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#5203 MAC to Develop GASB 74/75
RESOLUTION NO. 5203 A RESOLUTION APPROVING AN AGREENMENT BETWEEN THE CITY OF CANTON AND MARACON LLC FOR THE DEVELOPMENT OF THE GASB 74/75 HEALTH CARE ACTUARIAL STUDY FOR THE CITY OF CANTON WHEREAS, the Mayor of the City of Canton has determined that it is necessary and in the best interests of the City of Canton to enter into an agreement for Maracon LLC to provide a GASB 74/75 health care actuarial study for the City, as set forth in Exhibit "A" attached hereto and incorporated herein, and WHEREAS,the City Council of the City of Canton has made a similar determination and further consents to the healthcare actuarial study by Maracon LLC. NOW,THEREFORE,BE IT RESOLVED BY THE MAYOR AND CITY COUNCIL OF THE CITY OF CANTON,ILLINOIS,AS FOLLOWS: 1. That the agreement attached hereto and incorporated herein as Exhibit "A" is hereby approved by the Canton City Council. 2. That the Mayor of the City of Canton, Illinois is hereby authorized and directed to execute said Agreement on behalf of the City of Canton. 3. That this Resolution shall be in full force and effect immediately upon its passage by the City Council of the City of Canton, Illinois and approval by the Mayor thereof. PASSED by the City Council of the City of Canton, Illinois at a regular meeting this 3 day of September 2019 upon a roll call vote as follows: AYES: Aldermen Ryan Mayhew, Quin Mayhew, John Lovell, Craig West, Angela Hale, Jeff Fritz, Angela Lingenfelter NAYS: None ABSENT: Alderman Justin Nelson APPROVED: Kent McDowell, Ma or ATTEST: Diana Pavley-Rock, City Clerk 4301 Saint Vincent Ave.,Saint Louis,MO 63119-3408 r 314-646-1993 Fax 612-241-7353 MARACON, LLC 8/27/2019 Ms. Crystal Wilkinson Treasurer City of Canton 2 N Main St. Canton, IL 61520 Dear Crystal: RE: PROPOSAL FOR DEVELOPMENT OF GASB 74/75 HEALTH CARE ACTUARIAL STUDY FOR THE CITY OF CANTON The City of Canton ("Canton') has requested a proposal from MarACon, LLC,("MAC')to develop a GASB 74/75 Health Care Actuarial Study. Scope of Work and Deliverables ° Canton will provide the following experience data and benefit descriptions: Active and Retiree Health Benefit Plan descriptions Employer,employee,and retiree contribution schedule Current census data for active and retirees including age and gender Health claim history for 2016, 2017, 2018,and 2019 Covered lives by month for 2016, 2017, 2018,and 2019 Liability estimates for 2016, 2017, 2018,and 2019 ° Data will be provided by the claims administrator. ° Canton will also provide other required material as needed and requested by MAC. ° MAC will prepare a report with the projected for the GASB 74/75 Health Care Actuarial Study. Fees and Timeline The fee for these services is estimated to be$4,000.I will be the primary consultant for this project and estimate completion within three weeks after receiving all required data. Conditions for Consulting By signing this agreement Canton agrees to the following conditions. • Al reports provided to Canton are deemed for internal use only. No documents may be shared to third,parties without explicit written consent by MAC. • MAC will maintain all materials provided by Canton as confidential and maintain them for this project only. Either party may terminate this project at any point with a 30 day notice to the other party. If MAC terminates this agreement,Canton will be entitled.to a refund of prorated fees based on actual hours worked to that point. • The liability for MAC is limited to the actual fees.This includes all punitive damages. • This document contains the entire agreement between Canton and MAC for this project. I look forward to your aooeptance of the engagement. Please sign and return a copy back to me indicating your acceptance. Sincerely, F. Ray Martin,FSA, MAAA President and Consultant Accepted and agreed: City of Canton By: Print Name: Print Title: Date: 2 4301 Saint Vincent Ave.,Saint Louis,MO 63119-3408 314-646-1993 Fax 612-241-7353 u I. MARACON, LLC 8/27/2019 Ms. Crystal Wilkinson Treasurer City of Canton 2 N Main St. Canton, IL 61520 Dear Crystal: RE: PROPOSAL FOR DEVELOPMENT OF GASB 74/75 HEALTH CARE ACTUARIAL STUDY FOR THE CITY OF CANTON The City of Canton ("Canton') has requested a proposal from MarACon, LLC, ("MAC')to develop a GASB 74/75 Health Care Actuarial Study. Scope of Work and Deliverables ° Canton will provide the following experience data and benefit descriptions: Active and Retiree Health Benefit Plan descriptions Employer, employee,and retiree contribution schedule Current census data for active and retirees including age and gender Health claim history for 2016;;2017, 2018, and 2019 Covered lives by month for 2016, 2017, 2018, and 2019 Liability estimates for 2016, 2017, 2018, and 2019 ° Data will be provided by the claims administrator. ° Canton will also provide other required material.as needed and requested by MAC. ° MAC will prepare a report with the projected for the GASB 74/75 Health Care Actuarial Study. Fees and Timeline The fee for these services is estimated to be $4,000. I will be the primary consultant for this project and.estimate completion within three weeks after receiving all required data. r.'` Conditions for Consulting By signing this agreement Canton agrees to the following conditions. • Al reports provided to Canton are deemed for internal use only. No documents may be shared to third parties without explicit written consent by MAC. •- MAC will maintain all materials provided by Canton as confidential and maintain them for this project only. • Either party may terminate this project at any point with a 30 day notice to the other party. If MAC terminates this agreement, Canton will be entitled to a refund of prorated fees based on actual hours worked to that point. • The liability for MAC is limited to the actual fees. This includes all punitive damages. • This document contains the entire agreement between Canton and MAC for this project. I look forward to your acceptance of the engagement. Please sign and return a copy back to me indicating your acceptance. i Sincerely, F. Ray Martin,FSA, MAAA President and Consultant Accepted and agreed: City Canto By: Print Name: Y`� Print Title: Date: 9 2^ 2 Renewal-FY20 Employer's Share 77.5%-Employee's Share 22.5% ER 0.7750 0.225 1.00 PPO Emp E+S E+C Family Monthly Premium 797.66 1,588:10 1,453.82 2,244:25 Annual Premium 9,571.92 19,057.20 17,445.84 26,931.00 Employees Oare 77:5%-Employee's Share 22.5% 618.19 1,230.78 1,126.71 1,739.29 ER Share Annual 7,418.24 14,769.33 13,520.53 20,871.53 Employer's Share 77.5%-Employee's Share 22.5% 179.47 357.32 327.11 504.96 EE Share Annual 2,153.68 4,287.87 3,925.31 6,059.48 E_E Share per Pay:Pe lnd89:74. .178:66 163.55 252148 19,057.20 Employer's Share 77.5%-Employee's Share 22.5% High Deductible/Health Savings Acct Emp E+S E+C IFamlIV Monthly Premium 68913 1,372.03 1,256.01 1,938.91 Annual Premium 8,269.56 16,464.36 15,072.12 23,266.92 Employer's Share 77.5%-Employee's Share 22.5% 618.19 1,230.78 1,126.71 1,739.29 Difference between HDHP and 80%PPO 70.94 141.25 129.30 199.62 Employee's Monthly Portion 70.94 141.25 129.30 199.62 ER Share Monthly 618.19 1,230.78 1,126.71 1,739.29 ER Share Annual 7,418.24 14,769.33 13,520.53 20,871.53 EE Share Annual 851.32 1,695.03 1,551.59 2,395.40 EE Share per Pay: 1 35:47. 70.63, .64.65 99.81 Health Savings Contribution Renewal-FY20 Employer's Share 77.5%-Employee's Share 22.5% PPO Emp E+S E+C Family Monthly Premium 2078 42 19 n 556 .yam_ 81'84 Annual Premium 249.36 506.28 661.92 982.08 Emptoyer's Share 77.5%-Employee's Share 22.5% 16.10 32.70 42.75 63.43 ER Share Annual 193.25 392.37 512.99 761.11 Employer's Share 77.5%-Employee's Share 22.5% 4.68 9.49 12.41 18.41 EE Share Annual 56.11 113.91 148.93 220.97 EE.Share per Pay.Pgrlod 2:34 4:75 6:21 9.21. Renewal - FY20 Employer's Share 80%- Employee's Share 20% ER 0.8000 PPO Emp E+S E+C Family Monthly Premium 797.66 1,588.10 1,453.82 2,244.25 Annual Premium 9,571.92 19,057.20 17,445.84 26,931.00 Employer's Share 80%-Employee's Share 20% 638.13 1,270.48 1,163.06 1,795.40 ER Share Annual 7,657.54 15,245.76 13,956.67 21,544.80 Employer's Share 80%-Employee's Share 20% 159.53 317.62 290.76 448.85 EE Share Annual 1,914.38 3,811.44 3,489.17 5,386.20 EE Share,per=Pay Period 79:77., 158.81. 145:38. 224.43 19,057.20 Employer's Share 80%- Employee's Share 20% High Deductible/Health Savings Acct Emp E+S E+C Family Monthly Premium 689.13 1,372.03 1,256.01 1,938.91 Annual Premium 8,269.56 16,464.36 15,072.12 23,266.92 Employer's Share 80%-Employee's Share 20% 638.13 1,270.48 1,163.06 1,795.40 Difference between HDHP and 80%PPO 51.00 101.55 92.95 143.51 Employee's Monthly Portion 51.00 101.55 92.95 143.51 ER Share Monthly 638.13 1,270.48 1,163.06 1,795.40 ER Share Annual 7,657.54 15,245.76 13,956.67 21,544.80 EE Share Annual 612.02 1,218.60 1,115.45 1,722.12 EE Share•perPay 25:50 50:78 46.48 71.76 . Health Savings Contribution - - - - Renewal - FY20 Employer's Share 80%- Employee's Share 20% PPO Emp E+S E+C Family Monthly Premium ya 20 78 4219 55_=16_` 8184F. Annual Premium 249.36 506.28 661.92 982.08 Employer's Share 80%- Employee's Share 20% 16.62 33.75 44.13 65.47 ER Share Annual 199.49 405.02 529.54 785.66 Employer's Share 80%-Employee's Share 20% 4.16 8.44 11.03 16.37 EE Share Annual 49.87 101.26 132.38 196.42 EE Shar per;Pay,Perlod 2:08. . 4:22 5.52_, 8.18 Renewal - FY20 Employer's Share 77% - Employee's Share 23% ER 0.7700 PPO Emp E+S E+C Family Monthly Premium 797.66 1,588.10 1,453.82 2,244.25 Annual Premium 9,571.92 19,057.20 17,445.84 26,931.00 Employer's Share 77%-Employee's Share 23% 614.20 1,222.84 1,119.44 1,728.07 ER Share Annual 7,370.38 14,674.04 13,433.30 20,736.87. Employer's Share 77%-Employee's Share 23% 183.46 365.26 334.38 516.18 EE Share Annual 2,201.54 4,383.16 4,012.54 6,194.13 EE Share.perPaTPeriod 91:73 182.63 167.19 258.09 19,057.20 Employer's Share 77%- Employee's Share 23% High Deductible/Health Savings Acct Emp E+S E+C Family Monthly Premium 689.13 1,372.03 1,256.01 1,938.91 Annual Premium 8,269.56 16,464.36 15,072.12 23,266.92 Employer's Share 77%-Employee's Share 23% 614.20 1,222.84 1,119.44 1,728.07 Difference between HDHP and 80%PPO 74.93 149.19 136.57 210.84 Employee's Monthly Portion 74.93 149.19 136.57 210.84 ER Share Monthly 614.20 1,222.84 1,119.44 1,728.07 ER Share Annual 7,370.38 14,674.04 13,433.30 20,736.87 EE Share Annual 899.18 1,790.32 1,638.82 2,530.05 EE Share-per'Pay 37.47 74.60 68.28 105.42 Health Savings Contribution I - I - Renewal - FY20 Employer's Share 77%- Employee's Share 23% PPO Emp E+S E+C Family Monthly Premium 20 78 42 19� 7 5516, 4 a 4 8184<< Annual Premium 249.36 y 506.28 661.92 982.08 Employer's Share 77%-Employee's Share 23% 16.00 32.49 42.47 63.02 ER Share Annual 192.01 389.84 509.68 756.20 Employer's Share 77%-Employee's Share 23% 4.78 9.70 12.69 18.82 EE Share Annual 57.35 116.44 _ 152.24 225.88 EE Share per Pay.Period 2:39. 4:85 6.34 9.41. 'S l Summary of Benefits and Coverage:What this Plan Covers &What You Pay For Covered Services Coverage Period: 05/01/2018-04/30/2019 IllucQ] illlup—Weld '•' uf1°l°°�� : BPP72322 BluePrint PPO Coverage for: Individual/Family I Plan Type: PPO 0 The Summary of Benefits and Coverage-(SBC)document will help you choose ahealth -a-n.The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of thisIlan (called therep mium)will be provided separately.This is only a summary. For more information about your coverage,or to get a copy of the complete terms of coverage,visit www.bcbsil.com/member/policy- forms/2018 or by calling 1-800-541-2768. For general definitions of common terms, such as allowed amount, balance.billin coinsurancecopayment, deductible. provider, or other underlined terms see the Glossary.You can view the Glossary at https://www.cros.gov/CCIIO/Resources/Forms-Reports- { and-Other-Resources/Downloads/UG-Glossary-508:I df or call 1-855-756-4448 to request a copy. j Important Questions nswers_ "y This Matters: What is the overall Individual: Participating $500 Generally,you must pay all of the costs fromrove iders up to the deductible amount before deductible? Non-Participating $1,000 this pLan begins to pay. If you have other family members on theIlan,each family member Family is equivalent to 3 must meet their own individual deductible until the total amount of deductible expenses paid individuals. by all family members meets the overall family deductible. Are there services covered Yes. Doesn't apply to certain ThisIlan covers some items and services even if you haven't yet met the deductible amount. before you meet your preventive care. Copays and per But a copayment or coinsurance may apply. deductible? occurrence Deductibles don't count toward the Deductible. Are there other Yes. $300 Deductible for You must pay all of the costs for these services up to the specific deductible amount before deductibles for specific Non-Participating hospital thisIlan begins to pay for these services. services? admission.There are no other specific Deductibles. What is the out-of-pocket Yes. Individual: The out-of-pocket limit is the most you could pay in a year for covered services. limit for thisIlan? Participating $1,000 Non-Participating $2,000 Family is equivalent to 3 individuals. What is not included in the copayments, Deductible. Even though you pay these expenses,they don't count toward the out-of-pocket limit. out-of-pocket limit? Premiums,balance billed charges, and health care this Plan doesn't cover. Will you pay less if you use Yes. See www.bcbsil.com or call This plan uses arop vider network.You will pay less if you use arop vider in theIp an's network. a network provider? 1-800-541-2768 for a list of You will pay the most if you use an out-of-network provider,and you might receive a bill from Participating Providers. arop vider for the difference between the provider's charge and what your plan pays(balance billing).Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with yourrop vider before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL Non-HMO LG-2018 1 of 6 ® All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. ProviderWhat You Will Pay Common Services You May Need Participating Provider Non-Participating Medical Event (You will pay the least) Primary care visit to treat an $20 ca a ment visit 30% coinsurance No benefits will be provided for services injury or illness which are not, in the reasonable judgment of Blue Cross and Blue Shield, medically necessary. If you visit a health care ealist visit $40 co a ment visit 30% coinsurance none Preventive provider's office or care/screening/ $20 copayment/visit 30% coinsurance Individuals age 16 and over are limited to one clinic immunization physical exam plus one gynecological exam per calendar year. You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood, 10% coinsurance 30%coinsurance If you have a test work) none Imaging(CT/PET scans,MRIs) 10%coinsurance 30% coinsurance If you need drugs to Generic drugs $10/$20 co a ment $10 copayment treat your illness or prescription prescription condition Preferred brand drugs $20/$40 copayment E $20 copayment/ 30 day retail supply/90 day home delivery. For More information about prescription prescription Out-of Network drug Provider you are prescription drug Non-preferred brand drugs $35/$70 copayment $35 co a ment responsible for 25% of the eligible amount coverage is available at prescription prescription after the copay. You may be eligible to https://www.bcbsil. Specialty drugs Covered Covered synchronize your prescription refills,*please com/member/ see your benefit booklet for details. prescription-drug-plan- information/drug-lists If you have outpatient Facility fee (e.g., ambulatory 10% coinsurance 30% coinsurance surgery center) none surgery Physician/surgeon fees 10%coinsurance 30% coinsurance *For more information about limitations and exceptions,seethe plan or policy document at www.bcbsil.com/member/policy-forms/2010. 2of6 What You Will-Pay Common Services You May Need Participating p. Exceptions, OtherImportant Medical Event (You will p. pay the Information Emergency room care $150co a ment visit $150copayment/visit copayment waived if admitted. If you need immediate Emergency medical 20%coinsurance 20% coinsurance medical attention transportation none Urgent care 10%coinsurance 30% coinsurance If you have a hospital Facility fee (e.g., hospital 10%coinsurance 30% coinsurance $300 Deductible per admission for stay room) Non-Participating Providers. Physician/surgeon fees 10% coinsurance 30% coinsurance none Outpatient services 10% coinsurance 30% coinsurance Preauthorization is required for Psychological If you need mental testing; Neuropsychological testing; Electroconvulsive therapy; Repetitive health,behavioral health, or substance Transcranial magnetic Stimulation;and abuse services Intensive Outpatient Treatment. Inpatient services 10%coinsurance 30% coinsurance $300 Deductible per admission for Non-Participating Providers. Office visits $20 copayment 30% coinsurance Copayment applies to first prenatal visit per pregnancy.Cost sharing does not apply to certain preventive services. Depending on the type of services,coinsurance or deductible may apply. Maternity care may include tests If you are pregnant and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/deliveryprofessional 10%coinsurance 30% coinsurance services $300 Deductible per admission for Childbirth/delivery facility 10%coinsurance i 30% coinsurance Non-Participating Providers. services Home health care 10% coinsurance 30% coinsurance If you need help Rehabilitation services ; 10% coinsurance ,30% coinsurance none recovering or have Habilitation services 10% coinsurance 30% coinsurance other special health Skilled nursing care i 10%coinsurance 30% coinsurance needs Durable medical equipment 10%coinsurance 30% coinsurance Benefits are limited to items used to serve a medical purpose. DME benefits are provided 3of6 What You Will Pay Common Participating p. Other Important Services You May Need Medical Event (You will p.y the least) Provider(You will pay the Information for both purchase and rental equipment (up - to the purchase price). Hospice services 10%coinsurance 30% coinsurance none Children's eye exam Not Covered Not Covered If your child needs Children's glasses Not Covered Not Covered none dental or eye care Children's dental check-up Not Covered Not Covered Excluded Services&Other Covered Services: Services Your Plan Generally Does NOT Cover(Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture Hearing aids • Routine eye care (Adult) • Cosmetic surgery • Long-term care • Weight loss programs • Dental care (Adult) • Most coverage provided outside the United States. See www.bcbsil.com Other Covered Services(Limitations may apply to these services. This isn't a complete list. Please see your plan document) • Bariatric surgery • Infertility treatment (4 invitro attempt maximum • Private-duty nursing • Chiropractic care with special approval up to 6 per benefit period) • Routine foot care (Only.in connection with • Non-emergency care when traveling outside the diabetes) U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends.The contact information for those agencies is:the plan at 1-800-541-2768, U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA(3272) or www.dol.gov/ ebsa/healthreform,or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cclio.cros.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against yourIlan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights,look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal,ora grievance for any reason to your Ilan.. For more information about your rights, this notice,or assistance,contact:Blue Cross and Blue Shield of Illinois at 1-800-541-2768 or visit www.bcbsil.com,or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA(3272) or visit www.dol.gov/ebsa/healthreform. Additionally,a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) 527-9431 or visit htt insurance.illinois.gov. 4of6 Does thisIlan provide Minimum Essential Coverage?Yes If you don't have Minimum Essential Coverage for a month,you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does thisIlan meet the Minimum Value Standards?Yes If yourIlan doesn't meet the Minimum Value Standards,you may be eligible for a premium tax credit to help you pay foraIlan through the Marketplace. Language Access Services: Spanish (Espanol):Spanish (Espanol): Para obtener asistencia en Espanol, Ilame al 1-800-541-2768. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-541-2768. Chinese (►P3�-): PQAIN5!r-p3Zn�, mrIM , -ifllj%kT]-`� 1-800-541-2768. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-541-2768. To see examples of how thislean might cover costs for a sample medical situation, see the next section. 5of6 About These Coverage Examples: This is not a cost estimator.Treatments shown are just examples of how this plan might cover medical care.Your actual costs will be different depending on the actual care you receive,the prices yourrop viders charge, and many other factors. Focus on the cost sharing amounts (deductiblescopayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different healthIp ans. Please note these coverage examples are based on self-only coverage. DiabetesPeg is Having ababy Managing Joe's type 2 (9 months of in-network pre-natal care anda a year of routine in-network care of a (in-network emergency room visit and follow up hospital delivery) well-controlled condition) care) ■ TheIp an's overall deductible $500 ■ The plans overall deductible $500 ■ TheIp an's overall deductible $500 ■ Specialist copayment $40 ■ Specialist copayment $40 ■ Specialist copayment $40 ■ Hospital (facility) coinsurance 10% ■ Hospital (facility)coinsurance 10% ■ Hospital (facility)coinsurance 10% ■ Other coinsurance 10% ■ Other coinsurance 10% ■ Other coinsurance 10% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care(including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment(glucose meter) Total Example Cost $12,800 1 Total Example Cost $7,400 i l Total Example Cost $1,900 In this example, Peg would pay: In this example,Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles _ $500 _Deductible_s 1 ._ _$100 Deductibles _ $500 Copaymehts 100 Copayments'- $1,200 Copayments $100 Coinsurance -- $1,200 -Coinsurance 1-----$0 Coinsurance $70 What isn't covered What isn't covered _ _ What isn't covered _ Limits or exclusions $60 Limits or exclusions $60 Limits or exclusions $0 i The total Peg would pay is $1,860 i The total Joe would pay is $1,360 ; ` The total Mia would pay is $670 s TheIlan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6 BlueCross B1ueShield of Illinois If you,or someone you are helping,have questions,you have the right to get help and information in your language at no cost. To speak to an interpreter,call the customer service number on the back of your member card.If you are not a member,or don't have a card,call 855-710-6984. 4u>,,.11 yl aly.ec c}Si tJ jLv.'�.l'+.,Yoo'l9U".14�'c JsS:�dl c`'lo.11 0.�.1i�1)c�e J,oil.yrJS9 z'.r`w�I ,.Liz.:ldls;4.l')-I jo yiL LJs,`oll�,lsptull y e.�cL J1�c Arabic .855-710-6984 L�-J—'u Ai ,!�V:i;s ru*J[ A1 , ?�:� t; llfilflt >tr ���,1�: Iltl? E37PR ( 1�i1Ailo Chinese *fift%855-710-69840 Frangais Si vous,ou quelqu'un que vous 6tes en train d'aider,avez des questions,vous avez le droit d'obtenir de I'aide et]'information dans votre langue a aucun cont.Pour parler a un interprete,composez le numero du French service client indiqu6 au verso de votre carte de membre.Si vous n'etes pas membre ou si vous n'avez pas de carte,veuillez composer le 855-710-6984. Deutsch Falls Sie oder jemand,dem Sie helfen,Fragen haben,haben Sie das Recht,kostenlose Hilfe and Informationen in Ihrer Sprache zu erhalten.Um mit einem Dolmetscher zu sprechen,rufen Sie bitte die German Kundenservicenummer auf der ROckseite Ihrer Mitgliedskarte an.Falls Sie kein Mitglied sind oder keine Mitgliedskarte besitzen,rufen Sie bitte 855-710-6984 an. EAArl=d E6v EcydS n OTTOIOS TrOU 0Og96TE£XET£EPWTt OFEIS,tXETE TO 6I01Wp0 Va MOM 00t&I0 K01 Tfhripo(oplES OTq yA6jacra cras XWpiS Xptwarl.rl0 VO plXf OFETE crE£vav 61EPPrlV✓a,KCIAOTE TOV Opl8p6 E�uTrrlpETgariS Greek TTEAQT(bv Trou OVOypd(tT01 O-ro Triaw pEPOs TrlS KdpTaS N£AouS QOS.E6v 6Ev E1oTE pEAOS f 6EV tXETE K6pTa,KaMOTE Tov ap10p6 855-710-6984. 31-Rlc{l cU-1;1. Z4P2 ct1 ctA }LEE 8141 2f+tl c zt 2�Lca 8-0 C41T czdptt L QtlRul 211a ulct 82ul ul�, dl-IM ;RCizluE�il Sl�-fl %E%fl ZgLl LGL 3,1158 Rul *q:2 u2 Skl 82Z. Gujarati 9d Z1ltl xWRA lE QU EMctcil c c1, z{-tcll ZAlt1� 141a 8l� QL4 ctl 855-710-6984 -icgR tt2 AR SRt. Wr uf& ,zrr3iitff uuq�rrzFff�9Tut,wwrt,-�?r3lruiEFfi3mwtm-fife:uF;EF uFzr�u3 f srtcff wi;rw3r'ft T tIf�T*H-Fiq�#zra wi-�r 4;f�4v,xq-�r u&TqT947 Hindi t&f kV 7M Wff$dr F'Lrf zft-,Tit 1 zrf�3rTtr Nei-jTft t,sir 3Mt mfr zF�4 t,c-t1855-710-6984 7f zft zF I Italiano Se to o qualcuno the staff aiutando avete domande,hai it diritto di ottenere aiuto a informazioni nella tua lingua gratuitamente.Per parlare con un interprete,puoi chiamare if servizio clienti al numero riportato sul tato Italian posteriore della tua tessera di socio.Se non sei socio o non possiedi una tessera,puoi chiamare it numero 855-710-6984. Z4�401 EL°b-7-lofg`?10- )f MP--101z�01VEf°t -lloiff= �zi2ty921xJ zoCAEll 011 °l" "11ALflIli Korean E1foi^G'Al2.sa A01 01 LIA171Lf 9E-1--7t 01-0A1111855-710-6984—0-if-T-10f'1LI A19. Dine T'Sa ni,of doodago la'da bika ananflwo'fgff,na'fdflkidgo,ts'fda bee na ah66ti'i't'aa nfik'e nad a'doolwol.Ata'halne'i bich'j'hadeesdzih ninfzingo ei kwe'e da'fniishgi aka anfdaalwo'igff Navajo bich'i;'hodfflnih,bee neeh6zinii bine'd�g'bikaa'.Kojf atah naaltsoos na hadit'eeg66 of doodago bee neeh6zinfgff 5dingo koJi'hodfflnih 855-710-6984. Polski Jesli Ty lub osoba,kt6rej pomagasz,macie jakiekolwiek pytania,macie prawo do uzyskania bezplatnej informacji i pomocy we wlasnym jgzyku.Aby porozmawiab z tiumaczem,zadzwo6 pod numer podany na Polish odwrocie karty czlonkowskiej.Jeteli nie jested czlonkiem lub nie masz przy sobie karty,zadzwon pod numer 855-710-6984. PyCCKHN EcnH y Bac HnH 4enoBeKa,KOTOPOMy Bbl noMOraeTe,B03HHKnN BOnPOCbI,y Bac eCTb npaBO Ha 6ecnnaTHy1O nOMOUAb H HH#pMa4wio,npegociT BneHHy@ Ha BaWeM MbWe.4To6bl norOBOPNTb C nepeB0,g4HKOM, Russian n03BOHWTe B oTgen 060yNMBaH119 KnHeHTOB no Tene(f loHy,yKa3aHHOMy Ha 06paTHOA CTOpOHe BaWeh KaPTO4KH y4aCTHHKa.ECnH Bbl He ABnneTecb y4aCTH14KOM M114y BaC HeT KaPT04KH,n03BOH11Te no Tene*OHy 855-710-6984. Espanol Si usted o alguien a quien usted este ayudando tiene preguntas,tiene derecho a obtener ayuda a informaci6n en su idioma sin costo alguno.Para hablar con un interprete comuniquese con el numero del Servicio al Spanish Cliente que figura en el reverso de su tarjeta de miembro.Si usted no es miembro o no posee una tarjeta,flame al 855-710-6984. Tagalog Kung ikaw,o ang Tsang taong iyong tinutulungan ay may mga tanong,may karapatan kang makakuha ng tufong at impormasyon sa iyong wika nang walang bayad.Upang makipag-usap sa isang tagasalin-wika, Tagalog tumawag sa numero ng serbisyo para sa kust1ome<r sa Iikod ng iyong kard ng miyembro.Kung ikaw ay hindi isang miyembro,o kaya ay wafang kard,tumawag sa 855-710-6984. CY YS JW'- } Xa U S) r^a S�C C � t�n�?j a C LY is�rS J atm »(3a4 uio u'uV J c :l,s 1�2 l s �u!:'J.) �s��rS qui C'>6��. ;i LI-5 rt)-)i�ur L,-6 Urdu -LP-A Ju}+855-710-6984 �o u Tieng Vii t Neu quy vi hoac ngtv6i ma quy vi gi6p db c6 bat ky cau h6i neo,quy vi c6 quyen dlvac ho tra vA nhan thong tin bang ng6n ng(r c6a minh mien phi.{)e n6i chuyen vbi thong dich vi@n,ggi so dich vu khach Vietnamese hang nam&phfa sau the hoi vi6n c6a quy vi.Neu quy vi kh6ng phai la hoi vien hoac kh6ng co the,gqi so 855-710-6984. bcbsil.com BlueCross B1ueShield of Illinois Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at 855-710-6984. If you believe we have failed to provide a service,or think we have discriminated in another way,contact us to file a grievance. Office of Civil Rights Coordinator Phone: 855-664-7270(voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: Civil RightsCoordinator anhcsc.net You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health &Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.htmi bcbsil.com Summary of Benefits and Coverage: What this Plan Covers &What You Pay For Covered Services Coverage Period: 05/01/2018-04/30/2019 BlueCrom BlueShield ofllBnolc : MPS91605 BlueEdge HSA Coverage for: Individual/Family I Plan Type: HSA ( ® The Summary of Benefits and Coverage(SBC)document will help you choose a health plan.The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called therep mium)will be provided separately. This is only a summary. For more information about your coverage,or to get a copy of the complete terms of coverage,visit www.bcbsiI.com/member/policy- forms/2018 or by calling 1-800-541-2768. For general definitions of common terms,such as allowed amount, balance billing,coinsurance,copayment, i deductible. provider,or other underlined terms see the Glossary. You can view the Glossary at https://www.cros.gov/CCIIO/Resources/Forms-Reports- ossa�� 8-M and-Other-Resources/Downloads/UG-Gl50M. df or call 1-855-756-4448 to request a copy. important Questions Answers Why This Matters: What is the overall Individual: Generally,you must pay all of the costs fromrop viders up to the deductible amount before deductible? Participating/ this plan begins to pay. If you have other family members on the policy,the overall family Non-Participating $1,500 deductible must be met before theIlan begins to pay. Family: Participating/ Non-Participating $3,000 Are there services covered Yes. Doesn't apply to certain This plan covers some items and services even if you haven't yet met the deductible amount. before you meet your preventive care. But a copayment or coinsurance may apply. For example,this plan covers certain preventive deductible? services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of-pocket Yes. Individual: The out-of-pocket limit is the most you could pay in a year for covered services. If you have limit for thisIlan? Participating/ other family members in this p1an.the overall family out-of-pocket limit must be met. Non-Participating $3,000 Family: Participating/ Non-Participating$6,000 What is not included in the Premiums,balance billed charges, Even though you pay these expenses,they don't count toward the out-of-pocket limit. out-of-pocket limit? and health care this Plan doesn't cover. Will you pay less if you use Yes. See www.bcbsil.com or call ThisIlan uses arop vider network.You will pay less if you use arop vider in the plans network. a network provider? 1-800-541-2768 for a list of You will pay the most if you use an out-of-network provider,and you might receive a bill from Participating Providers. arop vider for the difference between the provider's charge and what your plan pays(balance Willing).Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with yourrop vider before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL Non-HMO LG-2018 1 of 6 0 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. ProviderWhat-You Will'Pay Common Services You May Need Participating Provider Non-Participating Limitations, Exceptions, & Other Important Medical Event (You will pay the least) Primary care visit to treat an No Charge 20% coinsurance Acupuncture not covered. injury or illness Virtual visits may be available,please refer to your policy for more details. provider's office or If you visit a health care S e� cialist visit No Charge 20% coinsurance none clinic Preventive care/screening/ No Charge 20% coinsurance You may have to pay for services that aren't immunization preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood No Charge 20% coinsurance If you have a test work) none Imaging(CT/PET scans,MRIs) No Charge 20% coinsurance If you need drugs to Preferred generic drugs 20% coinsurance 20% coinsurance treat your illness or Non-preferred generic drugs 20% coinsurance , 20% coinsurance Certain women's preventative services will be condition Preferred brand drugs 20°i°coinsurance 20°i°coinsurance covered with no cost to the member. For a Non-preferred brand drugs 20°i°coinsurance 20°i° coinsurance full list of these prescriptions and/or services, More information about please contact customer service.You may be prescription drug Specialty drugs 20%coinsurance 20°x° coinsurance eligible to synchronize your prescription coverage is available at refills,*please see your benefit booklet for https://www.bebsil. details. You may be eligible to synchronize com/member/ your prescription refills,*please see your prescription-drug-plan- benefit booklet for details. , .information/drug-lists If you have outpatient Facility fee (e.g., ambulatory No Charge 20% coinsurance surgery center) none surgery physician/surgeon fees No Charge j 20%coinsurance Emergency room care ; 10°i°coinsurance ; 10% coinsurance If you need immediate Emergency medical No Charge No Charge none medical attention transportation Urgent care , No Charge ! 