laredo transit management inc. · laredo transit management inc. 1301 farragut street, laredo, tx...

Laredo Trans i t Management Inc . 1301 Farragut Street , Laredo, TX 78040-4902 (956) 795-2288 (956) 795-2258

Re: Request for Sealed Bids. Health, Dental, Vision, Short-Term, and Life Insurances Laredo Transit Management, Inc. hereby requests sealed bids for the provision of Health, Dental, Vision, Short-Term, and Life Insurance, for the period of January 1, 2012 to December 31,2012 with option of 4 years in one year increments. All sealed bids are to be marked Laredo Transit Management Inc. Insurance Services and delivered to Gustavo Guevara, Laredo’s City Secretary at Houston St, 3rd floor, Laredo, Texas 78041. Bids must be received no later than 2:00 p.m., Friday, November 18, 2011, at which time they will be opened and read publicly. Laredo Transit Management Inc. reserves the right to accept or reject any and/or all bids that are in the best interest of the company. A pre-bid conference to answer questions or clarify information in this RFP will be conducted on Wednesday, November 14, 2011 at 10 a.m. in the Transit Center, 1301 Farragut St. Laredo, Texas, 78041, 3rd floor Conference room. Interested parties should request official bid specifications and bid forms from. Mari Royster, AGM. Administration and Finance 1301 Farragut St. Laredo, Texas 78041 (956) 795-2288 ext. 256 [email protected]

Re: SPECIAL SPECIFICATIONS LAREDO TRANSIT MANAGEMENT, INC.-MEDICAL INSURANCES

1. SCOPE This request for proposal (RFP) is created for the purpose of obtaining medical, dental, vision and life insurances in accordance with all specifications, terms and conditions within this RFP document.

2. TERM OF COVERAGE The Term of Coverage shall be for a period of a year, Jan.1, 2012-Dec.31, 2012, with options to extend coverage for a period of 4 years, in one year increments. Any increases in premium will be notified to the company no later than November 15th of the initial plan year and every option year.

3. COST

The cost quoted for each insurance provided shall be based on the attached benefit summary. The costs quoted shall exclude all federal, state, and local taxes. Costs quoted shall include rates for Employee only coverage, Employee +Child(ren), Employee +Spouse, and Family.

3.1 The cost quoted in the contractor’s RFP shall be FIRM/ FIXED for the initial one year Term of the Contract.

4. AWARD OF CONTRACT

LAREDO TRANSIT MANAGEMENT, INC. reserves The right to reject any and all proposals.

5. INSURANCES SPECIFICATIONS PLAN BENEFITS: All amounts payable shown are for covered Medical Services after meeting the Annual Deductible and are subject to Reasonable and Customary limitations and medical necessity reviews. Annual Plan Maximum $1,000,000 per person for 2011 $1,250,000 per person for 2012 per the Affordable Care

Act $2,000,000 per person for 2013 per the Affordable Care Act No Annual Plan Maximum effective 1/1/12014 per the Affordable Care Act Annual Deductible $200 per Individual; $400 per Family Annual Out-of-Pocket Annual Out-of-Pocket $1,000 per Individual; $2,000 per Family in non-deductible Covered Charges Network PPO Physician Office Visit $20 Employee co-payment

Network Wellness Benefit-Adult $20 Network office visit co-payment to cover (Member and Spouse Only) Annual Physical Exam (including a pap test and Mammogram for women at 100%under the Women’s Health Benefit). Additionally, after Plan Deductible is Met, routine screening tests and procedures to be covered at 80%, subject to medical necessity. A Network physician must be used. Network Wellness Benefit-Child A $20 Network office visit co-payment covering (Child and Adult Child) Well Child Exams and Immunizations at 100%, subject to medical necessity. A Network physician must be used. Out-of-Network Benefits Non-emergency care outside the network at Not more than a 10% reduction in payable benefits by the Plan. Hospital Expenses After Plan Deductible, 100% of Semi-Private Room Rate. No Maximum Day Limit. Ambulance Expense Benefit After Plan Deductible, 100% Outpatient Accidental Injury After Plan Deductible 100% on the first day of treatment only. Surgery and Obstetrical After Plan Deductible 100% Outpatient Diagnostic X-Ray and After Plan Dedcutible80%; 100% after Out-of-Pocket Lab Expense Limit is met. Major Medical Benefit Eligible medical charges which are not covered under Basic Benefits to be covered after Plan Deductible at 80%; 100% after Out-of-Pocket Expensed Limit is met. Outpatient Cancer Treatment After Plan Deductible, 100% of Covered Charges for Benefit outpatient nuclear therapy, radiation therapy, chemotherapy, and x-ray and lab procedures for the

treatment of cancer. If treatment is provided in a doctor’s office, a $20 Network office visit copayment to be due at the time of visit. Organ Transplant Benefit After Plan Deductible, 100%. All organ transplant Procedures must have prior approval. A Pre- determination of Benefits along with medical documentation must be submitted through the Network for review. Psychiatric, Drug Abuse and After Plan Deductible, 80% of Covered Charges. Alcoholism Treatment- Maximum 21 Days per person per calendar year; Inpatient Maximum 42 Days per person Lifetime. Out-of Pocket Expenses Limit shall not apply. Psychiatric, Drug Abuse and After Plan Deductible, 80% of Covered Charges. Alcoholism Treatment- Maximum 30 Visits per person per calendar Outpatient year. Out-of-Pocket Expense Limit shall not apply. Hearing Aid Benefit After Plan Deductible, Maximum $2,000 for two (2) aids every 36 months. Chiropractic Expense After Plan Deductible, 80% Maximum $1,000 per person per calendar year. Out-of-Pocket Expense Limit shall not apply. PRESCRIPTION DRUGS If a generic equivalent of a brand name drug is available the employee must take the generic or be responsible for the cost difference. Also, by the third fill, long-term Maintenance medications must be filled through the Caremark Mail Order Program/ Maintenance Choice

or be subject to a 50% co-pay if filled through the Retail Card Program.

75% ; Under Retail Card program, insured pays 25%

co‐pay

80%; Under Mail Order program, insured pays 20%

co‐pay

Employee’s maximum expenses to be capped at

$200 per prescription

Out‐of‐Pocket Expenses Limit shall not apply

SHORT-TERM DISABILITY Also referred to as Loss of Time (Employee Only) $350 per week for first 10 weeks, $350 per week for last 16 weeks. Maximum 26 weeks. Includes continued coverage while on Short-Term Disability. DENTAL BENEFITS VISION BENEFITS LIFE INSURANCE Annual Dental Deductible $0 Eye Exam $25 Member $40,000 Annual Max Per Person $1,500 Frames $30 Accidental $40,000 Preventive Services 100% Single $30 Spouse $ 4,000 Diagnostic 100% Bi-Focals $40 Child/Adult $ 2,000 Child Restorative 100% Tri-Focals$50 TPD/Waiver $16,000 Crown/Bridge Work 80% Lenticular $60 Employee Only Dentures (Full or Partial) 100% Contacts $60 Orthodontic (Child/ $1,500 Adult Child) Lifetime Max Annual Dental Maximum does not apply to covered children under the age of 19 Eye Exam benefit for glasses for covered children under the age of 19 from non-Eye med Providers will be subject to reasonable and customary limitations or subject to the Plan’s PPO office visit co pay. 6. Proposes may quote all requested coverage’s in a single rate, or broken down by individual coverage’s.

BLUE INSIGHT MONTHLY REPORT

LAREDO TRANSIT MANAGEMENT, INC.: ALL

01/01/2011 to 10/31/2011

Non-HMO Fully Insured

TABLE OF CONTENTSTABLE OF CONTENTS

EXECUTIVE SUMMARY 1

FINANCIAL OVERVIEW 2Summary of Financial Measures 2.1

Components of Medical Billed and Allowed Amounts 2.2

Key Financial Measures by Service Category 2.3

Medical Claim Expense Distribution by Claimant 2.4

Medical Out of Pocket Distribution by Claimant 2.5

Medical Out of Pocket Analysis 2.6

Medical Lag Report 2.7

MEDICAL FINANCIAL SERVICE 3Overall Medical Paid Expenses by ICD-9 Diagnostic Category 3.1

Inpatient Facility Paid Expenses by ICD-9 Diagnostic Category 3.2

Outpatient Facility Paid Expenses by ICD-9 Diagnostic Category 3.3

Professional Paid Expenses by ICD-9 Diagnostic Category 3.4

MEDICAL AND PHARMACY LOSS RATIO OVERVIEW 4

PHARMACY FINANCIAL SUMMARY 5Summary of Pharmacy Financial Measures 5.1

ENROLLMENT 6Enrollment Overview 6.1

Enrollment by Age and Gender 6.2

Enrollment by Coverage Tier 6.3

Enrollment/Disenrollment 6.4

Enrollment by Type of Coverage 6.5

EXPENSE AND UTILIZATION OVERVIEW 7Key Indicators 7.1

MEDICAL SERVICE 8Inpatient Admission Analysis 8.1

Inpatient Provider Summary 8.3

Outpatient Facility Visit Type Analysis 8.4

Outpatient Facility Visit Type Detail for Emergency Room, Ambulatory Surgery and Radiology 8.6

Outpatient Provider Summary 8.8

Professional Service Type Analysis 8.9

PHARMACY 9Key Indicators Summary 9.1


TABLE OF CONTENTSTABLE OF CONTENTS

Generic Versus Formulary Experience 9.3

Top Therapeutic Drug Classes 9.4

Top Prescription Drugs 9.5

Specialty Drug Analysis 9.6

GLOSSARY 10


CPT copyright 2010 American Medical Association. All rights reserved.


EXECUTIVE SUMMARYEXECUTIVE SUMMARY

CHAPTER DESCRIPTION

The Monthly Report presents key financial and utilization components for the current reporting month as well as

renewal year to date. The chapters are intended to highlight key analysis criteria to demonstrate how LAREDO

TRANSIT MANAGEMENT, INC.: ALL is doing fiscally, with focus on what is driving their costs. In addition this

report highlights what healthcare services are being utilized and how this impacts the overall cost. The report

starts with components that provide financial data showing paid claims on a month and year to date (YTD) basis.

After the enrollment chapter, components that provide utilization data are shown on an incurred year over year

basis. The data in this report can be used to predict how LAREDO TRANSIT MANAGEMENT, INC.: ALL can

budget for health costs and what they are facing in the future. In this chapter there is a brief description about the

subsequent chapters and key metrics to summarize their findings.

1.1

FINANCIAL

The financial overview chapter provides gross financial information for LAREDO TRANSIT MANAGEMENT, INC.:

ALL based on paid claims for the current reporting month and for the renewal year to date. The claims have not

been aggregated or summarized, so all transactions are reflected based on the paid date and balances back to your

Billing and Accounts Receivable System (BARS) bill.

Report Description: This report provides an overview of LAREDO TRANSIT MANAGEMENT, INC.: ALL's total health

care expenses for the current reporting month and for the year to date.


TOTAL EXPENSES OCT'11 YEAR TO DATE

MEDICAL PAID $129,310 $1,449,294

CAPITATION PAID

PHARMACY PAID $12,024 $143,453

DENTAL PAID

TOTAL PAID $141,334 $1,592,747

RECOVERIES $0 $0

PAID + RECOVERIES $141,334 $1,592,747

FEES & CREDITS $0 $0

GROUP LIABILITY $141,334 $1,592,747

Key Findings: Medical paid made up 91.5% of the total paid amount for the current month. Medical paid made up

91.0% of the total paid amount for the year to date.


1.2

MEDICAL CLAIM EXPENSE DISTRIBUTION BY CLAIMANT

Report Description: The distribution of medical paid expense by claimant and the average medical paid per claimant

amount are shown for the year to date.


YEAR TO DATE

PAID CLAIMANTS CLAIMANTS % PAID PAID %

PAID/

CLAIMANT

LESS THAN $200 78 26.8% $5,726 0.4% $73

$200 - $1,000 97 33.3% $47,752 3.3% $492

$1,001 - $5,000 84 28.9% $163,290 11.3% $1,944

$5,001 - $10,000 12 4.1% $82,500 5.7% $6,875

$10,001 - $30,000 9 3.1% $146,383 10.1% $16,265

SUMMARY LESS THAN $30,001 280 96.2% $445,651 30.7% $1,592


PAID/

CLAIMANT

$30,001 - $50,000 4 1.4% $171,443 11.8% $42,861

$50,001 - $75,000 1 0.3% $61,327 4.2% $61,327

$75,001 - $100,000 2 0.7% $156,550 10.8% $78,275

$100,001 - $150,000 3 1.0% $326,121 22.5% $108,707

$150,001 - $200,000

$200,001 - $250,000

$250,001 - $500,000 1 0.3% $288,201 19.9% $288,201

GREATER THAN $500,001

SUMMARY $30,001 OR GREATER 11 3.8% $1,003,643 69.3% $91,240

COMBINED SUMMARY 291 100.0% $1,449,294 100.0% $4,980

Key Findings: The proportion of claimants who received less than $200 in services for the year to date was 26.8%.

These claimants spent 0.4% of the total paid expenses and the average paid expense per claimant was $73.

3.8% of claimants had expenses over $30,001 for the year to date. These claimants spent 69.3% of the total paid

expenses and the average paid expense per claimant was $91,240.




1.3

NETWORK SAVINGS ANALYSIS

Report Description: This report displays the covered amount, discount amount, discount percent and paid amount

based on paid claims. Displayed by Medicare and non-Medicare primary indicator, and by in and out of network for

the year to date. The "Discount %" is calculated as Discount/Covered.


MEDICARE PRIMARY

INDICATOR NETWORK INDICATOR SERVICE CATEGORY COVERED DISCOUNT DISCOUNT % PAID % OF PAID

NO IN-NETWORK INPATIENT FACILITY $2,125,808 $1,468,714 69.1% $635,222 43.8%

OUTPATIENT FACILITY $1,062,852 $623,413 58.7% $380,699 26.3%

PROFESSIONAL $1,231,678 $746,669 60.6% $411,252 28.4%

SUMMARY $4,420,338 $2,838,797 64.2% $1,427,173 98.5%

OUT-OF-NETWORK INPATIENT FACILITY

OUTPATIENT FACILITY $391,273 $368,874 94.3% $12,028 0.8%

PROFESSIONAL $56,309 $45,946 81.6% $3,713 0.3%

SUMMARY $447,583 $414,821 92.7% $15,741 1.1%

SUMMARY $4,867,921 $3,253,618 66.8% $1,442,914 99.6%

YES IN-NETWORK INPATIENT FACILITY

OUTPATIENT FACILITY $9,688 $0 0.0% $291 0.0%

PROFESSIONAL $8,920 $3,838 43.0% $1,098 0.1%

SUMMARY $18,609 $3,838 20.6% $1,389 0.1%

OUT-OF-NETWORK INPATIENT FACILITY

OUTPATIENT FACILITY $827,265 $0 0.0% $4,918 0.3%

PROFESSIONAL $1,159 $795 68.6% $73 0.0%

SUMMARY $828,424 $795 0.1% $4,991 0.3%

SUMMARY $847,033 $4,633 0.5% $6,379 0.4%

SUMMARY $5,714,954 $3,258,251 57.0% $1,449,294 100.0%

Key Findings: LAREDO TRANSIT MANAGEMENT, INC.: ALL's overall network savings discount (excluding Medicare)

was 64.2% for the year to date. The in-network paid percent was 98.6% for the year to date.

ENROLLMENT

The enrollment chapter presents descriptive information on LAREDO TRANSIT MANAGEMENT, INC.: ALL's

subscribers and dependents enrolled in BCBSTX. Information on coverage tier, membership size, age and gender

are presented for subscribers and dependents for the current reporting month and the renewal year to date.

Report Description: This report shows the average subscribers, dependents and overall members for LAREDO

TRANSIT MANAGEMENT, INC.: ALL.


OCT'11 YEAR TO DATE

AVERAGE SUBSCRIBERS 158 157

AVERAGE DEPENDENTS 208 205

AVERAGE MEMBERS 366 362

AVERAGE CONTRACT SIZE 2.32 2.31

AVERAGE AGE (YEARS) 34.9 34.9

Key Findings: LAREDO TRANSIT MANAGEMENT, INC.: ALL's overall membership was 366 in the current reporting

month and 362 for the year to date. The average age of members was 34.9 for the current reporting month and

34.9 for the year to date.


