consult the Imaging Technology database for prescription verification purposes. • Customer service representatives also utilize images of customer records in order to quickly and efficiently respond to inquiries. RightSourceRx employs a dedicated, specially- trained pharmacy staff that identifies prescriptions appropriate for intervention activities according to client - specific plan designs and established clinical criteria. Intervention activities may include contacting prescribers and patients regarding "dispense as written" prescriptions, activities directed toward formulary compliance, patient compliance with medication regimes, and other related clinical issues as determined by the client. Initial Fill Ordering from RightSourceRx is easy. For the initial order, the patient completes a registration and order form. The patient mails the registration and order form, the original prescriptions, and the appropriate copayments to the mail service pharmacy. Patients may also submit their completed forms to a physician who faxes the prescription directly to RightSourceRx. Once the initial order information is entered into the mail service database, the member has the option of ordering refill prescriptions by phone, fax, or online. City of Corpus Christi 60 HUMANA. Guidance when you need it most Subsequent Refills Patients who choose phone refills can call a dedicated toll -free number and order refills using a touch - tone phone. The toll -free number for the touch -tone refill service is dedicated solely for phone -in refills. A separate number is dedicated to the customer service department. Should a touch -tone caller repeatedly fail to execute the proper steps or if the online edits detect that the prescription is not eligible for refill, the call automatically transfers to the customer service department. The touch -tone refill service prompts participants through a series of simple order steps. The participant is asked to enter the prescription refill number, delivery zip code, and a credit card number and its expiration date. Participants can exit and speak to a customer service representative during any step in the process. In addition, a call automatically transfers to a customer service representative if the caller repeatedly fails to execute the proper steps or if the online edits detect that the prescription is not eligible for refill. The touch -tone refill service is provided in English only. Patients may also refill their prescriptions by completing doctor fax forms. This form is provided as a part of the original prescription, and is available via the Internet or through the benefit administrator. The completed form must be submitted to a prescriber who may fax the form to RightSourceRx. Only a prescriber's fax will be accepted. Patients may choose to refill their mail order prescription over the Internet 24 hours a day, seven days a week. By visiting Humana's Website, Humana.com, members need only fill in the prescription number provided on the mail order prescription label, zip code, and credit card information. Information is transmitted securely as it passes between the mail order facility and the member's computer through data encryption, a sophisticated encoding system that prevents personal information from being recognized or altered. Prior to the last refill of a prescription being dispensed, an email message is sent to the member to alert them that there is only one refill left for the medication. The email also directs the member to call their doctor to request a new prescription, and contains a link to an instructional document that tells the member how to submit a new prescription to RightSourceRx. This information is also provided to the member via an outbound telephone call. Members also receive renewal instructions, a refill request slip, and an order form with each prescription. This personalized information includes how many refills are available under that prescription, the date after which refills may be ordered, and a form for the prescriber to enter additional refills when the current number expires. Members may mail in the new prescription to RightSource Rx, or may have their doctor fill out and fax a Physician Fax Form. This form is provided as a part of the original prescription, and is also available via the Internet or through the benefit administrator. The completed form must be submitted to a prescriber who may fax the form to RightSourceRx. Only a prescriber' s fax will be accepted. If a member uses a self- service option to order a refill of a prescription that either has no refills remaining or has expired, RightSourceRx will fax the member's physician for a new prescription. City of Corpus Christi 61 HUMANA. Guidance when you need it most 98. Do you own your mail order facility? If not, name subcontractor along with length of current contract. Yes, in January 2006, Humana Pharmacy Solutions opened its state -of- the -art mail -order facility, RightSourceRx. This home - delivery service is available to all Humana Pharmacy Solutions members. In 2006, RightSourceRx, processed 582,063 prescriptions. This number grew to more than 2.7 million in 2007. In its third year of operation, RightSourceRx has grown to dispensing more than 120,000 prescriptions per week, and has dispensed over 5 million prescriptions in 2008. H. Communications and Enrollment If your response differs for medical and pharmacy, you must provide details for each program separately. 99. Will you be willing to have representatives available at annual enrollment meetings to answer questions? Please keep in mind City employees work at various locations, around the clock. Yes, Humana assists with the retiree open enrollment meetings including providing promotional items, ensuring necessary meeting equipment, providing sales support, etc. provided a minimum of 25 or more Medicare beneficiaries is guaranteed to attend each retiree meeting. Meeting costs must be reasonable and mutually agreed upon in advance of any meeting. Humana employs an experienced Medicare sales team in each market that has met stringent CMS compliance requirements. Humana's Medicare sales representatives assist retirees in answering any questions as well as enrolling interested eligible retirees. In select markets, Spanish - speaking representatives are available. Humana is confident that its sales professionals understand the senior marketplace and will provide excellent resources and knowledge to the City's retirees. 100. What unique approaches are used to communicate with retirees? Humana' s enrollment approach allows retirees to be active in the enrollment process while receiving assistance from Humana's specially - trained enrollment staff. Humana deploys a multi - pronged, comprehensive communication and enrollment strategy. Written information and group seminars will be offered to beneficiaries. Humana's nationwide network of dedicated Medicare sales representatives are trained and certified by Humana. The representatives ensure that beneficiaries have the information and guidance they need when they need it. The `Let's Talk' campaign even features one -on -one guidance for seniors and their families. Humana's Medicare Direct Marketing Services call center can be a valuable tool to assist with enrolling eligible beneficiaries. The call center has the ability to contact every retiree via outbound calls inviting them to attend a group seminar or to arrange in -home appointments. On an inbound basis, the call center can collect meeting RSVPs and provide other logistics services. Humana will make earnest attempts to reach out to every single eligible retiree and family member for initial and subsequent enrollments. 101. Are EOBs mailed for in- network and out -of- network services? If so provide a sample. Medical Any claim that, when processed, indicates member responsibility will generate an EOB. This includes claims that are denied and out -of- network claims. Providers receive remittance payments for services ;ity of Corpus Christi 62 HUMANA. Guidance when you need it most performed if these services are not capitated. EOBs are issued to RPPO members for claims that are either paid or rejected. Pharmacy Experts from Humana conducted extensive research asking seniors what they wanted to see in a health benefits statement regarding their pharmacy expenses. Consumers said they want an EOB that clearly and easily explained Part D benefits, as well as one that provided personalized guidance regarding quality of care, healthcare spending, pharmacy expenses, and overall healthcare decisions. Humana responded by developing a pharmacy EOB called the SmartSummary Rx. In 2008, Medicare Advantage members began receiving a SmartSummary Rx that also includes medical claims. Members receive the following based on plan type: • Medicare Advantage Only members receive a monthly medical SmartSummary statement each month they incur medical claims. • Medicare Advantage with Prescription Drug Coverage members receive a monthly consolidated medical and prescription SmartSummary each month they incur medical claims or Part D prescription claims. • Prescription Drug Plan members will continue to receive a SmartSummary Rx statement as their Part D EOB. Please refer to Attachment L for a sample medical EOB and to Attachment M for a sample SmartSummary statement. 102. Are EOBs automatically produced by the claims administration system? Yes, EOBs are automatically generated for every PPO claim regardless of whether or not the claim is paid or denied. EOBs for prescription drug claims are provided through Humana's monthly SmartSummary Rx statement. Medicare Advantage members will receive a monthly consolidated medical and prescription SmartSummary each month they incur medical claims or Part D prescription claims. 103. Does the EOB show the amount of deductible that the retiree has yet to satisfy? While Humana's EOB does not show the status of the deductible or other inside plan limits, the EOB shows the out -of- pocket maximum once it is reached. In addition, the status of the deductible is presented on members' SmartSummary statements. 104. What is the average I.D. card turnaround (number of days between employer reporting a new member and plan mailing I.D. card)? The City's members will receive their Medicare Advantage ID cards within seven to 10 business days from receipt of a clean enrollment file from the group. City of Corpus Christi 63 HUMANA® Guidance when you need it most 105. Please provide a copy of a new member communication /orientation package. Humana sends its Medicare Advantage enrollees a welcome kit at no additional charge. Welcome kits are mailed as applications are received and processed. The welcome kit includes: • Welcome letter • Summary of benefits • Guidebook • Grievance and appeals procedures • Privacy notice • Extra services brochure • Directory • Rx benefit summary (schedule), if applicable • Rx drug guide (formulary), if applicable • RightSourceRx brochure (Rx home delivery service) Please refer to Attachment N for sample welcome kit materials. 106. Describe your communication strategy and tools to encourage consumerism and help educate retirees about their health. Through many years of Medicare experience, Humana has developed a plan with consistent results. Humana has prepared a campaign targeting the retiree population, which clearly explains the benefit plans and the value available to members. For the City, Humana offers a comprehensive campaign with preliminary mailings introducing Humana, along with some of the services available. If requested, Humana can also send out seminar invitation reminders after the informational kits are mailed. Mail dates will be based on the enrollment period, effective dates, and the client review process. Please refer to Attachment 0 for an overview of Humana's Medicare Advantage member communications experience. Informational kits should be mailed at least two weeks before the enrollment period begins. The informational kit includes: • Introduction Letter • Informational brochure • Summary of benefits • Application • Seminar invitation (if applicable) • Prescription drug benefit summary • Pharmacy chain flyer Welcome kits are mailed as applications are received and processed. The welcome kit includes: • Welcome letter • Summary of benefits • Guidebook • Grievance and appeals procedures City of Corpus Christi 64 HUMANA® Guidance when you need it most • Privacy notice • Extra services brochure • Directory • Rx benefit summary (schedule), if applicable • Rx drug guide (formulary), if applicable • RightSourceRx brochure (Rx home delivery service) A letter acknowledging receipt of the member's application and ID cards will be mailed within three weeks after enrollment. Within four to six weeks after enrolling, the member will receive: • Confirmation letter • Evidence of Coverage • Coordination of benefits survey The following communication materials are sent to members on an ongoing basis throughout the plan year: • Welcome call/health risk assessment • Letters • Enrollment • Claims • Grievance and appeals • Disenrollment • Billing (if applicable) • Explanation of benefits • Clinical guidance — case, disease, and pharmacy management • Phone calls • Letters • Booklets • Humana Active Outlook program mailings • SmartSummary statement • Humana Active Outlook (HAO) magazine (quarterly) • Annual notice of change /evidence of coverage (annually) • Letter (describing any changes in their plan for the upcoming year) • Evidence of coverage for upcoming year • Prescription drug guide • Renewal Kit (annually) • Letter • Prescription drug schedule • Benefit summary • Guidebook • Extra services brochure • Directories (annually) • Surveys • Working aged (annually, MA and MAPD groups) City of Corpus Christi 65 HUMANA® Guidance when you need it most I. Reporting 107. Describe enhanced reporting capabilities beyond your standard reporting package. Describe any additional fees for ad hoc or special reporting. Humana provides standard reporting to its Medicare Advantage groups on a quarterly basis. Humana's claims and related operating systems are fully integrated and in- sourced allowing Humana to provide the City a vast array of reports using its preferred method of delivery. Humana's capabilities range from providing a standard set of reports to customized ad hoc reporting to delivery of a detailed claims file to a data management firm. As part of Humana's initial planning /implementation meeting, it will work with the City to design a reporting plan that aligns with the City's specific needs. As an industry- leading Medicare Advantage plan, Humana generates thousands of internal and external (e.g. CMS) reports relating to the areas referenced in this questionnaire. Humana provides its standard reporting package at no cost to the City. Humana is willing to discuss customer- specific reporting needs; including details such as scope, frequency, contact, and associated costs prior to making commitments in connection with client- specific reports. Any applicable fees can be negotiated at the time of the request. 108. Do you have normative data against which the city's claims experience can be compared? Is this included in standard reports? If not, explain. Yes, Humana's standard reporting includes comparisons to Humana's average results in that market for retirees. For the City's reporting, Humana will provide comparisons of the City's data to the data for other South Texas retiree averages. J. Customer Service and Account Management If your response differs for medical and pharmacy, you must provide details for each program separately. 109. What are the telephone hours and the office location for the member services unit that will service the City? The Medicare member service hours of operation are 8 a.m. to 11 p.m. Eastern Time, Monday through Friday, and 8 a.m. to 6 p.m., Eastern Time, Saturday (customer service hours of operation may be extended during peak operating times). An automated information line is available 24 hours a day, seven days a week. Extensive self- service functions are also available on Humana's Website, Humana.com. Humana's mail order program is serviced by RightSourceRx in Phoenix, Arizona. RightSourceRx's customer service hours are 8:00 a.m. to 11:00 p.m., Monday through Friday, and Saturday from 8:00 a.m. to 6:30 p.m., Eastern Standard Time. The facility dispensing hours are 6:30 a.m. to 3:00 p.m., Monday through Friday, Mountain Standard Time. Humana has been providing mail order services to its members since 1985. City of Corpus Christi 66 HUMANA® Guidance when you need it most 110. State what the standards are for the following? a. Length of time for a call to be answered Humana strives to answer at least 80 percent of all calls within 20 seconds. b. Abandonment rate Humana strives for a call abandonment rate of three percent or less. c. Length of time a caller is placed on hold Humana does not have a performance goal for this metric; however, the average amount of time a member is placed on hold during a call is 54 seconds. d. Maximum length of time to return a call Humana strives to resolve at least 91 percent of all member service issues during the first call. 111. What is the average speed to answer in seconds? Medical In 2008, approximately 79.6 of all calls to Humana's Medicare customer service unit were answered within 20 seconds. Pharmacy The average speed of answer for Humana's RightSourceRx mail order facility is approximately 10 seconds. 112. What is the percent call abandonment rate? Medical In 2008, the call abandonment rate for Humana's Medicare customer service center was approximately 5 percent. Pharmacy The call abandonment rate for Humana's RightSourceRx mail order facility is less than one percent. 113. What is the ratio of member services staff per 1,000 members? Medical The ratio of Group Medicare Customer Care representatives to members is 0.78 to 1,000. Pharmacy The ratio of Humana's RightSourceRx mail order customer service staff to members is 1.42 to 1,000. City of Corpus Christi 67 HUMANA. Guidance when you need it most 114. Identify the specific services and information a member would access via your toll-free number with regard to eligibility, benefits, pre - certification, claim questions, network information, complaints, etc. Medical The Humana interactive voice response system is available to members, providers, and plan sponsors. The member module provides the following options: • Eligibility • Basic benefit information and copayments • Claim status • ID card request The provider module offers the following options: • Eligibility • Selected benefit information and copayments • Claim status • Claim mailing address • Precertification status • Precertification initiation/creation • Faxback option The plan sponsor module offers the following options: • Eligibility • Billing • ID card requests • Policy changes Pharmacy The RightSourceRx mail service customer service phone staff is available to answer routine order status questions, take refill orders, and perform other related functions. Benefits communications come directly from Humana. Upon request, a customer service professional transfers the caller to a pharmacist for consultation. A pharmacist is always on duty in the mail service pharmacy customer service unit. 115. Do you have a correspondence tracking system to log in, assign, and track correspondence? Yes, Humana's Customer Care Portal is a logging, tracking, and contact resolution tool used to provide Humana's world class customer service. This intranet -based application uses computer telephony integration to transfer information entered into the interactive voice response system directly to a Customer Care representative's desktop. 116. Describe the computer and phone system that supports and tracks member services calls and staffing. The Louisville Customer Service Center utilizes a Nortel Meridian Option 81C phone system with Symposium Call Center Server, enabling skills -based routing to Customer Care representatives. Over 800 lines connect Humana's Louisville Customer Service Center to members and providers. An interactive 42ity of Corpus Christi 68 HUMANA. Guidance when you need it most voice response system allows plan members, providers, and agents/brokers access to claim status and eligibility records. Call flow data analysts and operations supervisors are responsible for system monitoring and reporting. The Louisville Customer Service Center utilizes quality monitoring recording, announcements, and on -hold music technologies. Humana also uses the Customer Care Portal, which is a logging, tracking, and contact resolution tool used to provide Humana's world class customer service. This intranet -based application uses computer telephony integration to transfer information entered into the interactive voice response system directly to a Customer Care representative's desktop. Within the Customer Care Portal, the user can efficiently service customers through various windows of information. Examples include: • Eligibility information • Summary of benefits (customized to each plan) • Detailed benefits (customized to each plan) • Claims status information (claims summary, claim detail, and claim search) • Update, add, and change demographics • Update, add, and change other insurance information • Provider participation information • Links to required information regarding communication center procedures, processes, FAQs, product specific information, and precertification /review and disease management lists The Customer Care Portal allows simplified logging and tracking of customer contacts. These include: • Transaction logging • Autologging of information given to contact • Identification of contact type (member, provider, agent, broker) • Category, reason, and disposition of each contact • Transaction history • Internal messaging or tasking to other business units • Alert functionality (group and member specific information) • Reporting to support daily operations 117. What percentage of participant calls is recorded? Medical Humana's phone system records 100 percent of calls made to the customer service center. Pharmacy RightSourceRx records 100 percent of all member calls. City of Corpus Christi 69 HUMANA. Guidance when you need it most 118. What is your initial call resolution rate? Medical In 2008, the initial Medicare customer service call resolution rate was 63.4 percent. Pharmacy RightSourceRx has an initial call resolution rate of 95.31 percent. 119. Will your member services department support the City's annual enrollment by answering questions from retirees or providers participating in your network? Yes, Humana offers a call center located in Tampa, Florida that receives inbound calls specifically for open enrollment questions from retirees. The toll -free phone number for this unit is 800 - 824 -8424. Humana also offers a toll -free customer service number that providers may call for any questions. 120. Can I.D. cards be customized for the City? Humana attempts to honor clients' requests for ID card customization; however, Humana's Medicare Advantage health plans are prohibited from adding the names or logos of other vendors or co- branded network partners on its member ID cards per CMS regulations. 121. Provide a detailed list of the types of plan services participants can perform via internet, IVR and service representative. Medical Interactive Voice Response System The Humana interactive voice response system is available to members, providers, and plan sponsors. The member module provides the following options: • Eligibility • Basic benefit information and copayments • Claim status • ID card request The provider module offers the following options: • Eligibility • Selected benefit information and copayments • Claim status • Claim mailing address • Precertification status • Precertification initiation/creation • Faxback option City of Corpus Christi 70 HUMANA. Guidance when you need it most The plan sponsor module offers the following options: • Eligibility • Billing • ID card requests • Policy changes Customer Care representative Members can also speak to a Customer Care representative for questions about their benefits, provider network status, claim details, and for any other plan - related questions they may have. MyHumana at Humana.com Through their personal MyHumana page, retirees have a variety of information available to them. Information is displayed in panels allowing easy navigation. Employees can view plan administration details, use health and well -being tools and references, and check their financial status relating to plan benefits. These capabilities include: • Access claim history, benefits summaries, and eligibility verification • An online electronic version of a medical claims EOB (e -EOB) • Request replacement ID cards • View summary of benefits • Access secure message center • Utilize a multitude of pharmacy tools to: order prescription, view claims, view benefits, search for lower -cost drug equivalents, find a pharmacy, and research drug interactions • Find a physician, hospital, dentist, pharmacy and alternative medicine providers with Physician Finder Plus and a vision discount provider with EyeMed's provider finder • Maintain a personal health record to share with the member's physician, if necessary • Use specific condition centers for education and health management quizzes, calculators and assessments available to all members and those tailored to specific employers or groups of members • Compare hospitals and outcomes by procedure and condition chosen and obtain the member's estimate maximum out of pocket cost for the procedure/condition chosen • Access to health library and guides • Health Conditions Program: members can access information about programs available to all members as well as those tailored to specific groups of members through links to specific health and wellness sites • View current benefits, amounts applied toward deductibles, current total of out -of- pocket costs, and copayment history (medical and prescription drug) Pharmacy The RightSourceRx mail service customer service phone staff is available to answer routine order status questions, take refill orders, and perform other related functions. Benefits communications come directly from Humana. Upon request, a customer service professional transfers the caller to a pharmacist for consultation. A pharmacist is always on duty in the mail service pharmacy customer service unit. City of Corpus Christi 71 HUMANA€ Guidance when you need it most Humana members have access to a broad array of pharmacy related internet capabilities through the Prescription Tools and Prescription Resource sections of MyHumana. The Prescription Tools include the following: • Drug Pricing: Members can manage their prescription drug costs by researching which drugs are covered on their Humana plan and view estimated prices. • Rx Calculator: Members can estimate future drug cost by reviewing past prescription costs. • Drug List Search: Members can search the latest list of medications covered under their specific benefit plan, download a printable Drug List, and find drug authorization forms. • Drug Library: Members can explore specific medications in the Drug Library. • Mail Order Drugs: Members can research mail order cost and time savings through RightSourceRx, Humana's preferred prescription home delivery service and set up their RightSourceRx accounts from this tool. • Pharmacy Locator: Displays in- network pharmacies throughout the United States, along with useful information such as hours of operation, phone numbers, and drive- through availability. • Rx Claims: Provides members with the ability to view up to 24 months of prescription history for themselves or any covered dependents under the age of 18. The Pharmacy Resources section of MyHumana provides information about prescription and over -the- counter drugs, including tips that can help members get the most from their medications and save money. These resources include: • Drug Dictionary: Members can browse information about their prescriptions and over- the - counter medications, including storage tips and potential side effects. • Drug Interactions: This easy -to -use tool allows members to check their prescriptions for possible interactions with foods and other medications. • Patient Assistance Programs: Provides links to drug companies that provide patient assistance for prescription drugs. • Generic Alternatives: Members can research possible alternative brand -name and generic drugs. 122. Will a dedicated member service representative be available to answer City staff questions? Humana will assign a dedicated account concierge who will work with City's benefit administrators and other group contacts as well as sales and account implementation business partners. The account concierge takes a proactive approach to building a relationship with the City by serving as a single point of contact for clients to resolve escalated issues. 123. Can calls that are more appropriately serviced by other areas be automatically re- routed by member services? Customer Care representatives in Humana's Group Medicare Advantage service unit are specifically trained to address the concerns and questions of Humana's Medicare Advantage members and can answer most questions asked by members. In the event that a transfer is needed, Humana's Customer Care representatives can provide warm transfers to other areas. City of Corpus Christi 72 HUMANA. Guidance when you need it most 124. Are customer service satisfaction surveys conducted regularly? If so: a. How often and by whom? Humana has partnered with UCNBenchmarkPortal to utilize a tool called Every Customer Has Opinions or ECHO. ECHO is a customer - focused tool that provides a random outbound- automated phone survey to Humana members. ECHO surveys are conducted on a daily basis. It gives Humana an opportunity to listen to members and gauge their experience with Humana. Through ECHO, randomly selected members are asked a series of questions about their experience after their call with one of Humana's Customer Care representatives in the dedicated Medicare customer service unit. b. Can they be client specific? Humana's ECHO surveys are not conducted on a client- specific basis. c. What have the results been? Humana does not publish the results of ECHO surveys externally; instead, survey results are used to identify customer service improvement opportunities. 125. Provide information as to how the incoming mail is logged and handled. Medical Affiliated Computer Services, Inc., (ACS) located in Lexington, Kentucky, provides mailroom, imaging, and data entry services for all paper medical and dental claims mailed to Humana. Members and providers have been notified as to the correct mailing address for Claims and Customer Service. ACS's contracted service levels for turnaround require that all mail be opened, sorted, prepared, and scanned within 24 hours of receipt. Electronic data must be forwarded to Humana's claims system within a maximum of 36 hours. Humana closely monitors turnaround compliance. Both the non -paper claims received via clearing houses and the ACS electronic claim data files are routed to Humana's Customer Service Center for adjudication. The ACS images are stored on a dedicated database accessible via the Humana intranet by claim adjusters, Customer Care representatives, or others who have a business need to work with claims. Pharmacy Mail is delivered to RightSourceRx daily at 3:30 a.m. and 6:30 a.m. local time and opened and batched in orders of 25. Orders are scanned in batches using high volume scanners. Checks are automatically separated by the scanners. DLN numbers (the equivalent of bar code numbers) are sprayed onto the documents in each order during the scanning process. Orders are stored numerically by batch number. Orders are routed to clerks to be data perfected through optical recognition. Orders are then electronically routed to the Item Entry queue to be entered into the MailRx prescription processing system by a licensed pharmacy technician. City of Corpus Christi 73 HUMANA. Guidance when you need it most K. Performance Guarantees If your response differs for medical and pharmacy, you must provide details for each program separately. 126. Provide performance guarantees detailed connection with the implementation of services and for those services that are to be provided on an ongoing basis. The details of these guarantees will be negotiated during the finalist selection process. For the standards listed below please indicate whether or not you will agree to the performance standards and the percent of fees you are willing to put at risk. The Proposer will be expected to conduct regular internal audits and report the results to the City for use in enforcing performance guarantees. If you are not willing to meet the proposed standard, please explain and propose an alternative performance measure. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 127. Member ID Card must be processed and mailed to participant within ten (10) working days of member's data being submitted by City staff. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 128. 90% of all City enrollees' calls routed to the selected Contractor's automatic call distribution system unit shall be answered and serviced within an average of 45 seconds during normal business hours. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 129. 95% of all enrollees/providers' appeals shall be resolved within 60 days of receipt. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 130. At a minimum, the City requires the following claims service guarantees: a. All enrollees' clean claims will be paid within a minimum of 14 calendar days from receipt date. b. 93% of all claims will be correctly coded. c. 93% of all claims will be accurately processed. d. 95% of all claims will be paid accurately. e. 95% of all claims will be accurately coordinated with other plans. f. 99% of all claims will be financially drafted correctly. g. 95% of all City enrollees claims submitted by the Contractor to the insurer shall be paid within 21 days of receipt. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. City of Corpus Christi 74 HUMANA® Guidance when you need it most 131. Selected Contractor shall provide a quarterly report indicating their compliance with their published performance standards. Proposers shall provide monetary remedies for failure to meet their performance standards. Describe how you will monitor your performance of these standards. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 132. The Contractor must guarantee that accurate management reports will be delivered no later than the agreed upon due date. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 133. The Contractor must guarantee at a minimum, that enrollment data provided by the City will be loaded into the Proposer's enrollment system within 24 hours of receipt. An eligibility discrepancy report must be provided to the City within seven (7) working days following receipt of enrollment data. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 134. What level of in- network discount guarantees will you give to the city? Detail how this discount will be calculated. Humana does not offer discount guarantees for its fully- insured Medicare Advantage plans. L. Contract 135. PROPOSER SHALL PROVIDE ALL CONTRACT DOCUMENTS THAT CITY WILL BE REQUIRED TO SIGN. SAID CONTRACT DOCUMENTS SHALL BE COMPLETED AND SIGNED BY PROPOSER'S AUTHORIZED REPRESENTATIVE AND SHALL BE READY FOR CITY'S COUNTER - SIGNATURE. Humana has provided a sample contract in Attachment A. Humana cannot provide a completed contract for the City to sign until the business is awarded to Humana and all coverages, requirements, and contract terms have been established. Please refer to Attachment A for a sample contract. City of Corpus Christi 75 HUMANA. Guidance when you need it most SECTION 3.6 RATE SCHEDULE 1. Quotes shall be provided net of fees and taxes. The City will not pay commissions and/or fees to an agent or broker working on behalf of Contractor. Any commission/fees must be paid to the agent/broker by the Proposer at Proposer's expense. Any such fees paid or to be paid must be fully disclosed including specific amounts/percentages and the name and address of the individual or organization to whom said fees are paid. Humana's Medicare Advantage quote and taxes for the City have been provided net of commissions. Please refer to Section VIII for Humana's quote for the City. 2. Rates must be guaranteed for a one -year period of time. Extended rate guarantees are invited. Fully detail any contingencies impacting rate guarantees. For Medicare Advantage products, a large portion of the required revenue to cover expected claims comes from the Centers for Medicare & Medicaid Services (CMS) reimbursement. The Medicare reimbursement levels are adjusted on an annual basis and carriers are notified through a CMS publication in April. The renewal rates for the following year will not be available until late June of the current year (e.g., January 2010 renewal rates will not be available until at least late June 2009). Due to CMS regulations, Humana cannot guarantee monthly Medicare premium rates. Humana has provided a five -month rate and can provide a 12 -month rate for 2010 once these rates have been finalized. 3. Please explain your renewal rating methodology. The following is Humana's Group Medicare rating methodology for renewals: Humana uses both adjusted community rating and experience rating or a blend of the two methodologies to determine premiums for its Medicare Advantage group offerings. The rating methodology used varies based on group size and credibility. Experience rated groups, including the City, use the following formula: Calendar Year 2007 Claims - Pooled Claims = Claims net of Pooled Claims x Pooling Charge x Trend x Benefit Adjustment Factor = 2009 Projected Claims The following formula is used to determine the final group /member premium: 2009 Projected Claims + Retention - CMS Medical and Rx Payments = Group/Member premium City of Corpus Christi 1 HUMANA® Guidance when you need it most EXCEPTIONS Proposer: Humana Insurance Company Document Exceptions Proposer shall clearly state the exception and the reason for taking exception. Proposer shall describe each item and state clearly any price consequences. Important Note: The Proposer must complete this form. If the Proposer has no objection or exception, the Proposer should indicate "NONE" on this page. This completed form must be included with each copy of the proposal submitted. Clarifications and exceptions for the requested services and requirements have been outlined below by section. 2.39 Indemnification Contractor shall fully indemnify, defend (with counsel satisfactory the city), save, and hold harmless the city of corpus christi, its officers, employees, representatives, and agents (indemnitees) against any and all damages, losses, property losses and damages; personal injuries, (including without limitation, workers' compensation and death claims), judgments, claims, and any other damage or loss of any kind, arising out of or in connection with contractor's performance, under this agreement, including all expenses of litigation; court costs; and attorneys' fees. This indemnity shall survive termination of this agreement. To the extent not prohibited by the statutes of the state of texas and the texas constitution, the city shall indemnify, save, and hold harmless the contractor, its officers, employees, and representatives against any and all damages, losses, judgments, claims or other monetary losses recovered from the proposer on account of any property loss or damage of any kind, or any other kind of damages which are attributable to the city's gross negligence, willful acts or omissions (as determined by final judgment of a court of competent jurisdiction which is no longer subject to appeal or further review) while receiving services under this agreement and including all expenses of litigation, court costs, and attorneys' fees incurred by the city in connection with defending itself in any actions resulting in these monetary losses. Humana agrees to indemnify and hold the City harmless from and against damages, claims, or liabilities that arise as a result of acts or omissions on its part or the part of its employees in the performance of the contract. Humana does not include in its contracts a hold harmless provision that indemnifies the City for general legal action from members, employees, subcontractors, or other vendors. Humana does not indemnify the City as a result of the acts or omissions of third parties, including providers of services to its members. When named as a co- defendant to any legal action, Humana retains its own legal representation. Humana is responsible for payment to the counsel retained to represent Humana, and its litigation expenses. City of Corpus Christi 1 HUM ANA Guidance when you need it most General Requirements 8. Provide a plan of comparable design and level of benefits as the current Citicare Civilian plan. The benefits should be interpreted and claims processed in accordance with the summary plan description. Highlight any deviations from the current Citicare Civilian benefits offered. See attached Exhibits A and D. Humana is proposing a Regional PPO plan that closely resembles the plans currently offered to City retirees. Please refer to Section IX for deviations from the current. 16. The City prefers online access for real time updating of the eligibility data. Humana does not offer online access for eligibility updates at this time; however, Humana can provide automated enrollment and maintenance of eligibility information for the City via electronic transfer. Adds, changes, and deletes in the standard or mutually agreeable format are requested on a weekly basis. In addition, the eligibility file is updated anytime there are additions or terminations within the City's membership or if there is a change in a member's data. 33. The City does not guarantee a minimum participation in the plan. For Humana's Medicare Advantage plans, Humana requires a minimum case size of 10 members per product. All renewing groups also require a minimum of 10 members per product. Technical Solution 126. Provide performance guarantees detailed connection with the implementation of services and for those services that are to be provided on an ongoing basis. The details of these guarantees will be negotiated during the finalist selection process. For the standards listed below please indicate whether or not you will agree to the performance standards and the percent of fees you are willing to put at risk. The Proposer will be expected to conduct regular internal audits and report the results to the City for use in enforcing performance guarantees. If you are not willing to meet the proposed standard, please explain and propose an alternative performance measure. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 127. Member ID Card must be processed and mailed to participant within ten (10) working days of member's data being submitted by City staff. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. City of Corpus Christi 2 HUMANAS Guidance when you need it most 128. 90% of all City enrollees' calls routed to the selected Contractor's automatic call distribution system unit shall be answered and serviced within an average of 45 seconds during normal business hours. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 129. 95% of all enrollees/providers' appeals shall be resolved within 60 days of receipt. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 130. At a minimum, the City requires the following claims service guarantees: a. All enrollees' clean daims will be paid within a minimum of 14 calendar days from receipt date. b. 93% of all claims will be correctly coded. c. 93% of all claims will be accurately processed. d. 95% of all claims will be paid accurately. e. 95% of all claims will be accurately coordinated with other plans. f. 99% of all claims will be financially drafted correctly. g. 95% of all City enrollees claims submitted by the Contractor to the insurer shall be paid within 21 days of receipt. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 131. Selected Contractor shall provide a quarterly report indicating their compliance with their published performance standards. Proposers shall provide monetary remedies for failure to meet their performance standards. Describe how you will monitor your performance of these standards. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 132. The Contractor must guarantee that accurate management reports will be delivered no later than the agreed upon due date. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 133. The Contractor must guarantee at a minimum, that enrollment data provided by the City will be loaded into the Proposer's enrolbnent system within 24 hours of receipt. An eligibility discrepancy report must be provided to the City within seven (7) working days following receipt of enrollment data. Humana is not offering performance guarantees in its Medicare Advantage proposal for the City. 134. What level of in- network discount guarantees will you give to the city? Detail how this discount will be calculated. Humana does not offer discount guarantees for its fully- insured Medicare Advantage plans. City of Corpus Christi 3 HUMANA. Guidance when you need it most 135. PROPOSER SHALL PROVIDE ALL CONTRACT DOCUMENTS THAT CITY WILL BE REQUIRED TO SIGN. SAID CONTRACT DOCUMENTS SHALL BE COMPLETED AND SIGNED BY PROPOSER'S AUTHORIZED REPRESENTATIVE AND SHALL BE READY FOR CITY'S COUNTER - SIGNATURE. Humana has provided a sample contract in Attachment A. Humana cannot provide a completed contract for the City to sign until the business is awarded to Humana and all coverages, requirements, and contract terms have been established. Please refer to Attachment A for a sample contract. Rate Schedule 2. Rates must be guaranteed for a one -year period of time. Extended rate guarantees are invited. Fully detail any contingencies impacting rate guarantees. For Medicare Advantage products, a large portion of the required revenue to cover expected claims comes from the Centers for Medicare & Medicaid Services (CMS) reimbursement. The Medicare reimbursement levels are adjusted on an annual basis and carriers are notified through a CMS publication in April. The renewal rates for the following year will not be available until late June of the current year (e.g., January 2010 renewal rates will not be available until at least late June 2009). Due to CMS regulations, Humana cannot guarantee monthly Medicare premium rates. Humana has provided a five -month rate and can provide a 12 -month rate for 2010 once these rates have been finalized. 4. Illustrate rates in a four - tiered format for Non - Medicare Eligible retirees: • Retiree Only • Retiree & Spouse • Retiree & Child(ren) • Retiree & Family Humana's proposal for the City includes Medicare Advantage plans only; therefore, rates for non- Medicare eligible retirees are not applicable to this proposal. City of Corpus Christi 4 HUMANA. Guidance when you need it most Proposer's Authorized Sigma Name of Proposer's Authorized Representative: James H. Bloem Title of Authorized Representative: Senior Vice President and Chief Financial Officer and Treasurer Telephone Number 502 -580 -1000 Date: April 21.2009 City of Corpus Christi REQUEST FOR PROPOSAL ADDENDUM CITY OF CORPUS CHRISTI PURCHASING DIVISION Request for Proposal No.: BI- 0153 -09 Addendum No.: 1 March 26 2009 Prospective Proposers are hereby notified of the following modifications to Request for Proposal No. BI- 0153 -09. All terms, conditions and specifications of the original Request for Proposal not in conflict with this addendum remain unchanged and continue in full force and effect. I. The following is added to this RFP as Exhibit J: Retiree Contribution Rates Since 2006 (.'''',0i'-7 EE Only < 65 °� �z: -ebree on .17 on on . u on o = $ 310.09 - $310.09 EE + Spouse (< 65) 646.45 - 646.45 EE + Children ( <65) 577.67 - 577.67 EE + Family (< 65) 854.46 - .854.46 Spouse Only 368.35 - 368.35 Children Only 299.56 - 299.56 Retiree's Spouse & Children 576.36 - 576.36 EE Only > 65 240.66 - 240.66 Spouse Only > 65 240.66 - 240.66 EE + Spouse (both >65) 449.32 - 449.32 EE > 65, Spouse < 65 577.00 - 577.00 EE <65, Spouse >65 518.73 - 518.73 Retiree > 65 & children 508.20 - 508.20 Spouse >65, Children 508.20 - 508.20 EE >65, Family <65 785.02 - 785.02 Retiree < 65,Spouse >65, children 786.30 - 786.30 Retiree & Spouse >65 &children EE Only < 65 716.88 - 716.88 r * rte' Retiree Contribution Association Total $ - $ 392.40 ^$ 392.40 EE + Spouse (< 65) 474.98 392.40 867.38 EE + Children ( <65) 378.01 392.40 770.41 EE + Family (< 65) 768.48 392.40 1,160.88 Spouse Only 474.99 - 474.99 Children Only 378.01 - 378.01 Retiree's Spouse & Children 768.48 - 768.48 EE Only > 65 - 294.55 294.55 Spouse Only > 65 294.55 - 294.55 EE + Spouse (both >65) 294.53 294.55 589.08 EE > 65, Spouse < 65 474.98 294.55 769.53 EE <65, Spouse >65 294.56 392.40 686.96 Retiree >65, children 378.02 294.55 672.57 Spouse >65, Children 672.57 - 672.57 EE >65, Family <65 768.47 294.55 1,063.02 Retiree <65,Spouse >65,children 672.57 392.40 1,064.97 Retiree &Spouse >65, children 672.54 294.55 967.09 EE Only < 65 -Rakes Contribution Association Total $ 221.26 $ 103.72 $ 324.98 EE + Spouse (< 65) 613.99 103.72 717.71 EE + Children ( <65) 533.65 103.72 637.37 EE + Family (< 65) 856.36 103.72 960.08 Spouse Only 392.73 - 392.73 Children Only 312.40 - 312.40 Retiree's Spouse & children 635.13 - 635.13 EE Only > 65 244.07 - 244.07 Spouse Only > 65 244.07 - 244.07 EE + Spouse (both >65) 488.17 - 488.17 EE > 65, Spouse < 65 636.83 - 636.83 EE < 65, Spouse > 65 465.32 103.72 569.04 EE > 65 & Children 556.48 - 556.48 EE <65, Spouse >65,Children 777.72 1.03.72 881.44 Spouse >65, Children 556.48 - 556.48 EE >65, Family <65 879.19 - 879.19 Retiree &Spouse >65,children 800.57 - 800.57 "ALL OTHER ITEMS AND CONDITIONS REMAIN UNCHANGED" Paul Pierce Procurement Manager ACKNOWLEDGED BY: Humana Insurance Company .*I Vii.. FIRM NAME ORIZED SIGNATURE DATE April 24, 2009 ONE ORIGINAL SIGNED AND DATED ADDENDUM AND TWELVE COPIES OF THIS ORIGINAL SIGNE d AND DATED ADDENDUM 1 MUST BE RETURNED TO THE PURCHASING DIVISION WITH YOUR PROPOSAL. City of Corpus Christi Premium Information Date: Plan Year: Plan Name: HUM ANA. f.fzea<t nrac.0 wharf you need It most 04/22/09 August 1, 2009 until December 31, 2009 Humana Group Medicare RPPO 079 526 with Rx Option 3: 5/30/60125 %, $5 Generic in Cov. Gap Humana Group Sponsored Medicare Advantage Medical /Rs Benefit Overview In-Network/Out-of-Network Deductible None/$500 Inpatient Hospital $550/admit/$750/admit SklHed Nursing $124/day (days 21- 100)/30% Coins/day (days 1 -100) $10/$30/$35/$35 $95/30% Coins $50/30% Coins $100/$100 $50/$50 $3,00045,000 Rx Option 3: $5/30/60/25 %, $5 Generic in Cov. Gap _ Physic lan/Spedalist Outpatient Surgical Outpatient Non - Surgical Ambulance ER MOOR Pharmacy Market ARKANSAS FLORIDA GEORGIA TEXAS Todd Premium $ 59.00 per member per month $ 59.00 per member per month $ 39.00 per member per month $ 54.00 per member per month "See attached sheet for rating assumptions and stipulations City of Corpus Christi Rating Caveats The following items emir to the rates provided: HUMANA. Guidanee *then you need it mast Rates for 2010 are not yet available so we have provided a 5 -month rate. Once the 2010 rates become available, we will provide a 12 -month rate for 2010. The quoted rates are valid only for the specified effective date and are offered for the time period specified commencing with this effective date and are valid only if the following conditions are met. In the event that the effective date is other than the date listed above, the rates are subject to change. Humana reserves the right to change the rates and benefits 90 days after presentation of quote. In order to implement this plan effectively, an implementation meeting must be held with Humana 60 to 90 days prior to the effective date. The premium(s) and plan(s) quoted cannot be altered or adjusted in anyway, up or down, without Humana's approval. The quoted rates do not include a possible reduction for those eligible for the CMS regulated low income subsidy. If applicable, the rate reductions will be made available at a later date upon CMS releasing the new 2009 subsidies. This proposal assumes all members are retired and have enrolled in Medicare Part A and Part B. This quote is on an incurred basis. Humana will be responsible for all eligible claims incurred on or after the effective date through the end of the contract period. These rates are based on the assumption that there is no secondary plan wrapping around Humana's Medicare Advantage plan or Rx plan. This proposal is based on no employer contribution to the premium for the Fire and Citicare Retirees and no more than 82% employer contribution for the Public Safety Retirees. Humana follows the Center for Medicare and Medicaid Services (CMS) rules and regulations regarding enrollment and eligibility into the Employer Sponsored Medicare Advantage plans. CMS has strict guidelines in regards to a carrier's ability to accept members with a diagnosis of End Stage Renal Disease (ESRD). Outside of the initial open enrollment period and "aging -In" to the plan, there are very few times when Humana can accept Medicare members with an ESRD diagnosis. These rates assume that Humana will be the only sponsored Medicare Advantage plan offered to the City of Corpus Christi and it's Retirees. 30 Day Home Infusion Drugs (4) O 30 Day Mall Order Cost - sharing from Catastrophic to unlimited N co H L' P e O O T N r. 4 o O o O f9 H c 8 V l- Out of Pocket that triggers Catastrophic 30 Day Mail Order (3) from $0 to ICL (1) 0 COW Ni in- 30 Day Retail Cost - sharing from Catastrophic to unlimited M O �• �v v yc..'ry •v generic/multiple source drugs ($6 for all others) or 5% coinsurance N • I.- us. P e • r d H O O O T co H co o Y to Catasti "Covera N O T T Lo to or O N co P Retail C to IC N 145 1 o 2 H e Rx Option Number Co Plan /Option Out of Pocket that triggers Catastrophic 0 8 I 30 Day Mall Order Cost - sharing from Catastrophic to unlimited greater of $2.40 for generic/multiple source drugs ($6 for all others) or 5% coinsurance ler (3) from ICL rophic (2) L' P e O O T en ai F- o O o N P c 8 V l- 69 30 Day Mail Order (3) from $0 to ICL (1) et F N M O 49 N • I.- 0 c) 69 • r d H 0 Rx Option Number co c 0 a z 1 T o. a aa W T co 0 a) g d oa a a, ca co r 5 i 0 E • 0 L Z F- m E :" O 0 . o 5 13 o C0 N � E 7 _c a (7 i- 0. c a`s as y o Hi! La L x _« U 1 0 Y Q '� 5 as Q Q (5:" Q N • L ---35- • Y .2 Cd 8aa y 8 O pc...) Q1 3 c I— a7 3 C c t O = 7 . 