20% coinsurance *For more information about limitations and exceptions,see theIlan or policy document atwww.bcbsil.com/member/policy-forms]2018. 2of6 What You Will Pay Common Participating Participating- Other Important Services You May Need Medical Event (You will p. pay thl Information If you have a hospital Facility fee (e.g., hospital No Charge $300 comment visit room) plus 20%coinsurance none stay Physician/surgeon fees No Charge 20% coinsurance Outpatient services No Charge 20% coinsurance Preauthorization is required for Psychological testing; Neuropsychological testing; Electroconvulsive therapy; Repetitive If you need mental Transcranial magnetic Stimulation;and health, behavioral Intensive Outpatient Treatment. health, or substance Virtual visits may be available for Outpatient abuse services services, please refer to your policy for more details. Inpatient services No Charge $300 copayment visit plus 20%coinsurance none Office visits No Charge 20% coinsurance Cost sharing does not apply to certain preventive services. Depending on the type of services, copayment, coinsurance, or deductible may apply. Maternity care may If you are pregnant include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional No Charge '20°i°coinsurance � services I none Childbirth/delivery facility No Charge $300_ copayment visit . services . plus 20%coinsurance Home health care I No Charge 20% coinsurance � Rehabilitation services No Charge 20% coinsurance � If you need help Habilitation services ' No Charge 20°x° coinsurance I none recovering or have Skilled nursing care No Charge $300 copayment visit other special health plus 20%coinsurance needs Durable medical equipment No Charge '20% coinsurance I Benefits are limited to items used to serve a i I 1 medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). 3of6 What You Will Pay Common Services You May Need Participating o p. Other Important Medical p. pay the Information Hospice services No Charge 20%coinsurance none Children's eye exam Not Covered Not Covered If your child needs dental or eye care Children's glasses Not Covered Not Covered none Children's dental check-up Not Covered Not Covered Excluded Services&Other Covered Services: Services Your Plan Generally Does NOT Cover(Check your policy orIlan document for more information and a list of any other excluded services.) • Acupuncture • Hearing aids Routine eye care (Adult) • Cosmetic surgery • Long-term care Weight loss programs • Dental care (Adult) Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document) • Bariatric surgery • Infertility treatment (4 invitro attempt maximum • Private-duty nursing • Chiropractic care (30 visit max) with special approval up to 6 per benefit period) • Routine foot care (Only in connection with • Non-emergency care when traveling outside the diabetes) f U.S. Your Rights to Continue Coverage: There are agencies that.can help if you want to continue your coverage after it ends.The contact information for those agencies is:the plan at 1-800-541-2768,U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA(3272) or www.dol.gov/ ebsa/healthreform, or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cros.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against-your plan for a denial of-a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your Ilan. For more information about your rights, this notice,or assistance,contact:Blue Cross and Blue Shield of Illinois at 1-800-541-2768 or visit www.bcbsil.com,or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) 527-9431 or visit http:// insurance.illinois.gov. 4of6 Does thisIlan.provide Minimum Essential Coverage?Yes If you don't have Minimum Essential Coverage for a month,you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards?Yes If yourIlan doesn't meet the Minimum Value Standards,you may be eligible for a premium tax credit to help you pay foraIlan through the Marketplace. Language Access Services: Spanish (Espanol):Spanish (Espanol): Para obtener asistencia en Espanol, Ilame al 1-800-541-2768. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-541-2768. Chinese (��): Pp�W�rP5-rROWW 1-800-541-2768. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-541-2768. To see examples of how thislean.might cover costs for a sample medical situation, see the next section. 5of6 About These Coverage Examples: r This is not a cost estimator.Treatments shown are just examples of how this plan might cover medical care.Your actual costs will be different depending on the actual care you receive,the prices yourrop viders charge, and many other factors. Focus on the cost sharing amounts (deductibles,copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you t might pay under different healthIp ans. Please note these coverage examples are based on self-only coverage. Peg is Having a baby Managing Joe's type 2 Diabetes (9 months of in-network pre-natal care and a (a year of routine in-network care of a (in-network emergency room visit and follow up hospital delivery) well-controlled condition) care) ■ TheIp an's overall deductible $1,500 ■ TheIp an's overall deductible $1,500 ■ TheIp an's overall deductible $1,500 ■ Specialist $0 ■ Specialist $0 ■ Specialist $0 ■ Hospital (facility) $0 ■ Hospital (facility) $0 ■ Hospital (facility) $0 • Other $0 ■ Other $0 ■ Other $0 This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care(including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment(glucose meter) Total Example Cost $12,800 ; Total Example Cost $7,4001 ; Total Example Cost $1,900 In this example, Peg would pay: _ In this example,Joe would pay: In this example, Mia would pay: _ Cost Sharing --- Cost Sharing Cost Sharing Deductibles $1,500 Deductibles $1,500 Deductibles -- $1,500 Copayments — _$0 Copayments $0 Copayments _ _ $0 Coinsurance $10 Coinsurance $1,000 Coinsurance — - I V What isn't covered What isn't covered What isn't covered Limits or exclusions $60 Limits or exclusions i $60 Limits or exclusions $0 The total Peg would pay is $1,570 ' f The total Joe would pay is $2,56-0 : ; The total Mia would pay is $1,500 The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6 BlueCross BlueShield of Illinois If you,or someone you are helping,have questions,you have the right to get help and information in your language at no cost. To speak to an interpreter,call the customer service number on the back of your member card.If you are not a member,or don't have a card,call 855-710-6984. J o,l 14_J fl.y4 SII ui,5u,aaLSs Ll U9.1&.A,i1,:iajj -%,-t.. I mak.Jr�!I"id.11 1�L;Al-I..)mu!Ls.il yi a"SLS J Arabic .855-710-6984 L�-J-�AM.?Lluz V s Chinese a� �,A.AR1 .855-710-69840 Frangais Si vous,ou quelqu'un que vous 6tes en train d'aider,avez des questions,vous avez le droit d'obtenir de I'aide et('information dans votre langue a aucun coot.Pour parler 6 un interprete,composez le num6ro du French service client indiqu6 au verso de votre carte de membre.Si vous n'6tes pas membre ou si vous n'avez pas de carte,veuillez composer le 855-710-6984. Deutsch Falls Sie oder jemand,dem Sie helfen,Fragen haben,haben Sie das Recht,kostenlose Hilfe and Informationen in ihrer Sprache zu erhalten.Um mit einem Dolmetscher zu sprechen,rufen Sie bitte die German Kundenservicenummer auf der ROckseite Ihrer Mitgliedskarte an.Falls Sie kein Mitglied sind oder keine Mitgliedskarte besitzen,rufen Sie bitte 855-710-6984 an. WnVIKd E6v EQEIS t 1(670105 TrOU ROn86TE tXET£EPWTf O`ElS,QETE TO 61Kaiwpa va AdOETE pof E)E10'K01 TrArlpOTOpiES 079 yh(ocy TO uaS XWpiS Xptwcyq.ria va piAA (TETE QE tvav 6]EppgVta,KdtME TOV op19N6 E�uTTgptTrlariS Greek T F,\aTWV Trou OVOypdTET01 OTo Triaw ptpoS Tris KdpTaS ptAouS aaS.Edv 6EV EIOTE PHOS fl 6EV iXETE Kdp7a,KaMoTE TOV apil)p6 855-710-6984. 3,j-rRtc{l �f1 ci�l�Zl2lcll cid IEE Sri 2t?ll c 4 � s1>S oiler a z12l.cdl.zlil. fClilR41 2t1a cll.d szut )-[LL, ciI-1121 21CPA-46�11 81. di 1d1F9o1 Z4LCA Dat58 21c11 -ic}tz 142 Bkt 821. Gujarati %k ulltil RQzt- E Qil 4RILcicil SZcl, Z121c11 z4Mt ft 11121 81L QLC ct1 855-710-6984 -lc{2 1.12 akt 821. Tft zrf�3ugi ,zrr3rrrrf wumff wc T�g 3Uk,us�Tt,c�3ffq-.# aTTW#ft:sT EFuUz tr3ft a i o-h i t wc�T wc-t zFr AtFzwtl f�Ffr3r-ial #wffTT�r 4;f�m,3m;,r W&�-WWit 4; Hindi tt f�vTvwf$drF'gTzaw-.Btiqf�3uqu&�-iTftt,zrr3irgz'grWit 3:0t,cel'855-710-69841:RWkzhtl Italiano Se to o qualcuno the staff aiutando avete domande,hai ii diritto di ottenere aiuto a informazioni nella tua lingua gratuitamente.Per parlare con un interprete,puoi chiamare it servizio clienti al numero riportato sul tato Italian posteriore della tua tessera di socio.Se non sei socio o non possiedi una tessera,puoi chiamare ii numero 855-710-6984. `t-0i otot�lof�`�lof7f Afo101zff01VEft -I8fLT��DP-12-lya3foi�z?loh°1 °{01�1zTO1L-ai'_I7f°,tc,LICF.sI� 9f�__ 1 °����111111^ tHs-cl= Korean LlisEofd'Al2.1s1 A 0 1 OE LI Al 71 Lf 9F-1--7t 01 2AIM"855-710-6984 0-i�--' �i&I AI 9. Dinh T'aa ni,of doodago la'da bika ananflwo'igfi,na'fdilkidgo,ts'fda bee nA ah66tiT VdA nfik'e nilca a'doolwol.Ata'halne'f bich'i'hadeesdzih ninfzingo 6f kwe'e da'fnfishgi aka anfdaalwo'igif Navajo bich'i'hodfilnih,bee neehozinii bine'6r< 'bikaa'.Kojf atah naaltsoos na hadit'eeg66 ei doodago bee neeh6zinfgff Mingo koji'hodfflnih 855-710-6984. Polski Jesli Ty lub osoba,kt6rej pomagasz,macie jakiekolwiek pytania,macie prawo do uzyskania bezplatnej informacji i pomocy we wlasnym j@zyku.Aby porozmawiab z tlumaczem,zadzwoh pod numer podany na Polish odwrocie karty czlonkowskiej.Jezeli nie jester czlonkiem lub nie masz przy sobie karty,zadzwoA pod numer 855-710-6984. PyCCKHIA ECr1H y Bac Hr1H 4enOBeKa,KOTOPOMy Bbl nOMOraeTe,803HHKnH BOnpocbl,y Bac eCTb npaBO Ha 6ecnnaTHyio noM0U16 H HH#pMagHK),npegOCTaBneHHyKT Ha BaweM A361Ke.gm6bl norOBOPHTb C nepeBdA4HKOM,.• - Russian nO3BOH14Te B oTAen o6CJIY)MBaHNfl KnHeHTOB n0 Teneq)OHy,yKa3aHHOMy Ha o6paTHO9 CTOpOHe Baweh KapTO4KH y4aCTHHKa.EcnH Bbl He ABnfleTecb y4aCTH11KOM HnH y BaC Her KapTOgKH,n03BOH11Te n0 Teneki)OHy 855-710-6984. Espanol Si usted o alguien a quien usted esta ayudando tiene preguntas,tiene derecho a obtener ayuda a informaci6n en su idioma sin costo alguno.Para hablar con un interprete comuniquese con el numero del Servicio al Spanish Cliente que figura en el reverso de su tarjeta de miembro.Si usted no es miembro o no posee una tarjeta,Ilame al 855-710-6984. Tagalog Kung ikaw,o ang isang taong iyong tinutulungan ay may mga tanong,may karapatan kang makakuha ng tulong at impormasyon sa iyong wika nang walang bayad.Upang makipag-usap sa isang tagasalin-wika, Tagalog tumawag sa numero ng serbisyo para sa kustomer sa likod ng iyong kard ng miyembro.Kung ikaw ay hindi isang miyembro,o kaya ay waiang kard,tumawag sa 855-710-6984. y.1,1 J.!?W-)s JL�..r< .s-Y-U"9.Y"Ji...0 aC1 < c =-A uL+ lSG iyS c1.at-uleyla-.J91.1,<tsao u;.o i jl�, .,u'ql-�S'7'i c.Y uJ"li.•.J'JlJ11 L�!I <ui,�,yS.1.1n ui�S u"�.s$.1,j9�.,ul�..,s L�,s ui;s Urdu up-,s JLS-s;855-710-6984 y e.c,r �jLS crli q i y icy cru L�r A-c�y x'"'; �k)li� Tieng Vigt Neu quy vi hoac ngrrai ma quy vi gi6p da c6 bat ky cau hoi nao,qujr vi c6 quyen dvac ho tra va nhan thong tin bang ng6n ng(F cua minh mien phi.D'ndi chuygn v&i thong dich vi6n,goi so dich vu khach Vietnamese hang n6m d phia sau the hoi vi6n cua quy vi.Neu quy vi kh6ng phai la hlji vien hoac kh6ng co the,goi so 855-710-6984. bcbsil.com :.: B1ueCross B1ueShield of Illinois Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at 855-710-6984. If you believe we have failed to provide a service,or think we have discriminated in another way,contact us to file a grievance. Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. 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BlueCross B1ueShield Table of Contents •.• of Illinois 6 R PLAN PERFORMANCE Data Parameters 3 Pharmacy Financial Summary 15 Enrollment Overview 4 Key Indicators 16 Financial Overview Generic vs. Formulary Experience 17 Financial Summary 6 Medical & Pharmacy Loss Ratio 7 Top Non-Specialty Therapeutic Drug Classes 18 Network Overview 8 Top Non-Specialty Prescription Drugs 19 Blue Card Savings Analysis 9 Specialty Drug Analysis 20 Medical Claim Expense Distribution 10 Appendix 21 Glossary 24 High Cost Claimants 11 Medical Out of Pocket 12 Lag Report 13 Overall Medical Paid PMPM by ICD-9 14 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Data Parameters \ / of Illinois R Current Account Year To Date: The current reporting period represents claims paid from June 1, 2015 through January 31, 2016. Prior Account Year To Date: The prior reporting period represents claims paid from June 1, 2014 through January 31, 2015. Reporting Support Contact Information For reporting support, please contact Client Reporting Service Center Email: client_reporting@bcbsil.com Phone: 1-877-837-1866 Hours of Operation: Monday - Friday: 8:00am - 5:00pm CT Report prepared on 02/10/2016 s CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Enrollment Overview ► ► orIDinois ti Report Description:Provides the current enrollment based on the current account year to date period. Medical Medical Pharmacy Pharmacy Month Subscribers Members Subscribers Members Jun 2015 131 329 131 329 Jul 2015 130 329 130 329 +Aug 2015 129 327 129 327 Sep 2015 129 324 129 324 !Oct 2015 128 316 128 316 Nov 2015 129 319 129 319 Dec 2015 130 323 130 323 Jan 2016 130 322 130 322 'Feb 2016 Mar 2016 {Apr 2016 - - - --- - - -- --May 2016 Enrollment by Tier Gender Currerit- 20.5% - -k 19.6% 48.9% Current 46.8% i Prior 20.451 20.34/ 50.1% prior r'• 47.0% i Employee Only 0 Employee+One Employee+IDepls) Family =Mate Q Female 4_ CITY OF CANTON:PREM NON-HMO #----i BlueCross B1ueShield Enrollment OverviewF �E\V/ ofMinois Report Description: Provided medical demographics for the current account year to date period compared to the prior account year to date period and percent change. Medical Demographics Jun 2014-Jan 2015 Jun 2015-Jan 2016 %Change • Overall,membership decreased by 4.7%between reporting periods. ;Average Membership 340 324 -4.7% - • Employee 131 130 -0.8% The average age was 34.7 and increased by 2.2%between reporting _.__-_ _. .-- �___..___ _.-- -----_-.._-__._ ._-------_-_-_-._ r_____.___-.:- _._- _-- _._• periods. (Spouse 76 72 -5.3% --- - -- - - -- - - - • Contract size decreased by 4.0%between reporting periods. Dependent 134 122 -9.0% - -- - - - - - -- - o - • Females between the ages of 20 and 44 increased from 15.4%to 16.1% Average Contract Size 2.6 2.5 4.0/ between reporting periods. Average Age 34.0 34.7 2.2% Employee 47.5 47.8 0.7% Spouse 46.7 46.6 0.3/ Average Medical Membership Dependent 13.5 13.8 2.7% _. Under 30 42.7% 42.5% { - - - - - - - - --- - _ Current 22.2% ( 37.7% I 30 to 49 29.6% 27.5% %50 to 64 27.7% 29.9% 65+ 0.0% 0.2% Gender Proportion of Males 53.0% 53.2% prior 22.3% 39.4% - - _ - -- - -- - - --- - _ -- --- - -. I Proportion of Females 47.0% 46.8% j {{ Females Ages 20-44 15.4% 16.1% --------- --- Employee Spouse ; Dependent 5_ CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Financial Overview: Financial Summary ► \vJ of Illinois Report Description: Provides a breakdown of the medical order of reduction from billed to paid for the current month,current account year to date period,prior account year to date period and a percent change. This report may highlight key measures and their potential impact on paid expenses. Medical Order of Reduction Breakdown of Billed Amount Paid Month Jan 2016 Jun 2014-Jan 2015 Jun 2015-Jan 2016 %Change 100% ,Billed $170,028 $2,091,134 $1,831,166 -12.4% Not Covered $37,340 $84,624 $170,051 100.9% ------- - -------- ...--____---- -_.---- ..._____ -_'___-____--___1- .-- ------ -- -.--- ------.---- ___-..- - o 'Covered $132,687 $2,006,510 $1,661,114 -17.2% 80y - -----_---- - -- -- - - --- Not Covered Discount $53,833 $756,264 $703,361 -7.0% 70% --_---- -- _ -- - - --- __ - - --- _----------- _. -------- -- ----- ._.._ = Discount ;Allowed $78,855 $1,250,246 $957,753 -23.4% 60% I �; Out of Pocket - - - - - -- - -- i Out of Pocket - $14,210 - $115,021. $91,094 -20.8%- - 50% ® COB - ---- COB - $66 $10,784 $3,642 -66T2% COB Medicare COB Medicare $565 $14,595 $11,611 -20.4%20.4% 40% r- Other Reductions L_ ,Other Reductions ($502) $12,094 $14,241 17.8% 30% - - --_._-__..- _._.- - -- -- - _.- -. _.. ._- .. _- _ _.-- .- 0 Other Adjustments Other Adjustments $0 $0 $0 u _-- 20% Paid Provider Paid-Provider $64,516 ' $1,097,753 $837,165 -23.7% - ---- - -- - - -- ... --- - - --- -- -- - - --- ---- - - - -._._..-- --- ----- - ' 10% Other Payments $97 $921 $871 -5.5% Paid $64,614 $1,098,674 - $838,036 -23.7% 0% .-----_ .. -_-__-. ...-- _ ---- . --. _._.- ._ Current YTD Prior YTD Group Liability Breakdown Paid Month Jan 2016 Jun 2014-Jan 2015 Jun 2015-Jan 2016 %Change Medical Paid $64,614 $1,098,674 $838,036 -23.7% Pharmacy Paid $32,450 $290,900 $241,905 -16.8% Paid $97,064 $1,389,574 $1,079,940 -22.3% Recoveries Paid+Recoveries $97,064 $1,389,574 $1,079,940 -22.3% Group Liability $97,064 $1,389,574 $1,079,940 -22.3% Other reductions includes penalties, workers compensation savings,and subrogation savings. Other payments includes Blue Card access fees and surcharges.Also displayed are other adjustments. CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Financial Overview: Medical & Pharmacy Loss Ratio oflllinois cial Ov Report Description: Provides the medical and pharmacy loss ratio and claims for the most recent reported twelve months. ort Descripti Month Premium Medical Paid Claims Pharmacy Paid Claims Total Paid Medical and Pharmacy Loss Ratio Nork and ser Nov 2014 $168,103 $66,331 $57,563 $123,895 73.7% Dec 2014 $167,991 $173,955 $53,388 $227,343 135.3% Medicare 'Jan 2015 $167,051 $108,889 $57,888 $166,777 99.8% Feb 2015 $168,243 $115,602 $24,160 $139,761 83.1% Mar 2015 $167,602 " $116,552 . '$35,959 $152,511 91.0% Apr 2015 $166,397 $104,952 $21,769 $126,721 76.2% May 2015 $165,103 $105,759 $27,520 $133,279 80.7% Jun 2015 $172,213 $88,416 $27,778 $116,194 67.5/ ,,Jul 2015 $172,214 $136,826 $24,414 $161,240 93.6% No Aug 2015 $171,534 $82,721 $26,978 $109,700 64.0% 'Sep 2015 $170,350 $98,223 $27,506 $125,730 73.8% Oct 2015 $167,724 $115,623 $30,762 $146,386 87.3% Summary $2,024,526 $1,313,850 $415,685 $1,729,535 85.4% Loss Ratio By Month 140%- 120%_ 100% 80% Yes 60%- 40%- 20% 0% 40% 20% 0% Nov Dec ,tan Feb Mar Apr May !un Jul Aug Sep Oct Summ 20114 2014 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 Key Findings:The medical and pharmacy loss ratio for the most recent reported month was 1.8%higher than the average of the most recent reported twelve months,which y Finding! was 85.4%. CITY OF CANTON:PREM NON-HMO B1ueCross BlueShield Financial Overview: Medical Out of Pocket V of Illinois rt Report Description:Provides a distribution of claimants by their total medical out of pocket expenses for the current account year to date period compared to the prior account year to date period and percent change. This report helps determine the impact of any changes in plan design on out of pocket. Jun 2014-Jan 2015 Jun 2015-Jan 2016 %Change Out of Pocket Band Claimants Claimants% Out of Pocket Out of Pocket% Claimants Claimants% Out of Pocket Out of Pocket Claimants Change Out of Pocket Cha j<$100 110 38.6% $926 0.8% 141 48.5% $4,859 5.3% 28.2% 425.0% $101-$200 30 10.5% $4,706 4.1% 35 12.0% $5,268 5.8% 16.7% 11.9% '$201-$300 18 6.3% $4,536 3.9% 23 7.9% $5,734 6.3% 27.8% 26.4% $301-$400 24 8.4% $8,465 7.4% 12 4.1% $4,326 4.7% -50.0% - ---48.9% .$401-$500 10 3.5% $4,486 3.9% 11 3.8% $5,105 5.6% 10.0% 13.8% $501-$750 44 15.4% $26,913 23.4% 32 11.0% $19,573 21.5% -27.3% 27.3% '$751-$1,000 11 3.9% $9,565 8.3% 16 5.5% $14,244 15.6% 45.5% 48.9% $1,001-$1,500 24 8.4% $29,263 25.4% 9 3.1% $11,486 12.6% -62.5% -60.8% ;$1,501-$2,000 9 3.2% $15,231 13.2% 11 3.8% $18,217 20.0% 22.2% 19.6% $2,001-$2,500 5 1.8% $10,931 9.5% 1 0.3% $2,282 2.5% -80.0% -79.1% !$2,501-$3,000 0 0.0% $0 0.0% 0 0.0% $0 0.0% 0.0% - 0.0%^- $3,001-$4,000 0 0.0% $0 0.0% 0 0.0% $0 0.0% 0.0% 0.0% ;$4,001-$5,000 0 0.0% $0 0.0% 0 0.0% $0 0.0% 0.0% 0.0% $5,000+ 0 0.0% $0 0.0% 0 0.0% $0 0.0% 0.0% 0.0% Summary 285 100.0% $115,022 100.0% 291 100.0% $91,094 100.0% 2.1% -20.8% Out of Pocket Expense by Coverage Tier Jun 2015-Jan 2016 'Coverage Tier' Allowed 'Deductible Dedirctibli%of Allowed Copayment Copay/of Allowed Coinsurance Coins%of Allowed Out of Pocket OPX%of Allowed Paid Employee Only-- $282,374 $7,265 1' "'2,B% $4,125 1.5% $2,562 0.9% $13,952 4.9% $268,099 Employee+One $356,814 $11,405 3.2% $8,233 2.3% $8,235 2.3% ° $27,872 7.8/ $307,699 'Employee+Dependent(s) $49,357 $3,086 6.3% $2,872 5.8% $2,088 4.2% $8,046 16.3% $38,240 $11,934 4.4/015.3% _ _ _ '---------- - -------_-- ---- ----------- --- - Family $269,208 $16,950 6.3% ° _$12,340 4.6/0 $41,223 15.3.3 /0 $223,998 Summary $957,753 $38,706 4.0% $27,164 2.8% $25,224 2.6% $91,094 9.5% $838,036 This 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. This report is based on claim data and may not reflect client specific benefits being applied to member out of pocket.Please contact your Account Executive for ACCUMS reporting. 1 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Financial Overview: Lag Report \ / of Illinois Report Description: Displays,by paid month,the medical dollars paid and the corresponding month incurred for a 12 month rolling paid period(if available for your account). This report provides insight into the monthly claim lag and can help identify IBNR. Incurred Paid Month Month Feb 2015 Mar 2015 Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015. Jan 2016 Summary !ALL PRIOR ($12) ($27) ($360) ($399) I Feb 2014 ($65) `$65J._._. ;Mar 2014 Apr 2014 $0 May 2014 $215 ($54) $221 Jun 2014 $335 $146 $9 $489 ;Jul 2o1a (S151) -� {$151) ) 0...____-_- Aug 2014 ($7,103) $91 $76 ($57) ($6,992) !Sep 2014 $8,101 $257 $5 $13 $8,375 Oct 2014 $17 $132 $85 $21 ($70) $185 iNov 2014 ($815) .�_ ($154) _�,--$949��___._�._�.___-__:$97____.___ .-$30 $107 ; Dec 2014 $1,364 $729 $43 $146 $349 $23 $2,654 Jan 2015 $16,289 $23,022 $452 $8 $420 $43 $2,747 $42,981 f Feb 2015 $32,005 $80,792 $2,391 $1,133 $52 ($439) $295 $116,228 f Mar 2015 $81,310 $311-252 $4,083 ($230) $1,820 $1,110. $11 " ($4) '$7 $119,360 '{ Apr 2015 $50,282 $18,766 $33,258 $467 $587 $206 $126 $17 $59 ($18) $103,749 May 2015 $47,902 $51,092 $4,239' $2,122 $146 $33 ($17) $83 ($68) $105 531 Jun 2015 $63,323 $22,337 $1,013 $45 $43 $107 $86,869 ul 2015 $75,922 $41,019 $4,891" $15,008 $1,025 $132 $137,797 Aug 2015 $37,787 _-_ $40,695 $1,954__._-�$1,238 $17 $824 _.._._._.$82,515 iSep 2015 __---•_$59,561 $32,979 $2,528 $221- ($455)_- $94,835 Oct 2015 $38,482 $74,822 $1,384 $645 $115,332 iNov 2015 -- "- $31089 $77,605 $3,449, $112,143 Dec 2015 $49,609 $37,751 $87,360 ;Jan 2016 $22,677 $22,677 Summary $50,176 $186,315 $85,368 $71,906 $148,159 $104,861 $82,209 $107,080 $88,592 $110,770 $131,751 $64,614 $1,231,801 1� CITY OF CANTON:PREM NON-HMO Financial Overview: Overall Medical Paid PMPM by ICD-9 Diagnostic Category %�� IV ofIllinoissBlueShield Report Description: Lists the top 15 overall paid expense across inpatient facility,outpatient facility,and professional settings by ICD-9 diagnostic categories for the current month,current year to date period,prior year to date period and percent change. Account YTD Paid Period Jan 2016 Jun 2014- Jun 2015- %Change Medical PMPM by ICD-9 Diagnostic Category Jan 2015 Jan 2016 ICD-9 Diagnostic Category Paid PMPM Paid PMPM Paid PMPM Paid PMPM !Endocrine;nutritional;and metabolic $44 $79 $68 -13.0% Ldicoacoc and immimity riicnrriorc Diseases of the musculoskeletal system and o - connective tissue $35 $26 $55 107.9/ Diseases of the skin and subcutaneous tissue $28 $8 $15 81.3% � -- --------------- ----- -- ---- Injury and poisoning $26 $59 $20 -66.6% Symptoms;signs;and ill-defined conditions $15 $47 $26 45.2% "'- Land factors influencing health status_ Diseases of the respiratory system $13 $15 $12 -23.1% Mental Illness $8 $8 $7 -11.3% Diseases of the nervous system and sense z�2 $8 $16 $15 -8.3% organs I Diseases of the genitourinary system $8 $46 $25 -44.5% Infectious and parasitic diseases $5 $7 $7 -9.1% Diseases of the circulatory system $4 $19 $20 3.2% Complications of pregnancy;childbirth;and $4 $4 $2 -51.0% the Dueroerium ,Neoplasms $2 $39. $20 -49.1% Diseases of-the•digestive system $1= $20 $23 16.0% I Residual codes;unclassified;all E codes[259. !and 260.] $0 $4 $7 86.4% �_— -All Other Values $0 $7 $4 -44.9% Summary $201 $404 $324 -19.8% 0 $20 $40 $60 $$0 ® Jun 2014-Jan 2015 Jun 2015-Jan 2016 Key Findings:The top three ICD-9 Diagnostic Categories in the current reporting month based on Paid PMPM were Endocrine;nutritional;and metabolic diseases and immunity disorders,Diseases of the musculoskeletal system and connective tissue,and Diseases of the skin and subcutaneous tissue. 14 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Financial Summary ► ofillinois R Report Description:This report provides an overview of pharmacy order of reduction from billed to paid for the current month,current account year to date period, prior account year to date period,and percent change. Pharmacy Order of Reduction Jan 2016 Jun 2014-Jan 2015 Jun 2015-Jan 2016 %Change 'Billed y- - -- --- -- -$67,093 --+ $561,602 $534,687 -4.8% Not Covered $0 $0 $0 ;Covered $67,093 $561,602 $534,687 -4.8% ! Breakdown of Billed Amount Discount $29;967 $232,737 $255,473 100% (Allowed $37,126 $328,865 $279,214 15.1% Out of Pocket $4,676 $38,970 $37,534 -3.7% 90% - -- .-- _ - - - -- - __ -_._.--- - -- -. .. -- - - iCOB $0 $0 $0 COB Medicare $0 $0 $0 80% 'Other Reductions $0 $0 $0 Other Adjustments $0 ($1,005) ($225) 77.6% Paid_Provider - - $32,450 $290,900 $241,905 _16.8%_.__. 60% Other Payments $0 $0 - $0 y _ - ® Not Covered --- - - -- - - ---- - ---- - ------- ---__- -_- Discount iPaid $32,450 $290,900 $241,905 -16.8% 0% --- -- Out of Pocket Total Pharmacy Paid vs.Specialty Paid 40% COB COB Medicare $300,000 - - - Other Reductions 30% Current YTD © Other Adjustments $250,000 - -- ® PriorYTO - Paid Provider 20%- $206,000 0%$206,000 :1^ 10% $150,000 $100,000 0% ' Current YTD Prior YTD $50,000- $0 50,000$0 Total Paid Specialty Paid Year To Date $241,905 $45,348 Prior Year To Date $290,900 $98,473 1S CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Key Indicators • • V of Illinois R Report Description:This report provides an overview of the prescription expenses as well as providing percent change in these expenses between the current month,current account year to date period,prior year to date period and percent change. Key Indicators Summary Key Indicators Summary Jan 2016 Jun 2014-Jan 2015 Jun 2015-Jan 2016 %Change -Unique Pharmacy Members 322 356 341 -4.2% Average Age(Years) 34.9 34.0 34.7 2.2% :Proportion of Males 53.1% 53.0% 53.2% 0.3% Proportion of Females 46.9% 47.0% 46.8% -0.4% --- -------o----------. Member Months '322 2,722 2,589 .4.9% Claimants 138 239 232 -2.9% Services 380 3,240 3,156 2.6% Prescriptions PMPM 1.18 1.19 1.22 2.4% ,Paid $32,450 $290,900 $241,905 -16.8% Paid PMPM $100.78 $106.87 $93.44 -12.6% ;Allowed $37,126 $328,865 $279,214 -15.1% Allowed PMPM $115.30 $120.82 $107.85 -10.7% Avg.Ingredient Cost/Prescription $96.69 $100.30 $87.26 -13.0% Generic Dispensing Rate 82.1% 80.8% 82.1% 1.6% ,Formulary Compliance Rate 92.1% 89.9% 91.8/0 o _ 2.1/0 Generic Substitution Rate 100.0% 100.0% 99.9% -0.1% Out of Pocket Percent of Allowed 12.6% 11.8% 13.4% 13.4% Retail as a Percent of Prescriptions 96.6% 96.3% 96.3% 0.0% Mail Order as a Percent of Prescriptions 3.4% 3.7% 3.7% 0.9% Specialty Percent of Total Prescriptions 0.3% 0.2% 0.2% 2.7% !Specialty Percent of Total Paid 30.1% 33.9% 18.7% -44.6% Specialty-Average Ingredient. Cost/Prescription $9,773.06 $20,307.70 $9,492.11- -53.3% Cost Sharing Distribution Jan 2016 Jun 2014-Jan 2015 Jun 2015-Jan 2016 %Change Cost Sharing Distribution Retail Mail Retail Mail Retail Mail Retail Mail Member Out of Pocket 12.5% 13.4% 11.8% 11.9% 13.6% 11.6% 15.4% -2.6% Plan Paid 87.5% 86.6% 88.2% 88.1% 86.4% 88.4% -2.1% 0.3% Savings Summary Jan 2016 Jun 2014-Jan 2015 Jun 2015-Jan 2016 %Change Savings Summary Retail Mail Summary Retail Mail Summary Retail Mail Summary Retail Mail Summary iDiscount $27,853-_ 5 $255, 11 $ _ . 2,114 - $29,967 $202,967 $29,770 $232 737 $222,209 $33,26473 9.5% .7% 9.8% - _ MAC Savings $25,303 $1,309 $26,612 $_177,575 $19,397 $196,971 $206,843 $23,569 $230,412 16.5% 21.5% 17.0%49.1% 44.7% 40.2% 52.5% 41.4% 46.8% 55.8% 47.8% 16.4% 6.2% 15.3 Di444% +% Discount . % 0 0 1 Fi CITY OF CANTON:PREM NON-HMO BlUeCross B1ueShield Pharmacy: Generic vs. Formulary Experience 41. of Illnois Report Description:For the current year to date period,the prescription drug expenses are displayed below for retail and mail order providers and broken out by drug type and formulary indicator. Total Expense Member Expense Plan Expense of Total Allowed/ Out of Pocket/ Paid/ Retail Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription 'Generic 2,506 82% $56,801 $22.67 $18,365 $7.33 $38,437 $15.34 f Brand 533 18% $196,029 $367.78 $16,115 $30.23 $180,139 $337.97 Summary 3,039 100% $252,831 $83.20 $34,480 $11.35 $218,576 $71.92 Brand Type Breakdown _--_ 'Single-Source Brand 417 14% $145,109 $347.98 $13,097 $31.41 $132,207 $317.04 'Sin Multi-Source Brand 48 2% $24,006 $500.12 $1,260 $26.24 $22,746 $473.88 Multi-Source Brand w/DAWl -� - �- - 24 - - 1% - $22,310 -- _ T $929.60 _- $735 - - - $30.64 - $21,575-_ V $898.96 Brand Formulary 293 10% $92,203 $314.69 $6,719 $22.93 $85,484 $291.76 Brand Non-Formulary 240 8% $103,826 $432.61 $9,396 $39.15 $94,655 $394.40 Total Expense Member Expense Plan Expense %of Total Allowed/ Out of Pocket/ Paid/ Mail Prescriptions Prescriptions Prescriptions 'Allowed Prescription Out of Pocket Prescription Paid Prescription 'Generic 86 74% $8,346 $97.05 $1,307 $15.19 $7,039 $81.85 i Brand 31 26% $18,037 $581.83 $1,748 $56.38 $16,289 $525.45 Summary 117 100% $26,383 $225.49 $3,054 $26.11 $23,328 $199.39 5ingle_SourceBrand 24 21% $14,607 $608.61 $1,320 $55.00 $13,287 $553.61 Multi-Source Brand 5 4% $1,739 $347.79 $288 $57.56 $1,451 $290.23 Multi-Source Brand w/DAW1 2 2% $1,591. $795.59 $140 $70.00 $1,451 $725.59 Brand Formulary 12 10% $8,597 $716.42 $480 $40.00 $8,117_ $676.42 µ Brand Non-Formulary 19 16% $9,440 $496.83 $1,268 $66.73 $8,172 �-VY $430.11 Total Expense Member Expense Plan Expense %of Total Allowed/ Out of Pocket/ Paid/ Total Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription Generic _ 2,592 - -.-_--.82%. $65,148 $25.13 T $19,671_ _..____.. $7.559 $45,476 $1754 ___.._1 Brand 564 18% $214,066 $379.55- _$17,863 $31.67 $196,428 $348.28 Summary 3,156 100% $279,214 $88.47 $37,534 $11.89 $241,905 $76.65 Brand Type Breakdown Single-Sour eBran_d - 441 --�-`� 14% ^ $159,7_15 - n $3_62.17-$14,417__ $32.69_�_Y-^ $145,494 - -$329.92 w__j Multi-Source Brand 53- 2% v $25,745 $485.75 $1,547 $29.20 $24,197 _ -$456.55 iMulti-Source d w/DAW1 261%BranY-� -- 2 _--- __ ---_- $ 3,902 $919.29 $875 $33.67 $23,026 $885.62 ! Brand Formulary _- 305 10% $100,8_00 $330._49_ $7,199 $23.60 $93,601 $306.89 Brand Non-Formulary 259 8%- W$113,266 $437.32 $10,663 $41.17 w$102,827 - $397.02 17 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueSlueld Pharmacy: Top Non-Specialty Therapeutic Drug Classesi9 ® of Illinois R Report Description: The top 25 therapeutic drug classes for the current account year to date period are displayed below ranked by ingredient cost. Avg.Ingredient Avg.Ingredient Current/ Cost/ Cost/ Prior Utilizing Prescription Prescription % % Rank by Rank Plan Therapeutic Class Prescriptions Members Ingredient Cost (Current) (Prior) Formulary Generic Volume 1 1 Insulin 87 11 $49,964 $574.30 $473.38 90.8% 0.0% 7 2 3 Antimyasthenic Agents 8 1 $20,642 $2,580.30 $1,293.69 0.0% 0.0% 78 3 5 Sympathomimetics 54 26 - $10,174 T ^- $188.40-� $210.05 _ 98.1%-- 11.1% R 17 4 6 HMG CoA Reductase Inhibitors 183 36 $7,885 $43.09 $43.57 98.9% 16.9% 1 �5 2 Quinolinone Derivatives 13 2 $7,828 $602.13 $1,087.20 100.0% 15.4% 58 6 11 Diagnostic Tests 32 7 $5,677 $177.40 $161.63 87.5%- 0.0% 28 i 1 716 _ Impotence Agents 20____-.._ __..6 $4,995 � $249.73 --�-- $206.42 45.0% 0:0% 39 8 8 Anticonvulsants-Misc. 64 13 $4,837 $75.58 $120.59 100.0% 20.3% 12 9 9 Proton Pump Inhibitors 125 22 $4,829 $38.63 $46.17 96.8% 16.8% 5 10 10 Antihypertensive Combinations 92 17 $4,586 $49.85 $48.98 100.0% 16.3% 6 11 7 Dipeptidyl Peptidase-4(DPP 4)Inhibitors 8 2 $3,980 $497.46 $362.44 10b.0% 0.0% 87 12 14 Thrombin Inhibitors 8 2 $3,893 $486.58 $439.29 0.0% 0.0% 88 13 20 Stimulants-Misc. 26 5 $3,327 $127.97 ,$84.48 96.2% 19.2% 32 14 39 Estrogens 35 8 $2,897 $82.77 $41.79 42.9% 11.4% 26 15 44Phenothiazines- _Y__.