1.4LAREDO TRANSIT MANAGEMENT, INC.: ALL

MEDICAL AND PHARMACY PAID CLAIMS BY AGE AND GENDER

Report Description: This report identifies the total medical and pharmacy member counts and their paid claims, by

age and gender demographics, and by subscribers and dependents for the year to date. The report compares and

analyzes claims vs. member counts within one age band compared to another to identify the members and age

group that are driving the costs.


MALE FEMALE TOTAL

AVG

MEDICAL

MEMBERS

AVG

PHARMACY

MEMBERS PAID

AVG

MEDICAL

MEMBERS

AVG

PHARMACY

MEMBERS PAID

AVG

MEDICAL

MEMBERS

AVG

PHARMACY

MEMBERS PAID

SUBSCRIBERS UNDER 20

20-29 2 2 $1,889 1 1 $319 3 3 $2,208

30-39 16 16 $21,613 6 6 $5,071 22 22 $26,684

40-49 51 51 $47,230 13 13 $80,937 63 63 $128,167

50-64 50 50 $361,611 10 10 $113,509 60 60 $475,120

65+ 9 9 $347,819 9 9 $347,819

TOTAL 127 127 $780,163 30 30 $199,836 157 157 $979,999

DEPENDENTS UNDER 20 61 61 $28,396 56 56 $103,368 117 116 $131,764

20-29 18 18 $9,326 9 9 $15,438 27 27 $24,765

30-39 1 1 8 8 $14,367 9 9 $14,367

40-49 5 5 $1,358 23 23 $329,341 28 28 $330,699

50-64 23 23 $108,373 23 23 $108,373

65+ 2 2 $2,780 2 2 $2,780

TOTAL 84 84 $39,080 121 121 $573,668 205 205 $612,748

TOTAL MEMBERS 211 211 $819,243 150 150 $773,504 362 361 $1,592,747

Key Findings: The total subscriber count for males was highest in the 40 - 49 age range. Male subscribers in the 50

- 64 age group had the highest net paid claims. The total subscriber count for females was highest in the 40 - 49

age range. Female subscribers in the 50 - 64 age group had the highest net paid claims.

The total dependent count for males was highest in the Under 20 age range. Male dependents in the Under 20 age

group had the highest net paid claims. The total dependent count for females was highest in the Under 20 age

range. Female dependents in the 40 - 49 age group had the highest net paid claims.



EXPENSE AND UTILIZATION OVERVIEW

The expense and utilization overview chapter is intended to provide key metrics for LAREDO TRANSIT

MANAGEMENT, INC.: ALL's claims experience. Year-over-year changes and comparisons to the benchmark are

provided as well. Data in this chapter is reported based on incurred, 12-month rolling periods with 2 months

run-out.

Report Description: This report shows key metrics, paid PMPMs, and paid PEPMs by service category.


UTILIZATION SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE

INPATIENT ADMISSIONS/1000 125.3 98.9 26.7% 61.0 105.4%

OUTPATIENT VISITS/1000 2,342.1 2,211.2 5.9% 992.3 136.0%

PROFESSIONAL SERVICES/1000 21,930.8 19,213.9 14.1% 18,944.6 15.8%

PHARMACY PRESCRIPTIONS/MEMBER 9.3 9.1 2.2% 10.8 -14.1%

DENTAL SERVICES/MEMBER 3.4


PAID PMPM SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE

TOTAL MEDICAL $374.58 $313.30 19.6% $218.07 71.8%

CAPITATION $0.00

PHARMACY $45.36 $50.82 -10.7% $51.30 -11.6%

DENTAL $20.28

PAID PEPM

TOTAL MEDICAL $861.75 $738.49 16.7% $390.14 120.9%

CAPITATION $0.00

PHARMACY $104.29 $119.79 -12.9% $91.69 13.7%

DENTAL $39.80

Key Findings: Utilization for Inpatient had the largest increase in Admissions/1000 between the current and prior

reporting periods.

Between the current and prior reporting periods, LAREDO TRANSIT MANAGEMENT, INC.: ALL's medical PMPM

expenses increased 19.6%. The pharmacy paid PMPM decreased 10.7%. LAREDO TRANSIT MANAGEMENT,

INC.: ALL's medical PEPM expenses increased 16.7%. The pharmacy paid PEPM decreased 12.9%.

FINANCIAL OVERVIEWFINANCIAL OVERVIEW

CHAPTER DESCRIPTION

This chapter provides gross financial information for LAREDO TRANSIT MANAGEMENT, INC.: ALL based on paid

claims for the current reporting month and for the renewal year to date. The claims have not been aggregated or

summarized, so all transactions are reflected based on the paid date for each individual transaction. This means

that original claims are reflected based on the original processing date and adjustments are based on the date of

the adjustment, even if the original claim was processed at a different time.

Reports in this chapter will include medical amounts only unless specifically indicated as pharmacy or dental

amounts.

The first report provides a breakdown of key gross expenditures, from billed amount to paid amount, for the current

reporting month and for the year to date. This report may highlight key measures and their potential impact on

gross paid expenses.

The second report displays the percentage of the billed amounts accounted for by discounts and the allowed

amount. Also presented is the percentage of the allowed amount accounted for by out of pocket, COB, COB

Medicare, other reductions, other payments and the paid amount. It is important to monitor how these expense

categories impact the overall costs over time. For example, changes to the plan design may be reflected by a

change in the proportion of out of pocket to the allowed amount, and ultimately what is the liability of the plan,

changes in the percentage of discounts may reflect provider contract changes or shifts in provider-mix, and

changes in COB amounts may reflect a change in benefits or a changed focus to capture funds from these sources.

The third report presents gross allowed and paid amounts by service category, along with percentages these

amounts by service category are to the total allowed amount and total paid amount. This breakdown provides a

high level view of what service categories areas are driving expenses and potentially highlights areas for further

attention.

The fourth report focuses on how expenditures are distributed by claimant. The distribution of claimants by paid

amount shows the percentage of claimants at different levels of total payments for the current reporting month and

for the year to date. Analysis of this report can highlight the impact of high cost claimants on the overall costs.

The distribution of claimants by out of pocket shows the percentage of claimants at different levels of out of pocket

expenses. This report helps determine the impact of any changes in plan design on out of pocket.

Completing the chapter are reports that provide information on network savings (for PPO and POS products), and

insight into the monthly claim lag and that can help identify Incurred But Not Reported (IBNR).

Data Note

Current reporting month represents claims paid in Oct'11.

Year to date represents claims paid from Jan'11 through Oct'11.

Raw claims for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).

2LAREDO TRANSIT MANAGEMENT, INC.: ALL


SUMMARY OF FINANCIAL MEASURES

Report Description: This report provides an overview of LAREDO TRANSIT MANAGEMENT, INC.: ALL's health care

expenses from billed to paid for the current reporting month and for the year to date. Some key financial measures

are displayed below. These metrics include plan performance measures, such as the degree of discounts the plan

was able to achieve, as well as COB and COB Medicare recoveries that the plan was able to receive based on other

insurance contributing to the overall expenses. Information is also provided on the amount of overall health care

expenses that the member was directly responsible for, through deductibles, coinsurance or co-payments. Other

reductions includes penalties, workers compensation savings, and subrogation savings. Other payments includes

Blue Card access fees and surcharges. Also displayed are other adjustments. Finally, the report provides

information on the level and percent changes in paid expenses, which represents LAREDO TRANSIT

MANAGEMENT, INC.: ALL's liability, with a further breakout for Fees and Credits. Definitions of these financial

measures can be found in the glossary.

2.1

BREAKDOWN OF BILLED AMOUNT

OCT'11 YEAR TO DATE0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NOT COVERED

DISCOUNT

OUT OF POCKET

COB

COB MEDICARE

OTHER REDUCTIONS

OTHER

ADJUSTMENTS

PAID-PROVIDER


MEDICAL EXPENSES OCT'11 YEAR TO DATE

BILLED $512,860 $6,634,781

NOT COVERED $16,280 $919,827

COVERED $496,580 $5,714,954

DISCOUNT $351,648 $3,258,251

ALLOWED $144,932 $2,456,703

OUT OF POCKET $14,351 $161,984

COB $1,207 $17,597

COB MEDICARE $90 $829,371

OTHER REDUCTIONS $0 $0

OTHER ADJUSTMENTS $0 $0

PAID-PROVIDER $129,284 $1,447,751

OTHER PAYMENTS $26 $1,543

PAID $129,310 $1,449,294


TOTAL EXPENSES OCT'11 YEAR TO DATE

MEDICAL PAID $129,310 $1,449,294

CAPITATION PAID

PHARMACY PAID $12,024 $143,453

DENTAL PAID

TOTAL PAID $141,334 $1,592,747

RECOVERIES $0 $0

PAID + RECOVERIES $141,334 $1,592,747

FEES & CREDITS $0 $0

GROUP LIABILITY $141,334 $1,592,747


Paid-Provider excludes Other Payments, which are not part of the Billed Amount.


FEES & CREDITS OCT'11 YEAR TO DATE

SUMMARY $0 $0


2.2

COMPONENTS OF MEDICAL BILLED AND ALLOWED AMOUNTS

Report Description: The breakdown of LAREDO TRANSIT MANAGEMENT, INC.: ALL's medical billed and allowed

amounts are analyzed below. The discount amount, not covered amount and allowed amount are presented as a

percentage of the billed amount for the current reporting month and for the year to date. The out of pocket

amount, COB recoveries, other reductions, other adjustments, and paid-provider amount are presented as a

percentage of the allowed amount.

Billed Amount: The allowed amount was 28.3% of the billed amount for the current reporting month and 37.0% of

the billed amount for the year to date. Discounts were 68.6% of the billed amount for the current reporting month

and 49.1% of the billed amount for the year to date. The remaining not covered amount was 3.2% of the billed

amount for the current reporting month and 13.9% of the billed amount for the year to date.

Allowed Amount: Of the allowed amount in the current reporting month, the paid-provider amount was 89.2%, out

of pocket was 9.9%, COB was 0.8%, COB Medicare was 0.1%, and other reductions were 0.0%. Other

adjustments were 0.0%. For year to date, of the allowed amount, the paid-provider amount was 58.9%, out of

pocket was 6.6%, COB was 0.7%, COB Medicare was 33.8%, and other reductions were 0.0%. Other

adjustments were 0.0%.

BILLED AMOUNT ALLOWED AMOUNT


OCT'11 YEAR TO DATE

% NOT COVERED 3.2% 13.9%

% DISCOUNT* 68.6% 49.1%

% ALLOWED 28.3% 37.0%


OCT'11 YEAR TO DATE

% OUT OF POCKET 9.9% 6.6%

% COB 0.8% 0.7%

% COB MEDICARE 0.1% 33.8%

% OTHER REDUCTIONS 0.0% 0.0%

% OTHER ADJUSTMENTS 0.0% 0.0%

% PAID-PROVIDER 89.2% 58.9%

PERCENTAGE OF BILLED AMOUNT

28.3%37.0%

68.6% 49.1%

3.2%13.9%


20%

40%

60%

80%

100%

% NOT COVERED

% DISCOUNT

% ALLOWED

PERCENTAGE OF ALLOWED AMOUNT

89.2%

58.9%

0.0% 0.0%0.0% 0.0%

0.1%

33.8%

0.8%0.7%9.9% 6.6%


20%

40%

60%

80%

100% % OUT OF POCKET

% COB

% COB MEDICARE

% OTHER

REDUCTIONS

% OTHER

ADJUSTMENTS

% PAID-PROVIDER


*This reflects the overall discount as a percent of the billed amount. Please refer to page 1.3 'Network Savings Analysis' for

your network discount percent based off the Covered amount.


2.3

KEY FINANCIAL MEASURES BY SERVICE CATEGORY

Report Description: The percent allowed and paid for each service category (inpatient facility, outpatient facility,

professional, pharmacy and dental) is analyzed to determine which service categories have contributed the most in

these key financial measures in the current reporting month and for the year to date.


OCT'11 YEAR TO DATE

INPATIENT FACILITY ALLOWED $58,013 $657,094

ALLOWED % 36.0% 24.8%

PAID $53,890 $635,222

PAID % 38.1% 39.9%

OUTPATIENT FACILITY ALLOWED $43,377 $1,298,791

ALLOWED % 26.9% 49.0%

PAID $39,080 $397,937

PAID % 27.7% 25.0%

PROFESSIONAL ALLOWED $43,542 $500,818

ALLOWED % 27.0% 18.9%

PAID $36,340 $416,135

PAID % 25.7% 26.1%

CAPITATION PAID

PAID %

PHARMACY ALLOWED $16,127 $191,297

ALLOWED % 10.0% 7.2%

PAID $12,024 $143,453

PAID % 8.5% 9.0%

DENTAL ALLOWED

ALLOWED %

PAID

PAID %

SUMMARY ALLOWED $161,059 $2,648,000

ALLOWED % 100.0% 100.0%

PAID $141,334 $1,592,747

PAID % 100.0% 100.0%

ALLOWED % BY SERVICE CATEGORY

PAID % BY SERVICE CATEGORY

INPATIENT

FACILITY

OUTPATIENT

FACILITY

PROFESSIONAL PHARMACY DENTAL

0%

15%

30%

45%

OCT'11 YEAR TO DATE

OCT'11 YEAR TO DATE

INPATIENT

FACILITY

OUTPATIENT

FACILITY

PROFESSIONAL PHARMACY DENTAL

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Summary: Overall allowed expense for the current reporting month made up 6.1% of the year to date allowed

expenses. Overall paid expense for the current reporting month made up 8.9% of the year to date paid expenses.

Allowed % by Service Category: In terms of the proportion of overall allowed expenses by service category,

Outpatient Facility allowed expenses accounted for the greatest proportion of the overall allowed expenses for the

year to date. The next highest service category was Inpatient Facility, which accounted for 24.8% for the year to

date allowed expenses.

Paid % by Service Category: In terms of the proportion of overall paid expenses by service category, Inpatient

Facility paid expenses accounted for the greatest proportion of the overall paid expenses for the year to date. The

next highest service category was Professional, which accounted for 26.1% for the year to date paid expenses.


LESS THAN $200

$200 - $1,000

$1,001 - $5,000

$5,001 - $10,000

ALL OTHER

$1,001 - $5,000

$30,001 - $50,000

$100,001 - $150,000

$250,001 - $500,000

ALL OTHER

26.8%

33.3%

28.9%

4.1%

6.9%11.3%

11.8%

22.5%

19.9%

34.5%

CLAIMANTS PAID


2.4

MEDICAL CLAIM EXPENSE DISTRIBUTION BY CLAIMANT

Report Description: The distribution of medical paid expense by claimant and the average medical paid per claimant

amount is shown for the year to date. The graphs display the percentage of claimants and paid expenses for the

year to date.1


YEAR TO DATE


PAID/

CLAIMANT

LESS THAN $200 78 26.8% $5,726 0.4% $73

$200 - $1,000 97 33.3% $47,752 3.3% $492

$1,001 - $5,000 84 28.9% $163,290 11.3% $1,944

$5,001 - $10,000 12 4.1% $82,500 5.7% $6,875

$10,001 - $30,000 9 3.1% $146,383 10.1% $16,265

SUMMARY 280 96.2% $445,651 30.7% $1,592

The proportion of claimants who received less than $200 in services for the year to date was 26.8%. These

claimants spent 0.4% of the total paid expenses and the average paid expense per claimant was $73.

3.8% of claimants had expenses over $30,001 for the year to date. These claimants spent 69.3% of the total paid

expenses and the average paid expense per claimant was $91,240.

1This is a claimant analysis, where only members who had a claim are included. The tables exclude all medical enrolled

members that did not submit a claim.