0 N EE2L E �'- O,aiiE O) X80. > O al U .o L • :151_ ci LL rNl+f,,. 8 a N .c 'O co co c as .c . T C 0 0 N ea L 0 Q O 6 c L acv rn a�ca E O U c c7 E ai • L L a a) C :.o O V . w 4) O w 7 V as0 y O y d c 0 • ' E • 1:11) 0 E E Z as 0 '$cE 7 t 0 O >a 2009 Standard Rx Option 3 Out of Pocket that triggers Catastrophic O d 90 Day Retail Cost - sharing from Catastrophic to unlimited greater of $2.40 for generic/multiple source drugs ($6 for all others) or 5% coinsurance greater of $2.40 for generic/multiple source drugs ($6 for all others) or 5% coinsurance `m 1 a z t F O T Y to Catasti N t F SCI T r m t= O E» 90 Day Retail Copays from $0 to lCL (1) et m F.. Z N} ® F O CO Vi N as 1= 8 0. s T F- T Rx Option Number r) Plan /Option a. m Out of Pocket that triggers Catastrophic O A 40 90 day Mail Order Cost - sharing from Cstsstmnhin to unlin�it� greater of $2.40 for generic/multiple source drugs ($6 for all others) or 5% coinsurance m a z l- !h o ` O T sti era N e d 8 1- a. m et L. Q Z H O O N_ I- i). y Mail On to IC N H a) s v- s* Ea H Rx Option Number CO Plan /Option a d i 5 U 2 N c o. - °/ G c y S y 5 5 5 0 ~ ' 1 — • - ) - Rx formulary Tier 4 is restricted to a 30 -day supply. 2009 Standard Rx Option 3 Enrollees' benefits do not include the following, except as otherwise noted: All drugs not covered by Medicare unless covered by Rx Rider; Any drug prescribed for noncovered illness or injury; Any drug you receive before your effective date of coverage, or after the date your coverage has ended; fn U c ° W d G) 0. v. y N t d N — U r.. ) ° ea0 d 7 e_ 5« 8a Q 0 0 eo a, 7 To- a y o ° r 3 5 o a) . > L m o °r ga .0 m Q p0 7 U 13 t G) ) en d Q> G)". E c d c L .O (O CO U Z C P. 3_ 3a E7,, as 9 = N ° T t D) E 2;A 2� s d s d a) o c 0) 5 ° O a) .e N O O c pN g2 7O. i a) d C) C ›` G) C 8 e0 C Ct N 0 0 t O al 0 E > L ° 7 eC°A y U c co a C C U ca .0 o U C p) t, e E o O o (0 . a oz, a c d `act g ca W 0 0 R C r r .5 R > m a o. 447 8 rc ° ° c ° d a a e c 0. ^ N° O TA C C 0 2 C O eV C D a « C 2 t o a 8 c `0 Z' 'p N W O v c co = O U C Q O = 0 co o C 000 '0 .c o ' L a `o C C . GS (7 .r rn c a .� ° g. c a) c G) 2 E. c .c . m E a a c 0 o 0 A p. 0 .fie �' g m a, N G) a) a) 0 C a « .' o 7 di C a� •c C > C.2 'a N N p O) 0 c 'CO > ... C L ' c 0 03 E 2 cp a co ,� 7 O a y c N l0 N 'O O. j ° O ° v- -L �O D! Y O tc) a N -° N A e .O ° m 3 aoiv a c . V G) V 2 a�i N p r 3 a . .= E € c`o) o -c • e U i) G) e0 Q) .cc C o... en N G) C N d e en > a• 3 0 C a 7 7 'O O '° O a 2 ° a 0 °) V co `N V rC 7 ? U G) U 2 d a a .Q < o as 0 o.a a 2 yt < < a` <.o Q E 2009 Standard Rx Option 3 when you need it most COY of Corpus C Christi Attachments Apr&2009 I1 HUMANACTL wen you need itmost® Instructions for Template Usage Determine whether the vendor qualifies as a Business Associate 1. Does the vendor use, disclose, create or have access to Protected Health Information (PHI) from Humana? If the answer to any is yes, proceed to step 2. If the answer to all is no, no further action is required. 2. Does the vendor perform a healthcare operation or payment function on Humana's behalf? If the vendor performs a healthcare operation or payment function on Humana's behalf, proceed to next section. If Humana does not perform healthcare operations or payment functions, no further action is required. Healthcare Operations; activities such as quality assessment/improvement, reviewing qualifications of health care professionals, underwriting, premium rating, conducting or arranging for medical review, legal services, auditing, business planning /development, business management and general administrative activities (i.e. utilization management, member complaints and inquiries). Payment: activities to obtain premiums, determine the fulfillment of Humana's responsibility for coverage, obtain or provide reimbursement for the provision of health care. Complete the fields in this document and mail it to the vendor 1. Open the template as 'Read Only'. 2. In the first highlighted gray field (Humana Entity), click on the dropdown arrow to the end of the field. Select the appropriate Humana entity. Press the TAB key to move to the next section. 3. In the second highlighted gray field (Vendor Name), type in the name of the provider or vendor. Press the TAB key to move to the next section. 4. In the third highlighted gray field (Type of Agreement), enter in the type of agreement. Press the TAB key to move to the next section. 5. In the fourth highlighted gray field (Types of Service /Functions), type in the services /functions being performed on Humana's behalf. Note: IT BA Agreement / Addendum do not have this field. Press the TAB key to move to the next section. 6. In the `Permitted Uses and Disclosure' section, click on the appropriate checkbox next to the permitted uses and disclosures. You may select multiple checkboxes. Note: All choices will appear in the printed document with checks Indicating the use and disclosure chosen that are appropriate for the vendor. 7. Print the document. As the template is 'Read Only', you will be unable to save the changes made to the template. 8. Have the appropriate individual for your department (i.e. director or VP) sign the last page of the document. 9. Forward vendor information to your facility Compliance Director or the Corporate Privacy Office to be added to the Contracts Database. Update the Contract Database (These steps will be performed by your fadlity compliance director or the Corporate Privacy Office) 1. jf the vendor is determined to be a Business Associate; Complete all demographic information for the vendor. Click on 'Agreement Type' and choose Standard, Dental, IT or Legal Business Associate. Note: prior to signing a service /BA agreement with an IT Vendor, contact Carol Foreen. Prior to signing a Legal Service /BA Agreement, contact Karen Hartung. 2. Click on 'Use and Disclosure' and choose the most appropriate description of the type of information we disclose and for what purpose. 3. Indicate 'Active' in the Contract Standing Field. Make sure in the Contract Medium field, 'Written' or 'Verbal' is entered in the database. If you are unable to determine whether it is written or verbal, indicate 'Verbal'. Note: If you have indicated "Written" contract, you should be completing a bilateral BA Addendum. If you Indicated "Verbal ", you should be completing a bilateral BA Agreement. 4. jf the vendor is determined NOT to be a Business Associate; No action on the Contracts Database is required. Names of individuals to contact if the language in the document needs to be revised Karen Hartung Diana Bonifield Gregory Gish Legal Department Privacy Office Privacy Office Khartunaehumana.com Dbonifielde humana.com GaishOhumana.com 502 -580 -3703 502- 580 - 8860 502 -580 -1625 HIPAABA -02 0 HIPAA BUSINESS ASSOCIATE AGREEMENT THIS AGREEMENT is entered into by and between Select the correct entity from this list and their affiliates that underwrite or administer health plans (hereinafter "Humana ") and Enter the Name of the Provider or Vendor Here (hereinafter "Business Associate "). WITNESSETH WHEREAS, Humana and Business Associate desire to enter into a Enter type of arrangement here arrangement (hereinafter the "Arrangement) pursuant to which Business Associate agrees to provide Insert the services /functions performed the Business Associate services; and WHEREAS, Humana and Business Associate desire to enter into a HIPAA Business Associate Agreement (hereinafter the "Agreement) as follows: Scope of Agreement A. Humana discloses certain information ( "Information ") to Business Associate pursuant to the terms of this Agreement, some of which may constitute Protected Health Information ( "PHI "), as that term is defined under the Health Insurance Portability and Accountability Act of 1996, Public Law 104 -191 ( "HIPAA "). B. Humana and Business Associate intend to protect the privacy and provide for the security of PHI disclosed to Business Associate pursuant to this Agreement in compliance with H1PAA and the regulations promulgated thereunder by the U.S. Department of Health and Human Services, including, but not limited to, Title 45, Section 164.504(e) of the Code of Federal Regulations ( "CFR "), as the same may be amended from time to time and other applicable state and federal laws, rules and regulations. C. The parties acknowledge that state and federal laws relating to electronic data security and privacy are rapidly evolving and that further amendment of this Agreement may be required to provide for procedures to ensure compliance with such developments. The parties specifically agree to take such action as is necessary to implement the standards and requirements of HIPAA, the HIPAA Regulations and other applicable laws relating to the security or confidentiality of PHI. D. In the event of any conflict between this Agreement and the Arrangement as to the subject matter referenced herein, this Agreement shall control. In consideration of the mutual promises below and the exchange of Information pursuant to this Agreement, the parties agree as follows: 1. Obligation of Business Associate. a. Permitted Uses and Disclosures. Business Associate may create, use and /or disclose Humana Member's PHI pursuant to the Arrangement or this Agreement solely in accordance with the specifications set forth below. ❑ Eligibility and claims information for the sole purpose of claims processing and payment, billing and reimbursement decisions. ❑ Eligibility and diagnosis code(s) for the sole purpose of inpatient care coordination. ❑ Eligibility, claims information and diagnosis code(s) for the sole purpose of outpatient care coordination. ❑ Medical records for the sole purpose of auditing activities related to credentialing and recredentialing. HIPAABA -02 1 ❑ Eligibility and claims information for the sole purpose of utilization review and utilization management. ❑ Eligibility and claims information for the sole purpose of medical necessity reviews. ❑ Eligibility information for the sole purpose of referral approval decisions. ❑ Eligibility and claims information for the sole purpose of assisting in member specific quality improvement activities. ❑ Eligibility, claims information and utilization review and management information for the sole purposes of providing temporary staffing services ❑ Access to eligibility, claims information and utilization review and management information for the sole purpose of providing, repairing and maintaining equipment and supplies. ❑ Access to eligibility, claims information and utilization review and management information for the sole purpose of providing services in the form of creating forms and the printing of documents. ❑ Eligibility information for the sole purpose of providing a health information line. ❑ Member health information for the sole purpose of associate training. ❑ Claims data for the purpose of data referencing and archiving. ❑ Eligibility, claims information, and medical record for the sole purpose of claims processing - - -[ Formatted: Bullets and Numbering and payment, billing and reimbursement decisions. ❑ Eligibility, diagnosis code(s), claims information, member case management file and medical record for the sole purpose of inpatient care coordination. ❑ Eligibility, claims Information, diagnosis code(s), member case management file and medical record for the sole purpose of outpatient care coordination. ❑ Eligibility, claims information, diagnosis code(s), medical record, member specific adverse determination and case management files and referral data for the sole purpose of utilization review and utilization management. ❑ Eligibility, claims information, diagnosis codes, medical record, and member specific adverse determination (denial file) and case management files for the sole purpose of medical necessity reviews. ❑ Eligibility and medical record for the sole purpose of referral denial decisions. ❑ Eligibility, claims information, medical record, referral data, utilization management data and case management files for the sole purpose of assisting in member specific quality improvement activities. ❑ Medical records, referral data and utilization management data for the sole purpose of auditing activities related to credentialing and recredentialing. b. Data Aggregation Services. For purposes of this Section, "Data Aggregation" means, with respect to Humana's PHI, the combining of such PHI by Business Associate with the PHI received by Business Associate in its capacity as a Business Associate of another Covered Entity, as that term is defined under HIPAA to permit data analyses that relate to the health care operations of the respective Covered Entities. Business Associate shall provide the following Data Aggregation services relating to the health care operations of Humana, as such Business Associate, shall comply with restrictions on the use and disclosure of PHI. Humana shall notify Business Associate of such restrictions upon the effective date of this Agreement. • Outcomes data aggregation • Profiling of utilization patterns, outcomes and prescribing patterns of providers • Geographic profiling of patterns of care rendered to Humana Members c. Nondisclosure. Business Associate shall not use or further disclose Humana Member's PHI otherwise than as permitted or required by the Agreement or this Addendum or as required by law. d. Receipt. Humana is a Business Associate of certain other Covered Entities and, pursuant to such obligations of Humana, as such Business Associate, shall comply with restrictions on the use and disclosure of PHI. Humana shall notify Business Associate of such restrictions upon the effective date of this Addendum. e. Safeguards. Business Associate shall use appropriate safeguards to prevent use or disclosure of PHI other than as specifically provided for by the Arrangement or this Agreement. Such safeguards HIPAABA -02 2 shall at a minimum include: (1) a comprehensive written information privacy and security policy; and (11) a program that includes administrative, technical and physical safeguards appropriate to the size and complexity of the Business Associate's operations and the nature and scope of his /her /its activities; and (iii) appropriate confidentiality agreements with all employees, subcontractors, independent contractors and any entity to which Business Associate has delegated or sub - delegated his /her /its rights, duties, activities and /or obligations under the Arrangement or this Agreement which contain terms and conditions that are the same or similar to those contained in this Agreement. f. Reporting of Disclosures. Business Associate shall provide immediate written notice to Humana of any use or disclosure of PHI other than as specifically provided for by the Arrangement or this Agreement. Such notice shall be provided in the manner set out in this Agreement. g. Contractors. It is understood and agreed that Business Associate shall maintain written confidentiality agreements with contractors, including without limitation subcontractors and independent contractors, as necessary to perform the services required under the Arrangement, in a form consistent with, the terms and conditions established in this Agreement. Sample copies of the standard confidentiality agreements between Business Associate and contractors will be made available upon request. Business Associate agrees and shall require contractors to agree that in the event of any conflict between such Confidentiality Agreements and this Agreement, the language in this Agreement shall control. Business Associate agrees to notify Humana of any material change(s) to the aforementioned agreements at least thirty (30) days prior to Implementing such change(s). Business Associate shall ensure that any agents, including subcontractors, to whom it provides Humana Member's PHI received from, created by, or received by Business Associate on behalf of Humana agrees to the same restrictions and conditions that apply to Business Associate with respect to such PHI. If Business Associate intends to utilize any contractor(s) in performing Business Associate obligations under the Arrangement, such contractor(s) shall be identified as follows: • An executed agreement, including what is to be delegated and made available to Humana. • The responsibilities of the Business Associate and subcontractor. • The process by which the Business Associate evaluates the subcontractor. • The remedies, including termination of the Agreement if the subcontractor does not fulfill its obligation. • Evaluation of the subcontractor's capacity to perform the activities prior to the execution of the contract. • Humana retains the right to perform additional evaluation and /or oversight of the subcontractor, if deemed necessary by Humana. h. Availability of Information. Business Associate shall prepare, maintain and retain records relating to the use and disclosure of PHI in such form and for such time periods as required by applicable state and federal laws, rules and regulations to which Humana is subject, and in accordance with Humana standards. Humana may obtain, copy and have access, upon reasonable request, to any medical, administrative or financial record of Business Associate related to the use and disclosure of PHI. Copies of such records shall be at no additional cost to Humana. Business Associate shall make available to Humana such information as Humana may require to fulfill Humana's obligations to provide access to, provide a copy of, and account for disclosures with respect to PHI pursuant to HIPAA and the HIPAA Regulations, including, but not limited to, 45 CFR Sections 164.524 and 164.528. i. Amendment of PHI. Business Associate shall make PHI available to Humana as reasonably required to fulfill Humana's obligations to amend such PHI pursuant to HIPAA and the HIPAA Regulations, including, but not limited to, 45 CFR Section 164.526 and Business Associate shall, as directed by Humana, incorporate any amendments to PHI into copies of such PHI maintained by Business Associate. j. Internal Practices. Business Associate shall make its internal practices, books and records relating to the use and disclosure of PHI received from, created by, or received by Business Associate on HIPAABA -02 3 behalf of Humana available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining Business Associate's compliance with HIPAA and the H1PAA Regulations. k. Notification of Breach. During the term of the Arrangement, Business Associate shall notify Humana within twenty four (24) hours of any suspected or actual breach of security, intrusion or unauthorized use or disclosure of PHI and /or any actual or suspected use or disclosure of data in violation of any applicable federal or state laws or regulations. Business Associate shall take: (i) prompt corrective action to cure any such deficiencies and (ii) any action pertaining to such unauthorized disclosure required by applicable federal and state laws and regulations. Notwithstanding the above, any breach related to the sale, transfer,or use of PHI for commercial advantage, personal gain, or malicious harm shall be considered non - curable. 2. Obligations of Humana. Humana will use appropriate safeguards to maintain the confidentiality, privacy and security of PHI in transmitting same to Business Associate pursuant to the Arrangement and this Agreement. 3. Audits. Inspection and Enforcement. From time to time upon reasonable notice, or upon a reasonable determination by Humana that Business Associate has breached this Agreement, Humana may inspect the facilities, systems, books and records of Business Associate to monitor compliance with this Agreement. Business Associate shall promptly remedy any violation of any term of this Agreement and shall certify the same to Humana in writing. Waiver, whether expressed or implied, of any breach of any provision of this Agreement shall not be deemed to be a waiver of any other provision or a waiver of any subsequent or continuing breach of the same provision. In addition, waiver of one of the remedies available to either party in the event of a default or breach of this Agreement by the other party, shall not at any time be deemed a waiver of a party's right to elect such remedy(ies) at any subsequent time if a condition of default continues or recurs. To the extent that Humana determines that such examination is necessary to comply with Humana's legal obligations pursuant to HIPAA relating to certification of its security practices, Humana or its authorized agents or contractors, may, at Humana's expense, examine Business Associate's facilities, systems, procedures and records as may be necessary for such agents or contractors to certify to Humana the extent to which Business Associate's security safeguards comply with HIPAA, the HIPAA Regulations or this Agreement. 4. Termination. a. ' Material Breach. Notwithstanding anything to the contrary in the Arrangement or this Agreement, a breach by Business Associate of any provision of this Agreement, as determined by Humana, shall constitute a material breach of the Arrangement providing grounds for immediate termination of the Arrangement by Humana. b. Reasonable Steos to Cure Breach. Business Associate shall take reasonable steps to alleviate any potential, alleged or actual violations of permitted disclosures of PHI. If Business Associate's efforts are unsuccessful, Humana may: (i) terminate the Arrangement immediately or (ii) if termination of the Arrangement is not feasible, report Business Associate's breach or violation to the Secretary of the Department of Health and Human Services. c. Judicial or Administrative Proceedings. Either party may terminate the Arrangement, effective immediately, If: (i) the other party is named as a defendant in a criminal proceeding for a violation of HIPAA or (ii) a finding or stipulation that the other party has violated any standard or requirement of HIPAA or other security or privacy laws is made in any administrative or civil proceeding in which the party has been joined. d. Effect of Termination. Upon termination of the Arrangement for any reason, Business Associate shall return or destroy all PHI received from Humana (or created or received by Business Associate on behalf of Humana) that Business Associate still maintains in any form, and shall retain no copies of such PHI or, if return or destruction is not feasible, it shall continue to extend the protections of this Agreement to such information, and limit further use of such PHI to those purposes that make HIPAABA -02 4 the return or destruction of such PHI infeasible. Humana shall have the final determination on whether the Business Associate may destroy documents as opposed to returning the originals. 5. Indemnification. Humana and Business Associate will indemnify hold harmless and defend the other party to this Agreement from and against any and all claims, losses, liabilities, costs and other expenses incurred as a result of, or arising directly or indirectly out of or in connection with: (1) any misrepresentation, breach of warranty or non - fulfillment of any undertaking on the part of the party under this Agreement; and (ii) any claims, demands, awards, judgments, actions and proceedings made by any person or organization arising out of or in any way connected with the party's performance under this Agreement. 6. Disclaimer. Humana makes no warranty or representation that compliance by Business Associate with this Agreement, HIPAA or the HIPAA Regulations will be adequate or satisfactory for Business Associate's own purposes or that any information in Business Associate's possession or control, or transmitted or received by Business Associate, is or will be secure from unauthorized use or disclosure. Business Associate is solely responsible for all decisions made by Business Associate regarding the safeguarding of PHI. 7. Assistance in Litigation or Administrative Proceedings. Business Associate shall make itself, and any subcontractors, employees or agents assisting Business Associate in the performance of its obligations under the Arrangement, available to Humana, at no cost to Humana, to testify as witnesses, or otherwise, in the event of litigation or administrative proceedings being commenced against Humana, its directors, officers or employees based upon claimed violation of HIPAA, the HIPAA Regulations or other laws relating to security and privacy, except where Business Associate or its contractor, employee or agent is a named adverse party. 8. JJo Third Party Beneficiaries. The parties have not created and do not intend to create by this Agreement any third party rights under this Agreement, including but not limited to Members. There are no third party beneficiaries to this Agreement. 9. Receipt of PHI. Business Associate's receipt of Humana Member's PHI pursuant to the transactions contemplated by the Arrangement shall be deemed to occur beginning on the execution date below, and Business Associate's obligations under this Agreement shall commence with respect to such PHI upon such receipt. 10. Addendum Interpretation. The parties agree that any ambiguity in this Agreement shall be resolved in favor of a meaning that complies and is consistent with HIPAA and the HIPAA Regulations. HIPAABA -02 5 IN WITNESS WHEREOF, the parties hereto have duly executed this Agreement to be effective as of the thirteenth day of April 2003. HUMANA Business Associate By: By: Print Name: Print Name: Title: Title: Date: Date: Address for Notice: Address for Notice: COPY TO: Humana Inc. 500 West Main Street Louisville, KY 40201 Att.: Law Department COPY TO HIPAABA -02 6 mono \ 0 ■ 0 E E \22 4 —aac fI \ ¥C00)0�2 Cn m CO CO § § § % 555e5� Humana Confidential and proprietary 0 0 0 o o q o a a /3) ° « K s 0. i < 0 / Membership and Spend Distribution by Age Group .c • & * 0. of 121 LI \ a 0) ■ ■ ^ 04 _ _ _ g 4P - \ $ + 0 ■ ■ e ■ ■ ^ CD § 2 2 e- K 0) a a a _ _ 40 a _ _ r ■ A ■ 40 ■ ■ _ _ _ _ 0 e 0 ■ 1- k CO i 0 0 (K (0 § { 0 k k / § k 2 % ° $ U $ B e § 3 + k R e R a o 2 k■ 69 2 2 2 0E 7 E v 0 ' 2 co 0 § 0) k2 k ck 2 co ƒ• c 8 cri 0 k o c 0 e > 0 0 »2 11. — � � O ak 0 02c 0) Et ° Rk �k7 2a 8§2 °E ti a 2 $ o $\ F. @% $�2 L. 0 0 0 X i 0) a 0 2 k Maximum Out of Pocket Deductibles 7 a a Current Period Prior Period Current Period • Members Who Met Max Out of Pocket II Members Who Met Deductible • Members Not Meeting Deductible 2 PlanC=or p ss L t0 4- O >. t0 y.. N c ;� c O .c := 03 tl)"t 0) CCO h N co u) t00 6. L 0 L 0) O) 'o C . K N w0- C) 0) l0 co _ O t0 O2 co 0 C O t�0 ` O Q ` +� CO N U E CD N y CO a ) °t E > ` co L+' O co 1.0 ob O N 1 j N 7 u) ,00 6 C 13 v C O t1 2 O CO -o o C E 0 C (n Ix nO E 0 0 -e- 10t°�' mC c�.03 �) 5. o. Um Uc� c t0 y C 3 »°- t0i V :° U a� U N +—. O — 'c H U .a) t0 • C E d Y° E .c O 03 CO E y o E- m m o Uonn`.O .c . . CL a w .E o- 1— Humana confidential and proprietary 3 PlanCompas 0 0 O O C C e 0 e e 0 0 0 00 O O O O O G C o o O o C 0e O O 0 0 O O 00oe 0e 0 O O O O O O O 0 O O O O O O O O O O O O O ° O C W O O O e0e eeee O O O O O O O O o O o G O O O O O O O O O T G U 'C m 2 co co O �, y a 3 N N a O .y g C W l0 m C xN 'O :2 N 0 O Z W m V) tq to L t0 4- O >. t0 y.. N c ;� c O .c := 03 tl)"t 0) CCO h N co u) t00 6. L 0 L 0) O) 'o C . K N w0- C) 0) l0 co _ O t0 O2 co 0 C O t�0 ` O Q ` +� CO N U E CD N y CO a ) °t E > ` co L+' O co 1.0 ob O N 1 j N 7 u) ,00 6 C 13 v C O t1 2 O CO -o o C E 0 C (n Ix nO E 0 0 -e- 10t°�' mC c�.03 �) 5. o. Um Uc� c t0 y C 3 »°- t0i V :° U a� U N +—. O — 'c H U .a) t0 • C E d Y° E .c O 03 CO E y o E- m m o Uonn`.O .c . . CL a w .E o- 1— Humana confidential and proprietary 3 PlanCompas 2 k S 2 c • e co c E - °$g E 2 - §-6 c • e c $& 0 " E c § S g. 2 ■_ S a) 4-, 2 \§ 0— 7 §2 a2 c o co F§ .2 0> 0 E o >� o 2e$ o 5 &2 E0" 80� Ik O -- @§ c 2 O C 0. '0 a2 $$ /m 4-S 2 >0 Ea • - -0 ■ 2� § 2 k ) o k k_ 2 k ƒ§ k E ° S f c k 7 a a§ E§ 3 a® f -■ R2a 2: £a�■ $a ■ e « ■ @ _ e o 03 ■ ate© §% »£o� §sp 2JP 32 n kc a el) & c E ■ a a v ° $ f§ GE _)0(5 c= ■ a § 2 o m & _ § >°) —0 �o _cQ o co ca 2 §_ R v a� E t -o -o E 2 t c 6 c o f�� L f° 2 f co 0 ■ E • ■ « § o o /& S 12 8 - S CA 13 w$ 2 About This Pane #1 Clinical Condition These condition - specific graphs provide insights about: 0 0 Musculoskel Pancreas/Biliary #3 Clinical Conditic: ccn ) 2 § • k ■ c k > ■ Pancreas/Biliary k 3 ■ • :finical Condition Humana confidential and proprietary lanCompass 0 0 00 0 EA 0 O 0 N (A EA 0 'o o) 2 c a) co 7 ti N co) 0. 0:1 N t c o O L 3 '> 1- a> y `' E • m y o E y E m E a)E� i� c w 11) O To N. 0)0. N O � c 2 c .0 c z= C >> .c E m 0 y E 3 c 0) o.0E —om > o 0. > L Q 0 0) C o �p �j C m U -5-4 h : �E • O. m c '- • oY >,E >,c a_).om o C U O • .Q al m O co eci U) 5) c O E 0(p L c O V U O c .O a O 0 Q: +. t - .c • co Q. v) 0.10 tfs 13 R 0 aZ E 0 c O ofp E. t 0a.c 0,0 -o f'', Q' N A . m — j 0 y o j e a. c 0. o c' >ca m L c C ° Ems% f,$ e A O. a) a) • E m m a O 03mc • •w C E v e m co w 0 -Q .0 • CO 13 E • = N ro L• ,0EoE J E To E • Unrealized Opportunities ® Estimated Savings 0 0 0 0 0 0 0 0 0 0 0 0 — e- 0 e- 0 0 r) •- 0 0 0 0 0 0 0 dam' * e= 0 0 0 0 0 0 0 o. o 0 0 0 0 ((? o O O N 0 0 0 0 0 10 O 0 0 N 0 0 0 0 0 (00 0 E d 15 C 0 Commercial Case Management Chronic Kidney Disease Congestive Heart Failure End Stage Renal Disease Personal Nurse Rare Disease Humana confi PlanCcmpass (0 co e") CCI el N - cv , co > 0 a„ EO a N 0 U •Customer ■Humana Market Avg. ■Humana National Avg. 0 l+) C IA O 0 y 69 .y O co O e a r- i■. c� CI N 47 N % of Medical Claims Paid w co co Q. '11 L _ca ' = 2 ca m aa) >, c co `m a U) O. a) a) cQ1 O) 0 A co m co N G,s `� u) t l`a ca fa O N u, N �a w O t � c N > m 1 E a t ° IS E C_ c° E ° c a fn c t o o o o u, aa, en �me63 aE•,,�a�o0 .6 vi c. coc m °'o� ESC a .0�2 O O 0 ° E C O 'c ,C C C "5 d o_ o C Q �'a, s E E E o E w. a a) u d m a`a,,cdyu0, E °co E _ O E a7 ›` cca t N O E .4OE8V as �c m u, as a, ° > aa)i- 5,,c Q o >7. m 8 20a 1iLL O c 2 E c a� b y d m° d °fla'�cNa x c.Ea°iE III lCa O .V .0 co O L d a, a:j .y co to m:: -- c_ m.Ec c E> 6 V ai N 2 i .c c Ua co 0 = aa,aMa 1° Q. a7 C 0 L.L. , 2 .c , , , ., 1 Q 1 1 1 1 O 0f9 69 0 0 0 0 0 0 69 69 69 69 f9 69 69 O O O 0 0 0 0 0 0 0 1 x 1 1 X x x x 1 1 1 x Humana confidential and proprietary • a CL 0 H Paid Dollars c 32 •— f0 to a 2 C N U E mm _ (COLE y P ct Z o o m a W C O) W O . c_ 0 a y N N L •U E (3)c "662.52.1%/ E Q) o n C • L -o ` E N • O O 2 = 0. ` O E 0mc dc>°,o 5% m o L .'00' 0 3 0 w • _ (Door) • = c N I C O 13 E m 0 (0 C 0 y f0 L 0 0 0 •C O a O c0 co N O L w - E O O `y • E o m -co y A O • ° 0 L • c O O 0.)• 1—a III Customer II Humana Mkt. Avg. ■Humana Nat. Avg. co Lo 8 0 o e N co O • NM 2 c g E E Days/1000 Members .t' E a % of Medical Claims Paid (0 N O n N M >- >- >• z >- Y >• z } >- s a s s 6C9 6C9 s a s s o o 0 0 0 0 0 0 0 0 "ill IIItiiiI XXx X X x x X X 111 iglu ill 11111g11 5 0 0 0. tU m W CO N M 0 co 0to N CO (DD U 45 .10 5 0. w N 4s .F3 .� U • N — t • a N S • m 43 a CN a 43 ass° 0 0 0 0 0 0 0 0 0 0 • • co 0. co So 0 C Z 0. E co 0 O co a° 0 Hill Ili g'D$ 5r'n0 h 10a < Q a 0 t H 3 .0 4 O 0. CI) 7 0 w CI) CI) • Cl) =om E LO E 8 �c 0 a h c• o 0 3 CO D 86ENU; o0, mac. ° :cr. ., a y u0, r 0. 00 cod 1 U> t C U co Q c >+U o y .9- >, co co >, c s 3 1— -...0 E2 o 1- O a s . U • a 0 U a U } r >- z >- >- z >->-» oOOOOOOOOO E96969.69E9E96969.60Ea ;O 0 0 0 0 0 0 0 0 0 .. X X 1 X X . ix X X 111.1111 1 11 Oil X X X IiIiIiiIii sician Utilization 0) 0) 0 CO8� EA ER EA o• LO CO EA eA • e- CO ✓ CO CO EA ER EA EA EA ER EA EA EA ER 0 0 0 0 0 0 0 0 0 0 Humana confidential and proprietary 9 PlanCo a) a. a 1- 0 ER / Urgent Care Visits 0 0 0 u) 0 0 0 0 8 N 0 0 0 N � 0 • m 2 7 c m a) E O • L CiE c E a) 0 a) • O 1) o o c 3 0 c � m re 0 E O O O m w r a� E c po a€) d .- c) •0 m 0 E U 0) E it E Q 0 0 g . w • c O y C .=O 3 E o y O L > E 3 L E .c ov E 0 '9 E m Co O • 3 m o E8 *0 '_ m E c Q E ° Q y °a L -L L O N >t y W E • c d"0 E E E (1) ti 2 Q E ® Repeat ER Visitors • E a) 2 • N 40 40 0 0 C N_ oe N fH V! 'O 0 0 0 0 0 0 0 0 0 ACCA40E0 09 09COCOCNEA iO 0 0 0 coo 0 0 0 0 • sa0 0 0 0 0 0 0 0 49 49 49 49 49 69 40 69 0 0 0 0 0 0 0 0 0 0 X 'O 0 0 0 0 0 0 0 0 0 u44040 69 40 E90609 6969 0 0 0 0 0 0 0 0 0 0 a v ■ t 1 Humana confidential and proprietary 1 U 0, 8 2 4 N oP or N Excludin far a Claimants 1,954 1,955 -0.1% 4.3% 4.3% 0.6% ae 001 N M O 1. O C co N m !■ N O N ro N h H q ae op O N e W 0 6 Y 4 S m O p w N ae Ol es. co R O O! o N m ,- o G "� m a N g op m Q m N m i, o o o m m gi a ,- G C o o 0 N G G g pmt N <1 0 C co ": id a0 r .- O C O O N m 0011 O C C G C o O < A N O V N N m ti R M O qy yvy� O! Ol m o 0 m `� • `? aQ 2 R O PJ We N Ni O r C �` CC0 N^ t+! f� N O aeD" N h N 7 m G N • •- co at e+mj N - O O m R .... O C n b! f� n V7 m O fV pG O N N n V 00 O O C o o A Primary Care - Visits/1000 Members 2,272 - Percent of Medical Claims Paid 5.0% Specialist Care - Visits/1000 Members 2,493 - Percent of Medical Claims Paid 11.9% Freestanding tabs • - Percent of Net Paid 2.0% 3e O m * m e m m' e m m — ae N W 3e O G 2e 3e ae ae ae ;e co o o n a 07 G G G G_ Acute Hospital - Admits /1000 Members - Days/1000 Members - % of Medical Claims Paid (facility & physicians) Outpatient Surgeries - Visits/1000 Members - Percent of Medical Claims Paid Other Outpatient Procedures - Visits/1000 Members - Percent of Medical Claims Paid Emergency Room - Visits/1000 Members - % of Medical Claims Paid (facility & physicians) Urgent Care - Visits/1000 Members - % of Medical Claims Paid (facility & physicians) Behavioral Health % of Net Paid Chiropractic Services % of Net Paid Durable Medical Equipment % of Net Paid Home Health / Hospice % of Net Paid Ambulance % of Net Paid Other MdIIlary Services % of Net Paid ■ t 1 Humana confidential and proprietary 1 U Impact of Large Claimants on Net Paid Prior Period ) k 0 >, Z � c C.) © as e c w cD CO oeeu aEA5 co al .gs ( ) 0) co ' # 0I• @ co 'c E¢:. °\ kko -o0 7� §a .E,§ 2- c /22EI t§ / S0 E2 To Iv \g �£$© 2f 0)3 E 8 c �. t E a 0 u %CDbo \ �2 EI c 2 E e kEk /2 fa )0 z�t@§ C£ £E a- $k§$/ 2R ca. s /$f / k 0k aj'k43k kk kk oot =E>, 0{ e£ 2 \£$E§ $o At 13 Large Claimants ■AII Other Membe Large Claimant Top 10 Clinical conditions m o o■<< w z re z z o 0 2 0 0 e < < < F. ) F < o 0 / 0 0 0 0 o � 0 § f ƒ ■ 2 $ ■ 'co. @ k # § W # 6 # 0) CC I tf) c M Percent of Net Paid All Large Claimants Humana confidential and proprietary v Compass CO / 0 % 0 U a a k 0 2 22 e 2 � • Humana National Average DI Humana Market Average ® Customer — c U - u) U E ' \ k k c ° o \ 0. � § § § \ m Q.0 E = E o I pewoo as __m se _w % 0 /� (=- msqna _em peed 0 Customer Humana confidential and proprietary 13 PkrnCornpass Inbound C Inbound Calls: adAj Aq spie3 ;o D/, • Customer ® Humana Mkt. Avg. 0 Humana Nat. Avg. Cali Frequency (0 c 0 7 r "5 O co L • L L c5> 0°. of E •c ▪ 3° uLim m • e c m 7,3 m • E= E N m 0 0 0 y N o tcco E02m Z• �m O) C m ° 7> w O> mom 0>- ca mcE co To m6c ` H to ty 0 0 2 f0 O CD y l0 i O.0 N a) a. • o.CTv me ics o f m m c w O C N • '0 _ N E C. L_ v 0 33 .x N a. • 0. � il3t L. m cv E my � E .c 8 a 'o- f6 y .t -y, co mE L.ccc o.t°c00c `4 O 00 u.0coca >°E m 0 N'� — cnEE —y i E H cb co ` c.) 1— C>I— o.I tv t-t C11OorMore o8 0 o o o o WdWd SUeO 0 Sep -07 Oct-07 Nov -07 Dec-07 Jan -07 Feb-07 E 0 0 14 PL nCompa 0 •E000W 0000000000000000 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Np a .-wo ppo CD OD 03 N ( T p OD p CD CD N NN� O N N N N�M2 tAeTl-lnTC4T` N Ntl.: N p N 8 N pp N O M 8.3 N fN``D u) 0 0 F E v 0 O 0 E 2 0 0 N a 0 as a �16 CD CD Cr - 0) i: z "D 77 'D 'D 73 •D 'D •D 'D J T" _ j -D J J •D -D -D J 0 0 0 0 G) 0 0 G) 0 r c D c c 0. G) 0 c Cl) 0 0 0 0 to vi N N N G) 0 0 N d 0 0 0 0 0 0 e ,. fl.o do ;_ 0 0 0 �2. 000000'_,:: 00000000J� '..:.. f S i 0000 0 0 0 0 0 0 0 0 0 0 0 0 J J J J J J J J J J J J J J J J J J J 0 0 aS 0 0 0 0 0 0 as 0 as 00 as at aS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000000000000 N N N N N fA N ul N V1 N N V) to M 6 N N N c c C c c c c c c c c c c C c c c c c r r` o r- r r- O CP 00 CO OD O CA r` N- r` r- o 0 o O 0 t- r- as o pp 0 0 0 0) O O is 0 O O O O N N O O O O O O N O 0 0 0 O N N N N Zi co N N QV N N C4 ,t N N N N CD N OOOl1 NT��T.4-OON UC UD CI) mQ\RSw!OO T (\R2CN N�ww`�ww Z4 N ( N�/�C1I^^ y CD CD T T T ct .* CO Ul W V! T" T (� 0 CAD W X m co 1- u_ 0 a .0 E a -0 2 - >.- ?0 0 ., 0 3� x m s. ' ....C2 0 2V QS 0 0 C? C c'i N - D Taco E_ cn _ =� =22 = oza >U =U > > 6 Z> 2 vi > >= 0 y N V = vi 2 0 > > o • > c c > m > c = •� rn > > > Q .$.= E oco °vo.=_•c� aSU) 0 c ns > N m��(0- wI C< 0��Q0os m c0) <220 5C32YQaM2d¢0NI(32Q22cC CONFIDENTIA 1th through Guidance r; a c z, ence when you need it most To Our Stockholders: Humana Inc. Financial Highlights p' ar x � � (dollars in millions, except per common share results) fj/ `�,lumf�c`-: t the challenges - i rr,e (I }jam .- ; " 1 $ 2008 2007 2006 2005 2004 e .41 ,; _ �_ ., , ::: . t_.r Pk �9nda is rin -1.; Revenues $28,946 $25,290 $21,417 $14,418 $13,104 7, 0i we ('A'S2le' died niur reputation ;`. th,' Net income $647 $834 $487 $297 $270 H 4. !j„ ? _t,t oG��G "C 7CInSig Cie Diluted earnings per common share $3.83 $4.91 $2.90 $1.79 $1.66 1Iew forms of health and wellhess for our Financial Position 7,`",(7-: l,i p1,-,;1 ;r r"h_,.rc Totalassets $13,042 $12,879 $10,098 $6,847 $5,646 and mode MgMficant strBdes (1n pr paring Total shareholders' equity $4,457 $4,029 $3,054 52,509 52,124 cur INAledlIrairre pllan5 for ti-1.,. cc-Tr ing Intl; r.,: \ _E' r.rr kj t 1r`r"I 2er e alil...n. „ L d -1 )r`!, Cash Flows From Operations i Ic: �: ,� k t rE.:l ,i t1 dl . H \. E. IP r r nt t' I 1 " e :, :fit.; ' edreal Membership .'..�, i!� _ .% . . , 4 i{ ,, + Y sa ° n =. w - ,' e" " e. : ial� zh.v.. .� V: t.i. 1, 60:iic isi i' t,.,;l,rai` l.)us ess , Medicare stand -alone PDPs 3,066,600 3,442,000 3,536,600 – – ell Je y tr successful, 14. yea ` relationship Medicare Advantage 1,435,900 1,143,000 1,002,600 557,800 377,200 Medicaid 471,100 565,000 569,100 457,900 478,600 irV;[ I l- (i r c I i !nC i t 01 t tP, 1`_I_. Military Services 2,964,700 2,865,900 2,880,000 2,889,100 2,871,800 7,938,300 8,015,900 7,988,300 3,904,800 3,727,600 In Medicare Advantage, the expansion In the company's stand -alone Medicare w + : " ra r1 #:1." g' ; rE3'r' - 1 � � r is o of our provider networks and our Prescription Drug Plans (PDP), our r max , 1 .<.., 9 2,286,500 success in attracting increasing numbers processes were strengthened to ensure 1,978,800 1,808,600 1,754,200 1,999,800 Fully-Insured of Private Fee - for - Service members to the issues that negatively impacted net Administrative Services Only 1,642,000 1,643,000 1,529,600 1,171,000 1,018,600 our network -based products positions income in 2008 were corrected prior to 3,620,800 3,451,600 3,283,800 3,170,800 3,305,100 us well as we prepare for changes in submitting, in June 2008, our plan bids the Medicare program that will for 2009, with no lingering effects Total Medical Membership 11,559,100 11,467,500 11,272,100 7,075,600 7,032,700 effectively eliminate the traditional expected on these plans or on any — -- -- Private Fee- for - Service plan option other portions of Humana's business. in 2011. This is shown in the 2009 As expected, the 2009 plan bids Risk Mix Progressto,, enrollment season that began in the resulted in the attrition of approximately last several weeks of 2008. During this 924,000 stand -alone PDP members s period, we saw substantial progression in January 2009. Fully- Insured 55% 52% 53% 63% 69% in the number of members choosing �,:w,:, • . ••* -•,.� ^ ^ .w " " "` to enroll in a network -based plan, The combined impact of continued .. «r ,; • "" • " •.- ' with nearly 60 percent in such plans growth in our Medicare Advantage Total Commercial Medical Membership 100% 100% 100% 100% 100% in January 2009, up from 51 percent products and attrition in our stand -alone at the end of 2008. PDP offerings brought our total medical membership to approximately Specialty Membership 10.6 million in January 2009. For 2008, Dental 3,633,400 3,639,800 1,452,000 1,456,500 1,246,700 company revenues increased by 2,233,000 2,272,800 15 percent, to 528.95 billion from Vision 525.29 billion in 2007. Net income Other Supplemental Benefits 950,600 871,200 450,800 445,600 461,500 -. for 2008 was 5647 million, or $3.83 ,g per diluted share. Total Specialty Membership 6,817,000 6,783,800 1,902,800 1,902,100 1,708,200 2008 Annual Report T E L � w N L m N cd QmNC V Og 2,'u }qqq� O L c t[ o rn> O O E- 1 S - O 'a a� d 0 ar 3 W� — a T O O � j� N h� CI a+iomO1— E3mmom a E ;9 2 E E cv p.a$ u y N o o m 5 t G C al O O t., C O O O p v ry 9q. �>.3���Lw Tn Y`� N c ._ �+ u p C 0 O O p a- c m L �J' c E Swinda Orry v,L- m a3� 0 IA 5 We ° O o°�coe E ▪ C 7c= M 6 s .9 79 a i' ° p E w ar u 6C A o Q v E o s W V N O 3 O N N E a�y C V > C � �d �G�pp W p��r O= L m a 0 N Nil a O L ON E V m> y N N a a u c a 9 m E° C u a ; E 5 v 3 w c u c> a >^ > iiiiI g 31 -O_am o o E am gi O. al E t m o v ao o- T> O E1 L^ u m o m C m d u? . L E �,Q$p.Ng °v=`°o`omam._�v a�. NyE m m -4cEN rnE wo Tac`omo` yviE mcycL sac�� gEQ ?mom °-cwE`$iw�vyE�a`Q oi'�maoovYu z ar o v 3 ar ;r�a2mv c$'�C�wTity r,�'rnmm dre°'Z -28E o v m o? E 3�ar o x w a ai E av m$ 3 E= o' N v LVmta�aE� p C N p+'• •� L C C vdi Lc `rEo�E 7 c ae „ t — c c m a > o u o o a D S =Y-Dy LF s o m L L C E o N m > a3-m L E 1y r« V g m 9 O N O c .i Y E N °L gE rn v ��m EErrE opw°-0 o o> 3EaoRa3x0mv? E2,0a %oYoYmow Y m W ° 3 °1'C O°NO C E -O LZ��Ec d C v�m�m pmdvO�v E >. = L a +>s d C ._ L L >. C- OI m 7 O� d d p1 ` • C_ •°o umrn H 3crna Doa w YI J �g ';''coN amEorn Nn> a Y c are 2 O y Y ▪ m g6"-§-5 W m '° N C N p d O c C p W 8 C E 9 .E O m Of c4".7-'- L m 3 E T O q~ a 0 C O O a O L al V u O E a � .. YN = � Y T O� 4 t oO C C C A C r O uE 0 m Oc c 12 E 9 L3 C= « O �a V _ w u •_ L N0 ® C,'mw c a N v V L C N C c Oocc c ` • O c o_or> —C ; =6d r L$ E` aLN DII SW ?ag S. N CE a 3 m cg cL E Iu v•t oC p a rEE!vE ! L°V 3” >i ?= a a c -7,oL D P:woLoL w >c � m01— =8-g- a ,Fm C N 3 cE$ E O • O f > m Kw O N "' • 2008 Annual Report O E Y Y N O 6-r, , t Y e ao .L' 'w «e > ta- Yaoa raN Way. 023 32. '3 g v «Yc W c u 4€ E ill r= ?w i o ”0 c 3 E- 3 :1`4,E rat -13v . Y C N E v af0. v m1c0E cue m aa -02„, E z « E.o a� m E OQG r„, o o ° N E C. us, 0 T, N E .0c.. Y E N c O mAmE .0. E t rn N m d f E m T r j P E c i N o E i .> m w tvav 3 °i« il!:H 2-5 Y 31009-5?%-F,g 1O a d E JE°a.YmT 2. a, y a WitO m n ir y Y N yg Y9 co • -oa, :°" - Rc E�; c.yta . YC a cpYY `1� o = vE «Y Easrn�1 °> N .o o m o d d j E� O0 '0 c1 2 c T o E 9 > N Y y y o O v ' O 2 Y E Y C g N Y . E • ° O , d 0 Y �T Y E1° Yoc gy' -rn wLEm.v a YpE -O— °.Y°°cE-Em ›.-2 m cm 3mE u6a- °oo ° c -, Hua,7.ESoESu.o2.,.G1.cc ¢3 a « v 2 °Y N a ON a 0 3 O°E d - Y pAY E L'Y w • cOa wv L YOm. L' .L «C o�Y a > ~ °m co0 'a NwNY N Y o°@ 00 f YC '> O Y 0c N ° L 4Cv ` p0c Y E yOp E CaEc W i d 1 aY aEi c C auN � -c °0�rn� u i�0g O , 2 ' E rn c3• s-.�Y vC oO o.�> >w 0°ca� 1 mL� L— r ° mv -. c'mo u O �_ °oo.n EO c °0 vN °1Y N E > o E EY>.lE O y a N o Y O a> C Q � o O 1 $-c mc aVm 2 ,;uu . NtL mf0_. 0 m„O15, 2�cviV O m w n, 0L v2 21 L50 cEc�W °1a°Ay2 iEn°ABc0 rao0'1 0 E p c"o b w C OI- O' C L c Y !^ O E 3 m o T 6 m Y -0 10 C v 0 ,06 = 0 C "' 0 O a 0 W al 0 'O H T._ 01 w , C E .2 T C E E E O O F n v 0, N >"18.1- iCi1 d N 4'46 v W W g V w a, ,, j w - t r � O m m c 0 6 1J > .N a c '-' u Y 5 Y 0 Z c 0 • 4, 2. u 3 c a Y E m a`i ay '° >' o o i6c 3.E . Ib c5 O'oa°3o2OC Vim =g-°0 oEo $L- 2,3`''a ° ,a�Nc a1 o 'g?-=‘,=,..1,9:21-76.9.3_d va2 E._ N c›, m E o.v_+ -o E o c o - EY .--°.61:-_2.7,,%-E=3:3 - °Eo Y C c_ '- N n .- 0 c Y 01 ._ti o �apN ,aEN,6 °m oc o�oYm3a,mg pmoc t Y fg m t t 3 N m a1 m E t .N c ;L o- -o' o o `010 �, F. a- � = O1 1 ✓ L l' w �" > 0,2-f c E '« _° c -� ., v r Q o E c= .v 01 E v -o -o 1O 1O C a ,} opY i,i0ac>.EE 4E'RvcacUap E> :6.wEEc,E`6Ew Arm�c t §15.s Y= Io Tit 9,— N 376 d N 0 Z' E= O Y ° 0 , O a 0� N ' .- L ,, ta E C C ,C6 IO j u N= T 0 '= Y E ,2 c U ', E 2 e Y 'v O Y a y 0 o o 6 a 3 O `� 10 - U `w o of .Ei, o ° '6 ai » E 01 C O. A 01-° n n° a r a c- v�EE-uacpEvaN c`t.nca'ia_ca>�? 0'_ Y 'YO C O01 E L i6 E N Y Y C,_ °u = N Z "O c ° o 1 N m C c o a c o a- p k L O E. °1 Y T C O Y 0 L . j O U N Y v 0 E w r 5 ,, O � F-� mu+x�c`31 --0 0.�, a om oaovn3 6I c n N O M 0 o,m���000 0 o 0°,9 • 'or-r-ccoirna 2 Eag§Eil £ 0 O is y p 7 0 :g ! E v,2" C9. a stb a;s rikrOl8E 5Oc, =O u0. Ea' C [ w E< 5 Ci8 °14 FjU4 .2:�ir ;1 I S O •j § g p p R ° ° e7�v p Q N w U 'pp 5 4° i d }QJ ap %=1.=4-2''§.4 b0 Q "0" pp > 1' q p 1 t0 '2'J^ U°' T iC � V .a Cy U p S Q F .Z '� U tl �"' °' Q y0 ° 3 F m Cy CFCyy W � ° O N -`p c y 2 o.c u ffi s •p U ° •p a�i C0.• ° °f p � E 5u � fi yafi�a° u C t u d k C$ U U N g UN .4:2 `" E. Uu d ° p �yy.� ° P y E � W � .i o N 7 p� i O OG9 ° d� N v o ••g4p C kpA N •O w ° ' E1 'E E, 0 " 4 'G b0000 • 500p3g ° u81 .o. • E5 O,d9C oa o u•a VD " e4 ww 15 v 5 E I w o d.E ° a igt-00 E814.4' mO 1 `o 8 5 s 5 9 U 5 °25 u 2° 5 E 0. "E$dc v E E u s.��gm3 'O O �4 t T P. T >� 137. u p, U 1 g C° U p T5 Fe X b V U N N t -55.55 Ve > 5 d E :2.50.. E . o »°,5 a g a$ w5 T C3 ° U v3tE 8 8 0 E mo- o G =10'0'0 r� g O 'G p y 'O ti t S p55e82 p 1 Q d nN a tg5 • 0 1 01 tie 00 1° e{ pN O Cpl M W 00 N N - 8 'lc' N O III 1 III 888 h 0 W °w N ON rn N ■ Mi 0, c t+1 0 m c.i 8 Ni 00 M GO ao" 8 h 01 0000 v1 O a O NIMI h O O V � 00 W 8 O V°`'1 8 N 0000 cN I b 0I oo ri cps 0 . N 00 H1 a 0 00 8 0' b O N 00 00 00 8 00 O 8 00 iT i• t E 2J d O E I• d to 0 g d T �5C ° s §-8°- ,2s t 5,• 0g .wtg 3 m C 0 C Eat o m 0<. at2 U U O b * . 0i 0 N^ pi N V oo nn N NW 00 00 Pi N • 0 Cc 00 S M pO 00 0 O N • h V b M U 'F�O tTi 0.C.x w I om o - M • rn ° y N 00 8 7` 8 r b 8 00 E 0 U 5 H O • • _ '3 e . c ' . a >E v s ' . . '. : ' '' ' n . .'a O .:'C . R . . .- '7 C E .' o „°> o . •v E :.° . . T •. o 3 a Q a .> , 0.' oG .0 a °'• G c y � .v .v t `c E .•v >o '. „ E C Jc s N C N - Q y u T U moiC O w.E gC >o N y 90.0 G 41 :a E E N y 3 _8 E o a E E 0 v 3 o m 2 .. c s o U c y `d T E 3 s c b g a 1 v Q Ou 2 E -n y -..E, v d `aF' E u a c v z = U v o v a o a oo a, •v Z a v U^ °v o o.n ;11ii -52-=&;*,,,, N 3 ' ° E' ? 0 0 9 E y c E m n !q! a 3_> $ a a '.c v o% o ` 0,a,_ a r, E Q 9 90 l o E ` c o u ” _ : 24 o ,T «v c a t oo o ma cu 3 _ ° N u E y qiiiii!iii v y. s a u To « v a m .s E c m F"".4 Et- . E 28; q o o ° d v> t " it E E UE S a o 0 1 v v a° E o ma` u €. .0 �5r E �au Y "wo0a m _ m C C c l ° mT E w— _ C z ' - " 3 E s s- c0 F E E ' P o d c c a a « 3 s 0 _`,� o c � v vg 1:072V714 n ° — L)48 0't8 c v N ° ° 2"c N c o I N EN ¢�v L W X o� ° —T 8 = a aa �3 5 E o c EE a m °c . > v . �= E c s c 3 �o•p ^ au o 0 v v � ro �A m .. ,, , o o c a a 0 E >° o v a a E Bc a D ,o c v> •E E ° a A w o y F E 0 r h e 7 _ a 'o m ` m = -0, n ro o" m o T— 9 N F r ° c= t H y, g y o« E $ E _ t ,_ s E a t 0 9,: u ? n E - E Q s E c v v Q E O-WC C o .L ,. TD 3 E .p « - t ,9 E T - t` 9E: D 4 1 y q L 9 o i 0 9 C p ;.v.,21.° v o E v E en Q c D " Eo v m 9 E u Kt ,Et E- 3 « L-E O m C v 3 a 2 3 E ea mE a = a m E '1 •n o 3 --- 0 9E d o c l a o u v E a o ° E E c c L oa g c E E a 9 c v o o a.o m 3 ,n _ a a a u v y ` °m U D s n c E cm m 4o E o m O 'e A u 0V-E>,¢ v e oc E o 4 Tm y c A. acc g H v o w o m z,° u C i i u E w A a - 9 v t .d r' : :"Fog N 2 h u' 1 Q o q o c o-a , . ' v C v0 0A E 0 3 U m m a .DT O ` _ N c _° vi T 7 'oo .o Y€ '. Ern w = c 0 y E v v E a v M E o w o$_ liwilcE ¢ _ ,s w c co .ti " o Y w a N F4d 4 a .E . 9 m a' T ° =— c a 2 o S c a E m ? n p U v OO ,8 v o T 3 c O u .c m `o c � m y .n ° ° d a Q . $ r S w ,, ' v ` o o m,, 4 'OE u 'a 4d g v o v E E E °c 2- a°;3 G 00 u o - E a e o b c.. a ENE 32E,- o c i..o o .E g v t ° c p o p m 0 0 4 = T —m u v v p z U t1 v >o v u ocm U3- 9Q rn , 'o O « h 8 V O O u ' v c y 1. E 9 °Qa= o y °° . E. m ,h ,o c v m w n i c 'a v u iE v -° 5EEmEc`a i..2a ? .o r Pv m.,t a a 3 I ❑ v a a, • O .0 y T m C > ° E N *!A n v i `° i m •u'oE9EE 111 ° °- m °u U 9 c 7 3 > O - ` o s E O. m EY p 72: � O O U p •> m o 3 •o u '�a '�0.5 F c s3 a • E F W v N a v O -E1--, N — T .Q y N N Q o ? N ^t C oD V W .c r m s.5 v o d c y O n fi «.E v s E uc S 1V-7§ m C v° � m 1'c u 04,280 E c c a 'co N °' S e c• a i m O > d E ` 0« 0 - >UC c A a U • m v r E • d: a? c ° 9 ° d n yom C v a n `oo:;5" o w ,s a °' 2 Oo ° m v m d t t E o '4 ° '5 h w $ t--120:7:"e E ro y ? A a v T oo a c ° .W m € m c .-8.,=-2 8,0 2 °v 8NO `uO,o v y i o0 c . a' N n r o' r U y f- Nc co � N: ° V .E 8-0 N E E C. , e F v ; G 'C m , c � E i 't .G g o ou.o c s 2 cn °"- °' E ` E E . °° M ° =1 3 s h 1 .li F —� y E C >v = v E a E E w v E 1. o a Og 0.o - ° CO.EOV U c aC $- a v .64 o ° "- � TaO Q C yE r W d G 4°.= s Z•o i = 2 V `O «py d d- u° ° ° 2'y ° aa 41 ;' es « r,- �3uoo .2 20 v 0 v -o E U m. d i E g r o o b m c r vc y L ❑ c 9.10 v y o c u ` 11' A °« r m E � a o E :• m ::u d 2 u .g } 4 « ``.°,,t r s e v p E L a s i v (1•o 1 o . 1 ' a -m 0. o m .2. :-.',• 1 . .cb = w .0 ii 1 O 0 .a . o E o y d C F W o O a C" -E E � 1114!!:11E; O ' c vw0.Q . z d m v O ? , 4 EoE o n . » E 5 E. h a r > o uo :a :E 0 s C ._ m v O 0 o 0 o L g s c o v O g d 1 a1 ? I v ON a W . N 5 :6 O , U N 42 o a tc_ > gvb, 1.2. yv� Y�u h � 0000 b 88 01 01 N- M 00 M N m 0 8 oo • • 8 ro eee4ag *8eeee4*eeae ********* eeeee*** e FN 0 7 • • •-� 00 V N l N �O D\ b [� 0V g r i E > o0 g nm00,°.°M ,°NN ( :M'n No0000O- 0 2 00 12 .2 c w E m a 00 .• ,O c t N N vN In ,4 M O , to ° QE - T 0 . E ' , . _O O hN § J Y C . � , C 7 M M .. ._ ~ m 0o P� A�N �NhN I oo I I M I I I y _ b -. ,-.!0 .4: o0 ,n 01 01 ,o N O. M 0( 00 - o o ,`uC « ? « n, u u s m AE 01 .' a O0 8 M W E i] 0 �N M e v o en N �r p 5'E ta. - I . . . , . . a v so 5 �v+ E'U 1 V 0 . I 1 , O I ,p Em� wO .90 cO y O rcT,,M0,00NWetmON.I.NM oN V N .- m 0 V I a Mhn N NM b n , M y q E O O. 5 .i O' .F.1.8.8.2 E E O U O grI I I I I I I I I I I I I I I I I I I I I IHI * g a a& R 0 y g 100 oblmW3 9 r E F$ •• N 4 .8 'e g g S 1 m- .+ � M , C t� � � 1 h01 1 0 tV + W I I M rn 'M n I i g l ° . � 90. — e o e o E i y o a d e 3 O ,NMo0nMM bhNONN , •9a ' a g ; n ^c o 8 N NOtV Oo∎ 7OAoGOY10 Nh V N-V,O I I M at ,,!e NNM No0O.vN00 -,,o.N0NM0o O ,3 §40.:W n'w C 8.. s _ y b g o N(V 0 v 6 m s N oM O ,O N , pp O... .-7 - N V 0 I I N r,.o.. rn. �oatryo�vo.ovryo ,o ., i i1§.1(1 241 ' ,o, 00,0.-.,,,0 D M N N,o N, ., M.• N N � C, g •-..-2-3,5a4 «^ gg U y .2rc g.0 .. a ' d s s l m c E U d a V) O O . Q' 0yy 0 O Et d E$ p, =v0 4 :E `;',.E1 m ` Q ilB o 5 g cE E' u v a ° d . 1m N c m E ° I im ; E I > m0 H I lirnil3 � . 02 C8'6 §oE9 :2 9 G8O_rH a Vi- o ELm & 4g-ciFs I u.°a gC 2,.5 u4;.:0 y 0 p 7 w 5 E 000' N 0 a ,L o u oryo N °2-¢==0 po v v y Z c K v u E 0• 0 0 0 70.0 C .54.- 00 '' -s= x n° v too E o on L_. E o, o m , t a o u v w L u c> O O m o 'E C V O o Q y T 00 y N .`l.". E o c u y N W •� �' 7 d 0 4 p p g' G E E 9 0' N eD y 0 00 � N N C t •0 O E O 5 .0 c c o`oL a vM v E =- U v a h• o f x u ? 22 -: c F g °E' E. E v E o ,, c E ?• t 3 a 'o E o O c ilIUu c y a .S d Q o < .- y O< v .� ° O m m JE DO a «M a«? 3g:Em8.2..887,53rc `>,,g.,1-.,s,,>-.28.5-5 � N J p N m �G DON op o° E m,o (0' cae1 g E 'a5i Y: _ � u 0 c v c c `u v'5 a^' E m E `tl '' 3 m E E 3 0^ o.— . u E 2 5.Q o ` c o U c u 2 c; o 0 0 A o.E'-° °,2 ° o 5 E r. h 7 y a_ Y_ T o ,f,„20 .E y• s 88, v c > R m'1 v o« v E o o` a «._ g o o E w E c - 0 ^ a -` rEc o.: T E es 1 4, v : w. ..O o c S' 0 o u o; o ? . E m u ao c c a F E T F- C2 Q« N.-05 8 v a« a d .i d U 7 4' f..' .' L A C L C W o.- E > E.s .5 °E c u u v 4 E A v 5": U ' v a.o • m E m m= -Eta4E41 E C ode -' •E3m° 0 o c 3 o N$ 6 t t'-4! m K . C 7 V° .°.!1 m c? a!$ 3 E E .82 E a2 E'" E °° TAI .._. s d L U C a U• m p 7 • W' y G W rry c x^ m =n6141.; d g w U d V Ali d G L rJ' 7 7 c , d c e .E 3 C o o `S 8 E .I8 E d 8p 6 �>$. d o U' o u E 'dO ° d m E�� D1 E g£ 3 0 o d y.$ ;OEEE1 —£ p a c 7 -r„..12. T d u o . wi � R d d 079. <o a�iaa E a a$ °•� o o m o m .o i m w 4> CI TligEg u v A !It! Q.E c o m° °- �5Y "> E$ dN Pi E ie '� °' o .O15, 1¢111:4 5 v 1 a° o d° .d o T i x m 3 1 a .dc a s 1 d t a c £ 2 ° v on o a ,g82'8 c 9x v m a edo °° o:« 2 c N d 3, m o 0 0 G = o ^a °° Q 5 d^ 5n m❑ 'o v' a s c m d " E ^d d> $ c'E" i '2 a° Eo u ^° y o o� do at 3 � c 6. o ;Eli .� m d `0 3 o m c y c a u w y '.. O yd d �OQQ c 0000 ° C w Y 6 o 8 C 0L) >, .i, Or - 3 'O 'y -0•50,0' T E2 c u a ffi 'a env ._° m a Q y s a£i m a°i w N G ma y°' ,°= G u °' y d °,' a• =i u d a c a S..0 ?? F 0 1- c c t E 3 '° m 2; ° E a_ o f .ad, cm� >o� <'yQ b`g vov m��� -< m ..m$ o'Goo s°° 01E= o a 2 " 1 o . E o. °3' m c s .�. c T y A U S o Z $. o o u E . J a= d .0 m Q a 3 ° v 4 a� z 6 £' o G° 'o o£ c K ❑ 5 m oavEa a o ° d3 adw u £' d� y o Li ti Re ' 05.8-> '-.-' i ° G A z s c o Q, cdi ° .° d "' G v G 4 6g>, c m�d�°' c E o °� £oSc�Eam -a'1° c yw3•g?mQ a.c!; E d o 0 0 0 0 O a. Q .= m '' E 0 E£ m v •a o e A «' )a " y .' V o d p. 300. d d " r5 8. vp .°^ ,c;..§ o ... W ,o m A mT 2 o E3v ... $ >l.` >da ad g a "'ddd 5. d T�E3p �u d"? u v d Z. >21g p a �' d k 'E §-2.2 ;; E d Uu x o i.' x o yv o`'o E °5 "° tL =Eoo p. -$ Ed>$ °�y £ pp d Q ci .° en •a° o a v N , s £ ,E n 'n o .� d O m V .258 UC. 'o N C N N y mT 7 dN 'O .95 O C O. d C v°i N 850. „ ., .°° o , v 3 °22'5 6• = o « F E '� c E v.% "a "m a s o TAI G Q 1,7;''7 o ` q 'y m ;, u °° v u m t° a o a , '° .mc E vm ' m E did'. a" S o 1 w° "3 E d Q p o e> o S« ° m o .W fl d o f m 3 0 0 c o °o o c d' ^v) "1" = E 0 Vu aE a` � m �C'C :3 d o 4p : m.d .2 o,,, d'S o o `. 0 .0 an d '� T On OD . E G U m m c E d N L 0. A Cg t 3 d>-. �+ ° O p o 7 a£ d m 0, E b o a � v v m 33 E c eo y r�. E � m m� y Q � $ m G - m ,4.1811- w ee d c c E c o c d,e•S 'maa y = ° 055 g a° 3 2i a'2 Ub III d �°, ° „`o- m . °- � y -v d °°� m = y' c �°> _ '� v d ao 3$ 3 3 0 c d^ E d s 819,-g10,1 c 3 c d o x c o E a E H € n d m 8 d n . a E l v 9 3 a .l d w m 05 N e. $ 'y o° in t E d a E = 'QE° a. vx ooa 07u aU•Y .d.g co EY M0E3Sm3vc S^�ai �. O '� T O N 'C C C Q .„,e°08 p t0 y° N T O^ 0 g-.8 E O y m) tln U A A O£ 1 g° 111174 °a ° «CO 4.as °•a «63o'°8..s �m� >o E«�w °mm3oad a -5c Ga 50 uyc =1v 0)0._0)0000 fix 2 d5 §5c aa>oa•o>._, E G m S V a m ai w o a 1 a'S d �4 L' E E. cdi = t O� v .y ..-1:4, £ 56 S� v c C 0� ° .E.,5,5 am�O �3Eca 3x acm a� zEo �t 3 E saiWi.H 3a amx m.E a U 5 • increased use of medical facilities and services, including prescriptio • increased cost of such services; • the introduction of new or costly treatments, including new technologies; N 0 relating to the denial of health care benefit payments; -house mail -order pharmacy. cn N • disclosure of provider fee schedules and other data about payments to providers, sometimes called transparency; • disclosure of provider quality information; and • formation of regional purchasing pools for small employers and individuals. 1 c E T .6 u uu 5b c Ea81 U° q . . 1 m Aga , E o A 5i>.9a 0 0.1 g, o E U U V 9 .5 .U. 0 R 2 ye 'p 1 a ,i d c E v 4 m 1 1 1 s Hi 0 S 63 y° b d 845 gARE a82°31'41,di2 W g. « c j. 8.5 �'Q.8 8 - 8 ;o°1FuR8C8_T>v8 X53 �e.ao o '''������... c rx°I l� t 1 'O C 4 O w ° u > 3 C C ,8 m °j a0 Q p O O .9 §a Ea'g E T8 8 ° o u 9 v u' a =-.50.4; o °a 6 00 aS T O' ¢O1 O O .21 c o 3.8 G-i s°v'_385�D tOg6'o § >E -00.0 O Q E'° O N g e ° O § d eu 1 E 8A o- m U m.0 8 a o L'= 1 u s8 8 sib « 8 28. .8�E 48 changes in financial estimates and recommendations by securities analysts; 8 0 E •0 a o u ' C w o 0 c€ a E ag li 1 'a '0 o 0 N 12 m o. " y T O Q y §.. , • G .7 E o E p m o ▪ 5 m $ c d o rs o m C� y 1 v 111 U m U w p ai if O O • C Q E O O 0 X C O E > G a m Q N ' N g u 8 T 0 U — O 0 p 0 O a G - U i E U , y -a 8 ..a - w gy 81 r, ' y ` D o i 2 c b v o. x o o E c a.B x E a� V ° o .m o �, m N > T g N a) Market Information c v�v-, o.o 6 oonNh NO0N s l � 00b GS .