__ -Y8 Y. _1____ $2,843- $355.34 __$122.72 100.0% 12.5%_ 81 . _ 16 22 Antidiabetic Combinations 8 1 $2,757 $344.59 $298.97 100.0% 0.0% 77 17 -19 Selective Serotonin Reuptake Inhibitors(SSRIs) - - -- 165 34 $2,730 $16.54 $13.36 100.0% 20.6% 2 18 64 Direct Factor Xa Inhibitors 8 1 $2,689 $336.17 $295.87 100.0% 0.0% 85 i 19 48 Prostatic Hypertrophy Agents 28 8 • $2,594 $92.64 $55.25. 64.3% 21.4916 30 20 .- 56 Symptom mptom Agents 10W -�2 $2,574 $257.42 Y _ $394.00 0.0%� 0.0% _ 69 tor -.__.-_.._____._.-.__._.�._._.._.__.__._._______.____.___...___.___,.�.____.,... j 21 30 Gout Agents 21 6 $2,520 $120.01 $101.24 52.4% 19.0% 38 s 22 18 Calcium Channel Blockers 43 6 $2,508 $58.33 $61.89 100.0% 14.0% 22 23 24 Attention-Deficit/Hyperactivity Disorder(ADHD)Agents 7 .1 .$2,431 $347.28 -$278.44 0.0%• 0.0% 101 i 24 27 Bronchodilators-Anticholinergics 8 2 $2,298 $287.20 $296.49 100.0% 12.5%, 86 1�25�_21 'Opioid Combinations �- 83 32 $2,160 __-_-.-----$2,160 ^-'-�- $26.02 --��V- $20.83 Y 100.0%--Y---_38.6% `� 8 L 5 All Other 2,007 208 $65,052 $32.41 $40.72 92.5% 28.1% Summary 3,151 232 $228,668 $72.57 $68.97 91.9% 23.6% 1R CITY OF CANTON:PREM NON-HMO B1ueCross BlueShield Pharmacy: Top Non-Specialty Prescription Drugstiv of Illinois Report Description: The top 25 prescription drugs for the current account year to date period are displayed below ranked by ingredient cost. Avg.Ingredient Avg.Ingredient Current/ Cost/ Cost/ Prior Utilizing Ingredient Prescription Prescription Formulary Generic Rank by Rank Brand Name Plan Therapeutic Class Prescriptions Members Cost (Current) (Prior) Indicator Indicator Volume 1 1 MESTINON TAB 60MG Antimyasthenic Agents 8 1 $20,642 $2,580.30 $1,293.69 NO NO 121 2 3 NOVOLOG INJ 100/ML Insulin 12 2 $13,969 $1,164.06 $1,363.00 YES NO 42 3 4 NOVOLOG MIX INJ 70/30 Insulin 8 1 $9,692 $1,211.45 $1,018.57 YES NO 92 4 7 LANTUS INJ SOLOSTAR Insulin 20 4 $7,680 $383.98 $585.25 YES NO 15 5 ARIPIPRAZOLE TAB 5MG Quinolinone Derivatives 8 1 $5,740 $717.50 $0 YES YES 107 6 6 LANTUS INJ 100/ML Insulin 21 4 $5,382 $256.31 $237.90 YES NO 11 7 9 LEVEMIR INJ Insulin 9 1 $4,863 $540.30 $465.72 YES NO 69 8 8 CRESTOR TAB 10MG HMG CoA Reductase Inhibitors 12 3 $4,407 $367.23 $276.07 YES NO 43 9 11 PRADAXA CAP 150MG Thrombin Inhibitors 8 2 $3,893 $486.58 $439.29 NO NO 104 10 15 BENICAR HCT TAB 40-12.5 Antihypertensive Combinations 16 2 $3,294 $205.88 $173.23 YES NO 26 11 NOVOLOG INJ FLEXPEN Insulin 7 1 $3,144 $449.18 $0 YES NO 143 12 16 HUMALOG INJ 100/ML Insulin 5 1 $3,022 $604.48 $494.82 NO NO 210 13 130 KOMBIGLYZE TAB 2.5-1000 Antidiabetic Combinations 8 1 $2,757 $344.59 $305.45 YES NO 108 14 89 XARELTO TAB 20MG Direct Factor Xa Inhibitors 8 1 $2,689 $336.17 $295.87 YES NO 88 15 10 LYRICA CAP 150MG Anticonvulsants-Misc. 4 1 $2,603 $650.72 $538.09 YES NO 257 16 65 BRISDELLE CAP 7.5MG Vasomotor Symptom A ents 10 2 $2,574 $257.42 $394.00 NO NO 53 17 17 COMBIVENT AER RESPIMAT Sympathomimetics 3 1 $2,541 $846.84 $815.97 - YES- NO _ 354 18 22 STRATTERA CAP 40MG Attention-Deficit/Hyperactivity Disorder( 7 1 $2,431 $347.28 $278.44 NO NO 144 19 29 NEXIUM CAP 40MG Proton Pump Inhibitors 9 1 $2,327 $258.58 $244.57 YES NO 64 20 26 SPIRIVA CAP HANDIHLR Bronchodilators-Anticholinergics 7 1 $2,276 $325.19 $296.49 YES NO 149 21 DILTIAZEM CAP 360MG ER Calcium Channel Blockers 3 1 $2,152 $717.21 $0 YES YES 329 22 30 ULORIC TAB80MG Gout Agents 8 1 $2,145 $268.11 $234.66 NO NO 110 23 19 ADVAIR DISKU AER 500/50 Sympathomimetics 5 1 $2,114 $422.82 $385.51 YES NO 232 24 ARIPIPRAZOLE TAB 5MG Quinolinone Derivatives 5 1 $2,088 $417.53 $0 YES YES 248 25 40 VIAGRA TAB 100MG Impotence Agents 8 2 $2,064 $258.06 $205.83 NO NO 117 4-___- ------ All Other - 2,932 _- -___-231_....__._..-$112,180 $38.26 - __.--$47.98-----_- - ----.--.__._-----------_ _ _ Summary 3,151 232 $228,668 $72.57 $68.95 1A CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Specialty Drug Analysis • • ofIDinois ti 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.This report provides specialty drug analysis for the current month,current account year to date period, prior year to date period and percent change. Top Specialty Classes by Ingredient Cost for the Current Year to Date Specialty Drug Key Indicators Jan 2016 Jun 2014-Jan 2015 Jun 2015-Jan 2016 %Change Unique Pharmacy Members 322 356 341 -4.2% 17.6% - Member Months 322 2,722 2,589 -4.9% Claimants -_- -- - - -- 1 - 2 Z--- -- 0.0% Percent of Utilizing Members 0.3% 0.6%� - 0.6% - 4.4% I IServices 1 5 - -�5 0.0% Specialty Percent of Total Paid 30.1% 33.9% 18.7% 44.6% . ® CANCER-ORAL �PercentofTotal Prescriptions Paid 0.3% 0.2% 0.2% 2.7% Paid $9,774 $98,473 $45,348 -53.9% (Paid PMPM $30.35 $36.18 $17.52 51.6% + Q AUTOIMMUNE Average Ingredient Cost/Prescription $9,773 $20,308 $9,492 -53.3% out of Pocket $0 $3,070 $2,119 -31.0% Out of Pocket PMPM $0 $1.13 $0.82 -27.4% Out of Pocket Percent of Allowed 0.0% 3.0% 4.5% 47.6% •-- ---- __-------------_-- ----- ------ --------- -------------------------___---------------------' X82.4% Top 15 Specialty Drugs by Ingredient Cost for the Year to Date Avg.Ingredient Top Specialty Classes by Ingredient Cost for the Prior Year to Date Ingredient Cost/ Specialty Brand Name Specialty Class Cost Prescriptions Prescription Claimants LlMBRUVICA CAP140MG _ CANCER_ORAL - _ $39,992 4 $9,773:06 _ 1___-; STELARA INJ 45MG/0.5 AUTOIMMUNE $8,368 1 $8,368.32 1 5.6%-- IAII Other 0 Summary $47,461 5 $9,492.11 2 Q HEPATITIS C i Q AUTOIMMUNE i :I 94.4% 9n CITY OF CANTON:PREM NON-HMO B1ueCross B1ueSlrield Appendix: ICD-9 Category Definitions •.• © of Illinois N J Complications of Pregnancy,Childbirth and the Puerperium: Includes vaginal and cesarean deliveries and complications of pregnancy,such as ectopic and molar pregnancies. Puerperium refers to 42 days following childbirth and expulsion of the placenta. Refers to the mother only. Conditions Influencing Health Status:This includes post-surgical states,organ/tissue transplants,artificial limbs and replacements. Examples include knee replacements and kidney transplant status. Conditions in the Perinatal Period: Perinatal refers to the period beginning after the 28th week of gestation and ending 28 days after birth.Problems can include hemorrhage, digestive disorders,respiratory distress syndrome and disorders relating to short gestation and unspecified low birth weight. Congenital Anomalies: Includes the treatment of any condition present at birth.This includes Spina Bifida,cleft palate, Down's Syndrome,heart disease, kidney displacement &polycystic kidney disease. Diseases of the Blood and Blood Forming Organs: Includes any problems associated with white or red blood cells,platelets or plasma.An example includes Anemia,a deficiency in red blood cells. Diseases of the Circulatory System: Includes problems with the heart,blood vessels and circulation.Some common diagnoses include Coronary Artery Disease,cardiovascular disease,and stroke. Diseases of the Digestive System:Includes the treatment of any organ or area of the body pertaining to digestion.These areas include the mouth/teeth,esophagus,stomach, intestines,gall bladder,liver and pancreas. Diagnoses include: Esophageal Reflux,Gastroenteritis,Appendicitis and hernias. Diseases of the Genitourinary System: Includes problems related to the kidneys,bladder and male and female genitalia.Common diagnoses include Hematuria, Urinary Tract Infection,Acute or Chronic Renal Failure and Calculus of Kidney(stones). Diseases of the Nervous System: Includes treatment for disorders of the Central and Peripheral Nervous systems.Diagnoses include:Carpal Tunnel Syndrome,Obstructive Sleep Apnea, Epilepsy,Multiple Sclerosis,Alzheimer's Disease and Migraine headaches. Diseases of the Respiratory System: Includes treatment for diagnoses such as Asthma, Pneumonia, Emphysema,Pharyngitis,Sinusitis,Bronchitis and COPD.These can be acute or chronic in nature. Diseases of the Skin and Subcutaneous Tissue:This involves any condition relating to the skin or beneath the skin,including hair and nails.Some conditions include Acne, Corns,Cellulitis,Psoriasis,Dermatitis and fungal infections. 71 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Appendix: ICD-9 Category Definitions • • ofIDinois ti Ears and Mastoid: Includes any condition pertaining to the ear or the mastoid process.The mastoid process is the portion of the temporal bone extending down behind the ear.Diagnoses include Otitis Media,Tinnitus, Menieregs Disease,Hearing Loss and Labyrinthitis. Endocrine,Nutritional and Metabolic Diseases: Endocrine disorders include those of the endocrine glands and includes the thyroid,pituitary,pancreas,ovaries and testes. Disorders include Diabetes,thyroid disease,Obesity,Hyperlipidemia,Cystic Fibrosis and any disease affecting the immune system. Health Services:This includes elective surgeries,other procedures&aftercare,rehabilitation and dialysis.Specific examples include:long-term medication use,Physical Therapy and chemotherapy. Health Services:Reproduction and Development: Include services pertaining to the child only. For example,normal pregnancy, post-partum care and exam or health supervision of an infant or child. Infectious and Parasitic Diseases: Includes diseases caused by microbes outside of the body that infect and cause damage within the body.These diseases are recognized as communicable or transmissible.Diagnoses include HIV, Hepatitis,Colitis&intestinal disruptions such as food poisoning. Injury and Poisoning: Includes treatment for injuries to the body or for any poison ingested. Diagnoses include sprains&strains,fractures,burns and lead poisoning. Patients are most commonly seen in the emergency room for acute conditions. Mental Health: Refers to a group of disorders causing severe disturbances in thinking,feeling or relating. Includes treatment of any condition that affects mood or behavior. The most common diagnoses include anxiety disorders,depressive disorders and schizophrenia. Musculoskeletal and Connective Tissue Disease: Includes orthopedic treatment,-which would involve anything related to the bones,muscles,joints and soft tissue. Diagnoses: Arthritis,Tendonitis,back disorders,disc disorders,rheumatism,and scoliosis.These diagnoses are more chronic in nature. Neoplasms: Includes any abnormal growth of cells,either benign or malignant(cancer).Though these can be found at any spot of the body,some of the most common forms include neoplasms of the breast,prostate,stomach and brain.Other examples include Leukemia and Hodgkin's Disease. Other Circumstances:This includes convalescent care and follow-ups to surgeries and examinations. Potential Health Hazards: Personal or family history of diseases or disorders;e.g.,breast cancer. CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Appendix: ICD-9 Category Definitions •.• a of Illinois ti Procreative and Contraceptive Management:This includes artificial insemination,fertility testing,genetic counseling,family planning,sterilizations and contraceptive management. Signs,Symptoms and III-Defined Conditions:Includes signs,symptoms,abnormal lab results and ill-defined conditions for which no known cause can be found. For example,a patient may experience chest pain,but no known cause is found. Substance Abuse:Includes behavior marked by the use of chemically active agents,such as prescription or illicit drugs,alcohol or tobacco.Cognitive,behavioral and physiological symptoms indicate that the person continues use of the substance. Without Reported Diagnosis:This includes general medical examinations,gynecological exams,mammogram screenings,preventive services,physicals and special screenings for neoplasms. CITY OF CANTON:PREM NON-HMO Glossary Btu fiBlueSlueld �.� of Illinoisnois ti Admin Fees:The charge to an account for HCSC's operational cost of doing business. Administrative Services Only(ASO):A contract between HCSC and a self-funded plan where HCSC performs administrative services only and does not assume any financial risk.Services usually include claims processing but may include other services such as actuarial analysis and utilization review. Aggregate:Constituting or amounting to a whole.For example,an aggregate account report includes data for the entire account. Aggregate Stop Loss:A form of reinsurance that provides protection for medical expenses above a certain limit,generally on a year-by-year basis.Aggregate stop loss provides protection against the accumulation of total claims for a group as a whole exceeding a stated level. Allowed:Amount considered eligible for payment by the plan ASO Adjustments:An amount added or deducted from ASO(Administrative Services Only)fees.This includes Stop Loss Reimbursements. 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 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. 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 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. 94 CITY OF CANTON:PREM NON-HMO Glossary B1ueCrossBlueSlueld ►.� of Illinois F K 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 Co-payment: Flat rate that the member is responsible to pay for the claim 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. 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 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 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 75 CITY OF CANTON:PREM NON-HMO Glossary M Blu BlueSlueld ►.� of Illinois R 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 reporting period 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 Facility Inpatient claims International Classification of Diseases(ICD-9):An official list of categories of diseases,physical and mental,issued by the World Health Organization(WHO). 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 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 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. Not Covered:Amount considered not eligible for payment by the plan(excludes the discount amount) �P CITY OF CANTON:PREM NON-HMO Glossary B1uBlueSlueld � � of Illinois 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 Out of Pocket:Total amount that is the responsibility of the claimant.It is calculated as:(Copay+Deductible+Coinsurance) Outpatient Facility: Refers to Facility Outpatient 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/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 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 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 77 CITY OF CANTON:PREM NON-HMO Glossary Btu B1ueSlueld ►�� a of Illinoisinois R 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 Professional: Services provided by physicians or other professional providers 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. Rx Credit Fees: Drug rebates that are credited back to the account. Rx Paid PEPM:-Prescription drug.paid amount per employee per month Rx Paid PMPM: Prescription drug paid amount per member per month 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 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. Specific Stop Loss:A form of reinsurance that provides protection for medical expenses above a certain limit,generally on a year-by-year basis.Specific(or individual)stop loss limits the cost of eligible medical expenses for each covered individual. -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 and pharmacy dollars paid to cover healthcare services provided to members for claims that have been processed and approved for payment Workers Compensation Savings:Portion of amount eligible for payment that has been paid a third party Workers Compensation carrier 78 CITY OF CANTON:PREM NON-HMO ►.� aBtu noir B1ueSlrield of Illinois N Blue Insight - -- I Monthly Financial Report CITY OF CANTON: PREM NON-HMO F 400000 4 _• { ._ �' J 01/01/2016 to 12/31/2016 A Division of Health Care Service Corporation,a Mutual Legal Reserve Company(HCSC),an Independent Licensee of the Blue Cross and Blue Shield Association. 0 Copyright 2017 Health Care Service Corporation.All rights reserved. B1ueCross B1ueShield Table of Contents •.• e of Illinois R PLAN PERFORMANCE Data Parameters 3 Pharmacy Enrollment Overview 4 Financial Summary 15 Key Indicators 16 Financial Overview Financial Summary 6 Generic vs. Formulary Experience 17 Medical & Pharmacy Loss Ratio 7 Top Non-Specialty Therapeutic Drug Classes 18 Network Overview 8 Top Non-Specialty Prescription Drugs 19 Blue Card Savings Analysis 9 Specialty Drug Analysis 20 Dental Medical Claim Expense Distribution 10 High Cost Claimants 11 Dental Financial Summary 21 Dental Service Type Analysis 22 Medical Out of Pocket 12 Dental Loss Ratio 23 Lag Report 13 � Overall Medical Paid PMPM Leading Diagnostic Category 14 Appendix 24 Glossary 27 9 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Data Parameters •.• v of Illinois Current Period: The current reporting period represents claims paid from January 1, 2016 through December 31, 2016. Prior Period: The prior reporting period represents claims paid from January 1, 2015 through December 31, 2015. The report includes medical claims, pharmacy claims and dental claims. Reporting Segments: ALL Characteristics: ALL Group/Sections: ALL Reporting Support Contact Information For reporting support, please contact Client Reporting Service Center Email: client_reporting@bcbsil.com Phone: 1-877-837-1866 Hours of Operation: Monday- Friday: 8:00am - 5:00pm CT Report prepared on 01/10/2017 s_ CITY OF CANTON:PREM NON-HMO BlueCross B1ueSlueld Enrollment Overview of Illinois ti Report Description: Provides the current enrollment based on the current period. Medical Medical Pharmacy Pharmacy Dental Dental Month Subscribers Members Subscribers Members Subscribers Members 'Jan 2016 - 129 322 129 - --- .. 322— Feb 2016 129 321 129 321 War2016 129 320 129 320 Apr 2016 129 320 129 320 May 2016 130 321 130 321 131 322 Jun 2016 132 324 132 324 133 325 jJul2016 132 325. 132 325 133 326 Aug 2016 132 324 132 324 133 324 ;Sep 2016 133 323 133 323 134 323 i Oct 2016 133 323 133 323 134 323 Nov 2016 133 325 133 325 134 325 Dec 2016 132 324 132 324 133 324 Enrollment by Tier Enrollment by Gender Prior r .'. 20.2% 20.3% 48:9% prior 46.7% ' Current 19,9%• , I 39.9% 48.6% Current 46:6% Employee Only ® Employee+ogre r`1 Employee+Dep(s) ® Family _Male ® Female 4_ CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Enrollment Overview •.• ® ofBlinois a Report Description: Provided medical demographics for the current period compared to the prior period and percent change. Medical Demographics Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change • Overall, membership decreased by 2.1%between reporting periods iAverage Membership - - 330 323 - _ -- 2.1/ `Employee _ 131 131 The average age was 35.0 and increased by 1.4%between reporting us___ �_ periods. Spoe 73 71 -2.7% Contract size remained stable by 0.0%between reporting periods. Dependent 126 121 -4.0% --y--- ---- �� -� - - - -`-` ----------__-` - ------- ` ---"- - Females between the ages of 20 and 44 decreased from 15.8%to 15.2% Average Contract Size 2.5 2.5 between reporting periods. Average Age 34.5 35.0 1.4% Employee 47.7 48.1 0.8% Spouse 46.7 47.0 0.6% Average Medical Membership Dependent 13.7 13.7 0.6% Under 30 42.8% 41.4% -----__,_____ __._ ..---.___�.�_ Prior 22.1% 38.3% 30 to 49 27.9% 27.8% 50 to 64 29.3% 30.4% f%65+ 0.4% Gender. I - Proportion of Males 53.3%' 53.4% Current •'. 22:0% I 37.4% Proportion of Females 46.7% 46.6% Females Ages 20-44 x15.8% -_-`�-_15.2%' --I =Employee =Spouse = Dependent .5 CITY OF CANTON:PREM NON-HMO • i�� \�J of Illinois s B1ueShield Financial Overview: Financial Summary IV,R F Report Description:Provides a breakdown of the medical order of reduction from billed to paid for the current month,current period, prior period and a percent change. This report may highlight key measures and their potential impact on paid expenses. Medical Order of Reduction Breakdown of Billed Amount Paid Month Dec 2016 Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change 100% Billed $437,005 $2,964,597 $5,400,824 82.2% "___-. _ ____ _ _ . _ __ .__ _ __ _ ___. _. _ _ . _ __ -- 90% Not Covered $125,386 $277,411 $821,635 196.2% `Covered $311,619 $2,687,187 $4,579,190 70.4% 80% - ` .---- ------__-_,. _ Not Covered Discount $108,795 $1,124,353 $2,144,892 90.8% 70%- c pis ount Allowed $202,824 $1,562,834 $2,434,297 _ 55.8% ; 60% ; Out of Pocket Out of Pocket $10,780 $174,159 $183,621 5.4% - ® COB - - — - -- ---- - 50% f - iCOB $82 $23,732 $58,155 145.1% i ® COB Medicare COB Medicare $1,219 $18,755 $15,226 -18.8% 40% P j Other Reductions ;Other Reductions $1,250 $24,572 $21,272 -13.4% 30% ®Other Adjustments Other Adjustments ($25) $0 ($25) 0.0% 20% Paid Provider :Paid-Provider $189,517 $1,321,617 $2,156,048 63.1% __--- _...___________-_____,__-_---__._.__.._-_____._-__.____ ___.___.--_._ __-__. _----_ _ _—__-___ 10% Other Payments $179 $3,207 $1,915 -40.3% Medical Paid $189,697 $1,324,824 $2,157,963 62.9% 0% _-____. - __ . _-- __.._. -_- ____...____ .I _ _-_—__._..._..-__ _._ _-- -.__. _ ----- _____ Prior Current Group Liability Breakdown Paid Month Dec 2016 Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change ;Medical Paid $189,697 $1,324,824 $2,157,963 62.9% ' Pharmacy Paid $41,279 $377,719 $477;776 26.5% ;Capitation Paid. $0 $0 $0 0.0% ` Dental Paid $4,524 $0 $33,640 0.0% ;Total Paid Claims $235,499 $1,702,542 $2,669,379 56.8% Recoveries $0 $0 $0 0.0% 'Total Paid Claims+ Recoveries $235,499 $1,702,542 $2,669,379 56.8% L.___— .______-_ __.______.____._.--____A___ __--_ _ _---__-_--.__._- ------ Group Liability $235,499 $1,702,542 $2,669,379 56.8% Other reductions includes penalties, workers compensation savings,and subrogation savings. Other payments includes Blue Card access fees and surcharges.Also displayed are other adjustments. 6-- CITY OF CANTON:PREM NON-HMO ►.� Illinois s B1ueShield Financial Overview: Medical & PharmacyLoss Ratio R of Il Report Description: Provides the medical and pharmacy loss ratio and claims for the most recent reported twelve months. Month Premium Medical Paid Claims Pharmacy Paid Claims Total Paid Medical and Pharmacy loss Ratio Oct 2015 r.- - $167,724 -_---- $115,623 -, -^- $30,762 - _Y _ x$146,386 ----� - 87.33% - _-- Nov 2015 $168,309 $114,657 $34,502 $149,159 88.6% - - -- - - ------ -----__________- ----- - ---- __-_- -- ----- -_-- ------- ------- LDec 2015 - $170,255 $192,126 $41,039 $233,166 137.0% Jan 2016 $169,574 $122,704 $33,203 $155,907 91.9% Feb 2016 $169,574 $491,241 $38,658 $529,900 312.5% Mar 2016 $169,574 $195,652 $41,106 $236,757 139.6% (Apr 2016 $169,574 $158,242 $47,665 $205,907 121.4% May 2016 $180,919 $122,726 $36,296 $159,022 87.9% 11 2016 $183,095 $133,901 $37,993 $171,895 93.9% Jul 2016 --_-- $183,095--_--_-- $156,625 ----_--- $40,944-Y-_-_-w $197,569 107.9% _--- -- - Aug 2016 $184,422 $74,463 $46,340 -- - $120,803- _- 65.5% Sep 2016 -_ $181,358 $79,914 $54,089 $134,003 73.9% Summary $2,097,475 $1,957,874 $482,599 $2,440,473 116.4% Loss Ratio By Month 350%- 300%- 250%- 200%- 150%- 100%_ 50%300%25090 200%150%100% 50%- nF ' 111 ' 0% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2015 2015 2015 2016 2016 2016 2016 2016 2016 2016 2016 2016 Key Findings:The medical and pharmacy loss ratio for the most recent reported month was 42.5%lower than the average of the most recent reported twelve months,which was 116.4%. 7 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Financial Overview: Network Overview Q of Illinois ti Report Description: This report displays the discount amount,discount percent,paid amount and paid percent for medical claims split by Medicare/Non-Medicare;in/out of network and service category for the current period. Medicare Primary Indicator Network Indicator Service Category Covered Discount Discount% Paid %Of Paid iFacility Inpatient $1637,928 $977,054 59.7% $657,052 30.4/ j Facility Outpatient $1,388,115 $387,720 27.9% $860,299 39.9% In Network — _ j Professional $1,407,533 $754,999 53.6% $560,620 26.0% Summary $4,433,576 $2,119,773 47.8% $2,077,970 96.3% No I Facility Inpatient $35,019 $24,443 69.8% $8,221 0.4% Facility Outpatient $61,568 $51,187 2:4% Out of Network Professional $27,737 $676 2.4% $16,587 0.8% Summary $124,324 $25,119 20.2% $75,994 3.5% Summary $4,557,900 $2,144,892 47.1% $2,153,965 99.8% Facility Inpatient L Facility Outpatient $2,778 $117 In Network Professional $18,512 $3,882 0.2% Summary $21,290 $3,999 0.2% Yes Facility Inpatient Facility Outpatient Out of Network E Professional i Summary Summary $21,290 $3,999 0.2% Summary $4,579,190 $2,144,892 46.8% $2,157,963 100.0% Key Findings:The overall network savings discount(excluding Medicare)was 47.8%for the current period. The in-network paid percent was 96.5%for the current period. R CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Financial Overview: Blue Card Savings Analysis R0 of Illinois Report Description:The Blue Card Savings report illustrates the value of having access to other BCBS contracts within the United States through the Blue Card program. Savings from BCBS network discounts are passed to the client,providing savings on potentially costly out of state claims that would otherwise be paid at full provider billed amount. Jan 2016-Dec 2016 Par Plan State Billed Allowed Effective Discount Paid Effective Blue Card Allowed Rate Paid Rate Access Fee St. Louis MO $243,279 $126,565 52.0% $38,015 $121,053 49.8% $1,767 i DC $6,590 $4,416 67.0% $2,174 $3,757 57.0% $101 M N $9,329 $8,396 90.0% $933 $8,161 87.5% $0 Kansas City MO $2,273 $1,484 65.3% $790 $1,371 60.3% $37 IA $44,964 $8,335 18.5% $229 $5,224 11.6% $11 WA,AK $634 $632 99.6% $2 $537 84.7% - 'TX $898 $92 10.2% $0 $0 0.0% $0 FL $1,290 $484 37.6% $0 $334 25.9% $0 All Other Non-Blue Card $5,091,568 $2,283,893 44.9% _. $2,102,751 ;$2,017,526 39.6% $0 Summary $5,460,824 $2,434,297 45.1% $2,144,892 $2,157,963 40.0% $1,915 Key Findings:St.Louis MO had the greatest Blue Card savings amount,with a Discount amount of$38,015. The overall Effective Allowed Rate for the current period was 45.1%. 9 _ CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Financial Overview: Medical Claim Expense Distribution RD. of Illinois Report Description:The distribution of medical paid expense by claimant and the average medical paid per claimant amount are shown for the current period. Paid Band Claimants Claimants 9 Paid Paid 9 Paid/Claimant !Less than$200 78 25.5% $6,684 0.3% $200-$1,000 91 29.7% $45,644 2.19 $502 '$1,001-$5,000 74 24.2% $180,744 8.4% $2,442 $5,001-$10,000 28 9.29 $178,049 8.39 $6,359 ;$10,001-$30,000 22 7.29 $346,583 16.1% $15,754 $30,001-$50,000 5 1.69 $216,943 10.1%, $43,389 Summary<=$50,000 298 97.4% $974,645 45.2% $3,271 Paid Band Claimants Claimants 9 Paid Paid 9 Paid/Claimant " '$50,001-$75,000 4 1.39 $277,311 12.9% $69,328 $75,001-$100,000 $100,001-$150,000 2 0.79 $234,547 10.9% $117,274 $150,001-$200,000 1 0.39 $195,992 9.19 $195,992 1i$200,001 $250,00.0- $250,001- 250,00.0.$250,001-$500,000 1 0.39 $475,468 22.0% $475,468 $500,001+ j Summary$50,001 or Greater 8 2.69 $1,183,318 54.8% $147,915 Combined Summary 306 100.0% $2,157,963 100.0% $7,052 Key Findings:The proportion of claimants who received less than$200 in services for the current period was 25.59. These claimants spent 0.3%of the total paid expenses and the average paid expense per claimant was $86. 2.69 of claimants had expenses over$50,001 for the current period. These claimants spent 54.89 of the total paid expenses and the average paid expense per claimant was$147,915. 10 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Financial Overview: High Cost Claimants ofIIIinois R Report Description:This report provides a detailed listing of the top 20 high cost claimants with paid expenses of$50,000 or more for the current period. Jan 2016-Dec 2016 Age/Gender Inpatient Outpatient Professional Pharmacy Encrypted Member ID Relationship Band Leading Diagnostic Category Paid Paid Paid Paid Paid :6603063368255969790 Subscriber Male 40-49 Circulatory $334,499 $83,206 $57,763 $25,748 $501,216 5692798823633840187 Subscriber Male 60-64 Infectious/Parasitic $156,496 $17,069 $22,427 $1,592 $197,584 2138421671687468013 Subscriber Male 60-64 Endocrine $0 $16,310 $111,476 $8,148 $135,934 7333919212594852393 Spouse Female 50-59 $0 $2,659 $1,401 $121,890 $125,950 .332544881311853446 Subscriber Male 50-59 Injury/Poisoning $70,838 $15,236 $20,688 $2,500 $109,262 : 5334038076887966955 Spouse Female 20-29 Digestive $0 $63,560 $10,252 $16,100 $89,912 ,4424339353326140231 Spouse Male 30-39 Injury/Poisoning $0 $66,498 $6,340 $22 $72,860 1308153503870556903 Dependent Female 20-29 Pregnancy $14,138 $41,833 $11,610 $1,093 $68,674 2047582681437452388 Subscriber Male 60-64 Digestive $0 $46,597 $16,482 $914 $63,993 5525204414130289680 Dependent Female<1-19 Injury/Poisoning $22,880 $18,117 $6,831 $15,776 $63,604 9160460151111966325 Subscriber Male 40-49 Musculoskeletal $0 $41,712 $8,151 $1,048 $50,911 High Cost Claimant Total $598,851 $412,797 $273,421 $194,831 $1,479,900 11 CITY OF CANTON:PREM NON-HMO P_i B1ueCross B1ueShield Financial Overview: Medical Out of Pocket 41. IV, of Illinois Report Description: Provides a distribution of claimants by their total medical out of pocket expenses for the current period compared to the prior period and percent change. This report helps determine the impact of any changes in plan design on out of pocket. Claimant Distribution by Out of Pocket Expense Bands Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change Out of Pocket Band Claimants Claimants% Out of Pocket Out of Pocket% Claimants Claimants% Out of Pocket Out of Pocket% Claimants Change Out of Pocket Change Less than$100 107 33.6% $3,141 1.8% 95 31.0% $3,715 2.0% -11.2% 18.3% $101-$200 30 9.4% $4,587 2.6% 28 9.2% $4,188 2.3% -6.7% -8.7% `$201-$300 19 6.0% $4,662 2.7% 19 6.2% $4,913 2.7% 0.0% 5.4% $301-$400 16 5.0% $5,682 3.3% 13 4.2% $4,613 2.5% -18.8% -18.8% ;$401-$500 7 2.2% $3,148 1.8% 8 2.6% $3,659 2.0% 14.3% 16.3% $501-$750 47 14.8% $28,716 16.5% 40 13.1% $24,679 13.4% -14.9% -14.1% - - --- -- $751- $751-$1,000 31 9.7% $26,962 15.5% 32 10.5% $26,744 14.6% 3.2% -0.8% $1,001-$1,500 26 8.2% $31,532 18.1% 37 12.1% $44,513 24.2% 42.3% 41.2% '$1,501-$2,000 25 7.9% $42,842 24.6% 22 7.2% $37,272 20.3% -12.0% -13.0% $2,001-$2,500 8 2.5% $17,148 9.8% 7 2.3% $15,495 8.4% -12.5% -9.6% ;$2,501`$3,000 - - 1._ 0.3% $2,551 1.5% - 5 - - - 1.6% - $13,830 7.5% 400.0% - -442.2% - $3,001-$4,000 1 0.3% $3,189 1.8% 0.0% 0.0% $4,001-$5,000 0.0% 0.0% $Greater than$5,001 0.0% 0.0% Summary 318 100% $174,159 100% 306 100% $183,621 100% -3.8% 5.4% - Out'of Pocket Expens6 by-Coverage Tier Jan 2016-Dec 2016 Coverage Tier Allowed Deductible Deductible%of Allowed Copayment Copay%of Allowed Coinsurance Coins%of Allowed Out of Pocket OPX%of Allowed Paid Employee Only $825,175 $9,961 1.2% $5,503 0.7% $10,084 1.2% $25,548 3.1% $797,538 Employee+One $756,804 $21,264 2.8% $11,349 1.5% $20,359 2.7% ° $52,972 7.0/ $629,059 Lmployee+Dependent(s) _$216,441 --$15,261- -- 7.1% $8,670 4.0% $5,490 2.5% $29 422 13.6% $180,152 -------- --- - - ------- --- - --- --- -- -- --- - -- ------ Family ----Family $635,877 $36,525 5.7% $20,360 3.2% $18,793 3.0% $75,678 11.9% $551,214 Summary $2,434,297 $83,012 3.4% $45,882 1.9% $54,727 2.2% $183,621 7.5% $2,157,963 This 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. This report is based on claim data and may not reflect client specific benefits being applied to member out of pocket. Please contact your Account Executive for ACCUIVIS reporting. 