PAID/

CLAIMANT

$30,001 - $50,000 4 1.4% $171,443 11.8% $42,861

$50,001 - $75,000 1 0.3% $61,327 4.2% $61,327

$75,001 - $100,000 2 0.7% $156,550 10.8% $78,275

$100,001 - $150,000 3 1.0% $326,121 22.5% $108,707

$150,001 - $200,000

$200,001 - $250,000

$250,001 - $500,000 1 0.3% $288,201 19.9% $288,201

GREATER THAN $500,001

SUMMARY 11 3.8% $1,003,643 69.3% $91,240


2.5

MEDICAL OUT OF POCKET DISTRIBUTION BY CLAIMANT

Report Description: The impact of cost sharing provisions is analyzed to determine the overall liability incurred by

the member. This report provides a distribution of claimants by their total medical out of pocket expenses for the

year to date. If changes have been made to plan design, this report helps analyze what the impacts of those

changes have been to the member. The graphs display the percentage of claimants and out of pocket expenses for

the year to date.1


YEAR TO DATE

OUT OF POCKET CLAIMANTS CLAIMANTS % OUT OF POCKET OUT OF POCKET %

LESS THAN $100 146 50.2% $5,579 3.4%

$100 - $200 41 14.1% $5,769 3.6%

$201 - $300 15 5.2% $3,599 2.2%

$301 - $400 12 4.1% $4,255 2.6%

$401 - $500 5 1.7% $2,151 1.3%

$501 - $750 13 4.5% $8,457 5.2%

$751 - $1,000 11 3.8% $10,001 6.2%

$1,001 - $1,500 14 4.8% $16,837 10.4%

$1,501 - $2,000 7 2.4% $11,755 7.3%

$2,001 - $2,500 6 2.1% $12,487 7.7%

$2,501 - $3,000 2 0.7% $5,582 3.4%

$3,001 - $4,000 16 5.5% $54,544 33.7%

$4,001 - $5,000 1 0.3% $4,489 2.8%

GREATER THAN $5,001 2 0.7% $16,481 10.2%

SUMMARY 291 100.0% $161,984 100.0%

50.2%

14.1%

5.2%

4.1%

1.7%

4.5%

3.8%

4.8%

2.4%

2.1%

0.7%

5.5%

0.3%

0.7%

3.4%3.6%

2.2%

2.6%

1.3%

5.2%

6.2%

10.4%

7.3%

7.7%3.4%

33.7%

2.8%

10.2%

LESS THAN $100

$100 - $200

$201 - $300

$301 - $400

$401 - $500

$501 - $750

$751 - $1,000

$1,001 - $1,500

$1,501 - $2,000

$2,001 - $2,500

$2,501 - $3,000

$3,001 - $4,000

$4,001 - $5,000

GREATER THAN $5,001

CLAIMANTS OUT OF POCKET

The average out of pocket expense per claimant was $557 for the year to date. Claimants with under $200 in out

of pocket expenses were 64.3% for the year to date. Claimants with out of pocket expenses in the range of less

than $100 showed the highest number of claimants for the year to date.

1This is a claimant analysis, where only members who had a claim are included. The tables exclude all medical enrolled

members that did not submit a claim.


MEDICAL OUT OF POCKET ANALYSIS

Report Description: This report shows the deductible, copayment, coinsurance, and total out of pocket amounts as a

percent of the allowed amount by coverage tier for the year to date. The chart shows the total out of pocket amount

broken out by the percent the member paid for deductible, copayment, and coinsurance for claims for the year to

date.


2.6


YEAR TO DATE

COVERAGE TIER ALLOWED DEDUCTIBLE

DEDUCT

% OF

ALLOWED COPAYMENT

COPAY

% OF

ALLOWED COINSURANCE

COINS

% OF

ALLOWED

OUT OF

POCKET

OPX % OF

ALLOWED PAID

EMPLOYEE ONLY $709,651 $12,669 1.8% $9,760 1.4% $28,896 4.1% $51,325 7.2% $658,511

EMPLOYEE + ONE $1,119,668 $10,221 0.9% $7,699 0.7% $18,216 1.6% $36,136 3.2% $254,333

EMPLOYEE +

DEPENDENT(S) $85,174 $3,342 3.9% $5,169 6.1% $6,206 7.3% $14,718 17.3% $69,639

FAMILY $542,210 $18,765 3.5% $16,331 3.0% $24,710 4.6% $59,806 11.0% $466,810

SUMMARY $2,456,703 $44,998 1.8% $38,959 1.6% $78,027 3.2% $161,984 6.6% $1,449,294


OUT OF POCKET BREAKDOWN BY COVERAGE TIER

DEDUCTIBLE COPAYMENT COINSURANCE

27.8%

31.4%

22.7%

28.3%

24.7%

24.1%

27.3%

35.1%

21.3%

19.0%

48.2%

41.3%

42.2%

50.4%

56.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

SUMMARY

FAMILY

EMPLOYEE + DEPENDENT(S)

EMPLOYEE + ONE

EMPLOYEE ONLY

The overall total out of pocket amount as a percent of allowed for the year to date was 6.6.%. The coverage tier

with the highest deductible as a percent of allowed was Employee + Dependent(s). Copayment as a percent of

allowed was highest for Employee + Dependent(s). Coinsurance as a percent of allowed was highest for Employee +

Dependent(s).

Of the total out of pocket amount, 27.8% was attributed to the deductible amount. The copayment amount

attributed 24.1%. The remaining 48.2% was attributed to the coinsurance amount.



2.7


INCURRED

MONTH

PAID MONTH

NOV'10 DEC'10 JAN'11 FEB'11 MAR'11 APR'11 MAY'11 JUN'11 JUL'11 AUG'11 SEP'11 OCT'11 SUMMARY

ALL PRIOR �$2,375 $1,563 $210 $0 $0 $-72 $0 $-215 $0 $89 $277 $78 $4,305

NOV'09 �$0 $0 $0 $0 $-399 $0 $0 $-399

DEC'09 $119 $0 $0 $15 $0 $135

JAN'10 �$65 $234 $0 $0 $0 $0 $38 $0 $337

FEB'10 $23 $108 $0 $214 $0 $0 $0 $345

MAR'10 �$0 $62 $0 $-864 $0 $-802

APR'10 $94 $0 $0 $0 $0 $0 $94

MAY'10 �$159 $127 $103 $0 $0 $0 $389

JUN'10 $411 $308 $23,100 $2,534 $124 $377 $0 $38 $0 $492 $0 $27,383

JUL'10 �$342 $776 $2,118 $5,519 $141 $54 $0 $170 $9,119

AUG'10 $416 $103 $6,355 $5,511 $26 $0 $107 $42 $196 $0 $12,757

SEP'10 �$4,158 $1,719 $545 $237 $358 $46 $75 $0 $7 $0 $0 $28 $7,172

OCT'10 $26,560 $2,262 $758 $148 $453 $8 $197 $105 $0 $0 $0 $30,490

NOV'10 �$44,588 $24,568 $1,670 $826 $542 $-6 $0 $186 $0 $0 $116 $72,489

DEC'10 $30,342 $98,785 $9,494 $821 $464 $0 $435 $75 $100 $0 $140,516

JAN'11 � $14,041 $110,228 $43,608 $140,057 $108 $169 $240 $0 $128 $0 $308,580

FEB'11 $23,199 $48,581 $3,473 $3,653 $1,019 $4 $738 $594 $0 $81,261

MAR'11 � $44,014 $102,440 $8,062 $4,103 $396 $2,834 $433 $-303 $161,979

APR'11 $40,891 $56,812 $6,396 $837 $2,510 $-193 $17 $107,270

MAY'11 � $23,365 $127,830 $5,167 $3,190 $235 $279 $160,067

JUN'11 $22,020 $50,379 $4,582 $474 $5,045 $82,500

JUL'11 � $46,063 $53,164 $4,947 $1,667 $105,840

AUG'11 $47,328 $70,994 $3,174 $121,496

SEP'11 � $38,058 $69,638 $107,695

OCT'11 $49,571 $49,571

SUMMARY $79,309 $61,983 $147,709 $157,756 $138,771 $287,944 $92,272 $160,962 $103,060 $114,553 $116,958 $129,310 $1,590,586

MEDICAL LAG REPORT

Report Description: This report displays, by paid month, the net medical dollars paid and the corresponding month

incurred for a 12 month rolling paid period (or the available data for your account). This report provides insight into

the monthly claim lag and can help identify IBNR.

MEDICAL FINANCIAL SERVICEMEDICAL FINANCIAL SERVICE

CHAPTER DESCRIPTION

This chapter presents information on key expenses for LAREDO TRANSIT MANAGEMENT, INC.: ALL for the

current reporting month and for the year to date.

The first report presents the Top 15 overall medical paid expenses across inpatient facility, outpatient facility, and

professional setting by ICD-9 diagnostic categories.

The second report focuses on LAREDO TRANSIT MANAGEMENT, INC.: ALL inpatient facility admission experience

and examines the leading ICD-9 Diagnostic Categories to help pinpoint what conditions are driving LAREDO

TRANSIT MANAGEMENT, INC.: ALL inpatient expenses.

The third report analyzes expenses specifically related to services provided in the outpatient facility setting for

LAREDO TRANSIT MANAGEMENT, INC.: ALL. The report examines the leading ICD-9 Diagnostic Categories to

help pinpoint what conditions are driving LAREDO TRANSIT MANAGEMENT, INC.: ALL outpatient expenses. The

expenses presented in this report are for facility expenses only and include service types such as ambulatory

surgery, emergency room, radiology, dialysis and observation room.

The fourth report encompasses all the services for LAREDO TRANSIT MANAGEMENT, INC.: ALL provided by

physicians and other clinicans, ancillary services and supplies. The report examines the leading ICD-9 Diagnostic

Categories to help pinpoint what conditions are driving LAREDO TRANSIT MANAGEMENT, INC.: ALL professional

expenses. Physician and other clinician services include surgical procedures, evaluation and management (E&M)

services, anesthesia services, physical/occupational/speech therapy services and other medical services. Ancillary

services include radiology and laboratory/pathology services. Medical services and supplies are also included in the

professional service category. This service type represents services that have been submitted with a HCPCS

(Healthcare Common Procedure Coding System) code.

Data Note



Claims for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).

LAREDO TRANSIT MANAGEMENT, INC.: ALL 3


OVERALL MEDICAL PAID EXPENSES BY ICD-9 DIAGNOSTIC CATEGORY

Report Description: The table below lists the top 15 overall paid expenses across inpatient facility, outpatient

facility, and professional settings by ICD-9 diagnostic categories for the year to date and the respective experience

for the current reporting month.

LAREDO TRANSIT MANAGEMENT, INC.: ALL 3.1


OCT'11 YEAR TO DATE

ICD-9 DIAGNOSTIC CATEGORY PAID PAID % PAID PAID %

MUSCULOSKELETAL AND CONNECTIVE TISSUE $24,837 19.2% $366,486 25.3%

NEOPLASMS $5,172 4.0% $291,596 20.1%

HEALTH SERVICES $28,057 21.7% $159,265 11.0%

ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES $6,383 4.9% $103,015 7.1%

INJURY & POISONING $653 0.5% $96,899 6.7%

SYMPTOMS, SIGNS & ILL-DEFINED CONDITIONS $4,470 3.5% $88,368 6.1%

CIRCULATORY $7,125 5.5% $74,112 5.1%

GENITOURINARY $2,274 1.8% $50,877 3.5%

DIGESTIVE $11,259 8.7% $32,399 2.2%

INFECTIOUS AND PARASITIC $24,141 18.7% $29,939 2.1%

WITHOUT REPORTED DIAGNOSIS $873 0.7% $25,118 1.7%

EYES $793 0.6% $23,414 1.6%

SKIN AND SUBCUTANEOUS TISSUE $344 0.3% $21,746 1.5%

RESPIRATORY $362 0.3% $18,241 1.3%

NERVOUS SYSTEM $2,266 1.8% $12,279 0.8%

ALL OTHER $10,302 8.0% $55,541 3.8%

SUMMARY $129,310 100.0% $1,449,294 100.0%

The top three ICD-9 Diagnostic Categories in the current reporting month based on paid were Health Services,

Musculoskeletal And Connective Tissue, and Infectious And Parasitic.


INPATIENT FACILITY PAID EXPENSES BY ICD-9 DIAGNOSTIC CATEGORY

Report Description: The table below lists the top 15 inpatient facility paid expenses by ICD-9 diagnostic categories

for the year to date and the respective experience for the current reporting month.



OCT'11 YEAR TO DATE



NEOPLASMS $172,357 27.1%

HEALTH SERVICES $10,778 20.0% $68,227 10.7%

ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES $24,052 3.8%

INFECTIOUS AND PARASITIC $23,613 43.8% $23,613 3.7%

INJURY & POISONING $18,577 2.9%

GENITOURINARY $14,719 2.3%

CIRCULATORY $10,840 1.7%

SYMPTOMS, SIGNS & ILL-DEFINED CONDITIONS $8,371 1.3%

SKIN AND SUBCUTANEOUS TISSUE $6,259 1.0%

RESPIRATORY $5,789 0.9%

COMPLICATIONS OF PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM $4,102 0.6%

DIGESTIVE $2,892 0.5%

LIVEBORN INFANTS $1,410 0.2%

BLOOD AND BLOOD-FORMING ORGANS $0 0.0%

SUMMARY $53,890 100.0% $635,222 100.0%

The top three ICD-9 Diagnostic Categories in the current reporting month based on paid were Infectious And

Parasitic, Musculoskeletal And Connective Tissue, and Health Services.




OCT'11 YEAR TO DATE


HEALTH SERVICES $15,539 39.8% $87,035 21.9%




MUSCULOSKELETAL AND CONNECTIVE TISSUE $0 0.0% $32,378 8.1%

CIRCULATORY $2,448 6.3% $24,681 6.2%

NEOPLASMS $1,440 3.7% $23,407 5.9%

GENITOURINARY $1,531 3.9% $22,076 5.5%

DIGESTIVE $10,238 26.2% $20,648 5.2%



RESPIRATORY $5,443 1.4%

EYES $5,083 1.3%

NERVOUS SYSTEM $4,462 1.1%

EARS AND MASTOID PROCESS $3,586 0.9%

ALL OTHER $360 0.9% $5,940 1.5%

SUMMARY $39,080 100.0% $397,937 100.0%

OUTPATIENT FACILITY PAID EXPENSES BY ICD-9 DIAGNOSTIC CATEGORY

Report Description: The table below lists the top 15 outpatient facility paid expenses by ICD-9 diagnostic categories

for the year to date and the respective experience for the current reporting month.

The top three ICD-9 Diagnostic Categories in the current reporting month based on paid were Health Services,

Digestive, and Endocrine, Nutritional And Metabolic Diseases.

3.3


PROFESSIONAL PAID EXPENSES BY ICD-9 DIAGNOSTIC CATEGORY

Report Description: The table below lists the top 15 professional paid expenses by ICD-9 diagnostic categories for

the year to date and the respective experience for the current reporting month.



OCT'11 YEAR TO DATE


NEOPLASMS $3,732 10.3% $95,833 23.0%


CIRCULATORY $4,677 12.9% $38,591 9.3%




EYES $793 2.2% $18,331 4.4%

GENITOURINARY $743 2.0% $14,082 3.4%

OTHER CIRCUMSTANCES $8,611 23.7% $11,479 2.8%



DIGESTIVE $1,020 2.8% $8,858 2.1%

HEALTH SERVICES: REPRODUCTION AND DEVELOPMENT $33 0.1% $7,849 1.9%

NERVOUS SYSTEM $2,266 6.2% $7,817 1.9%

RESPIRATORY $362 1.0% $7,009 1.7%

ALL OTHER $3,566 9.8% $31,504 7.6%

SUMMARY $36,340 100.0% $416,135 100.0%

The top three ICD-9 Diagnostic Categories in the current reporting month based on paid were Other Circumstances,

Musculoskeletal And Connective Tissue, and Circulatory.

MEDICAL AND PHARMACY LOSS RATIO OVERVIEWMEDICAL AND PHARMACY LOSS RATIO OVERVIEW

4.1

CHAPTER DESCRIPTION

This chapter provides information for LAREDO TRANSIT MANAGEMENT, INC.: ALL based on paid claims,

membership and premium for the most recent twelve reporting months. Premium is reported on an incurred month

basis. Paid claims and premium include both medical and pharmacy dollars.