� Off. - O (.1 7OO- 00 V) h b b r r- 69 69 69 49 H9 b3 49 11 O u 8 0 8 8 O 0 co O '0 .0 8 xUp y F 8 E e 8 G F0 3 u u m Ca 2,1, y T 0 QQ m FI MNN't0 �.[n •' 0000000 7I • n]I MNN �vl a VOOOrn CO I en I0 I I Ib I I— II�II 11 1 1 1 1 1 1 I I*, II 1 1 1 1 1 1 1 1 I I II d) Equity Compensation Plan ITEM 6. SELECTED FINANCIAL DATA e) Stock Performance N 8 as o* az $ 81 8C1 e7 06.0 -0;0,0;1 Ocg en 0 8 O N g �I O O S •69 s9 A §8 RE 1i ' b 5 ••arppJ J 'J O T Q N 23 ,r.• a p O m c�o3a8'�d0. 15 U O F U • G ds g t Q w Gi • O' U • c c E m 2 E y a 0 0 n 0 «Y '. v o xU a 8 8 E p u N U p O 0 0 F 0 � U � y W 'J 2 < 8' O E $40 `•'d U U E N 0 w O w '5 r^ 70 c5, o .� G poCp p 7 N N¢ aD OOO T U U` C N E 0 y °a • m C E o c E3 t Ca 0 CO o • ca. Ceo o .,§ a•pg 4.1• t P.5.i g w0' p O O is u O� 0 R Cp o (VJ C ^ N 0o0 1 ODD O 'O g U N O O N L e0 W E a • M U W j 0 d W ai ,c O 0 E§VA:;: c' 8.m m 8 .E o> E u en 0o O S Q o G V a m O ij O C N ° it 9 el 1J.2 « w , E 'a m 5., 1 O rn .EO 4 › ? Virl 0 r wmo `> g > O. 3 3 1 a g g a 8 aOv da a m0 ° 0 $E ° E °T d �@ 'A wu o .O s.q G d Q 2 ~ 7 C V e. 1 1° 1 a ga '°g w C o cO ONa :ago U,c S NE� R 1.1p .°O ' ago 5 u°T w2 -8 ,2 s 5 o 1 2 4 E e E a o c 4 °^ a l E u 2 E i ail co a s N ` c. ° E. x g 3 o o c a >"8° 42 5 y ceas p vi. r V i O T O pm G N P ) hit: z E a U ° • 8 °' 0 3 U E A L ° 0 C a °-! mv ` 1) 111 0. v • n v'' 2 °t da ii %o m. E g- incp°•o ll m a a‘r °•5 °' �v O $ rogE 38g2 .. y E O ° b0 E O 'a F • 'E Z., w C 1 O C2 o C O E O 8 2:62 m C a U 8N u :15—`2' s R E 8 S.e oa$ F, 7 i os e. •6 'd Q N O v m •W A m o t E u '3 : ill ° y m b e U 30 . e v " w C tl Q Q w T m .y p ' •10 ^ °gp y .O ' o C N O c ° m 5 ,s E 8 C 0 0 v m S g^ s x a p' o 'Q. a' o m 'S 4 4 v n m 'E O m E. l vOIc c .g gCa 41 xw c a 0 3 p °E id,9 a s g° tu E ^ ^ 38 1 NR . a�. w ° 2-g' a o O ° o r E °� 'y o v m a u �o ci 3 Oc ' a n E rE G ic 0„., 'Eg 0, OcBmN 8g, 0 � ' ` -8* E.= 5 m v 3 8 e a Q $ d c E a 'N ,T a c o t o0 o4 m S g E B e Ks.- OQ c q a d' >, E s °.O E - ' 8 ^ a u m w W 0 a E Pitt 8 � 'E.4 3 T �s O aE s m °c � Oti E " p o r �O e' g $ g K C �C N ° N E C O ..El ao O 3 p .x p a •O 7 •0 O C $ E LO t i gE 8 -m 0. ° N K v. g a aE _U ° m 6 0..8 O « v E N 8 w o O o a 8 a? O 118 a ° .00120! 1.,' >, OA v m 4 o T v •w w •' >•° e i E ° 9 0 m a 0 m 14 Uaa w° 3 .T810! g . !,11:0. .'<l3 W,9‘ 8r • • 3 4 T 1581241 O,. O O y ] 01:-! 8"1 .8 E i a E av „u.-4i05 'a ' aZ g 8F v E ev i m 8 E it Eg a . 84 .E478 C %b ry O Or! W a t • 8S 9= m O • o 1°1144: d v c d c � c S - II 0 8 .°0 E t1111§1;1 u 8° l • s'OCT oa 5E,158u wine c. g$rd. 'a8"51'c� 3^ ° E �8 > c "' 3E � m � g.8,-28 °�� rc 0�b•°ov:° � 8 o v � q 3 o ra� ! 8M a E° o 4d11§4 'J C 'O p O m « C :� 9 'C J C p a a' C •p •� F' Q m L' W O a m '2g;-1 etl ' m O E ° C E i d N O ." T °, •b LC. ,°, t 'o 'M ,_ N E '`«- rd 8 .d a;a v 2 .. «s - T - g ; � '� �N w , ...8 � 'S s- '•„ , ' rD �.33 m❑ - �E :C 3 "wc" .a.. •"'$ c ' .' '. fliI C .$' .v !dO' ° b gi . u an N o f , E 83 o q 3 • 2 :r^ y° o ° 8 E" E as m . • C m f.o 3 , •O m a 0 ° E ° � C G o E a 0 0 m o, ° ,a v � v m> E u o °c -d O Oa ° °tN' tsvQ .g4-.E c8 E E im w .2.s2„1.6 a . .a a. ,51 > r-8.Q 3m5e O , g6 emc >1°^ 1P. C Ts^.-ir. :3 y03 Ea 8_ o Orm .o v 1 . mga •O cc y ow .6°8L• o go E3 >v� 0 np D �cmS•° : KE$?: - °°'m8 u g 3sa owEa .D 'ag aa 838s% °c c so c° mv?> 3 'n v O E EC S O " ;oao c ° O E ai c O •3> Es TO> S° o % 80.0.! 3 aE 3 E •a 0 h ° s8 E 5av 11 d- 0 N f0 a ,gcy r2 3 g md e y c $ Iv a E a t §. ° 0y>g 0 ' a mop<� > s o a a g ° i ° t 2°,,,17,.1 m m °s 4 1 O s E EO8a aD. .0'x 8 a ¢ w E. m w EEv h Xm . o `p E pN : c - w l2 8 -E m : °2 0141' C E a .,t °a V a5 E N O oo a . c .0 v° o ! « e < d 0 a c m m •y @ > I o ih!I u t mA 0g m8RdC c- 1 l9 a ° x E�18 ! mm� 2 04 cO u a E m ol, 'u o i, O g ., 0m c c u > •p o + d t v y o e a o n re o .2 E : a c E y ? ° a t = m u o o i • °t 2 1 s 8 i� 1 !Iola 8 4ie g,I g.8 O g %g e n° E ° 0 ' l T> a 7° « o ?A E:8 8 8 a° a 71e c rn Psaa o m m 'Dr d 3s op H 1 ?o0sw A E d m C •2 yn . E w ° o o a s E O .F.a i ,d 8 Em Q°K m 8o a E v ,As m io=.o ,$ 2-010e d e5 82 EGc. -y-.E C °om au " v e0rp '0!11:911 3 y C •• 3 O & 4'118'.°41 ;Or" 8& _ 8 o d m a O •a 0 o V gC' 0p 0430 1 e m a v« o m «9 3 o f En $ 3 a9 m $ 8* 18 G 2c $E_O o,-32a0. g s 3N—E8.1 -0 o Rt O x Q a q C° 3> i v m m °e a° F°8°c s° QmQ.A o c gmg• x° t :owo 3 . ' °c 2 E." ,c0.. JA;?`i r fi E 2 c a 14, 0; g� a"• >. � 8 u— E_ E E 4 2.8.0 3.r1.' � 4 ,. D c � o §' c E v � •g0 u4 q, m , V >v c 1 8.... E °. 5N la= I E lip lC"i..0O>$d5 W E �p a� � � W � �• c � c yc 3 � � m C � — O � � 'uq ad Q ° O qw v ..50= G. a o' �" 'U N '" ,9..1 be V.. i' w 'D EFc� aa0o wN'w W uo.$ a$o c°v� *g,4,8-8 $ m E E w C7 381 E a aEi o y r$ w E as wo o u S oN c'2 `emu 'c' aKi q EC7 >C, C7 3C""•Q$ `� cb4 1 a;i g'oo c u :Ui 2.00 E v ° O y o u y E c , .�5 vU Eca op�o EuEEaSb$8 a crod a $.� >a �u " AO '«R °w m 9 w1,9 > z o d " 8 o w 3 S m 5 ¢ .� `:74 " v -� 1 '`«� u 'C +q 8� S m V4 `a 'O U U� �C a m E. 3 s o 9 o� P41.1 o �yc ^ e�.e a °' o Q acv ° o °� 'E E 8 .'s ` a E . >, ° u r•f r -1 8P vUigl .; 4 o a g4'eb o4, A � � " .:' o ° O E'u'n g§§ E> �' l u o 1 n N o v n C u F _ $ c •.2 r-)<1 n.<o E 3 E <°v w° gWU Ec° .c_.E E Ca1u.'t _T v:..U. O ❑ w C u m vg " g• .E. c o4 g E4 en S 3 O ,P..163. N U " V r; 'C. E w 4 N O O w Et g ' W N g .O EO ° gg o E h e E o $E oa E E � ° i pt w gg lii l> o N p c w E O y � a a U C7 C S O -74 bit °° °E° g ° E, e N .o d $ $ a E p ° u c •5 d 4 o § g. 4 S g i o " -En o o 2o0Em ow c a m? o o E ° 00 m S Pawm m m 8 .E• 0 OM' ra c m o > u c � w p u • E • S c S by ° E c � g a �N q.0 o Eir 5 064 x a^ -.0 4 u v 's w o p m 0 6Q d N N" 2 m m$ 8 s c v W g« o E S gs.k E a E g$'E ''''''612— at °"o••c mU o a c riS v `. ' a• a SV m g.. u o d v o . E a E o E E e E E c° N It a° E E o fi O d c o oE SE � � 4 y w P o� ° d gg p Su aWR o a sc$s. A JZ EE OD fi E$i SmEAcu c��7 f o.$ GG.°.. g C w 8 - N w y o Ni pa c Cd E u O m ° 3.1 m A n° .. y G € W L.-i> ,s4,-.8 a y c E - "o ya w c^ _w 8 g i $ u w � S. t v w o 1 c' 9 � N u w §°aoEeEEd °a>oE aP:w owa .4E -0 uo E> ",-.:E c gnE $ay c a §5„,0.51,e, • m 1y 1 N 'm N a o E c g c m E.E p E c 3 ° .. E 3 1 o S F aE w o g u q o go 4 D. a c a o - �2w e " U m 10 w w rD mu Uh $a m ou lS QVE = gym'''A °m gE•aoV 0 1 Oom> m ES E Si Ou E g2821.%; diH y7 EC m u jiV ".0-05 g18.1 E t6 ' a E ww o aN1p ..s4u%. E � wm E ¢S-c E= .O2 E• m yBr E p. �w8 ob a ,E E ap ,g, o o u c d m c oo 'E " F .°a m S o u v N a. F c p o. T v a E 2 t E S w l y to' OR v ° S $ 6 � $ " 1 - E 8 2 v ` E d E y d e >c o S w y w Z at u o , a a c ° o.°S O E „Es F y T U . m E -1 $ iiw " e N S E s ,7e, m .. ' 5 ti . > a u 4 .S � y t > �a s- °E aS w l 1 a u E w .g C.1 u Qa E i� i E E a I 85 1 h Arg o ! i O o a y U a g i F o v u 1111101 ut-4§g-g d 4 g s m u ag p " o a a va. Ena vm a Noh °au a 8 8 A 0 4 1 MN Mn O\O, O o h�° N, vi ow N b M a O' O 8'0 syi a 2,0-o M rn m a N000W 100 OON prf l N N b amWIS °c2Mpar 9.M-O'J N'+ a 0 4, N 00 4, $152,893 $(60,745) Yr C mO C w � y d 2�u H fi: 1 m .r > 4 A iiu .ga o nI Q c h 2U^ d' U 'I 'E'§ 2.4.1.N G y ° w D O r ? 4 m° ...2 U P m 3 a Fag y C T 9 m T .g U � u a aU O C m , u E'y a$ 88 r o O» E .E a o ;;.` O .-E.00 C, N C g EE « E 11 8, 8 8 N ^ g 2g <fll °° w • s O • om m« n :a b %3 m - d ° u .$ WI I .o g e E m 3 o! m o C 7 V a g w Z u $ t og�p m o, a m u K o o O cWi .st v ..a,E.oEu E E2 a, « e8 d 0- e • m l'2 « U d O .2 R 11 d t! At d m E o i E a ▪ E. -02 o m E ao 4L 4 o E 0 E m h E = 1 ° Es t x g • E m m . c v U c aO T y m a 3° E a° 8E:; i ° C G b� m 7 q P, u> e c ,e? g we L' 8 -EN; O ..,:9 y C a v w 8 G v “a U a gE t° w y c„ d v o 3 G o < w 2 !":4 v 3 pp Ati EE4 Q M C O 0 m, Np °E p ° y s U V CO y''." • m = a m O ` E s Be . m E "214,1H1 U e y w 5 1 N] 0 It ° :t.T $ O N o E ' G C y 1 U E'.11. m C E 3 dy 0 w QTw h E d d 1 1 w E ^° 5- v mo ° ° y d •5 o d da m 0c ,s:d �°E ,° ffi y °v o Doti ds0 $� oE m 8 U 0 w ! p ° U N z Q N U X T d Gg C C N d 06 iw yC N G 7 T d C 1E 4 .-O. 7 U M Mv v d m� O C O d U b a . W^ ge r-get, a T? ° Oe dT N w o y O, m 8" X P °>v N E a oa w_m �yv of °limEvE .EE o Eoc 3s .Q.30`° Edu,`° °°'°'EE °1 • O • • } U 0U S2 5 O y C C T B Q D § N 0 ov v -1w N . 4 y,f, v • Q o 0 tlE o E d " S t A t 2 d c c i G o P c° TaG III u 4o c c° p °° m�-o o n o 8E 2my ;e ��.� E go o g . 2 l ' a. 1:4“-E-1 <4E-5 SE E v 00 0 H (96,021) (41,029) $412,725 $245,397 0.7S N •--� MM. ri oo a 69 a = 8 f9 M fH 0 O O iA In exchange for terminating interest -rate swap agreements in 2008, we received cash of $93.0 million. U U a c_'p '�+ 27 T 'x-0 55,03 a ,.v •=.04e E 3 u O F .:. 'S-d DE: 0,i t m $' F . c .8 ; C7E. 4 rn .5 1 E40 Fis•u•§ ° m c E eo2 i y ,? " U U I, d 0. 'O o g 3 ,,,'S E a � 3Q E ^ m .4 000 °4 ^ a�1 U 7 iJ 2 a E.E i ill m aE$mu� o0 0 �6,2t.0E�aa auc Y'. ;1116 Lco in 0 G > E El xgx. O p IP, a .E• a 3g a 3 NEu n E C r0 0 y q 142u1muca Hill C a O 2 z ca o v 1 o .c 4.011E o 13a i 3 E'S' �3E�3W cwyEg W . 45 NaN a.� os!OA'�m —8 F` 4 L N d m1 U r.q a , •St"..,zrnEx zaz Future Sources and Uses of Liquidity g a5a 3 •W" O �D O c 5 ° E 21 c b e bb V m ='A ? ▪ ° U -J b €g p . 01 . ° o. ° c , 5 �' U .o E S h« a ., g o s V •a -c W C •�.ab – N 9 O* a C W �N 'a E m m V b V m ,E U ., aa'.,'3 U v 2 .o A i .E a E o m°° ji U o 3 Ez E c c Q' E d! °' g o •g • ° 8$.�SNCy� a'•o� E�i u•� ° `°° rA ��••tippWEQ N n G i •t? �j °4§75.5 •O T rt hN gI m m0 g • 5 c d E.8 .� N 9 W Oa0 �' r° 'J S U • d Z lEn 'Q C a ag ° a 3 •F. E i^° v v " 6 o° ..o ',3 2 E E O p 7 Y O� C �. U o0 y N! P c m o 1 4 E 3 c u G u d'E.E h ° .E o o: 1 •5°S� . ; •o `�' � cn o o U � ' `° � ❑ .O ... a C m T 2 yv'dEW °MoEe" W m 'FEW _ • g E: c ,'.'§ ° a 8 U � g 7dUW '04, g G a aU m,11.B.- 822; t o m v E ;— l.% g E .^ E E “.s .... 9° 5 , EE U 2c.. S° ° p o a g5 c Po Nw.9gr g g .ca ...1 r a 5 c '^ ap .E '� '8i 0. 0 I g l u ." 1. 2 E °c9 33 N N A T `o • L E a\ 5 U? V m' W En-02s E o O .�-' y. a;..2. f 4 2 W W' E 'a t+ '° 3 " ° "3 a ion Stu itlU3dc s't° c c a `a d m E "gla°C4?W ° 1B vps va. oc O 9 m N au°N A48 3 > F c E ° E c . N ^ 1 F o E O rn v z S ° 8 o 6 E E ° 0 EU ° O p "m m 0 a J;;Itti d ° E3O y « y B w w C o O O w "1,.0%' N . o. • cw n a.D O N op g g a O O - OO.y 0 U U O O • e g••8 6 °1E1 5 E 8. .' .4 C' g a3 o'i�: i 3E°vaQ Ec E�m? E°vm a9c " 80s °o:v0 w °ra ° 10 .E 8• C .a .z a 0° c c ,v sv a � a` g " 5 a°c ?a 1 c c 3 E c ?o . o�ydo 6. E C • E u 'er E§ 00 Sc 70P••=-5 m. � ? N E !AIL °.5 $ G N� O • '.t ° pU I pv o N y s N g < to ; C 3 • ' E w0'' r« N o g a y °r o l -me�� ✓ C ta C 0 11 m .= N • Q . P w p E L',25 v 00 v° c u W ° ° E s E E % p°12 a C L v °O u 0 • . °OiC w E t3 W e2 -0 oE90 o$oq° •a;;� W L W V ° V 2°111 y m o E v' rJ' E U � � "' yT G W d A W p V .g ° T W O m C y U 0111 m 0 0 W ; O h -5 O 06.41 o°:'E 11111 C SOU W Uv= O y 7 U «O'. 2 E n c E m a? E C 7 .n .. E t v d i m y�•5 a �a...s.,. w O L L 0 ? O E A V d tp G E c m vJ 1 o N O y C O 1>o o 9„ d n o d a E Q a %, 4 u w .,a y ki W t=y v 1 t g & E v O w y m G g 2 , W Op y G§ O$ p d A , y u *" m a4 g 1- o m w O E O '4V."--'' p°ES c t!UI IIII 0 T!!! U O W y J W �zsEg dE.o 0, 18 o U au gq ,i•ox °i!'10 �O �a oE !tG d u3v �3 �W �a1 ,E8478E bn-g� w uM V o m m= A a 0 a'bE ° ,S Tpp3!$ W W uo Ti � gQ Dili!! Uhl E a' V a 6 E u m 7 0 0 d h 3 c �', .E .. i W y U 3g00t4g m HI,,t553- ;. aE 3 c .. e: —. g 8 ov ° c V E U o .0 Ll A •6,4,e8§ .A ° x o m I a•°1hooc r°�E1d ;1: 4; d ° 5 v, � v i E d B E U d . Q E U S ; t '''''''F'8°- ' CQ « i m U -gF m ° . Td W V W' G, N > ' ' $ C Y o y o o a3 IM" E a tl a ao app m y O N^ C O. y U t ak ��. C d) � 7 N U S •° S C C F F C Sd0Ot SE 3 • i =. lg. 7 01111 E Z tC Td ' ° Z M w C O Is E ^T ` aw c u ° o gtn8 ' � •c� s ? p a rE ES-80M s $ S °Q E ed! 0 2o Eg u3C R,; s; o “-"''A8 s a 1 N S 0.y E 0Q•0 C O u A 2 C tE a d 0U0 rY. d C C 0 -sgu355 :4 EAo 411111 E °�„o U y a0 '`i' O ooi Kt' o a ffi �o � � 'a a.o T5 ax E a =g,9§ y w w 2E3:3'52 o c0.0- n r of NO ° ro S 1- - N O ' n N b ma`D, 4 N can m N 00 rn te e o Off. O WM 0000 M N q a u N � T u u y 9 d m 8 E2. 18 8 X2..8 E§ 1 O ° O • z O N >.,; w p m � m as min y N j p x B ° a 94S a ° 2 E i m � o U°? o =4,h . �+ S� G S d e §44 ° g w T m V O D U EE o c o b Om E'ii m 3 v p yi�?.� g 00 C b a Sxim o ° aEi m T E 6" ° s m o' • 00 C N O U O >> C O v. C E"8 Oo u W Egg U E a � N •O � U T^ js 12t°' IV5 4 g E a E; E E 3 C O d x w j +A U ° a $ 9 .9 . z v y 2 •c E 3 a l ao H 4: C 8 • m• y a� W.0 o�v 6 1:11-1 W x U N'T+ $ Ed E'3a� it 88888 M N - -d.•'' mt 4,40* 6969 Vf °W g.=.1 > b L d §2 �tp � � w U F 9 a 9 E i6 m u u C 0 > 0 7 s m y 1 a v R; b O 2 y y ✓ $ ▪ E 8 3 0 ▪ :: G I 0 d O :7 0�� a . - 0 P U 8▪ ,62;48=4 O � R' 0 F o mz' 8a o� >w Mid^ . > el ° 4, d m 84▪ w :2 x14 0 U C g 5i U o °i ry a C 0 0 • a E J uj . is • � eo •O a � .2 .2, - F m w EA 0.00t.0 0' o 2' 8 V '• ' U F4 ,„ c v � ? a T F T 00 E 00 p7 00 ?4^ 1 C 3 A > m A 41,13 H U p OC F U -5 U 0 8 21 ° EeE2 g'® 9° E E N 4 sit a m dG � O 0 o m ° b �a ° O O ° U W U Iaw°!ji C',C-' W XJ U 1°9°2 pa 0 w V C WH ° C S . G m & C 3 F y,a 0IWo m U U UGC C w d m •+ D � � 3cdaod s,2 m1 a ° c o , ` e2 a y C d fi _c°. l�� gy G U o m .5 T ° « La 3 O 011,111 o F T A m U C d w E m = '� 1q ad :? 'J U ° W � b oypeso�q 8d o ta.gt ° d a'7. r EN1ods uaa� o. ac�V3 8 0 o u 8 n 7 d .e � O d d o•a38 hTi ?•053 8 •C E W H d d U a 0 d J ' 8 : 'a' d .4 U O U .r3 N du .r3 O O �.� G « W .E J E d ..>. U .°3 'a) .S'i •JC fV S u o 'op a s o e U .e .°2 d u i ry° ° x 9 0 4:°. 0 U d n 'G L '� . 2 0 E O. w o J-. YW ° vd F H g s 8 G° 3 mV C N r 8 e d 9 0 a5._ $ 0 . >,5L21 o.9 o Q Euy IwC8ER o 0 .E. gU ca.8•0a T 3 a> BE'' 1;g!:441 8 cit; . c 8 o 0 0 'o v c o '9 o E v o ° 8o m c a)1 m sgg$C� � E ou1111W4-%11111 o O d .o 'ENgAS3 Eqg NI..e a5f E0Ew=do V �D m.•. ,� y .5 mtIflI s E a°�uv e c E °, E U a d g e g •3 d a a °e ti E a! 50 ° ;," aD 2 mHN E A :v %Ld E c,E;g yL 0 V;,cs d xo°o3 ° 'av o4x .yJTS�oa2L UUU 8 m g 'C O L ° y O • , C { d t m ..° d 0 •a V N" m i G o° .E ; 0 E c d E N V C cY 8 o E g C CU p n m 2d q w O ed G 3 y d ° c h C 00V9,48,,.5 � w a cs ° 0 og o °io v o 5 U Q C. 0 U N c ,'.• s Z dN o m o 9' s $y o c � v ?a m m a A d ° N L C -° 6 1 'd a t m t. N d u 0. F oo y F � m ^Eo'a.a 8 �2 >ca..naNO�S+°aP9 EE° 5 .59a 2u°•- ...888"5..993 fV U� •Lp 3 a ,Q^� N '•ZCO>j. o b E d 2c . o o .. u a 0 E ?.m ,d" o g o o i o v t o a d l 1 $ 9 E a E V @ d $ m3 ti 'c. 8 2 dm a o A E $ o a 5 o g oo> y "m P o f F 0o N pa iT 5,u 01103/ 11 10 118L1!-8 •° O l y u p, a 1 V 1C lO 11° m T O > rE W H l I; m o O = 4 02L 0 r p° . G e0; 11 O O 88'`�Nw« ce8a; s11,uaaE P+u5.EKAE5age> d.epp'S vo N311410;12 V '.°7 •pp 0 C$ v a �?n o ° p$p as _9p a, •p3 •:fi a . °$ m tC . u �w w c 7 .x a..� u y o v 3 a o Q o G 4 u 33 EBB; 8 � I "s''d ° 2s .•r,�. :g E g i t3� y s d o° o ;a ° 3. 3 a G a W �i o a p >� m 3 d° O '3 u E o e.8 85.12222 8 s na 2`LE E c. 11.14104t OC 8 5 'n w C 5 U L 7 C "L C E c:Eoo d 0 o9 ° h o ao b09.8 ms ' ads41ebo w ° ° a E t o.' o 8. 5 •A A i O O> W 0 :' aoma.:a Eo•p' d•a� e 1 •G C p^ C G O 8 ° �pp a ° �n�pp' y C 9 d a U Cl L F« aiG 0 0.9 0 w w o V m W v d L u E mL u o S'O E °LW E" 5 d b u 3 e E 'o,'e g O.vryy�°D E.0 Oa,� 8o V ° O0 y m a' ° o n,u••C8C pp 0TO pa 5$ u .� y°� E ° �' a o O 2y2 y C O,1 b U d U aO d .0 C 'a ° N a y .di. QQ.. «' O p U 00 0 L 8 8 aaam2'3o.>c, d d o s o 8.9 h E 8p 8 5 dg1$JE d .yd d •dp ..>.. w a d RAID 5 5 y c 5 O 8 .0 EnL a S e g c c d ° 5 O E °4C w 4UP L C d � 3 9 a E I N aE Eon N >°2c5l. d d O C O w to E � m•�•o 3,0 �3 o V a 111,11 !:111;1 `� E w a E d E � p °p�� aEmo'a.ad °.88289 �m�o$ca�ppsy_� s C 'i ° 0 an d 88958.55 d= s 0 C d F d 9 C C E .� .O ' d m C i a� A N ri>>E 3��y C C ^' U .5 0\ $(203,364) $2,508,874 _A 5e C N N O 00 g S N i0i_`M-'N vry vi ., v, en 1 1 INI111 1 1 $ 4.11111 1 4 v 4 1 III III I 1 E A el El en 0 I ra M a M ocr Ilr ~� I IInWM 28,946,372 25,289,989 rA 884 N - M NV NO -- .r- M r 00 N N V W N V w OM MNO N � M O i 0 101!1 co M1 ro N N .4+ N . WW - W 06W M.. N sg 00 O ? N 0O N O N N N i P M S N O O 1 1 41111 1 a r N v g 1 182,948 30,491 1,357,077 1,909,098 N 11111 1 11111 1 1 1 INIWW M N 0+ M I 1 11 1 1 1 11F3$8 1 (256,987) 4,028,937 3 m QOO\.-•NO mom, .T. vrigv'^i r a 4 I 1 bO III 1 1 O g. 1 , 11111 I 1 11111 1 N 186,739 31,123 1,497,998 I 1 m 187,857 $31,309 $1,574,245 $3,389,936 $(175,243) $(363,057) $4,457,190 w e rX Nvg p qu m pah E C Fa I C ;'S 8 e— 0 1441111'4 p ` V x ° w . ° 0 'b',4„...-:,:z.7..5 ° ooy0�aoF c =b2o EFOaoai$ ty u Eae•Es• &x +a G Ii•u :z 0 Ex•�•S!: g 5 iz0 c8 Lo 0zo o84 8x� mu ueAmm Hra mu uommV,v, w W O r0 Net r N M. Net W mf0 10 M1 000 v4. LH ON LV LA 8 1h fA 69 0 ON N 69 vi 00 59 The accompanying notes are an integral part of the consolidated financial state 1. REPORTING 647,154 $ 833,684 $ 487,423 #g-'I mI O�N N h N m m N gtigg �O �P a8„ FinQ v N 8 8 9 isc gig 0 tdo 18:,0 °a1$ 982,310 1,224,262 (498,324) (1,845,391) 8 ON VOi808S M gAA/ NN. E���ppi I I I 'Wu yyp p� a1 gcr; NONm� N � ... pp� I�pmVOONV� Goa NN-+ "4!!": O zAr m mN Q c � RA %F. O M O O N 0 8 $ 1,970,423 $ 2,040,453 sElor u o E d Y o - m e o i u P. o a^•Qtl p m m „ 2SS O�a� `�G O mP. U BP , � - � y0 a C O y 9[' ° 1 3 1 mE > N as E y B 4 V 88 O T O Q _S E `� ea 3 o ny 9am49oa o g S ,� o .$ d :: C O'D m y ° 1. G t C O w Q 2 ry O o FF o m e V v g c•+ 0 a Uy •o c m u u E is e E b H H ag m.9 H H ,A O The accompanying notes are an integral par: of the consolidated financial statem 1g ^ O E " v d c C � o ° o o Y o c o s 2Z:'72 c r S o w T d s s _ E F U a U U C U .�C y e; a 114-01g11,50 7 y 1 ° O C '1'71.W" E a E E > U 'gin' � i ! .E ti ° 5 ; v Sm T: C � d W ; G ° pN . W a .^ o o iW p G a a .S tV . 0 o E i o? ; c 2" y o c 6 .'$.S ... g o, o:o > .:1 U Ea °o ^ i O o :� 3 ._ b wk d v 13.R.,6 p E sv.- O o p a v w _ . o m v a � Q a-y ° c o ! e v a v . y E d :s o = ° S S 3 . l E y y ti a y c c C 3 a A- c $ a y o a 5 . -7 . , ,.0 U u s- . E ° .� C o 4 c .a ° e o o o F. m $ ^ C N 1 >c w C o a 3 cJowu ; a O c i C 0 o c ° a ti . E `Q E ' 6 01 v 1 . E C u o 13 w^ 1 3 5 m ' 36 8 :c u n h w E y a w a$ ° o U l v a �c x E oe oy 70 EC > °o�$ c rk 0 $lE W c m° °� E o E w= o r . cO N y �E o wow _° .° o „, t .° E � m a°^ O w o o° d ° S O U «cw 3 c n E. 2E2 c iiji!V c a° w 1 o " 3 c u m o a c E s o a o '� 0,>...,,i w C c v ui.c K a ^ Xb w "Flt `a ,& g ao e m Tca Z c o Q f'a y o e, I ? 010 E 2 ?ti. u > ° $:w .o o O 'z °' 3_ H 3 3 v$ d c° °' Z' °E .� o c o D c o y l o ) y C? Vg . >vE ;�u21 49,4,, o gtei,°c oy° ^a c loo °'_ .g c l .% 4 ;� L N' o o '� c i 5 aH ,2" .9 aGi :n s^ C o„ c 3 G o 'w . E° §' v v o' m `a a 9 w E o^ d O. .S ,°. c O v .., O o o K d o s O w a .�: c � `� �' � °o � QQ m •W d v d as '� � x � o :c u v C ° ai 'ts 4—.3.4- ° ... Z .t * °m m an �, 4E" ? o w y .q ..„ 0 , O, y x u ; 'e ° m � ›.,112e ° g . 's y 'a .0..9 V .,.E� $qA.�_N a8.52=ry y5 3 eat',>c°y�grJd:z°° m on I ft E g E w a c .6 a .�a„ 6 v S o u w° :0 a a. o$ T u' a �g m o m .�.Eeu 1 49 ud d m3• Tao or, 41.. , E—a o" ? d'a;E = v eu °ch�'ar u°O gwu•a �.g o° ..,,,,.,415g...; U „d.... F 1 � 3 E E 3 0 7 C « 4 9 7 . ° C U v 'O $ TS, G C C S .,25__...4 a E ° o d i dI C 4 m E E o 111 P441 AID" 1 y ! 4 E =t e o E w 3 c = i .°. A lk a P.w 1- w 6 1011p o, ea1D `$9 g0d K cam oaso m i, � �°' S� ijiU «' . • 'S .d . ' . ijij .' ' 1 ` . • n Q? " T. O O E '$ " ° u w � 9 N 5 m b W o. s w C y te.c ,o aL.9 o a Z a F w $ C° a $o d S g-5$ el! " mo j1i ao� •n 306 a $ da. 3 En« a tU o T as. co o oG, j g w003!11 v4« lwu 1Gt , 3z 6 ° o a 21 9 °$°5 1�p .4 3 a '8 ° lay110 � mom = m 4 g°,sdp .. 2 u ✓S m u E mW o 0 F. 5 awTO � v ° �yE o a u oy w aC« " ; 3 c U a s ° S om3;EmE dc -4 C 91 iiird E m sd 1 a$Iv LQ 14 %.'-'4° m t o p o a'�iw �Go ° °"O °o Riw 5o 1 3 3' U 0 v ° u t E E $ m 2 y o t d 9 OF 9 E« as o °uwa ,E c' vEo S a ° + � ?go2a a wo lOCy�ba `!o . 0 1F ' o a ❑ y,- � c> 5 5 °. s B a 9 a a 0 3 I t o2 d r d .0 v ." .A o c y ae )E F z g°14 � 1I! ° v caw o 'gig ' w° w y t k 6 E iq 5m E:3 d 4 c a a .S g t' 003 , a u o.s o'er ° l 1 E- 2 1 as a 3 1 S I w o E °d. E u 3 E. Edo o L� m o c°i I (i v E m u d o :a v m .'' .Q .o v S a a � `.d o. S a o All o .� rd 7j d .�. i 5 '° m m O 2 ! 3 a Z;341 m § 1 -o v Z a i a S3 E v t t a 'u " C •^ cimc SvZii8a° m°'O,$ glis wogs E§g. d s g U N d .,, N 8 � o N go 0. fz C ^d a p Q"a� > a °s' A glm oc �a.Ns>G iO3a co Sg p`'�c o',p_°q fferz ::: .� 03 gamy° o 8"s.q mm•b '1 ° hcooimaw §cc > 2x5d s v�>'�o° �:a8..v . F.g wgiov Y �°,1",:.8.,,. ° y 3 c§ ..51.61:6° r� ' ;c E i 4'a• °E w i m T u N ac= «hhl e° i "ggg w o c E@g a'Of u B. d '° E' .4,0e.. 's o o u u m .° l w a ny K o x g ow 8�11l E a o c• u a $ • 3 *g A. a e ° O u d g.o ° cla w W a a h E c '1 a„ ° a 2 E a m ,a u e w c w u b 9 .5 o$ ., e.: o o a X h o G°.ga >vt> =m 'i°'a�3� u. :y5o as >mor�mc„ Qay b W °u LL° i3 a B.= a c &T. �.a a.��ay 4� v �9 « g Ev d o...-0,-- o° E. y �SnSO 3cti�Y max ��cS�3d °a°�d au °co « >�a m° 14F81. �ca.a�.. c 1 g u s W o 0 u s g 3 u .a o t' E 5 •a .11 M S cwt �.� � v•0 ° S a m ' 2 $ 6, o .a1Y.a >9 ro • v� a ,3 ca Q m °'C2 `' r 1° B 1 e. .- 2 'o • .n —›.—'6' � E - ° .1111 a c i Z ° u a 3 9 a .° S S v T a .o o -41-°3°.11° m e 'C '° Rt $a H9<o4b S° 'va "Ca$ C o°3 e' Ewo• ° ^o aov.ao O Z ti c •1 Q k. d >. w n u H b E' '8 a. v o o d V g= .1 Q �'a `-,128..'2,g...-- - - ,118 —rs' c.�s° w o E l- .o 11:0 . .0o•$'� 5v T E cr2 g: g.. ° e V c T E O g 0 > 3 .^ c c 5� v u c m w y� > •c s'S E g7.07).°0 >Ko a� o. aa. ..A .g��.�om9 d$ �w°� em IijILIllIH u°,, awe c c. > m w '' c agd°° oE°G In °`°' 4 .'awd a•4.v IN°ela!II :47. g. Easauae 5c11 ibm v � N 0 4 E a E °° a 3 s .s.nm'a_a'ou v. ham, F u 3 ,$ •o '. > u i '>d. G A' ° .' o a a a a ° u a >. u G a E m y m o v ,s y a w° 'E�ggg�0''W.1 .1.z...1817,-2 +. d?0—...; u n . fin« w e v °'8 • E0;60. 0. o .E 'o$p'S T. b, o e .a d N ° u y W .S 'O N .a «td y m. O. .2 E E D 1. N .a .'O G "' s Q N 3 O Q g O .: v .s v Q 1 ° 22.5 y o 8.7>2.3 . 7> w ° .o c m .a z se.gw ulAC)°1 Q'D Qw�u, '8td ° .8o> uusaEE hill da�au ms sw c t u `3> 1 d- :: a o ° a H 'F : > P g h .a °� ., a.E w '° a >� 3 > o �• g n o a r>.2.22.0 1 m w UliDf d o. w h ." ° 7 112480'01 i R •^n •1 Pcc C L O U .s k. W a . L '.:: �'ii tliig21 4"1 U C C E N -O. art :2101 E o � N o &E� 5E E8 t g41.8 d Uyy py f.' ,71711 1 1 I d l G !I G h A • do v d 6e E I 1r go r ot 2 a> S9 a �qui w m O w • .pq E A x q° o .9ara�o • -a' d 2 w ▪ IlgGb So 3 58 g E. m 015—es i u `o S° ati i J ♦mga of T w° p U G g C O U ailo 'o �r 3 0 $ 1 Sgt as a dQ 13 N u w p g 0.0 w D 6 C W raj z u -0,..,'P ° • 2 T `C° xUp 13 O ,'oE O33 U G _ F >o.N.E 3 u u P4 u O 3 3 '''c'° ° N w o u F a o § z 8.410 'a _.. a . z N �j = T .`3 `gym W d b. S� ,4z) C v .5 ° o N I i'w C❑ %g A N U pp U O A O ° Py ° g..e 0 a- a g a z °m� w'E m Ug. e a 1 69 N N b $5,445,322 $83,156 a 0 1°! ° 0 0 °.! ?"84 q° O 4 k- i s Sig N C O° p 4 O O 8 A O a (r V-2.5°.,,, , 3 c❑ ° c t °u w°.. KE 2-030 E d y k101 E c E d c o u .D E $ o o a rc T C U . E w s a m :re u 7 G e C g, U -u 1' 4 8 8 aw g....E.—'i.o .'g te S q /9u"'uM Wg 2 m � Q c y" c � w a c oz 8-a TU$•4Eo ' > 4mu _ "180 a8 . $.1 °a .o 3 g ld y a o v °quo ? E ° o u $ > E .° a v u ti t . . •a E w ° :° 3 a a 7 .a o a p u s o cK o E uu $ 20 m ° c 4EvKC� w. $ g a o a U o a5aso mK'g' m3 da I 30:!01; m oi° c u dw E u ii 11.21 zooipa ayq iac$t n ril mm ad�om °w8 a T2a t . � ` -�o1g 4P.3 yo `ai u EIAol FWr nU w1°'C > ° Z c C' o u c ° o m r d x m — c F o g .g om o 1 m B g°! y a a m f m'°40U40 o .s - °g>. 42' r Po wo. 2gT �$3 ode > oErr Sccre'84 P j 8 �„ rn ' g°p0' 9 a'S U uo 4m o1g -TS e Z .)2 is wu E. o 8-.01.1,8 °N= 82 69 m a 0000 00 00 CO N ti 0.000 $133,602 $110,909 N z G 0 O 0 0 0 8 gy0 O L1 O li O 0� O u 0 4E E y U G y E W E . 3 11 0.9 '1 0 0 Zg U ist IlE N �O 00 10 0. N 00 CO V9 O v1 Ow CO 00 O N 0O 0\ 00 '0 Vi O0 ^ rn �m'o vi aoovOS a 0) 40 5 000 ° e �0 10 00 00 0 01 00 O0' el CO v mrn�o mlo 0 0 d d 00,O�Nm e L N N N N N H aO N 69 0 is N V 69 O\ E s O w .3Q e F C� 1 1. Mg; TO NO E z E 1 E. 0 41 a z i A o z a 2 -5•0 x X 2 W C V a w °N fa a 0 00 «g z z p0) 0 V EO • 00 E. U 4 I 0 E. a DI 'e E z C., a Q 8 a 8 u W e rl T Net income available for common stockholders .. v 01 V 0 m 00 00 tn N N ti 000 00 00 b b 00 N 69 8 h 69 CO ri 4. E U 00 04 et 69 Vi Diluted earnings per common share 15. STOCKHOLDERS' EQUITY O N 4 3 g C G O p g> $E oonB a1 '� `^E o °q 00 o G❑ 3 a o .� .� ' .7;2',E2 ° a8 a 1 c o E' E ," C O •d g N y g 0 JE U 0) 0 b 0 0 C CN w 0 m %� '� O� O O P stogy ; 0m 0od.aag�>, 8H "0y�gEyod o'o' G Vow40 O '� � b 35§1.1.10 cb } 00 O 7 T E O.G 8 a.O G'7 • a o 0 E t0 u o o ° e $ b o V > y • -. pp 5 r0) E.1. 01 o y a .8 11.2 ' O N N V ,,CC0 -g" YU • y- NFL O V 4 0 W G C ti , a O W g 0 U 0 0 0 E -gipF ms cE cr 00 8 .O m E bG0CN dw N V oo °z'O. p 3 p -.("000 0.0 0000 0 o E0E g o C U s. a o �fl .h aaa ' 1 EU Ca E W° o> R m a 0.1.....1011 24 -,9- 6455tBd o.°.pu �gs w°ao ©C°= BSc ��., © O F a tit •$ d U g w .'c. 0204. flU'1 ...d+ Q •n .a g o 3 00.5 O en S U F d O v°G $ O O y N Q 00 O c, a^ S . *5 ! ra fJ s8 k N g g N u y$ w t a ..a� 5z o u Q:p la afi c c•9 s 8 E a o $ a 2 a eoat5 $ l l ru a o _ 4411 s g Q b ;4E, 4E, *UgQ$ gt- ltcS1a F u Q ° a,Q$o o w'a y w o a d N . og . W 3 a 1'o a o 9 - o 0g g o _ T „� g .�E 8„ a c- a E .eeF AO, 0'$F W I.. 0� . c u C •$ 3 L a d g Nx_ c d WE Q E° , F y o g � o d y g 8 l wi' TTgn + I O C o38E•$y$ov G .24 S g oi0 'Sa a S 98 0 - , 4 84 5 >'-1 $° 1 .k = 8 dU a iE1 .' s e •5 ° e O d° E d T g c .t °.. w^ °1 o �F 'g a a G >° '� a �r o 3 yy $ '9 jyk3 '� . . .. ^g a ° ,g-s! Rw} 8 ° . x 'O lip ° WQ 4/ G7 G V �N . yy ° �x b V a C °{ G 6 goo' "NV E4EO �d_ •Hp JD IIIUU o�d� -.- o 55r=>ew'a 85.61 n 3F>'$ va�J i'goi g�i•a �o�g1 ° � � S' '°' w n 'sr 3 d o•3H § °° '° 8 :a-2g a w C 'g'c�o �Ii111fluJI1Ij4flH o 1] 7° O V o> 1I1114 ° tl? E ' W '� Ri i ° w N pT y 7 .0 N 7 2 ' m.0 C d § O 0,E?;5Ec g�'•°�.�Ec o :g O 4 tl o g'm 1 d o..a u g �1ac,°,E.Ox.yeoo o .8° vi d du 0 S w a ov o «•a o a •aa" v 1 p m 8 � a 0 g 5 T° E B g l i u wv'Ti a, o RI k°c °w' 8 i'.E &.E 'e.8 i,riw •w'm c. v ° m N c w ; E g .g aTy i o p0 U E 2 v LE- ? E c 3 og cw 8° o E 2 o d o Lgu o o : IERS. 3 o 00 d C .l i C m d c a 5 m a° g i E g c g ° O 8 p. q 1-0.$`6-g y g8 ° d $ dy E 1/4/v .O p O 0 -0 .4"'5 T p N d E _a ba F a U3 T > a RT O d .+ [ g 3po6c I:u cnn !3 y c a a° � rpm w .n c E .. o ° u m o w S^ c t O r GaEsF3gg dy��o 00 a�°o3 8 d -T °1T Tire. g§~4: G i g v• o ” u' m�' w a •E z h ° o e3 l 8 m> g m 8.6 ,a 0 S • d g e m y l t wg u ° 9 E C O 1 ry ad .�m E w o a v 'B5 E . a2 g v° Eq 1, 11C ton 9 m d W 'O h O F F A of 3 N WI a E 3 p !� T N n1 V o o x yy 11,01 U o a W b r A y •� gpy m acT c i v� A %,.7;d :0 n FO L i Q n 1 b ilgUt o ° 0 1E G . '= o P N20.4 ltE14 d m a v art58's" ' g o f a !VW yea ?.' °" w e U p • E v N E p �T ° ate d 1O a g� o `fl $ L o L § o S a c x o $ a 0y �' y 4 6e 8 002oQ 9.; "12' 2411, 8 -A 1E 8 y v v 7 0 0 .J' � 0 0 0 J "" Ew ,gUx o t E1 p Fs.p a K x a 2 • q. iu d E d s p1 3o F 1 1 3 1 4 v v 3o 3 m t w8�o adaF� mm�aa .4r.g. E�acd .�TW47m> `ae $ .d .LC .>. u E ; 4 U a�a. 2. q a 5' WWI• au 5moma ° .3 E d m g o w U u° z E ei •a E s �4., g •'pe Uu W m YL° l; o d' p E o; C 3 d'8 U`. E U o o° q .. F U 0 T.o P u a :: 0 c a E 4' m S c a° .� s o 0 g� •3 2g 2 x E o> 8 d u o 1 Oda Q 1 0 •.Lr° ] `8 0 U E T ° a 9 3 4F 14 N x a , 1 L w W rn NOTES TO CONSOLIDATED FINANCIAL STATEMENTS—(Continued) ° g U�� c^ a s °' a c° W o c $, a' c g m a <d g g .T.... > :G GTp U .14 .F1 C te a0. w E E€ g v 3 0 5 2 a Wg E pp �• p m e e y� `� � :� Q � aa 3 m v a .wW. e a 9 i 4 u ^' Q EgRg.ccp c°.°Nzo¢n 1 x ^ 8 = ::.^ v S3 as � .� W � a3 'E •- ... mhgxgg9ouwoocS'EW F m m 3 y c 3 a O g W E x a C c$ t '2p • $, g 0 E�m O O W 6 � °1S PI s °c E g'E °'1 1...w]a E•Og O o a a o s N W w 3 3 c w aP4g 8 o2$ =off8cv o U 4g °E gra.. 8•� • Eg x Q S Z V a. 'E G G •�y' N N ‹ e .e F3 a W u N C. a< o a a o° OO o s E a o a E_ o v o TK•' 2 g 9 8 a 1 .g 2 NA E..0 Nw P. .Ei a 0 •u -S' 3 gfib $� ova c"FN'•uap g ag `� W a A N Q.g meot..G 9 8w yo ¢ c p,,,4 4o •b.O pus. E N N 8 a c °�a�oE o'ONU w^o -o v a3 c d w E �s � Ev �¢,s$ s' m�o l-.o :: aow 8g 8c a 2 3 e4 E ao Provider Litigation Z o a c E a o d .8 8 t 'a '^ N•� ¢, a N o w E ° E S V O E m N E 3 o O k o .1 (5 QU,c0U9E_9.99o§ 0° Ua"aEw a �°j W C '''< h u E a F '> vi a o H E£ u U 7-4 u o 8 F �i y 3 u F F t$S'q'n,�'us $6tgQOoo 1Agm a F 3 ... 'g > ,, U- ..E W? u g E a m 8 o E a c m .p p ,oe '•qq a u s oa E o .a N o a °, ° W.�NF FF .m a .09 3do 2. a.'o �w '�c,,51 .o 2o�°° o ,cm F4' 6. _ 1z, aa;5 0 E `'U g E a 5v xN2i oUN.,. 4 u'y �' ".1-"'"4- a, tai Q N o u °' :Sao =°3 ° as '^ °2E8 om2mx°•m$•FO 3 $ a I m d o c w$ 0 3 . N g.1 5 m I t s .• E n s° T •5 a � o+ 4 u �m u. W E p o N o s^ F o i T U ' m 'C [ir N � � $ U U 7 � m '� 0. C `� m o.p w °.c a 8.E 3. c 8 i$.�ra s o ov o 4 >. ▪ d w 4 8 '� o o .. W a. y Ou .°_� o o o .$0W'� 9 g g•E2 v E uY3° °<°,., v TOa4 o N m <i o y c U E °E a g y s u v x E> g v aui v a a E c e p m a a0 E x 'a c A= 5 9 . 8 9 y o ao u .a 8 rn 'S 3 g U ° o° $ L' l A u ° •= g m' 'o �+ uW °ox y d N$ v 2 d `v u s u a •o rn g ..x %A s lm m, o E °vIh• yv o 1 m 1 W y y a v 0 ,$ v U$ s° E° E v c x o f W au. W u a1. z y �+ �''p'°$.n E dv a 3 2 aou•aQ�a'Uoc °,(VX Xc8o 1 U o '2 ,� xxy o f .NC m :2 .3^ �' C W q WE ypcvo &9 W.T1w`o5o .2, f.gu 2 4 °> v E t E o m a^ m o« •° o E -T$ e • v 'u W u °, o•So'Q O 3 ='6 g • r; 8 u m E 1, i �3 2 v m 1 U= '1 a o m x 4r z'9 a'7 a E e 8e' g8w p o.e¢.Ega a •O^ •3 v E u E c'3 •S pc�� u! gxg a W E i l S '3 '� •a :a o I P V c' E N x 3 x 9 . .a E .2 " wo ° °' E S '$ d v •� .°c a.4 .. V* w m. F O° 'q 'J C k a U C ,� ^, Q C m Q m F E o.. Name$tj o o = tEN u•o•' ^ °'6 E a''oo y °y°�i ° 11::::;;;; ,c t aS m .. .`^3 a° i° m u c .. ai 4g V .k •5 °� •o e a" U a c, a 'a o. e op N T 4^ u w w N a N -',3 c N > E 1 g m c> o W E v 8 e _ :7 A g m a c w i ° 3 g e g 5 m E a d c' r m$ .^ m y a `� a B& x .NN. d ,? u I 0.-.=. a 9 E F 88i Q W 8 'o E A S o er ° u > u a$ x� �� ^ Q N Z Z B.F. `( u ^.oyr,.•C :o a i.- ..,.00 W FEE u y m v;; v . u Jj _ m °' k o w 55 "'" c u N c k m E ° .. ,3 .° v o 0 8 'll g i3 > s g r W °�� A F ^ u 8 � ' a o Er'2gZ�o$! 74=2 Ew o9N ^0.90)'9 gE9 2 >a9 u3g F 0)p 0ae n� 8 �.$ mA AogU�•xp E�,x > ~ c. >•O a� Q'$$ d e8 mOw F� N$ �N m= q q 0. g o E F O r N 4 N g F a g g m a u .n G rd y a. F 2 'n � d . i N O E ge g- 0.$ m as N° 8¢ > a '� ^ 0. e m .G $& h W .e v y v °0 .4-6L E" ,., c W a ?. H :c d> p > W g .^ E °' t° 0.i .N. u 8 �' u °: .� a0 v a E • e >. o o !: o `� ;3 c > F $ q" u :F o tO 5. m> '$ W �' �:, c a > °• 8 w o 6 a N m " U 0. W o .p w, m ea! N i ni' U!ijjU! N 8 1 o•o b° °, $ "o E m c o ^ o° N 0 4 § ¢ E N,_ u z¢ A g .a a s : Oy F N -2 0. 0.N > g pP W 0) v �., .°� d° [°„ ' c W G W '�� E v u 0. 3 0.. -° w y ai Y.' w v oS L' s v 8- g o fl W j E .:: ,u" u a> - ": i u o 0. •° a.1 750:&04.4.907, 2 g ig`.Fg 0.o k 8 w yw ^v y u °A Qx g c h ao'� � � g o0. v W •0.° W g o N .. w a .� '� K ^p$ �' Sri o 'c ac' •E Q 6'o U N u '6 -. 8, w u 8 O n o '^ °, a° o F d N w y� O a E a o F F E g, w W ^o E-° N C O> 9�� 8, 8 .o N° o.8 m _ pW `.d 'n T O O. W y 1 4 U 'C T I U n C g° ea 3 C N O. ^ Cj N C Y. C 6 C .¢, ri F am °" m y w V ^O k U >" �' o o m E> 3 8 9 ° N c N 'bb • mew1E °co 380.8�:,°& 9^'cU°•ErauN=8vEg °N°oWNw x"o383,?: w y �Nj w 0. 0.°p u E F g O o N 1.§..r.,9,2,0„1. W E r0. o r¢ E q Wiii:11 z 'm,0.>.K. 3- 8.omgJ.90,0 or o °� E §'°oG,g €gE-gg o o • 3c�V SSc�O m� 3cA a � g �� � v o 0. a g a� m ° m W o F v o" i .012'° -7C7"-JA W 3u ,,: gvc 3o F'1Aa '244:h" a�„-uu O F> U a z s C W F u O '�, U u W 0. U 'O w ° C C SS.. ° U g; . 'O p�" 0.o- = a$ '¢Nn x' o w= 'n° o o c o _w u `° a>' E o u`� z 8 w° 8 m E ° m e 'o `� oo 'S 'O u Z g Eaa m K°'$8 u.0. =ogu �C.1 01 a 0479, V o1p,u°..E a ov'g 0)E N V' a V C p E A E 'g w o g o .8 i T U x ; A N L .� v e ? N0. d o d •-a, a� .".45''-''1"5 g° N g x E g u g a N .°i O :O d 7 0..y 'o 7 V O '� 4 0. W F 9 'S ° C O i. '0)0 S o ;; u :a c � i° ,o v p, " n u o ^ a - '-.085 F a o >, 1 5 �gg -.cv o 8 a g °^ $ o.op 3 d. °.g 'e ° u - m m'.5 4 E ° 9 0 �-� 7. a . z War d E¢ 1 .0 E' e g e> '+W O d W Ig N o $ a c 3 C w .E 9 3 m G ° e° QU E 9 N G oo ✓G : uga8° xQ uc Ea.3E F .°.,u '�«.ri a'voc goy 8 a> okEo in U O x U pp x E g t z 3 v U 2 ° °� •d .. § d .� c i . e Rti. u w m o= w 'o 0) v b .. I E v.' e'i Fa,^ E� `� g •. �"z�5 F aUp o aAA m gum w¢ara¢ •NO.� 0).a cXz ca a 1 00 O O 00 N 1n m 00 Non—. a Fn. N Vt o BQ Mw a 00 0h. ▪ OO n 0: � 0,,,r. mrn"D aN C or; a ar y C h h b r N. O N V Vl '. N .a N. -. ^ No w w g O N N O 7 VD Os C Vl ,O O Q� O ,O V1 E. • 7 O. as el O O aOA V1N m _- m �O W. r:...1.. N 'D 'O I� N �O N N O r- Vt an C`N N-. h O�Nm O vt r l: 1B@ V. ▪ OmO h N 7 Ng� V 8 m O y N 00 00 tri N ^ -+ -� 4`4 SS �0� pp pp�� p�p sr/ n en Ne as mN go�o.� r O D��-�0 -�. 0 N 'iw coo con 0o v; h., r`rig .i �c v� zp Nen n.. N 01 00' --. .�. 8F1— m a0 m N u gP- m9 m ti m N W N 0 4 C T N O Q a 1 w u 3 d m°' O U A Bo w S °' > 5 I a. m v 5.6 0 E• v v o w E , „, N . ° 55 n °= F c TI F '. F cc a a m gt'a I g v> a eo o§ ! o .a 22 _G E L o 4, gig w $, 42 ° e Ili iii 1 a O U 8 w C 1 a0 O Os W a yM ." r 00 m v 0, 4, N M 00 h §E'" U 00 0, C 00 1 b '+ MN Sooe O • ° ti N r a 00 r b v, vi 0, sms 0 N o, a N b V T N h N m a N 80* 0 O\ 00 b h 'c o 00 0, Ca 0 7 N m h N CV 0 0M N 00 0, d' b9 e r N o ac v c c a W � c .P 0 7 C b0 Q N 1 U O " 2 G 8t b 5pp N J °'? O 0. g5 a y m 3 y 'x O" E 0. " rJ" e G U m' d 0p' gg E q N G 2 U Y 00 ER ca o a �a Re 8� g , a x 4; ^y g O 7 ° ° O g. E o $4' e s aP e 1 Cv 'AO a 3 w g 4 8 " 98 8 'o,>.Smm'S$ 8 g. a g.:13-18 6 O P4 au°�E�aL3E .OD.� t E p E 1 3 u a� b 00 y Z§>1 Uu- v � 7 V O 1 a b N Q a U m E y M a.E 3 t w o U yy U G a ,6 C U G m. w d 5. w o aai�E EcT. &8088 eo'L,u 3a» .2E8 SE v E o �yAgw �owy vgv a G c uy 0. F u U u•�;; .� u vP' c E W d„.'J L.V+ai q p tl p EE ET'8 0:.06 .4;40,4S a 00 0 0 C Q � y Z N .a WMMC L i °3 >.? 1 v 3 s M e O !1111:1 o4 c Sao 7O 2 8EM 3 c i o m $ v A U d > .P .:° �i m � DE a .. � 3 C o a `� 8> ❑ pyU� 2=ur= .15448g a aC m d v' _* E N d' a >c E'�ocE W °$°°corc S q -4 2 y oo E 0 y �'Y�y� uo G�gn u `� u E 5' N a ma c � Q w o .-. vi ^E 3$ g c g c E l Q a 8 6 P4 g i W° u 8 8 2u > d S d N u u gg .. $ 0.8 0 0 " ,L S ? 3 T v ° o v o ° g w . •mE 5 m c m v , aa i T m p ,. ' — `•°.e a u amt E m.: ; m p .0 v u° o = o° 0 Het Nai o« °v o s,4 3 g 0 2.2. i. S .e '63 'y ° c a E a: E , •E u w c g v a a oq1 ig'e 1 §1m c o v u «a18'caiv p� O An Nv o g 4 m d n o t 4 'o > o 1 m c w o m 4,3 2 a A E g a > E g ' E o ° .= �g m m K 'G pFa 'o vE • w I. 0$ .E .4$ 4 o y u nr5-5 0 'n" 1°°V• e5oc3 • a Eud°�Eo•r 5:F8 g 1 §c. m E OEE •gO ,12 o,gOrta o201 E3ytc fl U vM-.R.. gY'E311eau m.a mo.v3cO4'0_ E0 tC„ U 1 C.�m. gib 20g.. vc°A.nEEm°.,3 �P5;];'2119/1 Ea ve E og$r� e a m i E- E a 9 °�, E° v o n, c o E c t . B s E$ . ;3 v •o a W o v «' v Y v •t° m .3 ►] �d N$w a « �p w °0.S y m E v mw p:E_ " .n �','•e E '2" m - i O— .0 « 0� 0 45 w .° ! o OC m O m W I tE 4" O C �i I d p g« p N O 0.° n �` a E? c E c °-a ° 'u a$ �� c G u m0. e gg° p G c w d h «c�, - um-a� l'�`.vm"c.. O3 , E15RSFi. .� c-n° w ..� E y m u.' f. m S r 7 g z °=. K a c ° « y g o •-• o. E a v > .c Wg a' • °'3 c E c m - a a c. a °3 B g — 1 w^ •°Et ,° c ° .ao a r`. G € ... v=, —go E. 't 1-"- -E c° 6 $i A u'E c 4 g-e 0 .04 c E u 3.� x• G o v gt.5 u 0. m V.' Q `�' « m > ctl w 0.0 m❑ q '� O d u T E v a_,e, ac 8 c Wis ^ x rn m c g c •-88 1 0: 1°• , c am y M D .2 5 u o o m a :hr . �5 •E •o .e ,c °m u d ° ,3 • ° c g c E s .c t v v e a %' •o a l eo `� `a n° .c . O 3 Tp a,.,1-4:d C 'S 4 .Vp Pa « 0 •p m nmv by m u �+ U A d U m °+ N C CN • C •pm� �. E # 7 0 C G g,;:: G C 8 O C a O Z 4 m,F ° t u 5 E w u o e6 o Wr 'y u °3 s .a., t o , , 5 0 m .v w u .� • v e, i i O a U m 0 O to O A G �! u .O •Ei U> N ,3 •O c> •O C° E n',% W ar[ .T•o` -` zv5�1g2Bp,tos9iSc>:3S•o' 'ou_v =y•tc.onE mJ $ 3g m S e qty E °a$ d E5. mPga w^ c 0a § o m g c g° o 1°.P 2 v1 E .T• C— C 0« C u J « O n C n N C C -0 E °; m w y o, o f m p p c E a. ,S rs . m= c m v •0 o> :.. m g ° A"4 '3g acu Ec•P a a5.ao53- .�av O spa dgo °u °'3c15, 8.00 =5 %00._,0 m° =guawm> diOm o .V4-174'.2..=.6' 5 ,*c, G ¢ v o 5 a m 3 .3 E T— o .d E o .a c O E eA 5 ...c $ ° 4a aEi > m$ m- TE 3 4 o al ° $ e a N c'� �,m a 3 mm E d E P. o °vdac.cm ma>c�'"m�9 >,vxc o .cu'..�� c5 ��o W b c •c1150u ogou °'$e13a141.a,uE .T^m cv 9 •e g °— E e °m ' g Fi - a a u � .o c y ��- r, � •� E a m m .E u e p 3 .Q E r,_, a. m m u ° gg ve &y ^�.=t07 104 °5°a,c5 .01 s°02. p, •3oaQ om2 ygmfi. pE e° eo 5mg`oS umo o5u E a p V8,, 0.... uE g§ ° u m a i ;3 c ro i• • • F e 0 3 s 3 •° a °> a e v e 6 8 c v T 8 o^ o 5W -o A uy E .: ' E °gsgEs a4g•"•n'$ ¢•2•E?E`l o.E 3, 01,5B E9 $r' --�5�g oJ«a°i:791 t.y 6• 8 11 mc°�c ! E c•o F .§' To3c:E W. .E0:o ,g 5i3.E mdvwua.° Eg...gaSowcg •ckga 0 > '8 ° .W W a m .0 E 0 o 0 E. N `o O W •�0 21 u F u d 8 ° U O .a p C°Ij . . O I ° 0 c •D S & .t 3 2 -a t q '8 g s S U U > g m •00j• mF §. a U ° . F U U o H. 'D 5 W > h •p U m T 0 .. 6 v C K 7 el O a o 0 0 m y u o u g w o F a 4 r 'O g 5 G ^ F 8 5 q 0 . U �; w Z T 0 C "5q O T 7 6 's o S k 3 G �- f. o :: m W � F o d V E W —m o° Fa: g E 2 1 y F. E 1 l a' a 1 U x U 'S 'S 'S . 0 0 0 ! 0 4 E E o 0.0 o o ,o 0 8'5 Ss' p '3 " '8 q U 047101 ui yy C 3 i7 G7 rJ 1 F GG �gC98 U ttl N fn F m O ii qq 5 "i >4o• $ 0 o F u 8 O A O F 5w5dq ^E V > N h y° « a U O 2 U w U 9 U O C W H�i U F� F u o 8 3 o Tg � 'J F m .a �O a g o o 8 .a�a E c s 0. �^ as o Q W ', 3 N G O .g .0 0 F '2 0 0' UO o 0 El! z O 'O ., T U ❑ F F V, .,r d q .g F •o . E. c �' Q . o ri N '. A?-1 Si E m .g F .a °o � 'S '5 ° ,� E o 4 8. 5'0a ° s C' F§p ao U % m p g c oat 5 .a g ° o %,5 :g78... r m• $ oU .4 'a 0..8 m .02Q u u v •o .5 v 8 00 te •L o...ao^'.5 9 O U E C O!i F q C U • FW 'ri vy� T O . >$ T d. F 0 O 2 y 4 2 F o:hU N G G•. Uw U • 44 0 00 •pW o V Y g Dm — r a E F m T E p§ Fyp Alg 1.' O C 00 i t g i vvg p. T !it' d O y q O T5 G u 2 l 2 ti U'E. Z •o e q U u E 4, '1:5,-8 !12HIUi T T° ° 6 ,t °i C m a. ' gF�g:1� !4rw's8 ig • °.oU U _ u 3 o �4 T 2 ct 2 ! i u 'o 0 'O ° Qh g 0 .°• ; 0 0 � ma§ g3. g4 i° E' i i s4 -F,.5,`-:,,E ;'d TO To�rn� 3'g .G T •N N C FG.• 2 Q •� s 0 G o° ^ T O a U t 8 y �eq EA m �O w3 a_ o E pp .2o OR C F I t NA U iU J7 U O W.tl p g?w _ G 0 y C z � `i C 0O °` c Q e d O O 0 'J 0.0 d y o •g ., $ d o a8 w tiO .� F ° h T 5 '+o as O • "p 0 0.8 U $ 3 > Q ° ° v O d O >"8 E W •O 0 U x g 2 2 0 D W F 0` o 2 ,, O o T •C = 5t ° 6U ,c2 G u 5¢ 5 s p 3 22R t'.2, 2 U c 5 u c q `^ LE IN ar-r 3 U o W` s o •$ W U U ° W i1i g 3s; U 3'a o E W °. '4 W O N O F O .'L+ � 4 Dp p ° m.a0a°i No 3�" o p p O W {A ..11FCC 8 6 o 0 0 9 .> V m W'8 F 0 a o 2.5 5 a E b E E3 G.6 F C ...5 O U t g 4 F, =•°iE28 "'3 ^3 C7 F c 0 o 3 an d -41-0o o Q o 420 0 0 .0u ° ° q U u 1 v °ap2vaa�Q 00. .m U F ° 3 W v u W F 81 3 W� �D v a y � 40L4-0 aF ° a a •e > N ° g zr4_.g E zi $ d S • F E D o g 3:3 s E W Q E Z u o g' 3 g N NN u o I i u ° O O C 4 E , x °o kN V o 6 ° D C vm 8g 0F i q U xg0 . ° ' x e 3 ;83 O . W w avmE y . F w O0 G 3 i° 8.8 O p u o 5 o d 1. C T ? C 0 0 w1A ° O y ° O y T� '4 ,2 o 0 o C ° a d •E W ag° L ti C E O U 4 0. 3 m c c$ 9 x v o e 'p" 'i�. H m YO. 5 ° F O � .� W Y. dN G S. 3 N N12°2...11.2-0 U g m U 8 5 wC� U F F W W F O E° a W o v 2 080i:41 F E 8 W 5 o 'o o u. 2 o Q ° n 1 E,S vUWi t •5 U 3 p'Fd. o 300 O Schedule I Parent Company Financial Information Schedule II Valuation and Qualifying Accounts All other schedules have been omitted because they are not applicable. .0 v F.. w sel w¢ w c X • u4't a y+ u o o C F Z V E fn a E w 0 O F C0 U ..t ! X R° U T >..6 '. o y o y o Q 5la e 000 03 a • E 3v E t 3 • a R s • c Q, 3e u F m a, ▪ w alc" �Q e N p z N o 5 .2 t p N • P ° V el . 62 EE.0 R a y E' w w 0 G' a T W QF r C - . o Q .5 .c G e s 'c O eo w ys8 .2.°.1 ill 3 i 8 S y All VA ; -Sae il w • auO '3 r�° m .aa a "a' W 1;11 w c+ !i A. ▪ F o i g g 5 •� -.r.,;-..; A U aw R :6 Z R $ b4 110 1 • 02-zi 1.1 '0X.8 4 'd2p - w <o= aH .F aS 0 o '0op 0 3 3 N ^ g a 8i "Z N N S y d o, Wr° m 82 W p a4 T a H x O i N o 5 '9 z S w c yE 8 a A - c y m M a ov oZ az 8 .0.f °f l .I.o . fl U m m m g d IV: QC c0 2 .n 5,8>° .6. •.a'L R o a:oo El Sp x . 5° x . o G 0 � ° 4 V R R Na 00.D GF C u � a� R t 5 wFcxF°w Fix .0 s oy o dq EO 110 8 g. cega � T u�+ S . .!If r; g 7 m N xc0 gs� g 4 a U o ti E E E sEt v a '3 a m C 5'0 � W t S U O m 8444 W g I c 0 u ggg E 3 c Es 2 0 0 g -0 0` 3 d .^ a u = 7 0 '''.E . a u ° : d Ocw . zti `c ur c P70" r w II' x U x •3 C 0 « .2-c, C • a g-0 0-8 v o 'i m g A W W c ? °E a 2 a Q ° E a ,c c x E c E c At. L" x A' v s S c >E 8 m E E g d •o E v 2 E G 8 E '8• ,°- ° a • u EB ° E u °.T . a vs 1: :GO OVA' y p 0 • . O V g ° WN s n m l X e v x §..g. E' w S o W e . � x a ELI C.n0 g S w �rn W c�` W, . ww 4 Eo ac U a, ...s `teop yrocQ w Eo sL .0 � o c .a. 4. 8.,;') 8=‘;-.: .4'4 Z'.7.;.,,- DC U& „ C r g v pp N w 8 8,2 84 v E s U S— L.0 S' 3 b.E co .O N v! 8 c'3 " ° v p 6 = E 6 p E L i'N O U O p? O N$ $ o u d wW C o. W W o p d C d $ o rn E o N o N .0 Z. U w c Tl W g W u a E m a a ru v g S'o N E c 'Jc .E m g T E a C u. !L 7 p c ' o d • w G- a g " C g N Q w tN c E E 0 O A C x x x Co TE 8 '. .N . w .0 E N C v) L v oo . N 0, 2 . C g g o e O ,O sd ,e a g le„, b„ ... N Z T .T U O pw .O U 'D of y T g0 8 T 9 ' 8 o; O W° 2 '0r O L 7 U p x > C ul N E O O O c O p P d L o O 0 c..p : W O G RG � C E CO A 0?2o N .I ' c v ..7,'-- >? ° v ...J 0/.8 E s O E g" .' l I E Q - --. N cr .8o 'v .E N c g o ,t,,"9",2 X ^ N0. 3;„.;,„:- '.7 y 0 C° c 1 U° s g 4,= g O `- r .y E i ' a.^ v) § co 8d 0.w Z ›, E °S °, a t O o dN VEX s 0 0 2 g E 0 g 1•5 E g W " 'n 0C) 8. c K o < o E a g E ,, 2 a g Q 2 o 4 g U c 0, J vrn u � u ) E 3 w W u W c o u o o W a o C s. °x 22 g °W" � m - m w c z . w E o° ti 6-e O 4, ft.. m O u ° °) o 8 6p au w vg m a p >,E oEE c V C^ 12-2 0.o.: 4 0' W .s1,2 .,p, Q oo8 sW .. C N C g 4 U U EP b " ,, E O GO° O c K y ' N g i E" ° g o F ° , g .vC ... ie 'I O ..,.go? .w U y ,a .G tC 1_7r, y E Z s C Zcw ° O,. 1 ° Q O p z y m W .',5,-; c W c O � T l y p o U IF! W x : ^ • c3 W . §z E 6 c g..4,g..4,24 E 8a d w 3 E 0 5 _h .. s a °rn m g`°oz °`" E C c• o4E Uy '" " oo d�° E 24 'o Et. p y °` x „m oil0 E u E x g' � 8 08 ° o 3 w > o >§ ~ U° .- w„ U E ,4 m o m E d u — xi . g c w -o wwx a w 81.O S'."4:4 kCS x i x Pgj e.' w F; rn fgt.. ell i °u = E m c y 'gE o a a s v E v0 t a 34, the Company 3 MI as 11 N 4-0 B G 'd tg U �g Bow : G O U E g. w FC o z P d CD z a$ a N a 7;; z El V § • O t d W E I ▪ d W d W▪ W h N ON III III III III O• II 0 4 N <m° y 7 rN may a vi February 20, 2009 S N 0 F /S/ DAVID A. JONES, JR. z February 20, 2009 e February 20, 2009 /S/ W. ROY DUNBAR February 20, 2009 February 20, 2009 2 /S/ WILLIAM J. MCDONALD William J. McDonald G) coco co X Ta 43, 7 E E O U Sgt lh asziE 3 1 3 t i a o At ___L_ __L_ _L_. _1_ gJiM &t • _L _L_J__L_ 1 --L _1_ 1 _l_ _1 gI iLia NI a g8 Big e$ 2 co ME rn usan �' mef — Manager of Safes Adman - Small Grou J__ 6 -- E U e — it, — (1 p Liz $ $1 IP Hg 1 --L- --L —T— ih 1 x is ON $1 di ill IMI 1/1 III ill Ss I I —1- I Implementation Timeline Group Medicare Implementation Timeline - 60 Days Plan Effective Date: HUMANA® Guidance when you need it most August 1, 2009 1 Group Medicare Carrier Selection Implementation Customer Timeline - 60 Optimal performance is recognized when activity occurs 120 days prior to the enrollment period. A 60 -day lead is reflected in the "Target Date" listed. Days June 1, 2009 0 61 2 Customer Detail Meeting: Confirm Plan Designs Discuss Markets Confirm Rates Discuss Implementation and Communication Strategy Confirm Pre-/ Post - enrollment Communications and Materials Customer / Humana Typically held within a week of the carrier selection date. June 7, 2009 6 55 3 Communication to Humana Internal Areas Confirm with Markets, Sales Team and DMS Humana June 7, 2009. 6 55 f 1 5 Plan Enrollment Meetings Customer / Humana Optimal performance is recognized when activity occurs 60 to 90 days prior to the enrollment period. A 15 -day enrollment meeting period is reflected. June 15, 2009 14 47 finalize and Order Benefit Summaries / Enrollment Kits / Employee Meeting Materials Customer / Humana Optimal performance is recognized when activity occurs 30 days prior to Open Enrollment Meetings. July 1, 2009. 30 31 6 Weekly Implementation Meetings or Conference Calls (as needed) Customer / Humana Will begin after the Customer Detail July 1, 2009 30 31 7 Conduct Enrollment Meetings _ Customer / Humana _Meeting. Based on Enrollment Period. r � ;tea ., 8 Open Enrollment Begins Customer / Humana Optimal performance is recognized when activity occurs 60 days prior to the Plan Effective Date. A 30 -day enrollment date is reflected. July 1, 2009 30 31 9 Open Enrollment Ends Customer / Humana July 8, 2009 37 24. 10 Process Applications (start) Applies to Paper Forms Enrollment Humana All applications will be processed and entered into the system within 72 hours of receipt by the Louisville Service Center. July 11, 2009 40 21 11 Mail ID Cards to Employees Humana Optimal performance is recognized when enrollment applications are received 30 to 45 days prior to the plan effective date. Due to time constraints, a 15 -day lead is reflected in the "Target Date" listed. July 15, 2009 44 17 12 Verify ID Cards received Humana Optimal performance is recognized when activity occurs 10 to 14 days after the ID cards are mailed. 'Target Date" listed is 14 days. July 29, 2009 58 3 :13. PIIa'n ;Eff Mctl,+rr#late =` _ . ,.. . ; 1 61 o ' ' ■ . Conduct Wrap -up Meeting Humana / Customer Optimal performance is recognized when activity occurs 15 to 30 days after the Plan Effective Date. 'Target Date° listed is 30 days. August 31, 2009 91 -30 iJ a= z 1- m 0 0 d at at U co w co c c 2 • HUMANA. Guidance when you need it most CLAIMS PROCESSING PROCEDURES AT A HIGH LEVEL 2ity of Corpus Christi 1 1 ••• tip ■■ •• II VII •■ •iV■ • DWI ■ •••VN■VM ■V N/■ ■V •N • ■VVV •••••r/Y••• • ■ • ■V SW 1 Initial Determination sued or G &A mination Issued Determination Disputed G&A Received Will case be worked within compliance deadline? G&A scanned. into Human's Werner & CCP2 Systems _► Request le . transferred to the G&A Work Tank In CCP2 Assigned to G&A Specialist 4— CCP2 Is forwarded to the correct Service Center GSA Worlc Tank Forward to the correct department CCP2 Work Tank s it within the. G&A submission timeframe? Appea Grievance -• NO Yes MA Review conducted by the appropriate parties Partial Overturn or Uphold uIl Overturn, Partial Overturn, or Uphold? Overturn Claim Reprocessing or Authorization Is done Acknowledgement Letter sent Determination Letter sent Submitted to the appropriate review area for investigation and resolution 4 End High Level Internal Medicare Grievances and Appeals Process Flow 'pecialist will refer appeal upholds or partial overturns to Maximus OSA Specialist Maximus Specialist will prepare case for Maximus Reconsideration Maximus Specialist will send to Maximus Maximus will review case and renders decision Uphold or Overturn? Overturn Maximus sends overturn letter to the member and copies Humana 1 Humana pays claim or issues authorization Humana provides proof of effectuation to Maximus Uphold—is. Maximus sends uphold bitter tole End meMbmberend copies Humana ,C3 , `r fs ! "� physician s Guide -to �� qa�s��t �� �� �..... y Humana's Clinical Programs Medication Therapy Management — Medicare Rare Diseases Managed By Humana's RxMentor pharmacists and MTM Managed By: Accordant Health Services registered nurses community pharmacist specializing in rare diseases Eligibility: Medicare members who meet Centers for Eligibility. Commercial members diagnosed with one of r Medicare & Medicaid Services (CMS) and following: amyotrophic lateral sclerosis (ALS Humana criteria or Lou Gehrig's disease), chronic inflammatory Primary Focus: Optimizing the outcomes of medication demyelinating poyradkuloneuropathy (CIDP), < use, improving health literacy, minimizing cystic fibrosis, dermatornyositis, hemophilia, drug- induced adverse events and assisting in lupus, multiple sclerosis, myasthenia gravis, - identifying lower -cost alternatives through Parkinson's disease, polymyositls, rheumatoid mailings and personal consultations arthritis. scleroderma or sickle cell disease ' r To Refer- Call 1-888-686-4486 Primary Focus: Monitoring members to minimize crisis events and instructing them on the use of specialty medications - Neonatal Intensive Care To Refer Call 1- 866.655 -7442 Managed By Alere (formerly ParadigmHealth) Eligibility: Commercial program for babies who have RxMenfor" been admitted to a Neonatal Intensive Care 3` r,. Unit (NICU) Managed By A team of Humana pharmacists Primary Focus: Collaborating with neonatologists and Eligibility: Commercial and Medicare members who ' a ', neonatal nurses and providing parents meet specific eligibility criteria and members �,, -> 3 with support and education; management referred by other Humana programs -,1�` - may include on -site or telephonic support. Primary Focus: Telephonic consultations on the following concurrent review, discharge planning and topics: drug induced adverse events, lower r{ e x £; follow -up until 30 days post discharge cost altematives, member health literacy, and `.t ���; To Refer. Call Alere at 201412 -7191 or toll free at nutrition and wellness information; follow -up +� : a ''‘1/4......,:::8:.., ; , 1-800-396-0706 (at the automated message, consultations are offered as needed . t " t r'" : press option 2 to make a referral), or call To Refer. For urgent referrals, send a fax to : r w X Humana at 920.337- 8508 502- 508 -3277. Include the member's name z ` F and Humana ID number, and your contact „ ? " &'q; information and tax ID. Please allow up to 48 s i Personal Nurse' hours for processing. - �'f Managed By: Humana registered nurses trained in Members may call 1-888-210-8622 motivational interviewing and -� � %a , health coaching - f + , Eligibility: Commercial fully insured members only with Transplant Management • �n bs general care man agement needs, including Managed By Humana's registered nurses �.i r x low- to moderate - acuity diabetes or asthma. ' `y° . .?,'''"� '�` who don't meet disease management Eligbiliyy: Commercial, Medicare and Medicaid members _ 'S` r program criteria needing to be evaluated fora solid organ or bone marrow transplant or waiting to receive .T;? Primary Focus: Assisting members in following physician a transplant ? t i } * t "fir.; treatment plans and providing guidance to , Focus: Guiding members to Humana's National F ` " meet long -term health goals yt Transplant Network (NTN) facilities, xis -' ` To Refer. Providers and members can call maximizing member benefits and coordinating 1477. 416.8773 transplant- related care T .. >: , _. ; To Refer. Call 1-866-421-5663 -`''":'" Hc__NA. it most VJULIV51.1 HUMANA P.O. BOX 14601 LEXINGTON, KY 40512-4601 GROUPS/ HUMANA HEALTH PLAN, INC. HUMANA® Register on www.humana.com today and review claims, benefits and copays any time! EXPLANATION OF BENEFITS - THIS IS NOT A BILL ID NO.: NAME: PAT. NO.: CLAIM NO.: REL.: PRODUCT LINE: 5C GROUP NO,: 2- 2 SEQUENCE NO. DATE 10-04-02 '"Zw.fk;C;;L'ADE ';;AEMSOU.AIM 08/28/021 08/28/02 1 •Sx.:,..:;:s.',,;SSSS:iSV...sS:54,. -"kkookiter: : . 99213C 28.00 100 TOTALS ■ COORDINATION OF BENEFITS 99213C PHYSICIAN VISIT ELIGIBLE AMOUNT MINUS AMT. PAID BY • . ,SSS.k.S,SS.SSS:4:5:SSMS.S.SSZS: BENEFITS PAID TO THE FOLLOWING 28.00 SEE ATTACHED FOR APPEAL RIGHTS IF YOU ARE COVERED BY WORE THAN ONE HEALTH PLAN, YOU SHOULD FILE ALL YOUR CLAIMS WITH EACH PLAN. ANY QUESTIONS - PLEASE CONTACT HUMANA LAUS OFFICE P.O. BOX 14601 LEXINGTON, KY 40612-4601 OR CALL 1-000-4HURANA HUMANA. www.humana.com Form No. GOUTT-Rov. DBTO2 Your Appeal Rights If you have questions about your claims, we want to help you find answers. Follow these steps when you need information or want to file an appeal about a claim. You may request more explanation when your claim is denied or the cost of the service you received was not fully covered. Contact usl when you: • Do not understand the reason for the denial; • Do not understand why the cost was not fully covered; • Cannot find the applicable provision in your Benefit Plan Document; • Want a copy (free of charge) of the guideline, criteria or clinical rationale that we used to make our decision; or • Disagree with the denial or the amount not covered and want to appeal. If your claim was denied due to missing information, you or your provider may resubmit the claim with the complete information.' If you are covered by more than one benefit plan, file all claims with each plan. Appeals: You must appeal a denial' (or any decision that does not cover expenses you believe should have been covered) within 180 days of the date that you receive the denia1.2 We will provide a full and fair review of your claim. You may provide us with additional information that relates to your claim and you may request copies of information that we have that pertains to your claim. We will notify you of our decision in writing within 60 days of receiving your appeal.3 External Review: You may have the right to pursue an independent medical review that may be available in your state. For derails, please review your Benefit Plan Document or contact us.' Court Review: If your plan is governed by ERISA (your employer can tell you) and you want a court to review our final decision, you may file a civil action under Section 502(a) of the Employee Retirement Income Security Act (ERISA). Be sure you have exhausted your ERISA appeal rights. 'See address and phone number on the enclosed Explanation of Benefits if you have questions on this notice. 2Unless your plan or any applicable state law allows you additional time. 3Some states and plans allow you more (or less) time to file an appeal and less (or more) time for our decision. See your Benefit Plan Document for your state's appeal process and to determine if you're eligible to request an External Independent Review in your state. HUMANA. GN- 14135- HH(fully insured/ Form No. ERDOC 1 Roy 09» (-_,\r‘t- Srna rtSummarysM Your personal prescription and medical benefits statement HUMANA. Guicla.nce when you need it most Member name: Member ID: Plan name: John Sample H12345678 Humana Gold Plus HMO H4007 -002 't.ttcruent }period: August 1 -31. 221)1)7 Your 2007 medical spending inside eel plan 2 tion plan works 3 II Your responsibility • What your plan paid Humana discounts $618 36 Our me al claims 4 claims from previous year 5 prescription claims 6 Yaur:_Portable Health Record 10 Your Rx Record 11 1 Total billed charges Your 2007 prescription sperrdin What you pal II What your plan- paid Look for these markers Savings alerts Health alerts Prescription coverage changes Online resources How your plan works You are in Stage 1. have $1,556.80 left -in prescription costs th'- ,Lage. discounts rag4 arltpnce $1,786.66 A5481880123200820400000004 JOHN SAMPLE 500 W. MAIN STREET LOUISVILLE KY 40202 © 2008 Humana Inc., Patent Pending Contact us Benefit questions visit Hunana.com or call 1 -877- 691 -1983 Hours of operation Monday to Friday 8 a.m.- 8 p.m., Saturday 8 a.m.- 3 p.m. Alternate format TTY 1- 800 - 833 -3301 (speech and hearing impairment) SmartSummarysM HUMANA. Guiclanoa when you need k man Your personal prescription and medical benefits statement Your medical plan John Sample page 2 of 12 Health and wellness services available to you through your playa. You are eligible for additional benefits and value -added services. If you have any questions about your coverage, refer to your Evidence of Coverage (EOC) or value -added services brochure for details. Benefits • Vision • Dental • Fitness Program • Smoking Cessation Value -Added Services • Member Assistance Program • TruHearing Discount • NutriSystems Discount Numbers to watch - What you've .