12 CITY OF CANTON:PREM NON-HMO B1ueCross BlueShield ► Financial Overview: Lag Report of Illinois� 0 Report Description: Displays,by paid month,the medical dollars paid and the corresponding month incurred for a 12 month rolling paid period(if available for your account). This report provides insight into the monthly claim lag and can help identify IBNR. Incurred Paid Month Month Jan 2016 Feb 2016 Mar 2016 Apr 2016 May 2016 Jun 2016 Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Summary All Prior ($430) ($242) $65 ($587) ($1,194) Jan 2015 $0 Feb 2015 ($238) $150 ($88) j Mar 2015 $0 ;Apr 2015 ($18) ($18) i May 2015 ($68) $30 $30 ($8) 'Jun 2015 $107 $5 $112 Jul 2015 $132 $56 $188 Aug 2015 $824 ($26) $28 $826 Sep 2015 ($455) $452 $35 $112 $542 $686 ,Oct 2015 $645 $1,879 $281 $335 ($5) $56 ($104) $3,088 i Nov 2015 $3,449 $835 $488 $15 ($47) $4,740 Dec 2015 $37,751 $3,625 ($83,420) $516 $29 $406 $131 ($24) ($40,985) i Jan 2016 $22,677 $91,069 $189,784 $1,876 $660 $1,488 $120 $158 $307,832 Feb 2016-- $79,794 $78,476 $328,666 $53 $144 $307 $54 $487,496 Mar 2016 $78,011 $109,537 $4,660 $3,989 $216 $63 $7 ($147) $35 $196,370 'Apr 2016 - --- _ $47,020 $105,662 $2,688 $1,233 $110 $11 $441 $157,164 May 2016 $73,712 $46,950 $1,099 $59 $4,117 $125,937 Jdn-4016 •$85,843- $39,372' $5,592 $117 $234. $86' "•$817 $131,731 -- ---- ---- - 1u12016 - - $73,578 .$80,233 $2,374 . $608 $585- $157,378 Aug 2016 $51,329 $18,663 $3,161 $496 $3,987 $77;635 Sep 2016 $39,384 $29,948 $4,558 $1,714 $75,604 Oct 2016 $51,108 $114,252 $10,964 $176,324 Nov 2016 $124,683 $46,079 $170,761 Dec 2016 $126,382 $126,382 Summary $64,614 $177,202 $263,859 $487,950 $184,890 $141,451 $115,926 $137,545 $65,497 $84,911 $244,420 $189,697 $2,157,963 13 CITY OF CANTON:PREM NON-HMO B1ueCross BlueShield Financial Overview: Overall Medical Paid PMPM by Leading Diagnostic Category 41. IV of Illinois Report Description:Lists the top 15 overall paid expense across inpatient facility,outpatient facility,and professional settings by leading diagnostic categories for the current month,current period,prior period and percent change. Paid Period Dec 2016 Jan 2015- Jan 2016- %Change Medical PMPM by Leading Diagnostic Category Dec 2015 Dec 2016 Leading Diagnostic Category Paid PMPM Paid PMPM Paid PMPM Paid PMPM Digestive $105 $32 $47 46.9% i Musculoskeletal $87 $39 $53 35.9% Injury/Poisoning $79 $41--- $73- `- 78.0% Endocrine $72 $64 $41 -35.9% ;Symptoms/III-Defined $70 $31 $60 93.5% Pregnancy - $62 $1_ $19 -'- -- 1,800.0% I I !Respiratory $30 $10 $19 90.0% I i Circulatory $21 $25 $115 360.0% - 66 1 Nervous System $18 $15 $25 66.7% ! Mental Health $6 $6--_---$7 ----- 16.7% Residual/Unclassified $6 $6 $5 -16.7% --------------- - ---- —--- -- ------ - —_- - - -— - - - ` Genitourinary -- --- - - - --- -$3 — --520 - $22- T10.0% Infectious/Parasitic $7 •$38 442.9% (Neoplasms $2 -- -�$22 713 ----_--40.9% All Other Values $1 $15 $19 26.7% Summary $585 $335 $557 66.3% 0 $20 $40 $60 $80 $100 $120 Cj Jan 2015-Dec 2015 =Jan 2016-Dec 2016 Key Findings:The top three Leading Diagnostic Categories in the current reporting month based on Paid PMPM were Digestive,Musculoskeletal,and Injury/Poisoning. 14 CITY OF CANTON:PREM NON-HMO BlueCros • 41' � of Illinois s 131ueShield Pharmacy. Financial Summary Report Description: This report provides an overview of pharmacy order of reduction from billed to paid for the current month,current period,prior period,and percent change. Pharmacy Order of Reduction Dec 2016 Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change LBilled-- -- $95,432 $824,768 $1,019,325 23.6% i Not Covered $0 $0 $0 0.0% iCovered $95,432 $824,768 $1,019,325 23.6% Breakdown o Bi a Amount Discount $49,357 $385,133 $489,686 27.2% 100% - - -- -- -- -- __$4_3__9_,6__36____ ---- -$- - 5--29,-639— - -2 20_.5/o- Allowed - . $46,075 Out of Pocket $4,841 $62,202 $52,088 16.3/° 90% _. $0 --- — -- $0 __- - -----$° - --0.0% 1 s0% - -A - COB Medicare $0 $0 $0 0.0% Other Reductions $0 — $0 $0 __0__-0-% ! 70% Other Adjustments ($45) ($285) ($225) 21.1% r------------------------------ -------- - ----- -------------------- ------------_...___.._ � Paid-Provider $41,279 $377,719 $477,776 26.5% 6096 - -- -- L. ---- -------.------- --- -- . M Not Covered Other Payments $0 $0 $0 0.0% _ - - Discount Taid -_--— —- `$41,279 - --- $377,719'— '- $477,776`- 26_5% --- 50gO i Out of Pocket 40% COB COB Medicare Total Pharmacy Paid vs.Specialty Paid Other Reductions 30%- other Adjustments Prior =Current � Paid Provider 20 �_... $500,000 10% $40,000 -- -- -' = $300,000 - - 0% Prior Current $200,000 $100,000 $0 ! Total Paid Specialty Paid Prior $377,719 $78,233 Current _ $477,776 - — $141,719 5 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Key Indicators •.• a of Illinois Report Description:This report provides an overview of the prescription expenses as well as providing percent change in these expenses between the current month,current period,prior period and percent change. Key Indicators Summary Key Indicators Summary Dec 2016 Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change Unique Pharmacy Members 324 357 339 -5.0% ' Average Age(Years) 35.0 34.5 35.0 1.5% 'Proportion of Males 53.7% - 53.3% ------ 53.4% - -- - - 0.2% - - Proportion of Females 46.3% 46.7% 46.6% -0.2% Member Months 324 3,954 3,872 -2.1% Claimants 159 257 255 -0.8% ;Services 496 4,839 4,946 2.2% Prescriptions PMPM 1.53 1.22 1.28 4.4% i Paid $41,279 $377,719 $477,776 26.5% Paid PMPM $127.40 $95.53 $123.39 29.2% ;Allowed $46,075 $439,6B6 $529,639 20.5% Allowed PMPM $142.21 $111.19 $136.79 23.0% ,Avg.Ingredient Cost/Prescription $91.94 $89.63 $106.15 18.4% Generic Dispensing Rate 84.7% 81.9% 83.9% 2.4% Formulary Compliance Rate 93.4% 91.6% 92.7% 1.2% Generic Substitution Rate 100.0% 100.0% 99.7% -0.2% Out of Pocket Percent of Allowed 10.5% 14.2% - 9.8% Retail as a Percent of Prescriptions 97.8% 96.0% 96.4% 0.4% (Mail Order as a Percent of Prescriptions 2.2% 4.0% 3.6% -9.3% Specialty Percent of Total Prescriptions 0.2% 0.1% 0.4% 200.0% ;Specialty Percent of Total Paid 25.1% 20.7% 29.7% 43.2% Specialty Average Ingredient __.. . - - - Cost/Prescription $10,355.22 :$14,214.14 $7,87.9.30 -44.6% - Cost Sharing Distribution Dec 2016 Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change Cost Sharing Distribution Retail Mail Retail Mail Retail Mail Retail Mail ;Member Out of Pocket 10.3% 16.1% 14.5% 11.2% 9.8% 10.2% -32.3% -9.1% Plan Paid 89.7% 84.0% 85.5% 88.8% 90.2% 89.8% 5.5% 1.2% Savings Summary Dec 2016 Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change Savings Summary Retail Mail Summary Retail Mail Summary Retail Mail Summary Retail Mail Summary jDiscount - $45,714 -$3,643 $49,357 $329,381 - $55,751 - $385,133 $431,720 -$57,965 $489,68_6 31.1% _4.0% /0_ 27.2 1 0 0 0 MAC Savings $13,860 $0 $13,860 $301,306 $38,777 $340,084 $301,451 $28,687 $330,138 _-0.1% - -26.0% -- -2.9% - 1% Discount 50.5% 73.7% 51.7% 45.5% 55.3% 46.7% 47.0% 57.0% 48.0% 3.4% 3.2% 2.9%-------------- i 1F CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Generic vs. Formulary Experience •.• a of Illinois R 5 Report Description: For the current period,the prescription drug expenses are displayed below for retail and mail order providers and broken out by drug type and formulary indicator. Total Expense Member Expense Plan Expense %of Total Allowed/ Out of Pocket/ Paid/ Retail Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription 'Generic 4,018 84% $110,165 $27.42 $27,746 $6.91 $82,419 $20.51 Brand 749 16% $375,792 $501.72 $19,880 $26.54 $356,137 $475.48 Summary 4,767 100% $485,956 $101.94 $47,626 $9.99 $438,556 $92.00 Brand Type Breakdown Single-Source Brand 675 - - 14% $334,522 $495.59 $17,606 $26.0_8 $317,141 $469.84_ Multi-Source Brand 74 2% $41,270 $557.70 - $2,274 $30.73- --- -- $38,996-- - -- $526.97 ---- ---------- ----------- - -- -- -- ---- -- - - Multi-Source Brand w/DAW1 35 - -- 1%-- $30,417 $869.06 --- $1,182 --^ $33.78 -$29,235 _- $835.28 ;Brand Formulary 416 9% $159,359 $383.07 $9,931 $23.87 $149,428 $359.20 I Brand Non-Formulary 333 7% $216,433 $649.95 $9,949 $29.88 $206,709 $620.75 Total Expense Member Expense Plan Expense %of Total Allowed/ Out of Pocket/ Paid/ Mail Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription Generic 133 74% $9,830 -- -$73.91 $1,908 $14.35 $7,922 $59.57 i Brand 46 26% $33,852 $735.92 $2,554 $55.53 $31,298 $680.39 Summary 179 100% $43,683 $244.04 $4,462 $24.93 $39,220 $219.11 iSingle_Source Brand -- -- -A -- 38 - 21%- $30,033--- $790.34 $2,060 $54.21 $27,973 $736.13 i Multi-Source Brand 8 4% $3,820 $477.45 $494 $61.81 $3,325 $415.64 Multi-Source Brand w/DAW1 _ _._-_4 2 $3,605 $901.29 $280 $70.00 $3,325 $831.29 �- - -- ---- - - -- - -- - ------•---- - -- ---- ---- - --- - -- - - - - - - - - - Brand Formulary 20 11% $18,033 $901.67 $800 $40.00 $17,233 $861.67 i Brand Non-Formulary 26 15% $15,819 $608.42 $1,754 $67.48 $14,065 $540.94 Total Expense Member Expense Plan Expense %of Total Allowed/ Out of Pocket/ Paid/ Total Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription (Generic 4,151 84% $119,995 $28.91 $29,654 $7.14 $90,341 '$21.76 I Brand 795 16% $409,644 $515.28 $22,434 $28.22 $387,435 $487.34 Summary 4,946 100% $529,639 $107.08 $52,088 $10.53 $477,776 $96.60 Brand Type Breakdown Single-Source Brand -- - -- - 713 - - 14% ,-- ---$364,554_ `- -$511.30 19,666 -- `_$27.58 _ _ _ ___ -_ - _-_ $ -- _ _- $345,114 _ 484.03 _- ! Multi-Source Brand 82 2% $45,090 $549.87 $2,769 $33.76 $42,321 - $516.11 _ 'Multi-Source Brand w/DAW1 -- 39 I% $34,022 -- - - - - - - ---- - -$834.87--- -- _-_ .- - -- -- _ $872.37. _ --- -51,462 - - - -- $37.50--- -- $32,560- -- . - ----------- ------- -------------___..------------- -__j 'Brand Formula 436 9% $406.86- ------------------- ------------_._.- -------------- -------------, _ -ry__ ----- _.__ •_ _----._ - _.-_.___.___-_------.--_---5177,392 --- --- - $10,731 $24.61 _$166,662 $382.25 ---' Brand Non-Formulary 359 7% $232,252 $646.94 $11,704 $32.60 $220,773 $614.97 17 CITY OF CANTON:PREM NON-HMO •10 r_---iB1ueCross B1ueShield Pharmacy: Top Non-Specialty Therapeutic ®rug Classes • of Illinois f Report Description: The top 25 therapeutic drug classes for the current period are displayed below ranked by ingredient cost. Avg.Ingredient Avg.Ingredient Current/ t Cost/ cost/ Prior Utilizing Prescription Prescription % % Rank by Rank Plan Therapeutic Class Prescriptions Members Ingredient Cost (Current) (Prior) Formulary Generic Volume 1 1 Insulin 133 11 $78,569 $590.75 $501.32 95.5% 0.0% 9 2 2 Anti myasthenic/CholinergicAgents 11 1 $28,980 $2,634.51 $2,356.58 0.0% 0.0% 83 3 CMV Agents 9 1 $20,713 $2,301.48 $0 100.0% 100.0% 101 4 3 Sympathomimetics 72 27 $15,474 $214.92 $205.28 95.8% 23.6% 21 5 Hemostatics-Systemic 6 2 $10,643 $1,773.90 $0 50.0% 50.0% 121 6 5 HMG CoA Reductase Inhibitors 280 40 $9,770 $34.89 $42.70 98.6% 95.7% 1 7 12 Prostaglandin-Impotence Agents 34 7 $9,501 $279.43 $237.57 38.2% 0.0% 37 8 19 Direct FactorXa Inhibitors 19 4 $9,326 $490.85 $331.75 100.0% 0.0% 60 9 15 Stimulants-Misc. 58 7 $8,042 $138.66 $101.36 86.2% 86.2% 25 10 9 Antihypertensive Combinations 145 19 $7,058 $48.68 $51.97 100.0% 84.8% 6 - -- - - - --- --- - - -- _. ----- --..-.. -- -- - - -- - - - - - - - - - -- - _ - --- -- ---- - --- -- -- -- _ 11 8 Diagnostic Tests 46 10 $6,684 $145.31 $174.28 82.6% 0.0% 29 12 4 Quinolinone Derivatives 23 2 $6,542 $284.42 $825.18 100.0% 100.0% 51 13 7 Anticonvulsants-Misc. 107 12 $5,408 $50.55 $96.66 100.0% 88.8% 12 , 14 10 Proton Pump Inhibitors 201 30 $4,700 $23.38 $37.55 95.0% 95.0% 3 15 Amphetamines 29 7 $4,694 $161.87 $211.34 100.0% 58.6% 42 16 Corticosteroids-Topical 40 23 $4,585 $114.63 $133.06 90.0% 90.0% 33 17 6 Dipeptidyl Peptidase-4(DPP-4)Inhibitors 5 2 $4,571 $914.25 $434.53 100.0% 0.0% 125 18 13 Estrogens 43 7 $4,566 $106.20 $81.31 32.6% 32.6% 32 19 Immunosuppressive Agents 28 1 $4,443 $158.67 $0 100.0% 100.0% 43 20 25 Attention-Deficit/Hyperactivity Disorder(ADHD)Agents 11 1 $4,371 $397.38 $330.38 0.0% 0.0% 84 21 11 Thrombin Inhibitors 10 - 2- $4,104 $410.38 $499.60 0.0% 0.0% 9 22 23 Phenothiazines 12 1 $4,089 $340.76 $257.46 100.0% 100.0% 80 23 16 Antidiabetic Combinations 11 1 $4,069 $369.91 $336.12 100.0% 0.0% 82 24 Irritable Bowel Syndrome(IBS)Agents 7 2 $4,066 $580.88 $313.68 100.0% 0.0% 115 25 Thyroid Hormones 189 23 $3,846 $2035 $15:09 78.3% 78.3% 4 All Other 3,399 246 $114,365 $33.65 $35.66 94.7% 91.7% Summary 4,928 255 $383,181 $77.76 $72.09 92.9% 84.2% 18 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Top Non-Specialty Prescription Drugs ® oflllinois Report Description: The top 25 prescription drugs for the current period are displayed below ranked by ingredient cost. Avg.Ingredient Avg.ingredient Current/ Cost/ Cost/ Prior Utilizing Ingredient Prescription Prescription Formulary Generic Rank by Rank Brand Name Plan Therapeutic Class Prescriptions Members Cost (Current) (Prior) Indicator Indicator Volume 1 1 MESTINON TAB 60MG Antimyasthenic/Cholinergic Agents 11 1 $28,980 $2,634.51 $2,356.58 NO NO 121 2 2 NOVOLOG INJ 100/ML Insulin 16 3 $21,045 $1,315.28 $920.10 YES NO 55 3 VALGANCICLOV TAB 450MG CMV Agents 9 1 $20,713 $2,301.48 YES YES 201 4 3 NOVOLOG MIX INJ 70/30 Insulin 11 1 $14,240 $1,294.58 $1,163.02 YES NO 119 5 4 LANTUS INJ SOLOSTAR Insulin 33 4 $12,964 $392.85 $383.54 YES NO 11 I ----- --- -- --------- ------- ------ --- --- 6 14 NOVOLOG INJ FLEXPEN Insulin 20 4 $10,696 $534.82 $429.33 YES NO 37 7 5 LANTUS INJ 100/ML Insulin 29 4 $7,344 $253.25 $256.49 YES NO 15 8 17 XARELTO TAB 20MG Direct Factor Xa Inhibitors 15 4 $6,591 $439.41 $331.75 YES NO 64 9 7 LEVEMIR INJ Insulin 11 2 $6,025 $547.72 $529.20 YES NO 120 10 AMINOCAPR AC TAB 1000MG Hemostatics-Systemic 2 1 $5,370 $2,685.23 NO NO 572 11 13 BENICAR HCT TAB 40-12.5 Antihypertensive Combinations 22 2 $5,172 $235.08 $197.12 YES NO 32 12 AMICAR SOL 0.25/ML Hemostatics-Systemic 1 1 $4,942 $4,941.90 NO NO 789 13 21 STRA17ERA CAP 40MG Attention-Deficit/Hyperactivity Disorder( 11 1 $4,371 $397.38 $330.38 NO NO 114 - -- - - -- - -- --- - -._._. _.. - - - _ - --- - -- - -- - -- ------ 14 26 VIAGRA TAB 100MG Prostaglandin-Impotence Agents 15 4 $4,266 $284.37 $244.36 NO NO 61 15 76 LYRICA CAP 300MG Anticonvulsants-Misc. 12 1 $4,215 $351.27 $325.36 YES NO 95 16 12 JANUVIA TAB 100MG Dipeptidyl Peptidase-4(DPP-4)Inhibitors 4 1 $4,201 $1,050.33 $691.11 YES NO 333 i 17 6 PRADAXA CAP 150MG Thrombin Inhibitors 10 2 $4,104 $410.38 $499.60 NO NO 154 18 37 CHLORPROMAZ TAB 100MG Phenothiazines 12 1 $4,089 $340.76 $219.23 YES YES 101 19 16 KOMBIGLYZE TAB 2.5-1000 Antidiabetic Combinations 11 1 $4,069 $369.91 $336.12 YES NO 122 20 9 ARIPIPRAZOLE TAB 5MG Quinolinone Derivatives 12 1 $4,040 $336.70 $782.47 YES YES 104 21 19 SPIRIVA CAP HANDIHLR Bronchodilators-Anticholinergics 11 1 $3,769 $342.61 $317.95 YES NO 129 22 80 LINZESS CAP 290MCG Irritable Bowel Syndrome(IBS)Agents 6 1 $3,738 $622.92 $313.68 YES NO 263 23 15 COMBIVENT AER RESPIMAT Sympathomimetics 4 1 $3,624 $906.07 $834.49 YES NO 356 24 49 LIPITOR TAB 40MG HMG CoA Reductase Inhibitors 4 1 $3,605 $901.29 $795.59 NO NO 336 -- -- ---- --- 25 23 ADVAIR DISKU AER 500/50 Sympathomimetics 8 1 $3,585 $448.07 $408.04 YES NO 210 All Other 4,628 255 $187,423 $40.50 $45.13 Summary 4,928 255 $383,181 $77.76 $72.09 1A CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Specialty Drug Analysis •.• v oP111inois R S 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.This report provides specialty drug analysis for the current month,current period,prior period and percent change. Specialty Drug Ivey Indicators - Top Specialty Classes by Ingredient Cost for the Current Period Dec 2016 Ian 2015-Dec 2015 Jan 2016-Dec 2016 %Change Unique Pharmacy Members 324 357 339 -5.0% Member Months - - 324 3,954 3,872 -2.1% 1.7%--- -- ;Claimants 1 3 3 0.0% 12.4%- _-------- --- - - --- ----- - - -- ------ ------ - - Percent of Utilizing Members 0.3% 0.8% 0.9% 5.3% Services16_ 18..-_____-- 200.0% ' _ Specialty Percent of Total Paid 25.1% 20.7% - 29.7% 43.2% F'J ® CANCER-ORAL Percent of Total Prescriptions Paid 0.2% 0.1% 0.4% 193.5% Paid $10,356 _ $78,233- - $141,719 81.2% " s x l AUTOIMMUNE Paid PMPM $31.96 $19.79--- -� - $36.60 _-85.0% Average Ingredient Cost/Prescription $10,355 - -$14,214 - $7,879 - - -44.6% -- ,�," .- �•`- HEMOPHILIA , Out of Pocket $7,059 $120 -98.3% "r' t" k, x 4 Out of Pocket PMPM $1.79 $0.03 -98.3% !Out of Pocket Percent of Allowed 0.0% - 8.3%Y 0.1% -99.0%�E - -- - - ----- -------__- -- -- --- --85.9% Top 15 Specialty Drugs by Ingredient Cost for the Current Period Avg.Ingredient Ingredient cost/ Specialty Top Specialty Classes by Ingredient Cost for the Prior Period Brand Name Specialty Class Cost Prescriptions Prescription Claimants IMBRUVICACAP 140MGCANCER-ORAL STELARA [NJ 45MG/0.5 AUTOIMMUNE $17,607 2 $8,803.37 1 HUMATE-P_ SOL500-1200:-___-___HEMOPHILIA _$1,639 2 - ---- $819.69 HUMATE-P SOL250-600 HEMOPHILIA '$820. - 2- $409.84 1 Summary $141,827 18 $7,879.30 3 28.2% J37.5% HEPATITIS C . f I 1771 CANCER-ORAL I - AUTOIMMUNE 34.4%-- -- �n CITY OF CANTON:PREM NON-HMO y �� B1ueCross B1ueSlueld Dental Financial Summar ► of Illinois Report Description:This report provides an overview of dental expenses from billed to paid for the current month,current period,prior period and percent change. Dental Order of Reduction Dec 2016 Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change I Billed $11,445 $78,402 0.0% Not covered $190 $3,423 0.0% Breakdown of Billed Amount ;Covered $11,255 $74,979 0.0% ' 100% - Discount $3,186 $19,925 0.0% 90% - ,Allowed $8,069 $55,054 0.0% 80/ Out of Pocket $3,326 $20,028 0.0% 70 COB $218 $1,075 0.0% COB Medicare $0 $0 0.0% 60%- Not 0% Not Covered !Other Reductions $0 $0 0.0% 50%- -Discount Other Adjustments $0 $311 0.0% Out of Pocket :Paid-Provider $4,524 $33,640 0.0% COB 30% ® COB Medicare Other Payments $0 $0 0.0% Other Reductions 'Paid $4,524 $33,640 0.0% i 20%- ----- ---- 0%_______._ Other Adjustments 10% � Paid Provider— In-Network Expense 0% Dec 2016 Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change Current - Covered $11,255 $74,979 Discount $3,186 $19,925 Discount% 28.3% 26.6% i 71 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield ®ental: Service Type Analysis • • e ofIWnois ti t Report Description: Overall expense and utilization are displayed for the top 10 dental service types by paid PMPM for the current month,current period,prior period and percent change. Dental Service Type Analysis-Services Dec 2016 Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change Service Type Services/1000 Paid/Service Services/1000 Paid/Service Services/1000 Paid/Service Services/1000 Paid/Service RESTORATIVE 222.2 $217 203.7 $168 DIAGNOSTIC 740.7 $58 763.9 $55 (ENDODONTICS 74.1 $387 23.1 $363 PREVENTIVE 518.5 $54 694.4 $55 ORTHODONTICS 259.3 $77 134.3 $91 ADJUNCTIVE GENERAL SERVICES 0.0 $0 4.6 $157 IAII Other 64.8 $788 Summary 1,333.3 $126 1,203.7 $129 Dental Service Type Analysis-Paid Dec 2016 Jan 2015-Dec 2015 Jan 2016-Dec 2016 %Change Service Type Paid Paid PMPM Paid Paid PMPM Paid Paid PMPM Paid Paid PMPM RESTORATIVE $1,301 $4.01 $7,378 $2.85 DIAGNOSTIC $1,162 $3.59 $9,082 $3.50 LENDODONTICS $774 $2.39 $1,816 $0.70 — PREVENTIVE $753 $2.32 $8,299 $3.20 !ORTHODONTICS $536 $1.65 $2,634. $1.02 ADJUNCTIVE GENERAL SERVICES $0 $0.00 $157 $0.06 t � [AllOther "---$3,497-----_- $1.35 -----.—__.— —_M.T-._--- Summary $4,524 $13.96 $33,640 $12.98 - 77 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Dental: Loss Ratio •.• of Illinois N R Report Description: Provides the dental loss ratio and claims for the most recent reported twelve months. Month Premium Dental Paid Claims Dental Loss Ratio LOct 2015 I Nov 2015 Dec 2015 - Jan 2016 - !Feb 2016 Mar2016 — ----__— _——_� .—__------,--- ----._-____—_..-- Apr 2016 } May 2016 $7,561 $3,635 48.1% !Jun 2016 ----- ,$7,640--- --.--_.------- $4,436 58.1% Jul 2016 $7,640 $6,021 -- '-- -- _ 78.8%------ -!Aug 2016 2016 $7,702 $4,504 58.5% Sep 2016 $7,556 $4,094 54.2% Summary $38,100 $22,689 59.6% Loss Ratio By Month 80% - - - 60%- 40%- 20%- 0% 0%40%20%0% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2015 2015 2015 2016 2016 2016 2016 2016 2016 2016 2016 2016 Key Findings:The dental loss ratio for the most recent reported month was 5.4%lower than the average of the most recent reported twelve months,which was 59.6%. CITY OF CANTON:PREM NON-HMO BlueCross S1ueShield Appendix: ICD Category Definitions ® of Illinois ti Complications of Pregnancy,Childbirth and the Puerperium: Includes vaginal and cesarean deliveries and complications of pregnancy,such as ectopic and molar pregnancies. Puerperium refers to 42 days following childbirth and expulsion of the placenta. Refers to the mother only. Conditions Influencing Health Status:This includes post-surgical states,organ/tissue transplants,artificial limbs and replacements.Examples include knee replacements and kidney transplant status. Conditions in the Perinatal Period: Perinatal refers to the period beginning after the 28th week of gestation and ending 28 days after birth. Problems can include hemorrhage, digestive disorders, respiratory distress syndrome and disorders relating to short gestation and unspecified low birth weight. Congenital Anomalies: Includes the treatment of any condition present at birth.This includes Spina Bifida,cleft palate,Down's Syndrome,heart disease,kidney displacement &polycystic kidney disease. Diseases of the Blood and Blood Forming Organs: Includes any problems associated with white or red blood cells,platelets or plasma.An example includes Anemia,a deficiency in red blood cells. Diseases of the Circulatory System:Includes problems with the heart,blood vessels and circulation.Some common diagnoses include Coronary Artery Disease,cardiovascular disease,and stroke. Diseases of the Digestive System: Includes the treatment of any organ or area of the body pertaining to digestion.These areas include the mouth/teeth,esophagus,stomach, intestines,gall bladder,liver and pancreas.Diagnoses include:Esophageal Reflux,Gastroenteritis,Appendicitis and hernias. Diseases of the.Genitourinary System: Includes problems related to the kidneys,bladder and male and female genitalia.Common diagnoses include Hematuria, Urinary Tract Infection,Acute or Chronic Renal Failure and Calculus of Kidney(stones). Diseases of the Nervous System:Includes treatment for disorders of the Central and Peripheral Nervous systems. Diagnoses include:Carpal Tunnel Syndrome,Obstructive Sleep Apnea, Epilepsy,Multiple Sclerosis,Alzheimer's Disease and Migraine headaches. Diseases of the Respiratory System: Includes treatment for diagnoses such as Asthma, Pneumonia, Emphysema,Pharyngitis,Sinusitis,Bronchitis and COPD.These can be acute or chronic in nature. Diseases of the Skin and Subcutaneous Tissue:This involves any condition relating to the skin or beneath the skin,including hair and nails.Some conditions include Acne, Corns,Cellulitis,Psoriasis, Dermatitis and fungal infections. 94 CITY OF CANTON:PREM NON-HMO BlueCross B1ueShield Appendix: ICD Category Definitions 1U F V of Illinois Ears and Mastoid: Includes any condition pertaining to the ear or the mastoid process.The mastoid process is the portion of the temporal bone extending down behind the ear.Diagnoses include Otitis Media,Tinnitus,Menieres Disease,Hearing Loss and Labyrinthitis. Endocrine,Nutritional and Metabolic Diseases: Endocrine disorders include those of the endocrine glands and includes the thyroid,pituitary,pancreas,ovaries and testes. Disorders include Diabetes,thyroid disease,Obesity,Hyperlipidemia,Cystic Fibrosis and any disease affecting the immune system. Health Services:This includes elective surgeries,other procedures&aftercare,rehabilitation and dialysis.Specific examples include:long-term medication use, Physical Therapy and chemotherapy. Health Services:Reproduction and Development: Include services pertaining to the child only. For example,normal pregnancy, post-partum care and exam or health supervision of an infant or child. Infectious and Parasitic Diseases: Includes diseases caused by microbes outside of the body that infect and cause damage within the body.These diseases are recognized as communicable or transmissible.Diagnoses include HIV, Hepatitis,Colitis&intestinal disruptions such as food poisoning. Injury and Poisoning: Includes treatment for injuries to the body or for any poison ingested.Diagnoses include sprains&strains,fractures,burns and lead poisoning. Patients are most commonly seen in the emergency room for acute conditions. Mental Health:Refers to a group of disorders causing severe disturbances in thinking,feeling or relating. Includes treatment of any condition that affects mood or behavior. The most common diagnoses include anxiety disorders,depressive disorders and schizophrenia. Musculoskeletal and Connective Tissue Disease: Includes orthopedic treatment,which would involve anything related to the`bones,muscles,joints and soft tissue. Diagnoses: Arthritis,Tendonitis,back disorders,disc disorders, rheumatism,and scoliosis.These diagnoses are more chronic in nature. Neoplasms: Includes any abnormal growth of cells,either benign or malignant(cancer).Though these can be found at any spot of the body,some of the most common forms include neoplasms of the breast,prostate,stomach and brain.Other examples include Leukemia and Hodgkin's Disease. Other Circumstances:This includes convalescent care and follow-ups to surgeries and examinations. Potential Health Hazards: Personal or family history of diseases or disorders;e.g.,breast cancer. 25 CITY OF CANTON:PREM NON-HMO :: B1ueCross B1ueShield Appendix: ICD Category Definitions . 0 ofiliinois A C Procreative and Contraceptive Management:This includes artificial insemination,fertility testing,genetic counseling,family planning,sterilizations and contraceptive management. Signs,Symptoms and III-Defined Conditions:Includes signs,symptoms,abnormal lab results and ill-defined conditions for which no known cause can be found. For example,a patient may experience chest pain,but no known cause is found. Substance Abuse:Includes behavior marked by the use of chemically active agents,such as prescription or illicit drugs,alcohol or tobacco.Cognitive,behavioral and physiological symptoms indicate that the person continues use of the substance. Without Reported Diagnosis:This includes general medical examinations,gynecological exams,mammogram screenings,preventive services,physicals and special screenings for neoplasms. 99 CITY OF CANTON:PREM NON-HMO Glossary #---A ofMin ossB1ueSlueld ►.� V of Illinois Admin Fees:The charge to an account for HCSC's operational cost of doing business. Administrative Services Only(ASO):A contract between HCSC and a self-funded plan where HCSC performs administrative services only and does not assume any financial risk.Services usually include claims processing but may include other services such as actuarial analysis and utilization review. Aggregate:Constituting or amounting to a whole. For example,an aggregate account report includes data for the entire account. Aggregate Stop Loss:A form of reinsurance that provides protection for medical expenses above a certain limit,generally on a year-by-year basis.Aggregate stop loss provides protection against the accumulation of total claims for a group as a whole exceeding a stated level. Allowed:Amount considered eligible for payment by the plan ASO Adjustments:An amount added or deducted from ASO(Administrative Services Only)fees.This includes Stop Loss Reimbursements. 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 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. 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 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. 97 CITY OF CANTON:PREM NON-HMO Glossary B1uBlueShield ►�� ® of Illinois 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 Co-payment: Flat rate that the member is responsible to pay for the claim 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. 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. 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. 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 . 28 CITY OF CANTON:PREM NON-HMO Glossary BluElueShield ►.� of Illinois 2 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 reporting period 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 Facility Inpatient claims International Classification of Diseases(ICD):An official list of categories of diseases, physical and mental,issued by the World Health Organization(WHO). Leading ICD 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 Diagnostic Category for the reporting period MAC Program Savings:Savings achieved by using the MAC(maximum allowable cost)discount on generic medications 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 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. Not Covered:Amount considered not eligible for payment by the plan(excludes the discount amount) 7A CITY OF CANTON:PREM NON-HMO Glossary o flHin oss B1ueShield ►.� of Illinois ti 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 Out of Pocket:Total amount that is the responsibility of the claimant.It is calculated as: (Copay+Deductible+Coinsurance) Outpatient Facility:Refers to Facility Outpatient claims Paid:Total amount paid by the plan,including access fees,adjustments,and surcharges 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/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 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 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 �n CITY OF CANTON:PREM NON-HMO Glossary Btu BlueSlueld ► � \�/ of Illinois R 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 Professional:Services provided by physicians or other professional providers. 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. Rx Credit Fees:Drug rebates that are credited back to the account. Rx Paid PEPM: Prescription drug paid amount per employee per month Rx Paid PMPM:Prescription drug paid amount per member per month Service Category:A classification based on claim type Service Type:Classification based on principal diagnosis or ICD 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 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. Specific Stop Loss:A form of reinsurance that provides protection for medical expenses above a certain limit,generally on a year-by-year basis.Specific(or individual)stop loss limits the cost of eligible medical expenses for each covered individual. 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 and pharmacy dollars paid to cover healthcare services provided to members for claims that have been processed and approved for payment Total Paid Claims+Recoveries:The total amount paid by the plan plus any amount recovered through subrogation. Workers Compensation Savings: Portion of amount eligible for payment that has been paid a third party Workers Compensation carrier �1 CITY OF CANTON:PREM NON-HMO B1uB1ueShield ►.� 0 of Illinois R Blue Insight Monthly Financial Report d- F' Y d CITY OF CANTON: PREM NON-HMO ;0 :_ . % 03/01/2018 to 02/28/2019 A Division of Health Care Service Corporation,a Mutual Legal Reserve Company(HCSC),an Independent Licensee of the Blue Cross and Blue Shield Association. ©Copyright 2019 Health Care Service Corporation.All rights reserved. B1ueCross B1ueSlueld Table of Contents •.• v of Illinois fi PLAN PERFORMANCE Data Parameters 3 Pharmacy Enrollment Overview 4 Financial Summary 15 Financial Overview Key Indicators 16 Financial Summary 6 Generic vs. Formulary Experience 17 Medical & Pharmacy Loss Ratio 7 Top Non-Specialty Therapeutic Drug Classes 18 Network Overview 8 Top Non-Specialty Prescription Drugs 19 Blue Card Savings Analysis 9 Specialty Drug Analysis 20 Medical Claim Expense Distribution 10 Dental High Cost Claimants 11 Dental Financial Summary 21 Medical Out of Pocket 12 Dental Service Type Analysis 22 Lag Report "13 Dental Loss Ratio 23 Overall Medical Paid PMPM Leading Diagnostic Category 14 Appendix 24 Glossary 27 CITY OF CANTON:PREM NON-HMO 2 B1ueCross B1ueShield Data Parameters •.