MONTH

MEDICAL

SUBSCRIBERS

MEDICAL

MEMBERS

PHARMACY

SUBSCRIBERS

PHARMACY

MEMBERS

NOV'10 156 357 156 357

DEC'10 156 357 156 357

JAN'11 155 355 155 355

FEB'11 155 355 155 355

MAR'11 156 356 156 356

APR'11 155 355 155 355

MAY'11 157 366 157 366

JUN'11 157 365 157 365

JUL'11 158 365 158 365

AUG'11 158 364 158 364

SEP'11 158 366 158 366

OCT'11 158 366 158 366

SUMMARY 1,879 4,327 1,879 4,327

MONTH PREMIUM

MEDICAL

PAID CLAIMS

PHARMACY

PAID CLAIMS CAPITATION TOTAL PAID

MEDICAL AND

PHARMACY

LOSS RATIO

NOV'10 $132,342 $79,309 $30,538 $0 $109,847 83.0%

DEC'10 $132,342 $61,983 $23,115 $0 $85,097 64.3%

JAN'11 $135,262 $147,709 $14,981 $0 $162,690 120.3%

FEB'11 $135,262 $157,756 $13,066 $0 $170,822 126.3%

MAR'11 $135,857 $138,771 $9,994 $0 $148,765 109.5%

APR'11 $135,262 $287,944 $16,174 $0 $304,118 224.8%

MAY'11 $138,164 $92,272 $10,635 $0 $102,907 74.5%

JUN'11 $137,803 $160,962 $11,329 $0 $172,291 125.0%

JUL'11 $138,037 $103,060 $27,474 $0 $130,534 94.6%

AUG'11 $137,654 $114,553 $12,098 $0 $126,650 92.0%

SEP'11 $137,945 $116,958 $15,678 $0 $132,635 96.2%

OCT'11 $137,945 $129,310 $12,024 $0 $141,334 102.5%

SUMMARY $1,633,876 $1,590,586 $197,105 $0 $1,787,691 109.4%

NOV'10 DEC'10 JAN'11 FEB'11 MAR'11 APR'11 MAY'11 JUN'11 JUL'11 AUG'11 SEP'11 OCT'110%

25%

50%

75%

100%

125%

150%

175%

200%

225%

250%

LOSS RATIO BY MONTH

SUMMARY OF MEDICAL AND PHARMACY LOSS RATIO

Report Description: This report provides an overview of LAREDO TRANSIT MANAGEMENT, INC.: ALL's membership,

premium, and combined medical and pharmacy loss ratio and paid claims for the most recent twelve months.

Definitions of these financial measures can be found in the glossary.

SUMMARY OF FINDINGS

The medical and pharmacy loss ratio for the current month was 6.9% lower than the average of the most recent

twelve months, which was 109.4%.

Data Note

Reporting is based on paid, 12-month rolling periods.

Current reporting period represents claims paid from Nov'10 through Oct'11.

Paid claims for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).

PHARMACY FINANCIAL SUMMARYPHARMACY FINANCIAL SUMMARY

CHAPTER DESCRIPTION

Pharmacy includes all outpatient, non-professional prescription drug services provided to LAREDO TRANSIT

MANAGEMENT, INC.: ALL's members. This report provides a breakdown of key pharmacy expenditures, from

billed amount to paid amount, for the current reporting month and for the year to date on a paid basis. This report

will balance back to billing and accounts receivable system (BARS).

Data Note





PHARMACY FINANCIAL SUMMARYPHARMACY FINANCIAL SUMMARY


PHARMACY EXPENSES OCT'11 YEAR TO DATE

BILLED $30,858 $346,889

NOT COVERED $0 $0

COVERED $30,858 $346,889

DISCOUNT $14,731 $155,592

ALLOWED $16,127 $191,297

OUT OF POCKET $4,134 $47,875

COB $0 $0

COB MEDICARE $0 $0

OTHER REDUCTIONS $0 $0

OTHER ADJUSTMENTS $-30 $-30

PAID-PROVIDER $12,024 $143,453

OTHER PAYMENTS $0 $0

PAID $12,024 $143,453


SUMMARY OF PHARMACY FINANCIAL MEASURES

Report Description: This report provides an overview of LAREDO TRANSIT MANAGEMENT, INC.: ALL's pharmacy

expenses from billed to paid for the current reporting month and for the year to date. These key financial

measures are on a paid basis and balance back to your billing and accounts receivable system (BARS). These

metrics include plan performance measures, such as the degree of discounts the plan was able to achieve, as well

as COB and COB Medicare recoveries that the plan was able to receive based on other insurance contributing to

the overall expenses. Information is also provided on the amount of overall health care expenses that the member

was directly responsible for, through deductibles, coinsurance or co-payments. Other reductions include penalties,

workers compensation savings, and subrogation savings. Other payments includes Blue Card access fees and

surcharges. Also displayed are other adjustments. Definitions of these financial measures can be found in the

glossary.

Paid-Provider excludes Other Payments, which are not part of the Billed Amount.

NOT COVERED

DISCOUNT

OUT OF POCKET

COB

COB MEDICARE

OTHER REDUCTIONS

OTHER ADJUSTMENTS

PAID-PROVIDER

OCT'11 YEAR TO DATE 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BREAKDOWN OF BILLED AMOUNT

ENROLLMENTENROLLMENT

CHAPTER DESCRIPTION

The enrollment chapter presents descriptive information on LAREDO TRANSIT MANAGEMENT, INC.: ALL's

subscribers and dependents enrolled in BCBSTX. The ability to track changes in the characteristics of LAREDO

TRANSIT MANAGEMENT, INC.: ALL's enrolled population is critical information for effective plan management.

Information on membership size, age and gender are presented for subscribers and dependents for the current

reporting month and for the year to date. Enrollment by age band is shown for both subscribers and dependents for

the current reporting month and for the year to date. Additionally, the proportion of LAREDO TRANSIT

MANAGEMENT, INC.: ALL's enrollment by coverage tier is presented. The final report provides an analysis of

enrollment/disenrollment to provide detailed information necessary to understand monthly count variances.

Data Note

Current reporting month represents members enrolled in Oct'11.

Year to date represents average membership enrolled from Jan'11 through Oct'11.

Enrollment for active, retiree under 65, retiree 65 and over, and COBRA members are reported (if available).



ENROLLMENT OVERVIEW

Report Description: For medical membership only, the average number of subscribers, dependents, members and

average contract size for LAREDO TRANSIT MANAGEMENT, INC.: ALL are shown below in addition to the average

age, overall proportion of males, females, and females 20-44 years.

6.1


OCT'11 YEAR TO DATE

AVERAGE SUBSCRIBERS 158 157

AVERAGE DEPENDENTS 208 205

AVERAGE MEMBERS 366 362

AVERAGE CONTRACT SIZE 2.32 2.31

AVERAGE AGE (YEARS) 34.9 34.9

PROPORTION OF MALES 58.5% 58.4%

PROPORTION OF FEMALES 41.5% 41.6%

PROPORTION OF FEMALES (20-44 YEARS) 12.6% 12.3%

ENROLLMENT BY GENDER AND RELATIONSHIP

OCT'11 YEAR TO DATE OCT'11 YEAR TO DATE OCT'11 YEAR TO DATE0

50

100

150

200

250

300

350

400

SUBSCRIBERS DEPENDENTS MEMBERS

Size: LAREDO TRANSIT MANAGEMENT, INC.: ALL's overall membership was 366 in the current reporting month

and 362 for the year to date.

Gender: The average proportion of males was 58.5% in the current reporting month and 58.4% for the year to date.

Relationship:

Subscribers - For the current reporting month, 81.0% of subscribers were male and 19.0% were female. Forthe year to date, 80.9% of subscribers were male and 19.1% were female.

Dependents - For the current reporting month, 41.3% of dependents were male and 58.7% were female. Forthe year to date, 41.0% of dependents were male and 59.0% were female.

MALE FEMALE



ENROLLMENT BY AGE AND GENDER

Report Description: For medical membership only, LAREDO TRANSIT MANAGEMENT, INC.: ALL's average age of

subscribers (employees), dependents (spouse and/or children) and total members are displayed in the table below,

as well as the average age by gender for the current reporting month and for the year to date. The graph shows

various age bands for the year to date, broken down by subscribers, dependents and total members.


AVERAGE AGE (IN YEARS) BY GENDER

OCT'11 YEAR TO DATE

MALE FEMALE SUMMARY MALE FEMALE SUMMARY

SUBSCRIBERS 49.7 46.6 49.1 49.7 46.2 49.0

DEPENDENTS 16.3 29.7 24.1 16.1 29.7 24.2

MEMBERS 36.3 33.0 34.9 36.3 33.0 34.9

6.2

ENROLLMENT BY AGE BAND FOR THE YEAR TO DATE

<1-19 20-29 30-39 40-49 50-59 60-64 65+0

15

30

45

60

75

90

105

120

135

Subscriber Age: The average age for subscribers was 49.1 for the current reporting month and 49.0 for the year to

date. In the current reporting month, males were older than females and most subscribers fell into the 40-49 age

band.

Dependent Age: The average age for dependents was 24.1 for the current reporting month and 24.2 for the year to

date. In the current reporting month, males were younger than females and most dependents fell into the <1-19

age band.

SUBSCRIBERS DEPENDENTS MEMBERS

AGE BAND (YEARS)



ENROLLMENT BY COVERAGE TIER

Report Description: The average number of medical members and proportion of medical members in each coverage

tier are displayed in the table and chart below as well as the average contract size for the current reporting month

and for the year to date.

6.3


MEDICAL MEMBERS OCT'11 YEAR TO DATE

COVERAGE TIER

AVERAGE

MEMBERS % MEMBERS

AVERAGE

CONTRACT

SIZE

AVERAGE

MEMBERS % MEMBERS

AVERAGE

CONTRACT

SIZE

EMPLOYEE ONLY 84 23.0% 1.00 83 22.8% 1.00

EMPLOYEE+ONE 36 9.8% 2.00 40 11.0% 2.00

EMPLOYEE+DEPENDENT(S) 47 12.8% 3.36 45 12.3% 3.38

FAMILY 199 54.4% 4.74 195 53.9% 4.73

SUMMARY 366 100.0% 2.32 362 100.0% 2.31

ENROLLMENT BY COVERAGE TIER

22.8%

23.0%

11.0%

9.8%

12.3%

12.8%

53.9%

54.4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

YEAR TO DATE

OCT'11

Employee Only: Made up 23.0% of the overall membership in the current reporting month and 22.8% for the yearto date.

Employee + One: Made up 9.8% of the overall membership in the current reporting month and 11.0% for the yearto date.

Employee + Dependent(s): Made up 12.8% of the overall membership in the current reporting month and 12.3% forthe year to date.

Family: Made up 54.4% of the overall membership in the current reporting month and 53.9% for the year to date.

EMPLOYEE ONLY EMPLOYEE+ONE EMPLOYEE+DEPENDENT(S) FAMILY

PERCENTAGE OF MEMBERS



6.4

ENROLLMENT/DISENROLLMENT

Report Description: This report displays monthly medical subscriber and member enrollment and disenrollment counts

for the current policy year. This report breaks by Medicare and non-Medicare eligibility and enables you to identify

significant monthly count variances soon after they occur. This report is filtered to display Plan Eligibility only.


TOTAL MEDICAL SUBSCRIBERS

MONTH

MEDICARE NON-ELIGIBLE MEDICARE ELIGIBLE

TOTAL

SUBSCRIBERS

NEW

ENROLLMENT DISENROLLMENT

SUBSCRIBER

VARIANCE

NEW


SUBSCRIBER

VARIANCE

JAN'11 0 0 0 0 1 -1 155

FEB'11 0 0 0 0 0 0 155

MAR'11 1 0 1 0 0 0 156

APR'11 0 1 -1 0 0 0 155

MAY'11 2 0 2 0 0 0 157

JUN'11 0 0 0 0 0 0 157

JUL'11 1 0 1 0 0 0 158

AUG'11 0 0 0 0 0 0 158

SEP'11 0 0 0 0 0 0 158

OCT'11 1 0 1 0 1 -1 158

NOV'11

DEC'11

SUMMARY 5 1 4 0 2 -2 157


TOTAL MEDICAL MEMBERS

MONTH

MEDICARE NON-ELIGIBLE MEDICARE ELIGIBLE

TOTAL

MEMBERS

NEW


MEMBER

VARIANCE

NEW


MEMBER

VARIANCE

JAN'11 7 9 -2 1 1 0 355

FEB'11 0 0 0 0 0 0 355

MAR'11 1 0 1 0 0 0 356

APR'11 0 1 -1 0 0 0 355

MAY'11 11 0 11 0 0 0 366

JUN'11 0 1 -1 0 0 0 365

JUL'11 1 0 1 0 1 -1 365

AUG'11 0 1 -1 0 0 0 364

SEP'11 2 0 2 0 0 0 366

OCT'11 1 0 1 0 1 -1 366

NOV'11

DEC'11

SUMMARY 23 12 11 1 3 -2 361


ENROLLMENT BY TYPE OF COVERAGE

Report Description: This report provides a high-level view of LAREDO TRANSIT MANAGEMENT, INC.: ALL's

membership, broken down by employee status. These numbers show if a certain employee status was a key driver

to any changes in overall membership for the current reporting month and for the year to date.


6.5


AVERAGE ENROLLED MEMBERSHIP BY EMPLOYEE STATUS FOR OCT'11

EMPLOYEE STATUS MEDICAL PHARMACY DENTAL

ACTIVE 365 365

RETIREE UNDER 65

RETIREE 65 AND OVER

COBRA 1 1

SUMMARY 366 366


AVERAGE ENROLLED MEMBERSHIP BY EMPLOYEE STATUS FOR YEAR TO DATE

EMPLOYEE STATUS MEDICAL PHARMACY DENTAL

ACTIVE 361 361

RETIREE UNDER 65

RETIREE 65 AND OVER

COBRA 1 1

SUMMARY 362 361


EXPENSE AND UTILIZATION OVERVIEWEXPENSE AND UTILIZATION OVERVIEW

CHAPTER DESCRIPTION

The expense and utilization overview chapter is intended to provide key metrics for LAREDO TRANSIT

MANAGEMENT, INC.: ALL's claims and eligibility experience. Year-over-year changes and comparisons to the

benchmark are provided as well. Typically, when analyzing the health plan's overall performance in the last year,

two sets of questions are asked:

1. What is the percent change in membership and paid expenses?

2. How does LAREDO TRANSIT MANAGEMENT, INC.: ALL's experience compare to the benchmark?

The report provides a high-level breakdown of year-over-year expense and utilization changes and comparisons to

the benchmark. The Key Indicators table provides information related to the demographic make-up of LAREDO

TRANSIT MANAGEMENT, INC.: ALL and how paid expenses are distributed across all service categories.

Demographic information is calculated using medical enrollment only. All per 1000, per employee, and per

member measures are calculated using medical, dental, or pharmacy enrollment as appropriate. A graph is also

provided that shows the proportion of paid by service category.

Data Note

Reporting is based on incurred, 12-month rolling periods with 2 months run-out.

Current reporting period represents claims incurred Sep'10 through Aug'11 and paid through Oct'11.

Prior reporting period represents claims incurred Sep'09 through Aug'10 and paid through Oct'10.


Benchmarks are based on BCBSTX's non-HMO fully insured and self insured book of business. The book of

business includes all groups with between 51 and 500 subscribers.

7

SUMMARY OF FINDINGS

Overall membership decreased 4.0%. Contract size shrank and the average age remained stable.

Overall medical paid PMPM increased 19.6%. Paid PMPM for pharmacy decreased 10.7%. For medical paid

PMPM by service category, inpatient facility increased 47.7%, outpatient facility decreased 14.0% and

professional increased 30.1%.



KEY INDICATORS


SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK1 % VARIANCE

DEMOGRAPHICS (MEDICAL ONLY)

AVERAGE SUBSCRIBERS 156 159 -1.6%

AVERAGE DEPENDENTS 203 215 -5.7%

AVERAGE MEMBERS 359 374 -4.0%

AVERAGE CONTRACT SIZE 2.30 2.36 -2.4% 1.79 28.6%

AVERAGE AGE (YEARS) 34.8 34.4 1.2%

PROPORTION OF MALES 58.1% 56.4% 3.2% 51.8% 12.2%

PROPORTION OF FEMALES 41.9% 43.6% -4.1% 48.2% -13.1%

PROPORTION OF FEMALES (20-44 YEARS) 12.3% 13.1% -5.6% 21.2% -41.8%

OVERALL EXPENSES (PAID PMPM)

INPATIENT FACILITY $153.92 $104.24 47.7% $69.70 120.8%

OUTPATIENT FACILITY $100.05 $116.33 -14.0% $64.90 54.2%

PROFESSIONAL $120.62 $92.73 30.1% $83.48 44.5%

MANAGEMENT SERVICES $0.00

TOTAL MEDICAL $374.58 $313.30 19.6% $218.07 71.8%

PHARMACY $45.36 $50.82 -10.7% $51.30 -11.6%

DENTAL $20.28

OVERALL EXPENSES (PAID PEPM)

INPATIENT FACILITY $354.10 $245.70 44.1% $124.69 184.0%

OUTPATIENT FACILITY $230.17 $274.21 -16.1% $116.10 98.2%

PROFESSIONAL $277.49 $218.58 27.0% $149.35 85.8%

MANAGEMENT SERVICES $0.00

TOTAL MEDICAL $861.75 $738.49 16.7% $390.14 120.9%

PHARMACY $104.29 $119.79 -12.9% $91.69 13.7%

DENTAL $39.80

7.1

OVERALL EXPENDITURES (PAID) FOR CURRENT REPORTING PERIOD

36.7%

23.8%

28.7%

10.8%INPATIENT FACILITY

OUTPATIENT FACILITY

PROFESSIONAL

MANAGEMENT SERVICES

PHARMACY

DENTAL


1The benchmark is age/gender adjusted.