-Did you know? Fiber found in whole grains, fruits, and vegetables can improve your colon, red}#ce the risk'bf heart disease and cancer, and help lower cholesterol evels. Meth over 50 should get 30 grains of, er a day (about 2 cups of r example). "Excluded costs" represent the services or items that are not. responsible for paying for these services. Piiledi cal Costs - Copayments -Other medical costs Excluded costs Your responsibility oveired by your plan. You may be is year $25.00 $629.80 $629.80 $1::,499.39 Did you know you have access to a 24 -hour, seven - day -a -week nurse advice line? Humana First guides you to the health care information and resources you need to select the most appropriate level of care. To use this service, call 1- 800 - 622 -9529. WNW M0006_GHAOOUERR [01/08] SmartSummarySM HUMANA. Guidance when ru hind it mow Your personal prescription and medical benefits statement How your prescription drug plan works for you This information is current as of August 31, 2007. For more detailed information about your prescription drug coverage, please review your Evidence of Coverage or your benefits summary you received during enrollment. John Sample page 3 of 12 You pay: The plan pays: ins at $D in total.prestript o 0% 100% Your 2007 Spending this year: What you paid $169.23 • What plan paid $673.97 an dtounts $943.46 e " retail . Otte $1,786.66 ere Yourli move t ' St g 2 when to al o costs are $$43.20, leavi ,490':? You pay: The plan pays: 0% 1009 bpd of reaching this stage: cur Eurrent use of medications continues unchanged ghout the year, it is unlikely that you will enter this age before the end of this plan year. Your average prescription costs to date are $105.40 per month. You pay: The plan pays: 95% You pay: 5% or Preferred Generic drugs $2.15 minimum All other drugs $5.35 minimum The plan pays: 95% M0006_GHAOOUERR [01/081 SmartSummary5M HUMANA. Guidange when you need k meet Your personal prescription and medical benefits statement sr.r medical claims (for Aug 1 to Aug 31, 2007) John Sample page 4 of 12 This section lists new medical claims that were processed this month or previously processed claims that have been adjusted this month. As a Humana member, you pay a reduced price that has been negotiated by Humana with participating doctors and hospitals. The "Humana discounts" column represents these savings. The "Exclusions" column represents the services or items that are not covered by your plan, or amounts from an out -of- network provider that you may be responsible for paying to the doctor or hospital. If you have a question about information in this section, you can call the customer service number listed on the front of this statement. If you believe a claim was processed incorrectly, refer to your Explanation Of Benefits (EOB) for instructions. Humana Date of Service, Provider Name charge discounts ' Deductible opay' � p �e;��lons; paid (Processed on:Jan 24/06) Aug 19/07, Claim 123456789012348 Jefferson County Ambulance (In- network) Transport, Acute Respiratory 466.00 280.00 18 00 - - 168.00 (Processed on:Jan 25/06) Aug 19/07, Claim 123456789012349 St. Jude Hospital (In- network) Emergency Room, Acute Respiratory 609.80 essed on: Jan 25/06) 19/07, Claim 123456789012351 St. Jude Hospital (In network) — Inpatient Bed Stay 915.00 525.00 390.00 — Venous Blood Draw 18.00 Not Allowed This procedure is not allowed separately, as it is part of a more global code We. , reliedon internal criteria to make this determination. — Depo- Medrol Injection 37.00 - 37.00 Suspension 80 mg/ml You have a denied claim. If you believe this claim should be fully or partially covered, you may appeal by writing to us within 180 days of the date that you receive the denial (unless your plan or any applicable state law allows you additional time). Mail your appeal to Grievance and Appeals, P.O. Box 14618, Lexington, KY 40512 -4546. "'' M0006_GHA00UERR [01/08] S•martSurnmary S' HUMANA. Guidance when-you need it most Your personal prescription and medical benefits statement John Sample page 5 of 12 Medical claims from previous year This section lists claims that occurred in the previous plan year. As a Humana member, you pay a reduced price that has been negotiated by Humana with participating doctors and hospitals. The "Humana discounts" column represents these savings. The "Exclusions" column represents the services or items that are not covered by your plan, or amounts from an out -of- network provider that you may be responsible for paying to the doctor or hospital. If you have a question about information in this section, you can call the customer service number listed on the front of this statement. If you believe a claim was processed incorrectly, refer to your Explanation of Benefits (EOB) for instructions. Total Humana Date of Service, Provider Name charge discounts (Processed on: Jan 7/06) Nov 5/06, Claim 123456789012346 Jenny Jones, MD (Out -of- network) Screening Infection 512.00 (Processed on: Jan 25/06) Nov 19/00, Claim 123456789012349 St. Jude Hospital (In- network) aergency Room,Acute Respiratory 644.80 135.00 M0006_GHA00UERR [01/08] Humana paid - 332.00 - 332.00 SmartSummary 5N1 HLTMANA. Guidance when y u need k most Your personal prescription and medical benefits statement John Sample page 6 of 12 Your prescription claims (Pr Aug 1 to Aug 31, 2007) Humana negotiates a reduced price with the pharmacy for its members, which is reflected in "Prescription cost with plan" column. The prescription cost can vary by pharmacy, location, quantity, strength and dosage of the medication. Adjusted claims may not be reflected in the table below; or if displayed, the amount paid may not be accurately reflected due to the amount of the adjustment. The "Average Retail Price" is the retail price submitted by the pharmacy at the time your claim was processed. If you did not receive the medication below, please contact Humana's Special Investigations Unit at 1- 800 -558 -4444 (TTY 1- 800 - 325 -2025) Monday to Friday 8 a.m.- 8 p.m., Saturday 8 a.m.- 3 p.m. Drug name Average retail Prescription What you Paid on What the price cog with plan paid behalf plan paid Aug 1, 2007, Farmacia Lorraine Inc FLECAINIDE ACETATE 50 MG TAB 30 day supply Drug Category: Preferred Generic Total this month Total for this year $39.00 $3'x.82 $5:00 $0.00 $32.82 $5.00 $0.00 $32.82 843.20 $169.23 $0.00 $673.97 €* Using antibiotics when they are not needed can be harmful to your health. You should not use antibiotics to treat viral infections, such as a cold or influenza (t.1* lu). Using antibiotics when they are not needed can cause some bacteria to become resistant to antibiotics and can be harder to treat, which may require a possible stay in the hospital. Fiber found in whole grains, fiuits, and vegetables can improve your colon, reduce the risk of heart disease and cancer, and help lower cholesterollevels. Women over 50 should get 21 grams of fiber a day (about 3 cups of raisin bran or 2 cups ofraspberries for example). Exercise helps your brain! Studies show that people who exercise regularly are better able to make decisions than people who aren't physically active. WOW M0006_GHA00UERR [01/08] SmartSummary 5A" HUMANA. Guidance when you need it most Your personal prescription and medical benefits statement John Sample page 7 of 12 What's new in healthcare Articles are taken from a news service that focuses on healthcare. Where possible, we have tried to select topics that may be particularly interesting to you, based on information in our records from your insurance claims or other information you may have provided us. Heart benefits from just 10 minutes of daily exercise As little as 10 minutes of daily exercise can boost cardiovascular health, new research reports. The study, which appears in a recent issue of the Journal of the American Medical Association, found that when women who were out of shape, sedentary and over their ideal weight started exercising just 72 minutes a week, their cardiovascular fitness improved. The researchers also found that more exercise provided an even greater benefit. "For people who've been really sedentary, you're getting a benefit almost immediately. Just get off the couch," advised the study's lead author, Dr. 'imothy Church, the director of the Laboratory 4f Preventive Medicine Research at the inington Biomedical Research Center at Louisiana State University. Peak oxygen consumption -- an indicator of heart health -- increased 4.2 percent for the low exercise group. The moderately exercising group saw a 6 percent rise, ancitle heavy exercise group saw an 8.2 percent increase after'six months of exercise. "Physical activity is clearly We efici•`for your health. This sti y shows that'itty`activity is good, ,... said Dr 41-Min Lee, an or o ne at Brigham and it in 1 ton. :`Timothy Church, M.D., M.P.H., actor; Laboratory of Preventive P nnington Biomedical Research uisiana State University, Baton Rouge; ee; M.B.B.S., Sc.D., associate professor of dine, Brigham and Women's Hospital and The study included 464 postmenop'L.ai . womne' with some degree of high blood pressure All were overweight or obese, and tone were exercising at the start of the ;study. The. women were randomly assigned into one offou•Igro ips: one that remained sedentary, one that averaged about 72 minutes of exercise, another which averaged 136 minutes of physical activity, and the final group completed about 192 minutes of weekly exercise. MOM M0006_GHA00UERR [01 /08] Harvard aS,JGialC r: f &SOr of epidemiology, Harvard School of Public Health, Boston; May 16, 2007, Journal of the American Medical Association Copyright © 2007 ScoutNews LLC. All rights reserved. SmartSummary SM HUMANA. Guidance when you need it most Your personal prescription and medical benefits statement John Sample page 8 of 12 Changes to Huinana's formulary Humana may add or remove drugs from our formulary during the year. If we remove drugs from our formulary , add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost - sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective; unless the Food and Drug Administration deems a drug on our formulary to be unsafe, or the drug's manufacturer removes the drug from the market. Then we will immediately remove the drug from our formulary. The table below outlines upcoming changes to our formulary that will affect you as well as recent changes that may have affected you by a drug either being removed or added to the formulary or a change in its preferred or tiered cost - sharing status. As of the date listed below, please use the alternative listed. * If you have any questions about these changes, please call Customer Service. There are no formulary changes this month For your information and protection Your privacy At Humana, we consider your personal, health and financial uiforniation to be confidential. Humana protects your information and only uses or discloses your infor ation in accordance with federal and state privacy laws and Humana's privacy policy. For additidlatiWorni4ipn on Humana's privacy policy, please access Humana's Notice of Privacy Practices on the WeI5,aeklumaria.com. 'our rights .qumana ever denies coverage for your services orprescr iption drugs, we will explain our decision to you. You always have the right to appeal anal ask us to review the claim that was denied. In addition, if your physician prescribes a drug that is not on, our formulary; is not a preferred drug, or is subject to additional utilization requirements you may ask us to make a coverage exception. For more information about your Humana medical or prescription drug coverage, please review your Evidence of Coverage and other Plan materials. Your questions If you have any questions about Humatia, please contact customer service at 1-877-691-1983, Monday to Friday 8 a.m.- 8 p.m., Saturday 8 a.m.- 3 p.m.. TTY users should call 1- 800 - 833 -3301. Or, visit Humana.com on the Web. If you suspect fraud, please contact your plan or 1- 800 - MEDICARE (1- 800 - 633 -4227) 24 hours a day /7 days a week. TTY users should call 1- 877 - 486 -2048. If you would like to receive your SmartSummary (PDP EOB) in Spanish, please call 1- 866 - 255 -7451 and select option "For all other questions ", or log on to MyHumana to change your language preferences. Si guisiera recibir su SmartSununary (PDP EOB) en espafiol, por favor llame 1 -866- 255 -7451 y seleccione la opcon de 6, acceda MyHumana para cambiar su preferencias de idioma. ,. _,f M0006_GHA00UERR [01/08] SmartSummary5M HUMANA. Guidance whom you offoaa most Your personal prescription and medical benefits statement John Sample page 9 of 12 ,✓ledicare wants you to know about your prescription drug plan Content in this section of the document is required by Medicare. This document includes a summary of claims processed from 8/1/07 through 8/31/07. It also includes a cumulative statement of the benefits you have been provided this year. Keep this notice for your records. This is not a bill. Out -of- Pocket Expenses Note: Payments paid for drugs that are covered under an enhanced alternative plan as a supplemental benefit do not count towards any totals listed below. Annual deductible (Stage 1) You have met $843.20 of your $2,400 deductible for 2007. Amount paid for prescriptions You and /or others who have paid for your prescriptions have spent $843 20 rn co payn tints and /or co- insurance this year This amount counts toward your initial coverage limit. This amount does "not inchide payments made by your current or former employer /union, another insurance plan or policy or other excluded parties: Note: This amount may change from month to month based on the{ n amber of prescriptions you fill or if we learn that some of your drugs were paid by your current or former employer /urn on, another insurance plan or policy, or other excluded parties. Humana has paid $673.97. These payments count towards your „ini coverage limit. Together, $843.20 has been paid by both Humana, your a n d./orot ers. This is the total that counts towards your initial co '1erage limit of $3,850. Coverage Gap out -of- pocket payments:: �u have spent $0.00 in coverage gap coinsuranc Total out -of- pocket expenditures he t count t opardi the catastrophic coverage threshold You and /or others on your behalf have Beni a tot of $169.23 on prescription drugs covered by Humana for 2007. This total includes the amounts spent for 2 ur du ble, co- payments and co- insurance, and coverage gap payments. (This amount does rot tclude payments made by your current or former employer /union, another insurance plan or policy or oilier excluded parties.) Once this total reaches $380 }ou co payments and co- insurances will generally be 5 %. Total amount paid for your drugs this year $843.20. This is the total amount that has been spent on your drugs this year. It includes the amount paid by you and /or others on your behalf towards the initial coverage limit, coverage gap payments and catastrophic coverage. It also includes the amount Humana paid for drugs during your initial coverage limit and catastrophic coverage. It does not include the amounts paid by your current or former employer /union or other excluded parties for your deductible. It does not include the amounts paid by your current or former employer /union or other excluded parties for your deductible. M0006_GHA00UERR [01/081 th Record .. CHUMANA For August 31, 2006 to August 31, 2007 - John Sample This list is compiled from claims it formation submitted to Humana. This list is not intended to be a substitute for a medical record. It is provided as a courtesy to help you manage your interactions with your doctors. It may be helpful to take this record with you to your next visit to your doctor or hospital to give them a broader view of your healthcare interactions. Date Name of Provider Service Sep 15/06 Carol Jones, MD — Allergy shots Sep 22/06 Steven Smith, MD — Pulomonary functiorn,test — Venipuncture — Ofc /O t Visit E &M New -Mod Hi - OA Sexy" Med Exam & Eval; C Oct 15/06 Carol ones e -gl s Carol Jones, MD — ' erys�ot Nov 9/06 James Dean, MD Colo oidoscopy Aug 19/07 J efferson County Ambulance Transport , Aug 19/07 St. Jude Hospital e icy Room Tiatiert Bed Stay -= Dejso- Medrol Injection _ _‘g 21/07 Respiratory Care Group Acute Respiratory Regular physical activity is the key to maintaining good health from childhood into adulthood. Physical activity reduces your risk of heart .disease, high blood pressure, anxiety, and depression. You should get at least 60 minutes of moderate physical activity five or more days a week. Moderate activity includes walking briskly and recreational swirnmin.g. War M0006_GHA00UERR [01/08] HUMANA. Guidance when you need it most January 3L 2007 to December 31, 2007 John Sample Your Rx Record is provided as a courtesy to help you manage taking and refilling your medications and to communicate with your doctor or pharmacist about the medications you are taking. You may want to have this with you on your next visit with `your`doctor or pharmacy. The pictures displayed below should match the drugs you are currently taking: However, in some instances, your actual drug may look different .Contact your doctor or pharmacist for more information or if you have questions about the informanori displayed below. (commonly used Mental Health- Misc.) Category: Preferred brand Quantity: 30 TABS `Days supply: 30. Strength: 5MG Pharrnac : Far aacia Lorraine Inc Doctor fires Morges Refill. dates`.. 7U 1 DOLOGESIC (commonly used for: Pain Management' ase °T., r next refill date No Image Available Refill. dates Category: Non -P`i Quantity: 12 TABS Days supply: Stren �c) Pharmacy: Farmacia Lorraine Inc Doctor: Velez Please fill in your next refill date FLECAINIDE ACETATE'-'(cd3 imonly used for: Heart) Category: Preferred Generic Quantity: 10 TABS Days supply: 10 Strength: 50MG Refill dates 11th • 15th M0006_GHAOOUERR 101/08] Pharmacy: Farmacia Lorraine Inc Doctor: Vazquez -Tanus Please fill in your next ref ll date HUMANA. January 31, 2007 t0 December 31; 2007 OUR PRf ,( John Sample Xri..4conintonly used for Thyroid ) Category: Quantity: Days supply: Strength: Ref 11 dues Preferred Generic 30 TABS 30 25MCG Pharmacy: Farmacia Lorraine Inc Doctor: Flores Morales Please fill in your next refill date URPI,ErADRITE CITRATE (commonly used for Muscle /Bone) Refill dates • Category: Quantity: Days supply: :.Strength: Preferred Generic 12 TB12 6 100MG PULSTCORT TUR;$UHALER Category: I" ion- Preferred bran Quantity: 1.AET Days supply:30 ,; Strength MCG /INH Pharmacy:- Partnaciaorraine Inc Doctor: Vi lease fill in your next refill date Refill dates Pharmacy: Farmacia Lorraine Inc Doctor: Vazquez -Tanus Please fill in your next refill. date 11th VERA. 4m.!4L. HCL Category: Quantity: Days supply: Strength: Preferred Generic 60 TABS 30 MG M0006_GHA00UERR [01/08) Pharmacy: Farmacia Lorraine Inc Doctor: Vazquez -Tanus Please fill in your next refill date Humana Group Medicare PPO A Medicare Advantage Plan ana e when you need it most TABLE OF CONTENTS 3 About Humana 4 How the Humana Group Medicare PPO Plan Works • Introduction • Features • Doctors • Hospital and outpatient care • Emergency care 8 Important Phone Numbers 9 Information on Enrollment 10 Manage Your Health • MyHumana • Special services for certain health conditions 11 Stay Well • QuitNet • HAO Magazine • Humana Active Outlooks"" Program • SilverSneakers® Fitness Program • Silver &FitTM 17 Value -Added Services • Complementary and alternative medicine • TruHearing • Vision discount program • Mail -order health and wellness products • Rx discount • HumanaFirst® • Member assistance program • eHarmony.com • NutriSystem SiIverTM • Auto Assist Plus® 29 Frequently Asked Questions 34 Glossary 36 Privacy Notice Humana Inc., headquartered in Louisville, Kentucky, is one of the nation's largest publicly traded health benefits companies, with more than 11 million medical members throughout the United States and Puerto Rico, including about 4.6 million Medicare members. Humana offers coordinated health benefits and related services — to employer groups, labor groups, government- sponsored plans, and individuals. With more than 45 years of experience in the health industry, Humana is a recognized leader in the areas of wellness and chronic disease management programs for members. In addition to providing health benefits coverage, we educate members about their choices and guide them to make informed decisions about their health coverage and care. To find out more about Humana, visit our Website, Humana.com. Group Medicare: For you from Humana Because Original Medicare benefits may not go far enough for many people, your organization or former employer has worked with Humana to offer you an enhanced plan. Humana's Group Medicare benefits go beyond those of traditional Medicare. We're proud of our 20 years in the Group Medicare business. More important, we're pleased to offer you the advantages of that experience — in the form of a medical plan that fits your health coverage needs. HOW HUMANA GROUP MEDICARE PPO WORKS INTRODUCTION This booklet gives you an overview of the features and benefits of the Humana Group Medicare PPO Plan, a Medicare Advantage Preferred Provider Organization plan. A Medicare Advantage plan is a health plan option that is approved by Medicare, and part of the Medicare Program, but run by a private company. You simply show your Humana identification card each time you receive care, pay your copayment or coinsurance (your share of the cost of treatment), and there is virtually no paperwork. The coverage is comprehensive — from checkups in the doctor's office to emergency care and hospitalization. There's no need to worry whether your treatment is covered by Medicare Part A or B or a supplement plan. Humana Group Medicare PPO is a Medicare Advantage plan that gives you more than the benefits of Original Medicare. Your coverage includes doctor's visits, annual routine physical exams, and hospital stays — without the Medicare deductibles. You receive all this for a lower premium than you'd pay for most Medicare supplements. The plan gives you access to doctors across the country in our network. This Guide Book tells you about some features of the plan. It doesn't list every service the plan covers, every limitation, or every exclusion. After you enroll, you will receive a complete list of benefits called an "Evidence of Coverage" booklet, which will fully explain your plan. FEATURES OF YOUR COVERAGE • Your choice of providers — Choose any hospital, doctor, specialist, or other healthcare provider — but pay Tess for services from in- network providers. • Virtually no claims paperwork — The plan works directly with your provider to handle claims for you. • Limited out -of- pocket expenses — Your copayments and coinsurance are limited each year for most plans, protecting you from catastrophic expenses. • Coverage when you travel worldwide — Emergency room coverage is available, even outside the U.S. Annual Out -of- Pocket Limit Gives You Extra Protection In most Humana Group Medicare PPO plans, amounts you pay as coinsurance or copayment are limited each benefit plan year. If you reach this annual out -of- pocket limit, you pay no copayment or coinsurance for the rest of the plan year; the plan pays 100 percent of your Medicare - approved amounts for covered expenses. Certain amounts you pay do not count toward this out -of- pocket limit. Please refer to your Evidence of Coverage for more information. Get All the Facts About Your Plan Complete details of your Humana Group Medicare PPO Plan are in the "Evidence of Coverage" booklet you'll receive after you enroll. If your questions aren't answered completely, just call Humana at the Group Medicare Customer Service phone number listed on page 8. Using the Humana Group Medicare PPO Plan Is Easy! When you're a member, you'll have a Humana identification card to show you're covered by the Humana Group Medicare PPO Plan. Use this card each time you need care — you can put your Original Medicare card away in a safe place. Think of your Humana ID card as your passport to healthcare. WHEN YOU NEED TO SEE A DOCTOR Choose any doctor you need —a family practitioner, an internist or a specialist. Humana has formed an extensive network of doctors, specialists, and hospitals. You can use any doctor who is a part of our network. With the Humana Group Medicare PPO Plan, you may also go to any doctor outside of our network, but the cost of services will be higher for you. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up -to -date list. Our number is listed on page 8 of this Guide Book. Present your Humana ID card when you receive care. Your doctor bills Humana directly for your treatment, saving you the hassle of filing claims. When you're responsible for a copayment, you will pay that amount at the time of service. When you're responsible for paying a portion of the cost (coinsurance), the provider bills you directly. Sometimes the selection of in- network providers is limited in certain geographic areas or in some specialties. If the network in your area doesn't offer the specialist you need, you may be allowed to go to a non - network provider at the in- network rate. CaII the Group Medicare Customer Service phone number on page 8 to find out if you qualify and get more instructions. Be sure to contact non - network doctors before you see them to make sure they accept Medicare assignment and have agreed to accept payment from Humana. WHEN YOU NEED HOSPITAL OR OUTPATIENT CARE If your doctor recommends a hospital stay or outpatient treatment in a hospital or other treatment facility, present your Humana ID card when you arrive for care. You'll be billed for your share of the costs. When you are responsible for a copayment, you will pay that amount at the time of service. If you owe a coinsurance, you'll be billed for your share of the costs. Even though your plan does not require pre - approval of hospital admissions, Humana recommends asking your doctor to notify us of your admission. The healthcare professionals at Humana may have information and special programs your doctor can use to help speed your recovery. WHEN YOU NEED EMERGENCY CARE When you have a medical emergency, call 911 for assistance or go to the nearest hospital emergency room and show your Humana ID card. Your plan covers emergency care at any hospital emergency facility. You do not need a referral from your primary care physician or authorization from Humana to receive emergency services. Please see the Frequently Asked Questions, near the end of this Guide Book, regarding the difference between emergency or urgently needed care. We want you to fully understand your medical coverage. If you have questions about your plan, please call our special phone number listed below. It is dedicated to Group Medicare plan participants. Your Group Medicare Customer Care representatives are ready to help you. Some of the matters we can help you resolve are: • Questions about your benefits • Replacement ID cards • Finding a doctor or specialist in your area • Any additional information you need to use your plan To reach a Customer Care representative please call: HUMANA GROUP MEDICARE CUSTOMER SERVICE Hours of service for questions prior to enrollment: 8:30 a.m. — 5 p.m., Eastern time, Monday - Friday Hours of service for all other questions: 8 a.m. —11 p.m., Eastern time, Monday - Friday 8 a.m. — 6 p.m. Saturday 1- 866 - 396 -8810; TTY: 1- 800 -833 -3301 Also for your convenience, the official source of U.S. Government Medicare information is: MEDICARE Medicare.gov Hours of service: 24 hours a day, 7 days a week 1- 800 - 633 -4227 (1 -800- MEDICARE) TTY: 1- 877 - 486 -2048 INFORMATION ON ENROLLMENT What You Need to Know • You must be enrolled in Original Medicare (Parts A and B) to be eligible for the Humana Group Medicare PPO Plan. • You must continue to pay your Medicare applicable premiums if not otherwise paid for under Medicaid or by another third party. • If you are enrolling in the Humana Group Medicare PPO Plan because you are turning age 65, you must enroll in Original Medicare and be issued a Medicare Claim Number before you can enroll. Your group benefits administrator will choose how you will enroll in the plan — either using paper enrollment applications or using Electronic Data Interchange (EDI). Enrolling Using a Paper Enrollment Application • Each eligible person enrolls separately for Humana Group Medicare PPO Plan coverage. • If you and your Medicare - eligible spouse are enrolling for the plan, each of you must complete a separate enrollment form. • The form is printed on special, three -part paper. Use a ball -point pen and press hard to make sure your writing is legible on all three copies. Enrolling Using Electronic Data Interchange (EDI) • Your group benefits administrator will provide your enrollment information to Humana electronically, so you won't have to fill out an enrollment application. • Humana may request additional information from you by mail or by phone. 9 PLAN FEATURES TO MANAGE YOUR HEALTH MYHUMANA — YOUR PERSONALIZED ONLINE PLAN INFORMATION SOURCE With MyHumana, you can: • Review your plan benefits • Use health and wellness tools • Look up your medical claims • View or print your Evidence of Coverage booklet You can go to Humana.com and register for MyHumana as soon as you receive your Humana ID card. MyHumana is a secure, personal Website customized with your plan details, claims, records, and other health benefits information. SPECIAL SERVICES FOR CERTAIN HEALTH CONDITIONS SPECIAL SERVICES FOR CERTAIN HEALTH CONDITIONS If you're living with a serious disease or chronic illness, Humana's medical professionals can help. As a Humana Group Medicare member, your coverage includes three key services to help you improve your health and quality of life: Clinical Intake. A clinical staff member will review your medical profile and help your doctor find facilities and specialists to treat your condition. Case Management. A nurse and social worker keep in touch with you if you have complex needs and could benefit — physically and financially — by achieving certain health goals. Disease Management. Programs for specific medical conditions — such as congestive heart failure, chronic obstructive pulmonary disease, and end -stage renal disease — help you manage that condition and get the most from your benefits. We also have programs for the less- frequent diseases that affect senior members, such as rheumatoid arthritis, lupus, Parkinson's disease, and multiple sclerosis. Your case manager will be able to connect you with the program that best meets your needs. All Humana Group Medicare members are eligible for these services at no extra cost, and they may be in addition to any programs or services you already receive through your employer or union group. We'II contact you a we think one of these progran be helpful to you. PLAN FEATURES TO HELP YOU STAY WELL Quitting smoking is the most important thing you can do for your health. That's why we are partnering with QuitNet to help you meet one of the toughest challenges of your life! QuitNet provides support to persons while they are "kicking the habit" in many ways: 1. Start your free support program right now! QuitNet is the home of the world's largest community of smokers and ex- smokers. Don't go a day, or a minute, without help from other quitters. 2. See for yourself! QuitNet is here to help you stop smoking for good. Check out the support forums and see who is celebrating a quitting anniversary. 3. Find out more, and then join today! Read our popular resources — the Quitting Guide and Quit Medication Guide. The Goal of QuitNet is to make this quit your last! Visit Quitnet.com or call the Group Medicare Customer Service phone number on page 8 for more information. HAO magazine This award - winning magazine* provides inspirational and informative lifestyle content that connects with members in a personal way — celebrating who they are and their accomplishments. Each issue features useful, up -to -date information on new technology, financial matters, travel, and health and wellness. You'll enjoy meeting and reading about members, receiving practical health advice from our medical advisors, as well as trying out home and cooking tips from lifestyle expert Lucy Pereda. We mail the magazine to your home four times a year. * 2007 Healthcare Advertising Awards (HAA) A HAO Magazine netted three Gold awards, marking the fourth consecutive year that HAO has earned top honors at the HAA. 12 QUITNET QUIT ALL TOGETHER HUMANA ACTIVE OUTLOOK"" is a no -cost lifestyle enrichment program exclusively for Medicare members! Enjoy one -on -one healthy living advice and Medicare news through regular educational mailings, online content, seminars, and classes. Learn all about optimal living and the essential principles of good health and well -being from Humana Active Outlook. klikOmthiactek • Thrive! Live Life to the Fullest. Stay in the know on health conditions and the latest research into healthy aging. Learn how to keep your cholesterol and blood pressure in check. • Nourish! Eat, Drink, and Be Healthy. Get valuable information about keeping your diet nutritious and tasty, including wholesome recipes, tips on preparing meals for one or two people, and information about gaining and losing weight. • Discover! Health Is a State of Mind. Learn how to improve your mind and memory through self -help and educational opportunities and mental exercises. • Partner! Get Connected. Keep up to date on current issues that could affect your Medicare benefits, and check out opportunities to get involved and share your personal talents and experiences with others. • Inspire! Seize the Day. Discover how to motivate yourself to make healthy, positive changes that are vital to your well- being, and how to assess your goals, attain them, and enrich your life. • Nurture! Cherish Your Loved Ones. Enjoy a wealth of useful information and advice on caregiving, and have access to resources and tools that offer support and guidance to you and your family. 13 14 SILVERSNEAKERS' (where available)* When you become a Humana Group Medicare PPO Plan member, you'll be eligible to participate in the innovative SilverSneakers' Steps program or the award - winning* SilverSneakers' Fitness Program at no additional cost. Either program gives you a great way to stay physically active, make new friends, and help maintain an independent, healthy lifestyle! With SilverSneakers, you have free access to amenities like treadmills, weights, heated pools, and fitness classes that are included with a basic fitness center membership. After discussing with your physician, you can take signature SilverSneakers classes designed specifically for older adults and taught by certified instructors. Additional.,: SilverSneakers options may be available at selected fitness centers as your fitness level progresses. A designated fitness center staff member called a Senior Advisors' will help you along the way. SilverSneakers members have access to over 2,200 participating fitness centers. Once you're a SilverSneakers member, you can use any participating location in the nation. Visit Silversneakers.com to view lists by state, or for more details contact us at the Group Medicare Customer Service phone number on page 8. If a participating SilverSneakers fitness center is more than 15 miles from your home, check out the SilverSneakers Steps program! SilverSneakers Steps is a self - directed, pedometer -based physical activity and walking program that allows you to measure, track, and increase your activities. Steps provides the equipment, tools, and motivation necessary for you to achieve a healthier lifestyle through increased physical activity. Get Fit, Have Fun, Make Friend! Humana knows you care about your health. That's why we offer the SilverSneakers Fitness Program or SilverSneakers Steps as part of our many additional benefits. Go to Silversneakers.com or call today to find out more. *If you live in Arizona or Pennsylvania, please see the next page for more information. SILVER &FITS"" If you live in Arizona or Pennsylvania, Silver &Fit and Silver &Fit@Home is available for you! Silver &FitTM is a program designed for senior adults that incorporates exercise and health education to empower seniors to become physically fit. Silver &Fit includes: ✓ Basic membership at a local participating fitness club, which includes access to equipment such as weights and cardiovascular and resistance training equipment ✓ Group fitness classes designed specifically forseniors and focus on aerobic, flexibility and strength - training exercises ✓ Healthy aging classes with educational materials to help you make better health decisions ✓ Community social activities 1► Toll -free member hotline • Quarterly newsletter Siiver&Fit@HomeTM is a home -based fitness and health education program for members who either don't have access to a participating Silver &Fit fitness club or prefer to exercise at home. Silver &Fit ©Home offers a choice of either an exercise program or a walking program. Exercise Program Hand weights Resistance bands Instructional exercise DVD plus new programs each quarter Quarterly newsletter Toll -free member hotline Walking Program Pedometer Activity- tracking tools Quarterly newsletter Toll -free member hotline Please call the Group Medicare Customer Service phone number on page 8 for more details. VALUE ADDED SERVICES ere 16 d services described in this Guide Book are nor guaranteed under Humana's contract icare program uctsand services are not subject to the e appeals process. Any disputes regarding these prt cts and services may be subject to the Humana grievance process or the State Attorney General's office. Should a: problem arise with any value -added item or service, please call Humana Group Medicare Customer Service for assistance. See page 8 for the phone number. COMPLEMENTARY AND ALTERNATIVE MEDICINE Receive special offers which give you the lowest price available for complementary and alternative medicine (CAM) services, including chiropractic care, acupuncture, and massage. • Chiropractic care involves diagnosing spinal misalignments and correcting them by using the hands to manipulate, or adjust, the spine, joints and muscles. • Acupuncture is a therapy originating in China in which a trained professional inserts and rotates very thin needles at key points on the body. This process stimulates various organs and body systems. • Massage therapy is the scientific manipulation of the soft tissues of the body to normalize those tissues. It consists of a group of manual techniques that include applying fixed or movable pressure, holding or causing the body to move, using primarily the hands but sometimes other areas such as forearms, elbows, or feet. The American Whole Health (AWH) network provides CAM discount services for Humana members and includes more than 25,000 practitioners. You don't need a referral to visit a massage therapist, acupuncturist, or chiropractor participating in the discount program because this is not part of our insurance policy. You may visit AWH network providers as often as you like, although we do encourage you to let your doctor know about any treatment you are considering. As a Humana member, you simply select a provider through the AWH Website, Wholehealthmd.com, or call the Group Medicare Customer Service phone number on page 8. You'll need to show your Humana ID card when you receive services. TRUHEARING HEARING AIDS AND CARE TruHearing provides our members with services and discounts that include: • Savings of $600 to $2700 off retail costs on each hearing aid for state -of -the -art digital models • Free comprehensive hearing exam using the latest diagnostic equipment • Follow -up office visits beyond your initial appointment • 45 day from purchase return guarantee • One year lost or damaged instrument replacement and two -year limited product warranty • Parents and grandparents of Humana members can also receive hearing instrument discounts For more information just call the Group Medicare Customer Service phone number on page 8 or visit Truhearing.com. 17 PLAN SERVICES TO SAVE YOU MONEY 18 VISION DISCOUNT PROGRAM The vision discount program is available to you through HumanaVision and EyeMed. You have access to extensive EyeMed resources: 40,000 national providers at 20,000 locations, including optometrists, ophthalmologists, opticians and some of the most recognizable names in eye care: LensCrafters ®, Pearle Vision ®, Target, JCPenney Optical, and Sears Optical as well as many independent practices. To select an EyeMed participating provider, visit the EyeMed Website (Eyemedvisioncare.com) and select the Provider Locator option under the "Member Access" section or call EyeMed's provider locator service at 1- 866 - 392 -6056. To receive your discount, just present your HumanaVision Discount ID card below when you arrive at the provider's office or location. The EyeMed provider will take care of the rest. You have no claims to file and no waiting for reimbursement. The discount is applied directly to your purchase. Program Limitations and Exclusions: • Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing • Aniseikonic lenses • Medical or surgical treatment of the eye, eyes, or supporting structures • Services provided as a result of any Worker's Compensation law • Nonprescription lenses and nonprescription sunglasses (except for 20 percent discount) • Services or materials other than provided by this program • These discount programs are not part of your insurance • Discounts are available only at participating providers CUT OUT THIS CARD AND KEEP IT IN YOUR WALLET FOR HANDY REFERENCE. 1 MEMBER NAME: MEMBER ID: HUMANA. Guidance when you need it most For more information, call EyeMed: 1 -866- 392 -6056 This discount program is not part of your insurance. Discounts are only available at participating providers. EyeMed VISION CARE. You may receive a 20 percent discount on items purchased at participating providers that are not specifically mentioned here. This discount may not be combined with any other discounts or promotional offers, and it does not apply to EyeMed provider's professional service, or contact lenses. Please discuss your needs with your EyeMed provider to be sure to get the best discount for your situation. VISION CARE SERVICES YOUR COST Exam with Dilation as Necessary: $5 off routine exam $10 off contact lens exam Frames *: Discount on all frames available except when prohibited by manufacturer. * Frames, lenses, and lens options must be purchased in the same transaction. Items purchased separately will be discounted 20% off of the retail price. 35% off retail price Standard Plastic Lenses (per pair) * *: Single Vision $50 Bifocal $70 Trifocal $105 **Member cost is $15 higher in AK, CA, HI, OR, WA Lens Options: UV Coating $15 Tint (Solid and Gradient) $15 Standard Scratch- Resistance $15 Standard Polycarbonate $40 Standard Progressive * ** (Add -on to Bifocal) $65 Standard Anti - Reflective Coating $45 Other Add -Ons and Services 20% discount * ** The cost for Premium Progressive lenses equals the Basic Progressive lens retail price plus a 20 percent discount on the balance over this price. Contact Lenses (Discount applied to materials only): Conventional 15% off retail price Laser Vision Correction: Lasik or PRK from U.S. Laser Network 15% off retail price - or - 5% off promotional price Frequency: Examination Frames Lenses Contact Lenses Unlimited Unlimited Unlimited Unlimited 19 Mail -Order Health and Wellness Products Over -the- counter medicines, vitamins, and other health products can play an important part in maintaining your health. Many of the products you use today are likely available to you for discount prices through the mail. You can save money on: • Minerals and nutritional supplements • Pain relievers • Cough, cold, and allergy medicines • Stomach and digestion medicines • First -aid supplies Discount items are delivered right to your door, with no charge for shipping. If you have questions about the Health and Wellness products, call 1- 800 -558 -7710, 9 a.m. — 5 p.m., Eastern time, Monday - Friday (TTY users can call 1- 800 - 833 - 3301). To verify eligibility or order extra forms, call the Humana Group Medicare phone number listed on page 8. Note: Allow 14 working days from receipt of order. You will receive the generic comparable to brand. Please check with your doctor before taking any over -the- counter product or nutritional supplement. This product list and pricing is subject to change. You will receive an updated order form with each delivery. Please complete and mail the form on the following pages to: HUMANA HEALTH AND WELLNESS PRODUCTS PrescriblT 3600 Enterprise Way Miramar, FL 33025 QUANTITY GENERIC NAME COMPARE TO Cantidad Nombre Generico Comparar MINERALS 1 NUTRITIONAL SUPPLEMENTS * VitaminaslMinerales OTC10 Vitamin -C 500 mg Vitamin -C 500 mg OTC11 Daily Multivitamin and Mineral Advanced Formula Centrum® OTC12 Vitamin -E 400 IU Synthetic Vitamin -E 400 IU Synthetic OTC13 Ferrous Sulfate 5 gr Feosol• Folic Acid 400 mcg Omega -3 EFA Fish Oil 1000 mg Co -Enzyme Q -10 30 mg B- Complex with B -12 Echinacea 400 mcg Garlic Oil 1500 mg OTC14 OTCN1 OTCN2 OTCN3 OTCN4 OTCN5 OTCN6 OTCN7 OTCN8 OTCN9 OTCN10 OTCN11 PAIN RELIEVERS OTC16 OTC19 OTC47 OTC94 OTC2 OTC20 OTC21 OTC22 COUGH COLD OTC110 OTC23 OTC24 OTC95 OTC99 OTC97 OTC26 OTC96 OTC28 Folic Acid 400 mcg Omega -3 EFA Fish Oil 1000 mg Co -Enzyme Q -10 30 mg B- Complex with B -12 Echinacea 400 mcg Garlic 0111500 mg Glucosamine & Chondroitin 500/400 mg Eye Care Nutritional Support Saw Palmetto 500 mg Timed Release Niacin 500 mg Selenium 200 mcg Antioxidant Tablets * Analgosicos Aspirin Low Dose 81 mg EC Ibuprofen 200 mg Aspirin 325 mg Ibuprofen Suspension Acetaminophen 500 mg Acetaminophen 80 mg chewable Acetaminophen Elixir Acetaminophen Suspension Drops Osteo Bi -Flex® Ocuvite® Lutein Saw Palmetto 500 mg Timed Release Niacin 500 mg Selenium 200 mcg Antioxidant Tablets Bayer® Adult Low Strength EC Advil® Bayer® Children's Motrin® Extra Strength Tylenol® Tylenol® Children's Chewable Children's Tylenol® Elixir Tylenol® / ALLERGY * Tos / resfriado / alergia Antihistamine - Loratadine 10 mg Claritin® Antihistamin - Diphenhydramine 25 mg Benadryl® Antihistamine - Diphenhydramine Liquid Benadryl® Allergy Nasal Decongestant Spray Afrin® Saline Nasal Spray Ocean® Saline Nasal Spray Sinus - Acetaminophen/ Pseudoephedrine Cough Suppressant/ Expectorant Robitussin® DM Cough Supp /Nasal Decon. /Expectorant Robitussin® CF Cough Formula - Expectorant Robitussin® Tylenol® Sinus SIZE PRI Tamano 100 130 100 100 100 100 30 100 100 100 90 36 100 100 60 60 120 50 100 120 ml 100 30 120 m1 15 ml ANTI - DIARRHEALS l ANTACIDS / LAXATIVES/ETC* AntidiarreicoslAntiacidosl Laxantes OTC29 Anti - Diarrheal Tablets - Loperamide 2 mg lmodium® A -D OTC32 Antacid / Anti -Gas Liquid Mylanta® Precio $4 $5 $5 $3 $3 $5 $10 $4 $5 $5 $10 $5 $5 $5 $4 $5 $3 $4 $3 $6 $4 $3 $3 $3 30 $7 24 $3 120 ml $3 30 ml $3 45 ml $3 24 $3 120 ml 120 ml 120 ml $4 $4 $4 12 $3 360 ml $3 21 QUANTITY GENERIC NAME Cantidad Nombre Generico COMPARE TO Comparar SIZE PRICE Tamano Precio ANTI - DIARRHEALS / ANTACIDS / LAXATIVESIETC* Antidiarreicos!Antiacidos/ Laxantes OTC89 Antacid Double- Strength Chew Tab Mylanta° Double Strength 70 OTC33 Milk of Magnesia - Laxative/Antacid Phillips' Milk of Magnesia 360 ml OTC75 Antacid / Anti -Gas Chew Tab Maalox° Plus 100 OTC 104 Ranitidine 75 mg Tablets - Antacid Zantac° 30 OTC93 Laxative - Bisacodyl 5 mg Dulcolax' 25 OTC98 Extra Strength Gas Relief Tablets Gas -X' Extra Strength 30 OTC 101 Stool Softener Capsules Colace 100 OTC3 Enema Fleet' Enema 270 ml OTC31 Anti- Hemorrhoidal Ointment Preparation H' 60 mg FIRST AID I MEDICAL SUPPLIES * Primeros Auxilios OTC35 OTC36 OTC37 OTC38 OTC4 OTC40 OTC43 OTC44 OTC46 OTC48 OTC105 OTC 106 WOMEN'S HEALTH OTC107 OTC108 OTC41 OTC42 OTC15 OTC109 OTC16 OTC19 Alcohol Prep Pads Cotton Swabs Calamine Lotion Clotrimazole Cream 1% - Athlete's Foot Hydrocortisone Cream 1% Triple Antibiotic Ointment Medicated Chest Rub Plastic Bandages Muscle Rub Oral Thermometer (Digital Display) Lip Balm Sunblock SPF 45 * Salud de la Mujer One a Day Women's Multivitamin Phenazopyridine 95 mg Clotrimazole Vaginal Cream Miconazole-7 Vaginal Cream Oyster Calcium 500 mg + Vitamin D Calcium Citrate 600 mg + Vitamin D Aspirin Low Dose 81 mg EC Ibuprofen 200 mg Suplementos Medicos B -D' Alcohol Swabs Q -Tips° Caladryl' Lotrimin AF° Cortizone 10' Neosporin® Vicks VapoRub' Band Aids® Ben-Gay® B -D° Oral Thermometer Lip Balm Coppertone' SPF 45 One -A -Day Women's' Azo- Standard' Gyne-Lotrimin® Monistat -7' Os -Cal' Citracal' Bayer' Adult Low Strength EC Advil° Make checks payable to "PrescriblT." Check box if this is a new address: ❑ Name: 100 300 120 ml 15 gm 30 gm 30 gm 99 gm 100 120 gm 1 1 120 m1 60 30 45 gm 45 gm 60 60 $5 $4 $4 $7 $3 $4 $4 $3 $5 $4 $3 $3 $4 $3 $5 $5 $3 $5 $5 $2 $5 $4 $5 $6 $6 $4 $4 120 $3 50 $4 Humana ID Number: Date of Birth: Sex: M F (Circle one) YOUR TOTAL ORDER AMOUNT $ Address: City, State, Zip: Phone Number: Date: 22 Complete and mail to: Humana Health and Wellness Products PrescribtT 3600 Enterprise Way, Miramar, FL 33025 Rx DISCOUNT Certain types of prescription drugs often are not covered by prescription drug plans. But if your doctor prescribes any of these drugs for you, the Rx Discount service can make them more affordable. This discount program can save you an average of 20 percent or more for prescription medicines for: • Weight Toss • Impotence • Hair loss • Many other conditions To see if the drug qualifies for the discount program, go to Humana.com and use the "Savings Center" section of MyHumana. The Savings Center is in the lower left corner of your MyHumana homepage, so you'll need to scroll down to see it. All major pharmacy chains participate in this discount program, as well as many independent pharmacies, so it's easy to find a participating pharmacy near you. The RxDiscount is available with most plans. Please contact your benefits administrator, or call the Group Medicare Customer Service phone number on page 8 for more information. 23 HUMANAFIRST NURSES ARE ALWAYS AVAILABLE HUMANAFIRST NURSES ARE ALWAYS AVAILABLE Ever wish a medical professional was nearby? Someone you could call to get health information when you need it? Your Humana Group Medicare PPO Plan membership makes that wish come true. HumanaFirst is a toll -free, 24 -hour health information line Humana makes available for you. Can you manage your care at home, or should you see a medical professional? Call to speak with a registered nurse who can answer your general health questions. A simple phone call can get you the information you need to make your decision. There is no charge for calling HumanaFirst. Contact Group Medicare Customer Service at the phone number on page 8 for additional information. HumanaFirst is not intended for emergency situations. Always dial. 911 in an emergency. MEMBER ASSISTANCE PROGRAM When You Need to Talk with Someone... Just pick up the phone and call our Member Assistance Program. You may want help with a personal or emotional issue, such as stress or anxiety, or a referral to specific services. We can help — and all conversations are confidential. Some common concerns include: • Handling life changes • Information about care options • Understanding your health history • Assistance in independent living • Understanding legal issues • Addressing basic financial matters • Managing retirement issues When you call, a trained professional will: • Assess your situation Help you clarify the problem •. Provide information, tips, and printed materials • In some instances mail you a kit to help you keep track of important information or to help you live well and enjoy life • Refer you to appropriate resources In addition, you can access information 24 hours a day online at Humana.com. It doesn't have to be a "Big Issue" Many people who contact the Member Assistance Program have everyday concerns — so don't let the size of the issue keep you from seeking assistance. No issue is too large or small. Strictly Confidential Your personal information is strictly confidential. The program complies with all local, state and federal privacy laws. Easy to Access To receive valuable Member Assistance Program rvices, just call the Group Medicare Customer ,ervice phone number on page 8. MEET COMPATIBLE SINGLES THROUGH eHARMONY.COM "There's a real need for people our age to find companionship. I think you live longer and you're happy. I just enjoy living and she does too!" (Lonnie) Eunice & Lonnie Matched by eHarmony.com Married February 11, 2006 Are you looking to meet someone to enjoy life with? Would you like to meet someone who shares your traits and beliefs? If so, eHarmony.com can help. eHarmony provides a safe and supportive environment, designed to help you meet compatible singles. After getting to know you through a thorough questionnaire, eHarmony does the searching for you and only presents you with matches that are pre- screened for compatibility with you. So right from the start you have so much in common. Exclusive Offer for Humana Medicare Members Every day thousands of people of all ages are meeting through eHarmony.com, America's #1 trusted relationship site. And right now, as a Humana Medicare member, you can save 20% when you purchase a 6 -month eHarmony membership. That's a savings of over $40. And with 6 months you'll have all the time you need to get to know your matches at whatever pace is good for you. To take advantage of this offer, simply enter the promotional code HUMA6501 when purchasing your 6 -month membership. Call the Group Medicare Customer Service phone number on page 8 if you have any questions. 