• P---i of Illinois r Current Period:The current reporting period represents claims paid from March 1, 2018 through February 28, 2019. Prior Period: The prior reporting period represents claims paid from March 1, 2017 through February 28, 2018. The report includes medical claims, pharmacy claims and dental claims. Reporting Segments: ALL Characteristics:ALL Group/Sections: ALL Member MSA: ALL Reporting Support Contact Information For reporting support, please contact Client Reporting Service Center Email: client_reporting@bcbsil.com Phone: 1-877-837-1866 Hours of Operation: Monday- Friday: 8:00am - 5:00pm CT Report prepared on 03/12/2019 CITY OF CANTON:PREM NON-HMO 3 B1ueCross BlueShield Enrollment Overview of Illinois Report Description: Provides the current enrollment based on the current period. Medical Medical Pharmacy Pharmacy Dental Dental Month Subscribers Members Subscribers Members Subscribers Members Mar 2018 127 312 127 312 Apr 2018 126 310 126 310 May 2018 126 311 126 311 Jun 2018 126 309 126 309 :Jul 2018 127 309 127 309 Aug 2018 127 309 127 309 Sep 2018 125 307 125 307 Oct 2018 127 306 127 306 Nov 2018 125 303 125 303 Dec 2018 125 303 125 303 -Jan 2019 125 300 125 300 Feb 2019 125 301 125 301 Enrollment by Tier Enrollment by Gender Prior• 39.090 ` 18.2% "50.0% Prior o �• 46.0/ Current 18.9% 17.1% 50.9% Current 54.7% _ 45.3% Employee Only ® Employee+One �_.j Employee+Dep(s) ® Family Male © Female CITY OF CANTON:PREM NON-HMO 4 B1ueCross B1ueSlueld Enrollment Overview ► v of Illinois e Report Description: Provided medical demographics for the current period compared to the prior period and percent change. Medical Demographics Mar 2017-Feb 2018 Mar 2018-Feb 2019 %Change • Overall,membership decreased by 2.8%between reporting periods !Average Membership 316 307 -2.8% Employee 130 126 -3.1% The average age was 35.3 and increased by 0.6%between reporting - -_-, periods. ;Spouse 69 67 -2.9% Contract size remained stable by 0.0%between reporting periods. Dependent 118 114 -3.4% I Females between the ages of 20 and 44 increased from 14.3%to 14.8% ;Average Contract Size 2.4 2.4 between reporting periods. Average Age 35.1 35.3 0.6% Employee 48.0 48.1 0.2% F Spouse 47.1 47.2 0.2% Average Medical Membership i Dependent - 14-1 14.1 0.2% %Under 30 41.2% 40.5% Prior 40 21.7% { 37.4561 ° s%30 to 49 28.6% 28.9% 11 %50 to 64 29.5% 29.9 %65+ 0.7% 0.7% _ Gender `Proportion of Males 54.0% 54.7% Current 21.9% 37.1% Proportion of Females 46.0% 45.3% i Females Ages 20-44 14.3% 14.8% Employee Spouse ] Dependent CITY OF CANTON:PREM NON-HMO 5 y B1ueCross B1ueShield Financial Overview: Financial Summar • • ofIDinois R Report Description: Provides a breakdown of the medical order of reduction from billed to paid for the current month,current period,prior period and a percent change. This report may highlight key measures and their potential impact on paid expenses. Medical Order of Reduction Breakdown of Billed Amount Paid Month Feb 2019 Mar 2017-Feb 2018 Mar 2018-Feb 2019 %Change 100% Billed $199,731 $4,265,860 $4,331,007 1.5% - -- - -- - ---- -- - 90% Not Covered ($19,318) $582,602 $370,286 36.4/ ° I=, Overed $219,049 $3,683,258 $3,960,721 7.5% 80% --- I. ---------- - ----- ---- -- ------ ------ - - - ® Not Covered Discount $78,600 $1,644,145 $1,723,478 4.8% 70% -- r_.________.___.____.___---.--____._ Discount Allowed $140,449 $20039,113 $2,237,244 9.7% 60%-- Out of Pocket Out of Pocket $19,685 $188,432 $195,804 3.9% I ------ ----- -- ---- -- - - - - - 50% - - COB COB $10,853 $16,898 $12,900 -23.7% ; I --- - - -- ... - Medicare - -- --------- - - -------- - - ---. ° COB COB Medicare $4,728 $30,545 $180,978 492.5/ 40% - - -- - ----- - -- --- --- - --- -- --- -- - n Other Reductions :Other Reductions $442 $11,598 30% $5,390 -53.5% � ° - - -'Other Adjustments Other Adjustments ($29) ($50) ($81) -62.9% 20%- -- - -- -- - - - - - - Paid Provider ;Paid-Provider $104,770 $1,791,691 $1,842,253 - 2.8% ---- - - -- - - - - - -- - - - - - - 10% Other Payments $29 $1,292 $2,470 91.2% Medical Paid $104,799 $1,792,983 $1,844,723 2.9% 0% - -- - - -- - _ - - ---- -- - - ----- -. _ - - - _._..- Prior Current Group Liability Breakdown Paid Month Feb 2019 Mar 2017-Feb 2018 Mar 2018-Feb 2019 %Change :Medical Paid $104,799 $1,792,983 $1,844,723 2.9% ' Pharmacy Paid $21,644 $373,142 $313,852 -15.9% Dental Paid $0 `$12,288 :,`'afJ- --100.0% VBC Payments $141 $8 $1,297 16,363.6% 'Total Paid Claims $126,583 $2,178,420 $2,159,873 -0.9% Recoveries $0 $0 $0- 0.0% - --------- ----- ----------- Total Paid Claims+ jRecoveries $126,583 $2,178,420 $2,159,873 -0.9% HCA Draft Amount -$0 - $0 $0 0.0% - ;Group Liability $126,583 I $2,178,420 $2,159,873 -0.9% .- --- --- --- - - - - - --------------- - _ ----- --- - - J Other reductions includes penalties, workers compensation savings,and subrogation savings. Other payments includes Blue Card access fees and surcharges.Also displayed are other adjustments. CITY OF CANTON:PREM NON-HMO 6 B1ueCross B1ueShield Financial Overview: Medical & Pharmacy Loss Ratio of Illinois N K Report Description:Provides the medical and pharmacy loss ratio and claims for the most recent reported twelve months. Month Premium Medical Paid Claims Pharmacy Paid Claims VBC Payments Total Paid Medical and Pharmacy Loss Ratio lDec 2017- ---T-$172,580 - - -_$157,511 $22,844 - $0 $180,355 104.5% j Jan 2018 $172,580 $165,016 $30,466 ($1) $195,481 113.3% Feb 2018 $171,987 $209,195 $24,371 ($1) $233,564 135.8% Mar 2018 $172,709 $175,113 $40,508 ($1) $215,620 124.9% ;Apr 2018 $171,574 $164,684 $27,659 ($1) $192,342 112.1% May 2018 $176,407 $144,962 $33,801 ($1) $178,761 101.3% Jun 2018 $175,659 $274,019 $23,043 ($1) $297,061 169.1% Jul 2018 $175,793 $81,183 $22,201 $157 $103,541 58.9% lAug 2018 $175,692 $146,377 $24,931 $162 $171,471 97.6% -- -- - --- _ - - --- - ----_ _ - ------ -- ----_ - _-. __ ..__ ---- - _ - --- ---- ---- ----- -- Sep 2018 $174,204 $101,596 $22,038 $162 $123,797 71.1% 'Oct 2018 $174,763 $129,987 $24,183 $188 $154,358 88.3% j Nov 2018 $174,153 $151,761 $20,451 $179 $172,391 99.0% Summary $2,088,101 $1,901,405 $316,497 $840 $2,218,742 106.3% Loss Ratio By Month 200% -- - 150%--- 100%_ 50% -100% - 50%- 0%_ Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov 2017 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 Key Findings:The medical and pharmacy loss ratio for the most recent reported month was7.3%lower than the average of the most recent reported twelve months,which was 106.3%. CITY OF CANTON:PREM NON-HMO 7 B1ueCross B1ueSlueld Financial Overview: Network Overview •.• or Illinois Report Description: This report displays the discount amount,discount percent,paid amount and paid percent for medical claims split by Medicare/Non-Medicare,in/out of network and service category for the current period. Medicare Primary Indicator Network Indicator Service Category Covered Discount Discount% Paid %Of Paid r Facility Inpatient $906,527 $443,203 48.9% $446,240 24.2% Facility Outpatient $1,468,670 $530,361 36.1% $850,417T — 46.1% In Network Professional $1,358,005 $748,247 55.1% $514,260 27.9% ! Summary $3,733,201 $1,721,811 46.1% $1,810,917 98.2% No Facility Inpatient Facility Outpatient $7,435 $6,751 0.4% Out of Network F------- --- —— --- _---_ ----___.___ I Professional $27,977 $1,666 6.0% $19,946 1.1% I Summary $35,412 $1,666 4.7% $26,697 1.4% Summary $3,768,613 $1,723,478 45.7% $1,837,614 99.6% r Facility Inpatient Facility Outpatient $186,067 $4,275 0.2% InNetwork --- -- _ —_— _--_- --_____�____� --------_-- ______ .___— _._-- --____�___ ----•-----__-.� Professional $6,040 $2,834 0.2% ` Summary $192,108 $7,109 0.4% Yes + Facility Inpatient Facility Outpatient Out'of Network ' Professional Summary Summary $192,108 $7,109 0.4% Summary $3,960,721 $1,723,478 43.5% $1,844,723 100.0% Key Findings:The overall network savings discount(excluding Medicare)was46.1%for the current period. The in-network paid percent was 98.6%for the current period. CITY OF CANTON:PREM NON-HMO 8 BlueCross B1ueShield Financial Overview: Blue Card Savings Analysis VV of Illinois Report Description:The Blue Card Savings report illustrates the value of having access to other BCBS contracts within the United States through the Blue Card program. Savings from BCBS network discounts are passed to the client,providing savings on potentially costly out of state claims that would otherwise be paid at full provider billed amount. Mar 2018-Feb 2019 Par Plan State Billed Allowed Effective Allowed Rate Discount Paid Effective Blue Card Paid Rate Access Fee IA $82,014 $21,884 26.7% $51,151 $21,628 26.4% $2,199 LA $5,111 $1,548 30.3% $3,562 $1,486 29.1% $153 - ----- ------ -- - - --------- -- ----- DC $3,018 $1,586 52.5% $1,432 $1,194 39.6% 62 GA $2,815 $2,370 84.2% $445 $2,152 76.4% $19 WA,AK $1,088 $813 74.7% $275 $428 39.3% $12 FL $335 $130 38.8% $205 $139 41.4% $9 !BC CA $150 $0 0.0% $0 $0 0.0% $0 i St.Louis MO $655 $1,347 205.7% ($692) $1,253 191.3% ($31) `AII Other Non.Blue Card $4,235;821. $2,207,,565 52.1% $1,667,099- $1,816,442 42.9% $49 i Summary $4,331,007 $2,237,244 51.7% $1,723,478 $1,844,723 42.6% $2,471 Key Findings:IA had the greatest Blue Card savings amount,with a Discount amount of$51,151. The overall Effective Allowed Rate for the current period was 51.7%. CITY OF CANTON:PREM NON-HMO 9 B1ueCross B1ueShield Financial Overview: Medical Claim Expense Distribution oflllinois A Report Description:The distribution of medical paid expense by claimant and the average medical paid per claimant amount are shown for the current period. Paid Band Claimants Claimants% Paid Paid% ,Paid/Claimant less than$200 69 23.8% $3,726 0.2% $54 $200-$1,000 87 30.0% $43,691 2.4% $502 1,001-$5,000 68 23. $157,302 8.5% 4% _ - $2,313 $5,001-$10,000 26 9.0% $189,536 10.3% $7,290 I—- _..._._..__-_ __...-....__.---_"----'.-_.'-----_.---`---`_._.._.- ___.._-__._ --------------._.._----__--------- 1$10,001- ------1$10 001-$30,000 27 9.3% $509,136 27.6% $18,857 j $30,001-$50,000 7 2.4% $276,982 15.0% $39,569 Summary<=$50,000 284 97.9% $1,180,375 64.0% $4,156 Paid Band Claimants Claimants% Paid Paid% Paid/Claimant $50,001-$75,000 2' 0.7% $126,094 6.8% $63,047 $75,001-$100,000 3. 1.0% $249,165 13.5%' $83,055 ;$100,001-$150,000 $150,001-$200,000 .. �$200,001250,000..i__ $250,001-$500,000 1 0.3% $289,090 15.7% $289,090 $500,001+ Summary$50,001 or Greater 6 2.1% $664,348 36.0% $110,725 Combined Summary 290 100.0% $1,844,723 100.0% $6,361 Key Findings:The proportion of claimants who received less than$200 in services for the current period was 23.8%. These claimants spent 0.2%of the total paid expenses and the average paid expense per claimant was $54. 2.1%of claimants had expenses over$50,001 for the current period. These claimants spent 36.0% of the total paid expenses and the average paid expense per claimant was$110,725. CITY OF CANTON:PREM NON-HMO 10 B1ueCross B1ueShield Financial Overview: High Cost Claimants � of Illinois Report Description:This report provides a detailed listing of the top 20 high cost claimants with paid expenses of$50,000 or more for the current period. Mar 2018-Feb 2019 Age/Gender Inpatient Outpatient Professional Pharmacy Currently Encrypted Member ID Relationship Band Leading Diagnostic Category Paid Paid Paid Paid Paid Enrolled '1033190023097568182 Spouse Female 30-39 Musculoskeletal $130,822 $40,708 $117,560 $2,790 $291,880 Yes 3686179032122022586 Spouse Female 20-29 Genitourinary $20,294 $50,572 $14,848 $5,638 $91,352 Yes :5783355527578943938 Subscriber Male 40-49 Genitourinary $14,415 $54,730 $13,611 $3,638 $86,394 Yes 2975471553187423564 Subscriber Male 40-49 Musculoskeletal $72,119 $1,285 $7,292 $4 $80,700 Yes 1308153503870556903 Dependent Female 20-29 Pregnancy $24,950 $32,679 $14,147 $207 $71,983 Yes 1229490712847762885 Subscriber Male 40-49 Respiratory $0 $45,778 $8,539 $49 $54,366 Yes :8499945756175122378 Spouse Female 30-39 Respiratory $0 $32,918 $4,611 $15,964 $53,493 Yes High Cost Claimant Total $262,600 $258,670 $180,608 $28,290 $730,168 CITY OF CANTON:PREM NON-HMO 11 B1ueCross B1ueShield Financial Overview: Medical Out of Pocket \ / of Illinois R Report Description:Provides a distribution of claimants by their total medical out of pocket expenses for the current period compared to the prior period and percent change. This report helps determine the impact of any changes in plan design on out of pocket. Claimant Distribution by Out of Pocket Expense Bands Mar 2017-Feb 2018 Mar 2018-Feb 2019 %Change Out of Pocket Band Claimants Claimants% Out of Pocket Out of Pocket% Claimants Claimants% Out of Pocket Out of Pocket% Claimants Change Out of Pocket Change Less than$100 83 27.8% $1,551 0.8% 87 30.0% $3,017 1.5% 4.8% 94.5% $101-$200 31 10.4% $4,608 2.4% 22 7.6% $3,495 1.8% -29.0% -24.1% $201-$300 20 6.7% $4,795 2.5% 22 7.6% $5,333 2.7% 10.0% 11.2% 1 $301-$400 15 5.0% $5,057 2.7% 10 3.4% $3,600 1.8% -33.3% -28.8% x$401-$500 12 4.0% $5,323 2.8% 8 2.8% $3,565 1.8% -33.3% -33.0% $501-$750 47 15.7% $28,853 15.3% 43 14.8% $26,371 13.5% -8.5% -8.6% ��__.__-_--- --- -- - _- --------- -- -.------------ __ - -- --- -_ -__- - - --- - ----- --- ---- - _ --- ---- ;$751-$1,000 27 9.0% $23,479 12.5% 27 - 9.3% - $23,110 - - -11.8% - -^^ 0.0% - - -- -- 1.6%'„ J $1,001-$1,500 29 9.7% $36,835 19.5% 27 9.3% $34,128 17.4% -6.9% -7.3% x$1,501-$2,000 14 4.7% $24,363 12.9% 26 9.0% $44,110 22.5% 85.7% �-------------------------------�.___-_ - 81.1/ $2,001-$2,500 12 4.0% $26,670 14.2% 8 2.8% $17,639 9.0% -33.3% -33.9% I$2,501-$3,000 5 1.7% $13,558 7.2% 4 1.4% $10,880 5.6% -20.0% -19.8% $3,001-$4,000 4 1.3% $13,341 7.1% 6 2.1% $20,554 10.5% 50.0% 54.1% 1$4,001-$5,000 0.0% 0.0% $Greater than$5,001 0.0% 0.0% Summary 299 100% $188,432 100% 290 100% $195,804 100% -3.0% 3.9% =- but of Pocket Expense by Coverage Tier Mar 2018-Feb 2019 Coverage Tier Allowed Deductible Deductible%of Allowed Copayment Copay%of Allowed Coinsurance Coins%of Allowed Out of Pocket OPX%of Allowed Paid Employee Only _ $357,619 $15,870 4.4% $3,218 0.9% $7,019 2.0% $26,107 7.3% $159,829 Employee+One $402,688 $24,542 6.1% $9,613 2.4% $15,130 3.8% $49,285 12.2% $345,090 LEmpplloy�ee+Dependent(s) $193,648 $13,804 7.1% $6,474 3.3% - $6,414 3.3% _ $26,692 -- 13.8% - $155,989 Family $1,283,289 $41,462 3.2% $21,828 1.7% $30,431 2.4% $93,721 7.3% $1,183,816 Summary $2,237,244 $95,677 4.3% $41,133 1.8% $58,994 2.6% $195,804 8.8% $1,844,723 This 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. This report is based on claim data and may not reflect client specific benefits being applied to member out of pocket. Please contact your Account Executive for ACCUMS reporting. CITY OF CANTON:PREM NON-HMO 12 B1ueCross B1ueShield Financial Overview: Lag Report v of Illinois Report Description: Displays,by paid month,the medical dollars paid and the corresponding month incurred for a 12 month rolling paid period(if available for your account). This report provides insight into the monthly claim lag and can help identify IBNR. Incurred Paid Month Month Mar 2018 Apr 2018 May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Summary All Prior ($2,061) ($58) ($748) $58 $1,641 ($1,168) Mar 2017 $1,210 $1,210 .Apr 2017 $38 $38 May 2017 $643 $643 {Jun 2017 $106 -- - --- - -- - - --- --- --- ----- --- --' $106 Jul 2017 $0 :Aug 2017 - $35 ($3) $420 ._- $13 ($3) $463 Sep 2017 $380 $1,933 ($31) $4,772 $7,054 Oct 2017 $266 $583 $105 $29 $261 $966 $2,209 Nov 2017 $7,069 $1,585 $1,036 $1,274 $103 $107 $100 $325 $11,600 Dec 2017 $1,195 $390 $1,840 $261 $89 $3,774 Jan 2018 $1,603 $1,196 $2,017 $76 $4,892 Feb 2018 $129,304 $5,393 $325 $146 $114 $74 $76 $135,432 Mar 2018 $87,177 $82,405 $3,582 $2,090 $12 $438 $175,705 Apr 2018 $87,780 $67,131 $7,869 $197 $44 $1,755 $331 ($2,640) $162,466 May 2018 $67,635 $62,635 $582 $9,440 $897 $19 ($107) $141,102 !Jun 2018 $94,513 $127,524 $41,413 $8,902 $521 $77 $48 $272,998 Jul 2018 $49,504 $25,751 ($496) $1,539 $260 $76,558 - Aug 2078 $87,257 $35,546 $20,533 $2,015 $5;1'48 ;•$891 $908 4.3152,296 _ Sep 2018 $59,572 $34,048 $1,975 $911 $531 $32 $97,068 Oct 2018 $50,251 $58,144 $19,956 $2,168 $387 $130,906 Nov 2018 $102,719 $46,050 $1,094 $736 $150,599 Dec 2018 $103,230 $25,795 $29,368 $158,393 Jan 2019 - - - ----__-----_----_$87,058----- $43,237-_-_-_$130,295 j ;Feb 2019 --------_ ____ ____--------_.----- •_-s $30,082 $30,082 Summary $224,591 $180,357 $146,956 $167,221 $179,436 $164,379 $109,372 $111,431 $165,620 $175,340 $115,221 $104,799 $1,844,723 CITY OF CANTON:PREM NON-HMO 13 Financial Overview: Overall Medical Paid PMPM by Leading Diagnostic Category0. 9 of Ill noissBlueShield Report Description:Lists the top 15 overall paid expense across inpatient facility,outpatient facility,and professional settings by leading diagnostic categories for the current month,current period,prior period and percent change. Paid Period Feb 2019 Mar 2017- mar 2018- %change Medical PMPM by Leading Diagnostic Category Feb 2018 Feb 2019 Leading Diagnostic Category Paid PMPM Paid PMPM Paid PMPM Paid PMPM Injury/Poisoning $97 $77 $59 -23.4% Digestive $81 $41 $58 41.5% 7% i :Respiratory �— i $40 $22 $31 40.9% Musculoskeletal $33 $58 $112 93.1% Genitourinary $25 $32 $50 56.3% Symptoms/III-Defined $23 $58 $49 -15.5% Y ;Residual/Unclassified $10 $13 $6 -53.9% Nervous System $9 $21 $14 -33.3% i i I Mental Health $6 $9 $7 -22.2% L __.–---------- -- – Neoplasms $6 $62 $35 -43.6% 1Infectious/Parasitic $5 $7 $5 -28.6% I Circulatory $4 $29 $26 -10.3% I ' !Pregnancy $3 $13 $29. 123.1% � _. Endocrine $2' $13 $9 30.8% -� I N/A $2 $0 0.0% All Other Values $2 $20 $12 -40.0%`4 Summary $348 $472 $501 6.1% 0 $20 $40 $60 $80 $100 $120 ® Mar 2017-Feb 2018 = Mar 2018-Feb 2019 Key Findings:The top three Leading Diagnostic Categories in the current reporting month based on Paid PMPM were Injury/Poisoning,Digestive,and Respiratory. CITY OF CANTON:PREM NON-HMO 14 eCros Pharmacy: Financial Summary sluof Illlinoisinois BlueShield b F, Report Description: This report provides an overview of pharmacy order of reduction from billed to paid for the current month,current period,prior period,and percent change. Pharmacy Order of Reduction Feb 2019 Mar 2017-Feb 2018 Mar 2018-Feb 2019 %Change 'Billed $64,151 $931,065 $867,795 -6.8% Covered $64,151 $931,065 $867,795 -6.8% ------ ---- — — --—--- - ------- Breakdown of Billed Amount +Discount $38,532 $510,032 $506,135 -0.8% Allowed $25,619 $421,033 $361,660 -14.1% 100% - - - - -- - - 'Out of Pocket $3,976 $48,266 $48,167 0.2% Other Adjustments $0 ($375) ($360) 4.0% 90% --- - ... 1Paid-Provider $21,644 $373,142 $313,852 15.9/0 --- - ---_--- - - -- --- - ------- -- — _ _—.� - - _ _ - . ` 80% Paid $21,644 $373,142 $313,852 -15.9% 70%- 60%- Discount 0%60% Discount 50% - Out of Pocket 40%- Total 0%Total Pharmacy Paid vs.Specialty Paid { © Other Adjustments 30%- Prior 0%Prior Current - Paid Provider $400,000 20% • 10% 0% $200,000 Prior Current $100,000- $0 100,000$0 Total Paid Specialty Paid Prior. $373,142 $3,810 Current $313,852 $28,944 CITY OF CANTON:PREM NON-HMO 15 B1ueCross BIueSlueld Pharmacy: Key Indicators ► e of Illinois R Report Description:This report provides an overview of the prescription expenses as well as providing percent change in these expenses between the current month,current period,prior period and percent change. Key Indicators Summary Key Indicators Summary Feb 2019 Mar 2017-Feb 2018 Mar 2018-Feb 2019 %Change !Unique Pharmacy Members 301 332 321 -3.3% Average Age(Years) 35.5 35.1 35.3 0.5% Proportion of Males 54.8% 54.0% 54.7% 1.4% Proportion of Females 45.2% 46.0% 45.3% -1.6% _Member Months - - --- -- - ---------- ---3014 3,795 3,680 -3.0% Claimants 129 257 243 -5.4% [Prescriptions 405 5,141 4,902 4.6/ Prescriptions PMPM 1.35 1.35 1.33 1.7% Paid $21,644 $373,142 $313,852 - - _15.9%- Paid PMPM $71.91 $98.32 $85.29 -13.3% Allowed $25,619 $421,033-- --- $361,660 -14.1% Allowed PMPM $85.11 $110.94 $98.28 ------- Avg.Ingredient Cost/Prescription $62.60 $81.25 $73.13 -10.0% Generic Dispensing Rate 84.7% 84.9% 85.3% 0.5% !Formulary Compliance Rate- _ -_ - -- ---- 94.8% ---- --- 93_6%- -- --- - -- -- 93.7%- - ----- 0.2%� Generic Substitution Rate 98.8% 100.0% 99.8% -0.1% Out of Pocket Percent of Allowed 15.5% 11.5% 1_3.3% 16.2% I Retail as a Percent of Prescriptions 98.0% 97.1% - 97.1% 0.1% - - iMail Order as a Percent of Prescriptions 2.0% _ _2.9_% _ _2.9% _ -2.1% Specialty Percent of Total Prescriptions 0.2% 0.1% --' 0.2% _ 214.1% ` ,Specialty Percent of Total Paid 0.3% 1.0% 9.2% 803.2% Specialty Average Ingredient - Cost/Prescription $63.80 $967:89 $2,428.99= 151.0%. _ Cost Sharing Distribution + Feb 2019 Mar 2017-Feb 2018 Mar 2018-Feb 2019 %Change Cost Sharing Distribution Retail Mail Retail Mail Retail Mail Retail Mail i Member Out of Pocket 16.6% 7.1% 11.5% 10.9% 13.9% 8.5% 20.7% -22.2% L___.-,.._ Plan Paid _y-- - A----- 83.4% --"- - -92.9% --- --88.5%_-- -- 89.1% 86.1% 91.5% -2.7% 2.7% Savings Summary Feb 2019 Mar 2017-Feb 2018 Mar 2018-Feb 2019 %Change Savings Summary Retail Mail Summary Retail Mail Summary Retail Mail Summary Retail Mail Summary !Discount-- - -- - $36,522_ $2,010 _- $38,532 $463,227 - $46,805 $510,032 $460,972 -$45,163_ - $506,135 - -0.5% _- __3.5% -0.8%- Discount 61.7% 40.7% 60.1% 54.2% 61.4% 54.8% 58.8% 54.1% 58.3% 8.5% -11.9% 6.5% CITY OF CANTON:PREM NON-HMO 16 B1ueCross B1ueShield Pharmacy: Generic vs. Formulary Experience • • 0 of Illinois R Report Description:For the current period,the prescription drug expenses are displayed below for retail and mail order providers and broken out by drug type and formulary indicator. Total Expense Member Expense Plan Expense of Total Allowed/ Out of Pocket/ Paid/ Retail Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription ;Generic 4,073 86% $73,695 $18.09 $27,430 $6.73 $46,265 $11.36 ------------------------- Brand 688 14% $249,673 $362.90 $17,493 $25.43 $232,540 $337.99 Summary 4,761 100% $323,368 $67.92 $44,923 $9.44 $278,805 $58.56 Brand Type Breakdown - 1111- 1111- --- 111111 11 --1111-- -1111-- ----- --- 11111111-- --- ----1111-- Single-Source Brand 622 13% $237,194 $381.34 $15,708 $25.25 $221,846 $356.67 1 Multi-Source Brand 66 1% $12,479 $189.07 $1,785 $27.04 $10,694 $162.03 - - 1111- - - ---- - - - -- - - - ----- - - - -- --- - - - - - - - - ;Multi-Source Brand w/DAW1 7 0% $3,665 $523.51 $170 $24.32 $3,494 $499.19 ----- Multi-Source Brand w/DAW2 24 1% $4,799 $199.95 $840 $35.00 $3,959 $164.95 - - - - -- - - ---- - -- -- - 1111 - - -- -- - -- - - ----- Brand Formulary _ - - 393 -8% - $182,354 $464.00 $10,828 $27.55 $171,526 $436.45 - - Brand Non-Formulary 295 6% $67,319 $228.20 $6,665 $22.59 $61,014 $206.83 Total Expense Member Expense Plan Expense of Total Allowed/ Out of Pocket/ Paid/ Mail Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription Generic 110 78% $6,132 $55.75 $1,683 $15.30 $4,449 $40.44 . -- - - - --1111-- ---- - 1111-- ---1111-- --- - _1111----- -- - --------- - --- - - 1111--- -1111-- - --- ---- - 1111 -- -- --- - ---- - - - - -- - --- --- -' Brand 31 22% $32,160 $1,037.41 $1,561 $50.37 $30,598 $987.05 Summary 141 100% $38,292 $271.57 $3,245 $23.01 $35,047 $248.56 - -1111-- - --- -1111---- --_-_ - .- 1111-- 1111-- -1111 - 1111 �_...__ __._ .. . ---_ -_..__ --- --1111--_-- 1111---- -- Single-Source Brand 25 -- 18% $27,140 $1,085.59 $1,150 $46.00 $25,990 $1,039.59' - �---- Multi-Source Brand 6 4% $5,020 $836.68 $411 $68.56 $4,609 $768.12 Multi-Source Brand w/DAW1 4 3% $4,889 $1,222.18 $280 $70.00 $4,609 $1,152.18 1111 -------- --------..._._-- _-1111---11111111-- - 1111-- --- - --1111-------- --- ----__.__-_1111-111111111111-- --� ; __.__-_._.___ Multi-Source Brand w/DAW2 Brand Formulary _ - 20 14% $21,595 $1,079.76:_ $800 $40.00 - - -$20,795 _ $1,0_39.76 -- Brand Non-Formulary - ' 11 8% $10,565 $960:43 $761 " . '$ii9.t2 --$9,803 x}`891.21. Total Expense Member Expense Plan Expense of Total Allowed/ Out of Pocket/ Paid/ Total Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription Generic4,183 85% $79,827 $19.08 $29,113 $6.96 $50,714 $12.12 _._ --_- 111 1-1111-- - --._-•-_-_---_.___1111-----1111_' Brand 719 15% $281,833 $391.98 $19,054 $26.50 $263,139 $365.98 Summary 4,902 100% $361,660 $73.78 $48,167 $9.83 $313,852 $64.03 Brand Type Breakdown ----- ---------------------1111-- ---- ------1111-- --1111- __ --1111- - _ _--- 1111 1111- 111.1 --- 1111---1111-- --- �-.------- 1111- --- - -----------, ISmgle-Source Brand 647 13% _ w $264,334 - $408.55 $16,858 - $26.06 Y- $247,836 $383.05 -- - - --------- - ----- 1111- -- ----- -- 11 11----1111-- - ------ --- -- - ------ ---- Multi-Source Brand 72 1% $17,499 $243.04 $2,196 $30.50 $15,303 $212.54 L_ L Multi-Source Brand w/DAW1 11 0% $8,553 $777.57 $450 $40.93 $8,103 - $736.64 - ---. .. .- --- - - - - --._ --- -_ Multi-Source Brand w/DAW2 24 0% $4,799 $199.95 $840 $35.00 $3,959 $164.95 Brand Formulary--- _- 413 - 8% - $203,949 $493.82 $11,628 $28.16 $192,321 $465.67 - --- - 413 -- - - 1111 -- - --- - $49 1111 -- - $ . 2,321 - ----- Brand Non-Formulary 306 6% $77,884 $254.52 $7,426 $24.27 $70,818 $231.43 CITY OF CANTON:PREM NON-HMO 17 BlueCross B1ueShield Pharmacy: Top Non-Specialty Therapeutic Drug Classes ►.�� a of Illinois Report Description: The top 25 therapeutic drug classes for the current period are displayed below ranked by ingredient cost. Avg.Ingredient Avg.Ingredient Current/ Cost/ Cost/ Prior Utilizing . Prescription Prescription % % Rank by Rank Plan Therapeutic Class Prescriptions IMembers Ingredient Cost (Current) (Prior) Formulary Generic Volume 1 1 Insulin 112 9 $72,039 $643.21 ° $618.12 89.3/ 0.0% 12 2 4 Sympathomimetics 95 27 $20,444 $215.20 $199.21 93.7% 12.6% 15 3 y6 _ Direct Factor Xa Inhibitors19 _. 5 ��- $14,316 � $753.48 $462.56 _ 100.0% 0.0% _ 61 ; -__-__._.___ _-.__�_-_ __-----_---- .___----_ ------.----_- _.-.-_---- ---- I 4 5 Sodium-Glucose Co-Transporter 2(SGLT2)Inhibitors 27 3 $12,511 $463.37 $427.47 81.5% 0.0% 49 5 9 Selective Serotonin Reuptake Inhibitors(SSRIs) 269 40 $8,856 $32.92 $27.76 95.2% 95.2/ 2 6 13 Combination Contraceptives-Oral 120 22 $8,594 $71.61 $45.21 80.8% 80.8% 10 j 7- 7 Impotence Agents 25 5 $8,103 $324.12 $337.67 100.0% 72.0% 53 8 14 Anticonvulsants-Misc. 171 21 $6,716 $39.28 $38.01 100.0% 93.0% 4 9 18 Antidiabetic Combinations 17 2 $6,629 $389.97 $382.80 70.6% 0.0% 64 10 12 HMG CoA Reductase Inhibitors 304 40 $6,497 $21.37 $20.52 98.7% 98.7% 1 11 Irritable Bowel Syndrome(IBS)•Agents 7 2 $6,461 $922.98 $1,014.93_-� 100.0% _ 0.0% 104 12 11 Phenothiazines 14 2 $5,985 $427.51 $406.96 100.0% 100.0% 74 13 10 Diagnostic Tests 41 9 $5,857 $142.84 $123.86 100.0% 0.0% 31 14 8 Dipeptidyl Peptidase-4(DPP-4)Inhibitors 4 1 $4,979 $1,244.76 $618.11 100.0% 0.0% 114 15 21 Bronchodilators-Anticholinergics 13 2 $4,910 $377.71 $377.33 100.0% 7.7% 76° r 16 16 Amphetamines 31 6 $4,500 $145.15 $135.10 100.0% 61.3% 44 17 Stimulants- 15 Misc. - 32 -7 --------$4,404____---- ° ° L17 - $137.64 $107.00 75.0% 75.0% 42 j 18 23 1 Gout Agents '- _ 37 4 ---$4,394 - 'N'$18.76 - - $115.79 '` 59.5% 59.5%_ -36` F 19 19 Anti Obesity Agents 16 3 $4,220 $263.74 $201.99 0.0% 0.0% 66 20 Incretin Mimetic Agents(GLP-1 Receptor Agonists) 6 1 $4,150 $691.63 $802.96 100.0% 0.0% 106 21 _ 22 -Fibromyalgia Agents 4 1 $4,087 $1,021.79 $935.46 ' 0.0% 0.0% 115 ! 22 Digestive Enzymes --------3 ti $3,989�~y'---$1,329.79---~�-$763.55 -� 100.0% - 0.0% 126 'f 23- 20MThyroid Hormones �-�- - �- _�-- ®.160 ���-�18 �- $3,784 ._ $23.65---$21.59 77.5% 77.5% 6-� 24 Calcium Channel Blockers 80 9 . $3,691 $46.14 $32.75 100.0% 100.0% 18 25 Beta Blockers Cardio-Selective y 128 17 $3,237 $25.29 _$21.21 89.8% 89.8%- 9 All Other 3,146 226 $81,051 $25.76 $55.40 95.4% 93.3% Summary 4,881 243 $314,405 $64.41 $80.27 93.8% 85.6% CITY OF CANTON:PREM NON-HMO 18 B1ueCross B1ueShield Pharmacy: Top Non-Specialty Prescription Drugs ► ® of Illinois G S Report Description: The top 25 prescription drugs for the current period are displayed below ranked by ingredient cost. Avg.Ingredient Avg.Ingredient Current/ cost/ Cost/ Prior Utilizing Ingredient Prescription Prescription Formulary Generic Rank by Rank Brand Name Plan Therapeutic Class Prescriptions Members Cost (Current) (Prior) Indicator Indicator Volume 1 3 NOVOLOG INJ 100/ML Insulin 9 2 $16,942 $1,882.48 $1,479.19 YES NO 181 2 4 NOVOLOG MIX INJ 70/30 Insulin 11 1 $15,970 $1,451.79 $1,404.80 YES NO 132 3 6 XARELTO TAB 20MG Direct Factor Xa Inhibitors 16 4 $12,909 $806.81 $499.07 YES NO 54 4 8 LANTUS INJ 100/ML Insulin 29 4 $8,256 $284.69 $248.39 YES NO 11 5 11 ADVAIR DISKU AER 500/50 Sympathomimetics 15 2 $7,685 $512.31 $473.61 YES NO 59 6 7 NOVOLOG INJ FLEXPEN Insulin 14 1 $7,605 $543.18 $526.36 YES NO 66 7 5 LANTUS SOLOS INJ 100/ML Insulin 19 2 $7,565 $398.16 $447.29 YES NO 37 8 10 LEVEMIR INJ Insulin 13 1 $7,471 $574.65 $490.40 YES NO 74 9 9 CHLORPROMAZ TAB 100MG Phenothiazines 12 1 $5,977 $498.12 $469.04 YES YES 104 10 12 JARDIANCE TAB 10MG Sodium-Glucose Co-Transporter 2(SGLT2) 12 1 $5,534 $461.20 $430.14 YES NO 103 it 14 ADVAIR DISKU AER 250/50 Sympathomimetics 12 2 $5,404 $450.35 $521.16 YES NO 94 12 16 LYRICA CAP 300MG Anticonvulsants-Misc. 12 1 $5,330 $444.20 $401.65 YES NO 90 13 21 JANUVIA TAB 100MG Dipeptidyl Peptidase-4(DPP-4)Inhibitors 4 1 $4,979 $1,244.76 $1,168.65 YES NO 323 14 LIPITOR TAB 40MG HMG CoA Reductase Inhibitors 4 1 $4,889 $1,222.18 NO NO 324 15 18 SPIRIVA CAP HANDIHLR Bronchodilators-Anticholinergics 12 1 $4,887 $407.28 $377.33 - YES NO 102 16 15 KOMBIGLYZ XR TAB 2.5-1000 Antidiabetic Combinations 12 1 $4,868 $405.68 $382.80 YES NO 95 17 13 JARDIANCE TAB 25MG Sodium-Glucose Co-Transporter 2(SGLT2) 10 1 $4,652 $465.23 $428.87 YES NO 161 18 27` LINZESS CAO_290MCG Irritable Bowel Syndrome(IBS)Agenti .. 5 1 $4,088' $817:67 $1,014.93 YES NO 284-'•' " 19 20 SAVELLA TAB 50MG Fibromyalgia Agents 4 1 $4,087 $1,021.79 $935.46 NO NO 338 20 HUMALOG INJ 100/ML Insulin 8 2 $4,074 $509.31 NO NO 204 21 33 CREON CAP 36000UNT Digestive Enzymes 3 1 g y $3,989 $1,329.79 $763.55 YES NO 393 ' 22 23 ULORIC TAB 80MG Gout Agents 12 1 $3,932 $327.63 $307.65 NO NO 120 23 25 LO LOESTRIN TAB 1-10-10 Combination Contraceptives-Oral 11 3 $3,495 $317.71 $192.55 NO NO 135 24 29 BELVIQ TAB 10MG Anti-Obesity Agents 12 1 $3,310 $275.79 $257.41 NO NO 118 25 24 VYVANSE CAP 70MG Amphetamines 11 1 $3,209 $291.72 $271.67 YES NO 146 ._--___-____.-._._._. _....._ .._. _. _ .-_-._...___._-_..___ ._. - .. .-.-_-- All Other 4,599 243 $153,297 $33.33 $54.38 Summary 4,881 243 $314,405 $64.41 $80.27 CITY OF CANTON:PREM NON-HMO 19 B1ueCross B1ueShield Pharmacy: Specialty Drug Analysis 0. 19 of Illinois 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.This report provides specialty drug analysis for the current month,current period,prior period and percent change. Specialty Drug Key Indicators Top Specialty Classes by Ingredient Cost for the Current Period Feb 2019 Mar 2017-Feb 2018 Mar 2018-Feb 2019 %Change Unique Pharmacy Members 301 332 321 -3.3% I Member Months 301 3,795 3,680 -3.0% 0.2% Claimants 1 2 4 100.0% 1.0 Percent of~Utilizing Members _- 0.3% _ - 0.6%-- 1.3% 106.9% Prescriptions _---- - -- - --1 - - - -4 -- ._.- -- 12 -- -- 200.0% AUTOIMMUNE Specialty Percent-of Total Paid-- - _ - 0.3% v 1.0% 9.2% 803.3% _ 39.1%---- Percent of Total Prescriptions Paid- - - _ 0.3% - _ 0.1% - - -0.2% _ - 214.7% R E 7-1 HEMOPHILIA Paid $55 $3,810 $28,944 659.8% ti, Paid PMPM $0.18-- - --$1.00- -- -- $7.87 - 683.5% $0. Average Ingredient Cost/Prescription $64 $968 $2,429 151.0% CANCER-ORAL Out of Pocket $30 $65 $210 223.1% , Out of Pocket PMPM $0.03 $0.02 $0.06 233.2% Out of Pocket Percent of Allowed 15.4% 1.7% 0.7% 57.1% _I Top 15 Specialty Drugs by Ingredient Cost for the Current Period Avg.Ingredient Ingredient cost/ Specialty Top Specialty Classes by Ingredient Cost for the Prior Period Brand Name Specialty Class Cost Prescriptions Prescription Claimants IHUMATE-P-SOL24000NIT^_.-_-__HEMOPHILIA -_ ._ _-$11,396_____- 3._�-__$3,798.53 _ --1 COSENTYX PEN INJ 300DOSE AUTOIMMUNE $9,342 1 $9,341.74 1 �XEUANZ TABSMG _- AUTOIMMUNE $8,045_ ? :$4,022.46 _-_--1-._� 3.2 MERCAPTOPUR TAB SOMG $60 37„•_-- 1 MERCAPTOPUR TAB SOMG_ - -- CANCER-ORAL --._ $64' 1 - $63.80 1 -I - Summary $29,148 12 $2,428.99 4 F+• I i ® AUTOIMMUNE ® 1 -= -- -96.3 CITY OF CANTON:PREM NON-HMO 20 B1ueCross B1ueSlueld Dental: Loss Ratio •.• e of Illinois k Report Description:Provides the dental loss ratio and claims for the most recent reported twelve months. Month Premium Dental Paid Claims Dental Loss Ratio ' 2017 - Jan 2018 - Feb 2018 Mar 2018 - -- - "Apr2018 -- ------- --------- •—, May 2018 �Jun 2018 Jul 2018 -----_ -_--• jAug 2018 Sep 2018 - --------------_-----.