7.2


SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE

INPATIENT FACILITY UTILIZATION AND EXPENSE

TOTAL INPATIENT FACILITY PAID $663,221 $467,817 41.8%

INPATIENT FACILITY PAID PMPM $153.92 $104.24 47.7% $69.70 120.8%

ADMISSIONS/1000 125.3 98.9 26.7% 61.0 105.4%

IN-NETWORK ADMISSIONS % 100.0% 100.0% 0.0% 98.4% 1.6%

DAYS/1000 593.2 623.0 -4.8% 288.1 105.9%

AVERAGE LENGTH OF STAY (ALOS) 4.7 6.3 -24.8% 4.7 0.3%

PAID/ADMISSION $14,738 $12,644 16.6% $13,707 7.5%

IN-NETWORK PAID % 100.0% 100.0% 0.0% 98.9% 1.2%

PAID/DAY $3,114 $2,008 55.1% $2,903 7.2%

OUTPATIENT FACILITY UTILIZATION AND EXPENSE

TOTAL OUTPATIENT FACILITY PAID $431,101 $522,097 -17.4%

OUTPATIENT FACILITY PAID PMPM $100.05 $116.33 -14.0% $64.90 54.2%

VISITS/1000 2,342.1 2,211.2 5.9% 992.3 136.0%

IN-NETWORK VISITS % 80.9% 79.6% 1.6% 96.2% -16.0%

PAID/VISIT $513 $631 -18.8% $785 -34.7%

IN-NETWORK PAID % 95.6% 90.9% 5.2% 97.5% -2.0%

EMERGENCY ROOM VISITS/1000 133.7 176.5 -24.3% 191.4 -30.2%

EMERGENCY ROOM PAID/VISIT $1,012 $1,183 -14.5% $912 11.0%

PROFESSIONAL UTILIZATION AND EXPENSE

TOTAL PROFESSIONAL PAID $519,731 $416,170 24.9%

PROFESSIONAL PAID PMPM $120.62 $92.73 30.1% $83.48 44.5%

VISITS/MEMBER 8.5 7.8 10.1%

SERVICES/MEMBER 21.9 19.2 14.1% 18.9 15.8%

IN-NETWORK SERVICES % 98.5% 98.2% 0.3% 97.5% 1.0%

PAID/VISIT $170 $144 18.1%

PAID/SERVICE $66 $58 14.0% $53 24.8%

IN-NETWORK PAID % 99.1% 99.3% -0.2% 98.8% 0.3%

OFFICE VISITS/MEMBER 5.3 4.7 11.0%

OFFICE SERVICES/MEMBER 12.8 11.8 8.2% 15.4 -16.6%

OFFICE PAID/VISIT $152 $143 6.5%

OFFICE PAID/SERVICE $62 $57 9.1% $43 45.8%

PHARMACY UTILIZATION AND EXPENSE

TOTAL PHARMACY PAID $195,329 $228,072 -14.4%

PHARMACY PAID PMPM $45.36 $50.82 -10.7% $51.30 -11.6%

PRESCRIPTIONS/MEMBER 9.3 9.1 2.2% 10.8 -14.1%

GENERIC DISPENSING RATE 65.9% 55.4% 18.9% 69.3% -4.9%

PAID/PRESCRIPTION $59 $67 -12.7% $57 2.9%

DENTAL UTILIZATION AND EXPENSE

TOTAL DENTAL PAID

DENTAL PAID PMPM $20.28

SERVICES/MEMBER 3.4

IN-NETWORK SERVICES % 50.7%

PAID/SERVICE $71

IN-NETWORK PAID % 45.3%

SUMMARY

TOTAL MEDICAL PAID PMPM $374.58 $313.30 19.6% $218.07 71.8%

AVERAGE SUBSCRIBERS 156 159 -1.6%

AVERAGE DEPENDENTS 203 215 -5.7%

AVERAGE MEMBERS 359 374 -4.0%


KEY INDICATORS, CONTINUED

MEDICAL SERVICEMEDICAL SERVICE

CHAPTER DESCRIPTION

This chapter presents information on key expense and utilization metrics for LAREDO TRANSIT MANAGEMENT,

INC.: ALL, how they changed over time and how they compare with the benchmark.

This first group of reports focuses on LAREDO TRANSIT MANAGEMENT, INC.: ALL inpatient facility admission

experience. The first inpatient report details key statistics for maternity and non-maternity admissions (medical,

surgical, mental health/substance abuse and non-acute) with percent change and benchmark comparisons. The

second inpatient report lists the top ten inpatient providers ranked by number of admissions and by paid PMPM.

The second group of reports analyzes expense and utilization specifically related to visits provided in the outpatient

facility setting for LAREDO TRANSIT MANAGEMENT, INC.: ALL. The first report presents outpatient expense and

utilization by visit type with percent change and benchmark comparisons. The second report examines the top ten

most frequent reasons for an outpatient emergency room visit, surgical procedure, and radiology service. The third

report lists the top ten outpatient providers ranked by number of admissions and by paid.

The last report encompasses all the services for LAREDO TRANSIT MANAGEMENT, INC.: ALL provided by

physicians and other clinicians, ancillary services and supplies. This report analyzes the expense and utilization of

professional services by service type with percent change and benchmark comparisons.

Data Note

Reporting is based on incurred, 12-month rolling periods with 2 months run-out.

Current reporting period represents claims incurred Sep'10 through Aug'11 and paid through Oct'11.

Prior reporting period represents claims incurred Sep'09 through Aug'10 and paid through Oct'10.


Benchmarks are based on BCBSTX's non-HMO fully insured and self insured book of business. The book of

business includes all groups with between 51 and 500 subscribers.



SERVICE TYPE


SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE

MEDICAL ADMISSIONS/1000 69.6 64.2 8.5% 23.2 200.2%

DAYS/1000 381.5 355.6 7.3% 108.7 250.9%

AVERAGE LENGTH OF STAY 5.5 5.5 -1.1% 4.7 16.9%

PAID PMPM $65.51 $39.58 65.5% $22.93 185.7%

PAID/ADMISSION $11,291 $7,401 52.6% $11,865 -4.8%

PAID/DAY $2,060 $1,335 54.3% $2,531 -18.6%

SURGICAL ADMISSIONS/1000 44.6 21.4 108.3% 17.6 152.6%

DAYS/1000 194.9 173.8 12.2% 80.4 142.4%

AVERAGE LENGTH OF STAY 4.4 8.1 -46.2% 4.6 -4.0%

PAID PMPM $85.96 $56.18 53.0% $37.31 130.4%

PAID/ADMISSION $23,150 $31,515 -26.5% $25,382 -8.8%

PAID/DAY $5,291 $3,879 36.4% $5,568 -5.0%

MATERNITY ADMISSIONS/1000 11.1 10.7 4.2% 15.0 -25.9%

DAYS/1000 16.7 18.7 -10.7% 44.4 -62.4%

AVERAGE LENGTH OF STAY 1.5 1.8 -14.3% 3.0 -49.2%

PAID PMPM $2.45 $1.62 50.9% $6.19 -60.4%

PAID/ADMISSION $2,638 $1,821 44.9% $4,938 -46.6%

PAID/DAY $1,759 $1,041 69.0% $1,672 5.2%

MENTAL HEALTH/

SUBSTANCE ABUSE

ADMISSIONS/1000 4.1

DAYS/1000 34.8

AVERAGE LENGTH OF STAY 8.5

PAID PMPM $1.64

PAID/ADMISSION $4,834

PAID/DAY $567

NON-ACUTE ADMISSIONS/1000 2.7 1.1

DAYS/1000 74.9 19.7

AVERAGE LENGTH OF STAY 28.0 18.5

PAID PMPM $6.86 $1.63

PAID/ADMISSION $30,800 $18,232

PAID/DAY $1,100 $988

SUMMARY ADMISSIONS/1000 125.3 98.9 26.7% 61.0 105.4%

DAYS/1000 593.2 623.0 -4.8% 288.1 105.9%

AVERAGE LENGTH OF STAY 4.7 6.3 -24.8% 4.7 0.3%

PAID PMPM $153.92 $104.24 47.7% $69.70 120.8%

PAID/ADMISSION $14,738 $12,644 16.6% $13,707 7.5%

PAID/DAY $3,114 $2,008 55.1% $2,903 7.2%


INPATIENT ADMISSION ANALYSIS

Report Description: Expense and utilization measures are displayed in the table below for the following admission

categories: maternity, medical, mental health/substance abuse, non-acute, and surgical. Current reporting period,

prior reporting period, and benchmark measures are analyzed in the table. Non-acute refers to admissions for

rehabilitation, skilled nursing facilities, and hospice care. The paid amount is based on the inpatient facility

component only. Inpatient professional statistics are not reported.


INPATIENT ADMISSION ANALYSIS, CONTINUED

Medical: Over the two reporting periods, LAREDO TRANSIT MANAGEMENT, INC.: ALL's expense (paid PMPM)

increased 65.5%, utilization (admissions/1,000) increased 8.5% and paid per admission increased 52.6% for

medical admissions. In addition, the average length of stay remained relatively stable. Compared to the

benchmark, LAREDO TRANSIT MANAGEMENT, INC.: ALL had higher expenses, higher utilization, lower paid per

admission and longer length of stay.

Surgical: Over the two reporting periods, LAREDO TRANSIT MANAGEMENT, INC.: ALL's expense (paid PMPM)

increased 53.0%, utilization (admissions/1,000) increased 108.3% and paid per admission decreased 26.5% for

surgical admissions. In addition, the average length of stay decreased 46.2%. Compared to the benchmark,

LAREDO TRANSIT MANAGEMENT, INC.: ALL had higher expenses, higher utilization, lower paid per admission

and slightly shorter length of stay.

Maternity: Over the two reporting periods, LAREDO TRANSIT MANAGEMENT, INC.: ALL's expense (paid PMPM)

increased 50.9%, utilization (admissions/1,000) increased slightly and paid per admission increased 44.9% for

maternity admissions. In addition, the average length of stay decreased 14.3%. Compared to the benchmark,

LAREDO TRANSIT MANAGEMENT, INC.: ALL had lower expenses, lower utilization, lower paid per admission and

shorter length of stay.

Mental Health/Substance Abuse: Insufficient data for comparison (>12 months required)

Non-Acute: Insufficient data for comparison (>12 months required)




INPATIENT PROVIDER SUMMARY

Report Description: The provider listings below include top ten inpatient facility providers ranked by admissions and

by paid for the current reporting period. Expense and utilization measures are featured in both listings.

The top three inpatient facility providers that comprised 86.7% of the total admissions were Doctors Hospital Of

Laredo, Laredo Medical Center, and Methodist Hospital.

The top three inpatient facility providers that comprised 85.3% of the total paid were Methodist Hospital, Laredo

Medical Center, and Doctors Hospital Of Laredo.

TOP 10 INPATIENT FACILITY PROVIDERS BY ADMISSIONS FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL

PROVIDER NAME

PROVIDER

STATE ADMISSIONS

% OF TOTAL

ADMISSIONS DAYS

AVG

LENGTH

OF STAY

PAID/

ADMISSION PAID

% OF TOTAL

PAID

DOCTORS HOSPITAL OF LAREDO TX 19 42.2% 84 4.4 $6,806 $129,311 19.5%

LAREDO MEDICAL CENTER TX 15 33.3% 58 3.9 $12,165 $182,482 27.5%

METHODIST HOSPITAL TX 5 11.1% 53 10.6 $50,733 $253,666 38.2%

UNIVERSITY HEALTH SYSTEM TX 3 6.7% 11 3.7 $22,823 $68,470 10.3%

CHRISTUS SANTA ROSA CHILDRENS HOS TX 2 4.4% 4 2.0 $11,149 $22,298 3.4%

METHODIST SPECIALTY AND TRANSPLANT

HOSPI TX 1 2.2% 3 3.0 $6,995 $6,995 1.1%

SUMMARY 45 100.0% 213 4.7 $14,738 $663,221 100.0%

TOP 10 INPATIENT FACILITY PROVIDERS BY PAID FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL

PROVIDER NAME

PROVIDER

STATE ADMISSIONS

% OF TOTAL

ADMISSIONS DAYS

AVG

LENGTH

OF STAY

PAID/

ADMISSION PAID

% OF TOTAL

PAID

METHODIST HOSPITAL TX 5 11.1% 53 10.6 $50,733 $253,666 38.2%

LAREDO MEDICAL CENTER TX 15 33.3% 58 3.9 $12,165 $182,482 27.5%

DOCTORS HOSPITAL OF LAREDO TX 19 42.2% 84 4.4 $6,806 $129,311 19.5%

UNIVERSITY HEALTH SYSTEM TX 3 6.7% 11 3.7 $22,823 $68,470 10.3%

CHRISTUS SANTA ROSA CHILDRENS HOS TX 2 4.4% 4 2.0 $11,149 $22,298 3.4%

METHODIST SPECIALTY AND TRANSPLANT

HOSPI TX 1 2.2% 3 3.0 $6,995 $6,995 1.1%

SUMMARY 45 100.0% 213 4.7 $14,738 $663,221 100.0%

MEDICAL SERVICE

OUTPATIENT FACILITY VISIT TYPE ANALYSIS

Report Description: Outpatient facility expense and utilization measures are displayed in the table below by visit

type. Current reporting period, prior reporting period, and benchmark measures are analyzed in the table. The

visit type Other Services refers to all visits that could not be classified into other visit types that are displayed

below.

MEDICAL SERVICE




RADIOLOGY $39.70 $23.45 69.3% $12.76 211.0%

SURGICAL $25.78 $27.51 -6.3% $24.43 5.5%

LABORATORY $15.98 $22.43 -28.8% $3.02 428.9%

EMERGENCY ROOM $11.28 $17.40 -35.2% $14.55 -22.5%

PT/OT/ST $3.32 $5.37 -38.1% $1.86 78.9%

OTHER SERVICES $2.23 $8.56 -74.0% $1.66 34.3%

DIALYSIS $1.38 $6.41 -78.6% $1.32 4.6%

OBSERVATION ROOM $0.39 $0.93 -58.1% $1.80 -78.4%

MEDICAL SPECIALTIES SERVICES $4.28 $2.82

PSYCHIATRIC $0.69

SUMMARY $100.05 $116.33 -14.0% $64.90 54.2%


VISITS/1000 SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE

RADIOLOGY 746.3 336.9 121.5% 253.4 194.5%

SURGICAL 222.8 171.1 30.2% 131.1 70.0%

LABORATORY 523.6 604.3 -13.4% 142.2 268.2%

EMERGENCY ROOM 133.7 176.5 -24.3% 191.4 -30.2%

PT/OT/ST 192.2 374.3 -48.7% 112.0 71.5%

OTHER SERVICES 139.2 243.3 -42.8% 54.3 156.2%

DIALYSIS 364.8 211.2 72.7% 49.2 641.0%

OBSERVATION ROOM 19.5 21.4 -8.9% 26.3 -25.8%

MEDICAL SPECIALTIES SERVICES 72.2 8.1

PSYCHIATRIC 24.3

SUMMARY 2,342.1 2,211.2 5.9% 992.3 136.0%


PAID/VISIT SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE

RADIOLOGY $638 $835 -23.6% $604 5.6%

SURGICAL $1,389 $1,929 -28.0% $2,236 -37.9%

LABORATORY $366 $445 -17.8% $255 43.6%

EMERGENCY ROOM $1,012 $1,183 -14.5% $912 11.0%

PT/OT/ST $208 $172 20.7% $199 4.3%

OTHER SERVICES $192 $422 -54.6% $366 -47.6%

DIALYSIS $45 $364 -87.6% $321 -85.9%

OBSERVATION ROOM $239 $521 -54.1% $821 -70.9%

MEDICAL SPECIALTIES SERVICES $711 $4,171

PSYCHIATRIC $343

SUMMARY $513 $631 -18.8% $785 -34.7%

$0 $5 $10 $15 $20 $25 $30 $35 $40 $45

PSYCHIATRIC

MEDICAL SPECIALTIES SERVICES

OBSERVATION ROOM

DIALYSIS

OTHER SERVICES

PT/OT/ST

EMERGENCY ROOM

LABORATORY

SURGICAL

RADIOLOGY

0 150 300 450 600 750 900

PSYCHIATRIC


OBSERVATION ROOM

DIALYSIS

OTHER SERVICES

PT/OT/ST

EMERGENCY ROOM

LABORATORY

SURGICAL

RADIOLOGY

$0

$5

00

$1

,00

0

$1

,50

0

$2

,00

0

$2

,50

0

$3

,00

0

$3

,50

0

$4

,00

0

$4

,50

0

PSYCHIATRIC


OBSERVATION ROOM

DIALYSIS

OTHER SERVICES

PT/OT/ST

EMERGENCY ROOM

LABORATORY

SURGICAL

RADIOLOGY

SEP'10-AUG'11 SEP'09-AUG'10 BENCHMARK

8.4

PAID PMPM

VISITS/1000

PAID/VISIT

MEDICAL SERVICE

OUTPATIENT FACILITY VISIT TYPE ANALYSIS, CONTINUED

Expense: Overall, LAREDO TRANSIT MANAGEMENT, INC.: ALL's change in paid PMPM for outpatient facility visits

was -14.0%, which was 54.2% above the benchmark. A comparison of paid PMPM by visit type shows that

ambulatory surgery was 5.5% above the benchmark, emergency room was 22.5% below the benchmark and

radiology was 211.0% above the benchmark.