25 Nutri System SilverTM Join the legendary football Coach Don Shula and his wife Mary Anne Shula in losing weight and looking great: The NutriSystem SiIverTM program is specifically designed to help older Americans lose weight simply and conveniently in order to live vibrant, healthy lives. We have selected foods from our NutriSystem® Nourish' menu to create a low calorie, nutritionally supercharged weight Toss program that is a good source of protein, fiber and "good" fats —and tempered with lower sodium, reduced cholesterol and fewer saturated fats —to help older Americans shed pounds sensibly. Plus, NutriSystem Silver is designed for people like you, and so easy to follow. You just grab an entree, add -in a few grocery items like fresh fruit, vegetables, salad and dairy items and you're ready to go. But that's not all. With NutriSystem Silver, you get the Glycemic Advantage—the incredible scientific weight -loss breakthrough that gives you the benefits of a low -carb diet, but lets you eat carbs. NutriSystem foods contain "good carbs," so you can eat your favorite foods, including pizza, pasta, cookies and chocolate. And it's so easy to get started! Simply select your foods online or on the phone. There is a huge variety of great tasting meals and snacks to choose from and they arrive on your doorstep, all ready to heat and eat. And since all of the prepared NutriSystem foods are perfectly 26 portioned, there is never any weighing, measuring or counting calories and points. Plus! You get to eat six times a day to help reduce those cravings between meals. And you can call or email our counselors, nutritionists and dietitians any time for free without ever having to go to a meeting! Plus, you get FREE membership and counseling, as well as FREE access to the NutriSystem community through our support boards. And when you sign up for our 28- Day NutriSystem Silver program, you also get a FREE 30 -day supply of Nutrihance® multivitamins! The best part is as a Humana member, you'll also get $30 off every program order simply by calling us toll -free at 1- 888 - 294 -7821 or by going online to www.nutrisystem.com/health and entering promo code Humana07. "Thanks to NutriSystem Silver, I look and feel so much better, and so does Coach. In fact, my little grandson told me, 'Granny Mary Anne, you're looking hot!' Just try NutriSystem Silver. It worked for Coach and me and it can work for you." (MaryAnn Shula) "Hey, guys. Is your weight making you feel old and tired? Do you want to get back in the game? Take it from me, Coach Don Shula, NutriSystem Silver can help you get back in the game." (Don Shula) HOW MUCH ARE YOU PAYING FOR ROADSIDE ASSISTANCE COVERAGE? WHEN YOU'RE INSURED WITH HUMANA, YOU CAN SAVE A BUNDLE! Get roadside assistance for only $49.90 a year! Now you can get comprehensive roadside assistance coverage for you 'and your spouse in any owned vehicle you drive with Auto Assist Plus® 24 -hour Roadside Assistance Service; as an exclusive offering for our Humana customers. That's sign and drive convenience and priceless peace of mind for towing assistance, flat tire assistance, battery assistance, fuel assistance, collision assistance, lock -out assistance, and more at the Humana member -only price of $49.90 per year! This quality of coverage normally retails at $89 year. Plus, you'll enjoy additional everyday savings opportunities on hotels, car rentals, and automotive service, at no additional cost, that quickly combine to pay for your Auto Assist Plus® membership over the course of the year. Peace of mind, convenience, and savings...24 /71365. Get covered with Auto Assist Plus® and save! 24 -hour roadside assistance service for Auto Assist Plus® includes: • Towing assistance • Oil, fluid and water delivery service • Fuel delivery service • Lock -out assistance • Flat tire assistance • Battery assistance • Collision assistance Additional Services for Auto Assist® Plus: (included at no additional cost) • $500 emergency travel expense reimbursement - If your covered vehicle is disabled due to a collision 100 miles or more from your residence, you may qualify for reimbursement of up to $500 for emergency travel expenses. (A maximum of $167.00 per day for up to three 3 days) • Emergency message relay - We will provide assistance relaying an emergency message to up to 3 family members, friends, business associates, etc. for any covered member in a vehicular emergency. • Custom trip routing -For business or pleasure, we offer our members custom trip routing maps. Detailed information is prepared in easy -to -read, easy -to- follow formats by professional experts and mailed to you. • Hotel savings program - Next time you travel, save money with our pre- negotiated savings at participating hotels all over the country! • Rental car savings - Drive On! Enjoy great deals on rental cars around the nation with our pre - negotiated savings opportunities. • Automotive service savings - Everyday savings opportunities really add up when you take advantage of your pre- negotiated automotive service savings on oil changes, tune -ups, tire rotations, etc. Just sign and drive! Help is just a toll -free phone call away! Our courteous and professional Assistance Coordinators are trained to meet your roadside emergency needs 24 hours a day, 7 days a week, 365 days a year. Simply sign for covered services at the time of a breakdown up to the coverage limit per occurrence, and drive on...with no out of pocket expense to you. eat onont ifback fthlsageand mail-kin with your Check or credit card information.. 27 AUTO ASSIST PLUS ROADSIDE ASSISTANCE COVERAGE APPLICATION MEMBER INFORMATION First Name M.I. Last Name Spouse's Full Name (if applicable) Street Address City State /Providence Zip Code Home Phone Number E -Mail Address ❑ SIGN ME UP! I want to save 44% off the retail price for Roadside Assistance Coverage. Enclosed is my payment of $49.90 for one year of Auto Assist Plus® Membership. METHOD OF PAYMENT: 0 Check Enclosed (make payable to Road America) 0Visa ❑ Mastercard ❑ Discover ❑ American Express Credit Card Account Number Expiration Date Signature ❑ EASY RENEWAL PLAN! Please renew my Auto Assist Plus® package on an annual basis to the credit card listed below. (Credit card will be automatically debited 60 days prior to your renewal date.) MAIL COMPLETED APPLICATION TO: Auto Assist Plus Roadside Assistance Program Road America Motor Club 7300 Corporate Center Drive, Suite 601 Miami, FL 33126 ATTN: HUMANA FOR MORE DETAILS OR TO ORDER BY PHONE: CALL: 866.641.5442 FAX: 305- 392 -4402 OR VISIT US ONLINE AT W W W.ROAD- AMERICA.COM /HU MANA After approval of your application online, over the phone, or through the mailed in application above, you should receive your Auto Assist Plus® fulfillment package within weeks, including your Auto Assist Plus® membership card for you and your spouse, full terms and conditions, and special savings coupons! FULL TERMS AND CONDITIONS APPLY. Prices in U.S. Dollars. Benefit Limit: $100 limit for Roadside Assistance Services per occurrence. Coverage: Insured and spouse in any owned vehicle. Limitation of (3) three uses within (12) twelve month period. Emergency Travel Expense Reimbursement benefit is not available by law to residents of California, New York and Tennessee. Ask for full details when you sign up with Road America. Certain restrictions and /or exclusions apply. Please note that the information you provide on the Auto Assist Plus® Roadside Assistance Application is being provided to Road America Motor Club so that it may provide the services to you. Road America and its vendors are private firms offering services to members. Humana is not party to any contract or agreement between these companies and Humana members.These benefits apply to each vehicle owned per enrolled member. All Claims are underwritten by Road America. Services provided by Brickell Financial Services Motor Club, Inc., d.b.a. Road America Motor Club. In Mississippi & Wisconsin, services provided by Brickell Financial Services Motor Club 'nc. For California members, services provided by Road America Motor Club, Inc.See member handbook for full details. 28 FREQUENTLY ASKED QUESTIONS How can I compare Humana's Group Medicare PPO Plan to Original Medicare? You can compare Humana Group Medicare PPO and the Original Medicare plan using the "Summary of Benefits" that is included in your enrollment folder. The charts list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers, plus additional benefits, which may change from year to year. How do I enroll? Please read over all of the information supplied in this Guide Book. If your group benefits administrator has chosen enrollment using the paper enrollment applications, each eligible person must enroll separately for Humana Group Medicare PPO Plan coverage. If you and your Medicare eligible spouse are enrolling for the plan, each of you must complete a separate enrollment form. The form is printed on special, three -part paper. Use a ball -point pen and press hard to make sure your writing is legible on all three copies. If your group benefits administrator has chosen enrollment using Electronic Data Interchange (EDI), your group benefits administrator will provide your enrollment information to Humana. If Humana needs additional information from you, you will be contacted by mail or by phone. Please follow the directions indicated to provide the necessary information. Be sure to review the flyer in your kit with the heading "Please Read This Important Information About Enrollment," which serves as your record of enrollment. You must be enrolled in Original Medicare (Parts A and B) to be eligible for the Humana Group Medicare PPO Plan. In addition to the plan premium (if applicable) for this plan, you must continue to pay your Medicare applicable premiums, if not otherwise paid for by another third party. Starting in 2007, you may have to pay a surcharge in addition to your Medicare Part B premium, based on your "modified adjusted gross income." For details, contact Medicare at 1- 800 - MEDICARE (1- 800 - 633 - 4227); TTY: 1- 877 - 486 -2048, 24 hours a day, 7 days a week. If you are enrolling in the Humana Group Medicare PPO Plan because you are turning age 65, you must enroll in Original Medicare and be issued a Medicare Claim Number before you can enroll. Medicare rules do not allow you to complete an enrollment form more than 90 days before your coverage would begin. Please contact your benefits administrator if you have any questions. What should I do if I have filled out a paper application, but I don't have a business reply envelope (BRE)? If you are filling out a paper application, a business reply envelope should be included in your enrollment kit. If the business reply envelope is not in your kit, please call the Group Medicare Customer Service phone number on page 8 to get the mailing address. 29 How do I pay my monthly plan premium? if you are responsible for a monthly plan premium, you have a choice of three convenient payment options: • Automatic withdrawal — Have your plan premium amount automatically withdrawn from your checking or savings account on the third business day of each month. • Automatic payment by credit card — Select a credit card to use for premium payments and have the plan premium amount charged to that account each month. • Personal check with payment coupon — Humana sends you a payment coupon book. Each month, you write a personal check and mail it to Humana with a coupon. How do I pick my payment method? If you are responsible for a monthly plan premium, and you are enrolling using a paper application, simply choose the payment option that you prefer. If your group is enrolling using EDI, your information will be sent to Humana electronically. Humana may request additional information from you by mail or by phone. If you decide that you would like to change your payment method, simply call Group Medicare Customer Service at the number listed on page 8 and we can make this change for you. When will my membership benefits begin? Check with your benefits administrator for the proposed effective date of your enrollment. You will receive a letter from Humana confirming your enrollment after the Centers for Medicare & Medicaid Services (CMS) provide their approval. It is important to continue your current healthcare coverage until your enrollment in Humana's Medicare Advantage 30 plan has been confirmed. Some overlap in coverage may occur. Who do I call if I have questions about my plan? Customer Care representatives are available to provide guidance if you have a question or problem. Simply call your dedicated Group Medicare Customer Service phone number listed on page 8. Do 1 need to select a primary care physician for Humana's PPO plan? No. With Humana Group Medicare PPO plan, you don't need to choose a primary care physician. You can see any doctor who participates in the Humana network and save money, or any doctor outside of the network and pay more for your care. However, it's always a good idea to have one doctor to coordinate your care, who knows your medical history, any medications you take, and your personal preferences in healthcare. At a minimum, be sure to check that the doctor you choose accepts Original Medicare. I'd like to consult a specialist who is listed in your Provider Directory. Can I see that doctor? If you have Humana Group Medicare PPO plan, you can see any specialist you like without a referral. lust remember that you'll save money by using a specialist who participates in the network. What if I want a second opinion? You can see any doctor you choose. Just remember that you will have lower copayments or coinsurance if you use doctors who participate in the network Do I need to give both my Humana ID card and my Medicare ID card to my doctor or hospital? No. Once your Humana Group Medicare PPO Plan coverage begins, you should not present your Medicare ID card to any provider; your Humana card is the only card you should need. Keep your Medicare ID card in a safe place — or use it only when it's needed for discounts and other offers from retailers. What do I show if my ID card has not yet arrived or I do not have it with me? You should use your completed enrollment form if you have not received your card. If you have no proof of membership, you may call Group Medicare Customer Service to verify your benefits. In the rare case that your enrollment form has not been processed and you are not in the Humana system yet, you may have to submit a claim for reimbursement. What should I do if I have to file a claim? To request reimbursement for a charge you paid for a service, just send the provider's itemized receipt and a copy of your Humana ID card to the claims address on the back of the ID card. Make sure the receipt includes your name and Humana Member ID number. What if I have coverage through other health insurance? If you have other health insurance coverage, show your Humana ID card, in addition to all other insurance cards, when you see a healthcare provider. The Humana Group Medicare PPO Plan may be used in combination with other types of health insurance coverage you may have. This is called "coordination of benefits." What's the difference between emergency and urgently needed care? Emergency care means medical conditions that are severe or cause severe pain. The severity of these symptoms or pain would lead a person with average knowledge of health and medicine to reasonably expect that immediate medical attention is needed to prevent any of the following: • Serious risk to your health • Serious damage or impairment to the functioning of your body • Serious dysfunction of any organ or part of your body Examples of covered emergency services include: • Chest pain • Difficulty breathing • Severe burns • Penetrating wounds • Vomiting blood Urgently needed care means covered services that are medically necessary due to an unforeseen illness, injury, or condition. What if I have a condition such as the flu or fever, which needs medical care, but l do not believe it is an emergency? Whether you are traveling or at home, call your family doctor. Even if it is after office hours, 31 you will be instructed on how to handle the condition or directed to an appropriate facility for treatment. What should I do in the case of emergency or urgently needed care? When you have a medical emergency, call 911 for assistance or go to the nearest emergency room or nearest network hospital for immediate treatment. You are covered for emergency care wherever you are. You do not need a referral from your primary care physician or authorization from us to receive emergency services. It is important for either you or the facility where you are receiving emergency care to notify us or your primary care physician as soon as you are stabilized so that your primary care physician is involved in planning any follow up care. If an emergency situation arises, you are covered. You may go to any doctor, specialist, immediate care facility or hospital. If you use a hospital emergency room, you would only be required to pay your copayment, whether you use a network or non - network hospital. However, if you use an emergency room at a non - network hospital and need to be admitted to the hospital, you would be required to pay the out -of- network benefits. In the case of urgently needed care, you are covered. You may go to any doctor, specialist, immediate care facility or hospital. When you receive services from a network provider, your costs will be lower than if you receive care from a non - network provider. 32 What should I do if I move? If you change your physical address, it may affect your plan. Once you leave the plan's service area, you must disenroll from the plan. Please contact your sponsor benefits administrator to see if optional plans are available. Can my membership be canceled by the plan? Your membership cannot be canceled for reasons of age or health. Your membership can only be canceled by Humana if: • You become ineligible for Medicare Part B coverage or are no longer enrolled in Part A. • You or your group benefits administrator fail to pay any monthly plan premiums (if applicable). • You engage in fraudulent or disruptive behavior that affects your health or the health of other members. • Your group benefits administrator notifies Humana that you are no longer eligible for their group plan. In most cases, Humana will transfer your coverage to a Humana Individual Medicare Advantage plan, if available, so you will not lose your healthcare coverage. • Your group benefits administrator notifies Humana that they are canceling their group coverage with Humana. They will decide whether coverage will be canceled or allow Humana to transfer your coverage to a Humana Individual Medicare Advantage plan, if available. • Our annual contract with CMS is not renewed in the service area where your group benefits administrator is headquartered. If this happens, Humana will notify you in advance. If 1 lose or cancel my Humana Group Medicare PPO Plan coverage, can I still be covered by Medicare? Yes, you can return to coverage by Original Medicare (Parts A and B). Please notify your benefits administrator if you decide to cancel your plan. What are my protections in this plan? If the plan ever denies your claim or a service, we will explain our decision to you. You always have the right to appeal and ask us to review the claim or service that was denied. If a decision is not made in your favor, your appeal will be reviewed by an independent organization that works for Medicare. 33 GLOSSARY Behavioral healthcare Treatment of psychiatric, emotional, or chemical dependency disorders. Coinsurance The percentage of the charge for covered services that you pay, after you pay any deductible or copayment. Copayment A specific dollar amount you pay directly to the provider for covered services. Deductible The amount you must pay for specified covered services each year before the plan pays any benefits. Licensed representative Certified representatives of Humana/MarketPOINT who hold a state insurance license. Only licensed representatives may answer questions about the features and benefits of the Humana Group Medicare PPO Plan before coverage begins. Limiting charge The highest amount of money you can be charged for a covered service by doctors and other healthcare suppliers who do not accept Medicare assignment. The limiting charge only applies to certain medical services, not to medical supplies or equipment. Medicare Advantage plan A Medicare plan offered by a private insurer, which includes all of the benefits of Original Medicare (also called "traditional Medicare ") and may also include Medicare Part D prescription drug coverage, as well as extra benefits. When you have a Medicare Advantage plan, you still have Medicare and must continue paying Medicare premiums. Medicare assignment When a provider agrees to accept the Medicare - approved amount. 34 Medicare - approved amount The amount or cost of payment deemed reasonable and customary by Medicare, for an item or service. These amounts are subject to change from time to time. Providers accepting Medicare assignment cannot charge you or the plan more than your share of the Medicare - approved amount. Original Medicare Medicare Parts A (hospital insurance) and B (medical insurance). Part A coverage is automatic for most people deemed to be disabled by the Social Security Administration, or age 65 and older; Part B is optional and requires a monthly premium. Out -of- pocket costs Any amounts you may have to pay out of your pocket for most plans, such as deductibles, copayments or coinsurance. Out -of- pocket limit The maximum amount of covered expenses you pay in a calendar year for most plans. Once you reach your annual out -of- pocket limit, the Humana Group Medicare PPO Plan pays 100 percent of the Medicare- approved amount for most covered charges. PPO PPO is short for "Preferred Provider Organization," a type of health plan that gives you freedom to choose your own doctors and hospitals. However, your out -of- pocket costs are usually lower if you choose health care providers that participate in the plan's network. 35 NOTICE OF PRIVACY This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Relationships are built on trust. One of the most important elements of trust is respect for an individual's privacy. We at Humana value our relationship with you, and we take your personal privacy seriously. This notice, effective April 1, 2003, explains Humana's privacy practices, our legal responsibilities, and your rights concerning your personal and health information. We reserve the right to change our privacy practices and the terms of this notice at any time, as allowed by law. This includes the right to make changes in our privacy practices and the revised terms of our notice effective for all personal and health information that we maintain. This includes information we created or received before we made the changes. When we make a significant change in our privacy practices, we will change this notice and send the notice to our health plan subscribers. What is personal and health information? Personal and health information (hereafter referred to as "information ") includes both medical information and individually identifiable information, such as your name, address, telephone number or social security number. The term "information" in this notice includes any personal and health information that is created or received by a healthcare provider or health plan that relates to your physical or mental health or condition, the provision of healthcare to you, or the payment for such healthcare. How does Humana protect my information? In accordance with federal and state laws and our own policy, Humana has a responsibility to 36 protect the privacy of your information. We have safeguards in place to protect your information in various ways that include: • Limiting the access to who may see your information • Limiting how we use or disclose your information • Informing you of our legal duties regarding your information • Following our policies • Training of our associates • Requesting approval from you for any potential situations where your information would be used for reasons other than payment and health plan operations How does Humana use and disclose my information? We must use and disclose your information: • To you or someone who has the legal right to act on your behalf; • To the Secretary of the Department of Health and Human Services; and • Where required by law. We have the right to use and disclose your information: • To a doctor, a hospital or other healthcare provider which asks for it in order for you to receive medical care; • To pay claims for covered services provided to you by doctors, hospitals or other healthcare providers; • For healthcare operation activities including processing your enrollment, responding to your inquiries and requests for services, coordinating your care, resolving disputes, conducting medical management, reviewing the competence of healthcare professionals, and determining premiums; • For performing underwriting activities • To your plan group benefits administrator to permit them to perform plan administration functions; • To contact you with information about health - related benefits and services, appointment reminders, or about treatment alternatives that may be of interest to you Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. We may use or disclose your information: • To your family and friends if you are unavailable to communicate, such as in a medical or other emergency; • To provide payment information to the subscriber for Internal Revenue Service substantiation; • To public health agencies if we believe there is a serious health or safety threat; • To appropriate authorities regarding abuse, neglect, or domestic violence; • In response to a court or administrative order, subpoena, discovery request, or other lawful process; • For law enforcement purposes; • To military authorities; • For research purposes in limited circumstances; • For procurement, banking or transplantation of organs, eyes, or tissue; and • To a coroner, medical examiner or funeral director. Will Humana use my information for purposes not described in this notice? In all situations other than described in this notice, Humana will request your written permission before using or disclosing your information. You may revoke your permission at any time by notifying us in writing. We will not use or disclose your information for any reason not described in this notice without your permission. What does Humana do with my information when I am no longer a Humana member? Your information may continue to be used for purposes described in this notice when your membership is terminated. After the required legal retention period, information is destroyed following strict procedures to maintain the confidentiality of the information. What are my rights concerning my information? The following are your rights with respect to your information: • Access - You have the right to review and obtain a copy of your information that may be used to make decisions about you such as claims and case or medical management records. You also may receive a summary of 37 this health information. If you request copies, we may charge you a fee for each page, and per hour for staff time to locate and copy your information, and postage. • Alternate Communications — You have the right to receive confidential communications of information in a different manner or at a different place to avoid a life- threatening situation. We will accommodate your request, if it is reasonable. • Amendment — You have the right to request an amendment of information we maintain about you if you believe that it is wrong or incomplete. We may deny your request if we did not create the information, we do not maintain the information, or the information is correct and complete. If we deny your request, we will provide you a written explanation of the denial. • Disclosure — You have the right to receive a listing of instances in which we or our business associates have disclosed your information for purposes other than treatment, payment, health plan operations, and certain other activities. Effective April 1, 2003, Humana began maintaining these types of disclosures and will maintain this information for a period of six (6) years. If you request this list more than once in a 12 -month period, we may charge you a reasonable, cost -based fee for responding to these additional requests. • Notice — All Humana members and prospective members have the right to receive a written copy of this notice upon request at any time. 38 • Restriction — You have the right to ask to restrict uses or disclosures of your information. We are not required to agree to these restrictions, but if we do, we will abide by our agreement. You also have the right to agree to or terminate a previously submitted restriction. How do I exercise my rights or obtain a copy of this notice? All of your privacy rights can be exercised by obtaining the applicable privacy rights request forms. You may obtain any of the forms by: • Contacting us at 1- 866 -861 -2762 (TTY users can call 1- 800 -833 -3301) at any time • Accessing our Website at Humana.com and going to the Privacy Zink • E- mailing us at privacyoffice@humana.com Send the completed request form to Humana's Privacy Office at: Humana Inc. Privacy Office P.O. Box 1438 Louisville, KY 40202 What should I do if I believe my privacy has been violated? If you believe your privacy has been violated in any way, you may file a complaint with Humana by calling us at 1- 866 -861 -2762 (TTY users can call 1-800- 833 -3301) at any time. You may also submit a written complaint to the U.S. Department of Health and Human Services, Office of Civil Rights (OCR). We will provide you with the appropriate OCR regional address upon request. You also have the option to email your complaint to OCRComplaintthhs. gov. We support your right to protect the privacy of your personal and health information. We will not retaliate in any way if you elect to file a complaint with us or with the U.S. Department of Health and Human Services. Humana follows all federal and state laws, rules, and regulations addressing the protection of personal and health information. In situations when federal and state laws, rules, and regulations conflict, Humana follows the law, rule, or regulation which provides greater member protection. The following affiliates and subsidiaries also adhere to Humana's privacy policies and procedures: Humana Employer's Health Plan of Georgia, Inc. Humana Health Insurance Company of Florida, Inc. Humana Health Plan of Ohio, Inc. Humana Health Plan of Texas, Inc. Humana Health Plan, Inc. Humana Health Plans of Puerto Rico, Inc. Humana Insurance Company Humana Insurance Company of Kentucky Humana Insurance of Puerto Rico, Inc. Humana Medical Plan, Inc. Humana Wisconsin Health Organization Insurance Corporation HumanaDental Insurance Company The Dental Concern, Inc. The Dental Concern, Ltd. Humana Health Plan Interests, Inc. Humana Health Benefit Plan of Louisiana, Inc. Health One, Inc. Humana Insurance Company of New York 39 HUMANA. Guidance when you need it most A Medicare approved PPO available to anyone enrolled in both Part A and Part B of Medicare through age or disability. Copayment, service area, and benefit limitations may apply. GN91102RR08 Humana.com 1207 GNAOOT8RRO9 ON O = u C m ° c m c ,moo mo��° 0 `00- 3 .°� o c a 3° -al 2 N a; 7 g t E -� Y A E • .E , ' a N o •C O c1 S vi ffi y V - 9 p t u u oz o 3 .c o C a) - w m w o ° `n E v 5 O Z Z E c u T c CD Way 410- g 1 _0 m d p m E Q N L O ., O N N J L Cl./ C -0 ` N y C - Q Lti CU o .N, flh `c c 0 0 c 30 j E g g ° �1 ,p .� V m +L-' 2 i D t50 w C O , 1 4� 7C .v O> C 7 Ca Z .� W t. A. pi _ per' o N v� o N a � mn Nf0 Er, 2 vy a L N A E S C } D a b ‘A., j .a. C w cv �: y C a 2 Oft tai a`3 a 1 t F E vi w � ai '' > R d p, Ti •2 m 7 N ` C O •Q 7 .Q N .� N .0 c_`o �.J Ei_-C EE/ a ° ° 10 o hoc m L °Ea-a 'c ='^ co o -E O S 3 u o z > O m a d n v m m d Y aL 'v, p1 0 C c t.a 1. C E r a o N a a> L " E �' cm ..,e z o c m e o Q a • d 0 y m S o o m o c d t o o A a c o 0 3 ,„0 'N YQ ..c _ a L L^ C N a - a C1 = Cl_ Y v =v c m S E vi c u m c p o' n s ,'^„ 18 o °- '> -o Luca vici, L O C d O e� O 0.. _C v }• V C 0 d N u a, a d 7u v m c 0 c C '^ E. — .L •a, -Q w r , `' ,c o o n m 0E+j c 5 ��^1 - �' d. E ar o 4., = GNA004NRRO9 ft C • Quarterly newsletter �ra EE� g. q, 03 EocEA ~ 5. d E O (1 01'Y oE' o aim TQf vY �oa ��cn w ro� 3 1 1 c i Gv4c c mL 7103E, c $`s E m oca 3 t w o Div 1 E ro � a .crt R 2. 45 L.,-; ro > i-° °>' s LEI o 0 '- tal a' z ns v .� 4— * E vy -J O i V Q O co ii5 a) a � Q o °�o , E o v o `o C3 J r0 Q) 0 Y 0 E TE EL c p o . o Et E 2 &� > ms �'E RE d N yj ro Y01 . - 3 -, � ,Eo 4, E 2 E E •g ro LI E2 •91 FE� ry N • • • tfs 0 2009 Prescription Drug Guide Humana Group Medicare Abbreviated Formulary List of Covered Drugs C0006_PDG_09_FINAL_10 KC0808 M0006_PDG_09_FINAL_1 0 KC0808 GNA024MRRPDGPLS09_2 you need it most e Welcome to Humana Group Medicare! PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. What is the Humana Group Medicare Formulary? A formulary is a list of covered drugs selected by Humana Group Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Humana Group Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Humana Group Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. The enclosed drug list is a partial formulary and includes only some of the drugs covered by Humana. For a complete listing of all prescription drugs covered by Humana, please visit our Website at Humana.com. You can also call Customer Service at the number listed on the back of your member ID card for a better customer experience. Customer Service representatives are available Monday through Friday 8 a.m. to 11 p.m. and Saturday 8 a.m. to 6 p.m. Eastern Time. Can the Formulary change? Generally, if you are taking a drug on our 2009 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2009 coverage year except when a new, Tess expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost - sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and /or step therapy restrictions on a drug or move a drug to a higher cost- sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60 -day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 2009. You can also call Customer Service at the number listed on the back of your member ID card for a better customer experience. Customer Service representatives are available Monday through Friday 8 a.m. to 11 p.m. and Saturday 8 a.m. to 6 p.m. Eastern Time. PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 1 How do I use the Humana Group Medicare Formulary? Alphabetical Listing The formulary begins on page 8. The drugs in this formulary are listed in alphabetical order. The formulary also lists the Tier, Utilization Management Requirement, Therapeutic Category , and Limited Access. Drugs are grouped into one of four tiers -1, 2, 3, or 4. • Tier 1 - Preferred Generic • Tier 2 - Preferred Brand • Tier 3 - Non - preferred Brand • Tier 4 - Specialty Here's how to read the Utilization Management Requirement codes: PA - Prior Authorization QL - Quantity Limits ST - Step Therapy LA - Limited Access See page 2 for more details on Utilization Management Requirements. What are generic drugs? Humana Group Medicare covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having.the same active ingredient(s) as the brand name drug. Generally, generic drugs cost less than brand name drugs. How much will I pay for Humana Group Medicare Covered Drugs? If you qualified for extra help with your drug costs, your costs may be different than those described below. Please refer to your Evidence of Coverage or call Customer Service to find out what your costs are. Humana Group Medicare pays part of the costs for your covered drugs and you pay part of the costs as well. The amount you pay depends on which drug category your drug falls under in the formulary and whether you fill your prescription at a network pharmacy. Drug categories • Preferred Generic - drugs that have the same active ingredients as brand drugs and are prescribed for the same reasons. The Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength, purity, and stability as brand drugs. Your cost for generic drugs is usually lower than your cost for brand drugs. • Preferred Brand - Brand prescription drugs that Humana Group Medicare offers at a lower cost to you than non - preferred drugs. • Non - preferred Brand - More expensive brand prescription drugs that Humana Group Medicare offers at a higher cost to you than preferred drugs. • Specialty - Some injectables and other high -cost drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: 2 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY • Prior Authorization: Humana Group Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Humana Group Medicare before you fill your prescriptions. If you don't get approval, Humana Group Medicare may not cover the drug. • Quantity Limits: For certain drugs, Humana Group Medicare limits the amount of the drug that Humana Group Medicare will cover. For example, Humana Group Medicare provides 30 tablets per 30 days for Simvastatin. This may be in addition to a standard one month or three month supply. Specialty drugs are limited to a 30 -day supply regardless of tier placement. • Step Therapy: In some cases, Humana Group Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Humana Group Medicare may not cover drug B unless you try Drug A first. If Drug A does not work for you, Humana Group Medicare will then cover Drug B. • Limited Access: In some cases, Humana Group Medicare may limit access for certain drugs. Humana Group Medicare may provide coverage only at certain pharmacies. For more information, you can contact Customer Service. For drugs that require prior authorization, step therapy, or fall outside of the noted quantity limits, the doctor must call Humana Group Medicare at 1- 866 - 396 -8810. (Representatives are available Monday through Friday, 8 a.m. to 11 p.m., and Saturday 8 a.m. to 6 p.m., Eastern Time) You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can ask Humana Group Medicare to make an exception to these restrictions or limits. See the section, "How do I request an exception to the Humana Group Medicare formulary?" for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this list of covered drugs, you should first contact Customer Service and ask if your drug is covered. If you learn that Humana Group Medicare does not cover your drug, you have two options: • You can ask Customer Service for a list of similar drugs that are covered by Humana Group Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Humana Group Medicare. • You can ask Humana Group Medicare to make an exception and cover your drug. See below for information about how to request an exception. Note: Due to a change in Medicare as of January 1, 2007, most Medicare Part D Plans will no longer cover erectile dysfunction drugs like Viagra, Cialis, Levitra, and Caverject. Call Customer Service for more information. How do 1 request an exception to the Humana Group Medicare Formulary? You can ask Humana Group Medicare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. • You can ask us to cover your drug even if it is not on our formulary. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Humana Group Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more. • You can ask us to provide a higher level of coverage for your drug. If your drug is usually considered a non - preferred drug, you can ask us to cover it as a preferred instead. This would lower the amount you must pay PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 3 for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, Humana Group Medicare will only approve your request for an exception if the alternative drugs are not included on the plan's formulary, the lower- tiered drug or additional utilization restrictions would not be as effective in treating your condition and /or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician's supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30 -day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30 -day supply, we will not pay for these drugs, even if you have been a member of the plan Tess than 90 days. If you are a resident of a long -term care facility, we will cover a temporary 34 -day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34 -day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Throughout the plan year, you may have a change in your treatment setting due to the level of care you require. Such transitions include: • Members who are discharged from a hospital or skilled nursing facility to a home setting. • Members who are admitted to a hospital or skilled nursing facility from a home setting. • Members who transfer from one skilled nursing facility to another and are serviced by a different pharmacy. • Members who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to now use their Part D plan benefit. • Members who give up Hospice Status and revert back to standard Medicare Part A and B coverage. • Members discharged from chronic psychiatric hospitals with highly individualized drug regimens. • Members currently requesting an appeal of an initial Coverage Determination and/or Exception. For these changes in treatment settings, Humana Group Medicare will cover up to a 34 day temporary supply of a Part D covered drug when your prescription is filled at a network pharmacy. If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization and receive approval for continued 4 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY coverage of your drug. Humana Group Medicare will review these requests for continuation of therapy on a case -by -case basis when you are stabilized on drug regimen, which if altered, is known to have risks. PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 5 For More Information For more detailed information about your Humana Group Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Humana, please visit our Website at Humana.com. You can also call Customer Service at the number listed on the back of your member ID card for a better customer experience. Customer Service representatives are available Monday through Friday 8 a.m. to 11 p.m. and Saturday 8 a.m. to 6 p.m. Eastern Time. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1- 800 - MEDICARE (1- 800 - 633 -4227) 24 hours a day/7 days a week. TTY users should call 1- 877 - 486 -2048. Or, visit www.medicare.gov. 6 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY Humana Group Medicare Formulary fhe formulary that begins on the next page provides coverage information about some of the drugs covered by Humana Group Medicare. Remember: This is only a partial list of drugs covered by Humana. If your prescription is not listed in this partial formulary, please visit our Web site at Humana.com. You can also call Customer Service at the number listed on the back of your member ID card for a better customer experience. Customer Service representatives are available Monday through Friday 8 a.m. to 11 p.m. and Saturday 8 a.m. to 6 p.m. Eastern Time. The first column of the chart lists the drug name in alphabetical order. The second column lists the tier of the drug. The information in the Utilization Management Requirements column tells you whether Humana Group Medicare has special requirements for covering that drug. If the column is blank, then the supply is based on benefits and whether your doctor prescribes a 30 -, 60- or 90 -day supply. The last column lists the Therapeutic Category of the drug. PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 7 IIT1117AT1(li1 iOUIH1`111; ABILIFY 1 MG /ML SOLUTION 3 Central Nervous Systems Agents ABILIFY 9.75 MG /1.3ML SOLUTION 3 Central Nervous Systems Agents ABILIFY 10 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY 15 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY 2 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY 20 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY 30 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY 5 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY DISCMELT 10 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY DISCMELT 15 MG TABLET 3 QL Central Nervous Systems Agents ACCOLATE 10 MG TABLET 2 QL Respiratory Tract Agents ACCOLATE 20 MG TABLET 2 QL Respiratory Tract Agents ACCUNEB 0.63 MG /3ML NEBULIZER 3 Autonomic Drugs ACCUNEB 1.25 MG /3ML NEBULIZER 3 Autonomic Drugs ACCURETIC 12.5 MG;10 MG TABLET 3 Cardiovascular Drugs ACCURETIC 12.5 MG;20 MG TABLET 3 Cardiovascular Drugs ACCURETIC 25 MG;20 MG TABLET 3 Cardiovascular Drugs ACCUTANE 10 MG CAPSULES 4 Skin And Mucous Membrane Agents ACCUTANE 20 MG CAPSULES 4 Skin And Mucous Membrane Agents ACCUTANE 40 MG CAPSULES 4 Skin And Mucous Membrane Agents ACEON 2 MG TABLET 3 Cardiovascular Drugs ACEON 4 MG TABLET 3 Cardiovascular Drugs ACEON 8 MG TABLET 3 Cardiovascular Drugs ACETAMINOPHEN /CODEINE #2 300 MG;15 MG TABLET 1 QL Central Nervous Systems Agents ACETAMINOPHEN /CODEINE #3 300 MG;30 MG TABLET 1 QL Central Nervous Systems Agents ACETAMINOPHEN /CODEINE #4 300 MG;60 MG TABLET 1 QL Central Nervous Systems Agents ACIPHEX 20 MG TABLET 3 QL, ST Gastrointestinal Drugs ACLOVATE 0.0005 CREAM 3 Skin And Mucous Membrane Agents ACLOVATE 0.0005 OINTMENT 3 Skin And Mucous Membrane Agents ACTIGALL 300 MG CAPSULES 3 Gastrointestinal Drugs ACTOPLUS MET 500 MG;15 MG TABLET 2 QL Hormones And Synthetic Substitutes H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 8 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY I1TII17,,TI(>r; (,)U1RF_P.1L�s I' ACTOPLUS MET 850 MG;15 MG TABLET 2 QL Hormones And Synthetic Substitutes ACTOS 15 MG TABLET 2 QL Hormones And Synthetic Substitutes ACTOS 30 MG TABLET 2 QL Hormones And Synthetic Substitutes ACTOS 45 MG TABLET 2 QL Hormones And Synthetic Substitutes ACULAR 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT) Preparations ACULAR LS 0.004 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT) Preparations ACULAR PF 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT) Preparations ACYCLOVIR 200 MG CAPSULES 1 Anti - Infective Agents ACYCLOVIR 200 MG /5ML SUSPENSION 1 Anti - Infective Agents ACYCLOVIR 400 MG TABLET 1 Anti- Infective Agents ACYCLOVIR 800 MG TABLET 1 Anti - Infective Agents ADALAT CC 30 MG TABLET 3 QL Cardiovascular Drugs ADALAT CC 60 MG TABLET 3 QL Cardiovascular Drugs ADALAT CC 90 MG TABLET 3 QL Cardiovascular Drugs ADDERALL XR 1.25 MG;1.25 MG;1.25 MG;1.25 MG CAPSULES 3 QL Central Nervous Systems Agents ADDERALL XR 2.5 MG;2.5 MG;2.5 MG;2.5 MG CAPSULES 3 QL Central Nervous Systems Agents ADDERALL XR 3.75 MG;3.75 MG;3.75 MG;3.75 MG CAPSULES 3 QL Central Nervous Systems Agents ADDERALL XR 5 MG;5 MG;5 MG;5 MG CAPSULES 3 QL Central Nervous Systems Agents ADDERALL XR 6.25 MG;6.25 MG;6.25 MG;6.25 MG CAPSULES 3 QL Central Nervous Systems Agents ADDERALL XR 7.5 MG;7.5 MG;7.5 MG;7.5 MG CAPSULES 3 QL Central Nervous Systems Agents ADVAIR DISKUS 100 MCG /DOSE;50 MCG /DOSE MISC 2 QL Autonomic Drugs ADVAIR DISKUS 250 MCG /DOSE;50 MCG /DOSE MISC 2 QL Autonomic Drugs ADVAIR DISKUS 500 MCG /DOSE;50 MCG /DOSE MISC 2 QL Autonomic Drugs ADVAIR HFA 115 MCG /ACT;21 MCG /ACT AEROSOL 2 QL Autonomic Drugs ADVAIR HFA 230 MCG /ACT;21 MCG /ACT AEROSOL 2 QL Autonomic Drugs ADVAIR HFA 45 MCG /ACT;21 MCG /ACT AEROSOL 2 QL Autonomic Drugs ADVICOR 20 MG;1000 MG TABLET 2 QL Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 9 i ADVICOR 20 MG;500 MG TABLET 2 I I TII I7ATIW .I,,P.,(1I ".i! -i'i; RLOliII l r 1!_L! QL Cardiovascular Drugs ADVICOR 20 MG;750 MG TABLET 2 QL Cardiovascular Drugs ADVICOR 40 MG;1000 MG TABLET 2 QL Cardiovascular Drugs AEROBID 250 MCG /ACT AEROSOL SOLUTION 3 QL, ST Hormones And Synthetic Substitutes AEROBID -M 250 MCG /ACT AEROSOL SOLUTION 3 QL, ST Hormones And Synthetic Substitutes AGGRENOX 25 MG;200 MG CAPSULES 2 Cardiovascular Drugs ALLEGRA 180 MG TABLET 3 QL, PA Antihistamine Drugs ALLEGRA -D 12 HOUR 60 MG;120 MG TABLET 3 QL, ST Antihistamine Drugs ALLEGRA -D 24 HOUR 180 MG;240 MG TABLET 3 QL, ST Antihistamine Drugs ALOCRIL 0.02 SOLUTION 3 Respiratory Tract Agents ALPHAGAN P 0.001 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT) Preparations ALPHAGAN P 0.0015 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT) Preparations AMBIEN CR 12.5 MG TABLET 3 QL, ST Central Nervous Systems Agents AMBIEN CR 6.25 MG TABLET 3 QL, ST Central Nervous Systems Agents AMIODARONE HCL 200 MG TABLET 1 Cardiovascular Drugs AMITRIPTYLINE HCL 10 MG TABLET 1 Central Nervous Systems Agents AMITRIPTYLINE HCL 100 MG TABLET 1 Central Nervous Systems Agents AMITRIPTYLINE HCL 150 MG TABLET 1 Central Nervous Systems Agents AMITRIPTYLINE HCL 25 MG TABLET 1 Central Nervous Systems Agents AMITRIPTYLINE HCL 50 MG TABLET 1 Central Nervous Systems Agents AMITRIPTYLINE HCL 75 MG TABLET 1 Central Nervous Systems Agents AMLODIPINE BESYLATE 10 MG TABLET 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE 2.5 MG TABLET 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE 5 MG TABLET 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE/BENAZ 10 MG;20 MG CAPSULES 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE /BENAZ 2.5 MG;10 MG CAPSULES 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE /BENAZ 5 MG;10 MG CAPSULES 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE /BENAZ 5 MG;20 MG CAPSULES 1 QL Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 10 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY AMOXICILLIN/CLAVULANATE P 200 MG;28.5 MG CHEWABLE 1 11 111 fI A11(>r1 RE UUIRE F.1L., ; Anti - Infective Agents AMOXICILLIN /CLAVULANATE P 400 MG;57 MG CHEWABLE 1 Anti- Infective Agents AMOXICILLIN/CLAVULANATE P 200 MG /5ML;28.5 MG /5ML SUSPENSION 1 Anti - Infective Agents AMOXICILLIN / CLAVULANATE P 200 MG /5ML;28.5 MG /5ML SUSPENSION 1 Anti- Infective Agents AMOXICILLIN / CLAVULANATE P 400 MG /5ML;57 MG /5ML SUSPENSION 1 Anti - Infective Agents AMOXICILLIN /CLAVULANATE P 600 MG /5ML;42.9 MG /5ML SUSPENSION 1 Anti - Infective Agents AMOXICILLIN/CLAVULANATE P 250 MG;125 MG TABLET 1 Anti- Infective Agents AMOXICILLIN /CLAVULANATE P 500 MG;125 MG TABLET 1 Anti- Infective Agents AMOXICILLIN / CLAVULANATE P 875 MG;125 MG TABLET 1 Anti - Infective Agents AMPHETAMINE SALT COMBO 2.5 MG;2.5 MG;2.5 MG;2.5 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALT COMBO 5 MG;5 MG;5 MG;5 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALT COMBO 7.5 MG;7.5 MG;7.5 MG;7.5 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 1.25 MG;1.25 MG;1.25 MG;1.25 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 1.875 MG;1.875 MG;1.875 MG;1.875 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 2.5 MG;2.5 MG;2.5 MG;2.5 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 3.125 MG;3.125 MG ;3.125 MG;3.125 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 3.75 MG;3.75 MG;3.75 MG;3.75 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 5 MG;5 MG;5 MG;5 MG TABLET 1 Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 11 AMPHETAMINE SALTS COMBO 7.5 MG;7.5 MG;7.5 MG;7.5 MG TABLET 1 1 Tlll7fvTIM f E QUIN LIE HI Central Nervous Systems Agents ANAGRELIDE HYDROCHLORIDE 1 MG CAPSULES 1 Miscellaneous Therapeutic Agents ARANESP ALBUMIN FREE 100 MCG /0.5ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 100 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 150 MCG /0.3ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 150 MCG /0.75ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 200 MCG /0.4ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 200 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 25 MCG /0.42ML SOLUTION 3 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 25 MCG /ML SOLUTION 3 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 300 MCG /0.6ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 300 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 40 MCG /0.4ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 40 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 500 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 60 MCG /0.3ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 60 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARICEPT 10 MG TABLET 2 QL Autonomic Drugs ARICEPT 5 MG TABLET 2 QL Autonomic Drugs ARICEPT ODT 10 MG TABLET 2 QL Autonomic Drugs ARICEPT ODT 5 MG TABLET 2 QL Autonomic Drugs ARIMIDEX 1 MG TABLET 2 QL Antineoplastic Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 12 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY i;Tll1 /Fa -TIM , 1r i1UIfiC(.il.iJi`, ARIXTRA 10 MG /0.8ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis ARIXTRA 2.5 MG /0.5ML SOLUTION H _ 3 QL Blood Formation, Coagulation, And Thrombosis ARIXTRA 5 MG/0.4ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis ARIXTRA 7.5 MG /0.6ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis ASACOL 400 MG TABLET 2 QL Gastrointestinal Drugs ASMANEX 120 METERED DOSES 220 MCG /INH AEROSOL POWDER 2 QL Hormones And Synthetic Substitutes ASMANEX 14 METERED DOSES 220 MCG /INH AEROSOL POWDER 2 QL Hormones And Synthetic Substitutes ASMANEX 30 METERED DOSES 220 MCG /INH AEROSOL POWDER 2 QL Hormones And Synthetic Substitutes ASMANEX 60 METERED DOSES 220 MCG /INH AEROSOL POWDER 2 QL Hormones And Synthetic Substitutes ASTELIN 137 MCG /SPRAY SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations ATACAND 16 MG TABLET 3 QL Cardiovascular Drugs ATACAND 32 MG TABLET 3 QL Cardiovascular Drugs ATACAND 4 MG TABLET 3 QL Cardiovascular Drugs ATACAND 8 MG TABLET 3 QL Cardiovascular Drugs ATACAND HCT 16 MG;12.5 MG TABLET 3 QL Cardiovascular Drugs ATACAND HCT 32 MG;12.5 MG TABLET 3 QL Cardiovascular Drugs ATENOLOL 100 MG TABLET 1 Cardiovascular Drugs ATENOLOL 25 MG TABLET 1 Cardiovascular Drugs ATENOLOL 50 MG TABLET 1 Cardiovascular Drugs ATRIPLA 600 MG;200 MG;300 MG TABLET 4 Anti - Infective Agents ATROVENT HFA 17 MCG /ACT AEROSOL SOLUTION 2 QL Autonomic Drugs AVALIDE 12.5 MG;150 MG TABLET 2 QL Cardiovascular Drugs AVALIDE 12.5 MG;300 MG TABLET 2 QL Cardiovascular Drugs AVALIDE 25 MG;300 MG TABLET 2 QL Cardiovascular Drugs AVANDAMET 1000 MG;2 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDAMET 1000 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDAMET 500 MG;2 MG TABLET 2 QL Hormones And Synthetic Substitutes H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 13 1111 1 /,u 1(,ri HI li \l71 [it REow[r.lErai` AVANDAMET 500 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDARYL 1 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDARYL 2 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDARYL 4 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDIA 2 MG TABLET 2 QL Hormones And Synthetic Substitutes AVAPRO 300 MG TABLET 2 QL Cardiovascular Drugs AVAPRO 75 MG TABLET 2 QL Cardiovascular Drugs AVASTIN 100 MG /4ML SOLUTION 4 QL, LA Antineoplastic Agents AVASTIN 400 MG /16ML SOLUTION 4 QL, LA Antineoplastic Agents AVELOX 400 MG TABLET 3 Anti - Infective Agents AVELOX ABC PACK 400 MG TABLET 3 Anti - Infective Agents AVODART 0.5 MG CAPSULES 2 QL Miscellaneous Therapeutic Agents AVONEX 30 MCG /0.5ML KIT 4 QL, PA Miscellaneous Therapeutic Agents AVONEX 30 MCGNIAL KIT 4 QL, PA Miscellaneous Therapeutic Agents AZILECT 0.5 MG TABLET 2 QL Central Nervous Systems Agents AZILECT 1 MG TABLET 2 QL Central Nervous Systems Agents AZOPT 0.01 SUSPENSION 2 Eye, Ear, Nose, And Throat (EENT) Preparations BACLOFEN 10 MG TABLET 1 Autonomic Drugs BACLOFEN 20 MG TABLET 1 Autonomic Drugs BENICAR 20 MG TABLET 2 QL Cardiovascular Drugs BENICAR 40 MG TABLET 2 QL Cardiovascular Drugs BENICAR 5 MG TABLET 2 QL Cardiovascular Drugs BENICAR HCT 12.5 MG;20 MG TABLET 2 QL Cardiovascular Drugs BENICAR HCT 12.5 MG;40 MG TABLET 2 QL Cardiovascular Drugs BENICAR HCT 25 MG;40 MG TABLET 2 QL Cardiovascular Drugs BISOPROLOL FUMARATE 10 MG TABLET 1 Cardiovascular Drugs BISOPROLOL FUMARATE 5 MG TABLET 1 Cardiovascular Drugs BISOPROLOL FUMARATE /HYDRO 10 MG;6.25 MG TABLET 1 Cardiovascular Drugs BISOPROLOL FUMARATE /HYDRO 2.5 MG;6.25 MG TABLET 1 Cardiovascular Drugs BISOPROLOL FUMARATE /HYDRO 5 MG;6.25 MG TABLET 1 Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 14 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY 11111 {7AT1()f1 11 1: �l_�)Ulhl Li 1 i' BUDEPRION SR 100 MG TABLET 1 QL Central Nervous Systems Agents BUDEPRION SR 150 MG TABLET 1 QL Central Nervous Systems Agents BUDEPRION XL 300 MG TABLET 1 QL Central Nervous Systems Agents BUPROBAN 150 MG TABLET 1 QL Central Nervous Systems Agents BUPROPION HCL 100 MG TABLET 1 QL Central Nervous Systems Agents BUPROPION HCL 75 MG TABLET 1 Central Nervous Systems Agents BUPROPION HCL SR 200 MG TABLET 1 QL Central Nervous Systems Agents BUSPIRONE HCL 10 MG TABLET 1 Central Nervous Systems Agents BUSPIRONE HCL 15 MG TABLET 1 Central Nervous Systems Agents BUSPIRONE HCL 30 MG TABLET 1 Central Nervous Systems Agents BUSPIRONE HCL 5 MG TABLET 1 Central Nervous Systems Agents BUSPIRONE HCL 7.5 MG TABLET 1 Central Nervous Systems Agents BYETTA 250 MCG /ML SOLUTION 3 QL, PA Hormones And Synthetic Substitutes BYETTA 250 MCG /ML;1.2 ML SOLUTION 3 QL, PA Hormones And Synthetic Substitutes CADUET 10 MG;10 MG TABLET 3 QL Cardiovascular Drugs CADUET 10 MG;20 MG TABLET 3 QL Cardiovascular Drugs CADUET 10 MG;40 MG TABLET 3 QL Cardiovascular Drugs CADUET 10 MG;80 MG TABLET 3 QL Cardiovascular Drugs CADUET 2.5 MG;10 MG TABLET 3 QL Cardiovascular Drugs CADUET 2.5 MG;20 MG TABLET 3 QL Cardiovascular Drugs CADUET 2.5 MG;40 MG TABLET 3 QL Cardiovascular Drugs CADUET 5 MG;20 MG TABLET 3 QL Cardiovascular Drugs CADUET 5 MG;40 MG TABLET 3 QL Cardiovascular Drugs CADUET 5 MG;80 MG TABLET 3 QL Cardiovascular Drugs CARBAMAZEPINE 100 MG CHEWABLE 1 Central Nervous Systems Agents CARBAMAZEPINE 200 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA /LEVODOPA 10 MG;100 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA/LEVODOPA 25 MG;100 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA/LEVODOPA 25 MG;250 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA/LEVODOPA CR 25 MG;100 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA/LEVODOPA ER 50 MG;200 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA/LEVODOPA SR 50 MG;200 MG TABLET 1 Central Nervous Systems Agents CARDURA XL 4 MG TABLET 3 QL Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 15 1ITII I7, ?TIfri R[ 1 lI E [if fil'� CARDURA XL 8 MG TABLET 3 QL Cardiovascular Drugs CATAPRES -TTS -1 0.1 MG /24HR PATCH 3 QL Cardiovascular Drugs CATAPRES -TTS -2 0.2 MG /24HR PATCH 3 QL Cardiovascular Drugs CATAPRES -TTS -3 0.3 MG /24HR PATCH 3 QL Cardiovascular Drugs CELEBREX 100 MG CAPSULES 2 QL, ST Central Nervous Systems Agents CELEBREX 200 MG CAPSULES 2 QL, ST Central Nervous Systems Agents CELEBREX 400 MG CAPSULES 2 QL, ST Central Nervous Systems Agents COMTAN 200 MG TABLET 2 QL Central Nervous Systems Agents CONCERTA 18 MG TABLET 3 QL Central Nervous Systems Agents CONCERTA 27 MG TABLET 3 QL Central Nervous Systems Agents CONCERTA 36 MG TABLET 3 QL Central Nervous Systems Agents CONCERTA 54 MG TABLET 3 QL Central Nervous Systems Agents COPAXONE 20 MG /ML KIT 4 QL, PA Miscellaneous Therapeutic Agents COREG CR 10 MG CAPSULES 3 QL, PA Cardiovascular Drugs COREG CR 20 MG CAPSULES 3 QL, PA Cardiovascular Drugs COREG CR 40 MG CAPSULES 3 QL, PA Cardiovascular Drugs COREG CR 80 MG CAPSULES 3 QL, PA Cardiovascular Drugs COSOPT 2 %;0.5 % SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations COUMADIN 5 MG SOLUTION 3 Blood Formation, Coagulation, And Thrombosis COUMADIN 3 MG TABLET 3 Blood Formation, Coagulation, And Thrombosis COUMADIN 6 MG TABLET 3 Blood Formation, Coagulation, And Thrombosis COVERA -HS 180 MG TABLET 3 QL Cardiovascular Drugs COVERA -HS 240 MG TABLET 3 QL Cardiovascular Drugs COZAAR 100 MG TABLET 3 QL Cardiovascular Drugs COZAAR 25 MG TABLET 3 QL Cardiovascular Drugs COZAAR 50 MG TABLET 3 QL Cardiovascular Drugs CRESTOR 10 MG TABLET 2 QL Cardiovascular Drugs CRESTOR 20 MG TABLET 2 QL Cardiovascular Drugs CRESTOR 40 MG TABLET 2 QL Cardiovascular Drugs CRESTOR 5 MG TABLET 2 QL Cardiovascular Drugs CYMBALTA 20 MG CAPSULES 2 QL Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 16 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY 1IT1117.vT?