- ---- --- Oct 2018 -- -- ----- -- - Nov 2018 Summary - - 120% Loss Ratio By Month 100% 80% 60Y- 40%- 20% 0%u 40%20% 0% Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov 2017 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 Key Findings:The dental loss ratio for the most recent reported month was0.0%was similar to than the average'of the most recent reported twelve months,which was0.0%. CITY OF CANTON:PREM NON-HMO 21 B1ueCross B1ueShield Appendix: ICD Category Definitions • • 0 of Illinois R S Complications of Pregnancy,Childbirth and the Puerperium:Includes vaginal and cesarean deliveries and complications of pregnancy,such as ectopic and molar pregnancies. Puerperium refers to 42 days following childbirth and expulsion of the placenta.Refers to the mother only. Conditions Influencing Health Status:This includes post-surgical states,organ/tissue transplants,artificial limbs and replacements.Examples include knee replacements and kidney transplant status. Conditions in the Perinatal Period:Perinatal refers to the period beginning after the 28th week of gestation and ending 28 days after birth. Problems can include hemorrhage, digestive disorders,respiratory distress syndrome and disorders relating to short gestation and unspecified low birth weight. Congenital Anomalies:Includes the treatment of any condition present at birth.This includes Spina Bifida,cleft palate, Down's Syndrome,heart disease,kidney displacement& polycystic kidney disease. Diseases of the Blood and Blood Forming Organs:Includes any problems associated with white or red blood cells,platelets or plasma.An example includes Anemia,a deficiency in red blood cells. Diseases of the Circulatory System:Includes problems with the heart,blood vessels and circulation.Some common diagnoses include Coronary Artery Disease,cardiovascular disease,and stroke. Diseases of the Digestive System:Includes the treatment of any organ or area of the body pertaining to digestion.These areas include the mouth/teeth,esophagus,stomach, intestines,gall bladder,liver and pancreas.Diagnoses include:Esophageal Reflux,Gastroenteritis,Appendicitis and hernias. Diseases of the Gen Ito urliri'ary5Ystem:Includes problems relayed to the kidneys,bladder and male and female genitalia.Common diagrioses_include Hematuria, UrinaryTract -Infection,Acute or-ChronicRenal-failure and Calculus of Kidney'(stones). Diseases of the Nervous System:Includes treatment for disorders of the Central and Peripheral Nervous systems.Diagnoses include:Carpal Tunnel Syndrome,Obstructive Sleep Apnea,Epilepsy,Multiple Sclerosis,Alzheimer's Disease and Migraine headaches. Diseases of the Respiratory System:Includes treatment for diagnoses such as Asthma, Pneumonia,Emphysema, Pharyngitis,Sinusitis,Bronchitis and COPD.These can be acute or chronic in nature. Diseases of the Skin and Subcutaneous Tissue:This involves any condition relating to the skin or beneath the skin,including hair and nails.Some conditions include Acne, Corns,Cellulitis,Psoriasis,Dermatitis and fungal infections. CITY OF CANTON:PREM NON-HMO 22 B1ueCross B1ueShield Appendix: ICD Category Definitions 0 of Illinois R Ears and Mastoid:Includes any condition pertaining to the ear or the mastoid process.The mastoid process is the portion of the temporal bone extending down behind the ear. Diagnoses include Otitis Media,Tinnitus, Menieres Disease,Hearing Loss and Labyrinthitis. Endocrine,Nutritional and Metabolic Diseases: Endocrine disorders include those of the endocrine glands and includes the thyroid,pituitary,pancreas,ovaries and testes. Disorders include Diabetes,thyroid disease,Obesity, Hyperlipidemia,Cystic Fibrosis and any disease affecting the immune system. Health Services:This includes elective surgeries,other procedures&aftercare,rehabilitation and dialysis.Specific examples include:long-term medication use,Physical Therapy and chemotherapy. Health Services:Reproduction and Development:Include services pertaining to the child only. For example,normal pregnancy,post-partum care and exam or health supervision of an infant or child. Infectious and Parasitic Diseases:Includes diseases caused by microbes outside of the body that infect and cause damage within the body.These diseases are recognized as communicable or transmissible.Diagnoses include HIV, Hepatitis,Colitis&intestinal disruptions such as food poisoning. Injury and Poisoning:Includes treatment for injuries to the body or for any poison ingested.Diagnoses include sprains&strains,fractures,burns and lead poisoning. Patients are most commonly seen in the emergency room for acute conditions. Mental Health: Refers to a group of disorders causing severe disturbances in thinking,feeling or relating. Includes treatment of any condition that affects mood or behavior.The most common diagnoses include anxiety disorders,depressive disorders and schizophrenia. -Musculoskeletal and.Connective Tissue Diseasei`[t cludes orthopedic.treatment;which would involve anythingg,related to the bones,•muscles,joints an,l Soft-tissue. Djagnoses: Arthritis,Tendonitis;back disorders,disc disorders,rheumatism,and scoliosis.These diagnoses are-more chronic in nature. Neoplasms: Includes any abnormal growth of cells,either benign or malignant(cancer).Though these can be found at any spot of the body,some of the most common forms include neoplasms of the breast,prostate,stomach and brain.Other examples include Leukemia and Hodgkin's Disease. Other Circumstances:This includes convalescent care and follow-ups to surgeries and examinations. Potential Health Hazards:Personal or family history of diseases or disorders;e.g.,breast cancer. CITY OF CANTON:PREM NON-HMO 23 B1ueCross B1ueShield Appendix: ICD Category Definitions :.:w \ / of Illinois Procreative and Contraceptive Management:This includes artificial insemination,fertility testing,genetic counseling,family planning,sterilizations and contraceptive management. Signs,Symptoms and III-Defined Conditions:Includes signs,symptoms,abnormal lab results and ill-defined conditions for which no known cause can be found.For example,a patient may experience chest pain,but no known cause is found. Substance Abuse:Includes behavior marked by the use of chemically active agents,such as prescription or illicit drugs,alcohol or tobacco.Cognitive,behavioral and physiological symptoms indicate that the person continues use of the substance. Without Reported Diagnosis:This includes general medical examinations,gynecological exams,mammogram screenings,preventive services,physicals and special screenings for neoplasms. CITY OF CANTON:PREM NON-HMO 24 Glossary B1uB1ueShield ►.� of Illinois R Admin Fees:The charge to an account for HCSC's operational cost of doing business. Administrative Services Only(ASO):A contract between HCSC and a self-funded plan where HCSC performs administrative services only and does not assume any financial risk. Services usually include claims processing but may include other services such as actuarial analysis and utilization review. Aggregate:Constituting or amounting to a whole.For example,an aggregate account report includes data for the entire account. Aggregate Stop Loss:A form of reinsurance that provides protection for medical expenses above a certain limit,generally on a year-by-year basis.Aggregate stop loss provides protection against the accumulation of total claims for a group as a whole exceeding a stated level. Allowed:Amount considered eligible for payment by the plan ASO Adjustments:An amount added or deducted from ASO(Administrative Services Only)fees.This includes Stop Loss Reimbursements. 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 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. 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 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. CITY OF CANTON:PREM NON-HMO 25 Glossary U B1uB1ueSlueld o.� of Illinois 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 Co-payment:Flat rate that the member is responsible to pay for the claim 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. DAW2:Indicates that the Physician has allowed a substitution,but the patient requested brand to be dispensed Deductible: Portion of annual deductible amount member is responsible to pay applied to the claim. Dental Loss Ratio:Calculated as the Dental Paid Claims Amount divided by the Billed.Dental Premium Amount 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 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 CITY OF CANTON:PREM NON-HMO 26 GlossaryBlueCrossBlueShield 41, of Illinois 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 reporting period 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 Facility Inpatient claims International Classification of Diseases(ICD):An official list of categories of diseases,physical and mental,issued by the World Health Organization(WHO). Leading ICD 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 Diagnostic Category for the reporting period MAC Program Savings:Savings achieved by using the MAC(maximum allowable cost)discount on generic medications 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 divided bythe 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. Not Covered:Amount considered not eligible for payment by the plan(excludes the discount amount) CITY OF CANTON:PREM NON-HMO 27 Glossary B1uB1ueSlueld ►.� of Illinois 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 Out of Pocket:Total amount that is the responsibility of the claimant. It is calculated as: (Copay+Deductible+Coinsurance) Outpatient Facility:Refers to Facility Outpatient claims Paid:Total amount paid by the plan,including access fees,adjustments,and surcharges 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/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 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'daims:.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 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 CITY OF CANTON:PREM NON-HMO 28 Glossary B1ueCross B1ueShield ►.� IV of Illinois RD" 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 Professional: Services provided by physicians or other professional providers 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. Rx Credit Fees:Drug rebates that are credited back to the account. Rx Paid PEPM: Prescription drug paid amount per employee per month Rx Paid PMPM:Prescription drug paid amount per member per month Service Category:A classification based on claim type Service Type:Classification based on principal diagnosis or ICD 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 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. Specific Stop Loss:A form of reinsurance that provides protection for medical expenses above a certain limit,generally on a year-by-year basis.Specific(or individual)stop loss limits the cost of eligible medical expenses for each covered individual. Subrogation Savings:Portion of amount eligible for-payment originally-paid by the plan but that has since-been recovered through-a legal action T 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 and pharmacy dollars paid to cover healthcare services provided to members for claims that have been processed and approved for payment Total Paid Claims+Recoveries:The total amount paid by the plan plus any amount recovered through subrogation. Workers Compensation Savings:Portion of amount eligible for payment that has been paid a third party Workers Compensation carrier CITY OF CANTON:PREM NON-HMO 29 � B1ueCross B1ueShield ►.� ® of Illinois ti Blue Insight , [� Monthly Financial Report R CITY OF CANTON: PREM NON-HMO 00,00 02/01/2017 to 01/31/2018 f ' A Division of Health Care Service Corporation,a Mutual Legal Reserve Company(HCSC),an Independent Licensee of the Blue Cross and Blue Shield Association. ©Copyright 2018 Health Care Service Corporation.All rights reserved. B1ueCross B1ueShield Table of Contents •.• 0 of Illinois R PLAN PERFORMANCE Data Parameters 3 Pharmacy Financial Summary 15 Enrollment Overview 4 Key Indicators 16 Financial Overview Financial Summary 6 Generic vs. Formulary Experience 17 Medical & Pharmacy Loss Ratio 7 Top Non-Specialty Therapeutic Drug Classes 18 Network Overview 8 Top Non-Specialty Prescription Drugs 19 Blue Card Savings Analysis 9 Specialty Drug Analysis 20 Medical Claim Expense Distribution 10 Appendix 21 High Cost Claimants 11 Glossary 24 Medical Out-of Pocket : 12 - Lag Report 13 Overall Medical Paid PMPM Leading Diagnostic Category 14 2 _ CITY OF CANTON:PREM NON-HMO BlueCross B1ueSlueld Data Parameters 0 of Illinois Current Period: The current reporting period represents claims paid from February 1, 2017 through January 31, 2018. Prior Period: The prior reporting period represents claims paid from February 1, 2016 through January 31, 2017. The report includes medical claims and pharmacy claims. Reporting Segments: ALL Characteristics: ALL Group/Sections: ALL Reporting Support Contact Information For reporting support, please contact Client Reporting Service Center Email: client—reporting@bcbsil.com Phone: 1-877-837-1866 Hours of Operation: Monday- Friday: 8:00am - 5:00pm CT Report prepared on 02/10/2018 s _ CITY OF CANTON:PREM NON-HMO 16•.• � BlueCross B1ueShield Enrollment Overview of Illinois 4 Report Description: Provides the current enrollment based on the current period. Medical Medical Pharmacy Pharmacy Month Subscribers Members Subscribers Members Feb 2017 132 322 132 322 Mar 2017 132 321 132 321 ,Apr 2017 131 320 131 320 May 2017 131 320 131 320 Jun 2017 131 320 131 320 Jul 2017 131 320 131 320 ;Aug 2017 130 317 130 317 Sep 2017 128 311 128 311 ,Oct 2017 129 314 129 314 Nov 2017 129 314 129 314 Dec 2017 128 314 128 314 Jan 2018 128 314 128 314 Enrollment by Tier Enrollment by Gender Prior 19.7% i 19.8% 48.7% Prior 46.6% f Current 19.0% 18.4% 49.8% Current 46.4961 i Employee Only [= Employee+One F___j Employee+Dep(s) ® Family Male Female 4 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Enrollment Overview © of Illinois 0r Report Description: Provided medical demographics for the current period compared to the prior period and percent change. Medical Demographics Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change I Overall,membership decreased by 1.9%between reporting periods Average Membership 323 317 -1.9% Employee 131 130 _0.8% The average age was 35.1 and increased by 0.3%between reporting periods. Spouse 71 69 -2.8% ~ -- --- ---- -- - ---- - -- ---- ---- - -- -- - 3 Contract size decreased by 4.0%between reporting periods. Dependent 121 119 -1.7% Average Contract Size 2.5 2.4 -4.0% Females between the ages of 20 and 44 decreased from 15.0%to 14.3% i between reporting periods. Average Age 35.0 35.1 0.3% Employee 48.1 - - 48.0 ---- -- --0.2% Spouse 47.0 47.1 0.2% Average Medical Membership iDependent 13.7 14.1 0.2% i Under 30 41.3% 41.1% Prior ° 37.4% 21:9-/ r 30 to 49 27.9% 28.7% I 50 to 64 30.3% 29.5% j 1%65+ 0.5% 0.7% - - - -- - - - --I - -_ _.. -J.-. - • =Gender - . - .:; . . - • ,- ,' r .. i - .- �� _ ,Proportion of Males 53.4% 53.6% Current 21.6% 37.4% Proportion of Females 46.6% 46.4% r-- Females Ages 20-44 15.0% 14.3% I - L___ Employee ®Spouse [!�D Dependent 5 CITY OF CANTON:PREM NON-HMO y �� B1ueCross B1ueSlueld Financial Overview: Financial Summar ► of Illinois Report Description: Provides a breakdown of the medical order of reduction from billed to paid for the current month,current period, prior period and a percent change. This report may highlight key measures and their potential impact on paid expenses. Medical Order of Reduction Breakdown of Billed Amount Paid Month Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change 100% Billed $417,955 $5,832,402 $4,174,714 -28.4% Not Covered $48,989 $838,080 $591,322 -29.4% .Covered $368,967 $4,994,322 $3,583,391 -28.3% 80% -- - — ---- - - - - - -- --- --- - - - -` ® Not Covered Discount $146,209 $2,353,141 $1,583,068 -32.7% 70%- -- 0% - Discount _. .__.-.--_ __._ __---- ____ _._.__.. ----. .-___..---- -.--. --..___._____------.__ _ ____. ___ _ 60% Out of Pocket [ Allowed $222,757 $2,641181 $2,000,324 -24.3% __, ' Out of Pocket $26,015 $192,541 $193,589 0.5% 50% - COB - - --- - - --- -- - - - - -COB------ $6-,-625 6-,-625_- -- - -- _$19,242_______-___.$58,6-5 0--- - -67.2% COB Medicare re COB Medicare $2,308 $14,909 $30,468 104.4% 40% -- [-. Other Reductions - ------------ — iOther Reductions $456 $22,970 $11,410 -50.3% 30% --- Other Adjustments Other 20%s us Adjtment $0 ($50) ($25) 50.0% -_ _ -_ __- __ __ _ "_ � Paid Provider Paid-Provider $187,354 $2,352,160 $1,745,640 -25.8% — - - -- -- - - -- - 10% - Other Payments $2 $1,910 $1,234 -35.4% ---- _-_.- - _—_--- - -- ----- -- - - - - _ - - 0/ Medical Paid $187,356 $2,354,070 $1,746,874 -25.8% �... _-- - - -- - - ---- •- _. - -— - - - - — -- Prior Current Group Liability Breakdown Paid Month Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change Medical Paid $187,356 $2,354,070 $1,746,874 -25.8% Pharmacy Paid $26,112 $480,172 $387,071 19.4% YBC_Payments - ($1) $ ;:•�:::��', $10 -90.5%-. j , Total Paid Claims $213,467 $2,834,349 $2,133,955 -24.7% Recoveries $0 $0 $0 0.0% Total Paid Claims+ Recoveries $213,467 $2,834,349 $2,133,955 24.7/ HCA Draft Amount —$0 $0 $0 0.0% Group Liability $213,467 $2,834,349 $2,133,955 -24.7% J Other reductions includes penalties, workers compensation savings,and subrogation savings. Other payments includes Blue Card access fees and surcharges.Also displayed are other adjustments. R CITY OF CANTON:PREM NON-HMO B1ueCross BlueShield Financial Overview: Medical & Pharmacy Loss Ratio \ / of Illinois A Report Description: Provides the medical and pharmacy loss ratio and claims for the most recent reported twelve months. Month Premium Medical Paid Claims Pharmacy Paid Claims VBC Payments Total Paid Medical and Pharmacy Loss Ratio ;Nov 2016 $181,650 $195,971 $35,890 $9 $231,869 127.7% j Dec 2016 $180,916 $312,419 $38,637 $9 $351,064 194.1% ,Jan 2017 $180,080 $101,645' $39,805 $1 $141,451 78.6% Feb 2017 $179,487 $126,864 $26,052 $1 $152,917 85.2% Mar 2017 $178,895 $240,651 $43,165 $3 $283,819 158.7% Apr 2017 $178,161 $131,618 $28,106 $3 $159,727 89.7% May 2017 $176,905 $89,499 $48,856 $2 $138,356 78.2% Jun 2017 $176,312 $68,676 $35,083 $1 $103,760 58.9% Jul 2017 $176,312 $174,769 $32,105 $1 $206,875 117.3% Aug 2017 $174,146 $106,105 $37,362 $1 $143,468 82.4% Sep 2017 - $173,838 $182,472 $22,282 - $1 $204,756 117.8% Oct 2017 $172,579 $162,000 $28,505 ($2) $190,504 110.4% Summary $2,129,281 $1,892,688 $415,848 $28 $2,308,564 108.4% Loss Ratio By Month 200%- 150%- 50%- 0% 00%150%50% Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 Key Findings:The medical and pharmacy loss ratio for the most recent reported month was 2.0%higher than the average of the most recent reported twelve months,which was 108.4%. 7 CITY OF CANTON:PREM NON-HMO of Illlinoisinois Financial Overview: Network Overview D 19 BluBlueShield F Report Description: This report displays the discount amount,discount percent,paid amount and paid percent for medical claims split by Medicare/Non-Medicare,in/out of network and service category for the current period. Medicare Primary Indicator Network Indicator Service Category Covered Discount Discount% Paid %Of Paid Facility Inpatient $729,820 $395,406 54.2% $328,969 18.8% Facility Outpatient $1,220,126 $355,465 29.1% $761,856 43.6% In Network - Professional $1,433,499 $771,887 53.8% $565,943 32.4% I Summary $3,383,446 $1,522,758 45.0% $1,656,768 94.8% No FacilityInpatient $88,515 $59169 66.8% In P $29,347 1.7% Facility Outpatient $48,769 $40,987 2.3% Out of Network __--- __ .. --.__--_---- ,-- __ --.__-. . _ -__.- -_.- __ _- Professional $23,391 $1,141 4.9% $14,717 0.8% Summary $160,676 $60,309 37.5% $85,050 4.9% Summary $3,544,121 $1,583,068 44.7% $1,741,818 99.7% Facility Inpatient Facility Outpatient $20,214 $1,029 0.1% In Network Professional $19,056 $4,026 0.2% Summary $39,270 $5,055 0.3% Yes Facility Inpatient Facility Outpatient Out fNetwork _ O ' Professional.. .•.`- ._ _ __ - .. _ - .. - - .`s= -:•. Summary Summary $39,270 $5,055 0.3% Summary $3,583,391 $1,583,068 44.2% $1,746,874 100.0% Key Findings:The overall network savings discount(excluding Medicare)was 45.0%for the current period. The in-network paid percent was 95.1%for the current period. 8 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Financial Overview: Blue Card Savings Analysis • • e of Illinois Report Description:The Blue Card Savings report illustrates the value of having access to other BCBS contracts within the United States through the Blue Card program. Savings from BCBS network discounts are passed to the client,providing savings on potentially costly out of state claims that would otherwise be paid at full provider billed amount. Feb 2017-Jan 2018 Par Plan State Billed Allowed Effective Discount Paid Effective Blue Card Allowed Rate Paid Rate Access Fee !St. Louis MO $67,633 $34,939 51.7% $22,012 $33,763 49.9% $995 DC $7,200 $4,939 68.6% $2,261 $4,251 59.0% $102 NC $3,065 $1,607 52.4% $1,458 $1,512 49.3% $66 IA $17,859 $4,625 25.9% $896 $3,079 17.2% $40 IWA,AK $3,835 $1,861 48.5% $221 $1,384 36.1% $10 i WI $1,438 $717 49.9% $219 $183 12.7% $10 Premera WA,AK $246 $78 31.9% $168 $86 34.9% $8 CO $78 $13 16.4% $65 $16 20.1% $3 ;BS CA - $39 $338.4.6% -•$fi _ 0:7% . - - ,. - BC Worldwide $590 $590 100.0% $0 $259 43.9% $0 !All Other Blue Card $926 $895 96.7% $0 $465 50.2% $0 i All Other Non-Blue Card $4,070,094 $1,950,301 47.9% $1,555,761 $1,702,135 41.8% $0 Summary $4,174,714 $2,000,324 47.9% $1,583,068 $1,746,874 41.8% $1,234 Key Findings:St.Louis MO had the greatest Blue Card savings amount,with a Discount amount of$22,012. The overall Effective Allowed Rate for the current period was 47.9%. 9 _ CITY OF CANTON:PREM NON-HMO • ►.� \�J of lllinoir s B1ueShield Financial Overview. Medical Claim Expense Distribution R Report Description:The distribution of medical paid expense by claimant and the average medical paid per claimant amount are shown for the current period. Paid Band Claimants Claimants% Paid Paid% Paid/Claimant !Less than$200 63 20.9% $3,020 0.2% $48 $200-$1,000 97 32.2% $50,283 2.9% $518 1$1,001-$5,000 75 24.9% $177,294 10.1% $2,364 $5,001-$10,000 21 7.0% $140,684 8.1% $6,699 1$10,001-$30,000 29 9.6% $434,677 24.9% $14,989 $30,001-$50,000 9 3.0% $359,453 20.6% $39,939 Summary<=$50,000 294 97.7% $1,165,411 66.7% $3,964 Paid Band Claimants Claimants% Paid Paid% Paid/Claimant {$50,001-$75,000 4 1.3% $241,176 13.8% $60,294 $75,001-$100,000 1 0.3% $89,666 5.1% $89,666 �__ $250,621 �$-100,001-$150,000M� 2 0.7/0 -�-_^14_3% $125,311 � $150,001-$200,000 $200,001-$250,000 .r . $250,001-$500,000 1$500,001+ r Summary$50,001 or Greater 7 2.3% $581,463 33.3% $83,066 Combined Summary 301 100.0% $1,746,874 100.0% $5,804 Key Findings:The proportion of claimants who received less than$200 in services for the current period was 20.9%. These claimants spent 0.2%of the total paid expenses and the average paid expense per claimant was $48. 2.3%of claimants had expenses over$50,001 for the current period. These claimants spent 33.3% of the total paid expenses and the average paid expense per claimant was$83,066. 111 CITY OF CANTON:PREM NON-HMO B1ueCross BlueShield Financial Overview: High Cost Claimants ofIDinois s Report Description:This report provides a detailed listing of the top 20 high cost claimants with paid expenses of$50,000 or more for the current period. Feb 2017-Jan 2018 Age/Gender Inpatient Outpatient Professional Pharmacy Encrypted Member ID Relationship Band Leading Diagnostic Category Paid Paid Paid Paid Paid ,1033190023097568182 Spouse Female 30-39 Neoplasms $17,771 $64,354 $60,056 $1,479 $143,660 7333919212594852393 Spouse Female 50-59 $0 $7,498 $53,932 $80,425 $141,855 332544881311853446 Subscriber Male 50-59 Musculoskeletal $39,753 $20,635 $48,053 _ $655 $109,096 143696049074934515 Spouse Female 30-39 Injury/Poisoning $76,359 $0 $13,307 $511 $90,177 - - - --- -- ------- __.._.- - ---- --- - -- - - - - - - - ------ __ ... -- - -- - - - _.._ -- ... _ _-- ------- 2672764549424886794 -----2672764549424886794 Dependent Female<1-19 Digestive $52,486 $7,299 $9,155 $341 $69,281 1308153503870556903 Dependent Female 20-29 Genitourinary $26,244 $22,762 $7,525 $257 $56,788 ,2548518157508363733 Dependent Male<1-19 Injury/Poisoning $0 $42,093 $12,182 $0 $54,275 7674413743403423770 Subscriber Female 60-64 Respiratory $23,979 $6,917 $5,156 $18,223 $54,275 213552257133132743 Subscriber Male 50-59 Musculoskeletal $34,670 $7,680 $7,425 $519 $50,294 8417890962930015693 Dependent Female 20-29 Neoplasms $14,090 $10,255 $25,520 $261 $50,126 High Cost Claimant Total $285,352 $189,493 $242,311 $102,671 $819,827 11 CITY OF CANTON:PREM NON-HMO � B1ueCross B1ueShield Financial Overview: Medical Out of Pocket IR V of Illinois Report Description: Provides a distribution of claimants by their total medical out of pocket expenses for the current period compared to the prior period and percent change. This report helps determine the impact of any changes in plan design on out of pocket. Claimant Distribution by Out of Pocket Expense Bands Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change Out of Pocket Band Claimants Claimants% Out of Pocket Out of Pocket% Claimants Claimants% Out of Pocket Out of Pocket% Claimants Change Out of Pocket Change Less than$100 91 29.6% $3,804 2.0% 84 27.9% $2,765 1.4% -7.7% -27.3% $101-$200 27 8.8% $4,078 2.1% 28 9.3% $4,320 2.2% 3.7% 6.0% $201-$300 17 5.5% $4,121 2.1% 19 6.3% $4,675 2.4% 11.8% 13.4% $301-$400 15 4.9% $5,090 2.6% 20 6.6% $6,867 3.5% 33.3% 34.9% ,$401-$500 10 3.3% $4,629 2.4% 13 4.3% $5,808 3.0% 30.0% 25.5% $501-$750 44 14.3% $27,885 14.5% 42 14.0% $25,838 13.3% -4.5% -7.3% $751-$1,000 29 9.4% $24,881 12.9% 26 8.6% $22,471 11.6% -10.3% -9.7% $1,001-$1,500 37 12.1% $45,273 23.5% 29 9.6% $36,083 18.6% -21.6% -20.3% -$1,501-$2,000 23 7.5% $39,554 20.5% 17 5.6% $28,915 14.9% -26.1% -26.9% $2,001-$2,500 9 2.9% $19,210 10.0% 15 5.0% $32,649 16.9% 66.7% 70.0% $2,501-$3,000 4 1.3% $10,781 5.6% 6 2.0% $16,532 8.5% 50.0% 53.3% $3,001-$4,000 1 0.3% $3,235 1.7% 2 0.7% $6,665 3.4% 100.0% 106.0% $4,001-$5,000 0.0% 0.0% $Greater than$5,001 0.0% 0.0% Summary 307 100% $192,541 100% 301 100% $193,589 100% -2.0% 0.5% :Oyt;of Pocket'Experise'by Coverage Tier Feb 2017-Jan 2018 Coverage Tier Allowed Deductible Deductible%of Allowed Copayment Copay%of Allowed Coinsurance Coins%of Allowed Out of Pocket OPx%of Allowed Paid Employee Only $259,533 $15,011 5.8% $5,638 2.2% $10,100 3.9% $30,749 11.8% $217,076 Employee+One $557,911 $26,714 4.8% $10,398 1.9% $18,454 3.3% $55,566 10.0% $462,384 'Employee+Dependent(s) $238,756 $13,123 5.5% $8,046 3.4% $4,968 2.1% $26,137 10.9% $212,224 Family $944,124 $34,061 3.6% $20,980 2.2% $26,096 2.8% $81,137 8.6% $855,189 Summary $2,000,324 $88,909 4.4% $45,062 2.3% $59,618 3.0% $193,589 9.7% $1,746,874 This 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. This report is based on claim data and may not reflect client specific benefits being applied to member out of pocket. Please contact your Account Executive for ACCUMS reporting. 19 CITY OF CANTON:PREM NON-HMO BlueCross B1ueShield Financial Overview: Lag Report of Illinois Report Description:Displays,by paid month,the medical dollars paid and the corresponding month incurred for a 12 month rolling paid period(if available for your account). This report provides insight into the monthly claim lag and can help identify IBNR. Incurred Paid Month Month Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Summary ;All Prior ($2,547) ($29) $200 ($150) ($2,526) Feb 2016 $263 $263 Mar 2016 $0 Apr 2016 ($58) $488 $430 --------_ -- - - --- __..- - ---`--- - ----- --- `-- -- - -- --- - -- - - - _- -- - ---- ------ ------------ ------f �May2016 $441 $7 $448 Jun 2016 $130 $1,132 $86 $1,347 iJul2016 $437 $106 $452 ($358) ($4) $28 $660 Aug 2016 $122 $77 ($238) $55 $28 $45 'Sep 2016 $114 $3,171 $1,224 ($628) $11 -$3,892 Oct 2016 $274 $617 ($323) $6 ($8,978) $11 ($8,393) i Nov 2016 $576 $974 $68 ($396) $143 $11 $1,376 ; Dec 2016 $2,244 $3,076 $9,075 $2,049 $683 $11 $17,138 ;Jan 2017 $21,321 $20,145 $1,213 $85 $27 $42,791 Feb 2017 $63,035 $64,836 $957 $148 $1,226 $171 $2,821 $133,193 Mar 2017 $126,066 $105,802 $3,823 $982 $1,044 $226 $1 ($7) $237,935 Apr 2017 $44,296 $58,676 $25,488 $1,566 $14 $130,040 May 2017 $70,850 $22,016 $4,494 $283 $38 $69 $97,751 Jun 2.017 $56,080 $10,965 $573 $90 $101 $67,809 gul 2017 $55,179 = .$45,1,32-7 $3,216 $68;14 $2,203- $299 - ..4$5,734) $168,489 , -{ Aug 2017 - $69,627 $31,864 $1;309 $345 $26,613 $129,7S8- Sep 2017 129,758Sep'2017 $53,519 $89,308 $2,607 $10,395 $6,435 $162,264 r Oct 2017 $109,832 --^-$40,853 --_-$8,599------$2,352 ---_ $161,635 Nov 2017 $64,779 $77,499 $12,262 $154,541 Dec 2017 $73,864 $75,330 $149,194 IJan2018 $96,792 $96,792 Summary $85,454 $219,468 $163,300 $131,816 $108,047 $74,187 $106,912 $90,021 $271,552 $111,459 $197,301 $187,356 $1,746,874 1� CITY OF CANTON:PREM NON-HMO B1ueCross,B1ueShield Financial Overview: Overall Medical Paid PMPM by leading Diagnostic Category ►.�r of Illinois Report Description:Lists the top 15 overall paid expense across inpatient facility,outpatient facility,and professional settings by leading diagnostic categories for the current month,current period,prior period and percent change. Paid Period Jan 2018 Feb 2016- Feb 2017- %Change Medical PMPM by Leading Diagnostic Category Jan 2017 Jan 2018 Leading Diagnostic Category Paid PMPM Paid PMPM Paid PMPM Paid PMPM !Digestive $129 $57 $42 -26.3% f Injury/Poisoning $125 $72 $72 0.0% ;Symptoms/III-Defined $93 $65 $56 -13.8% Neoplasms $51 $21 $57 171.4% Musculoskeletal $45 $51 $59 15.7% - Circulatory $38 $141 $31 -78.0% j Respiratory $26 $22 $22 0.0% Pregnancy $17 $19 $12 -36.8% Residual/Unclassified $16 $7 $13 85.7% Nervous System $13 $27 $20 -25.9% Endocrine $10 $40 $14 -65.0% - Skin Diseases $10 $11 $2 -81.8% !Blood Diseases $8 $2 $12 500.0%. Mental HealtR $7 $8 $9 12:5%: Genitourinary $7 $23 $27 17.4% All Other Values $3 $44 $11 -75.0% Summary $597 $608 $459 -24.5% 0 $20 $40 $60 $80 $100 $120 $140 $160 ® Feb 2016-Jan 2017 = Feb 2017-Jan 2018 Key Findings:The top three Leading Diagnostic Categories in the current reporting month based on Paid PMPM were Digestive,Injury/Poisoning,and Symptoms/III-Defined. 14 CITY OF CANTON:PREM NON-HMO s B1ueSueld Pharmacy: Financial Summary of Illinois • Report Description: This report provides an overview of pharmacy order of reduction from billed to paid for the current month,current period,prior period,and percent change. Pharmacy Order of Reduction Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change 'Billed .$66,019 $1,039,171 $951,008. -8.5% ._--- - - ..- - _.. Covered $66,019 $1,039,171 $951,008 -8.5% -- iDiscount $36,296 $507,210 $515,685 � 1.7% Breakdowno Billed Amount Allowed $29,723 $531,961 $435,322 -18.2% 100% - -$-'5'-2,-,0-13- -__,___._—__ _ _._---.-__-_8,___.._.__.____.__ i0ut of Pocket $3,626 $52,013 $48,611 6.5% Other Adjustments ($15) ($225) ($360) -60.0% 90% IPaid Provider $26,112 $480,172 $387 071 19 4% 80% Paid_ $26,112 �--- $480,172_.._._.- . $387,071___ _ --- _19.4% . 70%- 60%- Discount 0%60% Discount }" Out of Pocket 40%- Total 0%Total Pharmacy Paid vs.Specialty Paid Other Adjustments 30% Q Prior Current Paid Provider $500,000 - 20% "`�.` •.;- ._ $400;000 -:10% $300,000 0% $200,000 Prior Current $100,000 •-� - Total Paid Specialty Paid Prior $480,172 $142,301 j Current $387,071 $83,567 15 CITY OF CANTON:PREM NON-HMO BIueCross B1ueShield Pharmacy: Key Indicators •.• of Illinois Report Description:This report provides an overview of the prescription expenses as well as providing percent change in these expenses between the current month,current period,prior period and percent change. Key Indicators Summary Key Indicators Summary Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change Unique Pharmacy Members 314 339 333 -1.8% Average Age(Years) 35.1 35.0 35.1 0.3% ;Proportion of Males 53.8% 53.4% 53.6% 0.4% Proportion of Females 46.2% 46.6% 46.4% -0.5% Member Months 314 3,872 3,807 -1.7% Claimants 140 256 257 0.4% I Services 393 4,995 5,137 2.8% I _- --_1_______.________..__. - - - _ - ---- - --- - --- - - ------------ --- -------_._.- -.------- -- Prescriptions PMPM 1.25 1.29 1.35 4.6% Paid_-_ -- -- --- ---- --_ _ - - $26,112 . __ -- ----- -$480,172 ----- -- - - -$387,071 -_ --- -19.4% ----' Paid PMPM $83.16 $124.01 $101.67 -18.0% Allowed $29,723 $531,961 $435,322 -18.2% Allowed PMPM $94.66 $137.39 $114.35 -16.8% Avg.Ingredient Cost/Prescription $74.99 $105.59 $84.09 -20.4% - 1 Generic Dispensing Rate 84.7% 84.1% 84.7% 0.7% ;formulary Compliance Rate 92.9% 92.8% 93.5% 0.8% Generic Substitution Rate 100.0% 99.7% 99.9% 0.2% --------------r-- ---A----- --- - _ -- ------ --- -- - _ - -9-. -,,- 9-. -.. .._..__.