Utilization: The change in outpatient facility visits/1,000 was 5.9%, which was 136.0% higher than the

benchmark. A comparison of visits/1,000 by visit type shows that ambulatory surgery was 70.0% higher than the

benchmark, emergency room was 30.2% lower than the benchmark and radiology was 194.5% higher than the

benchmark.

Paid per Visit: The overall change in the paid per visit was -18.8% and was 34.7% lower than the benchmark. Paid

per visit for emergency room was 11.0% higher than the benchmark, 37.9% lower than the benchmark for

ambulatory surgery and 5.6% higher than the benchmark for radiology.

MEDICAL SERVICE


MEDICAL SERVICE

OUTPATIENT FACILITY VISIT TYPE DETAIL FOR EMERGENCY ROOM, AMBULATORY SURGERY ANDRADIOLOGY

Report Description: In the first table, key utilization and expense metrics are displayed for the ten most frequent

emergency room diagnoses in the current reporting period. The ambulatory surgery table shows key utilization and

expense metrics for the ten most frequent diagnostic categories in the current reporting period. The last table

displays key utilization and expense metrics for the most frequent outpatient radiology services in the current

reporting period.

MEDICAL SERVICE


EMERGENCY ROOM - TOP 10 DIAGNOSES BY VISITS FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL FOR THE CURRENT REPORTING PERIOD

3-DIGIT PRINCIPAL DIAGNOSES VISITS/1000

% OF TOTAL

VISITS/1000 PAID/VISIT PAID PMPM

% OF TOTAL

PAID PMPM

780 GENERAL SYMPTOMS 11.1 8.3% $1,230 $1.14 10.1%

789 OTHER SYMPTOMS INVOLVING ABDOMEN AND PELVIS 11.1 8.3% $599 $0.56 4.9%

844 SPRAINS AND STRAINS OF KNEE AND LEG 8.4 6.2% $1,272 $0.89 7.9%

382 SUPPURATIVE AND UNSPECIFIED OTITIS MEDIA 5.6 4.2% $855 $0.40 3.5%

592 CALCULUS OF KIDNEY AND URETER 5.6 4.2% $984 $0.46 4.1%

786 SYMPTOMS INVOLVING RESPIRATORY SYSTEM AND OTHER CHEST

SYMPTOMS 5.6 4.2% $2,399 $1.11 9.9%

924 CONTUSION OF LOWER LIMB AND OF OTHER AND UNSPECIFIED

SITES 5.6 4.2% $1,021 $0.47 4.2%

204 LYMPHOID LEUKEMIA 2.8 2.1% $1,011 $0.23 2.1%

276 DISORDERS OF FLUID, ELECTROLYTE AND ACID-BASE BALANCE 2.8 2.1% $587 $0.14 1.2%

381 NONSUPPURATIVE OTITIS MEDIA AND EUSTACHIAN TUBE DISORDERS 2.8 2.1% $251 $0.06 0.5%

ALL OTHER 72.4 54.2% $965 $5.82 51.6%

SUMMARY 133.7 100.0% $1,012 $11.28 100.0%

AMBULATORY SURGERY - TOP 10 DIAGNOSES BY VISITS FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL FOR THE CURRENT REPORTING PERIOD

ICD-9 DIAGNOSTIC CATEGORY VISITS/1000

% OF TOTAL


% OF TOTAL

PAID PMPM

ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES 78.0 35.0% $1,079 $7.01 27.2%

EYES 27.8 12.5% $564 $1.31 5.1%

NEOPLASMS 22.3 10.0% $956 $1.77 6.9%

SYMPTOMS, SIGNS & ILL-DEFINED CONDITIONS 19.5 8.8% $1,055 $1.71 6.7%

DIGESTIVE 16.7 7.5% $849 $1.18 4.6%

INJURY & POISONING 13.9 6.2% $4,235 $4.91 19.1%

GENITOURINARY 11.1 5.0% $3,309 $3.07 11.9%

WITHOUT REPORTED DIAGNOSIS 11.1 5.0% $840 $0.78 3.0%

CIRCULATORY 5.6 2.5% $6,136 $2.85 11.0%

HEALTH SERVICES 5.6 2.5% $503 $0.23 0.9%

ALL OTHER 11.1 5.0% $1,014 $0.94 3.7%

SUMMARY 222.8 100.0% $1,389 $25.78 100.0%



OUTPATIENT FACILITY VISIT TYPE DETAIL FOR EMERGENCY ROOM, AMBULATORY SURGERY ANDRADIOLOGY, CONTINUED

RADIOLOGY SERVICE CATEGORIES BY VISITS FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL FOR THE CURRENT REPORTING PERIOD

DETAILED SERVICE TYPE VISITS/1000

% OF TOTAL


% OF TOTAL

PAID PMPM

DIAGNOSTIC RADIOLOGY: OTHER 495.7 66.4% $408 $16.86 42.5%

THERAPEUTIC RADIOLOGY 156.0 20.9% $1,080 $14.04 35.4%

OTHER IMAGING 44.6 6.0% $398 $1.48 3.7%

CT SCAN 39.0 5.2% $1,712 $5.56 14.0%

MRI 11.1 1.5% $1,894 $1.76 4.4%

NUCLEAR MEDICINE

ALL OTHER

SUMMARY 746.3 100.0% $638 $39.70 100.0%

The top three diagnoses in terms of total ER visits were 780 General Symptoms, 789 Other Symptoms Involving

Abdomen And Pelvis, and 844 Sprains And Strains Of Knee And Leg. These diagnoses accounted for 22.9% of

the total ER visits evaluated in this analysis.

The top five paid ambulatory surgical procedures accounted for 58.8% of the total ambulatory surgical visits and

for 76.1% of the total ambulatory surgical expenses.

The top five paid radiology services accounted for 100.0% of the total radiology visits and for 100.0% of the total

radiology expenses.


OUTPATIENT PROVIDER SUMMARY

Report Description: The provider listings below include top ten outpatient facility providers ranked by visits and by

paid dollars for the current reporting period.

TOP 10 OUTPATIENT FACILITY PROVIDERS BY VISITS FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL

PROVIDER NAME

PROVIDER

STATE VISITS PAID

% OF TOTAL

PAID PAID/VISIT

LAREDO MEDICAL CENTER TX 354 $233,366 54.1% $659

DOCTORS HOSPITAL OF LAREDO TX 223 $124,813 29.0% $560

USRC LAREDO SOUTH DIALYSIS LP TX 130 $5,806 1.3% $45

GLOBAL NURSING SERVICES INC TX 28 $6,496 1.5% $232

LAREDO LASER & SURGERY LTD TX 28 $13,178 3.1% $471

LAREDO HOME HEALTH TX 25 $3,277 0.8% $131

CHRISTUS SANTA ROSA HOSP CITY CTR TX 15 $5,491 1.3% $366

UNIVERSITY HEALTH SYSTEM TX 8 $12,825 3.0% $1,603

CHRISTUS SANTA ROSA CHILDRENS HOS TX 6 $1,334 0.3% $222

METHODIST HOSPITAL TX 6 $6,469 1.5% $1,078

ALL OTHER 18 $18,047 4.2% $1,003

SUMMARY 841 $431,101 100.0% $513

TOP 10 OUTPATIENT FACILITY PROVIDERS BY PAID FOR LAREDO TRANSIT MANAGEMENT, INC.: ALL

PROVIDER NAME

PROVIDER

STATE VISITS PAID

% OF TOTAL

PAID PAID/VISIT

LAREDO MEDICAL CENTER TX 354 $233,366 54.1% $659

DOCTORS HOSPITAL OF LAREDO TX 223 $124,813 29.0% $560

LAREDO LASER & SURGERY LTD TX 28 $13,178 3.1% $471

UNIVERSITY HEALTH SYSTEM TX 8 $12,825 3.0% $1,603

GLOBAL NURSING SERVICES INC TX 28 $6,496 1.5% $232

METHODIST HOSPITAL TX 6 $6,469 1.5% $1,078

USRC LAREDO SOUTH DIALYSIS LP TX 130 $5,806 1.3% $45

CHRISTUS SANTA ROSA HOSP CITY CTR TX 15 $5,491 1.3% $366

THE CNTR FOR SPECIAL SURGERY TCA TX 2 $5,426 1.3% $2,713

CORPUS CHRISTI MEDICAL CENTER BAY

AREA

TX 2 $3,695 0.9% $1,847

ALL OTHER 45 $13,538 3.1% $301

SUMMARY 841 $431,101 100.0% $513




PROFESSIONAL SERVICE TYPE ANALYSIS

Report Description: Expense and utilization measures for professional services by service type are displayed in the

table below. Current reporting period, prior reporting period, and benchmark measures are analyzed in the table.



MEDICAL SERVICES & SUPPLIES (HCPCS II) $30.71 $14.65 109.6% $12.82 139.5%

EVALUATION & MANAGEMENT $25.30 $26.43 -4.3% $23.96 5.6%

SURGICAL $19.88 $12.90 54.1% $11.26 76.6%

MEDICAL $15.16 $18.94 -20.0% $13.49 12.4%

RADIOLOGY $12.55 $8.55 46.8% $7.44 68.7%

PATHOLOGY & LABORATORY $9.82 $6.66 47.3% $8.14 20.5%

ANESTHESIA $4.85 $2.99 62.1% $4.65 4.3%

PT/OT/ST $2.34 $1.60 46.9% $1.72 36.5%

OTHER $0.00

SUMMARY $120.62 $92.73 30.1% $83.48 44.5%


SERVICES/1000 SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE

MEDICAL SERVICES & SUPPLIES (HCPCS II) 1,690.4 978.6 72.7% 1,106.4 52.8%

EVALUATION & MANAGEMENT 4,366.7 4,569.5 -4.4% 4,193.3 4.1%

SURGICAL 1,203.1 799.5 50.5% 1,376.7 -12.6%

MEDICAL 2,667.9 2,582.9 3.3% 3,275.3 -18.5%

RADIOLOGY 1,821.3 1,478.6 23.2% 1,297.8 40.3%

PATHOLOGY & LABORATORY 8,705.5 7,510.7 15.9% 6,359.7 36.9%

ANESTHESIA 100.3 107.0 -6.3% 133.2 -24.8%

PT/OT/ST 1,375.7 1,187.2 15.9% 1,200.8 14.6%

OTHER 1.3

SUMMARY 21,930.8 19,213.9 14.1% 18,944.6 15.8%


PAID/SERVICE SEP'10-AUG'11 SEP'09-AUG'10 % CHANGE BENCHMARK % VARIANCE

MEDICAL SERVICES & SUPPLIES (HCPCS II) $218 $180 21.3% $139 56.8%

EVALUATION & MANAGEMENT $70 $69 0.2% $69 1.4%

SURGICAL $198 $194 2.4% $98 102.1%

MEDICAL $68 $88 -22.5% $49 38.0%

RADIOLOGY $83 $69 19.1% $69 20.2%

PATHOLOGY & LABORATORY $14 $11 27.1% $15 -11.9%

ANESTHESIA $581 $336 72.9% $419 38.6%

PT/OT/ST $20 $16 26.8% $17 19.1%

OTHER $27

SUMMARY $66 $58 14.0% $53 24.8%

Expense: Over the current reporting period, LAREDO TRANSIT MANAGEMENT, INC.: ALL's top three paid service

types were Medical Services & Supplies (HCPCS II), Evaluation & Management and Surgical.

Utilization: The highest utilized service type was Pathology & Laboratory which was 36.9% higher than the

benchmark. Next was Evaluation & Management which was 4.1% higher than the benchmark, followed by Medical.

Paid per Service: The most expensive service type was Anesthesia which was 38.6% higher than the benchmark.

Next was Medical Services & Supplies (HCPCS II) which was 56.8% higher than the benchmark, followed by

Surgical.

8.9

PHARMACYPHARMACY

CHAPTER DESCRIPTION

Pharmacy includes all outpatient, non-professional prescription drug services provided to LAREDO TRANSIT

MANAGEMENT, INC.: ALL's members. These services are categorized into generic, brand formulary, brand

non-formulary, and specialty drugs. Once the patent for a brand drug expires, a generic version of the drug which

is the same chemically as the brand version can be available at cheaper prices. Generic drugs are less expensive

because generic manufacturers do not have the investment expenses of a new drug developer. When appropriate,

plan sponsors encourage the use of generics over brand drugs. Formulary brand drugs are those that appear on the

plan's approved list of brands. Non-formulary brand drugs are all other brand drugs which generally have equally

effective and less expensive generic equivalents and/or have one or more formulary options. Specialty drugs

generally have unique uses, require special dosing or administration, are typically prescribed by a specialist

provider and are significantly more expensive than alternative drugs or therapies.

This chapter presents information on key expense and utilization metrics for prescription drugs. These metrics are

provided on a paid basis with compression logic applied, consequently the report will not balance back to BARS.

When available, metrics for the current reporting month are compared to the year to date.

Prescription drugs are classified by therapeutic class. Number of prescriptions, total paid by plan, and whether

generic or formulary is presented for the top 25 therapeutic drug classes. Descriptive information on the top 25

prescription drugs is also provided based on number of prescriptions, total paid by plan, and whether generic or

formulary.

A report on Specialty drugs is included showing key expense and utilization metrics.

Data Note





SUMMARY OF FINDINGS

Generic drugs were dispensed at a(n) 67.3% rate in the current reporting month. Increasing the generic

dispensing rate by 2% points would result in a savings of $9,178 for LAREDO TRANSIT MANAGEMENT, INC.:

ALL for the year to date.

Multi-source brand (brands with an exact generic equivalent) utilization was 2.0% for the year to date.

The top therapeutic classes, based on total ingredient cost in the year to date were HMG CoA Reductase Inhibitors,

Antihypertensive Combinations, and Proton Pump Inhibitors. The top prescription drugs, based on total ingredient

cost, were Lamictal Xr, Temodar, and Actos in the year to date. These drugs accounted for 14.8% of the total

ingredient cost amount.

The number of members utilizing specialty medication for the year to date was 3. These 3 members received 5

specialty medications which represented 8.3% of the total pharmacy paid amount for the year to date. The top

specialty drugs, based on total ingredient cost were Temodar, Enbrel, and Xeloda in the year to date. These drugs

accounted for 100.0% of the total ingredient cost amount.

PHARMACYPHARMACY

9.1

65.3%

69.4% 68.8%67.3% 67.8%

85.0% 85.9%88.2% 87.8% 86.5%

Q1 Q2 Q3 Q4 YEAR TO DATE 0%

15%

30%

45%

60%

75%


KEY INDICATORS SUMMARY

Report Description: This report provides an overview of LAREDO TRANSIT MANAGEMENT, INC.: ALL's prescription

expenses and utilization as well as providing percent change in these expenses between the current reporting

month and year to date periods.