(1P1 if1; f Ht [ i hLUUIRLF 1[ _YMBALTA 30 MG CAPSULES 2 QL Central Nervous Systems Agents CYMBALTA 60 MG CAPSULES 2 QL Central Nervous Systems Agents DEPAKOTE ER 250 MG TABLET 2 Central Nervous Systems Agents DEPAKOTE ER 500 MG TABLET 2 Central Nervous Systems Agents DEPAKOTE SPRINKLES 125 MG SPRINKLE CAPSULES 2 Central Nervous Systems Agents DETROL LA 2 MG CAPSULES 2 QL Smooth Muscle Relaxants DETROL LA 4 MG CAPSULES 2 QL Smooth Muscle Relaxants DIGITEK 0.125 MG TABLET 1 Cardiovascular Drugs DIGITEK 0.25 MG TABLET 1 Cardiovascular Drugs DIGOXIN 0.25 MG /ML SOLUTION 1 Cardiovascular Drugs DIGOXIN 0.125 MG TABLET 1 Cardiovascular Drugs DIOVAN 40 MG TABLET 2 QL Cardiovascular Drugs DIOVAN 80 MG TABLET 2 QL Cardiovascular Drugs DIOVAN HCT 12.5 MG;160 MG TABLET 2 QL Cardiovascular Drugs DIOVAN HCT 12.5 MG;320 MG TABLET 2 QL Cardiovascular Drugs DIOVAN HCT 12.5 MG;80 MG TABLET 2 QL Cardiovascular Drugs DIOVAN 'HCT 25 MG;160 MG TABLET 2 QL Cardiovascular Drugs DIOVAN HCT 25 MG;320 MG TABLET 2 QL Cardiovascular Drugs HIPYRIDAMOLE 25 MG TABLET 1 Cardiovascular Drugs DIPYRIDAMOLE 50 MG TABLET 1 Cardiovascular Drugs DIPYRIDAMOLE 75 MG TABLET 1 Cardiovascular Drugs DOVONEX 0.005% CREAM 3 QL Skin And Mucous Membrane Agents DOVONEX 0.005% SOLUTION 3 QL Skin And Mucous Membrane Agents DOXAZOSIN MESYLATE 1 MG TABLET 1 Cardiovascular Drugs DOXAZOSIN MESYLATE 2 MG TABLET 1 Cardiovascular Drugs DOXAZOSIN MESYLATE 4 MG TABLET 1 Cardiovascular Drugs DOXAZOSIN MESYLATE 8 MG TABLET 1 Cardiovascular Drugs DYNACIRC CR 10 MG TABLET 3 QL, PA Cardiovascular Drugs DYNACIRC -CR 5 MG TABLET 3 QL, PA Cardiovascular Drugs EFFEXOR XR 150 MG CAPSULES 2 QL Central Nervous Systems Agents EFFEXOR XR 37.5 MG CAPSULES 2 QL Central Nervous Systems Agents EFFEXOR XR 75 MG CAPSULES 2 QL Central Nervous Systems Agents EMEND 125 MG CAPSULES 3 QL Gastrointestinal Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 17 ! EMEND 40 MG CAPSULES I 3 117111 /rvJI ,r,,i(,t.r.i1 ',I fjOUIIVl I.IL H1 QL 11;1 Gastrointestinal Drugs EMEND 80 MG CAPSULES 3 QL Gastrointestinal Drugs ENABLEX 15 MG TABLET 3 QL Smooth Muscle Relaxants ENABLEX 7.5 MG TABLET 3 QL Smooth Muscle Relaxants ENBREL 25 MG KIT 4 PA Miscellaneous Therapeutic Agents ENBREL 50 MG /ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents ENBREL SURECLICK 50 MG /ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents EPOGEN 10000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis EPOGEN 20000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis EPOGEN 40000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ERBITUX 100 MG /50ML SOLUTION 4 Antineoplastic Agents FELODIPINE ER 10 MG TABLET 1 QL Cardiovascular Drugs FELODIPINE ER 5 MG TABLET 1 QL Cardiovascular Drugs FEMARA 2.5 MG TABLET 3 Antineoplastic Agents FEMHR11 /5 5 MCG;1 MG TABLET 3 Hormones And Synthetic Substitutes FEMHRT LOW DOSE 2.5 MCG;0.5 MG TABLET 3 Hormones And Synthetic Substitutes ,= ENOFIBRATE 134 MG CAPSULES 1 QL Cardiovascular Drugs FENOFIBRATE 200 MG CAPSULES 1 QL Cardiovascular Drugs FENOFIBRATE 67 MG CAPSULES 1 QL Cardiovascular Drugs FENOFIBRATE 160 MG TABLET 1 QL Cardiovascular Drugs FENOFIBRATE 54 MG TABLET 1 QL Cardiovascular Drugs FENTANYL 100 MCG /HR PATCH 1 QL Central Nervous Systems Agents FENTANYL 12.5 MCG /HR PATCH 1 QL Central Nervous Systems Agents FENTANYL 25 MCG /HR PATCH 1 QL Central Nervous Systems Agents FLOMAX 0.4 MG CAPSULES 2 QL Miscellaneous Therapeutic Agents FLOVENT HFA 110 MCG /ACT AEROSOL 2 QL Hormones And Synthetic Substitutes FLOVENT HFA 220 MCG /ACT AEROSOL 2 QL Hormones And Synthetic Substitutes FLOVENT HFA 44 MCG /ACT AEROSOL 2 QL Hormones And Synthetic Substitutes FLUCONAZOLE 100 MG TABLET 1 Anti- Infective Agents FLUCONAZOLE 150 MG TABLET 1 QL Anti - Infective Agents FLUCONAZOLE 200 MG TABLET 1 Anti - Infective Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 18 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY 11 f 1 I I, 1 I(OH ,l .tlf Cii I, ft) li I FLUOXETINE HCL 10 MG CAPSULES 1 QL Central Nervous Systems Agents FLUOXETINE HCL 20 MG CAPSULES 1 QL Central Nervous Systems Agents FLUOXETINE HCL 10 MG TABLET 1 QL Central Nervous Systems Agents FLUOXETINE HCL 20 MG TABLET 1 QL Central Nervous Systems Agents FOCALIN XR 10 MG CAPSULES 3 QL Central Nervous Systems Agents FOCALIN XR 15 MG CAPSULES 3 QL Central Nervous Systems Agents FOCALIN XR 20 MG CAPSULES 3 QL Central Nervous Systems Agents FOCALIN XR 5 MG CAPSULES 3 QL Central Nervous Systems Agents FORADIL AEROLIZER 12 MCG CAPSULES 3 QL Autonomic Drugs FORTAMET 1000 MG TABLET 3 QL, ST Hormones And Synthetic Substitutes FORTAMET 500 MG TABLET 3 QL, ST Hormones And Synthetic Substitutes FORTAZ 2 GM SOLUTION H 3 Anti - Infective Agents FORTEO 750 MCG /3ML SOLUTION 3 Hormones And Synthetic Substitutes FOSINOPRIL SODIUM 10 MG TABLET 1 Cardiovascular Drugs FOSINOPRIL SODIUM 20 MG TABLET 1 Cardiovascular Drugs FOSINOPRIL SODIUM 40 MG TABLET 1 Cardiovascular Drugs FOSINOPRIL SODIUM /HYDROCH 10 MG;12.5 MG TABLET 1 Cardiovascular Drugs FOSINOPRIL SODIUM /HYDROCH 20 MG;12.5 MG TABLET 1 Cardiovascular Drugs FRAGMIN 10000 UNIT /ML INJECTION 3 QL Blood Formation, Coagulation, And Thrombosis FUROSEMIDE 20 MG TABLET 1 Electrolytic, Caloric, And Water Balance FUROSEMIDE 40 MG TABLET 1 Electrolytic, Caloric, And Water Balance FUROSEMIDE 80 MG TABLET 1 Electrolytic, Caloric, And Water Balance GABAPENTIN 100 MG CAPSULES 1 QL Central Nervous Systems Agents GABAPENTIN 300 MG CAPSULES 1 QL Central Nervous Systems Agents GABAPENTIN 400 MG CAPSULES 1 QL Central Nervous Systems Agents GABAPENTIN 100 MG TABLET 1 QL Central Nervous Systems Agents GABAPENTIN 400 MG TABLET 1 QL Central Nervous Systems Agents GABAPENTIN 600 MG TABLET 1 QL Central Nervous Systems Agents GABAPENTIN 800 MG TABLET 1 QL Central Nervous Systems Agents GABITRIL 12 MG TABLET 3 QL Central Nervous Systems Agents GABITRIL 16 MG TABLET 3 QL Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 19 TII I7A11On lit .1 id twif;E 6ABITRIL 2 MG TABLET 3 QL Central Nervous Systems Agents GABITRIL 4 MG TABLET 3 QL Central Nervous Systems Agents GEMFIBROZIL 600 MG TABLET 1 QL Cardiovascular Drugs GEODON 20 MG CAPSULES 2 QL Central Nervous Systems Agents GEODON 40 MG CAPSULES 2 QL Central Nervous Systems Agents GEODON 60 MG CAPSULES 2 QL Central Nervous Systems Agents GEODON 80 MG CAPSULES 2 QL Central Nervous Systems Agents GEODON 20 MG SOLUTION 3 Central Nervous Systems Agents GLEEVEC 100 MG TABLET 4 QL Antineoplastic Agents GLEEVEC 400 MG TABLET 4 QL Antineoplastic Agents GLIMEPIRIDE 1 MG TABLET 1 Hormones And Synthetic Substitutes GLIMEPIRIDE 2 MG TABLET 1 Hormones And Synthetic Substitutes GLIMEPIRIDE 4 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE 10 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE 5 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE ER 10 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE ER 2.5 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE ER 5 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE / METFORMIN HCL 2.5 MG;250 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE /METFORMIN HCL 2.5 MG;500 MG TABLET 1 Hormones And Synthetic Substitutes GLUCOTROL XL 10 MG TABLET 3 Hormones And Synthetic Substitutes GLUCOTROL XL 2.5 MG TABLET 3 Hormones And Synthetic Substitutes GLUCOTROL XL 5 MG TABLET 3 Hormones And Synthetic Substitutes GLYBURIDE 1.25 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE 2.5 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE 5 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE MICRONIZED 1.5 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE MICRONIZED 3 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE MICRONIZED 6 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE / METFORMIN HCL 1.25 MG;250 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE /METFORMIN HCL 2.5 MG;500 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE /METFORMIN HCL 5 MG;500 MG TABLET 1 Hormones And Synthetic Substitutes H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 20 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY fl! I /ATIflfJ a(!■(�t �:'11 i f iEIJI HEPSERA 10 MG TABLET 4 PA Anti - Infective Agents HERCEPTIN 440 MG SOLUTION 4 QL Antineoplastic Agents HUMALOG 100 UNIT /ML SOLUTION 2 QL Hormones And Synthetic Substitutes HUMALOG MIX 50/50 50 %;50 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMALOG MIX 50/50 PEN 50 %;50 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMALOG MIX 75/25 25 %;75 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMALOG MIX 75/25 PEN 25 %;75 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMALOG PEN 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes HUMIRA 40 MG /0.8ML KIT 4 QL, PA Miscellaneous Therapeutic Agents HUMIRA PEN 40 MG /0.8ML KIT 4 QL, PA Miscellaneous Therapeutic Agents HUMULIN 50/50 50 %;50 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMULIN 70/30 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMULIN 70/30 PEN 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMULIN N 100 UNIT /ML SUSPENSION 2 Hormones And Synthetic Substitutes HUMULIN R 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes HYDROXYZINE HCL 10 MG TABLET 1 Central Nervous Systems Agents HYDROXYZINE PAMOATE 100 MG CAPSULES 1 Central Nervous Systems Agents HYDROXYZINE PAMOATE 25 MG CAPSULES 1 Central Nervous Systems Agents HYDROXYZINE PAMOATE 50 MG CAPSULES 1 Central Nervous Systems Agents HYZAAR 12.5 MG;100 MG TABLET 3 QL Cardiovascular Drugs HYZAAR 12.5 MG;50 MG TABLET 3 QL Cardiovascular Drugs HYZAAR 25 MG;100 MG TABLET 3 QL Cardiovascular Drugs IBUPROFEN 100 MG /5ML SUSPENSION 1 Central Nervous Systems Agents IBUPROFEN 400 MG TABLET 1 Central Nervous Systems Agents IBUPROFEN 600 MG TABLET 1 Central Nervous Systems Agents IBUPROFEN 800 MG TABLET 1 Central Nervous Systems Agents IMDUR 120 MG TABLET 3 Cardiovascular Drugs IMDUR 30 MG TABLET 3 Cardiovascular Drugs IMDUR 60 MG TABLET 3 Cardiovascular Drugs IMIPRAMINE HCL 10 MG TABLET 1 Central Nervous Systems Agents IMIPRAMINE HCL 25 MG TABLET 1 Central Nervous Systems Agents IMIPRAMINE HCL 50 MG TABLET 1 Central Nervous Systems Agents IMIPRAMINE PAMOATE 100 MG CAPSULES 1 Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 21 IMIPRAMINE PAMOATE 125 MG CAPSULES 1 11111 17t\1 IOf R1 ()U1i'E LiLfl I Central Nervous Systems Agents IMIPRAMINE PAMOATE 150 MG CAPSULES 1 Central Nervous Systems Agents IMIPRAMINE PAMOATE 75 MG CAPSULES 1 Central Nervous Systems Agents INDAPAMIDE 1.25 MG TABLET 1 Electrolytic, Caloric, And Water Balance INDAPAMIDE 2.5 MG TABLET 1 Electrolytic, Caloric, And Water Balance INVANZ 1 GM SOLUTION H 3 Anti- Infective Agents INVEGA 3 MG TABLET 3 QL, ST Central Nervous Systems Agents INVEGA 6 MG TABLET 3 QL, ST Central Nervous Systems Agents 1NVEGA 9 MG TABLET 3 QL, ST Central Nervous Systems Agents ISONARIF 150 MG;300 MG CAPSULES 1 Anti- Infective Agents ISONIAZID 100 MG /ML SOLUTION 1 Anti- Infective Agents ISONIAZID 50 MG /5ML SYRUP 1 Anti - Infective Agents ISONIAZID 100 MG TABLET 1 Anti - Infective Agents ISONIAZID 300 MG TABLET 1 Anti - Infective Agents ISOSORBIDE DINITRATE 5 MG SUBLINGUAL 1 Cardiovascular Drugs ISOSORBIDE DINITRATE 10 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE DINITRATE 30 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE DINITRATE ER 40 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE MONONITRATE 10 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE MONONITRATE 20 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE MONONITRATE ER 120 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE MONONITRATE ER 30 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE MONONITRATE ER 60 MG TABLET 1 Cardiovascular Drugs JANUMET 1000 MG;50 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes JANUMET 500 MG;50 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes JANUVIA 100 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes JANUVIA 25 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes JANUVIA 50 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes KALETRA 133.3 MG;33.3 MG CAPSULES 4 Anti - Infective Agents KALETRA 400 MG /5ML;100 MG /5ML SOLUTION 4 Anti - Infective Agents KALETRA 200 MG;50 MG TABLET 4 Anti - Infective Agents KEPPRA 100 MG /ML SOLUTION 2 QL Central Nervous Systems Agents KEPPRA 500 MG /5ML SOLUTION 2 QL Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 22 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY 1111 I7,0 Hr1 1i■fi.,t P. 11 I; 1;E [Mir KEPPRA 1000 MG TABLET 2 QL Central Nervous Systems Agents KEPPRA 250 MG TABLET 2 QL Central Nervous Systems Agents KEPPRA 500 MG TABLET 2 QL Central Nervous Systems Agents KEPPRA 750 MG TABLET _ 2 QL Central Nervous Systems Agents KETOPROFEN 50 MG CAPSULES 1 Central Nervous Systems Agents KETOPROFEN ER 200 MG CAPSULES 1 Central Nervous Systems Agents KINERET 100 MG /0.67ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents LAMOTRIGINE CHEWABLE DISP 25 MG TABLET 1 Central Nervous Systems Agents LANTUS 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes LEFLUNOMIDE 10 MG TABLET 1 QL Miscellaneous Therapeutic Agents LEFLUNOMIDE 20 MG TABLET 1 QL Miscellaneous Therapeutic Agents LESCOL 20 MG CAPSULES 3 QL, ST Cardiovascular Drugs LESCOL 40 MG CAPSULES 3 QL, ST Cardiovascular Drugs LESCOL XL 80 MG TABLET 3 QL, ST Cardiovascular Drugs LETAIRIS 10 MG TABLET 4 QL, PA, LA Cardiovascular Drugs LETAIRIS 5 MG TABLET 4 QL, PA, LA Cardiovascular Drugs LEVAQUIN 25 MG /ML SOLUTION H 2 Anti- Infective Agents LEVAQUIN 25 MG /ML SOLUTION 2 Anti - Infective Agents LEVAQUIN 5 %;750 MG /150ML SOLUTION H 2 Anti - Infective Agents LEVEMIR 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes LEVOTHROID 100 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 125 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 137 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 150 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 175 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 200 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 25 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 300 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 50 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 75 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 88 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 100 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 112 MCG TABLET 1 Hormones And Synthetic Substitutes H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 23 11TII17ATIflrJ R[ »JIRL JF rJJ': LEVOTHYROXINE SODIUM 137 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 150 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 175 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 200 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 25 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 300 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 50 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 75 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 88 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 100 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 112 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 125 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 137 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 150 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 175 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 200 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 75 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 88 MCG TABLET 1 Hormones And Synthetic Substitutes _EXAPRO 5 MG /5ML SOLUTION 2 QL Central Nervous Systems Agents LEXAPRO 10 MG TABLET 2 QL Central Nervous Systems Agents LEXAPRO 20 MG TABLET 2 QL Central Nervous Systems Agents LEXAPRO 5 MG TABLET 2 QL Central Nervous Systems Agents LIDODERM 0.05 PATCH 3 QL, PA Skin And Mucous Membrane Agents LIPITOR 10 MG TABLET 2 QL Cardiovascular Drugs LIPITOR 20 MG TABLET 2 QL Cardiovascular Drugs LIPITOR 40 MG TABLET 2 QL Cardiovascular Drugs LIPITOR 80 MG TABLET 2 QL Cardiovascular Drugs LISINOPRIL 10 MG TABLET 1 Cardiovascular Drugs LISINOPRIL 2.5 MG TABLET 1 Cardiovascular Drugs LISINOPRIL 20 MG TABLET 1 Cardiovascular Drugs LISINOPRIL 30 MG TABLET 1 Cardiovascular Drugs LISINOPRIL 40 MG TABLET 1 Cardiovascular Drugs LISINOPRIL 5 MG TABLET 1 Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 24 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY 1I it 11 111 17ATI(VJ 1 � >t�( �r11 RL(,}111f;LP,1l LISINOPRIUHYDROCHLOROTHI 12.5 MG;10 MG TABLET 1 Cardiovascular Drugs LISINOPRIUHYDROCHLOROTHI 12.5 MG;20 MG TABLET 1 Cardiovascular Drugs LISINOPRIUHYDROCHLOROTHI 25 MG;20 MG TABLET 1 Cardiovascular Drugs LITHIUM CARBONATE 150 MG CAPSULES 1 Central Nervous Systems Agents LITHIUM CARBONATE ER 300 MG TABLET 1 Central Nervous Systems Agents LITHIUM CARBONATE ER 450 MG TABLET 1 Central Nervous Systems Agents LOVASTATIN 10 MG TABLET 1 QL Cardiovascular Drugs LOVASTATIN 20 MG TABLET 1 QL Cardiovascular Drugs LOVASTATIN 40 MG TABLET 1 QL Cardiovascular Drugs LOVAZA 375 MG;465 MG;1 GM CAPSULES 3 QL Cardiovascular Drugs LOVENOX 100 MG /ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 120 MG /0.8ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 150 MG /ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 30 MG /0.3ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 300 MG /3ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 40 MG /0.4ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 60 MG /0.6ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 80 MG /0.8ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LUMIGAN 0.0003 SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations LUNESTA 1 MG TABLET 3 QL, ST Central Nervous Systems Agents LUNESTA 2 MG TABLET 3 QL, ST Central Nervous Systems Agents LUNESTA 3 MG TABLET 3 QL, ST Central Nervous Systems Agents LYRICA 100 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 150 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 200 MG CAPSULES 3 QL, ST Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 25 LYRICA 225 MG CAPSULES 3 lillI /. I-I( )rI R[ OLiwL .it Li QL, ST Central Nervous Systems Agents LYRICA 25 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 300 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 50 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 75 MG CAPSULES 3 QL, ST Central Nervous Systems Agents MAXALT 10 MG TABLET 3 QL Central Nervous Systems Agents MAXALT 5 MG TABLET 3 QL Central Nervous Systems Agents MAXALT MLT 10 MG TABLET 3 QL Central Nervous Systems Agents MAXALT-MIT 5 MG TABLET 3 QL Central Nervous Systems Agents MELOXICAM 7.5 MG /5ML SUSPENSION 1 QL Central Nervous Systems Agents MELOXICAM 15 MG TABLET 1 QL Central Nervous Systems Agents MELOXICAM 7.5 MG TABLET 1 QL Central Nervous Systems Agents METFORMIN HCL 1000 MG TABLET 1 Hormones And Synthetic Substitutes METFORMIN HCL 500 MG TABLET 1 Hormones And Synthetic Substitutes METFORMIN HCL 850 MG TABLET 1 Hormones And Synthetic Substitutes METFORMIN HCL ER 500 MG TABLET 1 QL Hormones And Synthetic Substitutes METFORMIN HCL ER 750 MG TABLET 1 QL Hormones And Synthetic Substitutes METHYLDOPA/HYDROCHLOROTHI 15 MG;250 MG TABLET 1 Cardiovascular Drugs METHYLDOPA/HYDROCHLOROTHI 25 MG;250 MG TABLET 1 Cardiovascular Drugs METOPROLOUHYDROCHLOROTHI 25 MG;100 MG TABLET 1 Cardiovascular Drugs METOPROLOUHYDROCHLOROTHI 25 MG;50 MG TABLET 1 Cardiovascular Drugs METOPROLOUHYDROCHLOROTHI 50 MG;100 MG TABLET 1 Cardiovascular Drugs MIACALCIN 200 UNIT /ACT SOLUTION 3 QL Hormones And Synthetic Substitutes MIACALCIN 200 UNIT /ML SOLUTION 3 QL Hormones And Synthetic Substitutes MICARDIS 20 MG TABLET 3 QL Cardiovascular Drugs MICARDIS 40 MG TABLET 3 QL Cardiovascular Drugs MICARDIS 80 MG TABLET 3 QL Cardiovascular Drugs MICARDIS HCT 12.5 MG;40 MG TABLET 3 QL Cardiovascular Drugs MICARDIS HCT 12.5 MG;80 MG TABLET 3 QL Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 26 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY IIT1117i1-IClt1 MICARDIS HCT 25 MG;80 MG TABLET 3 QL Cardiovascular Drugs MIRAPEX 0.125 MG TABLET 3 ST Central Nervous Systems Agents MIRAPEX 0.25 MG TABLET 3 ST Central Nervous Systems Agents MIRAPEX 0.5 MG TABLET 3 ST Central Nervous Systems Agents MIRAPEX 1 MG TABLET 3 ST Central Nervous Systems Agents MIRAPEX 1.5 MG TABLET 3 ST Central Nervous Systems Agents MIRTAZAPINE 15 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 15 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 30 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 30 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 45 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 45 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 7.5 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE 15 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE 30 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE ER 15 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE ER 200 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE ER 30 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE ER 60 MG TABLET 1 Central Nervous Systems Agents NAMENDA 10 MG TABLET 2 QL Central Nervous Systems Agents NAMENDA 5 MG TABLET 2 QL Central Nervous Systems Agents NAPROXEN DR 500 MG TABLET 1 Central Nervous Systems Agents NAPROXEN SODIUM 275 MG TABLET 1 Central Nervous Systems Agents NAPROXEN SODIUM 500 MG TABLET 1 Central Nervous Systems Agents NAPROXEN SODIUM 550 MG TABLET 1 Central Nervous Systems Agents NASONEX 50 MCG /ACT SUSPENSION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations NEULASTA 6 MG /0.6ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis NEXAVAR 200 MG TABLET 4 QL, LA Antineoplastic Agents NEXIUM 20 MG CAPSULES 2 QL Gastrointestinal Drugs NEXIUM 40 MG CAPSULES 2 QL Gastrointestinal Drugs NEXIUM 40 MG PACK 2 QL Gastrointestinal Drugs NIASPAN 1000 MG TABLET 2 Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 27 11TH1 i7ATIOf RE ()UIRE1,11- NIASPAN 500 MG TABLET 2 Cardiovascular Drugs NIASPAN 750 MG TABLET 2 Cardiovascular Drugs NIFEDIAC CC 30 MG TABLET 1 QL Cardiovascular Drugs NIFEDIAC CC 60 MG TABLET 1 QL Cardiovascular Drugs NIFEDIAC CC 90 MG TABLET 1 QL Cardiovascular Drugs NIFEDICAL XL 30 MG TABLET 1 QL Cardiovascular Drugs NIFEDICAL XL 60 MG TABLET 1 QL Cardiovascular Drugs NIZATIDINE 150 MG CAPSULES 1 Gastrointestinal Drugs NIZATIDINE 300 MG CAPSULES 1 Gastrointestinal Drugs NOVOLIN 70/30 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLIN 70/30 INNOLET 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLIN 70/30 PENFILL 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLIN N 100 UNIT /ML SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLIN R 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes NOVOLIN R INNOLET 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes NOVOLIN R U -100 PENFILL 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes NOVOLOG 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes NOVOLOG MIX 70/30 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLOG MIX 70/30 PENFILL 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLOG MIX 70/30 PREFILL 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes ONDANSETRON HCL 24 MG TABLET 1 QL Gastrointestinal Drugs ONDANSETRON HCL 4 MG TABLET 1 QL Gastrointestinal Drugs ONDANSETRON HCL 8 MG TABLET 1 QL Gastrointestinal Drugs ONDANSETRON ODT 4 MG TABLET 1 QL Gastrointestinal Drugs ONDANSETRON ODT 8 MG TABLET 1 QL Gastrointestinal Drugs OXAPROZIN 600 MG TABLET 1 Central Nervous Systems Agents OXYBUTYNIN CHLORIDE 5 MG TABLET 1 Smooth Muscle Relaxants OXYBUTYNIN CHLORIDE ER 15 MG TABLET 1 Smooth Muscle Relaxants OXYCODONE/ACETAMINOPHEN 325 MG;5 MG TABLET 1 QL Central Nervous Systems Agents PACERONE 200 MG TABLET 1 Cardiovascular Drugs PACERONE 300 MG TABLET 1 Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 28 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY !!TI117,,>JI( 1 f'.1L f' hLt1U11fEfJLM PACERONE 400 MG TABLET 1 Cardiovascular Drugs PATANOL 0.001 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT) Preparations PEGASYS 180 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON 120 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON 150 MCG /0.5ML KIT 4 QL, PA Anti- Infective Agents PEG - INTRON 50 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON 80 MCG /0.5ML KIT 4 QL, PA Anti- Infective Agents PEG - INTRON REDIPEN 120 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN 150 MCG /0.5ML KIT 4 QL, PA Anti- Infective Agents PEG - INTRON REDIPEN 50 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN 80 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN PAK 4 120 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN PAK 4 150 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN PAK 4 50 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG- INTRON REDIPEN PAK 4 80 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PHOSLO 667 MG CAPSULES 2 Electrolytic, Caloric, And Water Balance PLAVIX 75 MG TABLET 2 QL Blood Formation, Coagulation, And Thrombosis PREMARIN 0.3 MG TABLET 2 Hormones And Synthetic Substitutes PREMARIN 0.45 MG TABLET 2 Hormones And Synthetic Substitutes PREMARIN 0.625 MG TABLET 2 Hormones And Synthetic Substitutes PREMARIN 0.9 MG TABLET 2 Hormones And Synthetic Substitutes PREMARIN 1.25 MG TABLET 2 Hormones And Synthetic Substitutes PREMPHASE 0.625 MG;5 MG TABLET 2 Hormones And Synthetic Substitutes PREMPRO 0.3 MG;1.5 MG TABLET 2 Hormones And Synthetic Substitutes PREMPRO 0.45 MG;1.5 MG TABLET 2 Hormones And Synthetic Substitutes PREMPRO 0.625 MG;2.5 MG TABLET 2 Hormones And Synthetic Substitutes PREMPRO 0.625 MG;5 MG TABLET 2 Hormones And Synthetic Substitutes PREVACID 15 MG CAPSULES 2 QL Gastrointestinal Drugs PREVACID 30 MG CAPSULES 2 QL Gastrointestinal Drugs PREVACID SOLUTAB 15 MG TABLET 2 QL Gastrointestinal Drugs PROCRIT 10000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 29 l i!11117AT1oll PROCRIT 20000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, Ana Thrombosis PROCRIT 40000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis PROTONIX 40 MG SOLUTION 3 PA Gastrointestinal Drugs PROTONIX 20 MG TABLET 3 QL, PA Gastrointestinal Drugs PROTONIX 40 MG TABLET 3 QL, PA Gastrointestinal Drugs PROZAC WEEKLY 90 MG CAPSULES 3 QL Central Nervous Systems Agents QVAR 40 MCG /ACT AEROSOL SOLUTION 2 QL Hormones And Synthetic Substitutes QVAR 80 MCG /ACT AEROSOL SOLUTION 2 QL Hormones And Synthetic Substitutes RANEXA 500 MG TABLET 3 QL, ST Cardiovascular Drugs RAPTIVA 125 MG KIT 4 QL, PA, LA Skin And Mucous Membrane Agents REBIF 44 MCG /0.5ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents REBIF TITRATION PACK 0 SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents REGRANEX 0.0001 GEL 4 Skin And Mucous Membrane Agents RENAGEL 400 MG TABLET 2 Electrolytic, Caloric, And Water Balance RENAGEL 800 MG TABLET 2 Electrolytic, Caloric, And Water Balance REVATIO 20 MG TABLET 4 QL, PA Cardiovascular Drugs ZEVLIMID 10 MG CAPSULES 4 QL, LA Miscellaneous Therapeutic Agents REVLIMID 15 MG CAPSULES 4 QL, LA Miscellaneous Therapeutic Agents REVLIMID 25 MG CAPSULES 4 QL, LA Miscellaneous Therapeutic Agents REVLIMID 5 MG CAPSULES 4 QL, LA Miscellaneous Therapeutic Agents RILUTEK 50 MG TABLET 4 Central Nervous Systems Agents RISPERDAL 1 MG /ML SOLUTION 3 Central Nervous Systems Agents RISPERDAL 0.25 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL 0.5 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL 1 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL 2 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL 3 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL 4 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL CONSTA 12.5 MG SUSPENSION 3 QL Central Nervous Systems Agents RISPERDAL CONSTA 25 MG SUSPENSION 3 QL Central Nervous Systems Agents RISPERDAL CONSTA 37.5 MG SUSPENSION 4 QL Central Nervous Systems Agents RISPERDAL CONSTA 50 MG SUSPENSION 4 QL Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 30 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY 11 I 111111,-,11(1f1 1,r, f1I NE I�UI{i J,1 1l1 RISPERDAL M -TAB 0.5 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL M -TAB 1 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL M -TAB 2 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL M -TAB 3 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL M -TAB 4 MG TABLET 3 QL Central Nervous Systems Agents RITUXAN 10 MG /ML CONCENTRATION 4 QL, PA Antineoplastic Agents ROZEREM 8 MG TABLET 3 QL, ST Central Nervous Systems Agents SEREVENT DISKUS 50 MCG /DOSE AEROSOL POWDER 2 QL Autonomic Drugs SEROQUEL 100 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL 200 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL 25 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL 300 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL 400 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL 50 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL XR 200 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL XR 300 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL XR 400 MG TABLET 2 QL Central Nervous Systems Agents SINGULAIR 4 MG CHEWABLE 3 QL, ST Respiratory Tract Agents SINGULAIR 5 MG CHEWABLE 3 QL, ST Respiratory Tract Agents SINGULAIR 4 MG PACK 3 QL, ST Respiratory Tract Agents SINGULAIR 10 MG TABLET 3 QL, ST Respiratory Tract Agents SPRYCEL 20 MG TABLET 4 QL Antineoplastic Agents SPRYCEL 50 MG TABLET 4 QL Antineoplastic Agents SPRYCEL 70 MG TABLET 4 QL Antineoplastic Agents STRATTERA 10 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 100 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 18 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 25 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 40 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 60 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 80 MG CAPSULES 3 QL Central Nervous Systems Agents SUTENT 12.5 MG CAPSULES 4 QL Antineoplastic Agents SUTENT 25 MG CAPSULES 4 QL Antineoplastic Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 31 1'Tif I7ATI( N 1,�.17�Al�iLlf!. kL UIRE ( �:1LL, 1 r SUTENT 50 MG CAPSULES 4 QL Antineoplastic Agents SYMBICORT 160 MCG /ACT;4.5 MCG /ACT AEROSOL 2 QL Hormones And Synthetic Substitutes SYMBICORT 80 MCG /ACT;4.5 MCG /ACT AEROSOL 2 QL Hormones And Synthetic Substitutes SYNTHROID 100 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 112 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 125 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 137 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 150 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 175 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 200 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 25 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 300 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 50 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 75 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 88 MCG TABLET 2 Hormones And Synthetic Substitutes TAMIFLU 75 MG CAPSULES 3 QL Anti - Infective Agents TAMIFLU 12 MG /ML SUSPENSION 3 QL Anti - Infective Agents TAMOXIFEN CITRATE 10 MG TABLET 1 Antineoplastic Agents TAMOXIFEN CITRATE 20 MG TABLET 1 Antineoplastic Agents TARCEVA 100 MG TABLET 4 QL Antineoplastic Agents TARCEVA 150 MG TABLET 4 QL Antineoplastic Agents TARCEVA 25 MG TABLET 4 QL Antineoplastic Agents TEKTURNA 150 MG TABLET 3 QL, PA Cardiovascular Drugs TEKTURNA 300 MG TABLET 3 QL, PA Cardiovascular Drugs THALOMID 100 MG CAPSULES 4 QL Miscellaneous Therapeutic Agents THALOMID 200 MG CAPSULES 4 QL Miscellaneous Therapeutic Agents THALOMID 50 MG CAPSULES 4 QL Miscellaneous Therapeutic Agents TOPAMAX 100 MG TABLET 3 QL Central Nervous Systems Agents TOPAMAX 200 MG TABLET 3 QL Central Nervous Systems Agents TOPAMAX 25 MG TABLET 3 QL Central Nervous Systems Agents TOPAMAX 50 MG TABLET 3 QL Central Nervous Systems Agents TOPAMAX SPRINKLE 15 MG SPRINKLE CAPSULES 3 Central Nervous Systems Agents TOPAMAX SPRINKLE 25 MG SPRINKLE CAPSULES 3 Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 32 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY TORSEMIDE 10 MG TABLET 1 1,t y,II LL,n r.1 Electrolytic, Caloric, And Water Balance TORSEMIDE 100 MG TABLET 1 Electrolytic, Caloric, And Water Balance TORSEMIDE 20 MG TABLET 1 Electrolytic, Caloric, And Water Balance TORSEMIDE 5 MG TABLET 1 Electrolytic, Caloric, And Water Balance TRACLEER 125 MG TABLET 4 QL, PA, LA Cardiovascular Drugs TRACLEER 62.5 MG TABLET 4 QL, PA, LA Cardiovascular Drugs TRAVATAN 0.004% SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations TRAVATAN Z 0.004% SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations TRICOR 145 MG TABLET 2 QL Cardiovascular Drugs TRICOR 48 MG TABLET 2 QL Cardiovascular Drugs TYKERB 250 MG TABLET 4 QL Antineoplastic Agents VESICARE 10 MG TABLET 2 QL Smooth Muscle Relaxants VESICARE 5 MG TABLET 2 QL Smooth Muscle Relaxants VYTORIN 10 MG;10 MG TABLET 2 QL Cardiovascular Drugs VYTORIN 10 MG;20 MG TABLET 2 QL Cardiovascular Drugs VYTORIN 10 MG;40 MG TABLET 2 QL Cardiovascular Drugs VYTORIN 10 MG;80 MG TABLET 2 QL Cardiovascular Drugs VYVANSE 30 MG CAPSULES 3 QL Central Nervous Systems Agents VYVANSE 50 MG CAPSULES 3 QL Central Nervous Systems Agents VYVANSE 70 MG CAPSULES 3 QL Central Nervous Systems Agents WARFARIN SODIUM 1 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 10 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 2 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 2.5 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 3 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 4 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 5 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 33 WARFARIN SODIUM 6 MG TABLET 1 11Th i /x,111)(; 1:Hiliri 'aril Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 7.5 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis XALATAN 0.005% SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations XOLAIR 150 MG SOLUTION 4 QL, PA, LA Respiratory Tract Agents XOPENEX HFA 45 MCG /ACT AEROSOL 3 QL, ST Autonomic Drugs YASMIN 28 3 MG;0.03 MG TABLET 3 Hormones And Synthetic Substitutes YAZ 3 MG;0.02 MG TABLET 3 Hormones And Synthetic Substitutes ZOLPIDEM TARTRATE 10 MG TABLET 1 QL Central Nervous Systems Agents ZOLPIDEM TARTRATE 5 MG TABLET 1 QL Central Nervous Systems Agents ZOMIG 5 MG SOLUTION 3 QL Central Nervous Systems Agents ZOMIG 2.5 MG TABLET 3 QL Central Nervous Systems Agents ZOMIG 5 MG TABLET 3 QL Central Nervous Systems Agents ZOMIG ZMT 2.5 MG TABLET 3 QL Central Nervous Systems Agents ZOMIG ZMT 5 MG TABLET 3 QL Central Nervous Systems Agents ZONISAMIDE 100 MG CAPSULES 1 Central Nervous Systems Agents ZONISAMIDE 25 MG CAPSULES 1 Central Nervous Systems Agents ZONISAMIDE 50 MG CAPSULES 1 Central Nervous Systems Agents ZYPREXA 10 MG SOLUTION 3 QL Central Nervous Systems Agents ZYPREXA 10 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA 15 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA 2.5 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA 20 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA 5 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA 7.5 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA ZYDIS 10 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA ZYDIS 15 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA ZYDIS 20 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA ZYDIS 5 MG TABLET 2 QL Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 34 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY Prescription Drug Guide Appendix ,dome infusion Coverage — The below plans offer additional coverage in the gap for drugs marked with a H in the drug grid that begins on page 8 of the Prescription Drug Guide. 1\1 It Ht Group Medicare HMO Plan 076 Option 152 All Group Medicare HMO Markets Group Medicare HMO Plan 076 Option 516 All Group Medicare HMO Markets Group Medicare HMO Plan 076 Option 517 All Group Medicare HMO Markets Group Medicare HMO Plan 076 Option 608 All Group Medicare HMO Markets Group Medicare HMO Plan 076 Option 997 All Group Medicare HMO Markets Group Medicare RPPO Plan 079 Option 526 All Group Medicare HMO Markets Group Medicare LPPO Plan 079 Option 034 All Group Medicare LPPO Markets Group Medicare LPPO Plan 079 Option 035 All Group Medicare LPPO Markets Group Medicare LPPO Plan 079 Option 049 All Group Medicare LPPO Markets Group Medicare PFFS Plan 078 Option 003 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 017 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 026 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 030 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 031 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 042 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 043 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 046 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 056 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 062 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 063 All Group Medicare PFFS Markets Group Medicare RPPO Plan 079 Option 503 All Group Medicare RPPO Markets Group Medicare RPPO Plan 079 Option 505 All Group Medicare RPPO Markets Group Medicare RPPO Plan 079 Option 507 All Group Medicare RPPO Markets Group Medicare RPPO Plan 079 Option 525 All Group Medicare RPPO Markets PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 35 HUMANA. Guidance when you need it most — Medicare — Group Health — Individual health — Dental, Life, Vision — Pharmacy Medicare approved HMO, PPO, PDP, and PFFS plans available to anyone enrolled in both Part A or Part B of Medicare through age or disability. Must use network pharmacies. Humana.com C0006_PDG09 FINAL _10 KC0808 M0006_PDG__09__FINAL_10 KC0808 GNA024MRRPDGPLS09_20081 0 Notice of Privac Practices for your persona health and financial infor The privacy of your personal and health information is important This notice describes how Humana may use and disclose medical information about you and how you can get access to this information. Please review this notice carefully. You don't have to take any action unless you have a request or complaint. Relationships are built on trust. One of the most important elements of trust is respect for an individual's privacy. We at Humana value our relationship with you, and we take your personal privacy seriously. This notice, effective April 1, 2003, explains Humana's privacy practices, our legal responsibilities, and your rights concerning your personal and health information. We reserve the right to change our privacy practices and the terms of this notice at any time, as allowed by law. This includes the right to make changes in our privacy practices and the revised terms of our notice effective for all personal and health information that we maintain. This includes information we created or received before we made the changes. When we make a significant change in our privacy practices, we will change this notice and send the notice to our health plan subscribers. What is personal and health information? Personal and health information (hereafter referred to as "information ") includes both medical information and individually identifiable information, such as your name, address, telephone number, or Social Security number. The term "information" in this notice includes any personal and health information that is created or received by a healthcare provider or health plan that relates to your physical or mental health or condition, the provision of healthcare to you, or the payment for such healthcare. How does Humana protect my information? in accordance with federal and state laws and our own policy, Humana has a responsibility to protect the privacy of your information. We have safeguards in place to protect your information in various ways that include: GN- 14474 -HH 11/06 • Limiting the access to who may see your information • Limiting how we use or disclose your information • Informing you of our legal duties regarding your information • Following our policies • Training of our associates • Requesting approval from you for any potential situations where your information would be used for reasons other than payment and health plan operations How does Humana use and disclose my information? We must use and disclose your information: • To you or someone who has the legal right to act on your behalf; • To the Secretary of the Department of Health and Human Services; and • Where required by law. We have the right to use and disclose your information: • To a doctor, a hospital, or other healthcare provider that asks for it in order for you to receive medical care; • To pay claims for covered services provided to you by doctors, hospitals, or other health care providers; • For healthcare operation activities including processing your enrollment, responding to your inquiries and requests for services, coordinating your care, resolving disputes, conducting medical management, improving quality, reviewing the competence of healthcare professionals, and determining premiums; • For performing underwriting activities; • To your plan sponsor to permit them to perform plan administration functions; Notice of Privac Practices , ,, - ,,.; • To contact you with information about health - related benefits and services, appointment reminders, or about treatment alternatives that may be of interest to you. Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. We may use or disclose your information: • To your family and friends if you are unavailable to communicate, such as in a medical or other emergency; • To provide payment information to the subscriber for Internal Revenue Service substantiation. • To public health agencies if we believe there is a serious health or safety threat; • To appropriate authorities regarding abuse, neglect, or domestic violence; • In response to a court or administrative order, subpoena, discovery request, or other lawful process; • For law enforcement purposes; • To military authorities; • For research purposes in limited circumstances; • For procurement, banking, or transplantation of organs, eyes, or tissue; and • To a coroner, medical examiner, or funeral director. Will Humana use my information for purposes not described in this notice? In all situations other than described in this notice, Humana will request your written permission before using or disclosing your information. You may revoke your permission at any time by notifying us in writing. We will not use or disclose your information for any reason not described in this notice without your permission. What does Humana do with my information when I am no longer a Humana member? Your information may continue to be used for purposes described in this notice when your membership is terminated. After the required legal retention period, information is destroyed following strict procedures to maintain the confidentiality of the information. What are my rights concerning my information? The following are your rights with respect to your information: • Access — You have the right to review and obtain a copy of your information that may be used to make decisions about you such as claims and case or medical management records. You also may receive a summary of this health information. If you request copies, we may charge you a fee for each page, and per hour for staff time to locate and copy your information, and postage. • Alternate Communications — You have the right to receive confidential communications of information in a different manner or at a different place to avoid a lifethreatening situation. We will accommodate your request if it is reasonable. • Amendment — You have the right to request an amendment of information we maintain about you if you believe that it is wrong or incomplete. We may deny your request if we did not create the information, we do not maintain the information, or the information is correct and complete. If we deny your request, we will provide you a written explanation of the denial. • Disclosure — You have the right to receive a listing of instances in which we or our business associates have disclosed your information for purposes other than treatment, payment, health plan operations, and certain other activities. Effective April 1, 2003, Humana began maintaining these types of disclosures and will maintain this information for a period of six (6) years. If you request this list more than once in a 12 -month period, we may charge you a reasonable, cost -based fee for responding to these additional requests. • Notice — All Humana members and prospective members have the right to receive a written copy of this notice upon request at any time. • Restriction — You have the right to ask to restrict uses or disclosures of your information. We are not required to agree to these restrictions, but if we do, we will abide by our agreement. You also have the right to agree to or terminate a previously submitted restriction. How do I exercise my rights or obtain a copy of this notice? All of your privacy rights can be exercised by obtaining the applicable privacy rights request forms. You may obtain any of the forms by: • Contacting us at 1- 866 - 861 -2762 at any time; • Accessing our Website at www.humana.com and going to the Privacy link, or • E- mailing us at privacyoffice@humana.com. Notice of Privac Practices The completed request form should be sent to: Humana Privacy Office P.O. Box 1438 Louisville, KY 40202 What should I do if I believe my privacy has been violated? If you believe your privacy has been violated in any way, you may file a complaint with Humana by calling us at 1- 866 - 861 -2762 at any time. You may also submit a written complaint to the U.S. Department of Health and Human Services, Office of Civil Rights (OCR). We will provide you with the appropriate OCR regional address upon request. You also have the option to e-mail your complaint to OCRComplaint ©hhs. gov. We support your right to protect the privacy of your personal and health information. We will not retaliate in any way if you elect to file a complaint with us or with the U.S. Department of Health and Human Services. Humana follows all federal and state laws, rules, and regulations addressing the protection of personal and health information. In situations when federal and state laws, rules, and regulations conflict, Humana follows the law, rule, or regulation which provides greater member protection. The following affiliates and subsidiaries also adhere to Humana's privacy policies and procedures: Humana Employers Health Plan of Georgia, Inc. Humana Health Insurance Company of Florida, Inc. Humana Health Plan of Ohio, Inc. Humana Health Plan of Texas, Inc. Humana Health Plan, Inc. Humana Health Plans of Puerto Rico, Inc. Humana Insurance Company Humana Insurance Company of Kentucky Emphesys Insurance Company Humana Insurance of Puerto Rico, Inc. Humana Medical Plan, Inc. Humana Wisconsin Health Organization Insurance Corporation HumanaDental Insurance Company The Dental Concern, Inc. The Dental Concern, Ltd. Humana Health Plan Interests, Inc. Humana Health Benefit Plan of Louisiana, Inc. Health One, Inc. Humana MarketPOINT, Inc. PRIVACY NOTICE CONCERNING FINANCIAL INFORMATION Humana and our affiliates understand that the privacy of your personal information is important to you. We take your privacy seriously and your trust in our ability to protect your private information is very important to us. This notice describes our policy regarding the confidentiality and disclosure of personal financial information. How does Humana collect information about me? We collect information about you and your family when you complete applications and forms. We also collect information from your dealings with us, our affiliates, or others. For example, we may receive information about you from participants in the healthcare system, such as your doctor or hospital, as well as from employers or plan administrators, credit bureaus, and the Medical Information Bureau. What information does Humana receive about me? The information we receive may include such items as your name, address, telephone number, date of birth, Social Security number, premium payment history, and your activity on our Website. This also includes information regarding your medical benefit plan, your health benefits, and health risk assessments. Where will Humana disclose my information? We may share your information with affiliated companies and non - affiliated third parties, as permitted by law. We may also provide your information to other financial institutions with which we have joint marketing agreements in order to provide you with offers for products and services you may find of value or which are health - related. What can I prevent with an opt -out disclosure? You can prevent the disclosures to non - affiliated third parties that provide products and services not offered by Humana or where the non - affiliated company provides services related to your plan by requesting to opt -out of such disclosures. Your opt -out request will apply to all members or individuals covered under your identification number or member account. Notice of Privac Practices Your opt -out request will continue to apply until you revoke your request or terminate your membership. How do I request an opt -out? At any time you may instruct Humana not to share any of your personal information with affiliated companies that provide offers of non- Humana products or services. If you wish to exercise your opt -out option, or to revoke a previous opt out request, you need to provide the following information to process your request: your name, date of birth, and member identification number. You can use any of the methods below to request or revoke your opt -out: • Call us at 1 -866- 861 -2762 • E -mail us at privacyoffice @humana.com • Send your opt -out request to us in writing: Humana Privacy Office P. 0. Box 1438 Louisville, KY 40202 HUMANA. Guidance when you need k most GN- 14474 -HH 11/06 RightSource Make the smart choice - RightSource, Humana's prescription home delivery service Humana members have more than just a pharmacy. RightSource is a smart choice for convenience, cost savings, service, and accuracy. Prescription service is the most often used - and the fastest growing — of all healthcare benefits. Humana members should make RightSource their first choice. Here's why: Convenient home delivery and time savings • Easy ordering — Members can get a three month supply, four times a year from the comfort of home • Home delivery — Direct -to- your -door service in all kinds of weather saves members time and effort • Freedom of Choice — Members can use their local pharmacy for immediate needs, such as pain medications, antibiotics, and other short-term prescriptions • Doctors can order direct — RightSource accepts orders direct from healthcare providers, via phone or fax " The savings are great, courtesy a plus, speed of delivery couldn't be faster." — RightSource Customer, Kansas Easy payment and cost savings • Discounts — With 90 -day pricing, generic alternatives, and free home delivery, RightSource might help reduce member prescription drug costs • Payment options — RightSource gives payment choices, including the HumanaAccess' Visa® Debit Card, other credit cards, personal checks, or money orders Integrated Service • Humana RightSource fits — As part of a diversified portfolio of health insurance products and related services, RightSource is focused on the individual needs of Humana members • Direct communications — Humana members can speak directly with a pharmacist or technician to answer member questions • Notification — RightSource lets you know the status of your order, via email or phone. They also notify you when your prescription is ready to be refilled Accuracy and safety • Two or more RightSource pharmacists review each new prescription for accuracy and possible GH24112 02/08 HUMAN!rare Guidance when you need it most . drug -to -drug interactions • RightSource uses foil sealed containers for added safety How to use RightSource: Humana members can mail a completed Registration & Prescription form and new prescriptions to RightSource at P.O. Box 29200, Phoenix, Arizona, 85038 -8976. For refills, members have three ways to order: • Online — by logging into MyHumana, each Humana member's password - protected, personal page on Humana.com • By Phone — call our toll -free automated system anytime at 1- 800 - 379 -0092 (TTY: 1- 877 - 833 - 4486), • By Mail — complete and mail the order form sent with their last RightSource order. Physicians can call in the member's prescription to 1- 800 - 379 -0092 or fax it to RightSource at 1- 800 - 379 -7617. Physician Fax forms are available online at www.rightsourcerx.com. Please note that patients cannot fax their own prescriptions to RightSource. Only physicians can fax prescriptions. Find out more online at www.rightsourcerx.com. Humana Plans are offered by the Humana Family of Insurance and Health Plan Companies. Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance) for more information on the company providing your benefits. Our health benefit plans have Limitations and Exclusions. HUMANA. Humana Plans are offered by the Humana Famicsitlaijamialiivitttfllayetnilteeiet.itleinealfer to your Benefit Plan Document (Certificate of Coverage/Insurance) for more information on the company providing your benefits. Our health benefit plans have Limitations and Exclusions. GH24112 02/08 GH22514 607 N d 0 C13 C4 E t C O ag d Ts __ rt 361 -853 -0396 CC Cc�c7 co 1 361- 853 -7303 361 - 387 -0005 I CO � as 1 361- 241 -2323 1 O oM n TT - C.i ao c�� a. 1 178404 X78410 78410 78410 78405 1 78405 I— r ITX TX TX TX r r [CORPUS I 1CORPUS 'CORPUS 'CORPUS [CORPUS 'CORPUS 'CORPUS ICORPUS 1 [CORPUS 2741 S STAPLES ST 613 ELIZABETH STREET 13801 S STAPLES ST 113725 NORTHWEST BLVD 13141 GOLLIHAR RD 110525 LEOPARD ST 114041 NORTHWEST BLVD X3435 S ALAMEDA ST �913S PORT AVE 12601 HOSPITAL BLVD 107 BEL AIRE DRUGS INC DELEONS PHARMACY 1 IHAMLIN PHARMACY MEDICAL PLAZA INICHOLS SOUTHSIDE NICHOLS WESTWOOD 1NORTHWEST PHARMACY PEDIATRIC PHARMACY PORT AVENUE DRUG ISUNRISE PHARMACY INC 4508226 4516374 4516487 4515372 4516552 4516564 4543648 4534574 4516691 4525929 I. xa- „00 0 0 0 0 0 0 0 0 »»»»» I•I I I I I z I I H • W d � E CO E W▪ C as OS c t _j 0 0 ▪ W ) J -882-2586 03 �N000�p Fr- 01.- 1 rig 1- 1h1Qrii 1- CD1- f` t 1- OCOr, C Nl�r�+� r1+01 03 CO1Q c,cp g . q.D D NN qp - n 10 CD11)AO1O , c CO $ r1\OO lcO� cpCDO 2P 10d' N CDCDOCOC?cp t� NCDcm OQ) C�O po tr1° d IMONO)O0))1 1i 1010101 pp ii C/1 CD1 M MM8MMMMC988C98l 8381,+ 8cgig3A8 8COr1MRC7CO7t+ 8 101- NMOd CDMIOON r 01- M1-NC'9d' IO1-1 -N 001- 1>D1- 1O< N. N N n r` 1- r• N. F t` F N- N r` r- N N. P- N. 1` N f` n. N- 1■ n r` F r` t` r F- 1- HHHF- F- HI-- HHFX- HHIx- HHII-- HHFX- HHF- I--I-I- - II- -HH~F > » > co CORP CORP CORP CORP CORP CORP CORP CORP CORP CORP CORP Q CORF a CORF CORF CORF ICORF CORF CORF ICORF ICORF Qm o ICORF ICORF Q� CO RI ICORI ICORI 1110 AYERS ST 4102 AYERS ST 4166 S STAPLES ST 4801 S ALAMEDA ST 6601 EVERHART RD STE E 4101 C US HWY 77 2102 AIRLINE RD 14525 S PADRE ISLAND DR 5801 WEBER RD 4444 KOSTORYZ RD 11158 LEOPARD ST 4320 S ALAMEDA 3500 LEOPARD ST 5425 S PADRE ISLAND DR 3133 SOUTH ALAMEDA 3033 S PORT ST 1145 WALDRON 5313 SARATOGA 5425 SOUTH PADRE ISLAND DR STE 7163 S PADRE ISLAND DR 5702 WEBER ROAD 5601 SARATOGA BLVD 12101 MORGAN AVENUE 13750 S STAPLES 14501 AYERS ST 1301 AIRLINE RD 1800 S STAPLES STE 308B 11133 LEOPARD ST 3829 US HWY 77 1821 SOUTH PADRE ISLAND DR 110241 SOUTH PADRE ISLAND DRIVE 4833 SOUTH PADRE ISLAND DRIVE 13845 SOUTH PADRE ISLAND DRIVE I IS /S /S /S cn 1n =B =B : B m EB E B 03 EB EB 4RGET 'ALGREEN 'ALGREEN 'ALGREEN 'ALGREEN 'ALGREEN 'ALGREEN ►ALGREEN !ALGREEN ►ALGREENS IAL -MART IAL -MART IAL -MART 'AL-MART ECEPT 2 U 00 1 _ r- 6588 6639 6641 6627 6590 2650 3955 0177 8585 2987 0922 7167 7865 19057 7877 6235 CO O0)�NO1nONQ1r01�O�QDdO►N CMM'V CO nC'�)M 1-1-00010 a) a) N. �11� ?0462 11i r 10 N t^O L{7 t0O 11-O M et '�et47stI- d Nt I'd'd'd'd' hC YF ^# HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 HUM01 - . 0 0 0 0 0 0 0 0 0 0 O O O O 0 0 0 > > = > 1111 > M M ___ > > __ M = > = > = M = > > M 2.2= M I N d w •a V EW 1. E L as cu _ of J V O v y J J H d E i Z ( C at • am, • c as C O c irs o Z0 c C co E 2 O a J cc a 0 a S a a. w U w cc w cc z 0 w Z 2009 Prescription Drug Guide Humana Group Medicare Abbreviated Formulary List of Covered Drugs C0006_PDG_09_FINAL_10 KC0808 M0006_PDG_09_FINAL_1 0 KC0808 anCe when you need it most GNA024MRRPDGPLS09_20 Welcome to Humana Group Medicare! PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. What is the Humana Group Medicare Formulary? A formulary is a list of covered drugs selected by Humana Group Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Humana Group Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Humana Group Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. The enclosed drug list is a partial formulary and includes only some of the drugs covered by Humana. For a complete listing of all prescription drugs covered by Humana, please visit our Website at Humana.com. You can also call Customer Service at the number listed on the back of your member ID card for a better customer experience. Customer Service representatives are available Monday through Friday 8 a.m. to 11 p.m. and Saturday 8 a.m. to 6 p.m. Eastern Time. Can the Formulary change? Generally, if you are taking a drug on our 2009 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2009 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost- sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and /or step therapy restrictions on a drug or move a drug to a higher cost - sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60 -day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 2009. You can also call Customer Service at the number listed on the back of your member ID card for a better customer experience. Customer Service representatives are available Monday through Friday 8 a.m. to 11 p.m. and Saturday 8 a.m. to 6 p.m. Eastern Time. PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 1 How do I use the Humana Group Medicare Formulary? Alphabetical Listing The formulary begins on page 8. The drugs in this formulary are listed in alphabetical order. The formulary also lists the Tier, Utilization Management Requirement, Therapeutic Category , and Limited Access. Drugs are grouped into one of four tiers -1, 2, 3, or 4. • Tier 1 - Preferred Generic • Tier 2 - Preferred Brand • Tier 3 - Non - preferred Brand • Tier 4 - Specialty Here's how to read the Utilization Management Requirement codes: PA Prior Authorization QL - Quantity Limits ST - Step Therapy LA - Limited Access See page 2 for more details on Utilization Management Requirements. What are generic drugs? Humana Group Medicare covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient(s) as the brand name drug. Generally, generic drugs cost less than brand name drugs. How much will 1 pay for Humana Group Medicare Covered Drugs? If you qualified for extra help with your drug costs, your costs may be different than those described below. Please refer to your Evidence of Coverage or call Customer Service to find out what your costs are. Humana Group Medicare pays part of the costs for your covered drugs and you pay part of the costs as well. The amount you pay depends on which drug category your drug falls under in the formulary and whether you fill your prescription at a network pharmacy. Drug categories • Preferred Generic - drugs that have the same active ingredients as brand drugs and are prescribed for the same reasons. The Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength, purity, and stability as brand drugs. Your cost for generic drugs is usually lower than your cost for brand drugs. • Preferred Brand - Brand prescription drugs that Humana Group Medicare offers at a lower cost to you than non - preferred drugs. • Non - preferred Brand - More expensive brand prescription drugs that Humana Group Medicare offers at a higher cost to you than preferred drugs. • Specialty - Some injectables and other high -cost drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: 2 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY • Prior Authorization: Humana Group Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Humana Group Medicare before you fill your prescriptions. If you don't get approval, Humana Group Medicare may not cover the drug. • Quantity Limits: For certain drugs, Humana Group Medicare limits the amount of the drug that Humana Group Medicare will cover. For example, Humana Group Medicare provides 30 tablets per 30 days for Simvastatin. This may be in addition to a standard one month or three month supply. Specialty drugs are limited to a 30 -day supply regardless of tier placement. • Step Therapy: In some cases, Humana Group Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Humana Group Medicare may not cover drug B unless you try Drug A first. If Drug A does not work for you, Humana Group Medicare will then cover Drug B. • Limited Access: In some cases, Humana Group Medicare may limit access for certain drugs. Humana Group Medicare may provide coverage only at certain pharmacies. For more information, you can contact Customer Service. For drugs that require prior authorization, step therapy, or fall outside of the noted quantity limits, the doctor must call Humana Group Medicare at 1 -866- 396 -8810. (Representatives are available Monday through Friday, 8 a.m. to 11 p.m., and Saturday 8 a.m. to 6 p.m., Eastern Time) You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can ask Humana Group Medicare to make an exception to these restrictions or limits. See the section, "How do I request an exception to the Humana Group Medicare formulary?" for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this list of covered drugs, you should first contact Customer Service and ask if your drug is covered. If you learn that Humana Group Medicare does not cover your drug, you have two options: • You can ask Customer Service for a list of similar drugs that are covered by Humana Group Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Humana Group Medicare. • You can ask Humana Group Medicare to make an exception and cover your drug. See below for information about how to request an exception. Note: Due to a change in Medicare as of January 1, 2007, most Medicare Part D Plans will no longer cover erectile dysfunction drugs like Viagra, Cialis, Levitra, and Caverject. Call Customer Service for more information. How do 1 request an exception to the Humana Group Medicare Formulary? You can ask Humana Group Medicare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. • You can ask us to cover your drug even if it is not on our formulary. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Humana Group Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more. • You can ask us to provide a higher level of coverage for your drug. If your drug is usually considered a non - preferred drug, you can ask us to cover it as a preferred instead. This would lower the amount you must pay PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 3 for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, Humana Group Medicare will only approve your request for an exception if the alternative drugs are not included on the plan's formulary, the lower- tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician's supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30 -day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30 -day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long -term care facility, we will cover a temporary 34 -day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34 -day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Throughout the plan year, you may have a change in your treatment setting due to the level of care you require. Such transitions include: • Members who are discharged from a hospital or skilled nursing facility to a home setting. • Members who are admitted to a hospital or skilled nursing facility from a home setting. • Members who transfer from one skilled nursing facility to another and are serviced by a different pharmacy. • Members who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to now use their Part D plan benefit. • Members who give up Hospice Status and revert back to standard Medicare Part A and B coverage. • Members discharged from chronic psychiatric hospitals with highly individualized drug regimens. • Members currently requesting an appeal of an initial Coverage Determination and /or Exception. For these changes in treatment settings, Humana Group Medicare will cover up to a 34 day temporary supply of a Part D covered drug when your prescription is filled at a network pharmacy. If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization and receive approval for continued 4 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY coverage of your drug. Humana Group Medicare will review these requests for continuation of therapy on a case -by -case basis when you are stabilized on drug regimen, which if altered, is known to have risks. PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 5 For More Information For more detailed information about your Humana Group Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Humana, please visit our Website at Humana.com. You can also call Customer Service at the number listed on the back of your member ID card for a better customer experience. Customer Service representatives are available Monday through Friday 8 a.m. to 11 p.m. and Saturday 8 a.m. to 6 p.m. Eastern Time. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1- 800 - MEDICARE (1- 800 - 633 -4227) 24 hours a day/7 days a week. TTY users should call 1- 877 - 486 -2048. Or, visit www.medicare.gov. 6 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY Humana Group Medicare Formulary The formulary that begins on the next page provides coverage information about some of the drugs covered by Humana Group Medicare. Remember: This is only a partial list of drugs covered by Humana. If your prescription is not listed in this partial formulary, please visit our Web site at Humana.com. You can also call Customer Service at the number listed on the back of your member ID card for a better customer experience. Customer Service representatives are available Monday through Friday 8 a.m. to 11 p.m. and Saturday 8 a.m. to 6 p.m. Eastern Time. The first column of the chart lists the drug name in alphabetical order. The second column lists the tier of the drug. The information in the Utilization Management Requirements column tells you whether Humana Group Medicare has special requirements for covering that drug. If the column is blank, then the supply is based on benefits and whether your doctor prescribes a 30 -, 60- or 90 -day supply. The last column lists the Therapeutic Category of the drug. PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 7 iiljl %1? il, f l)UfKE_1'.11 rn ABILIFY 1 MG /ML SOLUTION 3 Central Nervous Systems Agents ABILIFY 9.75 MG /1.3ML SOLUTION 3 Central Nervous Systems Agents ABILIFY 10 MG TABLET 3 " QL Central Nervous Systems Agents ABILIFY 15 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY 2 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY 20 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY 30 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY 5 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY DISCMELT 10 MG TABLET 3 QL Central Nervous Systems Agents ABILIFY DISCMELT 15 MG TABLET 3 QL Central Nervous Systems Agents ACCOLATE 10 MG TABLET 2 QL Respiratory Tract Agents ACCOLATE 20 MG TABLET 2 QL Respiratory Tract Agents ACCUNEB 0.63 MG /3ML NEBULIZER 3 Autonomic Drugs ACCUNEB 1.25 MG /3ML NEBULIZER 3 Autonomic Drugs ACCURETIC 12.5 MG;10 MG TABLET 3 Cardiovascular Drugs ACCURETIC 12.5 MG;20 MG TABLET 3 Cardiovascular Drugs ACCURETIC 25 MG;20 MG TABLET 3 Cardiovascular Drugs \CCUTANE 10 MG CAPSULES 4 Skin And Mucous Membrane Agents ACCUTANE 20 MG CAPSULES 4 Skin And Mucous Membrane Agents ACCUTANE 40 MG CAPSULES 4 Skin And Mucous Membrane Agents ACEON 2 MG TABLET 3 Cardiovascular Drugs ACEON 4 MG TABLET 3 Cardiovascular Drugs ACEON 8 MG TABLET 3 Cardiovascular Drugs ACETAMINOPHEN /CODEINE #2 300 MG;15 MG TABLET 1 QL Central Nervous Systems Agents ACETAMINOPHEN /CODEINE #3 300 MG;30 MG TABLET 1 QL Central Nervous Systems Agents ACETAMINOPHEN /CODEINE #4 300 MG;60 MG TABLET 1 QL Central Nervous Systems Agents ACIPHEX 20 MG TABLET 3 QL, ST Gastrointestinal Drugs ACLOVATE 0.0005 CREAM 3 Skin And Mucous Membrane Agents ACLOVATE 0.0005 OINTMENT 3 Skin And Mucous Membrane Agents ACTIGALL 300 MG CAPSULES 3 Gastrointestinal Drugs ACTOPLUS MET 500 MG;15 MG TABLET 2 QL Hormones And Synthetic Substitutes H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 8 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY ,I I1 r ACTOPLUS MET 850 MG;15 MG TABLET I:. 2 1 1 II lI,,TIM(1 i , 1 d1f i 11 ;; I; E(,) Ilk i_1.1[1,i QL Hormones And Synthetic Substitutes ACTOS 15 MG TABLET 2 QL Hormones And Synthetic Substitutes ACTOS 30 MG TABLET 2 QL Hormones And Synthetic Substitutes ACTOS 45 MG TABLET 2 QL Hormones And Synthetic Substitutes ACULAR 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT) Preparations ACULAR LS 0.004 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT) Preparations ACULAR PF 0.005 SOLUTION 3 Eye, Ear, Nose, And Throat (EENT) Preparations ACYCLOVIR 200 MG CAPSULES 1 Anti - Infective Agents ACYCLOVIR 200 MG /5ML SUSPENSION 1 Anti - Infective Agents ACYCLOVIR 400 MG TABLET 1 Anti- Infective Agents ACYCLOVIR 800 MG TABLET 1 Anti - Infective Agents ADALAT CC 30 MG TABLET 3 QL Cardiovascular Drugs ADALAT CC 60 MG TABLET 3 QL Cardiovascular Drugs ADALAT CC 90 MG TABLET 3 QL Cardiovascular Drugs ADDERALL XR 1.25 MG;1.25 MG;1.25 MG;1.25 MG CAPSULES 3 QL Central Nervous Systems Agents ADDERALL XR 2.5 MG;2.5 MG;2.5 MG;2.5 MG CAPSULES 3 QL Central Nervous Systems Agents ADDERALL XR 3.75 MG;3.75 MG;3.75 MG;3.75 MG CAPSULES 3 QL Central Nervous Systems Agents ADDERALL XR 5 MG;5 MG;5 MG;5 MG CAPSULES 3 QL Central Nervous Systems Agents ADDERALL XR 6.25 MG;6.25 MG;6.25 MG;6.25 MG CAPSULES 3 QL Central Nervous Systems Agents ADDERALL XR 7.5 MG;7.5 MG;7.5 MG;7.5 MG CAPSULES 3 QL Central Nervous Systems Agents ADVAIR DISKUS 100 MCG /DOSE;50 MCG /DOSE MISC 2 QL Autonomic Drugs ADVAIR DISKUS 250 MCG /DOSE;50 MCG /DOSE MISC 2 QL Autonomic Drugs ADVAIR DISKUS 500 MCG /DOSE;50 MCG /DOSE MISC 2 QL Autonomic Drugs ADVAIR HFA 115 MCG /ACT;21 MCG /ACT AEROSOL 2 QL Autonomic Drugs ADVAIR HFA 230 MCG /ACT;21 MCG /ACT AEROSOL 2 QL Autonomic Drugs ADVAIR HFA 45 MCG /ACT;21 MCG /ACT AEROSOL 2 QL Autonomic Drugs ADVICOR 20 MG;1000 MG TABLET 2 QL Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 9 11111 IIru l(t! Ouwt [J, ADVICOR 20 MG;500 MG TABLET 2 QL Cardiovascular Drugs ADVICOR 20 MG;750 MG TABLET 2 QL Cardiovascular Drugs ADVICOR 40 MG;1000 MG TABLET 2 QL Cardiovascular Drugs AEROBID 250 MCG /ACT AEROSOL SOLUTION 3 QL, ST Hormones And Synthetic Substitutes AEROBID -M 250 MCG /ACT AEROSOL SOLUTION 3 QL, ST Hormones And Synthetic Substitutes AGGRENOX 25 MG;200 MG CAPSULES 2 Cardiovascular Drugs ALLEGRA 180 MG TABLET 3 QL, PA Antihistamine Drugs ALLEGRA -D 12 HOUR 60 MG;120 MG TABLET 3 QL, ST Antihistamine Drugs ALLEGRA -D 24 HOUR 180 MG;240 MG TABLET 3 QL, ST Antihistamine Drugs ALOCRIL 0.02 SOLUTION 3 Respiratory Tract Agents ALPHAGAN P 0.001 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT) Preparations ALPHAGAN P 0.0015 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT) Preparations AMBIEN CR 12.5 MG TABLET 3 QL, ST Central Nervous Systems Agents AMBIEN CR 6.25 MG TABLET 3 QL, ST Central Nervous Systems Agents AMIODARONE HCL 200 MG TABLET 1 Cardiovascular Drugs AMITRIPTYLINE HCL 10 MG TABLET 1 Central Nervous Systems Agents \MITRIPTYLINE HCL 100 MG TABLET 1 Central Nervous Systems Agents AMITRIPTYLINE HCL 150 MG TABLET 1 Central Nervous Systems Agents AMITRIPTYLINE HCL 25 MG TABLET 1 Central Nervous Systems Agents AMITRIPTYLINE HCL 50 MG TABLET 1 Central Nervous Systems Agents AMITRIPTYLINE HCL 75 MG TABLET 1 Central Nervous Systems Agents AMLODIPINE BESYLATE 10 MG TABLET 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE 2.5 MG TABLET 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE 5 MG TABLET 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE /BENAZ 10 MG;20 MG CAPSULES 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE /BENAZ 2.5 MG;10 MG CAPSULES 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE /BENAZ 5 MG;10 MG CAPSULES 1 QL Cardiovascular Drugs AMLODIPINE BESYLATE /BENAZ 5 MG;20 MG CAPSULES 1 QL Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 10 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY �_I ?1 1/),TIC)' ,H1111' id OUWE_FL1LH AMOXICILLIN/CLAVULANATE P 200 MG;28.5 MG CHEWABLE '1 Anti - Infective Agents AMOXICILLIN / CIAVULANATE P 400 MG;57 MG CHEWABLE 1 Anti - Infective Agents AMOXICILLIN / CLAVULANATE P 200 MG/5ML;28.5 MG /5ML SUSPENSION 1 Anti - Infective Agents AMOXICILLIN / CLAVULANATE P 200 MG /5ML;28.5 MG /5ML SUSPENSION 1 Anti - Infective Agents AMOXICILLIN /CLAVULANATE P 400 MG /5ML;57 MG /5ML SUSPENSION 1 Anti - Infective Agents AMOXICILLIN / CLAVULANATE P 600 MG /5ML;42.9 MG /5ML SUSPENSION 1 Anti - Infective Agents AMOXICILLIN / CLAVULANATE P 250 MG;125 MG TABLET 1 Anti - Infective Agents AMOXICILLIN /CLAVULANATE P 500 MG;125 MG TABLET 1 Anti- Infective Agents AMOXICILLIN/CLAVULANATE P 875 MG;125 MG TABLET , 1 Anti - Infective Agents AMPHETAMINE SALT COMBO 2.5 MG;2.5 MG;2.5 MG;2.5 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALT COMBO 5 MG;5 MG;5 MG;5 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALT COMBO 7.5 MG;7.5 MG;7.5 MG;7.5 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 1.25 MG;1.25 MG;1.25 MG;1.25 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 1.875 MG;1.875 MG;1.875 MG;1.875 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 2.5 MG;2.5 MG;2.5 MG;2.5 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 3.125 MG;3.125 MG;3.125 MG;3.125 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 3.75 MG;3.75 MG;3.75 MG;3.75 MG TABLET 1 Central Nervous Systems Agents AMPHETAMINE SALTS COMBO 5 MG;5 MG;5 MG;5 MG TABLET 1 Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare 'tans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 11 11111/, ■Tl(li 1 :I OHM E L11 1,11 AMPHETAMINE SALTS COMBO 7.5 MG;7.5 MG;7.5 MG;7.5 MG TABLET 1 Central Nervous Systems Agents ANAGRELIDE HYDROCHLORIDE 1 MG CAPSULES 1 Miscellaneous Therapeutic Agents ARAN ESP ALBUMIN FREE 100 MCG /0.5ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 100 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARAN ESP ALBUMIN FREE 150 MCG /0.3ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 150 MCG /0.75ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 200 MCG /0.4ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 200 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 25 MCG /0.42ML SOLUTION 3 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 25 MCG /ML SOLUTION 3 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 300 MCG /0.6ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 300 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 40 MCG /0.4ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 40 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 500 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 60 MCG /0.3ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARANESP ALBUMIN FREE 60 MCG /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ARICEPT 10 MG TABLET 2 QL Autonomic Drugs ARICEPT 5 MG TABLET 2 QL Autonomic Drugs ARICEPT ODT 10 MG TABLET 2 QL Autonomic Drugs ARICEPT ODT 5 MG TABLET 2 QL Autonomic Drugs ARIMIDEX 1 MG TABLET 2 QL Antineoplastic Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare flans that may have this coverage. PA — Prior Authorization; QL Quantity Limit; ST — Step Therapy; LA — Limited Access 12 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY l!T11 /Aili_lkJ i.,k! RfOI IRf_k.IAJ ARIXTRA 10 MG /0.8ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis ARIXTRA 2.5 MG /0.5ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis ARIXTRA 5 MG /0.4ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis ARIXTRA 7.5 MG /0.6ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis ASACOL 400 MG TABLET 2 QL Gastrointestinal Drugs ASMANEX 120 METERED DOSES 220 MCG /INH AEROSOL POWDER 2 QL Hormones And Synthetic Substitutes ASMANEX 14 METERED DOSES 220 MCG /INH AEROSOL POWDER 2 QL Hormones And Synthetic Substitutes ASMANEX 30 METERED DOSES 220 MCG/INH AEROSOL POWDER 2 QL Hormones And Synthetic Substitutes ASMANEX 60 METERED DOSES 220 MCG /INH AEROSOL POWDER 2 QL Hormones And Synthetic Substitutes ASTELIN 137 MCG /SPRAY SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations ATACAND 16 MG TABLET 3 QL Cardiovascular Drugs ATACAND 32 MG TABLET 3 QL Cardiovascular Drugs ATACAND 4 MG TABLET 3 QL Cardiovascular Drugs ATACAND 8 MG TABLET 3 QL Cardiovascular Drugs ATACAND HCT 16 MG;12.5 MG TABLET 3 QL Cardiovascular Drugs ATACAND HCT 32 MG;12.5 MG TABLET 3 QL Cardiovascular Drugs ATENOLOL 100 MG TABLET 1 Cardiovascular Drugs ATENOLOL 25 MG TABLET 1 Cardiovascular Drugs ATENOLOL 50 MG TABLET 1 Cardiovascular Drugs ATRIPLA 600 MG;200 MG;300 MG TABLET 4 Anti - Infective Agents ATROVENT HFA 17 MCG /ACT AEROSOL SOLUTION 2 QL Autonomic Drugs AVALIDE 12.5 MG;150 MG TABLET 2 QL Cardiovascular Drugs AVALIDE 12.5 MG;300 MG TABLET 2 QL Cardiovascular Drugs AVALIDE 25 MG;300 MG TABLET 2 QL Cardiovascular Drugs AVANDAMET 1000 MG;2 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDAMET 1000 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDAMET 500 MG;2 MG TABLET 2 QL Hormones And Synthetic Substitutes H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 13 THIli \TI(lH E'.1 E (1 f AVANDAMET 500 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDARYL 1 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDARYL 2 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDARYL 4 MG;4 MG TABLET 2 QL Hormones And Synthetic Substitutes AVANDIA 2 MG TABLET 2 QL Hormones And Synthetic Substitutes AVAPRO 300 MG TABLET 2 QL Cardiovascular Drugs AVAPRO 75 MG TABLET 2 QL Cardiovascular Drugs AVASTIN 100 MG /4ML SOLUTION 4 QL, LA Antineoplastic Agents AVASTIN 400 MG /16ML SOLUTION 4 QL, LA Antineoplastic Agents AVELOX 400 MG TABLET 3 Anti- Infective Agents AVELOX ABC PACK 400 MG TABLET 3 - Anti - Infective Agents AVODART 0.5 MG CAPSULES 2 QL Miscellaneous Therapeutic Agents AVONEX 30 MCG /0.5ML KIT 4 QL, PA Miscellaneous Therapeutic Agents AVONEX 30 MCGNIAL KIT 4 QL, PA Miscellaneous Therapeutic Agents AZILECT 0.5 MG TABLET 2 QL Central Nervous Systems Agents AZILECT 1 MG TABLET 2 QL Central Nervous Systems Agents AZOPT 0.01 SUSPENSION 2 Eye, Ear, Nose, And Throat (EENT) Preparations BACLOFEN 10 MG TABLET 1 Autonomic Drugs BACLOFEN 20 MG TABLET 1 Autonomic Drugs BENICAR 20 MG TABLET 2 QL Cardiovascular Drugs BENICAR 40 MG TABLET 2 QL Cardiovascular Drugs BENICAR 5 MG TABLET 2 QL Cardiovascular Drugs BENICAR HCT 12.5 MG;20 MG TABLET 2 QL Cardiovascular Drugs BENICAR HCT 12.5 MG;40 MG TABLET 2 QL Cardiovascular Drugs BENICAR HCT 25 MG;40 MG TABLET 2 QL Cardiovascular Drugs BISOPROLOL FUMARATE 10 MG TABLET 1 Cardiovascular Drugs BISOPROLOL FUMARATE 5 MG TABLET 1 Cardiovascular Drugs BISOPROLOL FUMARATE/HYDRO 10 MG;6.25 MG TABLET 1 Cardiovascular Drugs BISOPROLOL FUMARATE /HYDRO 2.5 MG;6.25 MG TABLET 1 Cardiovascular Drugs BISOPROLOL FUMARATE /HYDRO 5 MG;6.25 MG TABLET 1 Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 14 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY !WI I/ 11OLI 1r RfQUILILA[J1 BUDEPRION SR 100 MG TABLET 1 QL Central Nervous Systems Agents BUDEPRION SR 150 MG TABLET 1 QL Central Nervous Systems Agents BUDEPRION XL 300 MG TABLET 1 QL Central Nervous Systems Agents BUPROBAN 150 MG TABLET 1 QL Central Nervous Systems Agents BUPROPION HCL 100 MG TABLET 1 QL Central Nervous Systems Agents BUPROPION HCL 75 MG TABLET 1 Central Nervous Systems Agents BUPROPION HCL SR 200 MG TABLET 1 QL Central Nervous Systems Agents BUSPIRONE HCL 10 MG TABLET 1 Central Nervous Systems Agents BUSPIRONE HCL 15 MG TABLET 1 Central Nervous Systems Agents BUSPIRONE HCL 30 MG TABLET 1 Central Nervous Systems Agents BUSPIRONE HCL 5 MG TABLET 1 Central Nervous Systems Agents BUSPIRONE HCL 7.5 MG TABLET 1 Central Nervous Systems Agents BYETTA 250 MCG /ML SOLUTION 3 QL, PA Hormones And Synthetic Substitutes BYETTA 250 MCG /ML;1.2 ML SOLUTION 3 QL, PA Hormones And Synthetic Substitutes CADUET 10 MG;10 MG TABLET 3 QL Cardiovascular Drugs CADUET 10 MG;20 MG TABLET 3 QL Cardiovascular Drugs CADUET 10 MG;40 MG TABLET 3 QL Cardiovascular Drugs CADUET 10 MG;80 MG TABLET 3 QL Cardiovascular Drugs CADUET 2.5 MG;10 MG TABLET 3 QL Cardiovascular Drugs CADUET 2.5 MG;20 MG TABLET 3 QL Cardiovascular Drugs CADUET 2.5 MG;40 MG TABLET 3 QL Cardiovascular Drugs CADUET 5 MG;20 MG TABLET 3 QL Cardiovascular Drugs CADUET 5 MG;40 MG TABLET 3 QL Cardiovascular Drugs CADUET 5 MG;80 MG TABLET 3 QL Cardiovascular Drugs CARBAMAZEPINE 100 MG CHEWABLE 1 Central Nervous Systems Agents CARBAMAZEPINE 200 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA /LEVODOPA 10 MG;100 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA/LEVODOPA 25 MG;100 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA /LEVODOPA 25 MG;250 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA/LEVODOPA CR 25 MG;100 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA/LEVODOPA ER 50 MG;200 MG TABLET 1 Central Nervous Systems Agents CARBIDOPA/LEVODOPA SR 50 MG;200 MG TABLET 1 Central Nervous Systems Agents CARDURA XL 4 MG TABLET 3 QL Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 15 CARDURA XL 8 MG TABLET 3 111117∎, 1( 1'1 Ilt 1)01H 1:IEi11', QL Cardiovascular Drugs CATAPRES 4TS -1 0.1 MG/24HR PATCH 3 QL Cardiovascular Drugs CATAPRES -TTS -2 0.2 MG /24HR PATCH 3 QL Cardiovascular Drugs CATAPRES -TTS -3 0.3 MG /24HR PATCH 3 QL Cardiovascular Drugs CELEBREX 100 MG CAPSULES 2 QL, ST Central Nervous Systems Agents CELEBREX 200 MG CAPSULES 2 QL, ST Central Nervous Systems Agents CELEBREX 400 MG CAPSULES 2 QL, ST Central Nervous Systems Agents COMTAN 200 MG TABLET 2 QL Central Nervous Systems Agents CONCERTA 18 MG TABLET 3 QL Central Nervous Systems Agents CONCERTA 27 MG TABLET 3 QL Central Nervous Systems Agents CONCERTA 36 MG TABLET 3 QL Central Nervous Systems Agents CONCERTA 54 MG TABLET 3 QL Central Nervous Systems Agents COPAXONE 20 MG /ML KIT 4 QL, PA Miscellaneous Therapeutic Agents COREG CR 10 MG CAPSULES 3 QL, PA Cardiovascular Drugs COREG CR 20 MG CAPSULES 3 QL, PA Cardiovascular Drugs COREG CR 40 MG CAPSULES 3 QL, PA Cardiovascular Drugs COREG CR 80 MG CAPSULES 3 QL, PA Cardiovascular Drugs :OSOPT 2 %;0.5 % SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations COUMADIN 5 MG SOLUTION 3 Blood Formation, Coagulation, And Thrombosis COUMADIN 3 MG TABLET 3 Blood Formation, Coagulation, And Thrombosis COUMADIN 6 MG TABLET 3 Blood Formation, Coagulation, And Thrombosis COVERA-H5 180 MG TABLET 3 QL Cardiovascular Drugs COVERA -HS 240 MG TABLET 3 QL Cardiovascular Drugs COZAAR 100 MG TABLET 3 QL Cardiovascular Drugs COZAAR 25 MG TABLET 3 QL Cardiovascular Drugs COZAAR 50 MG TABLET 3 QL Cardiovascular Drugs CRESTOR 10 MG TABLET 2 QL Cardiovascular Drugs CRESTOR 20 MG TABLET 2 QL Cardiovascular Drugs CRESTOR 40 MG TABLET 2 QL Cardiovascular Drugs CRESTOR 5 MG TABLET 2 QL Cardiovascular Drugs CYMBALTA 20 MG CAPSULES 2 QL Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 16 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY ,11111 /AT!(1r J 'tt,kUIRtLi( , CYMBALTA 30 MG CAPSULES 2 QL Central Nervous Systems Agents CYMBALTA 60 MG CAPSULES 2 QL Central Nervous Systems Agents DEPAKOTE ER 250 MG TABLET 2 Central Nervous Systems Agents DEPAKOTE ER 500 MG TABLET 2 Central Nervous Systems Agents DEPAKOTE SPRINKLES 125 MG SPRINKLE CAPSULES 2 Central Nervous Systems Agents DETROL LA 2 MG CAPSULES 2 QL Smooth Muscle Relaxants DETROL LA 4 MG CAPSULES 2 QL Smooth Muscle Relaxants DIGITEK 0.125 MG TABLET 1 Cardiovascular Drugs DIGITEK 0.25 MG TABLET 1 Cardiovascular Drugs DIGOXIN 0.25 MG /ML SOLUTION 1 Cardiovascular Drugs DIGOXIN 0.125 MG TABLET 1 Cardiovascular Drugs DIOVAN 40 MG TABLET 2 QL Cardiovascular Drugs DIOVAN 80 MG TABLET 2 QL Cardiovascular Drugs DIOVAN HCT 12.5 MG;160 MG TABLET 2 QL Cardiovascular Drugs DIOVAN HCT 12.5 MG;320 MG TABLET 2 QL Cardiovascular Drugs DIOVAN HCT 12.5 MG;80 MG TABLET 2 QL Cardiovascular Drugs DIOVAN HCT 25 MG;160 MG TABLET 2 QL Cardiovascular Drugs DIOVAN HCT 25 MG;320 MG TABLET 2 QL Cardiovascular Drugs DIPYRIDAMOLE 25 MG TABLET 1 Cardiovascular Drugs DIPYRIDAMOLE 50 MG TABLET 1 Cardiovascular Drugs DIPYRIDAMOLE 75 MG TABLET 1 Cardiovascular Drugs DOVONEX 0.005% CREAM 3 QL Skin And Mucous Membrane Agents DOVONEX 0.005% SOLUTION 3 QL Skin And Mucous Membrane Agents DOXAZOSIN MESYLATE 1 MG TABLET 1 Cardiovascular Drugs DOXAZOSIN MESYLATE 2 MG TABLET 1 Cardiovascular Drugs DOXAZOSIN MESYLATE 4 MG TABLET 1 Cardiovascular Drugs DOXAZOSIN MESYLATE 8 MG TABLET 1 Cardiovascular Drugs DYNACIRC CR 10 MG TABLET 3 QL, PA Cardiovascular Drugs DYNACIRC -CR 5 MG TABLET 3 QL, PA Cardiovascular Drugs EFFEXOR XR 150 MG CAPSULES 2 QL Central Nervous Systems Agents EFFEXOR XR 37.5 MG CAPSULES 2 QL Central Nervous Systems Agents EFFEXOR XR 75 MG CAPSULES 2 QL Central Nervous Systems Agents EMEND 125 MG CAPSULES 3 QL Gastrointestinal Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 17 EMEND 40 MG CAPSULES 3 IJT1111,'4111)ri iLO'UM(1.1Lr, 1 QL Gastrointestinal Drugs EMEND 80 MG CAPSULES 3 QL Gastrointestinal Drugs ENABLEX 15 MG TABLET 3 QL Smooth Muscle Relaxants ENABLEX 7.5 MG TABLET 3 QL Smooth Muscle Relaxants ENBREL 25 MG KIT 4 PA Miscellaneous Therapeutic Agents ENBREL 50 MG /ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents ENBREL SURECLICK 50 MG /ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents EPOGEN 10000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis EPOGEN 20000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis EPOGEN 40000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis ERBITUX 100 MG /50ML SOLUTION 4 Antineoplastic Agents FELODIPINE ER 10 MG TABLET 1 QL Cardiovascular Drugs FELODIPINE ER 5 MG TABLET 1 QL Cardiovascular Drugs FEMARA 2.5 MG TABLET 3 Antineoplastic Agents FEMHRT 1/5 5 MCG;1 MG TABLET 3 Hormones And Synthetic Substitutes FEMHRT LOW DOSE 2.5 MCG;0.5 MG TABLET 3 Hormones And Synthetic Substitutes FENOFIBRATE 134 MG CAPSULES 1 QL Cardiovascular Drugs FENOFIBRATE 200 MG CAPSULES 1 QL Cardiovascular Drugs FENOFIBRATE 67 MG CAPSULES 1 QL Cardiovascular Drugs FENOFIBRATE 160 MG TABLET 1 QL Cardiovascular Drugs FENOFIBRATE 54 MG TABLET 1 QL Cardiovascular Drugs FENTANYL 100 MCG /HR PATCH 1 QL Central Nervous Systems Agents FENTANYL 12.5 MCG /HR PATCH 1 QL Central Nervous Systems Agents FENTANYL 25 MCG /HR PATCH 1 QL Central Nervous Systems Agents FLOMAX 0.4 MG CAPSULES 2 QL Miscellaneous Therapeutic Agents FLOVENT HFA 110 MCG /ACT AEROSOL 2 QL Hormones And Synthetic Substitutes FLOVENT HFA 220 MCG /ACT AEROSOL 2 QL Hormones And Synthetic Substitutes FLOVENT HFA 44 MCG /ACT AEROSOL 2 QL Hormones And Synthetic Substitutes FLUCONAZOLE 100 MG TABLET 1 Anti - Infective Agents FLUCONAZOLE 150 MG TABLET 1 QL Anti - Infective Agents FLUCONAZOLE 200 MG TABLET 1 Anti - Infective Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 18 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY r u?IIIZr°kIl();'J RI (11J1■( L1Li1W, FLUOXETINE HCL 10 MG CAPSULES 1 QL Central Nervous Systems Agents FLUOXETINE HCL 20 MG CAPSULES 1 QL Central Nervous Systems Agents FLUOXETINE HCL 10 MG TABLET 1 QL Central Nervous Systems Agents FLUOXETINE HCL 20 MG TABLET 1 QL Central Nervous Systems Agents FOCALIN XR 10 MG CAPSULES 3 QL Central Nervous Systems Agents FOCALIN XR 15 MG CAPSULES 3 QL Central Nervous Systems Agents FOCALIN XR 20 MG CAPSULES 3 QL Central Nervous Systems Agents FOCALIN XR 5 MG CAPSULES 3 QL Central Nervous Systems Agents FORADIL AEROLIZER 12 MCG CAPSULES 3 QL Autonomic Drugs FORTAMET 1000 MG TABLET 3 QL, ST Hormones And Synthetic Substitutes FORTAMET 500 MG TABLET 3 QL, ST Hormones And Synthetic Substitutes FORTAZ 2 GM SOLUTION H 3 Anti- Infective Agents FORTED 750 MCG /3ML SOLUTION 3 Hormones And Synthetic Substitutes FOSINOPRIL SODIUM 10 MG TABLET 1 Cardiovascular Drugs FOSINOPRIL SODIUM 20 MG TABLET 1 Cardiovascular Drugs FOSINOPRIL SODIUM 40 MG TABLET 1 Cardiovascular Drugs FOSINOPRIL SODIUM /HYDROCH 10 MG;12.5 MG TABLET 1 Cardiovascular Drugs FOSINOPRIL SODIUM / HYDROCH 20 MG;12.5 MG TABLET 1 Cardiovascular Drugs FRAGMIN 10000 UNIT /ML INJECTION 3 QL Blood Formation, Coagulation, And Thrombosis FUROSEMIDE 20 MG TABLET 1 Electrolytic, Caloric, And Water Balance FUROSEMIDE 40 MG TABLET 1 Electrolytic, Caloric, And Water Balance FUROSEMIDE 80 MG TABLET 1 Electrolytic, Caloric, And Water Balance GABAPENTIN 100 MG CAPSULES 1 QL Central Nervous Systems Agents GABAPENTIN 300 MG CAPSULES 1 QL Central Nervous Systems Agents GABAPENTIN 400 MG CAPSULES 1 QL Central Nervous Systems Agents GABAPENTIN 100 MG TABLET 1 QL Central Nervous Systems Agents GABAPENTIN 400 MG TABLET 1 QL Central Nervous Systems Agents GABAPENTIN 600 MG TABLET 1 QL Central Nervous Systems Agents GABAPENTIN 800 MG TABLET 1 QL Central Nervous Systems Agents GABITRIL 12 MG TABLET 3 QL Central Nervous Systems Agents GABITRIL 16 MG TABLET 3 QL Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 19 i11117ATIOf ;LUUIFA L1LL, , I: r GABITRIL 2 MG TABLET 3 QL Central Nervous Systems Agents GABITRIL 4 MG TABLET 3 QL Central Nervous Systems Agents GEMFIBROZIL 600 MG TABLET 1 QL Cardiovascular Drugs GEODON 20 MG CAPSULES 2 QL Central Nervous Systems Agents GEODON 40 MG CAPSULES 2 QL Central Nervous Systems Agents GEODON 60 MG CAPSULES 2 QL Central Nervous Systems Agents GEODON 80 MG CAPSULES 2 QL Central Nervous Systems Agents GEODON 20 MG SOLUTION 3 Central Nervous Systems Agents GLEEVEC 100 MG TABLET 4 QL Antineoplastic Agents GLEEVEC 400 MG TABLET 4 QL Antineoplastic Agents GLIMEPIRIDE 1 MG TABLET 1 Hormones And Synthetic Substitutes GLIMEPIRIDE 2 MG TABLET 1 Hormones And Synthetic Substitutes GLIMEPIRIDE 4 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE 10 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE 5 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE ER 10 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE ER 2.5 MG TABLET 1 Hormones And Synthetic Substitutes 1LIPIZIDE ER 5 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE/METFORMIN HCL 2.5 MG;250 MG TABLET 1 Hormones And Synthetic Substitutes GLIPIZIDE/METFORMIN HCL 2.5 MG;500 MG TABLET 1 Hormones And Synthetic Substitutes GLUCOTROL XL 10 MG TABLET 3 Hormones And Synthetic Substitutes GLUCOTROL XL 2.5 MG TABLET 3 Hormones And Synthetic Substitutes GLUCOTROL XL 5 MG TABLET 3 Hormones And Synthetic Substitutes GLYBURIDE 1.25 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE 2.5 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE 5 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE MICRONIZED 1.5 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE MICRONIZED 3 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE MICRONIZED 6 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE /METFORMIN HCL 1.25 MG;250 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE /METFORMIN HCL 2.5 MG;500 MG TABLET 1 Hormones And Synthetic Substitutes GLYBURIDE /METFORMIN HCL 5 MG;500 MG TABLET 1 Hormones And Synthetic Substitutes H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 20 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY JT11IlraTl +lfl I G ,.,r1, ,r fi kt 0111 1.1f i!I tit HEPSERA 10 MG TABLET 4 PA Anti- Infective Agents HERCEPTIN 440 MG SOLUTION 4 QL Antineoplastic Agents HUMALOG 100 UNIT /ML SOLUTION 2 QL Hormones And Synthetic Substitutes HUMALOG MIX 50/50 50 %;50 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMALOG MIX 50/50 PEN 50 %;50 % SUSPENSION 2 Hormones And. Synthetic Substitutes HUMALOG MIX 75/25 25 %;75 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMALOG MIX 75/25 PEN 25 %;75 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMALOG PEN 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes HUMIRA 40 MG /0.8ML KIT 4 QL, PA Miscellaneous Therapeutic Agents HUMIRA PEN 40 MG /0.8ML KIT 4 QL, PA Miscellaneous Therapeutic Agents HUMULIN 50/50 50 %;50 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMULIN 70/30 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMULIN 70/30 PEN 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes HUMULIN N 100 UNIT /ML SUSPENSION 2 Hormones And Synthetic Substitutes HUMULIN R 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes HYDROXYZINE HCL 10 MG TABLET 1 Central Nervous Systems Agents HYDROXYZINE PAMOATE 100 MG CAPSULES 1 Central Nervous Systems Agents IYDROXYZINE PAMOATE 25 MG CAPSULES 1 Central Nervous Systems Agents HYDROXYZINE PAMOATE 50 MG CAPSULES 1 Central Nervous Systems Agents HYZAAR 12.5 MG;100 MG TABLET 3 QL Cardiovascular Drugs HYZAAR 12.5 MG;50 MG TABLET 3 QL Cardiovascular Drugs HYZAAR 25 MG;100 MG TABLET 3 QL Cardiovascular Drugs IBUPROFEN 100 MG /5ML SUSPENSION 1 Central Nervous Systems Agents IBUPROFEN 400 MG TABLET 1 Central Nervous Systems Agents IBUPROFEN 600 MG TABLET 1 Central Nervous Systems Agents IBUPROFEN 800 MG TABLET 1 Central Nervous Systems Agents IMDUR 120 MG TABLET 3 Cardiovascular Drugs IMDUR 30 MG TABLET 3 Cardiovascular Drugs IMDUR 60 MG TABLET 3 Cardiovascular Drugs IMIPRAMINE HCL 10 MG TABLET 1 Central Nervous Systems Agents IMIPRAMINE HCL 25 MG TABLET 1 Central Nervous Systems Agents IMIPRAMINE HCL 50 MG TABLET 1 Central Nervous Systems Agents IMIPRAMINE PAMOATE 100 MG CAPSULES 1 Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 21 IMIPRAMINE PAMOATE 125 MG CAPSULES 1 t11 11 17L, T1(1r1 t +F(1UIhf P:111il`: Central Nervous Systems Agents IMIPRAMINE PAMOATE 150 MG CAPSULES 1 Central Nervous Systems Agents IMIPRAMINE PAMOATE 75 MG CAPSULES 1 Central Nervous Systems Agents INDAPAMIDE 1.25 MG TABLET 1 Electrolytic, Caloric, And Water Balance INDAPAMIDE 2.5 MG TABLET 1 Electrolytic, Caloric, And Water Balance INVANZ 1 GM SOLUTION H 3 Anti- Infective Agents INVEGA 3 MG TABLET 3 QL, ST Central Nervous Systems Agents INVEGA 6 MG TABLET 3 QL, ST Central Nervous Systems Agents INVEGA 9 MG TABLET 3 QL, ST Central Nervous Systems Agents ISONARIF 150 MG;300 MG CAPSULES 1 Anti - Infective Agents ISONIAZID 100 MG /ML SOLUTION 1 Anti - Infective Agents ISONIAZID 50 MG /5ML SYRUP 1 Anti - Infective Agents ISONIAZID 100 MG TABLET 1 Anti - Infective Agents ISONIAZID 300 MG TABLET 1 Anti- Infective Agents ISOSORBIDE DINITRATE 5 MG SUBLINGUAL 1 Cardiovascular Drugs ISOSORBIDE DINITRATE 10 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE DINITRATE 30 MG TABLET 1 Cardiovascular Drugs SOSORBIDE DINITRATE ER 40 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE MONONITRATE 10 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE MONONITRATE 20 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE MONONITRATE ER 120 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE MONONITRATE ER 30 MG TABLET 1 Cardiovascular Drugs ISOSORBIDE MONONITRATE ER 60 MG TABLET 1 Cardiovascular Drugs JANUMET 1000 MG;50 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes JANUMET 500 MG;50 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes JANUVIA 100 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes JANUVIA 25 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes JANUVIA 50 MG TABLET 3 QL, PA Hormones And Synthetic Substitutes KALETRA 133.3 MG;33.3 MG CAPSULES 4 Anti - Infective Agents KALETRA 400 MG /5ML;100 MG /5ML SOLUTION 4 Anti - Infective Agents KALETRA 200 MG;50 MG TABLET 4 Anti - Infective Agents KEPPRA 100 MG /ML SOLUTION 2 QL Central Nervous Systems Agents KEPPRA 500 MG /5ML SOLUTION 2 QL Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare clans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 22 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY 11r1i !7i °aTlU�'i htQHII;f lf [i KEPPRA 1000 MG TABLET 2 QL Central Nervous Systems Agents KEPPRA 250 MG TABLET 2 QL Central Nervous Systems Agents KEPPRA 500 MG TABLET 2 QL Central Nervous Systems Agents KEPPRA 750 MG TABLET 2 QL Central Nervous Systems Agents KETOPROFEN 50 MG CAPSULES 1 Central Nervous Systems Agents KETOPROFEN ER 200 MG CAPSULES 1 Central Nervous Systems Agents KINERET 100 MG /0.67ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents LAMOTRIGINE CHEWABLE DISP 25 MG TABLET 1 Central Nervous Systems Agents LANTUS 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes LEFLUNOMIDE 10 MG TABLET 1 QL Miscellaneous Therapeutic Agents LEFLUNOMIDE 20 MG TABLET 1 QL Miscellaneous Therapeutic Agents LESCOL 20 MG CAPSULES 3 QL, ST Cardiovascular Drugs LESCOL 40 MG CAPSULES 3 QL, ST Cardiovascular Drugs LESCOL XL 80 MG TABLET 3 QL, ST Cardiovascular Drugs LETAIRIS 10 MG TABLET 4 QL, PA, LA Cardiovascular Drugs LETAIRIS 5 MG TABLET 4 QL, PA, LA Cardiovascular Drugs LEVAQUIN 25 MG /ML SOLUTION H 2 Anti - Infective Agents LEVAQUIN 25 MG /ML SOLUTION 2 Anti - Infective Agents LEVAQUIN 5 %;750 MG /150ML SOLUTION H 2 Anti - Infective Agents LEVEMIR 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes LEVOTHROID 100 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 125 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 137 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 150 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 175 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 200 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 25 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 300 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 50 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 75 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHROID 88 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 100 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 112 MCG TABLET 1 Hormones And Synthetic Substitutes H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 23 11111 {7 ,\1 H)H ir i l . i {;CQUII LEVOTHYROXINE SODIUM 137 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 150 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 175 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 200 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 25 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 300 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 50 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 75 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOTHYROXINE SODIUM 88 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 100 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 112 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 125 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 137 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 150 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 175 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 200 MCG TABLET 1 Hormones And Synthetic Substitutes LEVOXYL 75 MCG TABLET 1 Hormones And Synthetic Substitutes EVOXYL 88 MCG TABLET 1 Hormones And Synthetic Substitutes LEXAPRO 5 MG /5ML SOLUTION 2 QL Central Nervous Systems Agents LEXAPRO 10 MG TABLET 2 QL Central Nervous Systems Agents LEXAPRO 20 MG TABLET 2 QL Central Nervous Systems Agents LEXAPRO 5 MG TABLET 2 QL Central Nervous Systems Agents LIDODERM 0.05 PATCH 3 QL, PA Skin And Mucous Membrane Agents LIPITOR 10 MG TABLET 2 QL Cardiovascular Drugs LIPITOR 20 MG TABLET 2 QL Cardiovascular Drugs LIPITOR 40 MG TABLET 2 QL Cardiovascular Drugs LIPITOR 80 MG TABLET 2 QL Cardiovascular Drugs LISINOPRIL 10 MG TABLET 1 Cardiovascular Drugs LISINOPRIL 2.5 MG TABLET 1 Cardiovascular Drugs LISINOPRIL 20 MG TABLET 1 Cardiovascular Drugs LISINOPRIL 30 MG TABLET 1 Cardiovascular Drugs LISINOPRIL 40 MG TABLET 1 Cardiovascular Drugs LISINOPRIL 5 MG TABLET 1 Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 24 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY 1,1111/AT1n1i RL(lUII�C(�1[ 111 i LISINOPRIUHYDROCHLOROTHI 12.5 MG;10 MG TABLET 1 Cardiovascular Drugs LISINOPRIUHYDROCHLOROTHI 12.5 MG;20 MG TABLET 1 Cardiovascular Drugs LISINOPRIUHYDROCHLOROTHI 25 MG;20 MG TABLET 1 Cardiovascular Drugs LITHIUM CARBONATE 150 MG CAPSULES 1 Central Nervous Systems Agents LITHIUM CARBONATE ER 300 MG TABLET 1 Central Nervous Systems Agents LITHIUM CARBONATE ER 450 MG TABLET 1 Central Nervous Systems Agents LOVASTATIN 10 MG TABLET 1 QL Cardiovascular Drugs LOVASTATIN 20 MG TABLET 1 QL Cardiovascular Drugs LOVASTATIN 40 MG TABLET 1 QL Cardiovascular Drugs LOVAZA 375 MG;465 MG;1 GM CAPSULES 3 QL Cardiovascular Drugs LOVENOX 100 MG /ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 120 MG /0.8ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 150 MG/ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 30 MG /0.3ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 300 MG /3ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 40 MG /0.4ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 60 MG /0.6ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LOVENOX 80 MG /0.8ML SOLUTION H 3 QL Blood Formation, Coagulation, And Thrombosis LUMIGAN 0.0003 SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations LUNESTA 1 MG TABLET 3 QL, ST Central Nervous Systems Agents LUNESTA 2 MG TABLET 3 QL, ST Central Nervous Systems Agents LUNESTA 3 MG TABLET 3 QL, ST Central Nervous Systems Agents LYRICA 100 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 150 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 200 MG CAPSULES 3 QL, ST Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 25 I11111;y`Inrl I�Lillilf;l Pil LYRICA 225 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 25 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 300 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 50 MG CAPSULES 3 QL, ST Central Nervous Systems Agents LYRICA 75 MG CAPSULES 3 QL, ST Central Nervous Systems Agents MAXALT 10 MG TABLET 3 QL Central Nervous Systems Agents MAXALT 5 MG TABLET 3 QL Central Nervous Systems Agents MAXALT MLT 10 MG TABLET 3 QL Central Nervous Systems Agents MAXALT-MIT 5 MG TABLET 3 QL Central Nervous Systems Agents MELOXICAM 7.5 MG /5ML SUSPENSION 1 QL Central Nervous Systems Agents MELOXICAM 15 MG TABLET 1 QL Central Nervous Systems Agents MELOXICAM 7.5 MG TABLET 1 QL Central Nervous Systems Agents METFORMIN HCL 1000 MG TABLET 1 Hormones And Synthetic Substitutes METFORMIN HCL 500 MG TABLET 1 Hormones And Synthetic Substitutes METFORMIN HCL 850 MG TABLET 1 Hormones And Synthetic Substitutes METFORMIN HCL ER 500 MG TABLET 1 QL Hormones And Synthetic Substitutes METFORMIN HCL ER 750 MG TABLET 1 QL Hormones And Synthetic Substitutes METHYLDOPA/HYDROCHLOROTHI 15 MG;250 MG TABLET 1 Cardiovascular Drugs METHYLDOPA/HYDROCHLOROTHI 25 MG;250 MG TABLET 1 Cardiovascular Drugs METOPROLOUHYDROCHLOROTHI 25 MG;100 MG TABLET 1 Cardiovascular Drugs METOPROLOUHYDROCHLOROTHI 25 MG;50 MG TABLET 1 Cardiovascular Drugs METOPROLOUHYDROCHLOROTHI 50 MG;100 MG TABLET 1 Cardiovascular Drugs MIACALCIN 200 UNIT /ACT SOLUTION 3 QL Hormones And Synthetic Substitutes MIACALCIN 200 UNIT /ML SOLUTION 3 QL Hormones And Synthetic Substitutes MICARDIS 20 MG TABLET 3 QL Cardiovascular Drugs MICARDIS 40 MG TABLET 3 QL Cardiovascular Drugs MICARDIS 80 MG TABLET 3 QL Cardiovascular Drugs MICARDIS HCT 12.5 MG;40 MG TABLET 3 QL Cardiovascular Drugs MICARDIS HCT 12.5 MG;80 MG TABLET 3 QL Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 26 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY 111I7!1THra to TM Iii HUM MICARDIS HCT 25 MG;80 MG TABLET 3 QL Cardiovascular Drugs MIRAPEX 0.125 MG TABLET 3 ST Central Nervous Systems Agents MIRAPEX 0.25 MG TABLET 3 ST Central Nervous Systems Agents MIRAPEX 0.5 MG TABLET 3 ST Central Nervous Systems Agents MIRAPEX 1 MG TABLET 3 ST Central Nervous Systems Agents MIRAPEX 1.5 MG TABLET 3 ST Central Nervous Systems Agents MIRTAZAPINE 15 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 15 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 30 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 30 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 45 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 45 MG TABLET 1 Central Nervous Systems Agents MIRTAZAPINE 7.5 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE 15 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE 30 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE ER 15 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE ER 200 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE ER 30 MG TABLET 1 Central Nervous Systems Agents MORPHINE SULFATE ER 60 MG TABLET 1 Central Nervous Systems Agents NAMENDA 10 MG TABLET 2 QL Central Nervous Systems Agents NAMENDA 5 MG TABLET 2 QL Central Nervous Systems Agents NAPROXEN DR 500 MG TABLET 1 Central Nervous Systems Agents NAPROXEN SODIUM 275 MG TABLET 1 Central Nervous Systems Agents NAPROXEN SODIUM 500 MG TABLET 1 Central Nervous Systems Agents NAPROXEN SODIUM 550 MG TABLET 1 Central Nervous Systems Agents NASONEX 50 MCG /ACT SUSPENSION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations NEULASTA 6 MG /0.6ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis NEXAVAR 200 MG TABLET 4 QL, LA Antineoplastic Agents NEXIUM 20 MG CAPSULES 2 QL Gastrointestinal Drugs NEXIUM 40 MG CAPSULES 2 QL Gastrointestinal Drugs NEXIUM 40 MG PACK 2 QL Gastrointestinal Drugs NIASPAN 1000 MG TABLET 2 Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 27 i 1, (l;tl ll NIASPAN 500 MG TABLET If I 2 li1111 /l;1(f)ri i,,rJriUl rll t Rf ()Uihi_P.1( Hl'; !!i I' 4' )i., Cardiovascular Drugs NIASPAN 750 MG TABLET 2 Cardiovascular Drugs NIFEDIAC CC 30 MG TABLET 1 QL Cardiovascular Drugs NIFEDIAC CC 60 MG TABLET 1 QL Cardiovascular Drugs NIFEDIAC