-_-. -- -- - -- - ---- - - iOUt of Pocket Percent of Allowed- 12.2% 9.8% 11.2% 14.2% � Retail as a Percent of Prescriptions 97.0% 96.2% 96.9% 0.7% ;Mail Order as a Percent of Prescriptions 3.1% 3.8% 3.1% -18.5% Specialty Percent of Total Prescriptions 0.0% 0.4% 0.2% -50.0% rSpecialty Percent of Total Paid 0.0% 29.6% 21.6% -27.2% i Specialty Average Ingredient Cast/Prescription" =• '; $0•. -, $7,911.64 - :- , : - $9,288.36 17.4% Cost Sharing Distribution Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change Cost Sharing Distribution Retail Mail Retail Mail Retail Mail Retail Mail Member Out of Pocket 12.2% 12.8% 9.7% 10.3% 11.3% 10.0% 15.8% Plan Paid 87.8% 87.3% 90.3% 89.7% 88.7% 90.0% -1.7% 0.3% Savings Summary Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change Savings Summary Retail Mail Summary Retail Mail Summary Retail Mail Summary Retail Mail Summary !Discount_ _ --- _ $33,163 __ $3,133 $36,296 $443,445 $63,765 _ $507,210 -$465,432- $50,253 $515,685 - 5.0% -21.2% 1.7% Discount 54.1% 65.7% 55.0% 47.7% 58.7% 48.8% 53.7% 59.4% 54.2% 12.7% 1.3% 11.1% 1 F; CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Generic vs. Formulary Experience •.• 0 of Illinois A Report Description: For the current period,the prescription drug expenses are displayed below for retail and mail order providers and broken out by drug type and formulary indicator. Total Expense Member Expense Plan Expense %of Total Allowed/ Out of Pocket/ Paid/ Retail Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription ;Generic 4,229 85% $81,335 $19.23 $28,277 $6.69 $53,058 $12.55 Brand 750 15% $319,682 $426.24 $16,900 $22.53 $303,142 $404.19 Summary 4,979 100% $401,017 $80.54 $45,177 $9.07 $356,200 $71.54 Brand Type Breakdown Single-Source Brand 678 14% $284,440 $419.53 $14,841 $21.89 $269,959 $398.17 Multi-Source Brand 72 1% $35,242 $489.47 $2,059 $28.60 $33,183 $460.87 Multi_Source Brand w/DAW1- 29 1% $31,055 $1,070.88 $996 $34.34 $30,060 $1,036.54 Brand Formulary - 433 9% $157,301 $363.28 $9,208 ---" $21.26 - - - $148,094- - $342.02 o• Brand Non-Formulary 317 6% $162,381 $512.24 $7,693 $24.27 $155,048 $489.11 Total Expense Member Expense Plan Expense %of Total Allowed/ Out of Pocket/ Paid/ Mail Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription Generic -- _-- - -- rt123 78% $5,533 $44.98 $1,623 $13.20 $3,910 $31.79 Brand 35 22% $28,773 $822.07 $1,811 $51.75 $26,961 $770.33 Summary 158 100% $34,306 $217.12 $3,434 $21.74 $30,871 $195.39 Single-Source Brand 27 17% $24,236 $897.64 $1,290- ------ -$47.78-._____-_ $22,946 $849.86 Multi-Source Brand 8 5% $4,536 $567.05 $521 $65.15 $4,015 $501.90 ;Multi-Source Brand w/DAW1 4 3% $4,295 $1,073.81 $280 $70.00 $4,015 $1,003.81 Brand Formulary - 20 13% $18,515 $925.75 $800 $40.00 $17,715 - _ $885.75 Brarid Non-Formulary 15 9%- $10,258-. $683.84 $1,011 $67.41_ $9,246 $616,42 - Total Expense•-• • Member Expense - Plan Expense %of Total Allowed/ Out of Pocket/ Paid/ Total Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription Generic 4,352- -------- 85% $86,868__ $19.96- $56,968 y-- $13_09 " - $29,900 - --- --$6.87 _ �------------ - __-�-_------------ ----- -- - ----------- ----- --- - - - ------- -- -------- ------ Brand 785 15% $348,455 $443.89 $18,712 $23.84 $330,103 $420.51 Summary 5,137 100% $435,322 $84.74 $48,611 $9.46 $387,071 $75.35 Brand Type Breakdown ;Single-Source Brand 705 14% $308,676 $437.84 -- --$16,131 _ - __ _--_-- ----.___ _ $22.88 - $292,905 _ __.. _. $415.47 _ .i Multi-Sour ce Brand 80 2% $39,778 $497.23 $2,580 $32.25- $37,198 $464.98- - - Multi-SSource Brand w/DAWl 33 1% $35,351 $1,071.23 $1,276--- - $38.66 - $34,075- - $1,032.57 "- Brand Formulary - 453 9% $175,816 $388.12 $10,008 $22.09 $165,809 $366.02 Brand Non-Formulary 332 6% $172,638 $519.99 $8,704 $26.22 $164,294 $494.86 17 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Top Non-Specialty Therapeutic Drug Classes •.• e of Illinois Report Description: The top 25 therapeutic drug classes for the current period are displayed below ranked by ingredient cost. Avg.Ingredient Avg.Ingredient Current/ Cost/ Cost/ Prior Utilizing Prescription Prescription % % Rank by Rank Plan Therapeutic Class Prescriptions Members Ingredient Cost (Current) (Prior) Formulary Generic Volume 1 1 Insulin 125 9 $78,138 $625.10 $584.88 96.0% 0.0% 11 2 2 Antimyasthenic/Cholinergic Agents 11 1 $30,438 $2,767.12 $2,648.38 0.0% 0.0% 87 ----- - ---- ---- - -- ---- -- - -- - - ---- - - - - ------- ------- -- -- - 3 4 Sympathomimetics 95 31 $21,090 $222.00 $209.70 95.8% 17.9/0 14 4 Sodium-Glucose Co-Transporter 2(SGLT2)Inhibitors 33 3 $14,035 $425.29 $393.13 100.0% 0.0% 44 5 6 Direct Factor Xa Inhibitors 26 5 $12,675 $487.50 $485.43 100.0% 0.0% 50 6 7 Prostaglandin-Impotence Agents 32 7 $10,924 $341.38 $283.03 37.5% 3.1% 45 7 14 Dipeptidyl Peptidase-4(DPP-4)Inhibitors 14 2 $8,288 $592.02 $825.36 100.0% 0.0% 72 -.__v___-----...___,.._._-__-_. 8 11 Diagnostic Tests 52 7 $6,371 $122.53 $144.74 88.5% 0.0% 27 9 22 Phenothiazines 15 3 $5,937 $395.81 $311.45 100.0% 100.0% 71 10 8 HMG CoA Reductase Inhibitors 283 43 $5,872 $20.75 $30.89 98.6% 98.6% 1 11 Selective Serotonin Reuptake Inhibitors(SSRIs) 228 34 $5,741 $25.18 $15.46 97.4% 97.4% 3 12 13 Anticonvulsants-Misc. 138 21 $5,328 $38.61 $51.64 100.0% 92.0% 8 13 9 Stimulants-Misc. 48 6 $5,280 $110.00 $139.90 89.6% 89.6/ 29 14 Combination Contraceptives-Oral 124 23 $5,250 $42.34 $26.38 86.3% 86.3% 12 15 20 Amphetamines 39 6 $5,200 $133.32 $157.34 100.0% 69.2% 37 16 10 Antihypertensive Combinations 148 18 $4,841 $32.71 $50.60 96.6% 94.6% 7 17 21 Antidiabetic Combinations .12 1 $4,571 $380.90 $369.91 - 100.0%. 0.0% 79 ` 18 �• 24 Thyroid Hormones 205 24 4, 43` $21.18 $10.27 77.1%'.` 77.1% 4 _ 19 25 Bronchodilators-Anticholinergics 12 2 $4,145 $345.41 $319.88 8.3% 82 ------2 __ ---- dil --- - -_ - - ------ - -- - --__12---- - ----- - __--- 4 --_ - --_ - - - -- -- --_____100.0q7.___- -- ----__- -- --- - 20 Anti-Obesity Agents 21 2 $4,104 $195.41 $164.94 0.0% 0.0% 61 21 Irritable Bowel Syndrome IBS Agents 4 2 $4,067 $1,016.65 $625.41 100.0% 0.0% 122 22 Gout Agents 33 5 $4,001 $121.23 $156.89 57.6% 57.6% 42 23 19 Fibromyalgia Agents 4 1 $3,742 $935.46 $551.39 0.0% 0.0% 121 24 15 Immunosuppressive Agents 26 1 $3,339 $128.41 $156.47 100.0% 100.0% 52 1 25 5 Hemostatics-Systemic 9 3 $3,317 $368.56 $1,773.90 88.9% 88.9% 100 j All Other 3,390 243 $85,805 $25.31 $43.23 95.5% 93.3% Summary 5,127 257 $346,840 $67.65 $77.36 93.7% 84.9% 1R CITY OF CANTON:PREM NON-HMO B1ueCross B1ueSlueld Pharmacy: Top Non-Specialty Prescription Drugs • • orli inois H Report Description: The top 25 prescription drugs for the current period are displayed below ranked by ingredient cost. Avg.Ingredient Avg.Ingredient Current/ Cost/ Cost/ Prior Utilizing Ingredient Prescription Prescription Formulary Generic .Rank by Rank Brand Name Plan Therapeutic Class Prescriptions Members Cost (Current) (Prior) Indicator Indicator Volume ' 1 1 MESTINON TAB60MG Antimyasthenic/Cholinergic Agents 11 1 $30,438 $2,767.12 $2,648.38 NO NO 140 j 2 3 NOVOLOG INJ 100/ML Insulin 15 2 $23,150 $1,543.31 $1,256.59 YES NO 71 3 4 . NOVOLOG MIX INJ 70/30 Insulin 11 1 $15,444 $1,404.02 $1,300.06 YES NO 139 j 4 5 LANTUS INJ SOLOSTAR Insulin 31 3 $13,854 $446.92 $392.32 YES NO 11 5 8 XARELTO TAB 20MG Direct Factor Xa Inhibitors 21 3 $10,960 $521.88 $435.85 YES NO 46 6 6 NOVOLOG INJ FLEXPEN Insulin 15 2 $7,818 $521.22 $536.34 YES NO 70 ! 7 7 LANTUS INJ 100/ML Insulin 29 3 $7,186 $247:81 $252.26 YES NO 15 8 23 ADVAIR DISKU AER 500/50 Sympathomimetics 14 2 $6,623 $473.10 $450.82 YES NO 75 9 17 CHLORPROMAZ TAB 100MG Phenothiazines 13 1 $5,930 $456.17 $337.18 YES YES 89 10 9 LEVEMIR INJ Insulin 12 1 $5,864 $488.63 $547.72 YES NO 104 j 11- --JARDIANCE TAB 10MG - Sodium-Glucose Co-Transporter 2(SGLT2 R� 13 ri 1 $5,558 $427.53 _ - YES NO 87 12 16 KOMBIGLYZ XR TAB-2.5-1000 Antidiabetic Combinations 12 1 $4,571 $380.90 $369.91 YES NO 106 13 19 VIAGRA TAB 100MG Prostaglandin-Impotence Agents 12 3 $4,402 $366.84 $279.66 NO NO 99 i 14 13 LYRICA CAP 300MG Anticonvulsants-Misc. 11 1 $4,351 $395,51 $353.12 YES NO 133 15 24 LIPITOR TAB 40MG HMG CoA Reductase Inhibitors 4 1 $4,295 $1,073.81 $901.29 NO NO 353 { 16 JARDIANCE TAB 25MG Sodium-Glucose Co-Transporter 2(SGLT2 10 1 $4,258 $425.77 YES NO 163 i 17 47 ADVAIR DISKU AER 250/50 Sympathomimetics - 8 2 $4,219 $527.38 $967.30 YES NO 212. 18 20. SPIRIttA `"CAPHANDIHLR Bronchodilators-Antichofihergics 11- 1 "$4,121 "$374.60 _ _$349.1'1-;"••"= YES'- NO Y ) g , , $4067 $1016.65' - $684 77 YES NO 366 19 27 LINZESS CAP 290MCG Irritable Bowel S hdrome IBS Agents 4 "2� � + 20 93 ONGLYZA TAB 5MG Dipeptidyl Peptidase-4(DPP-4)Inhibitors 10 1 $3,809 $380.90 $375.41 YES NO 159 SAVELLA.-TAB 50MG _A Fibromyalgia Agents -� - - 4__ 1. $3,742-" $935.46-" $594,42_ __-NO -_ NO--^368 22 26 ULORIC TAB 80MG Gout Agents 12 1 $3,674 $306.19 $286.50 NO NO 126 ( 23 32 VYVANSE• CAP 70MG Amphetamines . 12 1 $3,236 $269.66' $252.77 YES NO 125 24 75 LO LOESTRIN TAB Combination Contraceptives-Oral 17. 4 $2,935 $172.64 $111.34 NO NO 54 25 35 RAPAFLO CAP8MG _ Prostatic Hypertrophy Agents - _ - 12 -1 $2,719 $226.55 $212.69 NO NO 121 All Other 4,803 256 $159,617 $33.23 $48.93 Summary 5,127 257 $346,840 $67.65 $77.36 1A CITY OF CANTON:PREM NON-HMO (� B1ueCross B1ueShield Pharmacy: Specialty Drug Analysis \ / of Illinois 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.This report provides specialty drug analysis for the current month,current period,prior period and percent change. Specialty Drug Key Indicators Top Specialty Classes by Ingredient Cost for the Current Period Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change I Unique Pharmacy Members 314 339 333 -1.8% Member Months 314 3,872 3,807 -1.7% 4.5%-- -- !Claimants 3 2 -33.3% Percent of Utilizing Members 0.0% 0.9% 0.6% -32.1% IServices 18 9 50.0% ! Specialty Percent of Total Paid 0.0% 29.6% - 21.6% _ -27.2% A, © CANCER-ORAL ;Percent of Total Prescriptions Paid 0.2/ ---_ OVO% ^_ 0 4% °- ^-51.4/ h Paid $142,301 $83,567 -41.3% ' _+ (Paid PMPM $36.75-- _-- $21:95 40.3% AUTOIMMUNE Average Ingredient Cost/Prescription $7,912 $9,288 17.4% ----_-------— __.Out of Pocket $120 $35 -70.8% Out of Pocket PM PM $0.03 $0.01 -70.3% l Out of Pocket Percent of Allowed 0.0%#»vY � - L001% �-- 0.0% X50`3% ___95.5% Top 15 Specialty Drugs by Ingredient Cost for the Current Period Avg.Ingredient Ingredient Cost/ Specialty Top Specialty Classes by Ingredient Cost for the Prior Period Brand Name Specialty Class Cost Prescriptions Prescription Claimants �IMBRUVICA CAP140MGCANCER-ORAL_ $7_7,643 7 $11,091.81 XEUANB_2 TA5MG -_ AUTOIMMUNE-�_ _ $3,726 _ _ 1 _- v$3,72_6.3_8 1 VENCLEXTA TABSTARTPK- CANCER-ORAL $2,226 ------ $2,226.16 -__.____1�i 1.7%— Summary_:_ $83,595 - 9 $9,288.36:.'' 2 _ 124 - .i ' i ] CANCER-ORAL AUTOIMMUNE !_71 HEMOPHILIA 85.9 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueSlueld Appendix: ICD Category Definitions •.• a ofMinois x x Complications of Pregnancy,Childbirth and the Puerperium: Includes vaginal and cesarean deliveries and complications of pregnancy,such as ectopic and molar pregnancies. Puerperium refers to 42 days following childbirth and expulsion of the placenta. Refers to the mother only. Conditions Influencing Health Status:This includes post-surgical states,organ/tissue transplants,artificial limbs and replacements. Examples include knee replacements and kidney transplant status. Conditions in the Perinatal Period:Perinatal refers to the period beginning after the 28th week of gestation and ending 28 days after birth. Problems can include hemorrhage, digestive disorders,respiratory distress syndrome and disorders relating to short gestation and unspecified low birth weight. Congenital Anomalies: Includes the treatment of any condition present at birth.This includes Spina Bifida,cleft palate, Down's Syndrome,heart disease, kidney displacement &polycystic kidney disease. Diseases of the Blood and Blood Forming Organs: Includes any problems associated with white or red blood cells,platelets or plasma.An example includes Anemia,a deficiency in red blood cells. Diseases of the Circulatory System:Includes problems with the heart,blood vessels and circulation.Some common diagnoses include Coronary Artery Disease,cardiovascular disease,and stroke. Diseases of the Digestive System: Includes the treatment of any organ or area of the body pertaining to digestion.These areas include the mouth/teeth,esophagus,stomach, intestines,gall bladder,liver and pancreas.Diagnoses include:Esophageal Reflux,Gastroenteritis,Appendicitis and hernias. Diseases_of the G nitoAdriary System: Includes'prrob]ems.related to the kidneys,bladder and rale and female genitalia.Common`diagnoses ihclude"Fiertraturia;-Urinary Tract Infection,Acute or Chronic Renal Failure arid.Calculus of Kidney(stories).' Diseases of the Nervous System:Includes treatment for disorders of the Central and Peripheral Nervous systems. Diagnoses include:Carpal Tunnel Syndrome,Obstructive Sleep Apnea,Epilepsy,Multiple Sclerosis,Alzheimer's Disease and Migraine headaches. Diseases of the Respiratory System: Includes treatment for diagnoses such as Asthma,Pneumonia, Emphysema,Pharyngitis,Sinusitis, Bronchitis and COPD.These can be acute or chronic in nature. Diseases of the Skin and Subcutaneous Tissue:This involves any condition relating to the skin or beneath the skin,including hair and nails.Some conditions include Acne, Corns,Cellulitis,Psoriasis, Dermatitis and fungal infections. 71 CITY OF CANTON:PREM NON-HMO BlueCross B1ueShield Appendix: ICD Category Definitions •.• 0 of Illinois Ears and Mastoid: Includes any condition pertaining to the ear or the mastoid process.The mastoid process is the portion of the temporal bone extending down behind the ear.Diagnoses include Otitis Media,Tinnitus,Menieres Disease,Hearing Loss and Labyrinthitis. Endocrine,Nutritional and Metabolic Diseases:Endocrine disorders include those of the endocrine glands and includes the thyroid,pituitary,pancreas,ovaries and testes. Disorders include Diabetes,thyroid disease,Obesity,Hyperlipidemia,Cystic Fibrosis and any disease affecting the immune system. Health Services:This includes elective surgeries,other procedures&aftercare,rehabilitation and dialysis.Specific examples include: long-term medication use, Physical Therapy and chemotherapy. Health Services:Reproduction and Development: Include services pertaining to the child only.For example,normal pregnancy,post-partum care and exam or health supervision of an infant or child. Infectious and Parasitic Diseases: Includes diseases caused by microbes outside of the body that infect and cause damage within the body.These diseases are recognized as communicable or transmissible.Diagnoses include HIV, Hepatitis,Colitis&intestinal disruptions such as food poisoning. Injury and Poisoning:Includes treatment for injuries to the body or for any poison ingested.Diagnoses include sprains&strains,fractures,burns and lead poisoning. Patients are most commonly seen in the emergency room for acute conditions. Mental Health:Refers to a group of disorders causing severe disturbances in thinking,feeling or relating.Includes treatment of any condition that affects mood or behavior. The most common diagnoses include anxiety disorders,depressive disorders and schizophrenia. Musculoskeletal anl:Gonnective Tissue.Qisease: Includes orthbpedictreatment,which.vvouId.involve anything related.t&fHLi bones,muscles,join#s'anclsot tissue.Diagnoses': Arthritis,:T ndonitis,back disorders;di§c disorders, rheumatisp�„aM scoliosis.These-diagnoses are more chronic•in na'ture:> Neoplasms: Includes any abnormal growth of cells,either benign or malignant(cancer).Though these can be found at any spot of the body,some of the most common forms include neoplasms of the breast,prostate,stomach and brain.Other examples include Leukemia and Hodgkin's Disease. Other Circumstances:This includes convalescent care and follow-ups to surgeries and examinations. Potential Health Hazards: Personal or family history of diseases or disorders;e.g.,breast cancer. ?2 CITY OF CANTON:PREM NON-HMO onSBlueshieid Appendix: ICD Category Definitions f Ulios Procreative and Contraceptive Management:This includes artificial insemination,fertility testing,genetic counseling,family planning,sterilizations and contraceptive management. Signs,Symptoms and III-Defined Conditions:Includes signs,symptoms,abnormal lab results and ill-defined conditions for which no known cause can be found.For example,a patient may experience chest pain,but no known cause is found. Substance Abuse:Includes behavior marked by the use of chemically active agents,such as prescription or illicit drugs,alcohol or tobacco.Cognitive,behavioral and physiological symptoms indicate that the person continues use of the substance. Without Reported Diagnosis:This includes general medical examinations,gynecological exams,mammogram screenings,preventive services,physicals and special screenings for neoplasms. �3 CITY OF CANTON:PREM NON-HMO Glossary Blulinois B1ueSlueld ►.� � of Illinois A Admin Fees:The charge to an account for HCSC's operational cost of doing business. Administrative Services Only(ASO):A contract between HCSC and a self-funded plan where HCSC performs administrative services only and does not assume any financial risk.Services usually include claims processing but may include other services such as actuarial analysis and utilization review. Aggregate:Constituting or amounting to a whole. For example,an aggregate account report includes data for the entire account. Aggregate Stop Loss:A form of reinsurance that provides protection for medical expenses above a certain limit,generally on a year-by-year basis.Aggregate stop loss provides protection against the accumulation of total claims for a group as a whole exceeding a stated level. Allowed:Amount considered eligible for payment by the plan ASO Adjustments:An amount added or deducted from ASO(Administrative Services Only)fees.This includes Stop Loss Reimbursements. 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 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. ,,Billed:Amount submitted for-payment by:th'e 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 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. 94 CITY OF CANTON:PREM NON-HMO Glossary B1u s B1ueSlueld �.� ® of Illinois 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 Co-payment: Flat rate that the member is responsible to pay for the claim 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. Deductible;Portion of annual deductible amount member is responsible to pay applied to the claim. Dental Loss Ratio:Calculated as the Dental Paid Claims Amount divided by the Billed Dental Premium Amount. 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. 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 claimahat tells whether.a presc`riptierA:is single source brand;-multi-source brah&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 .�5 CITY OF CANTON:PREM NON-HMO GrossSlueShield Glossary ofIlli ►.� of Illinois fi 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 reporting period 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 Facility Inpatient claims International Classification of Diseases(ICD):An official list of categories of diseases,physical and mental,issued by the World Health Organization(WHO). Leading ICD 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 Diagnostic Category for the reporting period MAC Program Savings:Savings achieved by using the MAC(maximum allowable cost)discount on generic medications 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 divided by the total Billed Premium Amount for Medical and Pharmacy, wh&e 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. Not Covered:Amount considered not eligible for payment by the plan(excludes the discount amount) - 7R CITY OF CANTON:PREM NON-HMO Glossary B1ueCross B1ueSlueld �.� of Illinois R 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 Out of Pocket:Total amount that is the responsibility of the claimant.It is calculated as:(Copay+Deductible+Coinsurance) Outpatient Facility:Refers to Facility Outpatient claims Paid:Total amount paid by the plan,including access fees,adjustments,and surcharges 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/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 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:•Ari amount paidao covertfie+lealth Plan's liabilityfoe phatmacy services provided t'.Members-for claims thathaye-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 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 97 CITY OF CANTON:PREM NON-HMO Glossary (� BlueCross B1ueSlueld ►.� v of Illinois RD" 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 Professional:Services provided by physicians or other professional providers. 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. Rx Credit Fees:Drug rebates that are credited back to the account. Rx Paid PEPM: Prescription drug paid amount per employee per month Rx Paid PMPM:Prescription drug paid amount per member per month Service Category:A classification based on claim type Service Type:Classification based on principal diagnosis or ICD 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 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. Specific Stop Loss:A form of reinsurance that provides protection for medical expenses above a certain limit,generally on a year-by-year basis.Specific(or individual)stop loss limits the cost of eligible medical.expenses for each covered individual. Subrogation Savings: Portion of amdunt eligible for payment Qriginally=.paid•by the plan but that has since been-recovered•throvgh 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 and pharmacy dollars paid to cover healthcare services provided to members for claims that have been processed and approved for payment Total Paid Claims+Recoveries:The total amount paid by the plan plus any amount recovered through subrogation. Workers Compensation Savings: Portion of amount eligible for payment that has been paid a third party Workers Compensation carrier 9R CITY OF CANTON:PREM NON-HMO Btu B1ueSlueld ►�� 0 of Illinois n a Blue Insight Monthly Financial Report ,- a CITY OF CANTON: PREM NON-HMO Y; 1! 02/01/2017 to 01/31/2018 A Division of Health Care Service Corporation,a Mutual Legal Reserve Company(HCSC),an Independent Licensee of the Blue Cross and Blue Shield Association. ©Copyright 2018 Health Care Service Corporation.All rights reserved. B1ueCross B1ueShield Table of Contents •.• e ofIDinois N PLAN PERFORMANCE Data Parameters 3 Pharmacy Financial Summary 15 Enrollment Overview 4 Financial Overview Key Indicators 16 Financial Summary 6 Generic vs. Formulary Experience 17 Top Non-Specialty Therapeutic Drug Classes 18 Medical & Pharmacy Loss Ratio 7 Network Overview 8 Top Non-Specialty Prescription Drugs 19 Blue Card Savings Analysis 9 Specialty Drug Analysis 20 Medical Claim Expense Distribution 10 Appendix 21 Glossary 24 High Cost Claimants 11 Medical Out of Pocket 12 - Lag Report 13 - Overall Medical Paid PMPM Leading Diagnostic Category 14 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Data Parametersorlilinois ti ti Current Period: The current reporting period represents claims paid from February 1, 2017 through January 31, 2018. Prior Period: The prior reporting period represents claims paid from February 1, 2016 through January 31, 2017. The report includes medical claims and pharmacy claims. Reporting Segments: ALL Characteristics: ALL Group/Sections: ALL Reporting Support Contact Information For reporting support,,please contact Client Reporting Service Center Email: client_reporting@bcbsil.com Phone: 1-877-837-1866 Hours of Operation: Monday - Friday: 8:00am - 5:00pm CT Report prepared on 02/10/2018 s CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Enrollment Overview eof Illinois R Report Description: Provides the current enrollment based on the current period. Medical Medical Pharmacy Pharmacy Month Subscribers Members Subscribers Members Feb 2017 132 322 132 322 Mar 2017 132 321 _ 132 321 Apr2017 131 320 131 320 1 May 2017 131 320 131 320 jJun 2017 131 320 131 320 Jul 2017 131 320 131 320 ,Aug 2017 130 317 130 317 Sep 2017 128 311 128 311 Oct 2017 129 314 129 314 Nov 2017 129 314 129 314 ;Dec 2017 128 314 128 314 Jan 2018 128 314 128 314 Enrollment by Tier Enrollment by Gender i Prior 19.7% 19.8% 48.7% Prior = ''• 46.6% i Current 1%0% 18.45.1, 49.8% Current - ,46.4% )� Employee Only ® Employee+One Employee+Dep(s) - Family Male C] Female 4 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Enrollment Overview •.• e of Illinois n e Report Description: Provided medical demographics for the current period compared to the prior period and percent change. Medical Demographics Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change • Overall,membership decreased by 1.9%between reporting periods !Average Membership 323 317- -- --1.9%- -r Employee 131 130 -0-8% The average age was 35.1 and increased by 0.3%between reporting --------- - -T�_.- - __----- -- - -- -- - - ----- periods. !Spouse 71 69 -2.8% - ------- ------ -- - -- -- -- =- -- - - - - --- -� Contract size decreased by 4.0%between reporting periods. Dependent 121 119 -1.7% Females between the ages of 20 and 44 decreased from 15.0%to 14.3% Average Contract Size 2.5 2.4 -4.0% between reporting periods. Average Age 35.0 35.1 0.3% !Employee 48.1 48.0 -0.2% Spouse 47.0 47.1 0.2% Average Medical Membership !Dependent 13.7 14.1 0.2% Under 30 41.3% 41.1% -- -------.._..---- -- --- - -- - -- -- -------- -- - -, Prior 21:9% ! 37.49vo' 1%30 to 49 27.9% 28.7% 50 to 64 30.3% 29.5% 65+ 0.5% 0.7% ,Proportion of Males 53.4% 53.6% t Current 21.6% ' 37.4% Proportion of Females 46.6% 46.4% !Females Ages 20-44 15.0% 14.3% � -•----- = Employee Q Spouse = Dependent CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Financial Overview: Financial Summary © ofIDinois F Report Description:Provides a breakdown of the medical order of reduction from billed to paid for the current month,current period,prior period and a percent change. This report may highlight key measures and their potential impact on paid expenses. Medical Order of Reduction Breakdown of Billed Amount Paid Month Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change 100% - ;Billed $417,955 $5,832,402 $4,174,714 -28.4% - -- -- ----- - - -- - - - - - --- -- - 90% Not Covered $48,989 $838,080 $591,322 -29.4% Covered $368,967 $4,994,322 $3,583,391 28.3% 80% -`- -- - - -- -— --- - - ._ - -- - —-- — ---- ® Not Covered Discount $146,209 $2,353,141 $1,583,068 -32.7% 70%- Discount Allowed _ $222,757 $2 641,181 $2,000,324 -24.3% 60%- Out of Pocket Out of Pocket $26,015 $192,541 $193,589 0.5% - - - - - - _$ "- -- �--- 50% - COB $6,625- $58,650_ $19,242 -67.2%- CO Medicare COB Medicare $2,308 $14,909 $30,468 104.4% 4OYO ___. Other Reductions Other Reductions $456 $22,970 $11,410 -50.3% 30% ] Other Adjustments Other Adjustments $0 ($50) ($25) 50.0% o -- -- -- --- --- -- - - - -- - - --- -- - 20%- Paid Provider Paid-Provider $187 354 $2,352,160 $1,745,640 -25.8% ----- -- -- ---- - - ' - -- - - - -- ---- - - —- - 1070 Other Payments $2 $1,910 $1,234 -35.4% Medical Paid $187,356 $2,354,070 $1,746,874 -25.8% 0% Prior Current Group Liability Breakdown Paid Month Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change Medical Paid $187,356 $2,354,070 $1,746,874 -25.8% Pharmacy Paid $26,112 $480,172 $387,071 -19.4% 'VBC Payments ` ($1) $106 $10 -90.5% - total Paid Claims' $213,.467 $2;834,349 •$2,133,955 Recoveries $0 $0 $0 0.0% Total Paid Claims+ Recoveries $213,467 $2,834,349 $2,133,955 -24.7% i HCA Draft Amount $0 $0 $0 0.0% Group Liability $213,467 $2,834,349 $2,133,955 -24.7% Other reductions includes penalties, workers compensation savings,and subrogation savings. Other payments includes Blue Card access fees and surcharges.Also displayed are other adjustments. G CITY OF CANTON:PREM NON-HMO BlueCross B1ueShield Financial Overview: Medical & Pharmacyloss Ratio •.• of Illinois Report Description:Provides the medical and pharmacy loss ratio and claims for the most recent reported twelve months. Month Premium Medical Paid Claims Pharmacy Paid Claims VBC Payments Total Paid Medical and Pharmacy Loss Ratio Nov 2016 $181,650 $195,971 $35,890 $9 $231,869. 127.7% __-.-0..0.0.0__._____,_.-.0.000 ._---_.-....___:._..._��_-----._._--.----_._._-_-�._..._�v_.•_�_ �_M.-___-•.0000_ _.�-_____�_-0000._-__. __.____� Dec 2016 $180,916 $312,419 $38,637 $9 $351,064 194.1% {Jan 2017 $180,080 $101,645 $39,805_..- � _ $lu --.�- $141,45178.6% I 1 Feb 2017 $179,487 $126,864 $26,052 $1 $152,917 85.2% L 2017 $178,895 -$240,651 $43,165- $3 $283,819 158.7% Apr 2017 $178,161 $131,618 $28,106 $3 0000--- $159,72789.7% --.-...000.0.._..__-_----..00.0.0 000.0--_-• ,May 2017 $176,905 $89,499 `~ _ $48,856 -� - $2 -_---`$138,356 _ 78.2% Jun 2017 $176,312 $68,676 $35,083 $1 $103,760 58.9% j ' )Jul 2017 $176,312 $174,769 $32,105 $1 $206,875 117.3% Aug 2017 $174,146 $106,105 $37,362 $1 $143,468 82.4% :Sep 2017 $173,838 $182,472 $22,282 $1 $204,756 117.8% Oct 2017 $172,579 $162,000 $28,505 ($2) $190,504 110.4% Summary $2,129,281 $1,892,688 $415,848 $28 $2,308,564 108.4% Loss Ratio By Month 200% . .. - 150% - 100% 50% • Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 Key Findings:The medical and pharmacy loss ratio for the most recent reported month was 2.0%higher than the average of the most recent reported twelve months,which was 108.4%. 7 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Financial Overview: Network Overview of Illinois R Report Description: This report displays the discount amount,discount percent, paid amount and paid percent for medical claims split by Medicare/Non-Medicare,in/out of network and service category for the current period. Medicare Primary Indicator Network Indicator Service Category Covered Discount Discount% Paid %Of Paid I Facility Inpatient $729,820 $395,406 54.2% $328,969 18.8% Facility Outpatient $1,220,126 $355,465 29.1% $761,856 43.6% In Network - - - ---- -- -- - - - .. - - - -------.._. --- j Professional $1,433,499 $771,887 53.8% Y $565,943 32.4% Summary $3,383,446 $1,522,758 45.0% $1,656,768 94.8% No Facility Inpatient $88,515 $59,169 66.8% $29,347 1.7% Facility Outpatient $48,769 $40,987 2.3% Out of Network Professional $23,391 $1,141 4.9% $14,717 0.8% Summary $160,676 $60,309 37.5% $85,050 4.9% Summary $3,544,121 $1,583,068 44.7% $1,741,818 99.7% i R Facility Inpatient t Facility Outpatient $20,214 $1,029 0.1% In Network - - -- - - --- -- - -- - --- - -- Professional $19,056 $4,026 0.2% j Summary $39,270 $5,055 0.3% Yes 1 Facility Inpatient Facility Outpatient Out of Network.- r Professional _ ... Summary Summary $39,270 $5,055 0.3% Summary $3,583,391 $1,583,068 44.2% $1,746,874 100.0% Key Findings:The overall network savings discount(excluding Medicare)was 45.0%for the current period. The in-network paid percent was 95.1%for the current period. R CITY OF CANTON:PREM NON-HMO � B1ueCross BlueShield Financial Overview: Blue Card Savings Analysis ofIDinois Report Description:The Blue Card Savings report illustrates the value of having access to other BCBS contracts within the United States through the Blue Card program. Savings from BCBS network discounts are passed to the client,providing savings on potentially costly out of state claims that would otherwise be paid at full provider billed amount. Feb 2017-Jan 2018 Par Plan State Billed Allowed Effective Discount Paid Effective Blue Card Allowed Rate Paid Rate Access Fee iSt.Louis MO $67,633 $34,939 51.7% $22,012 $33,763 49.9% $995 ------------- DC $7,200 $4,939 68.6% $2,261 $4,251 59.0% $102 NC $3,065 $1,607 52.4% $1,458 $1,512 49.3% $66 IA $17,859 $4,625 25.9% $896 $3,079 17.2% $40 jWA,AK $3,835 $1,861 48.5% $221 $1,384 36.1% $10 WI $1,438 $717 49.9% $219 $183 12.7% $10 Premera WA,AK $246 $78 31.9% $168 $86 34.9% $8 CO $78 $13 16.4% $65 $16 20.1% $3 IBS CA '$39 $33 • •84.6% $6 - - 0.7%, BC Worldwide - $590 "$590 ` 100.0% - $0 - $2591•' 43.9% $0 fAll Other Blue Card $926 $895 96.7% $0 $465 50.2% $0 All Other Non-Blue Card $4,070,094 $1,950,301 47.9% $1,555,761 $1,702,135 41.8% $0 Summary $4,174,714 $2,000,324 47.9% $1,583,068 $1,746,874 41.8% $1,234 Key Findings:St.Louis MO had the greatest Blue Card savings amount,with a Discount amount of$22,012. The overall Effective Allowed Rate for the current period was 47.9%. 9 CITY OF CANTON:PREM NON-HMO � B1ueCross B1ueShield Financial Overview: Medical Claim Expense Distribution •.• of Illinois R Report Description:The distribution of medical paid expense by claimant and the average medical paid per claimant amount are shown for the current period. Paid Band Claimants Claimants% Paid Paid% Paid/Claimant Less than$200 63 20.9% $3,020 0.2% $48 I $200-$1,000 97 32.2% $50,283 2.9% $518 ;$1,001-$5,000 75 24.9% $177,294 10.1% $2,364 _. -_- _- - -- ------- - - _------ ----- __ _-------- ----- -- _--- - --- - -- - ----I $5,001-$10,000 21 7.0% $140,684 8.1% $6,699 $10,001-$30,000 29 9.6% $434,677 24.9% $14,989 i $30,001-$50,000 9 3.0% $359,453 20.6% $39,939 Summary<=$50,000 294 97.7% $1,165,411 66.7% $3,964 Paid Band Claimants Claimants% Paid Paid% Paid/Claimant $50,001-$75,000 4 1.3% $241,176 13.8% $60,294 I $75,001-$100,000 1 0.3% $89,666 5.1% $89,666 ---------- --- -- -- _ _ - _ ------- --- ---- --- ----- -- ---- - ----- -- - ---- ------7- 1$100,001- -1$100,001-$150,000 2 0.7% $250,621 14.3% $125,311 $150,0017$200,000 `.x;$204,001-.