SAVINGS SUMMARY

OCT'11 YEAR TO DATE

RETAIL MAIL ORDER SUMMARY RETAIL MAIL ORDER SUMMARY

TOTAL PHARMACY DISCOUNT $16,442 $16,442 $152,922 $2,810 $155,733

MAC PROGRAM SAVINGS $11,461 $11,461 $104,334 $2,796 $107,130

PHARMACY DISCOUNT % 45.7% 45.7% 44.4% 89.4% 44.8%

GENERIC DISPENSING AND FORMULARY COMPLIANCE RATES1


COST SHARING DISTRIBUTION

OCT'11 YEAR TO DATE

RETAIL MAIL ORDER RETAIL MAIL ORDER

MEMBER: OUT OF POCKET 25.2% 24.9% 84.2%

PLAN: PAID 74.8% 75.1% 15.8%


KEY INDICATORS SUMMARY OCT'11

YEAR TO

DATE

UNIQUE PHARMACY MEMBERS 366 371

PHARMACY MEMBER MONTHS 366 3,613

CLAIMANTS 105 238

PERCENT OF UTILIZING MEMBERS 28.7% 64.2%

PRESCRIPTIONS 278 2,669

PRESCRIPTIONS PMPM 0.76 0.74

PAID $14,650 $144,000

PAID PMPM $40.03 $39.86

AVERAGE INGREDIENT

COST/PRESCRIPTION $68.95 $70.47

GENERIC DISPENSING RATE 67.3% 67.8%

FORMULARY COMPLIANCE RATE 87.8% 86.5%

GENERIC SUBSTITUTION RATE 98.4% 97.2%

OUT OF POCKET PERCENT OF ALLOWED 25.2% 25.0%

RETAIL AS A PERCENT OF

PRESCRIPTIONS 100.0% 99.6%

MAIL ORDER AS A PERCENT OF

PRESCRIPTIONS 0.4%

SPECIALTY PERCENT OF TOTAL

PRESCRIPTIONS 0.4% 0.2%

1When displaying quarterly information, the first and last month of the reported quarters may have incomplete quarterly data.

GENERIC DISPENSING RATE

FORMULARY COMPLIANCE RATE

PHARMACYPHARMACY

KEY INDICATORS SUMMARY, CONTINUED

During the current reporting month there were 278 prescriptions dispensed for LAREDO TRANSIT MANAGEMENT,

INC.: ALL's members. The total amount paid for these prescriptions was $14,650.

Overall current reporting month pharmacy paid PMPM was $40.03. Pharmacy paid PMPM was $39.86 for the

year to date.

LAREDO TRANSIT MANAGEMENT, INC.: ALL's overall ingredient cost per prescription was $68.95 in the current

reporting month. The year to date ingredient cost per prescription was $70.47.

Generic drugs represented 67.3% of all claims in the current reporting month and 67.8% for the year to date.

Formulary drugs represented 87.8% for the current reporting month and 86.5% for the year to date.

For the current reporting month, members' out of pocket contribution was 25.2% to their prescription drug costs

through any applicable copay, coinsurance or deductible amounts. For the year to date the members' out of pocket

contribution was 25.0%. For the year to date at retail the members' share is 24.9%, while at mail it is 84.2%.

Specialty pharmacy claims represented 0.4% of all prescriptions during the current reporting month and 0.2% for

the year to date.


PHARMACYPHARMACY

GENERIC VERSUS FORMULARY EXPERIENCE

Report Description: For the year to date, LAREDO TRANSIT MANAGEMENT, INC.: ALL's prescription drug expenses

are displayed below for retail and mail order providers and broken out by drug type and formulary indicator. The

brand type is broken down by single-source and multi-source. In addition, the total expense for each category is

shown by the member and the plan.

RETAIL PRESCRIPTIONS PRESCRIPTIONS

% OF TOTAL

PRESCRIPTIONS

TOTAL EXPENSE MEMBER EXPENSE PLAN EXPENSE

ALLOWED

ALLOWED/

PRESCRIPTION

OUT OF

POCKET

OUT OF

POCKET/

PRESCRIPTION PAID

PAID/

PRESCRIPTION

GENERIC 1,798 67.7% $29,764 $16.55 $14,313 $7.96 $15,451 $8.59

BRAND 859 32.3% $161,828 $188.39 $33,362 $38.84 $128,496 $149.59

SUMMARY 2,657 100.0% $191,592 $72.11 $47,674 $17.94 $143,947 $54.18

BRAND TYPE BREAKDOWN:

SINGLE SOURCE BRAND 806 30.3% $157,611 $195.55 $31,330 $38.87 $126,311 $156.71

MULTI-SOURCE BRAND 53 2.0% $4,217 $79.57 $2,031 $38.33 $2,186 $41.24

MULTI-SOURCE BRAND W/DAW1 10 0.4% $602 $60.20 $306 $30.57 $296 $29.63

BRAND FORMULARY 500 18.8% $87,633 $175.27 $15,982 $31.96 $71,652 $143.30

BRAND NON-FORMULARY 359 13.5% $74,195 $206.67 $17,380 $48.41 $56,845 $158.34

MAIL ORDER PRESCRIPTIONS PRESCRIPTIONS

% OF TOTAL

PRESCRIPTIONS


ALLOWED

ALLOWED/

PRESCRIPTION

OUT OF

POCKET

OUT OF

POCKET/

PRESCRIPTION PAID

PAID/

PRESCRIPTION

GENERIC 12 100.0% $333 $27.73 $280 $23.33 $53 $4.39

BRAND

SUMMARY 12 100.0% $333 $27.73 $280 $23.33 $53 $4.39


SINGLE SOURCE BRAND

MULTI-SOURCE BRAND

MULTI-SOURCE BRAND W/DAW1

BRAND FORMULARY

BRAND NON-FORMULARY

TOTAL PRESCRIPTIONS PRESCRIPTIONS

% OF TOTAL

PRESCRIPTIONS


ALLOWED

ALLOWED/

PRESCRIPTION

OUT OF

POCKET

OUT OF

POCKET/

PRESCRIPTION PAID

PAID/

PRESCRIPTION

GENERIC 1,810 67.8% $30,096 $16.63 $14,593 $8.06 $15,503 $8.57

BRAND 859 32.2% $161,828 $188.39 $33,362 $38.84 $128,496 $149.59

SUMMARY 2,669 100.0% $191,924 $71.91 $47,955 $17.97 $144,000 $53.95


SINGLE SOURCE BRAND 806 30.2% $157,611 $195.55 $31,330 $38.87 $126,311 $156.71

MULTI-SOURCE BRAND 53 2.0% $4,217 $79.57 $2,031 $38.33 $2,186 $41.24

MULTI-SOURCE BRAND W/DAW1 10 0.4% $602 $60.20 $306 $30.57 $296 $29.63

BRAND FORMULARY 500 18.7% $87,633 $175.27 $15,982 $31.96 $71,652 $143.30

BRAND NON-FORMULARY 359 13.5% $74,195 $206.67 $17,380 $48.41 $56,845 $158.34


PHARMACYPHARMACY

TOP THERAPEUTIC DRUG CLASSES

Report Description: The top 25 therapeutic drug classes for the year to date are displayed below ranked by

ingredient cost.


TOP 25 THERAPEUTIC DRUG CLASSES BY INGREDIENT COST

PLAN THERAPEUTIC CLASS PRESCRIPTIONS

INGREDIENT

COST

% OF TOTAL

INGREDIENT

COST

AVG INGREDIENT

COST/

PRESCRIPTION % FORMULARY % GENERIC

RANK BY

VOLUME

1 HMG COA REDUCTASE INHIBITORS 213 $15,027 8.0% $70.55 77.0% 53.5% 1

2 ANTIHYPERTENSIVE COMBINATIONS 177 $12,126 6.4% $68.51 84.2% 54.8% 2

3 PROTON PUMP INHIBITORS 100 $12,053 6.4% $120.53 79.0% 46.0% 4

4 ANTIDIABETIC COMBINATIONS 75 $11,710 6.2% $156.13 100.0% 42.7% 10

5 ANTICONVULSANTS - MISC. 38 $11,608 6.2% $305.47 52.6% 50.0% 18

6 DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS 52 $10,749 5.7% $206.71 76.9% 0.0% 13

7 PHOSPHATE BINDER AGENTS 14 $9,516 5.1% $679.69 21.4% 14.3% 43

8 ALKYLATING AGENTS 3 $8,680 4.6% $2,893.21 0.0% 0.0% 107

9 INSULIN SENSITIZING AGENTS 32 $8,434 4.5% $263.58 100.0% 0.0% 24

10 INSULIN 32 $7,378 3.9% $230.55 100.0% 0.0% 23

11 STIMULANTS - MISC. 19 $4,568 2.4% $240.39 0.0% 0.0% 34

12 FIBRIC ACID DERIVATIVES 41 $4,514 2.4% $110.10 90.2% 2.4% 16

13

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

(NSAIDS) 83 $3,894 2.1% $46.91 97.6% 79.5% 8

14 ANGIOTENSIN II RECEPTOR ANTAGONISTS 48 $2,859 1.5% $59.55 97.9% 43.8% 14

15 INCRETIN MIMETIC AGENTS 7 $2,672 1.4% $381.71 0.0% 0.0% 74

16 ACNE PRODUCTS 15 $2,646 1.4% $176.42 26.7% 26.7% 39

17 ANTIMETABOLITES 5 $2,060 1.1% $412.10 80.0% 80.0% 92

18 CALCIUM CHANNEL BLOCKERS 87 $2,007 1.1% $23.07 100.0% 100.0% 5

19

SOLUBLE TUMOR NECROSIS FACTOR

RECEPTOR AGENTS 1 $1,877 1.0% $1,876.80 100.0% 0.0% 151

20 OXAZOLIDINONES 1 $1,854 1.0% $1,854.04 100.0% 0.0% 147

21 COUGH/COLD/ALLERGY COMBINATIONS 60 $1,825 1.0% $30.41 66.7% 65.0% 12

22 DIBENZAPINES 9 $1,745 0.9% $193.86 100.0% 0.0% 61

23 SEROTONIN AGONISTS 6 $1,706 0.9% $284.41 66.7% 0.0% 89

24 ANTIFUNGALS - TOPICAL 20 $1,700 0.9% $85.00 70.0% 70.0% 32

25 PLATELET AGGREGATION INHIBITORS 7 $1,642 0.9% $234.60 100.0% 0.0% 78

ALL OTHER 1,524 $43,241 23.0% $28.37 90.6% 82.9%

SUMMARY 2,669 $188,090 100.0% $70.47 86.5% 67.8%

The top three therapeutic drug classes based on ingredient cost for LAREDO TRANSIT MANAGEMENT, INC.: ALL

were HMG CoA Reductase Inhibitors, Antihypertensive Combinations, and Proton Pump Inhibitors. Together these

therapeutic classes accounted for 20.8% of the total ingredient cost and 18.4% of all prescriptions for year to

date.

The top three therapeutic drug classes based on volume for LAREDO TRANSIT MANAGEMENT, INC.: ALL were

HMG CoA Reductase Inhibitors, Antihypertensive Combinations, and ACE Inhibitors. Together these prescription

drugs accounted for 21.0% of all prescriptions for the year to date.


PHARMACYPHARMACY

TOP PRESCRIPTION DRUGS

Report Description: The top 25 prescription drugs for the year to date are displayed below ranked by ingredient cost.


TOP 25 PRESCRIPTION DRUGS BY INGREDIENT COST

BRAND NAME PLAN THERAPEUTIC CLASS PRESCRIPTIONS

INGREDIENT

COST

% OF TOTAL

INGREDIENT

COST

AVG

INGREDIENT

COST/

PRESCRIPTION

FORMULARY

INDICATOR

GENERIC

INDICATOR

RANK BY

VOLUME

1 LAMICTAL XR ANTICONVULSANTS - MISC. 17 $10,763 5.7% $633.09 NO NO 38

2 TEMODAR ALKYLATING AGENTS 3 $8,680 4.6% $2,893.21 NO NO 197

3 ACTOS INSULIN SENSITIZING AGENTS 32 $8,434 4.5% $263.58 YES NO 17

4 JANUVIA

DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITORS 40 $8,258 4.4% $206.45 YES NO 14

5 CRESTOR HMG COA REDUCTASE INHIBITORS 50 $7,577 4.0% $151.53 YES NO 8

6 ACTOPLUS MET ANTIDIABETIC COMBINATIONS 25 $7,320 3.9% $292.79 YES NO 23

7 LIPITOR HMG COA REDUCTASE INHIBITORS 49 $6,604 3.5% $134.78 NO NO 9

8 RENAGEL PHOSPHATE BINDER AGENTS 8 $6,588 3.5% $823.52 NO NO 91

9 NEXIUM PROTON PUMP INHIBITORS 33 $6,374 3.4% $193.16 YES NO 16

10 DIOVAN HCT ANTIHYPERTENSIVE COMBINATIONS 47 $4,900 2.6% $104.27 YES NO 11

11 ACIPHEX PROTON PUMP INHIBITORS 14 $3,874 2.1% $276.73 NO NO 47

12 NOVOLOG MIX 70-30 INSULIN 5 $3,669 2.0% $733.73 YES NO 131

13 JANUMET ANTIDIABETIC COMBINATIONS 17 $3,482 1.9% $204.84 YES NO 37

14 TRICOR FIBRIC ACID DERIVATIVES 27 $2,774 1.5% $102.75 YES NO 22

15 CELEBREX

NONSTEROIDAL ANTI-INFLAMMATORY

AGENTS (NSAIDS) 15 $2,631 1.4% $175.42 YES NO 44

16 VICTOZA 3-PAK INCRETIN MIMETIC AGENTS 6 $2,402 1.3% $400.38 NO NO 116

17 CONCERTA STIMULANTS - MISC. 9 $2,385 1.3% $264.96 NO NO 48

18 ONGLYZA

DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITORS 11 $2,295 1.2% $208.60 NO NO 63

19 DIOVAN ANGIOTENSIN II RECEPTOR ANTAGONISTS 21 $2,117 1.1% $100.80 YES NO 27

20 LANTUS SOLOSTAR INSULIN 10 $1,991 1.1% $199.13 YES NO 69

21

AMLODIPINE

BESYLATE-BENAZEPRIL ANTIHYPERTENSIVE COMBINATIONS 20 $1,955 1.0% $97.75 YES YES 31

22 FOSRENOL PHOSPHATE BINDER AGENTS 3 $1,906 1.0% $635.34 NO NO 181

23 ENBREL

SOLUBLE TUMOR NECROSIS FACTOR

RECEPTOR AGENTS 1 $1,877 1.0% $1,876.80 YES NO 287

24 ZYVOX OXAZOLIDINONES 1 $1,854 1.0% $1,854.04 YES NO 357

25 SEROQUEL DIBENZAPINES 9 $1,745 0.9% $193.86 YES NO 81

ALL OTHER ALL OTHER 2,196 $75,635 40.2% $34.44

SUMMARY 2,669 $188,090 100.0% $70.47

The top three prescription drugs based on ingredient cost for LAREDO TRANSIT MANAGEMENT, INC.: ALL were

Lamictal Xr, Temodar and Actos. Together these prescription drugs accounted for 14.8% of the total ingredient

cost and 1.9% of all prescriptions for the year to date.

The top three prescription drugs based on volume for LAREDO TRANSIT MANAGEMENT, INC.: ALL were

Simvastatin, Metformin Hcl, and Enalapril Maleate. Together these prescription drugs accounted for 9.0% of all

prescriptions for the year to date.


PHARMACYPHARMACY


KEY INDICATORS SUMMARY OCT'11

YEAR TO

DATE

UNIQUE PHARMACY MEMBERS 366 371

PHARMACY MEMBER MONTHS 366 3,613

SPECIALTY CLAIMANTS 1 3

PERCENT OF UTILIZING MEMBERS 0.3% 0.8%

PRESCRIPTIONS 1 5

SPECIALTY PERCENT OF TOTAL PAID 12.6% 8.3%

PERCENT OF TOTAL PRESCRIPTIONS PAID 0.4% 0.2%

PLAN EXPENSE: PAID $1,848 $11,962

PLAN EXPENSE: PAID PMPM $5.05 $3.31

AVERAGE INGREDIENT COST/PRESCRIPTION $1,877 $2,437

MEMBER EXPENSE: OUT OF POCKET $30 $230

MEMBER EXPENSE: OUT OF POCKET PMPM $0.08 $0.06

OUT OF POCKET PERCENT OF ALLOWED 1.6% 1.9%


SPECIALTY DRUG ANALYSIS

Report Description: Specialty drugs generally have unique uses, require special dosing or administration, are

typically prescribed by a specialist provider and are significantly more expensive than alternative drugs or

therapies. The report below shows LAREDO TRANSIT MANAGEMENT, INC.: ALL's prescription drug utilization

and expenses for the current reporting month and year to date.