CC 90 MG TABLET 1 QL Cardiovascular Drugs NIFEDICAL XL 30 MG TABLET 1 QL Cardiovascular Drugs NIFEDICAL XL 60 MG TABLET 1 QL Cardiovascular Drugs NIZATIDINE 150 MG CAPSULES 1 Gastrointestinal Drugs NIZATIDINE 300 MG CAPSULES 1 Gastrointestinal Drugs NOVOLIN 70/30 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLIN 70/30 INNOLET 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLIN 70/30 PENFILL 30 %;70 °A) SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLIN N 100 UNIT /ML SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLIN R 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes NOVOLIN R INNOLET 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes NOVOLIN R U -100 PENFILL 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes NOVOLOG 100 UNIT /ML SOLUTION 2 Hormones And Synthetic Substitutes NOVOLOG MIX 70/30 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLOG MIX 70/30 PENFILL 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes NOVOLOG MIX 70/30 PREFILL 30 %;70 % SUSPENSION 2 Hormones And Synthetic Substitutes ONDANSETRON HCL 24 MG TABLET 1 QL Gastrointestinal Drugs ONDANSETRON HCL 4 MG TABLET 1 QL Gastrointestinal Drugs ONDANSETRON HCL 8 MG TABLET 1 QL Gastrointestinal Drugs ONDANSETRON ODT 4 MG TABLET 1 QL Gastrointestinal Drugs ONDANSETRON ODT 8 MG TABLET 1 QL Gastrointestinal Drugs OXAPROZIN 600 MG TABLET 1 Central Nervous Systems Agents OXYBUTYNIN CHLORIDE 5 MG TABLET 1 Smooth Muscle Relaxants OXYBUTYNIN CHLORIDE ER 15 MG TABLET 1 Smooth Muscle Relaxants OXYCODONE/ACETAMINOPHEN 325 MG;5 MG TABLET 1 QL Central Nervous Systems Agents PACERONE 200 MG TABLET 1 Cardiovascular Drugs PACERONE 300 MG TABLET 1 Cardiovascular Drugs H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 28 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY �!T1117��T1O��! hLUUlRL��,1LPi1 ,i1 PACERONE 400 MG TABLET 1 Cardiovascular Drugs PATANOL 0.001 SOLUTION 2 Eye, Ear, Nose, And Throat (EENT) Preparations PEGASYS 180 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON 120 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON 150 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON 50 MCG /0.5ML KIT 4 QL, PA Anti- Infective Agents PEG - INTRON 80 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN 120 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN 150 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN 50 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN 80 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN PAK 4 120 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN PAK 4 150 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN PAK 4 50 MCG /0.5ML KIT 4 QL, PA Anti - Infective Agents PEG - INTRON REDIPEN PAK 4 80 MCG /0.5ML KIT 4 QL, PA. Anti - Infective Agents PHOSLQ 667 MG CAPSULES 2 Electrolytic, Caloric, And Water Balance PLAVIX 75 MG TABLET 2 QL Blood Formation, Coagulation, And Thrombosis PREMARIN 0.3 MG TABLET 2 Hormones And Synthetic Substitutes PREMARIN 0.45 MG TABLET 2 Hormones And Synthetic Substitutes PREMARIN 0.625 MG TABLET 2 Hormones And Synthetic Substitutes PREMARIN 0.9 MG TABLET 2 Hormones And Synthetic Substitutes PREMARIN 1.25 MG TABLET 2 Hormones And Synthetic Substitutes PREMPHASE 0.625 MG;5 MG TABLET 2 Hormones And Synthetic Substitutes PREMPRO 0.3 MG;1.5 MG TABLET 2 Hormones And Synthetic Substitutes PREMPRO 0.45 MG;1.5 MG TABLET 2 Hormones And Synthetic Substitutes PREMPRO 0.625 MG;2.5 MG TABLET 2 Hormones And Synthetic Substitutes PREMPRO 0.625 MG;5 MG TABLET 2 Hormones And Synthetic Substitutes PREVACID 15 MG CAPSULES 2 QL Gastrointestinal Drugs PREVACID 30 MG CAPSULES 2 QL Gastrointestinal Drugs PREVACID SOLUTAB 15 MG TABLET 2 QL Gastrointestinal Drugs PROCRIT 10000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 29 I)[,11r, rli(`,11 111111 /fV1Ir)1 It (m11),f- i'r';E r PROCRIT 20000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis PROCRIT 40000 UNIT /ML SOLUTION 4 QL, PA Blood Formation, Coagulation, And Thrombosis PROTONIX 40 MG SOLUTION 3 PA Gastrointestinal Drugs PROTONIX 20 MG TABLET 3 QL, PA Gastrointestinal Drugs PROTONIX 40 MG TABLET 3 QL, PA Gastrointestinal Drugs PROZAC WEEKLY 90 MG CAPSULES 3 QL Central Nervous Systems Agents QVAR 40 MCG /ACT AEROSOL SOLUTION 2 QL Hormones And Synthetic Substitutes QVAR 80 MCG /ACT AEROSOL SOLUTION 2 QL Hormones And Synthetic Substitutes RANEXA 500 MG TABLET 3 QL, ST Cardiovascular Drugs RAPTIVA 125 MG KIT 4 QL, PA, LA Skin And Mucous Membrane Agents REBIF 44 MCG /0.5ML SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents REBIF TITRATION PACK 0 SOLUTION 4 QL, PA Miscellaneous Therapeutic Agents REGRANEX 0.0001 GEL 4 Skin And Mucous Membrane Agents RENAGEL 400 MG TABLET 2 Electrolytic, Caloric, And Water Balance RENAGEL 800 MG TABLET 2 Electrolytic, Caloric, And Water Balance REVATIO 20 MG TABLET 4 QL, PA Cardiovascular Drugs REVLIMID 10 MG CAPSULES 4 QL, LA Miscellaneous Therapeutic Agents REVLIMID 15 MG CAPSULES 4 QL, LA Miscellaneous Therapeutic Agents REVLIMID 25 MG CAPSULES 4 QL, LA Miscellaneous Therapeutic Agents REVLIMID 5 MG CAPSULES 4 QL, LA Miscellaneous Therapeutic Agents RILUTEK 50 MG TABLET 4 Central Nervous Systems Agents RISPERDAL 1 MG /ML SOLUTION 3 Central Nervous Systems Agents RISPERDAL 0.25 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL 0.5 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL 1 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL 2 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL 3 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL 4 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL CONSTA 12.5 MG SUSPENSION 3 QL Central Nervous Systems Agents RISPERDAL CONSTA 25 MG SUSPENSION 3 QL Central Nervous Systems Agents RISPERDAL CONSTA 37.5 MG SUSPENSION 4 QL Central Nervous Systems Agents RISPERDAL CONSTA 50 MG SUSPENSION 4 QL Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 30 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY Illl lk (,uIf;E(,1EfJl RISPERDAL M -TAB 0.5 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL M -TAB 1 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL M -TAB 2 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL M -TAB 3 MG TABLET 3 QL Central Nervous Systems Agents RISPERDAL M -TAB 4 MG TABLET 3 QL Central Nervous Systems Agents RITUXAN 10 MG /ML CONCENTRATION 4 QL, PA Antineoplastic Agents ROZEREM 8 MG TABLET 3 QL, ST Central Nervous Systems Agents SEREVENT DISKUS 50 MCG /DOSE AEROSOL POWDER 2 QL Autonomic Drugs SEROQUEL 100 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL 200 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL 25 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL 300 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL 400 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL 50 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL XR 200 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL XR 300 MG TABLET 2 QL Central Nervous Systems Agents SEROQUEL XR 400 MG TABLET 2 QL Central Nervous Systems Agents SINGULAIR 4 MG CHEWABLE 3 QL, ST Respiratory Tract Agents SINGULAIR 5 MG CHEWABLE 3 QL, ST Respiratory Tract Agents SINGULAIR 4 MG PACK 3 QL, ST Respiratory Tract Agents SINGULAIR 10 MG TABLET 3 QL, ST Respiratory Tract Agents SPRYCEL 20 MG TABLET 4 QL Antineoplastic Agents SPRYCEL 50 MG TABLET 4 QL Antineoplastic Agents SPRYCEL 70 MG TABLET 4 QL Antineoplastic Agents STRATTERA 10 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 100 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 18 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 25 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 40 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 60 MG CAPSULES 3 QL Central Nervous Systems Agents STRATTERA 80 MG CAPSULES 3 QL Central Nervous Systems Agents SUTENT 12.5 MG CAPSULES 4 QL Antineoplastic Agents SUTENT 25 MG CAPSULES 4 QL Antineoplastic Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 31 11tH I/i 1lHr1 t�UIkEf':1F(Ji�, SUTENT 50 MG CAPSULES 4 QL Antineoplastic Agents SYMBICORT 160 MCG /ACT;4.5 MCG /ACT AEROSOL 2 QL Hormones And Synthetic Substitutes SYMBICORT 80 MCG /ACT;4.5 MCG /ACT AEROSOL 2 QL Hormones And Synthetic Substitutes SYNTHROID 100 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 112 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 125 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 137 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 150 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 175 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 200 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 25 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 300 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 50 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 75 MCG TABLET 2 Hormones And Synthetic Substitutes SYNTHROID 88 MCG TABLET 2 Hormones And Synthetic Substitutes TAMIFLU 75 MG CAPSULES 3 QL Anti - Infective Agents TAMIFLU 12 MG /ML SUSPENSION 3 QL Anti - Infective Agents TAMOXIFEN CITRATE 10 MG TABLET 1 Antineoplastic Agents TAMOXIFEN CITRATE 20 MG TABLET 1 Antineoplastic Agents TARCEVA 100 MG TABLET 4 QL Antineoplastic Agents TARCEVA 150 MG TABLET 4 QL Antineoplastic Agents TARCEVA 25 MG TABLET 4 QL Antineoplastic Agents TEKTURNA 150 MG TABLET 3 QL, PA Cardiovascular Drugs TEKTURNA 300 MG TABLET 3 QL, PA Cardiovascular Drugs THALOMID 100 MG CAPSULES 4 QL Miscellaneous Therapeutic Agents THALOMID 200 MG CAPSULES 4 QL Miscellaneous Therapeutic Agents THALOMID 50 MG CAPSULES 4 QL Miscellaneous Therapeutic Agents TOPAMAX 100 MG TABLET 3 QL Central Nervous Systems Agents TOPAMAX 200 MG TABLET 3 QL Central Nervous Systems Agents TOPAMAX 25 MG TABLET 3 QL Central Nervous Systems Agents TOPAMAX 50 MG TABLET 3 QL Central Nervous Systems Agents TOPAMAX SPRINKLE 15 MG SPRINKLE CAPSULES 3 Central Nervous Systems Agents TOPAMAX SPRINKLE 25 MG SPRINKLE CAPSULES 3 Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 32 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY 11T11I/A411W1 j,“,1 TORSEMIDE 10 MG TABLET 1 Electrolytic, Caloric, And Water Balance TORSEMIDE 100 MG TABLET 1 Electrolytic, Caloric, And Water Balance TORSEMIDE 20 MG TABLET 1 Electrolytic, Caloric, And Water Balance TORSEMIDE 5 MG TABLET 1 Electrolytic, Caloric, And Water Balance TRACLEER 125 MG TABLET 4 QL, PA, LA Cardiovascular Drugs TRACLEER 62.5 MG TABLET 4 QL, PA, LA Cardiovascular Drugs TRAVATAN 0.004% SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations TRAVATAN Z 0.004% SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations TRICOR 145 MG TABLET 2 QL Cardiovascular Drugs TRICOR 48 MG TABLET 2 QL Cardiovascular Drugs TYKERB 250 MG TABLET 4 QL Antineoplastic Agents VESICARE 10 MG TABLET 2 QL Smooth Muscle Relaxants VESICARE 5 MG TABLET 2 QL Smooth Muscle Relaxants VYTORIN 10 MG;10 MG TABLET 2 QL Cardiovascular Drugs VYTORIN 10 MG;20 MG TABLET 2 QL Cardiovascular Drugs VYTORIN 10 MG;40 MG TABLET 2 QL Cardiovascular Drugs VYTORIN 10 MG;80 MG TABLET 2 QL Cardiovascular Drugs VYVANSE 30 MG CAPSULES 3 QL Central Nervous Systems Agents VYVANSE 50 MG CAPSULES 3 QL Central Nervous Systems Agents VYVANSE 70 MG CAPSULES 3 QL Central Nervous Systems Agents WARFARIN SODIUM 1 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 10 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 2 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 2.5 MG TABLET 1 Blood Formation,'Coagulation, And Thrombosis WARFARIN SODIUM 3 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 4 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 5 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 33 1 111! 17f TH ri .l��il�ar,f 1.1 r; (lUiRLi, i WARFARIN SODIUM 6 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis WARFARIN SODIUM 7.5 MG TABLET 1 Blood Formation, Coagulation, And Thrombosis XALATAN 0.005% SOLUTION 2 QL Eye, Ear, Nose, And Throat (EENT) Preparations XOLAIR 150 MG SOLUTION 4 QL, PA, LA Respiratory Tract Agents XOPENEX HFA 45 MCG /ACT AEROSOL 3 QL, ST Autonomic Drugs YASMIN 28 3 MG;0.03 MG TABLET 3 Hormones And Synthetic Substitutes YAZ 3 MG;0.02 MG TABLET 3 Hormones And Synthetic Substitutes ZOLPIDEM TARTRATE 10 MG TABLET 1 QL Central Nervous Systems Agents ZOLPIDEM TARTRATE 5 MG TABLET 1 QL Central Nervous Systems Agents ZOMIG 5 MG SOLUTION 3 QL Central Nervous Systems Agents ZOMIG 2.5 MG TABLET 3 QL Central Nervous Systems Agents ZOMIG 5 MG TABLET 3 QL Central Nervous Systems Agents ZOMIG ZMT 2.5 MG TABLET 3 QL Central Nervous Systems Agents ZOMIG ZMT 5 MG TABLET 3 QL Central Nervous Systems Agents ZONISAMIDE 100 MG CAPSULES 1 Central Nervous Systems Agents ZONISAMIDE 25 MG CAPSULES 1 Central Nervous Systems Agents ZONISAMIDE 50 MG CAPSULES 1 Central Nervous Systems Agents ZYPREXA 10 MG SOLUTION 3 QL Central Nervous Systems Agents ZYPREXA 10 MG TABLET 2 QI. Central Nervous Systems Agents ZYPREXA 15 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA 2.5 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA 20 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA 5 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA 7.5 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA ZYDIS 10 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA ZYDIS 15 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA ZYDIS 20 MG TABLET 2 QL Central Nervous Systems Agents ZYPREXA ZYDIS 5 MG TABLET 2 QL Central Nervous Systems Agents H Home Infusion drugs that may be covered in the gap. Please refer to the appendix on 35 for Humana Group Medicare plans that may have this coverage. PA — Prior Authorization; QL — Quantity Limit; ST — Step Therapy; LA — Limited Access 34 - PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY Prescription Drug Guide Appendix Home Infusion Coverage — The below plans offer additional coverage in the gap for drugs marked with a H in the drug grid that begins on page 8 of the Prescription Drug Guide. P1,1n Group Medicare HMO Plan 076 Option 152 All Group Medicare HMO Markets Group Medicare HMO Plan 076 Option 516 All Group Medicare HMO Markets Group Medicare HMO Plan 076 Option 517 All Group Medicare HMO Markets Group Medicare HMO Plan 076 Option 608 All Group Medicare HMO Markets Group Medicare HMO Plan 076 Option 997 All Group Medicare HMO Markets Group Medicare RPPO Plan 079 Option 526 All Group Medicare HMO Markets Group Medicare LPPO Plan 079 Option 034 All Group Medicare LPPO Markets Group Medicare LPPO Plan 079 Option 035 All Group Medicare LPPO Markets Group Medicare LPPO Plan 079 Option 049 All Group Medicare LPPO Markets Group Medicare PFFS Plan 078 Option 003 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 017 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 026 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 030 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 031 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 042 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 043 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 046 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 056 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 062 All Group Medicare PFFS Markets Group Medicare PFFS Plan 078 Option 063 All Group Medicare PFFS Markets Group Medicare RPPO Plan 079 Option 503 All Group Medicare RPPO Markets Group Medicare RPPO Plan 079 Option 505 All Group Medicare RPPO Markets Group Medicare RPPO Plan 079 Option 507 All Group Medicare RPPO Markets Group Medicare RPPO Plan 079 Option 525 All Group Medicare RPPO Markets PRESCRIPTION DRUG GUIDE / HUMANA GROUP MEDICARE ABBREVIATED FORMULARY - 35 HUMANA. Guidance when you need it most — Medicare — Group Health — Individual health — Dental, Life, Vision — Pharmacy Medicare approved HMO, PPO, PDP, and PFFS plans available to anyone enrolled in both Part A or Part B of Medicare through age or disability. Must use network pharmacies. Humana.com C0006_PDG_09_FINAL_10 KC0808 M0006_PDG_09_FINAL_10 KC 0808 GNA024MRRPDGPLS09_200810 600? 1 /0, pan li ]Ail • • • • HUMANA. „u;dGf«when you need 2t mOSt Medicare- approved HMO, PPO, and PFFS plans. Dear Member, Happy New Year! We're thrilled to bring you this year's Haman Active Outlook live it Up! calendar showcasing some of your fellow members ... and they're pretty amazing! You'll read about Judie 0., who got over her fear of flying by leaming to fly a plane. And Margaret H., who ran her first marathon at 66 — now she's 85, and she finished the Great Wall Marathon in China. You'll get a chuckle out of Howard G., also known as Goldy the Clown, who spreads laughter at children's hospitals. All of our featured members are inspirational models for healthy, vibrant living. What's more, they're helping us kick off our Healthy Resolutions Challenge by sharing their own health and wellness goals for the upcoming year. You'll be hearing a lot about this exciting program all year long. All of us on the Humana Active Outlook team have been inspired to partner with you in resolving to lead healthy, active lives — by exercising more, tackling a project, leaming something new, or undertaking something else that's important to good health and well- being. We hope you'll join us by sending your healthy resolution (big or small) and sharing your challenges and successes throughout the year. We've included in this calendar a handy tracker tool to give you a place to write down your resolutions and track your progress. You can participate any time of year in the Healthy Resolutions Challenge. And you .can look forward to member stories and updates in HAO Magazine, Live It Up! Digest, and online at www.HumaseActiveOutlook.com all year long. The Healthy Resolutions Challenge is the perfect opportunity for all of us to start fresh and begin our joumey to better health. All the best in the year to come. Sincerely, Denise Damron and the Humana Active Outlook Team ti HEALTY RESOLUTIONS CHALLENGE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY ifYour Healthy Resolution: How will you improve your health in 2009? Will you eat more fruits and vegetables or leam to surf the Web? Tell us about it! Mail or e-mail your 1 tlewYearsDay 2 3 resolution and story to the address above. 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Martin Luther Kink Day 25 26 27 28 29 30 31 FEBRUARY 2009 S M 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 NACY W. Strikes, spares, sweet melodies... Nacy W., a Humana Medicare member in Clayton, North Carolina, am stays active bowing, playing songs MP on the piano, and counseling seniors. She's bowled in leagues for years, but started studying piano in 2007, taking lessons every Monday at a community college. 1 fmd playing Irelaxing and therapeutic," says Nacy, 71, a fan of songs made popular ' by Ella Fitzgerald, Tony Bennett, and Frank Sinatra. She also works part-time as an enrollee counselor at the Senior Community Service Employment Program. its a federal program that helps seniors age 55 and over find work at non -profit organizations," she says. It gives people the chance to learn new job skills and find employment." My Hear SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 1 2 3 4 6 7 7 8 10 11 12 13 14 Valentine's Day 15 16 Presidents Day 17 18 19 20 21 22 23 24 25 26 27 28 AIYour Healthy Resolution: If it's too cool to exercise outdoors, choose an indoor activity such as yoga, tai chi, or strength training, as long as your doctor approves. You also can take advantage of the SilverSneakers® Fitness Program if it's available in your area. S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 2 29 30 31 a Humana Medicare in Manassas, Virginia, stay around basketball Courts. "I play both luileart local says Jim, 70, the energetic the Team Virginia 3 on 3 team. A prostate cancer selves on the North Senior Olympics organizing and is coordinating the tournament. He's also regular, working out and -doing yoga. "It just Motivate me more." The - and veteran works *Old Dominion University i loner military personnel *ate .teachers. 1 help after SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 St Patrid's Day 18 19 20 21 22 23 24 25 26 27 28 29 30 31 CDYour Healthy Resolution: Resolve to quit smoking, but don't do it alone. Humana Active Outlook offers the QuitNet° smoking cessation program with telephonic counseling to help you quit for good. Visit the MarketPlace atwww.HumanaActive0utlook com for more details. CD CC S M T W T f S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 My Healthy Resolution: "Every year, I have to finish something: a family tree, a slide show for the children." • HATSUMI H. When she was a young woman in her native Japan, Humana Medicare member Hatsumi H. won a prestigious national dancing competition. But when she moved to the United States, married, and raised her three children, she gave up her dancing career ... or so she thought A few years ago, Hatsumi, now 79, decided to take dance classes again. She also set out to change her eating and exercise habits. "I'm so proud of myself," says the Fort Lauderdale, Florida, resident "I went on the Internet and learned about antioxidants and anti- inflammatory foods and what to eat to lower my high cholesterol." She also goes to SilverSneakers and Latin cardio dance workouts, but dancing remains her passion. "My body still remembers the moves;' she says. • • SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY rro Your Healthy Do you want Resolution: to help others but don't know where to start? 1 L 2 v 3 Visit your local senior center or www.volunteermatch.org for volunteer activities in your area. 5 6 7 8 9 10 11 Passover Begins 12 13 14 15 16 17 18 Easter Sunday 19 20 21 22 23 24 25 Earth Day 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 JUDIE 0. Judie 0., a Humana Medicare member in Mondovi, Wisconsin, wasn't always a high flyer. "I was afraid of planes when I was little," says Judie, 65. But that changed in 2001 when her future boyfriend asked her to a fly -in pancake breakfast in another town. 1 balked when he said we'd be flying there in a Piper J -3 Cub," she says. But I liked him, so I grit my teeth and went along." Judie doesn't have her pilot's license yet, but she's leaming, flying with her boyfriend once a week and taking the controls. At flying events, she's met famous folks like Brigadier General Paul Trbbets, pilot of the Enola Gay, and actor Cliff Robertson. Judie takes exercise classes and enjoys walking, gardenia, and hauling firewood. My Healthy Resolution: "Try something that's new to my brain." i!NfA:Y I MONDAY I TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY R Your Boost Healthy Resolution: your brain power and learn more ways to stay healthy by attending one of our local To find a class in your area, visit www.HumanaActive0utlook.com. 1 classes. 4 6 1 Mothers Day 11 12 13 1 1 ° N 18 19 2 L. 'mss Memorial Day 2`" 9 ,' -L z S 7 14 21 28 M 1 8 15 22 29 T W 2 3 9 10 16 17 23 24 30 T 4 11 18 25 F 5 12 19 26 S 6 13 20 27 HOWARD G. For Howard G., a Humana Medicare member in lake Worth, Florida, clowning around is serious business. About 60 times a year, he dons his Goldy the Clown costume and makeup to perform with a Shriners clown group. "We mainly go to hospitals, synagogues, churches, schools, malls, and nursing homes to spread a little cheer," says Howard, 75. We do most anything to make them smile." While he performs for all ages, Howard says he gets a great deal of satisfaction when Goldy the Clown performs for hospitalized children, like those in the bum units of Shriners Hospitals for Children. "1 find it rewarding to brighten their day," he says. "It's a wonderful feeling to help them forget about their problems for a while." SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Fathers Day 22 23 24 25 26 27 28 29 30 Your Healthy Resolution: If you have made big changes in your life through the Healthy Resolutions Challenge, you could be featured in the 2010 calendar. Just send us a photo of yourself along with your success story of 100 words or less. Mail or e-mail your story to the address on page 1 of this calendar. S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 > 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 eeping her wheels spinning — I\ bicycle wheels, that is — is the secret of good health for Estelle C., a Humana Medicare member in Metairie, Louisiana, who has logged an impressive 5,000+ miles biking in 2008 alone, including a New Orleans -to- Canada trip. The adventure traveler stays on the go to feed her passions: "I love the outdoors and I love to eat, so I need to exercise." And she does it in a big way. "When I retired at age 62, 1 left the next day for a two-week hike in the Amazon jungle," says Estelle, now 69. "In 2001, I rode from Los Angeles to New Orleans along with another lady who's 70," she says. They camped along the way, even spending a night at a desert campsite sleeping atop washing machines to avoid rattlesnakes. suon,fliose8 AW ;IeeH j9iOW sin! pue•" sappayos sseIo 1e30- ■ spool anpoeJalui 6pueH • SeS1310x0 dais- Aq -dais pale4snpI ■ sadpai snoiogap `Atpleaq cot UeL4I wow • sapRJe SSOUIIaen pue geaH • :6uipnpw `sexual gm pa){oed si ajisgaM asn- of -Asea `un siul -wonooOnpangoyeuewnH MMM ps!A,a6uail L13 suopnIosaH AtplBoH aye a noA dlay o; uopeWJolui ssaupaM pue way OJOW IUBM "ACTION s a great restorer and builder of confidence. Inaction is not only the result, but the cause, of fear. Perhaps the action you take will be successful; perhaps different action or adjustments will have to AS HUMANA active MARGARET H. Talk about over- achievers: Margaret H., a Humana Medicare member in Concord, North Carolina, won her first marathon at age 66, finished the Mount Everest Challenge Marathon in record time for her age group at 73, and eamed a Guinness World Record as the oldest person to complete a marathon on each of the seven continents. She didn't even take up the sport till she was 64, when she attended a smoking cessation class. "1 quit smoking and started running at the same time," says Margaret, 85. In 2008, she won a medal for being the oldest person to run in the Great Wall Marathon in China. That was the biggest achievement yet. Climbing all those steps wasn't easy." She's a National Senior Games gold medalist in triathlon. MONDAY 1 TUESDAY WEDNESDAY THURSDAY I FRIDAY SATURDAY ( Your Healthy Resolution: 1 1 Are you experiencing difficulties with your healthy resolution? Evaluate your progress or the ways you're falling behind with the Healthy Resolutions Challenge Log. If you no longer have the log, download a new one at www.HumanaActive0utlook.com. 3 4 5 7 10 11 12 1 14 15 16 17 18 19 20 21 22 Ramadan Begins 24 25 26 27 2l 2 , S M T W T F S 1 1 2 3 4 5 ES 6 7 8 9 10 11 12 s- 13 14 15 16 17 18 19 20 21 22 23 24 25 26 ,, 97 7R 9Q art Domingo C., a Humana Medicare member in Shavano Park, Texas, is used to covering a lot of ground ... and water, too. He and his wife often pack up their fifth wheel — a type of travel trailer —and hit the road for some camping. "I also enjoy fishing from my boat," says Domingo, 70. Tagging along on the road trips are his four Pomeranians: Honeybear, Sasha, Gordo, and Chiky. "They're like family, so we include them." Domingo also makes tracks on the dance floor. "I like ballroom dancing and Latin dancing," he says. "It's all good exercise and fun." Then there's bicycling, working in his one -acre yard, and swimming. "I keep busy, that's for sure." My 1Inalthy Resolution: "Stick to a diet of healthy foods, such a ;vegetables, and " fatty foods." • SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 1 2 3 4 5 6 7 Labor Day 8 9 10 11 12 13 Grandparents Day 14 15 16 17 18 Rosh Hashanah 19 29 21 22 23 24 25 26 27 Yom IGppur 28 29 30 Your Healthy Resolution: rfMake a play date with your grandchildren.You have a lotto share. And if you live far away, resolve to call them more often to strengthen your bond. CC CO O S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 SUNDAY 1 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 1 2 3 5 6 7 8 9 10 12 Columbus Day 13 14 15 16 17 8 19 20 21 22 23 24 5 26 27 28 29 30 31 Halloween Your Healthy Resolution: (=J Did you make a resolution to eat healthier? If so, be on the lookout for the Humana Nourish Member Cookbook wit recipe makeovers and loads of tips on how to shape up your diet. It will be available in the MarketPlace section of _.. u..____►�r.._n...� or„rne,ir fmn, ,nnLhnnl, calm will ha dnnatarl to Me k O0 WhPPIS LC LII S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 77 23 24 25 26 27 28 She's got music, she's got rhythm. 1 belong to an African dance group, and boy, do we dance," says Ann R., 76, a Humana Medicare member in Steamboat Springs, Colorado. The dance group meets twice a week and performs at various events during the year. "That's when we dress to the hilt in traditional African dance costumes," she says, adding that most of the dancers are local community college students, and she's "the lone senior in the bunch." When she's not dancing, Ann doesn't skip a beat. She's a downhill ski racer who's won gold medals in the senior division of NASTAR in the past two years. In her spare time, she serves as a volunteer forest ranger — preserving the wildemess is very important to her — and also volunteers at the local art center and hospital. 4L'A s MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 1 2 3 4 5 6 7 8 9 10 11 Veterans Day 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 -thanksgiving Day 27 28 29 30 Ati Your Healthy Resolution: Have you gotten your flu shot this year? October and November are generally the best and most effective months to get one. What about other important screenings and tests? Check with W ; w s 6 13 9n nn 7 14 91 1 2 3 4 8 9 10 11 15 16 17 18 97 71 7 a 25 5 12 19 26 'JAY If pux !Humana Cdaiatlo Summrti pullfin hitting C mJUry" sevsJav could re closed. decided JAY AND SALLY B. If you want to find Jay B., 78, a Humana Medicare member in Frisco, Colorado, try the ski slopes nearby in Summit County. That's probably where you'll find him and his wife, Sally, hitting the downhill runs from October to July. 'This year I skied 240 days," says Jay, nicknamed JayBee. He could have topped that, but the slopes closed. "I beat Sally by two days this year." One of those days, Sally, 74, decided to stay behind because it was 20 degrees below zero. Jay — who took up the sport when he was 50— contends that no other seniors ski as many days as they do. And he says skiing is keeping him healthy by helping control his diabetes. Last year, a knee replacement sidelined him, but he's rebounded. 1 doubt we'll stop anytime soon." Our Healthy Resolution: "Exercise' Beingat over 10.000 feaion thestopes is the- -, best medicine yet." e SUNDAY 1 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 1 2 3 4 5 6 7 8 9 10 11 First Day of Hanukkah 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Christtnas 26 Kwanzaa Begins 27 28 29 30 31 New Years Eve n •. T 1fl1 T C C Your Healthy Resolution: Did you resolve to make amends or forgive a family member? Letting go of anger is important to your mental and physical health, and you can use the holidays to show cc 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 NORMA N. The plays the thing for Norma N., 1 a Humana Medicare member in Independence, Missouri. Norma is a master decorative artist who not only helps out with the sets at the local children's theater, but she sometimes acts, too. She's an active member of the Independence Young Matrons, though "the title's a bit deceptive because were not that young," says Norma, 78. They stage a play each March for more than 5,000 schoolchildren. Last year, Norma got a kick out of playing the Duchess in the Brothers Grimm fairy tale The Elves and the Shoemaker." 1 just -- love to see the little children," she says. "Their eyes get big as saucers." While she gets plenty of exercise running around, the bouncy Norma has another fun way to work out: "I use a mini - trampoline in my front room all the time." fAY. MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY R Your Healthy Resolution: Q It never too late to improve your health. You get a second chance in life, and you can start today. Visit www.HumanaActiveOutlook.com for diet, health, and exercise tips, so you can live life to the fullest. 1 New Years Day 4 5 6 7 10 11 12 13 14 15 15 17 18 Martin Luther King Jr. Day 19 20 21 22 23 24 25 26 9 29 39 o a S 7 14 M 8 15 T W T 9 10 11 16 17 18 F 12 19 S 13 20 .sueld SHd PUe 'Odd 'NM panoidde- aJealpaW 60t0 ali8NE0VN9 9000W pieM JnyJyweil /W — i g 7! awoaaq uea coif `il warp ueo nod y :p °nappoe ueo nod 7.! eu16ewl ueo nof ! 5 lour Ixau li Id /ltua 'atop pLIP;'ip'�iltn fnogP pap,l1 ° "II un" ]IIOCI! pajl Y ltrnll(i Ilt low) 1slldulo^'m 11L SUNDAY I MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY Your Healthy Resolution: Read the summer issue ofHAO Magazine for Healthy 1 4 Resolutions Challenge success stories and an update Independence Day from the Humana Active Outlook team. 5 6 7 8 9 10 1. 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 S M T W T cn F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 10 1, 10 10 90 91 99 '4* 4 a+ld. ' • c euewnH and T N as A E E�� E Pm d- o- W M 43 ea E N E 4 la e g !1I 11 E O 0 a Q e x 1 Q LL0L-1.0Z017 AN 'apinsmo1 LLOOPL xo8 'Od auize6ey� OVH NOW 11 Daau no/ uagm - 18 TAKE ONE STEP AT A TIME ENJOY YOUR REWARDS V r = W z 0 10 GET INVOLVED El SI NEVER GIVE UP COVER PHOTO: Nash Baker Dear Members, m E as 5 a c c" c L _ U o w +° o y �, > 0 0— m m � yp� - _ ? _ : o rill F � y o p p N E .' C .0 c E E a) OL O O y 2 O V O) y O N y CD ` -0 O 7 Q -"0 mm c 3¢ 5> m ° %t > ffi OC 2 0 ° c.w ^ lO .g, =xt f0 0. T O U y '.�' y _ O `d E moa3 m { O° 0 E 8bw 0E >> mO y cc t - 1 0, -0C t O OJ N yy d N t 7 d Y m'a c d 0 y m� 2 w !-a o�Eo E >�� - N m Y ? d E y y c C -0 3o O W Z Y Y O Q C ii O - 0 0)d ° E c> m = p 0 d: C E 5, = m ' o ">> H o E E $ � ° t d -8 Y m Y • '� v °) y E o n • E ▪ •Y m m >'°m a O A O 3 a-) Ail E_ tel 3 3 mt m� L'` C �,� y Em; L S d 2 = o E H a c o C d mt.E U w sOS 0 C • d w 0 C °1 C d L d U 0 co 0) C C 0 CO • ND. E ¢ U T 0 L d ca d d C 103 C 2 :Y ,fl N d a+ 0) 7 0 C 0 0 = 1O d O N O 0 L ▪ = O 2 x 5 Tc+)ov O E m X N TW=ma oa= oO :J to know more? Go to www.HumanaActiveOuOook.com. 1 E C1,ys R5 t O 0 CO 0 N 0 0 0 0 Q m a) E E 3 L n1 m y o� o Y m 3 m U co N? � N N L ▪ ? U 0) N �/ � = N d O C C Y "O d 'O Y E @ N g._ C@ N m O NY 'ffi N rn 3 YJ co @ N .2-- @ -6 15 CD g 1.# @@ 2 m co 0 N> x N co r m 0) E@ L C. 3 O — o m o N a m cm .c 3 E M� c CD y o N@ ._ rn? m m m L aNi m c> °' N° 4' °' o r i if2 2c-, E ?7_10 0 .4 -5 r'' m @ �� > O D 2 • co m O � C - cpp N E @ > l W N O N O.0 @ N .9 u) N O N_o O O it @ N E ..t. -cc Y p r- - Y w N "m d" @ y C E 20 >o C @ u_ cn cw N a) 03 w � @ L@ �o 0s2 0 OJ @@ w 0 w E p Y U 1E1m m C.) G D G a t9 C7 Z �' N v, 2 03 Ii-4 m tift wo! C W H /c m IP TimINJ Q u • y r • I talu S y p o s V. on'v a a.n a 3 R u v , _0„... s ��x „.a o 3 u o" T > vxz o v' 30 x c c g w. ju - 2 g '� o o • .cln..e `E°,.ryuyc Bv- c,°o4v1iY °oG > 0q4� c o E o m xiX > o o•E w. g o y,�w o'Dm °gib m.Q a�P'a 8.2u ° aL v,X F. jump CO e0.. 3 m O N ° p0 O L fl m p O V G N O is ,.. > E .L , .,9 ' E 7 D d E 4 a oo'y . v 2 Nx.E ° gn corn° e°n? n.cm,a y a d' ° v o b 0 u v .L m O h0 �, v •E °v, iIii a,� a� V �. V` • m .Ly y m-d v C =. o v v W ..EEpap� .> °•�b "os . •a: o 0 m P .e3.oc 3v .Ey °A g o) >- a) L 1ufl�H E OVo= LE -) N vCca c 4-, o Ch CO 0 cp CO CO O CO N �• 7 C t L t t0 O U a) a) 0'5.74` r°cc47! st12 'Dmrn N C d (0 +N O m C a N E ■O UL' O m Y 0) L C j 00) J CO 02 y C T 0) 0) 0 N L C CO — a) () • Co) 40 • c%: The Rewards Are Huge BY ANDREA GOLLIN • Focus on realistic goals. • Get started right away. (0 N U !3., _ 0) C `C (YO'� ` 0 ++ U C O.N 0) O -o E a C 00 T o c 0) 0 . 0 p) >• N> 0) Y C O d C 0 L p7E�E.o) H Q .. ai > a) 0) C Ol O L a, O) CL = v -0 L 0 0 0 C C F- Um> -. — m • Eu FE p' ^ 0o. 8G A t v m e A F, (e o v G -8 ° c ,912-0 c°xfa.o k . ❑ ,.°� � ,� � .6 Go w b �" Ir •a T s a" ° �•�a (a w 4.5 9_ - o u oE- w° w 0-0 3 A a • Ta as ws my o 3 v a d° c` a �> �> -go > y v 0 3 o p77.0 a' 1 '3 rn i° 1 ,Y • O .y �-yy NN y0 0. O O [[ U u b v v W w 'O G '9 u u N 5 �f A 3 la u Op� .0 v L u .0 �. m 0 n 0 n '4! I ..0 E" " 011 T > on V - p °,,,1 Ts va � I . c 3U ?'Tu o - s o -s v o 3 o v a• a', O - ,, C ,N .0 m 'C p '1 w " '0 � C v 2 v . ° v O A • v O to ?"^ i v ), c s▪ n . ..p -6 .s5 x -o c v U " v O C m S'4 W C v x .E c �°u�°c a E_ G y o 3 c ^ Z y 0 o .r t y >.. o v 3 v �. " Oy x ,i >, F . m X w .� A w m °. y W " -va u .0 H . `C H L L▪ pp . N o >_ ." C h t o O v.oa E 9 b.° _2 'ro v •B R v h0'C ED O 1 H c 41 PS U • „o>e,hxey.T. =g .a •0 LI. o ` T p :0 w^ m G r s g L u c >. c> v." r ' ^ TC p >, - x 3 acCB .c .E v 't o s N p v y m („ . xo v o tg v I C a.� p a y ,* v ✓ t r v m v 8,d , - y o s 3� w T A � o xL) 3 W C W L v 4 a 0 U C �! N a' .G m s v o o W° u o 9 o 2 1, 0 p ? a [ u 3 av coo ° > 5s > ° P o yx ti i' a,°(��°�wmyon Liam a 3 b C m v C T O • a GQ v .° C v C,a i.x 0@a n-0 T` v � y0 3 C H u v 0.l v ea ,CO, y 0 p la ti p v W (Ci 0 �: N ..2 Ica .141 -8 3=8 N •-' fn >• • ++ -a w . C N c0 N f/) t6 7 co >✓ ci CO 3 N s L Qj E c0 C Q) i) G) i � +_+ ti) (C ++ Y N C U N co 'C - y i ca C) —_ N N O c c`0 v > E ca }> 2 O c 3 • O v no Homana11e0ve0.Nook.eom 7 0 p 53 'Cr) o O co m O ° -O m N h • 4 S m L > N T C `• C ,m m Y O T • ....e.. E F 7 '' 'i ! o & O m • • • • . • • • 5mc NU -O7 Ca CD X I VO >.° °) �> j. il1fl • + O T d Y O N G a T N O m m co T `' Cm Cp E ami ai ® tv E L N t m L CO ° m •- O. ° N 0 = ,1L Y o m bN E m C a y m (O N N ; m O m L Ca gf0 Eg co m� v5E o °) m v E •.. co ca oYN mccc co >L 3`—a°6 m o.c3 Z C •' a) m� E c n 'y ° c EY \•� ,,ca, " `° .a3' =a .�° :7E: E I E co 0 CO CO ~ l0 0°'cm` ° �°mm co �°)„ c°)c �LmY �: mE—° h �'y' U E cL� m° — Z+ �� �i o �_ E m Q c eL> C m b O 0 C m m C Y m N C 0 (O N O m 0 T O_ L _ m m 0 O .>. V O CO N U 4-, ,O E. U Y-5 � A m ++ O m L C E m m L c n, o o- N � c 3= > a 3 c C H= ec °c mo. >_ GCE E ooy 0 °L ' "E o> rn`m'm ®.. .S - c (O O N ° m CO CO L T° ` $ '3 T O) C 6 O) 5� 7 V o m m i° ° gym ° 7° m m` 6i > m 0 ca m .E •E O U E a) S C L WL.+++ • S L E C7 Y C O m I1!IIt h C 7 C)YC� H g . A.c . o. Ez a a t0 8 ;6 . o x o OZ mc a . ea .§ . o E m m 2 'Y 6 c u ''3 v>. `.A R.2 .. E e E E I 2 ' e° � ° .c �'b i .2, _ • -. ? es aEob�Aip �y a� O v .'v' L)) w � �a•° ❑ ens 3 3 .� ° a � ea o ^° ^�eq'" 3 oyC v Shy -°0 ear c 3 ° 3 Av ° v p °L v v 0 TA v -0 " O O v 0 0 ..0 bA � A' 'v-' 'D W 3 fi 0°Ra. a.3 o eoea a° a o o C v on a 3 v oa Se 6'a i 5 M z 1 o. o >w y 0 .0 C oa04TwH0 3w v3 a v .� c o to o o �--. > i"3 e o E o G Q 3 v° ° ): °-2 R, �. 33 o ii • m O) 0 E ° m co co oL m 0 N L+ EL"O —+ o( c m N -0 L 7 C m O 7 E > 0 C cO v CO Y 0 E m Y 7 m m CO 0 co L 'aul 1y6!fauid jo Asavno0 :S010Hd 8 1 1 S a c co °v C o 2 m w c E m N O N 3 m c o — a) C C m o m N m T ' 0 CO V N > •C 07 L m ) mLE�O 9 _ > c) a) E CO c- 7 0 7 w > O W O >- QC C O. m O) a= 'cmF.c_E L 5 -0 W_ •N ° CO >m CI. Y C `. m `m z 0. O o) m c oot 7 'O O C N Q 0 m m E c m 0 CD rn— o N QQC L _ 'O U O - ° 0 m ° l6 m L'- c 0N- C L lc)" N C N m A L o_ E "O 0_ E C c a) ° m m o c./) c o_oy C., CD m N a) ` E L m m O E 2 m ao.0 E m N -D-0 E E m co co 0 ° co 0 ,a2 7 0 m 0 O _ L N Z U 03 0 0 mc Continued on Page 9» E d c = ■2'-€ m >J — mQ U =L _ EWE ° CO tea° = NoEm m ae.N3 Y „33 yNy moo = +cE'oi Loo N W D J tW 9 E - z C co N -• rc i O -= c'-`' E — 45 cO c °v`mE O �02o,° c'cmm ME }' O y�Ec-m p O WN C EW c —c+W ooQ' O E Y U d r c m O w C Y L N O. W O C N W L W O LLL N o L T _. 92 C ! Y Y L o' N W h C d Vi D W o moi c m cu -.SW CD 0p W y dN L m ` C CL U O 'W dO N c . y T 'C 0 V � CL qWY C m m CO.R O_.. mgmE_ O _ O mn 'c . o 2cL m C. LLoN �tNL,o� C' coY 01H `O 7 . E ° a) o c co . > E a i i=` / O ' m ; ! E '� N .O micoti m 'O H ,05 >�cE'EE <5.'3 34.=,2 a o0 � 0 � BOO .°_ Plowy IlaN.O :010Hd v Ou v g io 1 y v ❑ T 0� Q v CG A " .� .A 'C C � ' . T c .° v n .� a .L oo° y q v , C 'A A''[ � i 5. 3 'E Ti p v 0 yN°'E•5 3.�e °° voY.? aw -,>, A roll , T..0 c > su 5 ay o m 0 q° .9 2'� w �C� a' >� y u — .an o, , 71.7,84-8. y° c; o •3 y yw ° c g o y° ,0=' :s- 0_ ----•;,,21., , h a w - ^> O .0 " y v t is v .0 V vvgi C v :4,i),91'. ,v : v Q y . 4 �e 8 N E 41.9-Er, v y ro .� (d A 7 CD �7Z 7 A O F� u U dC •bp O ° 2 5 o (« �' g .5 U (.., v A, 0 O • g o p v U C 0 U q �T' — v p N 'D .n p T a 6 O ^a C Q O. y e,.., u .F, 0- .:: O x, Z • 9 eOe y L. ,, u v v � '�-°.� � °z v!c ux � ° °� ° w>C 0 O i� �'�'v ^"° N ux aii1 ti o E n. a . uxa T� a onu- ° >•,;4 :4 .n .;:h' "x.T2),,... ° 9. o o S Cg Q m`°" . u u.o o « & �O g e u v o k v u °c vz y o av m.n g u,.;; c a,o E 9 3: ❑'may, u LE li o g o v „1 y 6 x N .� u w o a0 > r D p p' v P' o G 7a' q" G 0 x O 777 L c L • • 40 • • •Cr= i LO N S O 1. = E 1 e d e O C CO atm-. O m 0 .0 cma c W m o E > m m> G m -c V m y E m Z c— m E > m 3 5 c CD o t C E ° Z CO 4'n m m o W o Jo cs 0• 2 c p w W m® m m m m o xt ca �v m E E ov Y • 0 m ry 0 0. �> >WV —ma oa - w ` 2 c m W > a+ wm 5“3"; a 2 m g H L mc m m W E E U.a •oti Egs mt.) E M Me M Member M St Topic you would like to discuss with a care manager: 0 0 c > m s. a°Ei E Ja y ca c c°o 0 c 0 Iii ca c a c m E a) • t ,_ Y 0 Eo rrn o 0 >❑ 01- C v cta Q Y 70 .a) a) = pcp �>a °a m > m co 2 p V E Y es O > d L Z S 2 .p C -g- ca m 3❑ E❑ tp� 8 m _p 'a .r>O -_3 Iii - W $ ;3 m 0a� me E=c c pi5X C >N m .e C r, �m E; Td > crs 0} .0 i oo 0O m10 2Sa ❑30 a =a. 0 CC Q m U < 0. • ti ri y 2L.,"0,8-5 7 c0 •,V^ H A C O C N C ,V, v o •O ' .° 0 00 �`U.y ux y O •.�.. p..U.. to ° ro w w u •0 • gw yu. a C .-4 d ,u, C •y 7 0 A O N V .9, O. � ce 6D i^ .� C O y 'O 5� 9 V 5 O M Vs i, y y aCi O. w C'� O s a d o paaz N 5 8 d • • . • w u --' � •v m D '� v vDL� I . u w <1) w w T C O E a v7tri0 i � C .d . d Cg 0 Fq w N O o w u �c o 3• p h w O y 0 .a X i O p2 rM O O 7 O 'C ' •b y ,� ;� ey N -0 -a .0 •D 0 T 0. 0 �•fl iii` p b u 2 61 w O g.4 o = Ca "2 • • • • • • • 3 o• • • • O a .3Pi+3 U N t, r,— ..4 -0 0 . x y > .�e o ,. o y v a "' "a 8 ..-"' 6. .A c w b° 3 t 3 1 a " u >° > C o q ^ o 0 3o — _2 3L'.2w ao 0 O er O X wU ai —.A 0-o,›,1), a U ,T -8 d rt .E w an t 2 F2 `d C x q a. O. 3 h - K u y O O g T G O N 6, .�0 ., w o ° > u v v > • 'O O bA v y N d > � U N of N F', F O o F. °"^ rp o '1 ao t) O o.E ca w A r .,3 v G. T ,u is g + u O ., .". C O O N O W O 142 N O 1 V C C 1 2• w 1TE y 'D y A L 0 E= E V u V. :y ...9 7.1 E . '0 a U N H. 4 it,' O h y„ v O d° E •5 F a u ''eb b xx a o .. ti '5 t c5 o o .. • T ,A •� C TT C N N x O O. v w i O p N -O-- O vO iv ..0 . Q 4O + < _ y O T u'E c O 2 x N" • U C w :1 s. C 7 ,E .O O u O. y, i .-a O aa y Iumana Social Workers o m y m L _ co O C -0 co -O c F@ Y c U > 0 0 @ @ 3 = m v, E > 0 0 0,•y _ •0. @0_ O L m E0v0,_i 00 @mo E . 0 E. �._ m 0_� a w w n > L y q fn a m@ 2 C? 7 c L a) m .y @ E `@ @ U`> Y@ d m y o L O- >> c E m, -, 4- @ 17 -0„, 3 0 "•O m e y-0 OY =C m a c m c 0 C m a).: 0 m o)7 @C @O.m m -OOO e ao -/- L., 2Ec.L.>>>`"0,E`cm C @ U L_ co @ C @ C ' O E 2 2 i m 17� @ ns. d o, 0'a 0 m 3 m co cLi °'� @ a`i m °L 3 °cam o' "' Y CCO M d A G Ma' ,i d L U m y 0 c 0 m L E m 0 L c Q d m Z 0 L m m 1, EE.y>- _c .- o cy-00-0Ecoa >Ct 0 O •C N V t-+ N N N @ 2 > >U U V O L of 0.0mc E E ti y� Z -' m aa @ V @ C m to L U Y O E O j L m i N @ — = L L O o O @ L > y m 3 0 v 0 . o ' .1g 3 QJ m O- o O E V '5 0 j)„," t co § _ • \ (• § © B ( CO CO 0 4-, \ k \� §k o \® /) @ .a© {E�f2) 2 ■ a 2 @5/7{2#2 ca & \(\ 1 c 1 26(_>�a }co! .iot§ =� ■ co, • .§ §c° kk3( ;f /)G2/ o M et § / §I �;� © >-u 8co} ■&=(0 -(-0c oc [ Mill =0 •- ■f#§ ( - - : _ e , E 22/63 G$\(\ {&G) /j zse ■ m. /\k $ %)\k)\\\2} f &� !]k- 6°5I!1 •2> (t;$ 7$62(.2,= (2k }$ §f)%t§ff$ 1 a .CD n 3 ;13 i _- — (k]2fi32E@k •= ■��`�§ ■ ®§ [_{ ( \I< trial i . i :[a /■ -- =0> -!_(0 UJ co 2`k {fay } 12 a 5 v u A' 3 v o, x ._ O vi v t .E .. ip ., '0E5 p 0 v Q V �.•� u o s 1193.8 0 p u p. 11 0; ° al € coa,5 v1vv QW 7.09 u�H�'ti °° v— a Q a ao 2 o 4'Q a v 8Q y B 1 . L E g v ii ` 12 Yt t O v = ;2° BY TERRI SMITH 3 0 fkim IA 3 umenellntiveOu11ook.nom 21 N c o G IW C x, c a qu a =. . t--4- [ c .9 r o ° E a c -1-,.2. O U v p° u° z °�� Q T §.5 .1 v 8 m 1 09 8 'u C N a y v p t.• u O Z + h w a. . ri. v v v O C 9, ° � 3 gipy , u � E o o N ' _ O r.A p e ,2 „ -s , fi , V �� Wv w.5 v h rS Y YN V • O4 y ' 0 pr t Va ' „ o p1 o p . y �.U? X 4'"�O : V uu tr n e28L. w o e❑ u 'a 1wd ? a74 0 E m E u G.a� o.0 .gi E -eou " vc� 'p0 a o E.mzix " o o 'n g 0, � a ,Esau 000 c 2 Y aO ° c ° n a a d E Zti 7 , v ` y ' .o ° w, U d O 8 . 5 n, d xU� a.E u y dtFO r a A , ay Y w . .E u H t w- L. .� d O® " O m 0 'O O yw O^^ C O - 'E O y 0 p p Ci O • O v 1p O ° .n c= h g .0 c - c ° o 6 . tai y§ o '> ^u--11•10P0 w b cc C 'd 'C ,, Q o ili °, v v Y_p, - ° 8 E - A x- ,3 T , a m E °58c 2'tl2 N sas 3 . p, litii "4 , x o §udg o -=°Hti - o0y,".0 le v 1t. ,2;4 o98 o V o StA o 1Qq °"' U 7..J L H 8t u A. R 'C m n -SR, • •. L = 1 big C1 a C O .m v 1 C ft N 4 N a .N i+ PO / d Z a •y 2 ... CO it a O1 E an o 2 O1 m e C o° Y R `o�. i ~ c gyp. =t p i o c QV = d v A Z.-.* a u ov1 L o g L E N cn el a E o r ami i p v > o q °J _ �a �' 0 0 N w ck t c? r . v Q O� o A E o E N 0g .0.= N A E GO O v L - L A .� W� to as g n. M m m C m O i W N O. m C > N o m $ 0 L E n m m N ^ ° co m ° a) C 0 f 3 0 0 c 1 o W • > I .L O m = y t E E ;n m c G m o amo vi m CO Cm =vm N m n v >'�Z E30 I• oa mm 0 E �Z o =ym mm oc�o0 ° e°v o�a'a3 .Y>' co C7 , o >'A W Y • 5 E c m m t YA Y m m C > > m 7 Y ▪ 03 m m C O C C N C O E ICC G a W m >� C O N = w nm >3 ai uC.O yEc'3 N> m �'m °e ms t'"?.'-al o�Um �u0 >Y. m m E so o� a. -.,g >0 m Q 5 E p E J LC, ° c 4 o E �i m m c �1 0 N y m m Z C 7 N • aQ sg A m 0 •. m — mY • C O .°-• 0 m o. N O S • >, m y E L A 'rn m a r )Ca 0 1 ilf.. m C 2° m y Ym O Q W 0> }• Y CO > 3 m $_ ° • r E m m o ZC 0a' tE °> E� a3c ma 'm °ma°i"n OacW m ,o —°m =m d > m1 -c�v HV «o E me n"o mE m O i E 0 >j m p E O J W L7 LL y 0 m C C m e O o 7 p. r9 o O g. o �S >2>20O> O • • • • > v m AE o N O c u Jt C am-• _ c O a 0 ° lOCmm� c-° m O O 7 m .?0 2° m C E W c O N yt Ti •y y O S E O .0 . o' m o m c C ° O 0 N N m E t C S m c m 1 sEo •E> L O- 0 0 SO 03 t .O O W z N `. 'O b$ 0 i ao°m nos °C0EE3 LL m`oarpa,m 49 a) a)1 w.rsy°E'.N --.-0m n. ccNe *m Y 1 m rn c0OnE o�..m_ c 0-E• ! `a g �L�i u ' .0» c 0 °a > m m E"' as 0 E C 3 '0 N C W CO .2> ,x O m 6- C> N 0 y W 'P a)• E a'mE °°2inc n" "cE0m2•c m nN 7 L.' m .a O 2 m 0 o o . O ° c M C a C m C N E= m'>o v mm0E� > co 0 u nom •mn mvg• E e 7 y C ' y v rn y c K > 0 > m> �= f m 'c ' ''' E m > o m Ft O E ° m E N p y N E 3 0 1 N 0 m O 0 p p d O m o .'0 m =- c m o = ° m m `° d and = E w c a T m oo 0 nL "° v m ..N 4,10 'v 0 m m O m c y r n E .'i a` n?E c m �jm m m o w m •E o • O" x ° Y E 7 L ep y g Z m is m 7 .L' 0 m cc�� o :sepals 0 Q F- - L > N Q .y > y > 2 O 3 2 .9 co o. • • r vi O^ M N x w O> c 0. i o Q py o 5� CCWW V) 4x L= ! •? Y F Q W i I V u O'Cia 44(******** (n cJG W a V3,1 0 niba "O m Q O ▪ y> C 6C1 m c Y ` .., •«. • �, c ,- . „, o � � E Y m - m CO a3 n N O y SO O "O .N w m m c m e C ° as c .L.+ ° '6 E 0 0 O y a7 C L y d t6 m U p L O m r al 1 N m d C 7 0 m 0 ,C SO :=3 = m 0 0 y•� O m. ayi m E • E E y -o N m C R +L+ p OC 11�f c..‘” C E m C oo .° a+ 7 L C C 2 m O SOS _° 'EO L m y O - O r. N= E G'C m m 0,° E. • C O fa N d °. O O L N y V m x .(1:1 m 0(.0 Y S- OO � s �i O y m C Z L m m C: L O 2i -° C m O O E Ym ami � ° 0 � 0 (0 oa c c o °72 3+ �'5 E • yQ and ° in naQ.O E owe E o• @� E ▪ m �' "7:6120:1 Ot d y m3L m E+y.c.°•` -° uem = E .O E yL. O m>t m V O D` *go ^ Y Y E °.L Q O N'3 C O O y 7 N d SO O' C C7 y {T m 3 ▪ E E .L..• SON fa E '2 Y 0 o o E .c - g oc � � y �a a61 y t Y m y > j O +°•' m� _ •0 O > (/1 Q L O H C Ol C m d G O' O + m p 0— m y =w..II AddC o v L d n ` 'cis t�6 E > oyi °' L 'a '_ L u m° y F— E o L 0. L m L d_ 2 U.- 0 oV8c.C . v vC . C 8 9 .5.- K, g bn ° v . vC O A � 0 7 F eT Y -Y B . 0 n . >9 '4 5 x Ta> 74.0 s - �O ? O , It. w W 3 Y v N c N , ^d Y L 3 Y °' Cr ° c m y u b Y u , .V. -0 F > e•+ 0a Q F O Fu — - O h - -2 u - co Y .1 a. L. C ; � R u 5 v a c c 11 u vi �o� Q x 20' ..v L A 3� Oi °' Y c — 3 Y � 3'u � c ��-o I v Ya GC d !y 1.1 C Y ti For answers, see table of contents. Make Humana your choice When it comes to health benefits for seniors, every organization has different needs and preferences — and Humana responds with a full spectrum of practical, affordable solutions. Our efforts are sharply focused on what's important to you and your group members — before, during, and after enrollment. Our unique capabilities — built on 45 years in the healthcare industry, more than two decades as a Medicare benefits provider, and a deep understanding of seniors' health benefits needs — make Humana the right choice for your Group Medicare benefits. Humana and Medicare: A successful long -term relationship • 4.4 million Medicare beneficiaries among Humana's 11 million+ plan members • Offered our first Medicare plan in 1985 • Introduced Group Medicare benefits in 1991 • Added Part D prescription drug plan options in 2006 • Remained a major Medicare insurer in the years following the Balanced Budget Act of 1997 — when many other insurers decreased their involvement with Medicare Advantage plans What this means for you • You benefit from our longstanding relationship with the Centers for Medicare & Medicaid Services (CMS), the government agency that administers Medicare • You've chosen a company that understands Medicare and responds to what customers and members want in Group Medicare benefits 7��' NA �" when you need it most Our total solution sets us apart from other insurers Choices Broad selection of Humana Group Medicare plans: - Private Fee - For - Service (PFFS) -HMO - PPO local and regional - Prescription drug plans Savings Flexibility Ongoing support Value -added services - Competitive premiums - Low member cost -share - Coverage for annual routine physical exams - Worldwide coverage for emergency or urgently needed care - Health benefits packages that fit your needs and circumstances - Choice of contribution and cost - sharing levels - Dedicated account executive - Dedicated implementation team - Initial and annual enrollment meeting support - Health Resources to help decrease costs - World -class call center for members - Fast, accurate claims payment - RightSourcesM mail -order prescription drug service - Medication Therapy Management program - HumanaFirst® toll -free health information line - SmartSummary RxsM personal finance and health benefits statement - SilverSneakers® Fitness Program in most markets - Humana Active Outlooks"", a members -only health and wellness program - Humana Active Outlook® magazine Contact us and find out more about our Group Medicare products, programs, and services. We think you'll decide Humana is the right choice for you and your Group Medicare members. Humana Group Medicare: Phone: 1-800-788-0506, ext. 6365 E -mail: GroupMedicareSales @humana.com HUMANA. Guidance when you need it most GN1518ORR 8/06 Humana at- a- glance • Fortune 100 company with annual revenues of approximately $25.3 billion • Total assets of $12.9 billion • Net income for 2007 of $834 million - up 70 percent from 2006 • Investment grade credit ratings from Moodyt, Standard & Poort, Fitch Ratings, and A.M. Best • Medical membership of approximately 11.4 million • Diverse portfolio of health and supplemental benefits products and related services • Industry- leading clinical, network, e- health, service, and technology solutions Community Responsibility: Humana and the Humana Foundation contributed more than $9.7 million to charitable initiatives and community organizations in 2007. Ht r to n 's Value ,rcp3sitl c : k To deliver the Humana Guidance Solution' to provide lower cost and a superior experience for consumers. Humana's, Guidance Solution The Humana Guidance Solution brings four key disciplines together for coverage that works. • A complete range of products, from traditional to consumer - driven • Clinical solutions that focus on wellness, while addressing acute care and chronic conditions • Financial tools and forecasting that give members and employers ongoing insight and results • Consumer education resources to give members greater confidence and security in choosing, financing, and using their benefits Product. Offerings Humana's products for small businesses (two to 99 employees) and large groups (100+ employees) are designed to address a wide range of life situations and meet members' and employers' needs and comfort level: • Commercial Products - ASO - Administrative Services Only for self- funded medical and pharmacy benefits management - Fully- insured groups - including capped plans for Milita 5Services groups, with guaranteed limits on cost increases over several years - Individual products - HumanaOne Medicaid - Stand -alone pharmacy benefits 5 %* • Government Programs - Medicare Advantage plans and Group Medicare - Medicaid - Stand -alone PDPs - Military Services • Humana Specialty Benefits - Dental, vision - Life, disability, accident, critical illness - Supplemental Health - Behavioral Health, Integrated Medical- Behavioral Health, EAP- Work/Life - Wellness programs GN- 57745 -HH 4/08 Commercial ASO 14%* Medicare Stand -alone PDP 30 %* Commercial fully insured 16% Medicare Advantage 10 %* HUMAN~ticlanc , A. when you nCed it most Humana's Provider Network Humana provides a broad spectrum of products and networks to meet customers where they are today and allow for adaptation and flexibility for years to come. Here are just a few of Humana's network offerings: • Humana/ChoiceCaree network is our largest nationwide network - with competitive discounts that can help control medical costs. • National POS - Open Access offerings use a network similar in scope to a PPO, but with the benefit of additional discounts. • Humana Preferred'"" is a series of plan offerings, supported by a high performance network, which generally provides even greater savings when compared to our plans with larger networks. • Humana Choice PPO is the network used by Humana's Medicare Advantage PPO plans. Humana /ChoiceCare National PPO Network ❑ Humana National POS -Open Access Network Humana Preferred PPO Network ❑ Humana /Choic.Care National PPO Network Humana National POS -Open Access Network Clinical Guidance SoCu' itu;,ti s Humana provides a comprehensive suite of clinical programs and services to guide members at all levels of health. From personalized information online to health coaching and wellness solutions, we help members stay well — and we help them navigate the healthcare system when they're not. :ghat Hwi ;:ts;. offers - raemlx s and employers Humana has the experience to give you a simpler, more affordable health benefits plan. We provide innovation, products, and services that work together to guide .members in taking control of their health: The result is a better experience and lower healthcare costs for both members and employers. Please visit Humana.com or contact your local agent or Humana sales- representative to find out how we can help you. GN- 57745 -HH 4/08 HUMANA. =rt:Fd<rt erl when you need it most Offered by the Humana Family of Insurance and Health Plan Companies Please refer to your Benefit Plan document (Certificate of CoverageAnsurance) for more information on the company providing your benefits. Our health benefit plans have Limitations and Exclusions.