$250,000 -I $250,001-$500,000 $500,001+ I Summary$50,001 or Greater 7 2.3% $581,463 33.3% $83,066 Combined Summary 301 100.0% $1,746,874 100.0% $5,804 Key Findings:The proportion of claimants who received less than$200 in services for the current period was 20.9%. These claimants spent 0.2%of the total paid expenses and the average paid expense per claimant was $48. 2.3%of claimants had expenses over$50,001 for the current period. These claimants spent 33.3% of the total paid expenses and the average paid expense per claimant was$83,066. 1n CITY OF CANTON:PREM NON-HMO ► Bl, Of eCros s B1ueShield Financial Overview: High Cost Claimants Report Description:This report provides a detailed listing of the top 20 high cost claimants with paid expenses of$50,000 or more for the current period. Feb 2017-Jan 2018 Age/Gender Inpatient Outpatient Professional Pharmacy Encrypted Member ID Relationship Band Leading Diagnostic Category Paid Paid Paid Paid Paid 1033190023097568182 Spouse Female 30-39 Neoplasms $171771 $64,354 $60,056 $1,479 $143,660 7333919212594852393 Spouse Female 50-59 $0 $7,498 $53,932 $80,425 $141,855 332544881311853446 Subscriber _ Male 50-59 Musculoskeletal - �- - $39,753 - $20,635 - $48,053 $655 T$109,096 143696049074934515 Spouse Female 30-39 Injury/Poisoning $76,359 $0 $13,307 $511 $90,177 '2672764549424886794 Dependent Female<1-19 Digestive $52,486 $7,299 $9,155 $341 $69,281 1308153503870556903 Dependent Female 20-29 Genitourinary $26,244 $22,762 $7,525 $257 $56,788 2548518157508363733 Dependent Male<1-19 Injury/Poisoning $0 $42,093 $12,182 $0 $54,275 7674413743403423770 Subscriber Female 60-64 Respiratory $23,979 $6,917 $5,156 $18,223 $54,275 '213552257133132743 Subscriber Male 50-59 Musculoskeletal $34,670 $7,680 $7,425 $519 $50,294 8417890962930015693 Dependent Female 20-29 Neoplasms $14,090 $10,255 $25,520 $261 $50,126 High Cost Claimant Total $285,352 $189,493 $242,311 $102,671 $819,827 11 CITY OF CANTON:PREM NON-HMO • ► Bl Illinois s B1ueShield Financial Overview. Medical Out of Pocket Report Description:Provides a distribution of claimants by their total medical out of pocket expenses for the current period compared to the prior period and percent change. This report helps determine the impact of any changes in plan design on out of pocket. Claimant Distribution by Out of Pocket Expense Bands Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change Out of Pocket Band Claimants Claimants% Out of Pocket Out of Pocket% Claimants Claimants% Out of Pocket Out of Pocket% Claimants Change Out of Pocket Change Less than$100 91 29.6% $3,804 2.0% 84 27.9% $2,765 1.4% -7.7% -27.3% $101-$200 27 8.8% $4,078 2.1% 28 9.3% $4,320 2.2% 3.7% 6.0% i$201-$300 17 5.5%• $4,121 2.1% 19 6.3% $4,675 2.4% 11.8% 13.4% $301-$400 15 4.9% $5,090 2.6% 20 6.6% $6,867 3.5% 33.3% 34.9% '$401-$500 10 3.3% $4,629 '2.4% 13 4.3% $5,808 3.0% 30.0% 25.5% $501-$750 44 14.3% $27,885 14.5% 42 14.0% $25,838 13.3% -4.5% -7.3% 1$751-$1,000 29 _9.4%� $24,881 12.9% _ 26 _-8.6%--------$22,471__. .___ 11.6% -- -10.3%__.,._.._ 9.7% $1,001-$1,500 37 12.1% $45,273 23.5% 29 9.6% $36,083 18.6% -21.6% -20.3% !+$1,801-$2,000 23 7.5% $39,554 20.5% 17 5.6% $28,915 14.9% 26,1% -.26.9% $2,001-$2,500~ 9 2.9% $19,210 10.0% 15 5.0% $32,649 16.9% 66.7% 70.0% 1$2,501-$3,000 4 1.3% $10,781 5.6% 6 2.0% $16,532 8.5% 50.0% 53.3% $3,001-$4,000 _ 1 0.3% $3,235 1.7% 2 0.7% $6,665 3.4% 100.0% 106.0% i$4,001-$5,000 0.0% 0.0% $Greater than$5,001 0.0% 0.0% Summary 307 100% $192,541 100% 301. 100% $193,589 100% -2.0% 0.5% . Out 64 Pocket Expense by Coverage Tier- _ - � ._ - -• - •- Feb 2017-Jan 2018' -. •• - - Coverage Tier Allowed Deductible Deductible%of Allowed Copayment Copay%of Allowed Coinsurance Coins%of Allowed Out of Pocket OPX%of Allowed Paid !Employee Only -- $259,533 $15,011 5.8% $5,638 2.2% $10,100 3.9% $30,749 11.8% $217,076 j Employee+One $557,911 $26,714 4.8% $10,398 1.9% $18,454 3.3% $55,566 10.0% $462,384 !Employee+Dependent(s) $238,_756 $13;123 _5.5% $8,046_ 3.4% $_4,968 2.1% $26,137 10.9% $212,224 {Family -_ $944,124 $34,061 A-_-_ 3.6% $20,980 ___-- 2.2%_ _.._._ $26,096 --� 2.8% $81,137_-� 8.6% -� $855,189 _ Summary $2,000,324 $88,909 4.4% $45,062 2.3% $59,618 3.0% $193,589 9.7% $1,746,874 This 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. This report is based on claim data and may not reflect client specific benefits being applied to member out of pocket.. Please contact your Account Executive for ACCUMS reporting. 1� CITY OF CANTON:PREM NON-HMO eCros Financial Overview: Lag Report V Bluof Illlinoisinois BlueShield V 2 Report Description: Displays,by paid month,the medical dollars paid and the corresponding month incurred for a 12 month rolling paid period(if available for your account). This report provides insight into the monthly claim lag and can help identify IBNR. Incurred Paid Month Month Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Summary iAll Prior ($2,547) ($29) $200 ($150) ($2,526) Feb 2016 $263 $263 Mar 2016 $0 Apr 2016 ($58) $488 $430 May 2016 $441 $7 $448 Jun 2016 $130 $1,132 $86 $1,347 T Jul 2016 $437 $106 $452 ($358) ($4) $28 $660 Aug 2016 $122 $77 ($238) $55 $28 $45 .Sep 2016 $114 $3,171 $1,224 ($628) $11 $3,892 Oct 2016 $274 $617 ($323) $6 ($8,978) $11 ($8,393) Nov 2016 $576 $974 $68 ($396) $143 $11 $1,376 Dec 2016 $2,244 $3,076 $9,075 $2,049 $683 $11 $17,138 Jan 2017 $21,321 $20,145 $1,213 $85 $27 $42,791 j Feb 2017 $63,035 $64,836 $957 $148 $1,226 $171 $2,821 $133,193 Mar 2017 $126,066 $105,802 $3,823 $982 $1,044 $226 $1 ($7) $237,935 Apr 2017 $44,296 $58,676 $25,488 $1,566 $14 $130,040 May 2017 $70,850 $22,016 $4,494 $283 $38 $69 $97,751 Jun 2017 $56,080 $10,965 -,$573 $90 $101 $67,809 �Jul2017 -_- $55,179 $43,182 $3,216 $68,143 ::;$2;203 $299:• -($5,734) ' $168,489,J Aug 2017 $69,62,7. $31,864 $1.309 $345.-- $26,613.�; - _ --- --$129,758:_::-:•a_.: . - tSep 2017 __ __ __..----_ __--__. _-•--_----_.. . -.___---_ _. _-___ ._ __._ _-.--_-_ $53,519 $89,308 $2,607 $10,395 $6,435 $162,264 Oct 2017 $109,832 $40,853 $8,599 $2,352 $161,635 Nov 2017 $64,779 $77,499 $12,262 $154,541 Dec 2017 -$73,864 `$75,330 $149,194 ;Jan 2018 $96,792 $96,792 d Summary $85,454 $219,468 $163,300 $131,816 $108,047 $74,187 $106,912 $90,021 $271,552 $111,459 $197,301 $187,356 $1,746,874 12 CITY OF CANTON:PREM NON-HMO Financial Overview: Overall Medical Paid PMPM by Leading Diagnostic Category %�� of Ill noissBlueShield Report Description: Lists the top 15 overall paid expense across inpatient facility,outpatient facility,and professional settings by leading diagnostic categories for the current month,current period,prior period and percent change. Paid Period Jan 2018 Feb 2016- Feb 2017- %Change Medical PMPM by Leading Diagnostic Category Jan 2017 Jan 2018 Leading Diagnostic Category Paid PMPM Paid PMPM Paid PMPM Paid PMPM Digestive $129 $57 $42 -26.3% F Injury/Poisoning $125 $72 $72 0.0% ;Symptoms/III-Defined $93 $65 $56 -13.8% Neoplasms $51 $21 $57 171.4/ oa i Musculoskeletal, $45 $51 $59 15.7% Circulatory $38 $141 $31 -78.0% • (Respiratory $26 $22 $22 0.0/ 1 I � f Pregnancy $17 $19 $12 -36.8%, " Residual/Unclassified $16 $7 $13 85.7% I i I Nervous System $13 $27 $20 -25.9% � j IEndocrine $10 $40 $14 -65.0% i s Skin Diseases $10 $11 $2 -81.8% 1 Blood Diseases $8 $2 $12 500.0% i •i I_ ! :' -Mental Health $T $8.:– $9 .12.5% AI j ,t nitourina,y $7 —s $23 $27 17.4% All Other Values $3 $44 $11 -75.0% I Summary $597 $608 $459 -24.5% 0 $20 $40 $60 $80 $100 $120 $140 $160 i3 Feb 2016-Jan 2017 = Feb2017-Jan2018 Key Findings:The top three Leading Diagnostic Categories in the current reporting month based on Paid PMPM were Digestive,Injury/Poisoning,and Symptoms/III-Defined. 14 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Financial Summary ► of Illinois R R Report Description: This report provides an overview of pharmacy order of reduction from billed to paid for the current month,current period,prior period,and percent change. Pharmacy Order of Reduction Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change iBilled $66,019 $1,039,171 $951,008 -8.5% j Covered $66,019 $1,039,171 $951,008 -8.5% Discount —^ � —�$36,296�A—_ $507,210 _y $515;685 _ 1.7% s Breakdown of Billed Amount _ Allowed $29,723 $531,961 $435,322 -18.2% 100% - - - - - — IOut of Pocket $3,626 $52,013 $48,611 -6.5% Other Adjustments ($15) ($225) ($360) -60.0% 9090 "-" - --,Paid-Provider $26,112 $480,172 $387,071 -19.4% Paid $26,112' $480,172 $387,071 -19.4% 70%- 60% - „ Discount 50%- -- Out 0% - Out of Pocket 40%-- Total 0%Total Pharmacy Paid vs.Specialty Paid Other Adjustments 30%- Prior 0%Prior = Current _ Paid Provider :"$500,000 _:. _ _ - -- 20% .._. $400,000 10% - $300,000 0% $200,000 Prior Current $100,000 - $0 Total Paid Specialty Paid Prior $480,172 $142,301 iCurrent $387,071 $83,567�� 15 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Key Indicators \ / of Illinois Report Description:This report provides an overview of the prescription expenses as well as providing percent change in these expenses between the current month,current period,prior period and percent change. Key Indicators Summary Key Indicators Summary Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change Unique Pharmacy Members 314 339 333 -1.8% dd Average Age(Years) 35.1 35.0 35.1 0.3% Proportion of Males 53.8% 53.4% 53.6% 0.4% Proportion of Females 46.2% 46.6% 46.4% -0.5% IMember Months _314_ 3,872 �� ._"®._..3,807 -1.7% Claimants Claimants140 "______.._ -- •-�- 256 257 0.4% Services 393 4,995 _ 5,137 2.8% j Prescriptions PMPM 1.25 1.29 _ 1.35 4.6% $26,112 _ - -- ___ $480,172 $387,071. -19.4% Paid PMPM - $83.16 $124.01 $101.67 -18.0% Allowed $29,723 $531,961 $435 322 -18.2% (_--- __- -----------______-____.--- _ _ -..__--------- __. Allowed PMPM $94.66 $137.39 $114.35 -16.8% Avg.Ingredient Cost/Prescription $74.99 $105.59 $84.09 -20.4% ___....._.-. _---- --__-.---- -..___. Generic Dispensing Rate 84.7% 84.1% 84.7% 0.7% {Formulary Compliance Rate 92.9% 92.8% 93.5% 0.8% Generic Substitution Rate 100.0% 99.7% 99.9% 0.2% Out of Pocket Percent of Allowed 12.2% 9.8% 11.2% 14.2% I Retail as a Percent of Prescriptions 97.0% 96.2% 96.9% 0.7% ;Mail Order as a Percent of Prescriptions - 3.1% - A 3.8% _ 3.1% -18.5% - 1 Specialty Percent of Total Prescriptions 0.0% 0.4% 0.2% _ -50.0% (ISpecialty Percent of Total Paid 0.0% 29.6% 21.6% -27.2% Specialty Average Ingredient - -- Cost/Prescription .$0 `.$7;911.64 $9,288.36 - 17-.4% Cost Sharing Distribution-. Jan 2018 Feb 2016 Jan 2017 Feb 2017-Jan 2018 %Change Cost Sharing Distribution Retail Mail Retail Mail Retail Mail Retail Mail LMember�0ut of Pocket _ 12.2% _ ._ -,-12.8% 9.7%- - 10.3% _- -" 11.3% _ 10.0% 15.8%� - -2.9% Plan Paid 87.8% 87.3% 90.3% 89.7% 88.7% 90.0%_ -1.7% 0.3% Savings Summary Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change Savings Summary Retail Mail Summary Retail Mail Summary Retail Mail Summary Retail Mail Summary Discount $33,16_3_ $3,133 - $36,296 -$443,445-" $63,765 $507,210 $465,432 $50,253 $51_5,685 _5.0% 21.2%, 1.7% _ - �. % Discount 54.1% 65.7% 55.0% 47.7% 58.7% 48.8% 53.7% 59.4% 54.2% 12.7% �1.3% 11.1% 16 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Generic vs. Formulary Experience 0 ofHUnois Report Description: For the current period,the prescription drug expenses are displayed below for retail and mail order providers and broken out by drug type and formulary indicator. Total Expense Member Expense Plan Expense %of Total Allowed/ Out of Pocket/ Paid/ Retail Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription Generic4,229 85% - $81,335 - $19.23 $28 277 $6.69 $53,058 $12.55 - Brand 750 15% $319,682 $426.24 $16,900 $22.53 $303,142 $404.19 Summary 4,979 100% $401,017 $80.54 $45,177 $9.07 $356,200 $71.54 Brand Type Breakdown !Single-5ource Brand 678 14% $284,440 $419.53 $14,841 $21.89 $269,959 $398.17 Multi-Source Brand 72 1% $35,242 $489.47 $2,059 $28.60 $33,183 $460.87 :Multi-Source Brand w/DAW1 29 1% $31,055 $1,070.88 $996 $34.34 $30,060 $1,036.54 Brand Formulary' 433 9% $157,301 $363.28 $9,208 $21.26 $148,094 $342.02 Brand Non-Formulary 317 6% $162,381 $512.24 $7,693 $24.27 $155,048 $489.11 Total Expense Member Expense Plan Expense %of Total Allowed/ Out of Pocket/ Paid/ Mail Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription :Generic _.>.- 123 78%- $5,533 $44.98, $1,623 $13.20 $3,910 $31.79 Brand 35 22% $28,773 $822.07 $1,811 $51.75 $26,961 $770.33 Summary 158 100% $34,306 $217.12 $3,434 $21.74 $30,871 $195.39 Single-Source Brand 27 17% $24 236 $897 64 - $1.290 _ $47.78 $22,946 - $849.86 Multi-Source Brand 8 5% $4,536 $567.05 $521 $65.15 $4,015 $501.90 Multi-Source Brand w/DAW1 4 3/ $4,295 $1,073.81 $280 _$70.00 $4,015 $1003.81 _ _.__ _.___._. ...-_._ Brand'Formulary 13% -` $18,515 -- _ $925.75 _. $800 $40.00 $17,715 $885.75 - Br6nd-Non7Formulary15 _ 9%. $10,258- = ;. $683.84• •$1,011 $67.41.• $9,246 Tota[Expense Member Expense Plan Expense, ` %of Total Allowed/ Out of Pocket/' Paid/ Total Prescriptions Prescriptions Prescriptions Allowed Prescription Out of Pocket Prescription Paid Prescription (Generic 4;352 _ _. _.. .._.--_ 85% _..... $86,868_ $19.96. $29,900 ._.$6.87 _._.$56,968__- _-- $13.09____.__' Brand 785 15% $348,455 $443.89 $18,712 $23.84 $330,103 $420.51 Summary 5,137 100% $435,322 $84.74 $48,611 $9.46 $387,071 $75.35 Brand Type Breakdown 705 14/__ $308 676 ._ $437_84 ______.- _ _ $16,131 _ - _ '$22.88 - $292,905 -: ._- $415.47 Multi-Source Brand 80 2% $39,778 $497.23 $2,580 $32.25 $37,198 $464.98 $35.351 $1,07123 y$1,276 $38.66__ $34,075 $1,032.57 __________.._._.__..-_ i Brand Formulary - 453 9% - $17_5,8_16 $388.12 v $10,008 - $22.09 _ $_165_809_ $366.02, Brand Non-Formulary 332 6% $172,638 $519.99 $8,704- $26.22 $164,294 $494.86 17 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Top Non-Specialty Therapeutic Drug Classes 41. 0 of Illinois Report Description: The top 25 therapeutic drug classes for the current period are displayed below ranked by ingredient cost. Avg.Ingredient Avg.Ingredient Current/ Cost/ Cost/ Prior Utilizing Prescription Prescription % % Rank by Rank Plan Therapeutic Class Prescriptions Members Ingredient Cost (Current) (Prior) Formulary Generic Volume 1 1 Insulin 125 9 $78,138 $625.10 ° 11 $584.88 96.0/ 0.0/ 2 2 Anti myasthenic/CholinergicAgents 11 1 $30,438 $2,767.12 $2,648.38 0.0% 0.0% 87 $209.70 -- --- ------- ---- ---- ------------------ 3 4 Sympathomimetics 95 31 $21,090 $222.00 - 9S.8%° 17.9/° 14 4 Sodium-Glucose Co-Transporter 2(SGLT2)Inhibitors 33 3 $14,035 $425.29 $393.13 100.0% 0.0% 44 5 6 Direct Factor Xa Inhibitors 26 5 $12,675 $487.50 $485.43 100.0% 0.0% 50 6 7 Prostaglandin-Impotence Agents 32 7 $10,924 $341.38 $283.03 37.5/ 3.1/° 45 7 14 Dipeptidyl Peptidase-4(DPP-4)Inhibitors 14 2 $8,288 $592.02 $825.36 100.0% 0.0% 72 8 11 Diagnostic Tests 52 7 $6,371 $122.53 $144.74 88.5% 0.0% 27 9 22 Phenothiazines 15 3 $5,937 $395.81 $311.45 100.0% 100.0% 71 10 8 HMG CoA Reductase Inhibitors 283 43 $5,872 $20.75 $30.89 98.6/ 98.6/° 1 11 Selective Serotonin Reuptake Inhibitors SSRIs 228 34 $5,741 $25.18 $15.46 97.4% 97.4% 12 13 Anticonvulsants-Misc. 138 21 $5,328 $38.61 $51.64 100.0% 92.0% 8 - --------------- ----- - - ----- - - - - - -- -- - - -- - -- -- 13 9 Stimulants-Misc. 48 6 $5,280 $110.00 $139.90 89.6% 89.6% 29 14 Combination Contraceptives-Oral 124 23 $5,250 $42.34 $26.38 86.3% 86.3% 12 15 20 Amphetamines 39 6 $5,200 $133.32 $15734 100.0/ 69.2% 37 . 16 10 Antihypertensive Combinations 148 18 $4,841 $32.71 $50.60 96.6% 94.6% 7 17 21 Antidiabetic Combinations =".- "12 1 $.4,571 $380;90_ $369.91 100.0% .. 0.0% 79 18 24 Thyroid Hormones " _205-" • 24 $4,343• $21:18 ="` $20.27 7.7.T%."" 77.1% '4-"-- - - Thy-oi ---__.. -- i--- ------ _... ------- -------- --- - _._. _. 19 25. Bro6chodj giors,-Anticholinergics .. ._.•. Y- :... 2. , 5-145 -- -$345.41;..:._;{ y$319.88 - - 100,0%.":�,8.3%---�82 T-- - - - ------- ---- - _ ------- -- - - - - - - - -- - - -,145 - ----- - -- - - ----.0%.- --- -- - -- 20 Anti-Obesity Agents 21 2 $4,104 $195.41 $164.94 0.0% 0.0% 61 21 Irritable Bowel Syndrome(IBS)Agents 4 2 $4,067 $1,016.65 $625.41 100.0% 0.0% 122 22 Gout Agents 33 5 $4,001 $121.23 $156.89 57.6% 57.6% 42 1 23 19 Fibromyalgia Agents 4 1 $3,742 $935.46 $551.39 0.0W 0.0% 121 I 24 15 Immunosuppressive Agents 26 1 $3,339 $128.41 $156.47 100.0% 100.0% 52 25 5 Hemostatics-Systemic 9 3 $3,317 $368.56 $1,773.90 88.9% 88.9% 100 All Other 3,390 243 $85,805 $25.31 $43.23 95.5% 93.3% Summary 5,127 257 $346,840 $67.65 $77.36 93.7% 84.9% CITY OF CANTON:PREM NON-HMO B1ueCross B1ueSlueld Pharmacy: Top Non-Specialty Prescription Drugs ® of Illinois ti Report Description: The top 25 prescription drugs for the current period are displayed below ranked by ingredient cost. Avg.Ingredient Avg.Ingredient Current/ Cost/ Cost/ Prior Utilizing Ingredient Prescription Prescription Formulary Generic Rank by Rank Brand Name Plan Therapeutic Class Prescriptions Members Cost (Current) (Prior) Indicator Indicator Volume 1 1 MESTINON TAB 60MG Antimyasthenic/Cholinergic Agents it 1 $30,438 $2,767.12 $2,648.38 NO NO 140 i $2,7_7_12_.__ 2 3 NOVOLOG INJ 100/ML� �- Insulin _. -�- _i5 Z- $23,150 $1,543.31 $1,256.59 YES NO 71 3 4 NOVOLOG MIX INJ 70/30 Insulin 11 1 $15,444 $1,404.02 $1,300.06 YES NO ~ 139 4 5 LANTUS INJ SOLOSTAR Insulin 31 3 $13,854 $446.92 $392.32 YES NO 11 �..._..__.__.__._v..___._..__.v.__________---7777_-_.-_------- --_-----------_._.__._..�_._.._----------- ---__-.___---------7777_.---__--------. _...._+------_------_�..__._..__..__.._-----------_--•------_._._...._._-.-� 5_ 8 XARELTO -TAB 20MG WY _ Direct Factor Xa Inhibitors _ -�21 ^- 3 TT $10,960 , $521.88 i _ $435.85 ^-^YES -_NO 46 6 6 NOVOLOG INJ FLEXPEN Insulin 15 2 $7,818 $521.22 $536.34 YES NO 70 7� i7 LANTUS INJ 100/ML Insulin .- � 29 3_-- $7,186- ---$247.81_-- r $252.26YES 7777_�NO' 15 --_..5 8 23 ADVAIR DISKU AER 500/50 Sympathomimetics 14 2 $6,623 $473.10 $450.82 YES NO 75 9 17 CHLORPROMAZ TAB 100MG Phenothiazines 13 1 $5,930 $456.17 $337.18 YES YES 89 I L_ _.-77-_-_. __ 7777-_�_. _-___._____._-..----------- -________.__ 7777-.._ __ 7777__ -.--- 7777.__ __-------_._ -___=..___._.___.�_._._._...__-__..__.._ __j 10 9 LEVEMIR INJ Insulin 12 1 $5,864 $488.63 $547.72 YES NO 104 i 11 JARDIANCE TAB 10MG _ Sodium-Glucose Co-Transporter 2(SGLT2 13 1 v $5;558- $427.53 YES NO 87 �I 12 16 KOMBIGLYZ XR TAB 2.5-1000 Antidiabetic Combinations 12 1 $4,571 $380.90 $369.91 YES NO 106 13 19 VIAGRA, TAB 100MG Prostaglandin-Impotence Agents 12 3 $4,402 $366.84 $279.66 NO NO 99 7 14 13 LYRICA CAP 300MG Anticonvulsants-Misc. 11 1 $4,351 $395.51 $353.12 YES NO 133 F.- 15 24 LIPITOR TAB 40MG HMG CoA Reductase I.nhibitors 4 1 $4,295 $1,073.81 . $901.29 NO NO 353 16 JARDIANCE TAB 25MG Sodium-Glucose Co-Transporter 2(SGLT2 10 1 $4,258 $425.77 YES NO 163 _ 117- 47 AD_.-VAIR-DISKU AER 250/50 Sympathomimetics $ _.Z__ $4;219 w $527.38 $967.30_ YES NO 212_.-._____.______s_.____._.._ •.._..______.__7777 -- ;-18 20 SPIRIVA CAP HANDIHLR Bronchodilators-Anticholinergics 11 1 $4,121• $374.66 $347.11• YES NOT � 'I43 7777._ 7777_ 19 27 LINK "'.CAP 290MCG ;• drr�tableBowel Syndrome(IBS)-Agents 4 2, $4'067 $1016.65 $684.77 YES NO 44 _ _ _ _ __ 20 93 ONGLYZA TAB 5MG Dipeptidyl Peptidase-4(DPP-4)Inhibitors 10 y-_- 1 $3,809_ $380.90- __- $375.41 YES - NO 159 _ 21 15 SAVELLA TAB 50MG Fibromyalgia Agents 4 1 $3,742 $935.46 $594.42 NO NO 368 22 26 ULORIC TAB 80MG Gout Agents 12 1 $3,674 $306.19 $286.50 NO NO 126 `23 32 VYVANSE CAP 70MG, Amphetamines '12 1 $3,236 - $269.66, $252.77 ,YES NO 125 __.. 24 75 LO LOESTRIN TAB Combination Contraceptives-Oral 17 4 $2,935 $172.64 $111.34 NO NO 54 25 35 RAPAFLO CAP 8MG Prostatic Hypertrophy Agents 12 1 $2,719 $226.55 $212.69 NO NO 121 L__ ..-_- ---_----__ All Other 4,803 256 $159,617 $33.23 $48.93 Summary 5,127 257 $346,840 $67.65 $77.36 1Q CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Pharmacy: Specialty Drug Analysis 0 ofUflnois 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.This report provides specialty drug analysis for the current month,current period,prior period and percent change. Specialty Drug Key Indicators Top Specialty Classes by Ingredient Cost for the Current Period Jan 2018 Feb 2016-Jan 2017 Feb 2017-Jan 2018 %Change Unique Pharmacy Members 314 339 333 -1.8% Member Months 314 3,872 3,807 -1.7% 4.5%- -� ;Claimants 3 2 Percent of Utilizing Members 0.0% 0.9% 0.6% -32.1% Services 18 9 -50.0% Specialty Percent of Total Paid 0.0% 29.6% 21.6% -27.2% ©CANCER-ORAL :Percent of Total Prescriptions Paid _--- - 0.0% - -- - ---0.4% - -- — -0_2%- -- --51.4% Paid $142,301 $83,567 -41.3% (PaidPMPM $36.75 $21.95 -40.3% AUTOIMMUNE Average Ingredient Cost/Prescription $7,912 $9,288 17.4% 'Out of Pocket $120 $35 70.8% - — --- - _ Out of Pocket PMPM $0.03 -- --- $0.01 - - _70.3% Out of Pocket Percent of Allowed 0.0% 0.1% 0.0% -50.3% _ _- --- - - --- —.._- - ---- ---_-- --------. ._ �_---95.5 Top 15 Specialty Drugs by Ingredient Cost for the Current Period Avg.Ingredient Ingredient cost/ Specialty Top Specialty Classes by Ingredient Cost for the Prior Period Brand Name Specialty Class Cost Prescriptions Prescription Claimants IMBRUVICA__CAP 140MG CANCER-ORAL _---___$77,643__-___ XEUANZ TAB5MG AUTOIMMUNE $3,726 1 $3,726.38 1 ,VENCLEXTA TAB START PK CANCER-ORAL $2,226 1 $2,226.16 1 1.7-%— Summary. y $83,595 -9 $9,288.36 2 12.4%, J li ®CANCER-ORAL 'S ©AUTOIMMUNE E___1 HEMOPHILIA 85.9% �n CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Appendix: ICD Category Definitions •.• v of Illinois N Complications of Pregnancy,Childbirth and the Puerperium: Includes vaginal and cesarean deliveries and complications of pregnancy,such as ectopic and molar pregnancies. Puerperium refers to 42 days following childbirth and expulsion of the placenta.Refers to the mother only. Conditions Influencing Health Status:This includes post-surgical states,organ/tissue transplants,artificial limbs and replacements. Examples include knee replacements and kidney transplant status. Conditions in the Perinatal Period: Perinatal refers to the period beginning after the 28th week of gestation and ending 28 days after birth. Problems can include hemorrhage, digestive disorders,respiratory distress syndrome and disorders relating to short gestation and unspecified low birth weight. Congenital Anomalies: Includes the treatment of any condition present at birth.This includes Spina Bifida,cleft palate, Down's Syndrome,heart disease, kidney displacement &polycystic kidney disease. Diseases of the Blood and Blood Forming Organs: Includes any problems associated with white or red blood cells,platelets or plasma.An example includes Anemia,a deficiency in red blood cells. Diseases of the Circulatory System:Includes problems with the heart,blood vessels and circulation.Some common diagnoses include Coronary Artery Disease,cardiovascular disease,and stroke. Diseases of the Digestive System:Includes the treatment of any organ or area of the body pertaining to digestion.These areas include the mouth/teeth,esophagus,stomach, intestines,gall bladder,liver and pancreas.Diagnoses include: Esophageal Reflux,Gastroenteritis,Appendicitis and hernias. Diseases of the Genitourinary System:Includes problems related to the kidneys, bladder and male and female genitalia.Common diagnoses include Hematuria,Urinary Tract Infection,Acute or Chronic Renal Failure and Calculus of Kidney(stones). Diseases of the Nervous System: Includes treatment for disorders of the Central and Peripheral Nervous systems. Diagnoses include:Carpal Tunnel Syndrome,Obstructive Sleep Apnea,Epilepsy,Multiple Sclerosis,Alzheimer's Disease and Migraine headaches. Diseases of the Respiratory System: Includes treatment for diagnoses such as Asthma,Pneumonia, Emphysema,Pharyngitis,Sinusitis,Bronchitis and COPD.These can be acute or chronic in nature. Diseases of the Skin and Subcutaneous Tissue:This involves any condition relating to the skin or beneath the skin,including hair and nails.Some conditions include Acne, Corns,Cellulitis,Psoriasis,Dermatitis and fungal infections. 91 CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Appendix: ICD Category Definitions •.• 0 of Illinois Ears and Mastoid: Includes any condition pertaining to the ear or the mastoid process.The mastoid process is the portion of the temporal bone extending down behind the ear.Diagnoses include Otitis Media,Tinnitus, Menieres Disease, Hearing Loss and Labyrinthitis. Endocrine,Nutritional and Metabolic Diseases: Endocrine disorders include those of the endocrine glands and includes the thyroid,pituitary,pancreas,ovaries and testes. Disorders include Diabetes,thyroid disease,Obesity, Hyperlipidemia,Cystic Fibrosis and any disease affecting the immune system. Health Services:This includes elective surgeries,other procedures&aftercare,rehabilitation and dialysis.Specific examples include: long-term medication use,Physical Therapy and chemotherapy. Health Services:Reproduction and Development:Include services pertaining to the child only. For example,normal pregnancy, post-partum care and exam or health supervision of an infant or child. Infectious and Parasitic Diseases: Includes diseases caused by microbes outside of the body that infect and cause damage within the body.These diseases are recognized as communicable or transmissible.Diagnoses include HIV, Hepatitis,Colitis&intestinal disruptions such as food poisoning. Injury and Poisoning:Includes treatment for injuries to the body or for any poison ingested.Diagnoses include sprains&strains,fractures,burns and lead poisoning. Patients are most commonly seen in the emergency room for acute conditions. Mental Health:Refers to a group of disorders causing severe disturbances in thinking,feeling or relating.Includes treatment of any condition that affects mood or behavior. The most common diagnoses include anxiety disorders,depressive disorders and schizophrenia. Musculoskeletal and Connective Tissue Disease: Includes orthopedic treatment,which would involve anything related to the bones,muscles,joints and soft tissue. Diagnoses: Arthritis,Tendonitis,back disorders,disc disorders,rheumatism,and scoliosis.These diagnoses are more chronic in nature. Neoplasms:Includes any abnormal growth of cells,either benign or malignant(cancer).Though these can be found at any spot of the body,some of the most common forms include neoplasms of the breast,prostate,stomach and brain.Other examples include Leukemia and Hodgkin's Disease. Other Circumstances:This includes convalescent care and follow-ups to surgeries and examinations. Potential Health Hazards: Personal or family history of diseases or disorders;e.g.,breast cancer. 27_ CITY OF CANTON:PREM NON-HMO B1ueCross B1ueShield Appendix: ICD Category Definitions Iof Illinois R Procreative and Contraceptive Management:This includes artificial insemination,fertility testing,genetic counseling,family planning,sterilizations and contraceptive management. . Signs,Symptoms and III-Defined Conditions:Includes signs,symptoms,abnormal lab results and ill-defined conditions for which no known cause can be found.For example,a patient may experience chest pain,but no known cause is found. Substance Abuse: Includes behavior marked by the use of chemically active agents,such as prescription or illicit drugs,alcohol or tobacco.Cognitive,behavioral and physiological symptoms indicate that the person continues use of the substance. Without Reported Diagnosis:This includes general medical examinations,gynecological exams,mammogram screenings,preventive services,physicals and special screenings for neoplasms. 93 CITY OF CANTON:PREM NON-HMO Glossary B1uBlueShield ►.� of Illinois A Admin Fees:The charge to an account for HCSC's operational cost of doing business. Administrative Services Only(ASO):A contract between HCSC and a self-funded plan where HCSC performs administrative services only and does not assume any financial risk.Services usually include claims processing but may include other services such as actuarial analysis and utilization review. Aggregate:Constituting or amounting to a whole. For example,an aggregate account report includes data for the entire account. Aggregate Stop Loss:A form of reinsurance that provides protection for medical expenses above a certain limit,generally on a year-by-year basis.Aggregate stop loss provides protection against the accumulation of total claims for a group as a whole exceeding a stated level. Allowed:Amount considered eligible for payment by the plan ASO Adjustments:An amount added or deducted from ASO(Administrative Services Only)fees.This includes Stop Loss Reimbursements. 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 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. 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 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. 94 CITY OF CANTON:PREM NON-HMO Glossary Btu BlueSlueld ►.� of Illinois 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 Co-payment: Flat rate that the member is responsible to pay for the claim 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. Deductible:Portion of annual deductible amount member is responsible to pay applied to the claim. Dental Loss Ratio:Calculated as the Dental Paid Claims Amount divided by the Billed Dental Premium Amount. 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. 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 CITY OF CANTON:PREM NON-HMO Glossary Blu B1ueSlueld ►.� © of Illinois 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 reporting period 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 Facility Inpatient claims International Classification of Diseases(ICD):An official list of categories of diseases,physical and mental,issued by the World Health Organization(WHO). Leading ICD 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 Diagnostic Category for the reporting period MAC Program Savings:Savings achieved by using the MAC(maximum allowable cost)discount on generic medications 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 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. Not Covered:Amount considered not eligible for payment by the plan(excludes the discount amount) 2H CITY OF CANTON:PREM NON-HMO Glossary Btu BlueShield �.� of Illinois 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 Out of Pocket:Total amount that is the responsibility of the claimant.It is calculated as:(Copay+Deductible+Coinsurance) Outpatient Facility:Refers to Facility Outpatient claims Paid:Total amount paid by the plan,including access fees,adjustments,and surcharges 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/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 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 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 �7 CITY OF CANTON:PREM NON-HMO Glossary BluB1ueSlueld ►.� of Illinois 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 Professional:Services provided by physicians or other professional providers. 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. Rx Credit Fees:Drug rebates that are credited back to the account. Rx Paid PEPM:Prescription drug paid amount per employee per month Rx Paid PMPM:Prescription drug paid amount per member per month Service Category:A classification based on claim type Service Type:Classification based on principal diagnosis or ICD 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 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. Specific Stop Loss:A form of reinsurance that provides protection for medical expenses above a certain limit,generally on a year-by-year basis.Specific(or individual)stop loss limits the cost of eligible medical expenses for each covered individual. 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 and pharmacy dollars paid to cover healthcare services provided to members for claims that have been processed and approved for payment Total Paid Claims+Recoveries:The total amount paid by the plan plus any amount recovered through subrogation. Workers Compensation Savings:Portion of amount eligible for payment that has been paid a third party Workers Compensation carrier 7R CITY OF CANTON:PREM NON-HMO