71.2%

15.4%

13.4%


TOP 10 SPECIALTY DRUGS BY INGREDIENT COST FOR THE YEAR TO DATE

BRAND NAME SPECIALTY CLASS

INGREDIENT

COST PRESCRIPTIONS

AVG INGREDIENT COST/

PRESCRIPTION

SPECIALTY

CLAIMANTS

TEMODAR ORAL CANCER $8,680 3 $2,893 1

ENBREL ARTHRITIS & SKIN $1,877 1 $1,877 1

XELODA ORAL CANCER $1,629 1 $1,629 1

ALL OTHER ALL OTHER

SUMMARY $12,185 5 $2,437 3

The number of members utilizing specialty medication for the year to date was 3. These 3 members received 5

specialty medications which represented 8.3% of the total pharmacy paid amount for the year to date. The overall

specialty pharmacy paid PMPM was $5.05 for the current reporting month and $3.31 for the year to date. The

average cost of a specialty medication was $1,877 during the current reporting month and $2,437 for the year to

date.

The top three specialty drugs based on ingredient cost for LAREDO TRANSIT MANAGEMENT, INC.: ALL were

Temodar, Enbrel, and Xeloda. Together these specialty drugs accounted for 100.0% of the total ingredient cost

and 100.0% of all specialty prescriptions in the year to date.

TOP SPECIALTY DRUGS BY INGREDIENT COST FOR THE YEAR TO

DATE

TEMODAR

ENBREL

XELODA

ALL OTHER

GLOSSARYGLOSSARY

3-Digit Principal Diagnosis: Grouping of principal diagnoses based on the first three digits of the ICD-9 diagnosis

code

Admissions/1000: The number of hospital admissions for each 1000 persons covered within a given time period.

This allows for comparison of the group experience to a normative or benchmark population. It is calculated

as: (admissions/member months) *1000 * 12

Aggregate: Constituting or amounting to a whole. For example, an aggregate account report includes data for the

entire account.

Allowed: Amount considered eligible for payment by the plan

Allowed/Claimant: Amount considered eligible for payment by the plan per claimant. It is calculated as: Allowed /

Claimants

Allowed/Day: Amount considered eligible for payment by the plan per inpatient day. It is calculated as: Allowed /

Days

Allowed/Service: Amount considered eligible for payment per admit (inpatient facility), per visit (outpatient facility

and professional) or per script (prescription Rx). It is calculated as: Allowed / Services

Average Age: The difference between the claimant's year of enrollment and year of birth. Calculated using the

measure Average Age divided by the members represented in the report.

Average Contract Size: The average number of members per subscriber. It is calculated as: Medical Members /

Medical Subscribers

Average Dependents: Calculated using the measure Member Months (filtered on the Relationship = Dependents)

divided by the number of months in the report.

Average Ingredient Cost: Represents the cost of the medication and is determined from the lowest submission of the

pharmacy network rate, Usual & Customary amount, or Maximum Allowable Cost (MAC)

Average Length of Stay: Admit last date of service minus admit first date of service (plus 1 if last day=first day). It is

calculated as: Days / Services

Average Members: Calculated using the measure Member Months divided by the number of months included in the

report.

Average Subscribers: Calculated using the measure Subscriber Months divided by the number of months included

in the report.

Benchmark: Represents the BCBSTX book of business that is loaded into Blue Insight. The age/gender adjustment

factors are built using the paid claims and enrollment information over a 3 year period from BCBSTX book of

business. Some of the benchmark utilization and expense rates have been age/gender adjusted to reflect the

potential difference in the age/gender distribution between the individual company and BCBSTX book of

business. The demographic makeup of a specific group can be very different from any other group. It is for

this reason that it is beneficial in providing benchmarks that have been adjusted by age and gender. These

adjusted benchmarks will allow for more meaningful comparisons. These age / gender adjustments are present

in metrics such as the paid PMPM benchmarks as well as all benchmarks that are displayed as a 'per 1,000'

number however not all of the benchmark categories are adjusted by age / gender


GLOSSARYGLOSSARY

Billed: Amount submitted for payment by the provider

Billing and Accounts Receivable System (BARS): An HCSC financial system where all Administrative Services Only

(ASO) customer bills are generated.

Blue Card Access Fee: Interplan Teleprocessing Services fee charged on out-of-state claims for accessing the local

plan's provider network

Brand Formulary: Brand name medications that are listed on the formulary

Brand Non-Formulary: Brand name medications that are not listed on the formulary

Capitation: A method of payment, exclusively for HMO members, where a physician or hospital is paid a fixed

amount for each enrolled member for healthcare services regardless of the actual number or nature of services

provided to each individual

Claimants: Number of individual members submitting a claim

Claim Lag: The amount of time between the date a claim is incurred and the date the claim payment is made.

COB: Portion of amount considered eligible for payment that has been paid by another insurance company

(Coordination of Benefits)

COB Medicare: Portion of amount considered eligible for payment that has been paid by Medicare

COBRA Members: Consolidated Omnibus Budget Reconciliation Act - A federal law which requires most employers

sponsoring group health plans to offer employees and their families the opportunity for a temporary extension

of health coverage (called continuation coverage) when coverage under the plan would otherwise end.

Coinsurance: Portion of covered amount member is responsible to pay for the claim

Compression Logic: Used to roll up all claims data into episodes of care. By normalizing all claims data, it allows

for comparative analysis (e.g., benchmarking and trend analysis).

Co-payment: Flat rate that the member is responsible to pay for the claim

Cost Sharing Provisions: Provisions in which the subscriber, HCSC, Medicare or other carriers have responsibility for

a portion of the eligible charges.

Coverage Tier: Eligibility tiers which stratify enrollment data based on the employee and others enrolled under the

employee's coverage. Varying benefits can be assigned to tiers.

Covered Amount: Amount eligible for payment based on the terms of the medical/dental benefits agreement.

DAW/1: Indicates that the physician has specified 'do not substitute' on the prescription

Days: Count of days

Days/1000: Number of inpatient days per 1,000 members. It is calculated as: (Days / Member Months) * 1000 *

12

Deductible: Portion of annual deductible amount member is responsible to pay applied to the claim

Demographic Make-up: Derived from the age/gender mix of the account

Dental Loss Ratio: Calculated as the Dental Paid Claims Amount divided by the Billed Dental Premium Amount


GLOSSARYGLOSSARY

Dental Paid Claims: An amount paid to cover the Health Plan's liability for dental services provided to members for

claims that have been processed and approved for payment

Detailed Service Type: Classification based on CPT -- detailed level

Diagnostic Radiology: Refers to radiology services used for diagnostic purposes, as opposed to therapeutic purposes

Discount: Amount of reduction from billed amount that has been negotiated with the provider

Discount %: For medical claims, the discount percent is calculated as Discount / Covered

Dispensing Rate: The proportion of total drugs claims a certain drug or drug type is being dispensed

Drug Type: An indicator on each Rx claim that tells whether a prescription is single source brand, multi-source

brand or generic item.

Effective Discount %: The effective discount percentage is calculated as: Discount / (Discount + Paid)

Fees and Credits: Includes all account-specific member and account level fees. Can include Specific Stop Loss,

Aggregate Stop Loss, Administration, Access Fees, ASO Adjustments (either debits or credits), Rx Credits and

other miscellaneous fees.

Females (20-44 years): The total number of members who are women between the ages of 20 and 44 years. The

proportion of females (20-44 years) is calculated as: Member Months for Women between 20-44 years /

Member Months

Formulary Compliance Rate: The percentage of drugs dispensed that were included in the formulary

Generic Dispensing Rate: Proportion of potential generic prescriptions that were filled as generic. It is calculated as:

Number of generic scripts / Number of scripts

Generic Drugs: A medication for which the patent has expired, allowing any manufacturer to produce and distribute

the product under the chemical name.

Generic Substitution Rate: The rate in which generics were dispensed when a generic was available. It is calculated

by Number of generic Rxs / (Number of generic Rxs + Number of multi-source brand Rxs)

Group Liability: Total Claim Expense plus Fees and Credits

HCC: High Cost Claimant, a claimant with total paid amount over a specified threshold (e.g., $30,000 or $50,000)

within the twelve month reporting period

HCPCS: Healthcare Common Procedure Coding System, a coding system comprised of CPT-4 (Current Procedural

Terminology, Version 4) codes used to identify medical services and procedures furnished by physicians and

other health care professionals and other products, supplies and services not included in the CPT-4 codes.

IBNR: An acronym for 'incurred but not reported'. IBNR claims are that group which are incurred before the fund

reserving date, but not reported until after that date.

Ingredient Cost: The cost of the drug minus any taxes or dispensing fees

In-Network Paid %: Percent of total paid expenses for in-network claims. It is calculated as: In-Network Paid / Paid

Inpatient Facility: Refers to Inpatient Facility claims


GLOSSARYGLOSSARY

International Classification of Diseases (ICD-9): An official list of categories of diseases, physical and mental, issued

by the World Health Organization (WHO).

IP Paid PEPM: Inpatient facility paid amount per employee per month

IP Paid PMPM: Inpatient facility paid amount per member per month

Leading ICD-9 Diagnostic Category: For each patient, summarize total paid amount for each diagnosis and its

corresponding MDC. The MDC with the greatest paid amount for the patient becomes the Leading ICD-9

Diagnostic Category for the reporting period

MAC Program Savings: Savings achieved by using the MAC (maximum allowable cost) discount on generic

medications

Management Services: A combination of Capitation, Fees & Credits and Recoveries for medical services applied to

the Employer Group's account

MDC (DRG): Major Diagnostic Category based on DRG, available only in inpatient reports

Medical Paid Claims: An amount paid to cover the Health Plan's liability for medical (healthcare) services provided

to members for claims that have been processed and approved for payment

Medical/Pharmacy Loss Ratio: Calculated as the combined Medical and Pharmacy Paid Claims Amount plus

Capitation divided by the total Billed Premium Amount for Medical and Pharmacy, where appropriate

Member Months: Count of months of eligibility for members

Multi-Source Brand: Brand name medications with a generic equivalent

Network Indicator: An indicator that shows whether the claim was processed as in-network (e.g., in the Preferred

Provider Organization network) or out-of-network and paid accordingly

Network Savings Discount: The discount that is applied when a member receives services from a contract provider.

Non-acute: Refers to inpatient facility admissions for rehabilitation, skilled nursing facilities and hospice care

Not Covered: Amount considered not eligible for payment by the plan (excludes the discount amount)

Observation Room: A hospital room in an outpatient setting (less than 24 hours) that is necessary to

evaluate/monitor the patient's condition for possible inpatient admission.

Occupational Therapy: Therapy based on engagement in meaningful activities of daily life especially to enable

participation in such activities in spite of impairments or limitations in physical or mental functions.

OP Paid PEPM: Outpatient facility paid amount per employee per month

OP Paid PMPM: Outpatient facility paid amount per member per month

Other Adjustments: Minor payments or credits not captured in other specific expense measures

Other Payments: Combination of Blue Card access fees and surcharge expenses

Other Reductions: Combination of maximum reductions, penalties, workers compensation savings, and subrogation

savings


GLOSSARYGLOSSARY

Out of Pocket: Total amount that is the responsibility of the claimant. It is calculated as: (Copay + Deductible +

Coinsurance)

Outpatient Facility: Refers to Outpatient Facility claims

Paid: Total amount paid by the plan, including access fees, adjustments, and surcharges

Paid + Recoveries: The total amount paid by the plan plus any amount recovered through subrogation.

Paid-Provider: Amount paid to the provider by the plan

Paid/Claimant: Amount paid to the provider by the plan per claimant. It is calculated as: Paid / Claimants

Paid/Day: Amount paid to the provider by the plan per inpatient day. It is calculated as: Paid / Days

Paid/Service: Amount paid to the provider by the plan per admission (inpatient facility), per visit (outpatient facility

and professional) or per script (prescription Rx). It is calculated as: Paid / Services

Paid/Visit: Amount paid to the plan per professional visit. It is calculated as: Paid / Visits

Paid PEPM: Amount paid to the provider by the plan per employee per month. It is calculated as: Paid / Subscriber

Member Months

Paid PMPM: Amount paid to the provider by the plan per member per month. It is calculated as: Paid / Member

Months

Penalty: Amount charged to the user of health care services for a non-approved contractual service

PEPM: Per employee per month

Pharmacy Discount %: For pharmacy claims, the discount percent is calculated as Discount / (Discount + Allowed)

Pharmacy Paid Claims: An amount paid to cover the Health Plan's liability for pharmacy services provided to

members for claims that have been processed and approved for payment

Pharmacy Tier: An indicator on each Rx claim that tells whether a prescription is generic, preferred brand,

non-preferred brand, specialty, or other

Physical Therapy: The treatment of injuries or disorder through physical activity with goals of restoring and/or

maintaining functional activities.

Place of Service: An indicator of whether the professional services were rendered during an inpatient admission,

outpatient visit, office visit, or other

Plan Eligibility: Eligibility derived directly from the plan's enrollment system. It excludes eligibility created during

data processing for claims without matching records in the enrollment system.

PMPM: Per member per month

PR Paid PEPM: Professional paid amount per employee per month

PR Paid PMPM: Professional paid amount per member per month

Premium: An agreed upon fee paid to the Health Plan for coverage of medical and/or dental benefits for an

established benefit period and set intervals


GLOSSARYGLOSSARY

PT/OT/ST: See Physical Therapy, Occupational Therapy and Speech Therapy.

Recoveries: Subrogation and/or Reimbursements for claims that are included in BARS but not in HCSC's data

warehouse (since some of the reimbursements could be for members or claims that are no longer in our data

warehouse). Recoveries are loaded from the BARS System and included in Blue Insight for reconciliation

purposes.

Reporting Period: The date range for which the report was run. When data is not available for the complete reporting

period, partial totals will be displayed and comparisons may be inconclusive.

Rx Paid PEPM: Prescription drug paid amount per employee per month

Rx Paid PMPM: Prescription drug paid amount per member per month

Self-Administered Drugs: A drug furnished in an outpatient setting for therapeutic purposes which is usually

self-administered by the patient or caregiver.

Service Category: A classification based on claim type

Service Type: Classification based on principal diagnosis or ICD-9 Procedure Code

Services: Number of admissions (inpatient facility), number of visits (outpatient facility), number of claim lines

(professional), or number of scripts (prescription Rx)

Services/1000: Number of services per 1,000 members. It is calculated as: (Services / Member Months) * 1000 *

12

Services/Member: Number of services per member. It is calculated as: (Services / Member Months) * 12

Single Source Brand: Brand name medications with no generic equivalent

Specialty Drugs: Medications that generally have unique uses, require special dosing or administration, are typically

prescribed by a specialist provider and are significantly more costly than alternative drugs or therapies.

Speech Therapy: Corrective treatment of speech impairment which resulted from birth or from disease, injury or

prior medical treatment.

Subrogation Savings: Portion of amount eligible for payment originally paid by the plan but that has since been

recovered through a legal action

Surcharge: Amount charged as a tax by certain States on facility claims

Therapeutic Drug Class: Used to categorize or group prescription drugs which are considered similar by the disease

they treat or by the effect they have on the body

Total Paid: The total amount of medical, pharmacy and capitation dollars, where appropriate, paid to cover

healthcare services provided to members for claims that have been processed and approved for payment

Visits: Number of professional visits, where a visit is defined as a set of all professional services that occur on the

same date for the same claimant and the same professional provider. A visit relates to a physician interaction

with a patient and the place of service can be the office, inpatient facility or outpatient facility.

Visits/1000: Number of professional visits per 1,000 members. It is calculated as: (Visits / Member Months) *

1000 * 12


GLOSSARYGLOSSARY

Workers Compensation Savings: Portion of amount eligible for payment that has been paid a third party Workers

Compensation carrier


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